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.     

微小乳头状甲状腺癌的腔镜手术治疗

目的探讨腔镜手术治疗微小乳头状甲状腺癌（papillary thyroid microcarcinoma,PTMC）的可行性、有效性及安全性。方法2006年3月~2008年9月,行经胸乳入路腔镜下甲状腺手术204例,术中冰冻切片检查报告PTMC 16例,在腔镜下行患侧甲状腺腺叶全切除＋对侧腺叶次全切除＋Ⅵ区淋巴结清扫术。结果16例手术时间70~160 min,平均115min。肿瘤最大径0.2~1.0 cm,平均0.56 cm。2例（12.5%）术后一过性喉返神经损伤导致暂时性声音嘶哑,术后1~2个月恢复。无术后出血、皮下气肿、饮水呛咳以及低血钙。术后病理报告均为PTMC。Ⅵ区淋巴结清扫数目2~10个,平均4.6个,其中6例（37.5%）淋巴结有癌转移。随访时间6~30个月,平均18个月,其中7例〉24个月,B超和单光子发射计算机断层扫描（ECT）提示患侧甲状腺无残留腺体,局部无复发。结论腔镜甲状腺手术治疗PTMC是安全可行的,可作为PTMC手术治疗的一种选择。     

Current Strategies for Surgical Management and Adjuvant Treatment of Childhood Papillary Thyroid Carcinoma

Childhood papillary thyroid carcinoma is associated with more locally aggressive and more frequent distant disease than its adult counterpart. Recurrence rates tend to be higher in children, but cause-specific mortality remains low. Optimal initial treatment of childhood papillary thyroid carcinoma should include total or near-total thyroidectomy and central compartment node clearance. Modified neck dissections should be performed for biopsy-proven lateral neck disease. Every effort should be made to maintain parathyroid and laryngeal nerve function. Radical neck dissections are to be avoided. Radioiodine remnant ablation (RRA), appropriate thyroid hormone suppressive therapy (THST), and judicious use of therapeutic doses of ¹³¹I are applied to achieve a disease-free status, which is most often confirmed by negative neck ultrasonography, negative whole-body scan (either withdrawal or recombinant human thyroid-stimulating hormone-stimulated), and extremely low levels of serum thyroglobulin. Appropriate utilization of ¹³¹I, THST, repeat surgery, external beam radiotherapy, and rarely chemotherapy may provide long-term palliation and some cures in patients with recurrent/persistent disease. Follow-up should be lifelong, and the care of children after age 17 should subsequently be transferred to adult-care endocrinologists with expertise in managing thyroid neoplasia. Optimal surgical management can be achieved if adequate operations are routinely carried out by high-volume thyroid surgeons with expertise in the care of children. Nowhere is a multidisciplinary approach (endocrinologists, surgeons, nuclear medicine physicians, pediatricians, pathologists, oncologists) more critical than in the long-term management of papillary thyroid carcinoma that presents during childhood.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004.     

Percutaneous Microwave Ablation of Metastatic Lymph Nodes from Papillary Thyroid Carcinoma: Preliminary Results

World Journal of Surgery - Our purpose is to assess the effectiveness and safety of ultrasound-guided percutaneous microwave ablation (MWA) for lymph node metastases (LNMs) from papillary thyroid...     

Surgical Management of Metastases to the Thyroid Gland

Background

Metastases to the thyroid gland are uncommon, with rates reported between 0.02% and 1.4% of surgically resected thyroid specimens. Our goal was to present our experience with surgical management of metastases to the thyroid gland.

Methods

Twenty-one patients with metastatic disease to the thyroid were identified from a database of 1,992 patients with thyroid cancer who had surgery during 1986–2005. Patient, tumor, treatment, and outcome details were recorded by analysis of charts. The median age at time of surgery was 68 (range, 39–83) years; 12 were men and 9 were women.

Results

All patients were managed by surgery, including lobectomy in ten patients, total thyroidectomy in six, completion thyroidectomy in two, and subtotal thyroidectomy in one. In two patients, the thyroid lesion was found to be unresectable at the time of surgery. Histopathology revealed renal cell carcinoma in ten, malignant melanoma in three, gastrointestinal adenocarcinoma in three, breast cancer in one, sarcoma in one, and adenocarcinoma from an unknown primary site in three patients. Seventeen patients have died. The cause of death in all 17 was widespread metastatic disease from their respective primary tumors. The median survival from surgery to death or last follow-up was 26.5 (range, 2–114) months.

Conclusions

In patients with metastases to the thyroid gland, local control of metastatic disease in the central compartment of the neck can be successfully achieved with minimal morbidity with surgical resection in selected patients.     

Surgical Management of Diffuse Sclerosing Variant of Papillary Thyroid Carcinoma. Experience in 25 Patients

World Journal of Surgery - To delineate the clinicopathologic features and biologic behavior of the diffuse sclerosing variant of papillary thyroid carcinoma (DSV-PTC) and to report its outcome....     

The Value of Positron Emission Tomography in the Surgical Management of Recurrent Papillary Thyroid Carcinoma

Background Patients with papillary thyroid carcinoma (PTC) may suffer recurrence despite thyroidectomy and complete radioiodine (RAI) ablation. Reoperation is vitally dependent on accurate and complete disease localization, typically utilizing cervical ultrasonography (US) and/or computed tomography. Our aim was to determine the comparative value of F18-fluorodeoxyglucose positron emission tomography (PET) to US for localization of locoregional recurrence in patients who underwent reoperation for recurrent PTC. Methods From 1999 to 2004, 30 patients who underwent re-exploration and 100 nonoperated patients who were investigated with PET for possible recurrent PTC were reviewed. The surgical group [9 males, 21 females; mean age = 50 years (range = 18–84 years)] all had received RAI ablation. Preoperative thyroid-stimulating hormone (TSH), thyroglobulin (Tg), and location of metastasis were recorded for each imaging study and surgical exploration. All separate sites that contained disease pathologically must have been identified by imaging for a patient to be considered true positive (TP). Results PET scans were TP in 43%, false positive in 7%, false negative (FN) in 50%, and had a sensitivity of 46%. Comparable US results were 86%, 10%, 3%, and 96%. Of the 15 patients with FN PET scans, 13 had lymph node metastasis less than 2 cm in diameter, 11 had Tg ≤ 10 μg/L, and the TSH < 20 in 13. In only 3 of the 30 (10%) patients was PET deemed to add value. Conclusions At least with suppressed TSH, PET scanning in reoperative PTC patients appears to offer modest benefit beyond high-resolution US.     

Papillary Thyroid Carcinoma Variants

Papillary thyroid carcinomas are the most common thyroid cancers and constitute more than 70% of thyroid malignancies. The most common etiologic factor is radiation, but genetic susceptibility and other factors also contribute to the development of papillary thyroid carcinoma. The most common variants include conventional, follicular variant and tall cell variant. However, many other uncommon variants have been described including oncocytic, columnar cell, diffuse sclerosing and solid forms. Immunohistochemical staining with TTF-1 and thyroglobulin is very useful in confirming the diagnosis of papillary thyroid carcinoma especially in metastatic sites. Markers such as HBME-1 and CITED1 can assist in separating some difficult cases of follicular variants of papillary thyroid carcinomas from follicular adenomas. Molecular studies have shown that the BRAF V600E mutation is found mainly in papillary and anaplastic thyroid carcinomas. Other molecular markers such as HMGA2 and insulin-like growth factor II mRNA binding protein 3 have been used recently as molecular tests to separate papillary thyroid carcinoma and its variants from follicular adenomas and other benign thyroid nodules.     

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.     

Occult Contralateral Lateral Lymph Node Metastases in Unilateral N1b Papillary Thyroid Carcinoma

World Journal of Surgery - Therapeutic lateral neck dissection (ND) is recommended for N1b papillary thyroid carcinoma (PTC), while prophylactic contralateral lateral ND is not. Given the paucity...     

Patterns of Lymph Node Metastases in Papillary Thyroid Carcinoma: Results from Consecutive Bilateral Cervical Lymph Node Dissection

Background  

In patients with papillary thyroid carcinoma (PTC), the appropriate extent of lymph node dissection has not yet been established due to lack of accurate patterns of lymph node metastases (LNM). The aim of this study was to clarify the LNM pattern in PTC patients based on our institution’s experience with a consistent technique of bilateral neck dissection, and to consider the rational extent of lymph node dissection.     

Value of the Cervical Compartments in the Surgical Treatment of Papillary Thyroid Carcinoma

In the treatment of papillary thyroid carcinoma (PTC), supplementary lymph node dissection (LND) is not well standardized. The purpose of this study was to evaluate the significance of the cervical compartments in the lymphatic spread of PTC and the impact of modified radical neck dissection (MRND) as an additional surgical procedure to thyroid resection. From 1999 to 2002, LND of the central compartment (compartment A) was performed in 39 patients. Among this group, additional MRND of the ipsilateral compartment (compartment B) and the contralateral compartment (compartment C) was performed in 29 and 15 patients respectively, who met the selection criteria. The mean number of nodes resected was 11 (5–22) in compartment A, 23 (8–37) in compartment B, and 22 (10–31) in compartment C. Histopathologic findings revealed node invasion of compartment A in 25 patients (64.1%), of A and B in 20 patients (51,2%) and of A, B, and C in 13 patients (33.3%). From the 25 patients with metastases in compartment A, 80% (20 patients) already had metastases in compartment B and 52% (13 patients) had metastases in all three compartments. All patients free of metastasis (M0) in compartment A were also metastasis free in both lateral compartments. Postoperative whole-body scanning I¹³¹ in M0 patients showed no uptake at all. Mapping of the cervical anatomy in compartments seems to be a useful taxonomy for clarifying the lymphatic spread of PTC. Patients having PTC without metastasis in compartment A are almost certainly disease free at the time of operation. Lymph node metastasis in the central compartment appears to be a valuable indicator of lymphatic invasion of the lateral compartment and a strong indication for performance of a unilateral or bilateral MRND to complete the surgical removal of tumor. This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14–17, 2004. An erratum to this article is available at .     

Multifocal Versus Solitary Papillary Thyroid Carcinoma

Background

Papillary Thyroid Carcinoma (PTC) which accounts for >85 % of all thyroid cancers in iodine-rich areas, appears either as a single tumor or as two or more, neoplastic foci within the thyroid gland (Multifocal PTC). We present the comparative results between solitary and MFC PTC.

Materials and methods

Demographics, tumor characteristics (size, laterality, foci number, histologic subtype) and TNM staging were compared between solitary and MFPTC patients. The presence of lymphocytic or Hashimoto’s thyroditis was also recorded.

Results

From January 2008 to December 2012, among 647 PTC patients, 241(37.2 %) had MFPTC 177 females (73.4 %) and 64 males (26.6 %), mean age 48.5 years (range 12–87). Mean number of tumor foci was 3.3 (range 2–26). MFPTC patients presented with more advanced T stage (28.2 vs. 18.7 %, p = 0.01) and more LN metastases (28.6 vs. 15.5 %, p < 0.001). Foci number correlates with male gender and LN metastases (p = 0.014 and p = 0.019, respectively). Central (N1a) or lateral (N1b) LN involvement correlates strongly with male gender (p  = 0.024) and younger age (p < 0.001). The follicular variant was the next most frequent histologic subtype associated with extremely rare LN metastases.

Conclusion

MFPTC comprises a more aggressive form of papillary thyroid cancer since it is associated with more frequent N1a/ N1b disease and occurs more frequently in T3/T4 patients. MFPTC foci number correlates with male gender and LN metastases.

     

Optimal Surgery for Papillary Thyroid Carcinoma

n = 3100) would be required. Such a trial is critically dependent on the ability to select an appropriate endpoint. A cause-specific mortality trial proves to be the most objective and statistically valid endpoint.