Level V in therapeutic neck dissections for papillary thyroid carcinoma

Neck dissection for papillary thyroid carcinoma (PTC) is the standard of care for patients with clinical evidence of regional metastases. However, the extent of neck dissection is debatable. The purpose of the current study was to develop evidence‐based recommendations for when to include level V, or 1 of its sublevels, among patients with PTC undergoing neck dissection. A literature review of all studies evaluating the occurrence of metastases in level V in patients with regional metastases from PTC undergoing neck dissection was performed. Occurrence of metastases at level V is low in most series (5% to 10%), although a wide range was noticed. In cases in which metastases were found at level V, they occurred almost exclusively at sublevel VB. Sublevel VA was rarely, if ever, involved with metastatic lymph nodes. However, only recently have investigators begun to specify which sublevels of level V are at risk. Therapeutic dissection of level V is indicated when there is clinical evidence of disease involving this zone. Elective dissection of sublevel VB is indicated when there is involvement of level IV, or possibly multiple nodes at levels II and III. Under these circumstances, dissection of sublevel VB is indicated but sublevel VA may be spared. © 2012 Wiley Periodicals, Inc. Head Neck, 2013     

Intraosseous carcinoma of the jaws—A clinicopathologic review. Part I: Metastatic and salivary‐type carcinomas

This is the first part of a 3‐part comprehensive review of intraosseous carcinoma of the jaws. We have outlined 4 groups of intraosseous carcinoma of the jaws (metastatic, salivary‐type, odontogenic, and primary intraosseous carcinoma), emphasizing the need for accurate diagnosis and the problems associated with changing classification systems, standardization of diagnostic criteria and nomenclature, and the accuracy of existing literature. In this first part, the features of metastatic and the very rare salivary‐type carcinomas of the jaws are examined with particular emphasis on histologic and immunohistochemical characteristics, diagnostic difficulties, and uncertainties. © 2012 Wiley Periodicals, Inc. Head Neck, 2012     

Aggressive variants of papillary thyroid carcinoma

A number of histologic variants of well‐differentiated papillary carcinoma have been found to be associated with more aggressive tumor behavior. Tall cell, columnar cell, diffuse sclerosing, solid/trabecular, and insular variants of well‐differentiated papillary thyroid cancer are all potentially more aggressive than conventional papillary thyroid cancer. When subjected to multivariate analysis, however, evidence that the histologic subtype of tumor is an independent predictor of outcome is weak. Rather, the aggressive variants tend to present with features recognized by other staging systems as associated with a worse prognosis, including higher histologic grade, extracapsular spread, large tumor size, and the presence of distant metastases. Prognosis is directly related to the presence of these features. The state of our knowledge is limited by the relatively small number of cases that have been studied. The presence of an aggressive variant of papillary carcinoma should alert the surgeon that he is dealing with a potentially aggressive tumor. Clinical treatment decisions should be based on the stage of the disease, influenced by the knowledge that the aggressive variants tend to be associated with higher risk factors. The surgeon must be prepared to perform at the first, or second stage, a total thyroidectomy, central compartment neck dissection, additional lymphadenectomy, and/or resection of invaded surrounding structures, and search for distant metastasis. Postoperative radioactive iodine should generally be administered for these variants as they will generally be intermediate to advanced tumors. The tall cell variant is often refractory to such treatment but may be susceptible to treatment targeted against BRAF mutation. External beam irradiation may be used in cases of incomplete resection. © 2010 Wiley Periodicals, Inc. Head Neck, 2011     

Central compartment dissection in laryngeal cancer

We report here a review of the literature intended to clarify the nomenclature and boundaries of the nodes in the “central compartment” of the neck, the frequency with which tumors from the different laryngeal sites metastasize to these nodes, and the indications for central compartment node dissection in the treatment of cancers of the larynx. From this review, we conclude that, until consensus is reached about grouping of the lymph nodes in this area, it is best to refer to these nodes by their anatomic location, ie, prelaryngeal, pretracheal, or paratracheal lymph nodes. It is also advisable to describe dissection of these nodes as selective neck dissection (SND) with an annotation about the specific lymph node groups removed. Metastases in prelaryngeal and paratracheal lymph nodes in patients with squamous cell carcinoma of the larynx are associated with increased tumor recurrence, more frequent metastases in lymph nodes of the lateral compartment of the neck, and decreased survival. If untreated, they may lead to the development of peristomal recurrence. Therefore, elective treatment of level VI nodes is recommended in patients with squamous cell carcinomas of the subglottic region, advanced glottis carcinomas with subglottic extension, and in certain advanced carcinomas of the supraglottic region. © 2010 Wiley Periodicals, Inc. Head Neck, 2011