Skip Lateral Neck Node Metastases in Papillary Thyroid Carcinoma

Background  

Papillary thyroid carcinomas (PTCs) are commonly associated with lymph node metastases (LNMs), which are thought to disseminate sequentially, first to the central compartment and later to the lateral compartment. However, a small number of patients have skip metastases to the lateral compartment without central LNMs. This study was performed to evaluate the clinicopathologic characteristics of skip metastases in PTC.     

乳头状甲状腺癌颈淋巴结转移方式及其相关影响因素的研究

目的评估乳头状甲状腺癌（PTC）颈淋巴结的转移方式及相关影响因素在颈部不同区域淋巴结转移中的意义。方法回顾性分析笔者所在医院甲状腺外科2008年12月至2011年12月3年期间行手术治疗的223例PTC患者的临床资料,就患者性别、年龄、术前TSH水平、肿瘤直径、是否为多灶、是否侵及甲状腺被膜及其周围组织、是否合并桥本甲状腺炎、是否合并结节性甲状腺肿以及肿瘤的T分期等因素与颈部不同区域的淋巴结转移之间的关系进行分析。结果单变量分析结果显示,年龄≥45岁及合并结节性甲状腺肿与中央区淋巴结转移有关（P〈0．05）,多发病灶与颈侧区淋巴结转移有关（P〈0．05）;多变量分析结果显示,年龄≥45岁及合并结节性甲状腺肿是中央区淋巴结转移的保护因素（P〈0．05）,多发病灶是颈侧区淋巴结转移的危险因素（P〈0．05）。Ⅱ-Ⅳ区是颈侧区淋巴结转移的常见区域,其中Ⅲ区转移率最高,达100％;当出现跳跃性转移时,Ⅱ-Ⅳ区是转移高发区域。结论对年龄〈45岁的PTC患者应常规进行中央区淋巴结清扫;如果患者同时合并结节性甲状腺肿,中央区淋巴结转移的风险会显著降低;当原发肿瘤为多发病灶时,应加强术中对Ⅱ-Ⅳ区淋巴结的探查,尤其是Ⅲ区淋巴结;当可疑跳跃性转移出现时,Ⅱ-Ⅳ区淋巴结应是常规清扫范围。     

Superior Located Papillary Thyroid Microcarcinoma is a Risk Factor for Lateral Lymph Node Metastasis

Annals of Surgical Oncology - It is important to identify prognostic factors for lateral lymph node metastasis (LLNM) in papillary thyroid microcarcinoma (PTMC) because they determine the extent of...     

Medullary Thyroid Carcinoma Metastasis to the Breast and Axillary Lymph Nodes

Breast metastases of medullary thyroid carcinoma (MTC) are extremely rare, and only a few cases have been reported in the literature so far. Here, we report a case of metastatic MTC to the breast and axillary lymph nodes (LN). The case illustrates that (1) metastatic MTC of the breast could be clinically and pathologically misdiagnosed as primary breast cancer, such as invasive lobular carcinoma with axillary LN involvement; (2) unlike other metastatic breast cancer patients, who have very poor prognoses, our patient survived for more than 5 years after the breast and axillary surgery; and (3) metastasis of MTC to the breast is accompanied by axillary LN metastasis, which requires thorough axillary LN dissection, as in most primary breast cancers.     

Risk Factors for Lateral Cervical Lymph Node Involvement in Follicular Thyroid Carcinoma

Background  Metastases from follicular thyroid carcinoma (FTC) are usually blood borne and far less to lymph nodes (LN). The present study was designed to evaluate the factors that are associated with LN metastases in patients operated on for FTC. Methods  A retrospective review of 70 patients (25 men; mean age, 47 (range, 14–92) years) operated on between January 1995 and December 2005 for FTC was undertaken. All patients had histopathology study of the regional LN and postoperative radioiodine scintigraphy. According to LN invasion, they were divided into two groups in which various parameters were compared. Results  The length of follow-up was 52 (range 17–108) months. A total of 375 LN were examined from ipsilateral neck side and 87 LN from the contralateral side. LN metastases were found in five (7%) cases: all ipsilateral. Comparing data from the patients with and without LN metastases, respectively, age was 60 and 47 years (p = 0.12), male/female ratio was 1/4 and 24/41 (p = 0.44), tumor size was 68 and 37 mm (p < 0.01), tumor differentiation (well/moderate) was 3/2 and 25/19 (p = 0.89), distant metastases were detected in 1 and 8 cases (p = 0.72) .The tumor size was >40 mm in 35 (50%) patients. All patients with LN metastases were found in this group (5/35; 14%). Conclusions  Follicular thyroid carcinoma results in metastases to regional lymph nodes in 7% of cases but only to the ipsilateral neck side. Tumor size is the only factor that impacts it. We do not recommend lymph node dissection in follicular thyroid carcinomas <4 cm. Presented at the International Surgical Week, Montreal, Canada, August 26 to 30, 2007.     

Prediction of Mediastinal Lymph Node Metastasis in Papillary Thyroid Cancer

Because of the rarity of mediastinal lymph node metastasis, no evidence exists regarding risk factors indicating its presence. This study aimed to identify risk factors representing potential triggers of imaging for mediastinal lymph node metastasis. Carried out was an analysis of 392 consecutive patients with node-positive papillary thyroid cancer referred to a tertiary surgical center. Significant univariate associations (P ≤ 0.001) existed, after correction for multiple testing, between mediastinal lymph node metastasis and poor tumor differentiation (24% versus 2%), number of positive lymph nodes (mean 14.4 versus 7.3 nodes), and distant metastasis (43% versus 11%). Only nominally significant were age at first tumor diagnosis (47.7 versus 39.1 years; P = 0.042), extrathyroidal tumor extension (76% versus 53%; P = 0.044), and bilateral lymph node metastasis (81% versus 49%; P = 0.006). In the initial and optimized multivariate logistic regression models, which included all significant variables from the above analysis, only poor tumor differentiation (odds ratio 11.6–14.6) and distant metastasis (odds ratio 5.4–6.1) represented significant (P ≤ 0.005) predictors of mediastinal lymph node metastasis. These two variables featured excellent negative predictive values of 96%. Regarding prediction of mediastinal lymph node metastasis, poor tumor differentiation was more discriminatory than distant metastasis, as reflected in a better accuracy (94% versus 86%) and positive predictive value (42% versus 18%). We conclude that, subject to validation in independent series, patients with poorly differentiated papillary thyroid cancers, which are rare, should be ideal candidates for mediastinal imaging because 5 of 12 patients (42%) having this condition in the present investigation harbored mediastinal lymph node metastasis.     

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.     

Contribution of Computed Tomography to Ultrasound in Predicting Lateral Lymph Node Metastasis in Patients with Papillary Thyroid Carcinoma

Background

To evaluate the most accurate criteria using ultrasound (US) and contrast-enhanced computed tomography (CT) in predicting lateral lymph node metastasis in patients with papillary thyroid carcinoma (PTC).

Methods

A total of 122 lateral cervical lymph nodes of 113 patients diagnosed with PTC underwent preoperative US-guided fine-needle aspiration biopsy (US-FNAB) and CT. Degree of enhancement (DOE) was calculated by the differences of Hounsfield units (HU) between the lymph node and the ipsilateral sternocleiomastoideus muscle. Standard reference was set by surgical pathology results. Diagnostic performances of US, CT, and cutoff value for DOE were analyzed.

Results

Seventy lymph nodes (57.4%) were metastases, and 52 (42.6%) were benign. The cutoff value of DOE on CT was 35.7 HU. Diagnostic performance of CT including DOE of 35.7 HU was lower than US, but without significance (P = 0.321). When any suspicious CT feature was combined with the combination of suspicious US features, values of the area under the receiver operating characteristic curve decreased compared to the combinations of suspicious US features alone, 0.785 to 0.741, respectively (P = 0.225).

Conclusions

Contrast-enhanced CT does not greatly improve diagnostic values of US in the diagnosis of metastatic lateral cervical lymph nodes in patients with PTC.     

Risk Factors for Recurrence to the Lymph Node in Papillary Thyroid Carcinoma Patients without Preoperatively Detectable Lateral Node Metastasis: Validity of Prophylactic Modified Radical Neck Dissection

Background Although papillary carcinoma usually shows mild characteristics, it metastasizes and shows recurrence to the lymph node in high incidences. Of the two representative lymph node compartments to which papillary carcinoma metastasizes, the central compartment can be routinely dissected via the surgical incision made for thyroidectomy. However, the routine application of prophylactic lateral node dissection (modified radical neck dissection [MND]) remains controversial. In this study, we investigated risk factors for lymph node recurrence of papillary carcinoma to determine the appropriate application of prophylactic MND. Methods We investigated risk factors for lymph node recurrence in 1,231 patients without preoperatively detectable lateral node metastasis who underwent thyroidectomy, central node dissection, and prophylactic MND for papillary carcinoma between 1987 and 1995. Results The incidence of lateral node metastasis and the number of metastatic lateral nodes significantly increased with carcinoma size. The lymph node disease-free survival (LN-DFS) was also significantly worse in carcinoma with a maximal diameter greater than 3 cm. Massive extrathyroid extension, male gender, and age 55 years or older also reflected a poorer LN-DFS. The 10-year LN-DFS rates of patients with carcinoma having two and three or four of these features were low at 88.5% and 64.7%, respectively, although the rates of those with carcinoma having no or only one characteristic were better than 95%. Conclusions Prophylactic MND is recommended for cases of papillary carcinoma demonstrating two or more of the following four characteristics; male gender, age 55 years or older, maximal tumor diameter larger than 3 cm, and massive extrathyroid extension.     

Clinical Significance of Delphian Lymph Node Metastasis in Papillary Thyroid Carcinoma

Background

Delphian lymph node (DLN) metastasis has long been considered a prognostic marker of head and neck malignancy. These days, the significance of DLN in thyroid cancer has come to the fore. The objective of the present study was to evaluate the clinical significance of DLN metastasis in patients with papillary thyroid cancer (PTC).

Patients and methods

The study was carried out between July 2009 and December 2011, and DLN was detected in 245 of 898 PTC patients who underwent total thyroidectomy and bilateral central compartment neck dissection. In those 245 patients DLN status was correlated with clinical and pathologic factors, including age, gender, tumor size, extrathyroidal extension (ETE), lymphovascular invasion (LVI), and central and lateral nodal metastasis.

Results

DLN metastasis was found in 20 % of the patients studied (49 of 245), and DLN metastasis was correlated with tumor size, multicentricity, bilaterality, and LVI excluding ETE (all p < 0.05). The proportion of male patients was higher in the DLN metastasis positive group than in the DLN metastasis negative group (34.7 vs. 13.3 %; p < 0.05). Most of the patients (95.9 %) with DLN metastasis had other central neck node metastasis, and the metastatic central lymph node ratio was higher (0.38 ± 0.23 versus 0.09 ± 0.16; p < 0.001) and lateral neck node metastasis was more common (2.6 vs. 32.7 % <0.001) than in patients without DLN metastasis. For central and lateral compartment nodal metastasis, DLN status had sensitivity, specificity, positive and negative predictive values of 100, 37.4, 58.1, and 100 %, and 85.3, 76.2, 97.4, and 32.7 %, respectively. Multivariate analysis showed that the factors affecting DLN involvement were tumor size and LVI. Patients with positive DLN were ~1.6 times more likely to have further central compartment disease and 3.6 times more likely to have lateral compartment disease.

Conclusions

DLN metastasis in patients with PTC is related to a number of poor prognostic factors. Furthermore DLN involvement implies that the patients are predicted to have heavy burden of central neck node metastasis and are more likely to have further lateral neck node metastasis. It is recommended that DLN is evaluated and dissected in all patients with thyroid cancer. If DLN metastasis is suspected, the surgeon should thoroughly dissect the central neck compartment and pay particular attention to the lateral lymph node compartments.     

Clinical Implications of Bilateral Lateral Cervical Lymph Node Metastasis in Papillary Thyroid Cancer: A Risk Factor for Lung Metastasis

Background  

Distant metastasis to the lung in papillary thyroid cancer (PTC) is rarely detected, but it is known to be an important prognostic factor associated with survival. We investigated risk factors for lung metastasis in PTC.     

甲状腺乳头状癌淋巴结转移规律的临床研究

目的探讨甲状腺乳头状癌颈部淋巴结的转移规律及合理的手术方式。方法回顾性分析我院2004年9月至2009年9月期间收治的221例甲状腺乳头状癌患者的临床资料。结果本组行甲状腺全切除术32例,次全切除术189例。术后病理学诊断单侧甲状腺癌202例(91.40%),双侧甲状腺癌19例(8.60%)。甲状腺的原发肿瘤直径0.2~8.0 cm,平均3.5 cm。有包膜侵犯50例;多灶性33例。每侧颈清扫淋巴结数目10~24个,平均14.3个。颈部淋巴结转移总发生率为37.56%(83/221),中央组(Ⅵ区)淋巴结转移发生率为33.94%(75/221),颈深组(Ⅱ+Ⅲ+Ⅳ区)淋巴结转移发生率为18.10%(40/221)。当肿瘤直径>1.0 cm、肿瘤突破甲状腺包膜、多发灶或年龄>45岁时Ⅵ区及Ⅱ+Ⅲ+Ⅳ区的同侧淋巴结转移发生率明显增加(P<0.05)。结论甲状腺乳头状癌最常见的淋巴结转移为Ⅵ区淋巴结,其次为Ⅱ+Ⅲ+Ⅳ区淋巴结,初次手术应常规清扫Ⅵ区淋巴结,当肿块直径>1.0 cm、癌肿突破甲状腺包膜时或B超、CT等影像学检查有颈部淋巴结转移时,应清扫Ⅱ+Ⅲ+Ⅳ区淋巴结。     

Metastasis of Right Upper Para-Esophageal Lymph Nodes in Central Compartment Lymph Node Dissection of Papillary Thyroid Cancer

Background  

Although some lymph nodes (upper para-esophageal lymph nodes) that exist between the right recurrent laryngeal nerve and the esophagus should be involved in central-compartment lymph node dissection (CLND) in patients with papillary thyroid cancer, the procedure can cause some injury to the nerve. We set out to assess the incidence of right upper para-esophageal lymph node metastasis after routine CLND.     

The Efficacy of Lateral Neck Sentinel Lymph Node Biopsy in Papillary Thyroid Carcinoma

Background  

Although occult lymph node metastasis to the lateral neck compartment is common in papillary thyroid carcinoma, the incidence and patterns of lateral neck node metastasis in papillary carcinoma are not known. We hypothesized that sentinel lymph node biopsy (SLNB) with radioisotope in the detection of occult lateral neck node metastasis would be useful in characterizing metastasis in papillary carcinoma.     

Axillary Lymph Node Metastasis from Papillary Thyroid Carcinoma: Report of a Case

We report a case of axillary lymph node metastasis (LNM) from papillary thyroid carcinoma (PTC) in a 21-year-old man. The patient presented with bilateral cervical and right axillary lymphadenopathy, and computed tomography (CT) showed a primary tumor of the thyroid and gross lymphadenopathy from the neck to the right axilla. We performed a total thyroidectomy with therapeutic nodal dissection. The resection of the primary thyroid tumor and all the node metastases was curative. Pathological examination confirmed that the resected lesions were PTC and nodal metastases from the primary tumor. Six years after the operation, cervical, upper mediastinal, and axillary lymph node recurrence developed and multiple lung metastases were found on a CT scan. He was treated with radioactive iodine therapy. Axillary LNM from PTC is unusual and seems to be associated with a poor prognosis. Thus, comprehensive treatment strategies are needed to improve the outcome of patients with PTC who present with axillary LNM.