Lateral Cervical Lymph Node Metastases from Papillary Thyroid Carcinoma: Pattern of Nodal Metastases and Optimal Strategy for Neck Dissection

Background The pattern of lateral cervical metastases from papillary thyroid carcinoma (PTC) has been reported without a clear understanding of the distribution of central nodes at risk. The present study evaluated the pattern of central and lateral cervical metastases from PTC with respect to recently defined neck sublevels and subsites. Methods Between 2003 and 2006, 52 consecutive patients with lateral cervical metastases from previously untreated PTC underwent total thyroidectomy and therapeutic comprehensive neck dissection of the central and lateral compartments, including five bilateral neck dissections. Neck dissection specimens were separately obtained for analyzing lymph node involvement with respect to neck sublevels and subsites. Results For the lateral compartment, 75.9% of cases showed metastatic disease at level IV, 72.2% at IIa and III, 16.7% at IIb, 13.0% at Vai, 3.7% at Ib and Vb, and 0% at Vas. For the central compartment, 84.6% of cases showed metastatic disease at the ipsilateral paratracheal nodal site, 46.2% at the superior mediastinal, 30.8% at the pretracheal, and 8.9% at the contralateral paratracheal site. Forty-six of 57 lateral neck dissection samples (80.7%) showed multilevel disease, and skip lateral metastasis was found in five patients (9.6%). Level I and V involvements were always associated with multilevel disease. Conclusions Lateral cervical metastasis from PTC is commonly associated with multilevel disease and central nodal involvement. Neck dissection including ipsilateral central and lateral compartments may be the optimal treatment for these patients.     

Dissection of the submuscular recess (sublevel IIb) in squamous cell cancer of the upper aerodigestive tract: prospective study and systematic review of the literature

BACKGROUND: Selective neck dissection is commonly used to clear occult neck metastases in the N0 neck. The aim of this study was to identify the incidence of occult metastases in lymph nodes of sublevel IIb (submuscular recess; SMR) in upper aerodigestive tract squamous cell carcinoma in the setting of clinically and radiologically staged N0 necks and to perform a systematic review of the literature on the incidence of metastases in this setting. METHODS: We conducted a prospective study of 50 neck dissections and systematic review of the literature. RESULTS: (A) Prospective study: Tissue dissected out from the SMR was sent separately for histopathologic analysis. Between 0 and 7 nodes were harvested from sublevel IIb. One patient had a metastatic node in sublevel IIb with extracapsular spread in the ipsilateral neck. No other positive nodes were detected. Sixteen necks showed occult metastases at other levels. (B) Systematic review: The review identified 14 articles with 903 necks suitable for inclusion. The overall incidence of metastatic disease at this sublevel in the context of an N0 neck from any site is 2.0% (18 of 903). The incidence of occult metastatic disease in sublevel IIb for oral cavity, oropharyngeal, and laryngeal cancer is 3.9% (11 of 279), 5.2% (5 of 96), and 0.4% (1 of 230) patients, respectively. Contralateral positive nodes (0.9%) and isolated metastases (0.3%) at this sublevel were rare. CONCLUSION: Nodal metastases are uncommon in the SMR even in the presence of positive nodes in adjacent sublevel IIa. There appears to be no advantage in performing contralateral SMR dissection in N0 necks and in laryngeal primaries.     

Predictive Factors of Level IIb Lymph Node Metastasis in Patients with Papillary Thyroid Carcinoma

Background  The extent of neck dissection (ND) appropriate for necks yielding clinical evidence of metastases of papillary thyroid carcinoma (PTC) is controversial. The need for Ievel IIb lymph node (LN) dissection is particularly uncertain in view of its association with postoperative shoulder dysfunction. In the present study, we examined the frequency, pattern, and predictive factors of level IIb LN metastases in PTC patients with clinically positive lateral neck nodes. Methods  We reviewed the medical records of 76 PTC patients who underwent therapeutic lateral ND for the treatment of clinically positive lateral neck nodes between March 2005 and July 2008. ND specimens were separately obtained for analyzing LN involvement with respect to neck level. Results  Metastatic disease at levels II, III, IV, and V, was seen in 40 (52.6%), 55 (72.4%), 52 (68.4%), and 12 (15.8%) of the patients, respectively. The metastasis rate in level IIb was 11.8% (9 of 76). By univariate analysis, the rate of level IIb LN metastasis was significantly higher in patients with positive level IIa LNs and positive LNs in all lateral neck levels (levels IIa + III + IV) (P < .05). Multivariate analysis showed that positive LN involvement in all lateral neck levels (IIa + III + IV) was an independent predictive factor of level IIb LN metastasis (P = .044, odds ratio = 9.692). Conclusions  Level IIb LN dissection may be omitted in the treatment of positive neck nodes in PTC patients if multilevel involvement including level IIa involvement is absent.     

Candidates for Limited Lateral Neck Dissection among Patients with Metastatic Papillary Thyroid Carcinoma

Background

Papillary thyroid carcinoma (PTC) is associated with an excellent prognosis but frequently spreads to regional lymph nodes. The extent of neck dissection, particularly routine level II or V lymphadenectomy, is still controversial as it may lead to spinal accessory nerve injury and associated postoperative morbidities. We assessed the diagnostic value of preoperative ultrasonography (US) plus computed tomography (CT) for detecting metastatic lymph nodes and for identifying predictors of level II or V metastasis in patients with PTC.

Methods

The results of US and CT were compared with histopathologic findings at various neck levels in 209 previously untreated PTC patients with lateral cervical nodal metastases who underwent total thyroidectomy with central and lateral neck dissection. Clinicopathologic predictors for level II or V metastases were identified.

Results

Pathologic metastases to level II and V were observed in 53.6 and 25.4 % of patients, respectively. Occult metastases were found in 34.5 and 16.8 %, respectively. The sensitivities of US plus CT for levels II and V were 64.6 and 50.9 %, respectively. Image-based, isolated lateral level IV involvement and macroscopic extranodal extension were independently associated with level II metastasis or either level II or V metastasis (p < 0.01). Macroscopic extranodal extension was also independently associated with level V metastasis (p = 0.001).

Conclusions

Patients with image-based, isolated lateral level IV involvement and no macroscopic extranodal extension are potential candidates for limited level III–IV dissection or prophylactic level II lymphadenectomy omission. Level V lymphadenectomy may be omitted in patients without macroscopic extranodal extension.     

Lymph nodal recurrence in levels IV and V in oral squamous cell carcinoma after neck dissection

Background

The aim of the study was to determine the risk of lymph node recurrence in levels IV and V after tumour resection and neck dissection of level I–III and level I–V.

Methods

Data from 228 patients suffering from OSCC were analysed retrospectively. Patients with level I–III neck dissection were compared to those with level I–V neck dissection in terms of number and location of nodal recurrence. The incidence of level IV–V recurrence in patients who had received level I–III neck dissection was compared with that of patients who had received level I–V neck dissection. The incidence of level IV–V recurrence was also compared between patients with pN0 and pN+ necks.

Results

Overall, 19 patients developed metastases. Only in two cases appeared nodal recurrence in levels IV or V. There was no statistically significant difference between both groups.

Conclusions

Neck dissection of levels I–III seems to be sufficient treatment in cases of unsuspicious lymph nodes in levels IV and V, even in cases of positive nodes in levels I–III if adjuvant radiation therapy is applied. However, 5-year-disease free survival rate is lower in patients with nodal metastases in levels IV and V than in patients with metastases located in levels I–III.     

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??Preservation of the cervical plexus with a selective neck dissection through a low-collar incision in patients with differentiated thyroid carcinoma: an analysis of 112cases SUN Tuan-qi, WU Yi. Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center (FUSCC)??Department of Oncology, Shanghai Medical College of Fudan University, Shanghai200032, China
Corresponding author: WU Yi, E-mail: ywu@rddb.shanghai.gov.cn
Abstract Objective To determine the utility and experiences of preserving the cervical plexus in selective neck dissections for differentiated thyroid carcinoma (DTC). Methods Preservation of the cervical plexus was used for selective neck dissection through a low-collar incision in 112 cases of DTC from January 2009 to December 2010 in the Department of Head and Neck Surgery, Fudan University Shanghai Cancer Center. Results The most common site of cervical lymph node metastases was level VI (78.8%), followed by level IV (72.9%) and III (60.2%). The metastasis rates in level II and VB were 43.8% and 16.9%, respectively. No impairment of sensation of ears, lower necks and upper shoulders was found. There was no local recurrence at the time of follow-up for 1 to 25 months. Conclusion If utilized in the appropriate patient population, a selective neck dissection through a low-collar incision for DTC can be a successful alternative to the modified or radical neck dissection. It could be performed in N1b patients when there is no level VA lymph node metastasis, or when the metastasis is not aggressive.     

Relevance of skip metastases for squamous cell carcinoma of the oral tongue and the floor of the mouth.

OBJECTIVE: To analyze the therapeutic implications of the distribution of neck metastases (NM) in patients with squamous cell carcinoma (SCC) of the tongue and the floor of the mouth (FOM). PATIENTS AND METHODS: From January 1987 through December 1997, 339 previously untreated patients with T1-2 N0 M0 SCC of the tongue and the FOM underwent primary surgical treatment in our institution. A retrospective review of the pathology reports and outcome of these patients was made to ascertain the prevalence and distribution of NM. Patients were grouped by clinical neck status at the time of neck dissection: elective neck dissection (END) in the NO neck and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+ or regional recurrences after END. All patients were classified according to the American Joint Committee on Cancer (AJCC)/UICC 2002 TNM classification. RESULTS: All patients underwent surgical treatment of the primary cancer and had negative margins at frozen section. Overall incidence of NM was 41.3%. Twenty-seven point eight percent of T1 N0 M0 and 48.2% of T2 N0 M0 patients developed NM (P = .0004). Occult neck metastases occurred in 24.1% of patients. Clinically, N+ metastases occurred in 23.6% of patients. The overall incidence of NM in levels IV and V was 8.5%. Neck level IV nodes were involved in only 1.5% of patients in the END group versus 23.7% in the STD group (P < 0.001). Level V was always associated to nodal metastases in other neck levels. Only 2% of patients in our study presented "skip metastases" in the neck. CONCLUSIONS: Neck levels I and II were at great risk for the development of NM (46.9% and 75.3% respectively). Levels IV (6.5%) and V (2%) were rarely involved in our group of patients. The results found in this study support the indication of supraomohyoid neck dissection for N0 and a more comprehensive neck dissection (levels I-V) for N+ patients in Stage I-II SCC of the tongue and FOM. EBM rating: C-4.     

Selective dissection of levels II-III with intraoperative control of the upper and middle jugular nodes: a therapeutic option for the N0 neck

BACKGROUND: Selective neck dissections are accepted elective treatment in N0 patients. We present the results of a dissection of levels II to III and intraoperative pathologic control of a sample of subdigastric and supraomohyoid nodes in a group of patients with laryngeal carcinoma. When intraoperative analysis was positive, dissection of levels IV and V was completed. METHODS: Between 1991 and 1997, 145 neck dissections with intraoperative control were carried out in 79 patients with laryngeal carcinomas. Postoperative radiotherapy was used in 49 patients. RESULTS: There were occult metastases in 29 neck dissections (20%). In 22 cases (15%), tumor was found in the nodes sent to intraoperative pathologic study, and dissection of levels IV and V was completed. In 7 additional cases tumor was found in the postoperative study. The sensitivity of the use of frozen sections in the detection of occult metastases was 76%. In no case were positive nodes found at level V. There was no regional relapse in any of the 145 selective neck dissections. CONCLUSIONS: The lateral selective neck dissection is an effective method in the elective treatment of the neck of N0 laryngeal carcinoma patients. Dissection of level IV can be spared when intraoperative biopsy specimens of a sample of the subdigastric and supraomohyoid nodes are negative. According to our results, at present we do not consider it necessary to dissect level V in selective neck dissections in patients with laryngeal carcinoma.     

甲状腺乳头状癌隐匿性V区淋巴结转移的临床分析

目的 分析甲状腺乳头状癌V区淋巴结隐匿性转移的相关因素.方法 回顾性分析2001年1月至2009年6月收治的203例术前V区淋巴结临床阴性、颈侧区阳性的初治甲状腺乳头状癌患者的临床资料.其中男性60例,女性143例;年龄16～76岁,中位年龄42岁.手术范围包括病变侧甲状腺腺叶切除和同期同侧颈部淋巴结清扫术(Ⅱ～Ⅵ区).淋巴结清扫标本经病理证实颈侧区(Ⅱ～V)有淋巴结转移.单因素和多因素分析分别采用x2检验和二分类Logistic回归分析.结果 颈部Ⅱ、Ⅲ、Ⅳ区淋巴结阳性率分别为47.3%(96/203)、79.8%(162/203)、81.3%(165/203),V区隐匿性淋巴结转移率为14.3%(29/203).单因素分析显示,术前B超Ⅳ区淋巴结阳性(x2=5.651,P=0.017)和Ⅲ、Ⅳ区淋巴结同时阳性(x2=10.936,P=0.001)与V区淋巴结隐匿性转移密切相关.多因素分析显示术前B超颈部Ⅲ、Ⅳ区淋巴结同时阳性是隐匿性V区淋巴结转移的独立预测因素(P=0.046,OR=4.550).结论 甲状腺乳头状癌患者术前未发现Ⅳ区淋巴结阳性时可以不对V区进行预防性淋巴结清扫.

Abstract：

Objective To analyze the occult level V lymph node(LN)metastases in papilary thyroid carcinoma(PTC)with clinical factors.Methods The clinical data of 203 PTC patients with clinically positive neck lymph nodes in level Ⅱ ,Ⅲ and Ⅳ based on preoperative ultrasonography,who underwent therapeutic lateral neck dissection(level Ⅱ-V)between January 2001 and June 2009 were retrospectively reviewed.There were 60 male and 143 female patients in the study.The median age at diagnosis was 42 years(ranging from 16 to 76 years).The 203 patients had undergone ipsilateral thyroidectomy and stimultaneously neck dissections(Ⅱ -Ⅵ).All patients had no suspicion of clinicall positive neck nodes in level V.Univariate and Multivariate analysis were performed using the Pearson chisquare test and a binary logistic regression test,respectively.Results The rate of metastatic at levels Ⅱ,Ⅲ and Ⅳ was 47.3%(96/203),79.8%(162/203),81.3%(165/203),respectively.The rate of occult metastatic at level V were observed in 14.3%(29/203).In univariate analysis,LN metastasis in level V was statistically significantly more frequent in patients with positive level Ⅳ LNs(x2 =5.651,P =0.017)and positive LNs throughout the lateral neck(level Ⅲ +Ⅳ)(x2 = 10.936,P=0.001).Multivariate analysis showed that positive LN involvement in all lateral neck(level Ⅲ + Ⅳ)is an independent predictive factor of level V LN metastasis(P=0.046,OR=4.550).Conclusion In PTC patients without suspicious LNs in neck level Ⅳ by preoperative ultrasound,prophylactic level V LN dissection may be omitted.     

Frequency of metastases at the area of the supraretrospinal (level IIB) lymph node in laryngeal cancer

BACKGROUND: Neck dissection is the surgical gold standard for the treatment of patients with cervical lymphatic spread. The purpose of this study was to determine the presence of metastases in the supraretrospinal (level IIB) nodal group and the necessity of routine dissection of level IIB during neck dissection, in patients with squamous cell carcinoma of the larynx. METHODS: Over a 4-year period (between January 2000 and June 2004), the records of patients undergoing laryngectomy and neck dissection were retrospectively evaluated. The numbers of the lymph node and carcinoma metastases at level IIB were recorded. The American Joint Committee on Cancer tumor-node-metastasis classification system was used to classify the primary tumor and neck, and the Memorial Sloan-Kettering Cancer Center classification was used to classify the cervical lymphatic chain. RESULTS: Sixty-three patients with 98 neck dissections were included in the study. Two patients (3.17%) had subglottic lesions, 19 patients (30.15%) had glottic lesions, and 42 patients (66.66%) had supraglottic lesions. In total, 673 lymph nodes were dissected from level II, and 340 were dissected from level IIB. The 11 supraretrospinal lymph nodes of the 340 dissected nodes demonstrated histologic evidence of metastases (3.23%). Six patients (9.52%; 6/63) had metastases at level IIB, and 2 of them also had synchronous metastases at the contralateral level IIB. The patients without palpable lymph nodes at the neck had no metastases at level IIB. CONCLUSION: Our results showed that, if the level IIA shows positive metastatic changes, perioperative pathologic examination by frozen section that includes level IIb could be an alternative approach. This area may not be routinely dissected during the surgical management of laryngeal carcinoma with no palpable lymph nodes.     

甲状腺乳头状癌术中喉前及气管前淋巴结联合冷冻病理检测的临床价值

目的:探讨甲状腺乳头状癌(PTC)术中喉前淋巴结(DLN)及气管前淋巴结(PLN)联合冷冻病理检测的临床价值。方法:收集2015年1月—2016年12月昆明医科大学第二附属医院甲状腺乳腺外科术前经细针穿刺活检明确诊断并接受首次手术治疗的245例PTC患者的临床资料,患者均行DLN与PLN术中冷冻病理检测,并根据DLN与PLN转移情况选择手术方式。结果:245例患者术中冷冻病理均发现DLN与PLN,淋巴结数目2～11枚,126例(51.43%)发现DLN与PLN转移。术后病检气管旁淋巴结转移165例,侧颈区淋巴结转移62例。76例行单侧腺叶及峡部全切+患侧中央区淋巴结清扫,42例行全甲状腺切除+患侧中央区淋巴结清扫,101例行全甲状腺切除+双侧中央区淋巴结清扫,26例行全甲状腺切除+双侧中央区淋巴结清扫+侧颈区清扫。统计分析表明包膜侵犯是DLN与PLN转移的独立风险因素(OR=9.62,P=0.021)。结论:DLN与PLN可作为PTC前哨淋巴结,其转移与气管旁淋巴结转移、侧颈区淋巴结转移密切相关。术中行DLN与PLN联合冷冻病理检测有助于选择最佳手术方式,实现对PTC更加精准的治疗。     

Is Routine Dissection of Level II-B and V-A Necessary in Patients with Papillary Thyroid Cancer Undergoing Lateral Neck Dissection for FNA-Confirmed Metastases in Other Levels

Background  The purpose of the present study was to determine the utility of routine dissection of level II-B and level V-A in patients with papillary thyroid cancer (PTC) undergoing lateral neck dissection for ultrasound-guided fine-needle aspiration (FNA)-confirmed lateral nodal metastasis in at least one neck nodal level. Methods  In a retrospective review, we studied the charts of 53 consecutive patients (February 2002–December 2007) with PTC who had undergone therapeutic lateral neck dissection that included at least level II-(A and B) and/or level V-(A and B). The levels were designated as such in situ prior to surgical pathology specimen processing. Reports of the preoperative FNA cytopathologic findings, the extent of lateral neck dissection by levels, and the postoperative final histopathologic examination were reviewed. Results  A total of 53 patients underwent therapeutic lateral neck dissection for FNA-confirmed nodal metastasis of PTC at a minimum of one lateral neck level. All 53 patients had preoperative ultrasonography and FNA confirmation of lateral neck disease: 46 patients had PTC, 5 had the tall cell variant of PTC, and 2 had the follicular variant of PTC on final surgical pathology. Ten patients underwent neck dissection at the time of thyroidectomy, and 43 patients underwent neck dissection for lateral neck recurrence/persistence of PTC following a previous thyroidectomy and radioactive iodine ± previous neck dissection. A total of 46 patients underwent unilateral neck dissection and 7 patients underwent bilateral neck dissection; thus 60 neck dissection specimens were evaluated. Level II (A and B) was excised in 59/60 neck dissections, with 33 of 59 specimens (33/59 = 60%) positive for metastasis. Level II-B was positive 5 times (5/59; 8.5–95% CI: 2.4, 20.4), and each time level II-B was positive, level II-A was also grossly (and histopathologically—seen at the time of surgery) positive for metastasis. Level III was excised 58 times and was positive in 38 specimens (38/58 = 66%). Level IV was excised 58 times and was positive in 29 specimens (29/58 = 50%). Level V (A and B) was excised 40 times and was positive in 16 specimens (16–40 = 40%). Level V-A did not account for any of the positive level V results (0%). Conclusions  Cervical lateral neck metastases in PTC occur in a predictable pattern, with levels III, II-A, and IV most commonly involved. Patients with PTC who undergo lateral neck dissection for FNA-confirmed nodal metastases might harbor disease in level II-B, especially if level II-A is involved. We recommend elective dissection of level II-B only when level II-A is involved, based on FNA confirmation, or when it is grossly involved on intraoperative evaluation. Routine dissection of level V-B is recommended in this patient population, while elective dissection of level V-A is not necessary.     

The role of neck dissection in head and neck mucosal squamous cancer

The most clinically useful system of classification of neck lymph nodes is grouping into levels I-V. Anatomical, clinical and pathological studies demonstrate that although generally lymphatic flow is from above downwards, level I is often bypassed and level V is seldom involved. Neck dissection is classified into radical, modified radical, selective and extended radical neck dissections. Recent studies demonstrate that elective neck dissection is beneficial to the outcome of oral cancer patients, but not necessarily to laryngeal and pharyngeal cancer patients. Modified radical neck dissection is as effective as radical neck dissection when performed in the elective situation. Selective neck dissection in the form of supra-omohyoid neck dissection is useful as a staging procedure. Modified radical neck dissection is acceptable for the N1 neck provided postoperative radiotherapy is given.     

临床颈淋巴结阴性的甲状腺癌181例治疗分析

通过对临床颈淋巴结阴性的甲状腺癌治疗结果分析,提出采用甲状腺腺叶加峡部切除加中央区颈淋巴清扫术的治疗方法可获长期治愈的结果。方法:回顾分析1985年1月至2000年6月181例临床颈淋巴结阴性的甲状腺癌采用上法治疗的结果。结果:181例病人中仅12例(6.6%)补充作了同侧的颈淋巴结清扫术;12例行颈清扫术者中有10例见淋巴结转移。结论:对临床颈淋巴结阴性的甲状腺癌可以采用甲状腺腺叶加峡部切除加中央区淋巴结清扫术,其长期疗效同传统的甲状腺癌联合根治术,但生活质量却大为提高,值得临床推广。     

Central neck lymph node removal during minimally invasive video-assisted thyroidectomy for thyroid carcinoma: a feasible and safe procedure

BACKGROUND AND PURPOSE: In 1998, we developed a technique for video-assisted thyroidectomy (VAT) which we proposed using also in patients with small low-risk papillary thyroid carcinomas (PTC). In some cases, enlarged lymph nodes are incidentally found at surgery for PTC. These nodes should be removed because of the risk of metastases. In this paper, we report on the patients in whom we removed enlarged central neck lymph nodes during VAT for PTC and discuss the feasibility and safety of video-assisted central neck lymph node dissection (VALD). PATIENTS AND METHODS: The procedure is performed by a totally gasless video-assisted technique through a single 1.5-to 2.0-cm skin incision above the sternal notch. Dissection is performed under endoscopic vision using a technique very similar to that of conventional surgery. Only enlarged lymph nodes were removed and sent for frozen section examination (FS). No other dissection was performed in case of negative FS. Five patients underwent VALD during VAT for PTC. RESULTS: The mean number of lymph nodes removed was 2.4. No metastases were found at FS or final histology examination. Postoperative complications included two transient postoperative hypocalcemias. No evidence of residual or recurrent disease was observed at postoperative follow-up. The cosmetic result was excellent. CONCLUSION: Our experience demonstrates that removal of central compartment lymph nodes is feasible and safe. Perhaps also complete central neck lymph node dissection can be performed. Some doubts persist about the oncologic validity of this approach. For definitive conclusions, larger series and comparative studies are necessary.     

Skip metastases in medullary thyroid carcinoma: A single-center experience

PURPOSE: Total thyroidectomy (TT) with level VI and VII central neck dissection is the initial treatment for medullary thyroid carcinoma (MTC) without identifiable neck metastasis. Level II to V lateral neck dissection is performed if neck metastasis is present or suspected. We conducted this study to identify the frequency and clinical determinants of skip neck metastasis in MTC. METHODS: We reviewed the medical records of 32 patients who underwent TT and bilateral neck dissection for MTC. The clinical features were correlated with pN status in the central versus lateral compartments of the neck. RESULTS: Neck lymph node metastasis (pN+) was found in 20 patients (62.5%) and skip metastases were found in 7 (35%) patients. The sensitivity of the pN status of the central compartment of the neck to predict the pN status of the lateral compartment of the neck was 53.8% and specificity was 63.2%. We found pN+ in 90% of the patients with lymph nodes >15 mm in diameter versus 50% in those with lymph nodes <15 mm in diameter. CONCLUSIONS: There is skip metastasis in MTC. It is unsafe to use the lymph node status of the central compartment of the neck to define the pN status of the lateral neck. A lymph node greater than 15 mm in diameter is related to pN status.     

Minimally invasive video-assisted functional lateral neck dissection for metastatic papillary thyroid carcinoma

Functional lateral neck dissection requires a large incision providing adequate exposure of the surgical field. We evaluated the feasibility of minimally invasive video-assisted functional lateral neck dissection (VALNED) in patients with papillary thyroid carcinoma (PTC). Low-risk PTC patients with lateral neck metastases <2 cm, in absence of any evidence of great vessels involvement, were considered eligible. After accomplishing total thyroidectomy and central neck clearance, dissection was performed under endoscopic vision by using a technique very similar to conventional surgery through the single 4-cm skin incision used for thyroidectomy. Two patients were selected: 1 underwent bilateral and 1 unilateral VALNED. The mean number of the removed nodes was 25 per side. Both patients experienced transient postoperative hypocalcemia. No other complication occurred. No evidence of residual or recurrent disease was found at follow-up. VALNED is feasible, and the results are encouraging. For definitive conclusions, larger series and comparative studies are necessary.     

Neck level–specific nodal metastases in oropharyngeal cancer: Is there a role for selective neck dissection after definitive radiation therapy?

PURPOSE: To determine the extent of the required neck dissection for patients with persistent lymphadenopathy after definitive radiation therapy for oropharyngeal cancer. If feasible, a conservative approach using selective neck dissection would likely minimize the extent of neck fibrosis and other adverse sequelae. METHODS: Analysis of pretreatment and posttreatment radiologic scans and pathology reports of 76 patients with oropharyngeal carcinoma (35 tonsil; 41 base of tongue), who had radiologic evidence of persistent nodal disease for level-specific involvement. Patients were treated with twice-daily fractionations of external-beam radiation therapy (median dose, 76.8 Gy to the primary tumor) and planned neck dissection (levels I-V) for bulky nodes (N2-3) or salvage neck dissection for N1 disease. RESULTS: The distribution of clinical nodal disease by neck level on the basis of pretreatment and posttreatment radiologic scans indicated levels II and III to be most commonly involved. The false-negative rate for the restaging radiologic scans for each neck level was as follows: level I, 0%; level II, 8%; level III, 6%; level IV, 5%; and level V, 1.5%. Of the eight hemi-necks found to contain positive pathologic nodes in a neck level judged to be negative on the basis of restaging scans, five of the patients subsequently had disease recurrence in the primary site. Patients who had evidence of residual neck disease had a significantly lower rate of locoregional control (77% vs 100%, p =.0005). CONCLUSIONS: The extent of neck dissection for patients with nodal disease associated with oropharyngeal cancer treated with radiation therapy should include levels II-IV. It is reasonable to spare levels I and V in patients without radiologic and clinical evidence of positive nodes in levels I and V.     

Review of Distribution of Nodal Disease in Differentiated Thyroid Cancers in an Oncosurgical Center in Sri Lanka

Background There are not many publications on the prognostic implications of nodal disease in patients with papillary thyroid cancers (PTC). This study explored the distribution of nodes with respect to the levels, optimal management of the neck for patients with PTC, and its survival advantages. Methods Followup of 79 patients with thyroid cancer (59 with PTC) at the National Cancer Institute, Maharagama, Sri Lanka, was analyzed. Results The most common histologic type of all thyroid cancers presenting to the Institute was differentiated PTC which affected 59 patients (74.7%). Of them, 29 (50.0%) had positive lymph node metastases in the neck these nodes were found on clinical examination and confirmed by ultrasound in all. Therfore necessitating a comprehensive neck dissection. Among the patients with nodal disease, 5 had nodes in Level 1 at the time of presentation. All patients in this group had multiple levels of positive nodes. Metachronous nodal disease was found in 9 (31.4%) patients, with a disease-free period ranging from 2 months to 37 years. Among the patients with nodal disease, 13 had a single nodal group involvement and the majority of these were Level 4 nodes (46.2%). Central node (Level 6) involvement was found in nine (15.3%) patients. Multiple nodal group involvement indicating multifocal disease was present in 16 (27.6%) patients. Extracapsular nodal spread at presentation and extracapsular thyroid disease at presentation was 10 (16.9%) and 17 (28.8%), respectively. Nodal neck recurrences during followup were present in 2 patients. Conclusions Level 1 nodal metastases was present if 5 (8.5%) patients in our group. It is recommended that Level 1 nodes be explored during neck resection for PTC. Because 27.6% of the patients had multifocal disease, it may be important to recommend inclusion of a Level 1 clearance in the presence of multiple nodal involvement. There is a subgroup of patients who had highly aggressive nodes, indicated by extracapsular penetration, which even after radical clearance and external beam radiotherapy have a tendency to recur locally. This indicates an important prognostic feature of the nodal disease in PTC. Because 27.6% of the patients studies had multifocal nodal disease, we consider a comprehensive nodal clearance is necessary for patients with clinically positive nodes.     

Indications for neck dissection in carcinoma of the lip

In the past, neck dissections have been recommended only when nodes were clinically palpable or when they became so. A retrospective ten year study of thirty-seven patients with carcinoma of the lip and with an unusually high mortality has allowed reevaluation of indications for neck dissection. (1) Ten of thirty-seven patients died of this disease and nearly all of the ten died with and because of regional metastases. (2) Seven patients with nonpalpable nodes initially had nodal metastases later which, despite neck dissection at that later time, proved lethal. (3) Two patients who, despite nonpalpable nodes, had undergone neck dissections and were found to have occult bilateral nodal metastases were effectively cured with early neck dissection. This suggests that early bilateral supraomohyoid neck dissections for small carcinomas of the lip and ipsilateral radical neck dissections for large primaries may yield higher cure rates than currently achieved.