Indications for bilateral neck dissection in well-differentiated carcinoma of the thyroid

This paper analyses the results of sixty-eight patients with thyroid carcinoma in whom bilateral modified radical neck dissection was performed, and discusses the indications for bilateral modified radical neck dissection. High frequencies of bilateral jugular lymph node metastases were found in eleven patients with obviously widespread involvement of both thyroid lobes, 13 with cancer mainly located in the isthmus, 2 with clinically detectable bilateral or contralateral jugular chain lymph node metastases, and 10 with recurrent thyroid cancer. Bilateral modified radical neck dissection, therefore appears to be indicated for those conditions. On the other hand, lymph node metastases in the contralateral neck were histologically confirmed in 6 out of 27 patients (22 per cent), in whom papillary carcinoma was clinically confined to one lobe, and where there were no obviously enlarged lymph nodes in the contralateral neck. In those patients, the histological confirmation of the contralateral thyroid lobe involvements, and of the contralateral paratracheal lymph node metastasis, appears to be a valid indication for elective contralateral modified radical neck dissection.     

Indications for bilateral neck dissection in well-differentiated carcinoma of the thyroid

This paper analyses the results of sixty-eight patients with thyroid carcinoma in whom bilateral modified radical neck dissection was performed, and discusses the indications for bilateral modified radical neck dissection. High frequencies of bilateral jugular lymph node metastases were found in eleven patients with obviously widespread involvement of both thyroid lobes, 13 with cancer mainly located in the isthmus, 2 with clinically detectable bilateral or contralateral jugular chain lymph node metastases, and 10 with recurrent thyroid cancer. Bilateral modified radical neck dissection, therefore appears to be indicated for those conditions. On the other hand, lymph node metastases in the contralateral neck were histologically confirmed in 6 out of 27 patients (22 per cent), in whom papillary carcinoma was clinically confined to one lobe, and where there were no obviously enlarged lymph nodes in the contralateral neck. In those patients, the histological confirmation of the contralateral thyroid lobe involvements, and of the contralateral paratracheal lymph node metastasis, appears to be a valid indication for elective contralateral modified radical neck dissection.     

The necessity of intraoperative identification of the contralateral lobe in "struma uninodosa"

Between July 1st, 1988 and July 31st, 1989 we registered 74 consecutive patients with a unilateral goitre. In all these patients the preoperative sonography showed no pathologic finding in the contralateral lobe of the thyroid. In 16 cases we found and resected nodules in the lobe, which was supposed to be normal. A consequent exposure of the whole thyroid gland, independent of the preoperative sonographic finding, principally is necessary. So, the rate of "false" goitre recurrences might be decreased.     

GIANT DOUBLE PARATHYROID ADENOMA PRESENTING AS A HYPERCALCAEMIC CRISIS

The largest documented case of a double parathyroid adenoma is reported. The patient presented in hypercalcaemic crisis with a large intrathoracic mass. After removal of a massive cystic parathyroid adenoma from the right superior mediastinum. a second very large parathyroid adenoma was found on the contralateral side adjacent to the left thyroid lobe. This case illustrates the importance of the cervical approach, as well as routine bilateral neck exploration. for all cases of primary hyperparathyroidism.     

Urine calcitonin as a test for medullary thyroid cancer: a new screening procedure.

Although the radioimmunoassay of serum calcitonin (CT) has facilitated the diagnosis of medullary thyroid cancer (MTC) one may encounter patients whose basal serum levels of CT are normal or nearly normal. In such cases clinicians have utilized intravenous stimulation tests such as calcium or pentagastrin to obtain a diagnostic increase in serum CT. We have reported finding immunoreactive CT in the urine of man and have found it to be a useful technique for the diagnosis and study of patients at risk for MTC or other hypercalcitonemic diseases. Using basal urine CT alone we were able to separate 73% of patients at risk for MTC into clearly normal or abnormal groups. For the remaining 27% a stimulation test with subsequent determination of urine CT was required. The radioimmunoassay of urine CT is a simple, reliable, accurate test for the screening diagnosis of MTC. A protocol for the screening workup of a patient at risk for MTC is given.     

Bilateral cervical lymph node metastases in well-differentiated thyroid cancer

We analyzed the regional lymph node metastases of 98 patients with thyroid cancer who underwent bilateral modified neck dissection. Bilateral jugular lymph node metastases were frequent in patients with papillary carcinoma of the thyroid, especially in those patients with obvious carcinoma in both lobes of the gland, cancer arising in the isthmus, clinically detectable bilateral lymphadenopathy, and recurrent thyroid cancer. In patients whose cancer was clinically confined to one lobe, and where there were no obviously enlarged contralateral lymph nodes, the occurrence of contralateral jugular lymph node metastasis was significantly correlated with the contralateral paratracheal lymph node metastasis. The bilateral lymphadenectomy appears to be appropriate in these instances.     

Hemiaplasia of the thyroid associated with Graves' disease: Report of three cases and a review of the literature

We recently treated three additional patients with hemiaplasia of the thyroid associated with Graves' disease, making a total of eight such cases. All eight of these patients were women and their chief complaints were goiter in five cases, whereas exophthalmos or palpebral edema were noted in six cases. All eight patients underwent surgery for Graves' disease. The left lobe was absent in six cases and the right lobe in two, whereas the isthmus was absent in six cases and the pyramidal lobe in four. A total of 102 cases of hemiaplasia of the thyroid, including our present three cases, have been reported in the world literature since 1970, with 32 of them consisting of hemiaplasia associated with hyperthyroidism. Of these, the cause of hyperthyroidism was Graves' disease in 22 cases, an autonomously functioning thyroid nodule in 7, and thyrotoxic multinodular goiter in 3. The left lobe was absent in 19 cases while the right lobe was missing in 12, and laterality was unknown in 1 case.     

甲状旁腺肿瘤合并甲状旁腺功能亢进症诊治经验

目的 总结甲状旁腺肿瘤合并甲状旁腺功能亢进症的诊治体会。方法 回顾性分析我院2007年2月至2012年2月收治的4例甲状旁腺肿瘤合并甲状旁腺功能亢进症的临床特征、诊断过程、治疗情况与治疗效果。结果 以多发性骨折及颈前肿块为首发症状者各2例,入院时3例被误诊（误诊率75%,3/4）,3例并存泌尿系结石及甲状腺疾病;受检者全部存在高血钙、低血磷、高尿钙及甲状旁腺激素升高;术前B超、CT检查与术中及术后病理诊断符合率分别为75%及100%;术中见2例位于甲状腺右叶下极后下方,1例位于甲状腺左叶下极后下方,另1例位于左叶甲状腺腺体内;3例良性者（甲状旁腺腺瘤）行局部切除,1例恶性者（甲状旁腺癌）行左甲状腺全切除;术后早期均出现一过性低钙低钾低镁血症,2周内电解质、尿钙、甲状旁腺激素水平均恢复正常。结论 此病极易误诊,术前必须注重定性及定位诊断,外科手术切除是首选的治疗方法。     

Isolated cystic cervical lymphatic metastasis from occult papillary carcinoma of the thyroid: unusual and rather difficult diagnosis

Thyroid papillary carcinoma, exceptionally, can appear with cervico-lateral metastases in absence of thyroid evident disease. In that case we can have an infected branchial cyst, therefore is very important a correct preoperative diagnosis with FNAB. In literature were described 30 cases of cervico-lateral cystic masses that the histology revealed as occult papillary carcinoma metastases. Our experience is about 80 cases of papillary carcinoma, in only 2 cases the cancer was evident as a tight-elastic tumour in cervico-lateral region, hypoechogenic to the US scan with irregular and thick wall: one of the patient had multinodular goiter; the other one didn't have clinical of US scan character of thyroid disease. FNAB on lymph nodes shows doubtful cells evidence. Both patient had a total thyroidectomy with functional cervico-lateral and MAS lymphadenectomy. In one patient histology showed a papillary carcinoma of 4 mm in the right lobe, in the other patient the cancer was unknown. FNAB, in all doubtful cases, is the most important diagnosis test.     

Surgical treatment of thyroid carcinoma in a defined population: 1960 to 1977. Evaluation of the results after a conservative surgical approach

Ninety patients from a demographically well-defined area of, on an average, 243,000 inhabitants were surgically treated for thyroid carcinoma during an 18 year period. Sixty-five of the patients had papillary carcinoma, 20 follicular carcinoma, 4 medullary carcinoma, and 1 anaplastic carcinoma. Seventy-eight patients were operated on for cure, and among them, 23 had total thyroidectomy and 55 partial thyroidectomy. Additional therapy with thyroxine was given to all patients postoperatively. None of the patients treated for cure died from thyroid carcinoma at follow-up 2 to 20 years after diagnosis. One of 42 patients (2.4 percent) primarily treated for cure with lobectomy for papillary carcinoma had local recurrence in the thyroid bed which was excised successfully. No patient treated for cure of follicular carcinoma had local recurrence. All verified recurrences except one were diagnosed within 5 years of primary operation. We conclude that local recurrence after procedures less than total thyroidectomy that are considered to be curative is unusual provided that thyroxine is given postoperatively. Thus it seems that the reported high rates of microscopic carcinoma in the contralateral lobe in patients with unilateral cancer have little clinical significance. A conservative approach in most patients with localized thyroid carcinoma is indicated because it reduces the risk of postoperative complications.     

甲状腺微小癌（附71例报告）

目的 探讨甲状腺微小癌诊断和外科治疗的经验。方法 总结１９８５年１月至１９９８年８月间经手术和病理证实的甲状腺微小癌７１例,结果 仅有５例术前诊断微小工由病理证实３例出现颈淋巴结转移,１例骨转移,２６例行一侧腺叶全切除加对侧次全切除术,３例加颈淋巴结清扫术,其余行一侧腺叶全切除和一侧或两侧腺叶次全切除,随访病例中,术后复发１例（１．６％）,无一例死亡,结论 甲状腺微小癌发生率较高,提高术术,术中的     

Hepatic pulmonary fusion in an infant with a right-sided congenital diaphragmatic hernia and contralateral mediastinal shift

Hepatic pulmonary fusion is extremely rare with only 9 previous cases reported in the literature. In typical cases, the clinician should be alerted to the possibility of hepatic pulmonary fusion if the chest radiograph shows a large opacity on the right side without a contralateral mediastinal shift. The authors present a case of right-sided diaphragmatic hernia and hepatic pulmonary fusion with associated contralateral mediastinal shift discovered beyond the neonatal period. The 9 previous cases were retrospectively reviewed with special attention to mediastinal shift on preoperative chest radiograph, operative procedure, and mortality. Only one previous case demonstrated a contralateral mediastinal shift. The most common procedure performed was partial separation of the hepatic pulmonary fusion and approximation of the diaphragmatic defect. Four of the previous 9 patients died. In our case, reduction of bowel and approximation of the diaphragmatic defect around the fused liver and lung have been successful.     

Familial Nonmedullary Thyroid Carcinoma Characterized by Multifocality and a High Recurrence Rate in a Large Study Population

First-degree relatives of persons with thyroid cancer are known to be at relatively high risk for the disease. To better understand the clinicopathologic characteristics of familial nonmedullary thyroid carcinoma (FNMTC), we carried out a retrospective study in which we identified individuals treated at our institution who had at least one first-degree relative with the disease. We used data obtained from our patient records to compare the features of 258 cases of the disease with the features of sporadic papillary or follicular thyroid carcinoma in another group of patients. The 258 patients represented 154 families and were selected from among 6458 patients with papillary or follicular thyroid carcinoma who underwent thyroidectomy between 1946 and 2000. Compared to the patients with sporadic disease, the FNMTC patients were more likely to have intraglandular dissemination (28.5% vs. 40.7%; p < 0.0001) and multiple benign nodules (29.8% vs. 41.5%; p <0.0001). There were no significant differences between the two types of patients in terms of gender, age, tumor diameter, adhesion to or invasion of the surrounding tissues, macroscopic metastasis observed at surgery, histology, presence of single benign nodules, presence of chronic thyroiditis, microscopic metastasis, or rate of lymph node metastasis. Recurrence was statistically frequent in the FNMTC patients compared with that in the sporadic disease patients (16.3% vs. 9.6%; p = 0.0005), and the disease-free survival rate was significantly poorer in the FNMTC patients (p = 0.0041 by the Wilcoxon test and p <0.0001 by the log-rank test). No significant difference in the overall survival rate was found between the two groups. Multivariate analysis by Cox’s proportional hazards method showed FNMTC to be an independent predictor of shorter disease-free survival (risk ratio 1.88; confidence interval 1.35–2.54; p = 0.0003). Locoregional recurrence in the ipsilateral or contralateral lymph nodes and contralateral thyroid lobe was significantly more frequent in the FNMTC patients than in the sporadic disease patients, whereas no difference was found regarding distant metastases. We conclude that FNMTC is a clinically distinct entity with an aggressive nature. Because of the frequent presence of benign nodules, multifocality, and high rate of locoregional recurrence, total or near-total thyroidectomy with modified radical neck dissection in FNMTC patients is recommended.     

Completion thyroidectomy: a critical appraisal.

BACKGROUND. Completion thyroidectomy can most accurately be described as reexploration of the neck to remove the contralateral thyroid lobe. This procedure has commonly been performed when the histopathologic condition of the ipsilateral thyroid lobe reveals papillary or follicular carcinoma of the thyroid. Because of a definitely increased risk of complications with completion thyroidectomy, avoiding its routine use is important. The purpose of this paper is to define the specific indications for completion thyroidectomy. METHODS. Over the past 9 years, we have performed 400 thyroidectomies; the patients ranged in age from 18 to 88 years. Although we have routinely used preoperative needle biopsy and intraoperative frozen section, decisions regarding the extent of thyroidectomy have been based on the gross findings at operation, taking into consideration such prognostic factors as patient age, tumor grade and size, the presence of extracapsular spread or distant metastasis, and associated risk factors. The minimal procedure for solitary thyroid nodule has been lobectomy with isthmusectomy. If the contralateral lobe is grossly normal, lobectomy with isthmusectomy has also been the maximal operation in most of patients. Very few specific indications exist for removal of the opposite lobe. RESULTS. Only three patients underwent completion thyroidectomy. All three patients had aggressive follicular carcinoma requiring radioactive iodine ablation, and all were referred after the initial surgery. We have not performed completion thyroidectomy on any of the patients on whom we initially operated. CONCLUSIONS. The most common indication considered for completion thyroidectomy is a frozen section diagnosis of a benign follicular adenoma that is subsequently changed on permanent pathologic condition to follicular carcinoma based on the presence of capsular and/or vascular invasion. However, if minimal invasion has occurred, no difference exists in survival related to the extent of the thyroidectomy. Local recurrence in the contralateral lobe occurs in less than 10% of the time. Because completion thyroidectomy carries more risks, it should be avoided in most patients when possible. The definitive decision should be made during the initial operation based on gross findings, prognostic factors, and frozen section, and this plan should only be changed to mandate completion thyroidectomy in select circumstances.     

甲状腺手术中甲状旁腺损伤的预防和术后低钙血症的治疗

目的探讨甲状腺术中甲状旁腺损伤的预防和术后低钙血症治疗。方法选择134例接受甲状腺手术的患者作为研究对象,探讨不同手术方式术后甲状旁腺功能低下的发生情况、治疗效果及预后。结果双侧甲状腺叶全切除及中央区淋巴清扫术患者甲状旁腺功能低下症状的总发生率显著高于实施双侧腺叶次全切除术、单侧腺叶次全切除及对侧腺叶部分切除术及单侧或双侧甲状腺叶大部分切除术的患者,差异均有统计学意义(P0.05)。实施甲状腺手术后1 d,患者血清Ca2+水平均有所下降,除单侧或双侧甲状腺叶大部分切除术外,与术前相比,差异均有统计学意义(P0.05)。术后3 d血清Ca2+水平开始回升,术后5 d时,仅有一侧腺叶全切除及对侧腺叶部分切除术以及双侧甲状腺叶全切除及中央区淋巴清扫术两种术式较术前的血清Ca2+水平差异有统计学意义(P0.05)。全部患者中共有9例发生低钙血症。结论为患者实施甲状腺手术时,应避免伤及甲状旁腺及其血供,可减少低钙血症的发生。     

Unexpected findings during thyroid surgery in a regional community hospital: a 5-year experience of 738 consecutive cases

Unexpected findings during thyroid surgery in a nonuniversity setting have rarely been reported in large series. Our goal was to describe the unexpected findings during thyroid surgery in a busy regional community hospital. All thyroid operations conducted by the teaching staff at Greenville Memorial Hospital, a 735-bed nonuniversity regional hospital, from December 1998 through December 2003 were reviewed. Pre- and post-operative diagnoses, surgical procedure, and specimen histopathology were examined. Unexpected findings were defined as either thyroid pathology not anticipated based on preoperative diagnosis or as unsuspected nonthyroidal disease found during cervicotomy. During the 5-year study period, 738 patients presented with thyroid disease requiring surgery. Incidental thyroid cancer was discovered in 28 cases (3.8%), the predominance being papillary microcarcinoma. Synchronous benign thyroid disease, separate from the indication from surgery, was observed in 56 patients (7.6%). Forty patients had unexpected nodular goiter and 16 had lymphocytic thyroiditis. Primary hyperparathyroidism was observed in 33 patients (4.5%). Both solitary adenomas (22 cases) and multigland parathyroid disease (11 cases) were seen. Unexpected nonendocrine findings were less common, including solitary cases of large cell carcinoma, metastatic endometrial carcinoma, and tracheal duplication (bronchogenic cyst). In conclusion, unexpected findings during thyroid surgery at a busy community hospital are fairly common. Indeed, an unanticipated finding is encountered in one out of seven operations on the thyroid gland. Although most are of unclear clinical significance, there is a surprisingly high incidence of hyperparathyroidism. This underscores the need for preoperative screening, as the "thyroid patient" may also be the "parathyroid patient."     

Completion thyroidectomy after the unexpected diagnosis of thyroid cancer

The optimal surgical management of well-differentiated thyroid cancer (DTC) remains a controversial topic. Preoperative and peroperative investigations quite frequently fail to detect thyroid cancer in cold nodules, and only postoperative histological examination reveals malignancy. In these cases many physicians perform a completion thyroidectomy. Others recommend a conservative approach with close follow-up because of the increased risk of complications after re-operation. In our department, routine management includes completion thyroidectomy once the histopathological report concludes that there is carcinoma, except in cases of papillary carcinoma measuring less than 1 cm. The aim of our study was to determine the incidence of contralateral malignancy and of complications after completion thyroidectomy. We reviewed the records of 29 patients--25 women and 4 men-- who all underwent completion thyroidectomy because of an unexpected diagnosis of DTC. Residual malignancy was found in 12 patients (41.4%) after completion thyroidectomy. In ten patients (34.5%) the malignancy was localised in the contralateral lobe and two patients (6.9%) had lymph node metastases. Postoperative transient hypocalcaemia (< 8.0 mg/dl) occurred in five patients (17.2%) and permanent hypocalcaemia (lasting longer than 6 months) was a feature in two patients. One patient suffered transient laryngeal nerve injury occurred in one patient and there were no permanent lesions. In conclusion, we found residual DTC in 41.4% of patients undergoing reintervention. Because of the rather low re-operation rate, we prefer to perform a completion thyroidectomy to remove potential occult malignancy and to allow for postoperative 131I-treatment in all patients with a diagnosis of malignancy in their thyroid lobectomy specimen, with the exception of papillary carcinoma < 1 cm.     

Contralateral papillary thyroid cancer at completion thyroidectomy has no impact on recurrence or survival after radioiodine treatment

BACKGROUND: This study investigated the rate of contralateral papillary thyroid cancer (PTC) in low-risk PTC patients who had completion thyroidectomy, and were referred for radioactive iodine (RAI) therapy. The study sought predictors of contralateral disease and examined the impact of contralateral disease in RAI-treated patients. METHODS: We reviewed 20 years of data from a prospective registry for 150 patients with PTC. These patients had undergone thyroid lobectomy, followed by completion thyroidectomy, and had been referred for RAI. RESULTS: Of the 150 patients, 41% had PTC in the contralateral lobe. There was no difference in the rate of contralateral disease in low-risk patients (age <45 years, T1 tumors, lymph node-negative) compared with the remainder. There were no significant differences between patients with or without contralateral disease with respect to primary tumor size, mean age, time to completion thyroidectomy, or metastatic lymph node disease. Logistic regression analyses showed no histologic parameters that correlated with contralateral disease. There were no recurrence or survival differences in patients with or without contralateral disease after resection and RAI. CONCLUSIONS: The prevalence of tumor in the contralateral lobe of low-risk patients with PTC is significant and warrants consideration for completion thyroidectomy and radioiodine treatment. Our results, however, suggest that contralateral disease does not have an impact on recurrence or survival after treatment.     

Necessity and safety of completion thyroidectomy for differentiated thyroid carcinoma.

BACKGROUND. The diagnosis of thyroid carcinoma during the course of lobectomy for a dominant nodule occasionally cannot be rendered on the basis of frozen section. Once the diagnosis of carcinoma is made, the question of completion thyroidectomy arises. The decision to perform completion thyroidectomy and the timing, safety, and efficacy of this procedure are reviewed. METHODS. During the past 25 years (1965 to 1990), we operated on 351 consecutive patients with thyroid carcinoma. One hundred of these patients (84 women and 16 men) were initially treated by unilateral thyroid lobectomy for the previously stated reasons. Histopathologic examination of the permanent sections of the initial thyroid lobectomy specimen demonstrated papillary carcinoma in 70 patients and follicular carcinoma in 30 patients. Within a few months, a completion thyroidectomy was performed. RESULTS. The completion thyroidectomy specimen contained papillary carcinoma in 33 (47%) of the 70 patients with papillary carcinoma and 10 (33%) of the 30 patients with follicular carcinoma. Overall, 43 of these 100 patients harbored thyroid carcinoma in the contralateral lobe. Complications of completion thyroidectomy were transient recurrent nerve paresis in two patients and temporary hypoparathyroidism in three patients, requiring calcium and vitamin D therapy for a few months. CONCLUSIONS. Although the significance and treatment of papillary carcinoma are debated on the basis of size and grade of the primary lesion and age and sex of the patients, once the diagnosis is made in one lobe we believe that a completion thyroidectomy should be considered, not only for papillary carcinomas but also for follicular carcinomas because 47% (papillary) to 33% (follicular) of these patients will harbor the neoplasm in the contralateral lobe.     

Primary neurilemmoma of the thyroid gland in a 12-year-old girl

A case of a neurilemmoma of the thyroid gland in a 12-year-old girl is reported. The tumor was noted as a asymptomatic left lower neck swelling 9 months before admission. Ultrasound scan showed the solid lesion of predominantly hypoechoic structure measuring 17.2 × 12 × 26 mm within the left lobe. Pathologic examination of the excised lobe was consistent with neurilemmoma with both Antoni A and Antoni B histologic patterns. To date only 14 cases of this nonepithelial tumor of the thyroid gland have been described in the literature, and all occurred in adult patients. This is the first report of thyroid neurilemmoma in a child.