Management of lateral cervical metastases in papillary thyroid cancer: patterns of lymph node distribution

In this article we discuss the management of lateral cervical lymph node metastases in papillary thyroid cancer (PTC). We conducted a retrospective analysis of cases of PTC at our tertiary academic medical center involving 32 patients who underwent 39 neck dissections for the management of lateral cervical metastases from 2000 to 2007. Of these patients, 18 underwent primary neck dissections at the time of thyroidectomy after fine-needle aspiration biopsy confirmed the PTC. Secondary neck dissections for delayed metastases were performed in 14 patients who had previously undergone thyroidectomy for confirmed PTC. All 32 patients had positive nodes in at least one level. Our results highlight the high incidence of multilevel cervical metastasis associated with PTC and suggest the importance of including level II-B (submuscular recess) when performing a neck dissection; the upper posterior triangle (level V-A) is less likely to harbor occult tumor. Lateral neck metastasis from PTC is common and predictable; locoregional control is improved with a formal, comprehensive neck dissection at the time of thyroidectomy.     

Lymphatic metastases to level IIb in hypopharyngeal squamous cell carcinoma

OBJECTIVES: To evaluate the prevalence of level IIb lymph node (LN) metastasis and to identify potential clinical risk factors when level IIb metastatic diseases are present in patients with clinically node-negative (N0) and node-positive (N+) necks with hypopharyngeal squamous cell carcinoma (HPSCC). This will provide a basis for determining whether this region can be excluded in elective or therapeutic neck dissection in patients with HPSCC. DESIGN: Prospective analysis of a case series. SETTING: University hospital. PATIENTS: Fifty patients with HPSCC who underwent surgical treatment for a primary lesion and simultaneous neck dissection from January 1998 to February 2004. MAIN OUTCOME MEASURES: The incidences and clinical risk factors for level IIb LN metastasis and regional recurrence according to the presence or absence of pathologic LN involvement in level IIb. RESULTS: A total of 93 neck dissections were analyzed in this study. Of these dissections, 59 (63%) were elective and 34 (37%) were therapeutic. Three percent (2 of 59) of all N0 necks and 32% (11 of 34) of all N+ necks had level IIb LN metastases. Level IIb nodal metastases were significantly more prevalent in N+ necks (P=.007) than in N0 necks and in the presence of other positive LNs (P=.01) than in the absence of other positive LNs. Of the 35 patients with pathologic LNs, the regional recurrence rate was significantly higher in cases with positive level IIb LNs (33% [4 of 12]) than without (4% [1 of 23]; P=.04). CONCLUSIONS: Level IIb LN pads may be preserved during elective neck dissection in the treatment of patients with clinically N0 necks with HPSCC. This area should be removed during therapeutic neck dissection in the treatment of clinically N+ necks.     

甲状腺乳头状癌颈部淋巴结转移规律及影响因素分析

目的：探讨甲状腺乳头状癌颈部淋巴结转移规律及其相关影响因素,为甲状腺乳头状癌颈部淋巴结清扫术提供一定的临床依据。方法：回顾性分析314例甲状腺乳头状癌患者的临床资料。314例患者中,行甲状腺腺叶峡部切除、中央区淋巴结清扫术79例,甲状腺全切、中央区淋巴结清扫术173例,甲状腺全切、中央区淋巴结清扫术、侧颈部改良根治性颈部淋巴结清扫术62例。手术中清扫出淋巴结1～55个,其中阳性淋巴结0～14个。结果：314例患者中经病理证实共有168例（53．50％）患者有淋巴结转移,其中中央区淋巴结转移159例（50．64％）,中央区＋侧颈转移淋巴结55例（17．52％）,单纯侧颈淋巴结转移9例（2．87％）。患者年龄、肿瘤直径、甲状腺被膜受侵犯、临床分期是甲状腺乳头状癌颈部淋巴结转移的影响因素（P〈0．05）。结论：甲状腺乳头状癌患者最常发生中央区淋巴结转移,应常规进行中央区淋巴结清扫术。     

Level IIb lymph node metastasis in neck dissection for papillary thyroid carcinoma

OBJECTIVE: To determine the patterns of lateral cervical metastasis and the incidence of level IIb lymph node metastasis in papillary thyroid carcinoma. DESIGN: Retrospective medical record review. SETTING: Academic medicine. PATIENTS: From March 1, 2000, to April 30, 2006, 46 consecutive patients (38 women and 8 men) with papillary thyroid carcinoma. INTERVENTIONS: Patients underwent 55 modified radical neck dissections for the management of lateral cervical metastasis. MAIN OUTCOME MEASURES: All patients had preoperative evidence of a metastatic cervical lymph node. All specimens were labeled and mapped by the operating surgeon to identify their levels. RESULTS: Among 55 specimens, 82% (45 specimens) exhibited nodal disease at multiple levels. The incidences of metastases at level II, III, IV, and V nodes were 60% (33 specimens), 82% (45 specimens), 75% (41 specimens), and 20% (11 specimens), respectively. Skip metastases were present at a low rate (6% [3 specimens]). Among 12 specimens (22%) with metastatic lymph nodes at level IIb, 92% (11 specimens) had disease at level IIa. The rate of level IIb lymph node involvement in patients with metastatic lymph nodes at level IIa was 34% (11 of 32). CONCLUSIONS: Tumor involvement at multiple nodal levels usually occurs when patients have lateral cervical lymph node metastasis. Neck dissection should include the level IIb lymph node whenever level IIa lymph node metastasis is found. Level IIb dissection is probably unnecessary when level IIa lymph nodes are uninvolved because the incidence of metastasis to level IIb is low if level IIa is not involved.     

Papillary Thyroid Cancer: Controversies in the Management of Neck Metastasis

Objective/Hypothesis: To describe our institution's experience with the management of cervical metastasis in papillary thyroid carcinoma (PTC) and suggest a treatment strategy based on the incidence of pathologic nodes and cervical recurrence in patients undergoing varied surgical approaches to address lymphadenopathy over the study dates. Materials and Methods: Between December 1, 1972 and September 1, 2007, 183 total patients diagnosed with PTC at the University of Pittsburgh Medical Center were treated with lymphadenectomy. Pathologic parameters, including number of pathologic nodes and extent of lymphadenectomy were correlated to disease recurrence. Study Design: Retrospective chart review. Results: The incidence of pathologic nodes in lymphadenectomy specimens (57.9%) and the recurrence rate (33.7%) were high, in our study population. In comparing techniques with address lymphadenopathy, the highest recurrence rate was observed in patients with pathologic nodes treated with “lymph node plucking” procedures at the time of thyroidectomy and those patients with multiple nodes involved. Few patients with no pathologic nodes, regardless of lymphadenectomy extent recurred. Conclusions: Our data show that limited neck dissection and disease burden are associated with the highest rates of cervical recurrence in regional metastatic PTC. Comprehensive functional neck dissection would seem to offer the patient the best opportunity for control of cervical metastasis. The American Thyroid Association recommends thyroglobulin monitoring and ultrasound evaluation of the neck in all postoperative patients. Therefore patients with the diagnosis of papillary thyroid cancer need preoperative ultrasound of the lateral neck and fine needle aspiration of suspicious nodes to avoid undertreating patients scheduled for total thyroidectomy. Neck dissection of the compartments in which pathologic nodes were detected (central, lateral, or both) should then be undertaken at the time of initial thyroidectomy. Eliminating all disease remains elusive and the prognosticsignificance of cervical disease persistence and recurrence is still unknown. Patients with cervical metastasis are at substantial risk of regional recurrence, necessitating repeat surgery. Parathyroid implantation should be considered at the time of the initial surgery to reduce the risk of hypoparathyroidism should subsequent procedures be required. More information will be necessary to better understand the prognostic significance of these regional metastases. In the interim, many patients may be overtreated, whereas some remain at risk of death because of disease.     

Clinical study on papillary thyroid carcinoma presenting with lymph node metastasi

Papillary thyroid carcinoma (PTC) may metastasize to cervical lymph nodes. It is, however, uncommon for a palpable neck node alone to lead to the diagnosis of this disease when it is not apparent at presentation. Standard treatment for such cases has not yet been established. We retrospectively analyzed clinical courses in 8 patients with thyroid papillary carcinoma presenting with palpable lymph node metastasis at Hokkaido University Hospital between 1990 and 2003. Three had high thyrogloblin in cervical cystic lesions, leading to the diagnosis of PTC with lymph node metastasis. In 4, PTC was diagnosed by pathological examination of cervical lymph nodes initially diagnosed as lateral cervical cysts. Preoperative examination did not indicate PTC within the gland in any case. All 8 were alive at the last visit after follow-up from 23 to 150 months (mean: 78 months). Total thyroidectomy was done on 4 and thyroid lobectomy on 3. Pathological examination of resected thyroid glands confirmed multifocal papillary carcinoma from 4 mm to 15 mm in diameter. Six underwent unilateral neck dissection and 1 chose bilateral dissection. The other patient received no additional surgery on either the thyroid or neck after the single enlarged lymph node initially diagnosed as a lateral cervical cyst was resected. Postoperative radioiodine treatment was done in 2 undergoing total thyroidectomy. Recurrence in the cervical area were observed in 1 whose neck dissection was insufficient. Based on these observations, we concluded that patients who undergo thyroid lobectomy and adequate neck dissection may enjoy longer survival than those treated with total thyroidectomy without sacrificing thyroid and parathyroid function. We therefore propose a prospective study on the effectiveness of thyroid lobectomy with neck dissection including positive nodes in patients with occult PTC presenting with lymph node metastasis.     

Clinical impact of cervical lymph node involvement and central neck dissection in patients with papillary thyroid carcinoma: a retrospective analysis of 368 cases

The impact of cervical lymph node metastases and the optimal surgical management of the neck in patients with papillary thyroid carcinoma (PTC) remain controversial. The objectives of this retrospective study were to determine, in patients with PTC, the predictive factors and the impact on tumor recurrence rate of cervical lymph node involvement, and to evaluate the oncologic results and the morbidity of central neck dissection (CND). We reviewed the records of patients who had undergone surgical treatment for PTC at our institution between 1990 and 2000. A total of 368 patients (86 men and 282 women) were included in this study. Young age (p?=?0.02), tumor size (p?=?0.001) and extrathyroidal tumor extension (p?=?0.003) were significant predictive factors of cervical lymph node metastatic involvement (multivariate analysis). Initial metastatic cervical lymph node involvement was identified as an independent risk factor of tumor recurrence (multivariate analysis, p?=?0.01). Metastatic lymph node(s) were found in prophylactic CND specimens in 31% of the patients. CND increased the risk of postoperative hypocalcemia (p?=?0.008) and of permanent hypoparathyroidism (p?=?0.002). In conclusion, cervical lymph node metastatic involvement at the time of initial surgery is an independent risk factor of tumor recurrence. CND provided an up-staging of more than 30% of patients with a clinically N0 neck, but was associated with significant morbidity regarding parathyroid function.     

Level IIb lymph node metastasis in thyroid papillary carcinoma

The objective of the study was to evaluate the incidence of level IIb lymph node metastases in neck dissections for thyroid papillary carcinoma (TPC) patients. 47 neck dissections of 33 patients with TPC were prospectively evaluated. Selective neck dissections (levels II, III, IV, and V) were performed in all cases. If level I lymph node metastasis was suspected during the procedure, level I dissection was also performed. All level IIb specimens were sent separately from the remainder of the neck dissection for the pathological examination. The number of dissected and metastatic lymph nodes in each specimen was recorded. Twenty-two of 47 neck dissections (46.8%) were positive for the lymph node metastasis. Among 47 neck dissection specimens, the incidence of lymph node metastasis at level II was 12.7% (6 of 47) and level IIb was 2.1% (1 of 47). The rate of level IIb lymph node involvement among patients with metastatic cervical lymph nodes was 4.5% (1 of 22). The specimen with metastatic lymph node at level IIb had also metastasis at levels IIa, III, IV, and V. The results of the present study suggested that lymph node metastases in level IIb are rare in patients with TPC undergoing neck dissection.     

Predictive factors for central compartment lymph node metastasis in thyroid papillary microcarcinoma

OBJECTIVE: We examined the incidence of nodal involvement and attempted to determine the predictive factors for central compartment lymph node (LN) metastasis in thyroid papillary microcarcinoma (PMC). STUDY DESIGN: Retrospective chart review. METHODS: We undertook a retrospective study of 52 patients treated between January 2000 and December 2005 for PMC by total thyroidectomy and elective central compartment LN dissection with or without comprehensive lateral neck dissection (n = 9). There were 45 women and 7 men whose mean age was 47.6 +/- 11.5 years. The following criteria were used to study the predictive value of central compartment LN metastasis: sex, age, multifocality of the tumor, extracapsular spread (ECS), the involvement of the lateral neck LN, tumor size, and tumor location. RESULTS: In 16 of 52 (31%) patients, central compartment LN metastasis was found. With use of univariate and multivariate analysis, ECS, lateral LN metastasis, and tumor size (>5 mm) were independent correlates of central compartment metastasis. Sex, age, multifocality, and tumor location were not associated with central compartment LN metastasis and did not significantly influence the predictive value of these variables. CONCLUSIONS: We found a significant association among ECS, lateral LN metastasis, tumor size (>5 mm), and central compartment LN metastasis in patients with PMC. A prophylactic neck dissection of the central compartment should be considered particularly in patients with ECS of the tumors, metastatic LN in the lateral neck, and a greater than 5 mm tumor size.     

Diagnosis of lateral cervical lymph node metastasis of papillary carcinoma of the thyroid by ultrasonography

No consensus for papillary carcinoma of the thyroid exists on the preoperative diagnosis of lateral cervical lymph node metastasis, indications, or range of neck dissection, so we studied the usefulness and limits of ultrasonography and sufficient dissection by comparing preoperative ultrasonographic and postoperative histopathological diagnosis. Subjects were 45 patients (51 affected sides) with lateral cervical lymph node metastasis of papillary carcinoma of the thyroid who underwent modified neck dissection between July 1997 and July 2003. Preoperative ultrasonographic and postoperative histopathological diagnosis were compared. Specimens excised by neck dissection contained 1,325 lymph nodes. Of these, 198 (15%) detected by preoperative ultrasonography were selected for investigation of diagnostic criteria for metastasis-positive lymph nodes. The best criterion for the diagnosis of metastasis-positive lymph node was 0.5 or greater [minor axis/major axis] with 6 mm or greater minor axis at levels III, IV, or V (7 mm or greater at level II), and sensitivity, specificity, and accuracy were 78%, 100%, and 84% respectively. The lateral cervical lymph node metastasis rate obtained by this diagnostic criterion was 41%. Regional histopathological metastasis positivity was investigated in the lateral cervical region, and high positivity rates were obtained: 57% at level II, 71% at level III, and 84% at level IV. Considering these findings and the preoperative ultrasonographic diagnosis rate of 41%, sufficient dissection at levels II-IV may be necessary for patients in whom lateral cervical metastasis is observed before surgery. The metastasis rate was 10% at level V, but dissection should always be done in lateral cervical metastasis-positive patients because: 1) No trend was observed in age, gender, the number of metastatic lymph nodes, or regional metastasis rate; 2) no anatomical boundary is present between levels II, III, IV and level V; 3) no functional disorder due to preservation of the accessory nerve occurred; 4) the prognosis of patients with advancement to the accessory nerve was poor; and 5) improvement of the prognosis of papillary carcinoma of the thyroid by modified radical neck dissection has been reported.     

Computed tomography and ultrasonographic evaluation of metastatic cervical lymph nodes with surgicoclinicopathologic correlation

The detection of cervical lymph nodal metastasis and carotid artery invasion by metastatic lymph nodes is an important issue in the management of head and neck malignancies. This study compared the evaluation of metastasis by palpation, ultrasonography (USG) and computed tomography (CT) in patients with known head and neck malignancies. Twenty-five consecutive patients with head and neck malignancy were prospectively evaluated for the presence of cervical lymphadenopathy and carotid artery invasion. All patients underwent clinical examination (palpation), USG and CT examination. A modified CT criteria was employed which yielded acceptable results for the detection of metastatic nodes. Radical neck dissection was performed for 26 neck sides, and the results of pre-operative evaluation were confirmed by the surgical and histopathological findings. Palpation, ultrasound and CT have comparable sensitivity in the determination of metastasis involving cervical lymph nodes. Thus palpation should be employed as the primary method of assessment of secondaries in the neck. However, palpation is less sensitive than CT and USG in the detection of carotid artery involvement, hence the clinical suspicion of arterial invasion should be confirmed by either CT or USG which have similar accuracy in the detection of carotid artery invasion.     

Indications for and extent of elective neck dissection for lymph node metastasis from external auditory canal carcinoma

ObjectivesWe aim to clarify the frequency of lymph node metastasis of external auditory canal (EAC) carcinoma, including susceptible locations, adequate extent of elective neck dissection, and the relationship between the tumor infiltration site and lymph node metastasis.Patients and MethodsFrom 2003 to 2018, 63 patients with EAC carcinoma at Tokyo Medical and Dental University Hospital were enrolled in this study. The T and N stages, locations of clinically positive lymph nodes, prognoses, and anatomic site of tumor infiltration were analyzed after treatment.ResultsClinically positive lymph node metastasis (cN+) was detected in 18 patients (28.6%), consisting of T1, T2, T3, and T4 disease in 1 (6%), 2 (22%), 8 (38%), and 7 (41%) patients, respectively. The metastatic locations were at level II in 10 patients, parotid gland nodes in 7, preauricular nodes in 5, level Ib in 3, level Va in 3, level III in 1, and superficial cervical nodes in 1. Neck recurrence was determined in two of 45 patients with clinically negative lymph nodes (cN0), with the metastatic locations being levels II, Ib, and III. Among 18 cN+ cases, neck recurrence was noted in 2 of 9 patients who underwent neck dissection. Neck lesions were found to be manageable in all five patients who underwent docetaxel, cisplatin, 5-fluorouracil, and radiation therapy (TPF-RT). No relationship was noted between the tumor infiltration site and lymph node metastasis among T3/4 canrcinoma patients.ConclusionsElective neck dissection could be indicated only in T3/4 patients with free flap reconstruction. Levels Ib to III are considered appropriate for elective neck dissection in cN0 cases. Levels Ib to III and Va indicated favorable sites, even in cases with metastasis in the parotid gland or preauricular area. Furthermore, TPF-RT could be a useful option even in cN+ cases.     

Ⅵ区淋巴结在甲状腺乳头状癌颈淋巴转移中的意义

目的 进一步认识Ⅵ区淋巴结在甲状腺乳头状癌(papillary thyroid carcinoma,PTC)颈转移中的地位及PTC患者颈部转移淋巴结的分布特点,为PTC的颈部淋巴结处理提供依据.方法 回顾性总结2002年1月至2004年12月97例病变局限于一侧腺叶的PTC患者的临床资料:72例术前检查为cNO,25例为cN+;32例原发灶长径≤1 cm,65例原发灶长径＞1 cm.术中常规取Ⅲ、Ⅳ区淋巴结做冰冻病理检查,根据淋巴结病理结果、肿瘤原发灶大小及位置决定颈部淋巴结的清扫范围.Ⅲ、Ⅳ区淋巴转移患者行包括Ⅵ区的改良性颈清扫;伴有肿瘤包膜外侵患者行双侧Ⅵ区清扫;原发灶长径≤1 cm行患侧Ⅵ区清扫;原发灶长径＞1 cm行双侧Ⅵ区清扫.结果 97例患者行Ⅵ区清扫122侧,45.1%(55/122)发生淋巴转移.72例cN0患者45.8%(33/72)发生Ⅵ区淋巴转移,25例cN+患者76.0%(19/25)发生Ⅵ区淋巴转移,差异有统计学意义(x2=6.790,P=0.009).10例原发灶包膜外侵患者的淋巴转移发生率为65.0%(13/20),87例无包膜外侵患者的淋巴转移发生率为41.2%(42/102),差异有统计学意义(x2=3.833,P=0.047).32例原发灶长径≤1 cm的患者行患侧Ⅵ区清扫,43.8%(14/32)发生淋巴转移,65例原发灶长径＞1 cm患者行双侧Ⅵ区清扫,69.2%(45/65)有患侧Ⅵ区转移,23.1%(15/65)有双侧Ⅵ区转移,两组间同侧Ⅵ区转移率的差异有统计学意义(x2=5.843,P=0.016).结论 Ⅵ区为FTC较早发生淋巴转移的区域,伴有原发灶包膜外侵犯者易发生Ⅵ区淋巴转移.原发灶长径≤1 cm的患者可发生同侧Ⅵ区转移;原发灶长径＞1 cm者可发生双侧Ⅵ区转移.PTC颈淋巴转移可单独或同时发生在Ⅵ区或侧颈区的任何一个区域.术中应常规做Ⅲ、Ⅳ区淋巴结冰冻病理检查,淋巴结阳性者行包括Ⅵ区的改良性颈清扫.     

The effect of midline crossing of lateral supraglottic cancer on contralateral cervical lymph node metastasis

Conclusion: The degree of midline crossing of lateral supraglottic cancer does not significantly change its rate of contralateral cervical metastasis. The rate of occult metastasis is too high to take the risk of contralateral regional recurrence. We support routine bilateral neck dissection even in lateral supraglottic cancers with no or minimal midline crossing. Objectives: Data on the rate of contralateral cervical metastasis of laterally located supraglottic cancer, the effect of its degree of midline crossing on contralateral cervical metastasis, and its treatment are still controversial. Methods: This was a retrospective cohort, chart review involving 305 surgically treated patients with T1–3 squamous cell carcinoma of the supraglottic larynx. In all, 184 patients had bilateral neck dissection; 86 N0 contralateral necks were followed up. Thirty-five patients who needed postoperative radiation therapy because of the primary tumor or ipsilateral neck dissection specimen also received radiation therapy to the contralateral neck. The degree of midline crossing at the epiglottis was measured on a laryngectomy specimen with a ruler and expressed as ‘no,’ ‘<5 mm’ or ‘≥5 mm.’ Results: The rates of occult and overall contralateral metastasis in our series were 16% and 28%, respectively. There was no statistically significant difference between contralateral neck metastasis and recurrence rates in the neck dissection, follow-up, and irradiation groups according to the degree of midline crossing.     

Preliminary results of pre-radiation neck dissection in head and neck cancer patients undergoing organ preservation treatment

CONCLUSION: Pre-RT ND in patients with HNSCC undergoing organ preservation treatment is safe, advantageous, poses no additional morbidity owing to the elective neck dissection, and may possibly improve survival outcomes. OBJECTIVE: Establish the role of pre-radiation neck dissection (pre-RT ND) in patients with head & neck squamous cell carcinoma (HNSCC) undergoing organ preservation treatment. MATERIALS AND METHODS: Fourteen patients with histologically confirmed HNSCC in stages III approximately IV with proven regional metastasis were enrolled in the organ preservation approach incorporating pre-RT ND at a tertiary referral center between May 1998 and August 2004. Site matched patients treated with organ preservation intent in the conventional fashion were used as controls. Data were collected for their diagnosis, management, treatment outcome, and follow up. RESULTS: Disease free survival was significantly better for the pre-RT ND group. There was no significant difference in overall survival, pattern of recurrence, and primary organ preservation rate between the two groups. No significant morbidity owing to neck dissection was noted in patients who underwent neck dissection. Although the delivery of radiation to the primary site was delayed for patients in the pre-RT ND group, it did not influence the major outcomes.     

Level IIb lymph node metastasis in laryngeal squamous cell carcinoma

OBJECTIVES: Selective neck dissection, despite preservation of the spinal accessory nerve, can lead to some degree of postoperative shoulder dysfunction as a result of removal of level IIb lymph nodes. The aim of this study was to determine whether level IIb lymph nodes can be preserved in elective or therapeutic neck dissection as a treatment for patients with laryngeal squamous cell carcinoma (SCC). STUDY DESIGN: This was a prospective analysis of a case series. METHODS: A prospective analysis of 65 patients with laryngeal SCC who underwent surgical treatment of the primary lesion with simultaneous neck dissection from January 1999 to December 2002 was performed. During the neck dissection, the contents of the level IIb lymph nodes were dissected, labeled, and processed separately from the remainder of level II nodes and the main neck dissection specimen. The incidence of pathologic metastasis to level IIb lymph nodes and the regional recurrence within this area were evaluated. In addition, several potential risk factors for metastatic disease in the level IIb lymph nodes such as sex, age, cT stage, cN stage, and the presence of other positive lymph nodes were also evaluated. RESULTS: A total of 125 neck dissections were performed in this series. Of these dissections, 102 (82%) were elective and 23 (18%) were therapeutic. The prevalence of metastases in the level IIb lymph nodes was 1% (one of 46) and 0% (zero of 56) in clinically node-negative (N0) ipsilateral and contralateral necks, respectively, and 37% (seven of 19) and 0% (zero of four) in clinically node-positive ipsilateral and contralateral necks, respectively. There was a statistically significant association between level IIb metastases and clinically positive N stage (P<.001). The presence of other positive lymph nodes was also shown to have a statistically significant association with metastasis in the level IIb lymph nodes (P=.001). Only two of 46 patients (4%) with clinically N0 necks developed a regional recurrence. However, three of eight cases (38%) with positive pathologic level IIb lymph nodes developed regional recurrence. CONCLUSION: Level IIb lymph node pads may be preserved in elective neck dissection in patients with laryngeal SCC. However, this area should be removed thoroughly during therapeutic neck dissection in the treatment of clinically node-positive necks.     

甲状腺乳头状癌Ⅱ区淋巴结隐匿性转移的临床分析

目的 分析甲状腺乳头状癌Ⅱ区淋巴结隐匿性转移的相关因素。方法 回顾分析天津医科大学附属肿瘤医院头颈外科2003年1月至2009年12月收治的213例术前Ⅱ区淋巴结临床阴性,颈侧其他区阳性的初治甲状腺乳头状癌患者的临床资料。淋巴清扫标本经病理证实颈侧区（Ⅱ～Ⅴ）有淋巴转移。单因素和多因素分析分别采用卡方检验和二分类Logistic回归分析。结果 颈部Ⅵ区淋巴结转移率79.3％( 169/213),Ⅲ、Ⅳ、Ⅴ区淋巴结转移率分别为83.6％( 178/213)、75.1％ (160/213)、13.1％ (28/213),Ⅱ区隐匿性淋巴结转移率为16.0％(34/213)。单因素分析显示：术前颈侧区Ⅲ、Ⅳ区淋巴结同时阳性或者术前Ⅲ区淋巴结阳性,与Ⅱ区淋巴结隐匿性转移密切相关（x2值分别为11.120和5.614,P值均＜0.05）;多因素分析显示术前颈侧区Ⅲ、Ⅳ区淋巴结同时阳性是隐匿性Ⅱ区淋巴转移的独立危险因素(P=0.033,OR =3.846)。结论 甲状腺乳头状癌患者术前未发现Ⅱ区和Ⅲ区淋巴结阳性时,可以考虑暂时不进行预防性Ⅱ区颈淋巴清扫术。     

Incidence and clinical characteristics of prelaryngeal lymph node metastasis in papillary thyroid cancer

There is little data that determine the clinical characteristics of prelaryngeal lymph nodes (PLN) metastasis in patients with papillary thyroid cancer (PTC). The aims of this prospective study were to evaluate the incidence and the clinical characteristics of metastasis to the PLN for PTC patients who underwent total thyroidectomy and prophylactic central neck dissection. Sixty-seven patients who underwent total thyroidectomy and prophylactic bilateral central lymph node neck dissection for PTC were enrolled. Central neck compartment was further divided into prelaryngeal, ipsilateral/contralateral paratracheal, and pretracheal regions. Clinicopathologic factors including age, sex, tumor size and location, extrathyroidal extension, and central and lateral nodal metastasis were evaluated. Of the 67 patients who underwent PLN dissection, 13 (19.4 %) had evidence of PLN metastasis. Tumor size was significantly larger in patients with PLN involvement (2.28 versus 1.12 cm; p = 0.020). Additionally, primary tumors larger than 1 cm, extrathyroidal extension, and isthmus involvement were more prevalent in PLN-positive patients. Patients with positive PLNs were also more frequently found to have lateral lymph node metastasis (23.1 vs. 1.9 %; p = 0.021), pretracheal lymph node metastasis (76.9 vs. 27.8 %; p = 0.003), and bilateral central lymph node metastasis (38.5 vs. 11.1 %; p = 0.031) than PTC patients without PLN involvement. The incidence of PLN metastasis in PTC patients who underwent prophylactic central lymph node neck dissection was 19.4 %. PLN metastasis was associated with tumor size, extrathyroidal extension, isthmus involvement, and other compartment lymph node metastasis.     

成人侧颈区孤立囊性肿块的诊断

目的 收集初诊为成人侧颈区良性囊肿患者的临床病理学资料,探讨良恶性的鉴别要点,提高术前诊断准确性。方法 回顾性分析2014年1月—2021年12月北京友谊医院耳鼻咽喉头颈外科诊治的成年患者,初步诊断为鳃裂囊肿或囊性水瘤。总结分析患者的临床、影像学以及病理学资料。结果 共37例初诊为颈部良性囊肿的患者中,最终总恶性率为13.5%(5/37),其中口咽鳞状细胞癌颈淋巴结转移2例,甲状腺乳头状癌颈淋巴结转移3例。颈部肿块存在分隔或囊壁局限性增厚是成人侧颈区孤立囊性肿块最终诊断为颈部淋巴结转移癌的独立危险预测因素(P<0.05)。结论 成人孤立侧颈区囊性肿块需要警惕为颈部不明原发灶转移癌。对于成人侧颈区孤立囊性肿块,尤其当颈部肿块存在分隔或囊壁局限性增厚时,需要结合多种诊断方法,排除颈部不明原发灶转移癌。     

Safety of modified radical neck dissection for differentiated thyroid carcinoma

OBJECTIVES/HYPOTHESIS: The management of cervical metastases from differentiated thyroid carcinoma (DTC) remains controversial. Most surgeons perform a neck dissection (ND) for clinically apparent disease. The extent of nodal dissection varies from regional to comprehensive. Morbidity from ND in the setting of DTC remains high, particularly when performed in the setting of a thyroidectomy (TT). To determine complications from ND for DTC, we retrospectively reviewed our surgical experience of modified radical neck dissection for nodal metastases. STUDY DESIGN: Retrospective chart review. METHODS: Between 1997 and 2002, 39 consecutive patients (31 females and 8 males) underwent 44 comprehensive NDs of levels II-V for DTC. Central compartment dissection (CCD) (levels VI and VII) was also performed during 23 of these procedures. Twenty (45.5%) patients had prior treatment elsewhere. Preoperative pathology revealed papillary carcinoma in 22 patients (56.4%), tall cell variant in 11 (28.2%), and follicular variant in 6 (15.4%). RESULTS: Ten patients (20%) underwent ND alone, whereas 6 (14%) underwent simultaneous ND and TT. Fifteen patients underwent simultaneous ND, TT, and CCD (30%). Temporary hypocalcemia occurred after 21% of NDs that were performed in the setting of either TT or CCD or both. There were no cases of permanent hypoparathyroidism. Transient regional lymph node (RLN) paresis occurred in two patients and was associated with a concomitant central compartment nodal dissection; there were no permanent RLN palsies. Transient spinal accessory nerve paresis developed after 27% of NDs performed. Two patients developed chyle leaks. CONCLUSIONS: When ND is necessary for the treatment of thyroid malignancies, the procedure can be performed safely with acceptable morbidity.