Lymph node management in clinically node-negative patients with papillary thyroid carcinoma

Aims

Systematic lymph node dissection in patients with papillary thyroid carcinoma (PTC) remains controversial. The objective of this study was to study the pattern of lymph node spread in patients with PTC clinically node-negative and then to propose a lymph node management strategy.

Methods

We retrospectively reviewed the records of patients who had undergone total thyroidectomy and a systematic central neck dissection (CND) and lateral neck dissection. Ninety patients with PTC without lymph nodes metastases (LNM) detected on preoperative palpation and ultrasonographic examination were included.

Results

Forty-one patients (45.5%) had LNM. Twenty-eight patients (31%) had a central and a lateral involvement. Thirteen patients (14.5%) had only a central involvement. All the patients without LNM in the central compartment were also free in the lateral compartment. There was no correlation between LNM status and TNM staging.The largest LNM in the central compartment was smaller than or equal to 5 mm in 66% of the cases, and that could explain the lack of sensitivity of the preoperative ultrasonographic examination.

Conclusion

CND could be considered at preoperative or intraoperative diagnosis of PTC whereas lateral neck dissection should be performed only in patients with preoperative suspected and/or intraoperatively proven LNM. Systematic CND allows an objective evaluation of lymph node status in this central cervical area where the LNM are particularly small and difficult to detect preoperatively.     

Clinical outcomes in older or younger patients with papillary thyroid carcinoma: Impact of lymphadenopathy and patient age

Aims

To examine lymph node metastasis (LNM) from papillary thyroid carcinoma (PTC) according to clinicopathological features and outcomes associated with the nodal status.

Methods

We reviewed 231 patients with PTC (≥1.0 cm) who underwent initial thyroidectomy with modified neck dissection. LNM was examined in the central and lateral compartment and risk factors for disease-free survival (DFS) were evaluated. Nodal status and outcomes were further evaluated in four subgroups, 19 older patients (≥45 years old) with palpable lymphadenopathy (PLA) and 134 without PLA, and 11 younger patients (<45 years old) with PLA and 67 without PLA, because multivariate analysis revealed that age (p < 0.05, Hazard ratio (HR) 3.51) and PLA (p < 0.0001, HR 14.9) were risk factors for DFS.

Results

Central and lateral LNM were found in 176 and 151 patients. Seventeen exhibited skip metastasis. Recurrence and disease death occurred in 23 and 5. In analysis of the four subgroups, recurrence was significantly frequent in older patients with PLA than in younger patients with PLA or older patients without PLA (8/19 vs. 3/11 or 12/134). Younger patients without PLA did not exhibit recurrence.

Conclusions

Prognosis is worse in older patients with PLA. Such patients should be treated carefully with a considerable treatment strategy.     

Neck management in medullary thyroid carcinoma

Aims

The aims of this study were to retrospectively evaluate incidence and patterns of lymph node metastases, surgical treatment and prognostic factors of medullary thyroid carcinoma.

Methods

Out of a group of 70 MTC patients data of 67 patients were collected. Sixty-two of these patients underwent surgery. Apart from thyroidectomy, 16 patients underwent a bilateral neck dissection, 21 a unilateral neck dissection and 29 a paratracheal dissection or node-picking operation. Thirty-six patients were irradiated, of which 31 postoperatively and five with palliative intent.

Results

Lymph node metastases were found in 91% of the ipsilateral neck dissection specimens, 91% of the paratracheal dissections and 63% of the contralateral dissections. Of the 12 elective neck dissections, 5 were tumor positive. Level VI was positive in 91% of the cases where a dissection was done, whereas preoperatively only 16% were scored tumor positive. During follow-up 22 of the 67 patients developed one or more locoregional recurrences (in total 28 recurrences). The most important factors that were correlated with a worse prognosis of survival were late stage of disease (stage III and IV) (p = 0.0014), high number of positive lymph nodes (p = 0.0023) and incomplete surgical resection (p = 0.0002).

Conclusions

The high rate of locoregional recurrences in this study are a strong argument for a more aggressive approach to the primary and neck. A routine central and ipsilateral selective neck dissection of levels II–V should be considered in all MTC patients based on the high incidence of metastases and the relative low morbidity of a unilateral neck dissection. Patients referred after thyroidectomy alone with elevated (stimulated) calcitonin levels should be re-operated, performing an elective or therapeutic central and unilateral neck dissection.     

Sentinel lymph node biopsy in papillary thyroid cancer: Comparison study of blue dye method and combined radioisotope and blue dye method in papillary thyroid cancer

Aim

Occult lymph node metastasis is common in differentiated thyroid cancer (DTC). However, the role of lymph node dissection in the treatment of DTC remains controversial. The authors investigated the usefulness of methylene blue dye only method and combined radioisotope and methylene blue dye method for detecting SLN and compared the values of these two methods in patients with DTC.

Methods

From February to May 2008, 97 patients with DTC underwent sentinel lymph node biopsy (SLNB). The methylene blue dye method (dye only method) was used in 54 of the 97 patients, and radioisotope and methylene blue dye method (combined method) in 43 patients.

Results

The SLNs were identified in 89 patients, and the sensitivity and specificity of SLNB in the 97 patients were 85% and 100% respectively. For the dye only method, sensitivity, specificity, and the false negative rate (FNR) were 79%, 100%, and 21%; and for the combined method (43 patients) the corresponding figures were, 91%, 100%, and 9%, respectively. Six patients with SLN metastasis in the lateral neck underwent additional modified radical neck dissection (MRND).

Conclusions

SLNB was found to be feasible, repeatable, and accurate in evaluating the lymph node status in patient with DTC. The present study indicates that the combined method could reduce false negative rate and increase detection rates of sentinel lymph node metastases, especially in lateral neck, compared to the dye only method.     

Sentinel lymph node biopsy as guidance for central neck dissection in patients with papillary thyroid carcinoma

BACKGROUND.

Occult lymph node metastasis of papillary thyroid carcinoma (PTC) can be detected by sentinel lymph node (SLN) biopsy, but studies in larger patient cohorts undergoing complete central neck dissection may be required to assess the diagnostic accuracy of SLN. Therefore, the authors prospectively assessed the usefulness of SLN biopsy for the detection of central lymph node metastasis in patients with differentiated PTC who had no suspicious cervical lymphadenopathy.

METHODS.

After peritumoral injection of methylene blue, SLN biopsy was performed in 50 patients with newly diagnosed PTC who had no palpable or ultrasound (US)‐detected lymph node involvement. After SLN biopsy, all patients underwent total thyroidectomy and central neck dissection. The diagnostic accuracy of intraoperative SLN sampling was calculated by comparison with the final pathologic diagnosis.

RESULTS.

SLNs were identified in 46 of 50 patients (92%); of these, 14 SLNs were positive and 32 SLNs were negative on intraoperative frozen sections. One patient had a positive SLN in the jugular region and subsequently underwent modified radical neck dissection. Final pathologic examination revealed that 18 patients (36%), including 4 who had negative SLNs, had central lymph node metastasis. Thus, the sensitivity, specificity, accuracy, and positive and negative predictive values of SLN biopsy were 77.8%, 100%, 92%, 100%, and 88.9%, respectively. Temporary and permanent hypocalcemia developed in 19 patients and 1 patient, respectively. There were no direct complications of SLN sampling.

CONCLUSIONS.

SLN biopsy in patients with PTC without gross clinical or US lymph node involvement was able to detect occult metastasis with high accuracy and may have the potential to select patients who require central neck dissection. Cancer 2008. © 2008 American Cancer Society.     

Total laparoscopic radical hysterectomy and pelvic lymphadenectomy in patients with Ib1 stage cervical cancer: Analysis of surgical and oncological outcome

Aim

To evaluate safety, feasibility and oncological outcome of total laparoscopic radical hysterectomy (TLRH) in patients with early invasive cervical cancer.

Methods

Data of patients with Ib1 cervical cancer who underwent TLRH were prospectively collected. Inclusion criteria were: good general condition, tumor size <3 cm, and no evidence of lymph node metastases in imaging study (MRI and/or CT and/or PET). Radical hysterectomy was performed with a PlasmaKinetic tissue management system. Adjuvant therapy was administered according to surgical risk factors.

Results

Between September 2001 and October 2007 107 patients underwent laparoscopic radical hysterectomy and pelvic lymphadenectomy. Conversion to laparotomy was necessary in 6 patients. Median number of resected pelvic lymph nodes was 26. Median blood loss was 200 ml and median duration of surgery was 305 min. Minor intraoperative complications were registered in two patients, while five patients needed a second surgery for postoperative complications. Thirteen patients had microscopic nodal metastasis. A total of 24 patients received adjuvant therapy. After a median follow-up of 30 months 11 patients had a recurrence; survival rate is 95%.

Conclusion

Total laparoscopic radical hysterectomy, in experienced hands, has to be considerate an adequate and feasible surgical technique. Considering historical data the oncological outcome can be considered comparable to patients treated with laparotomy, as the relapse rate in our population was 11% and the overall survival good.     

Metastasis of oral cancer to the parotid node

Background

The parotid node is an uncommon site of metastasis in head and neck cancer. This study was intended to clarify the incidence and indicators of oral cancer metastases to the parotid node.

Patients and methods

We reviewed the records of 253 patients with oral carcinomas who had undergone a total of 289 neck dissections between April 2001 and December 2006. The histologic diagnoses of the primary tumors were squamous cell carcinoma in 239 patients, mucoepidermoid carcinoma in 5, adenoid cystic carcinoma in 4, and miscellaneous others in 5. In all neck dissections, the tail of the parotid gland below the marginal mandibular branch of the facial nerve was resected. The cervical and parotid lymph nodes were isolated from the surgical specimens. One section through the maximum cross-sectional area of each node was examined histologically.

Results

From 183 of the 289 neck specimens, we collected 539 parotid nodes: 222 extraglandular and 317 intraglandular. Of the 253 patients, 10 (4.0%) had 19 parotid node metastases, of which 4 were extraglandular and 15 intraglandular. Parotid node involvement occurred in 2.5% of oral squamous cell carcinoma cases. For the other cancers, there were too few cases to determine a meaningful frequency. In terms of indicators, the likelihood of metastasis to the parotid nodes increased with the number of cancer-positive cervical nodes.

Conclusions

Metastasis to the parotid nodes should be considered in patients with oral cancer. Resection of the tail of the parotid gland is warranted during the neck dissection.     

Role of robot-assisted laparoscopy in adjuvant surgery for locally advanced cervical cancer

Objective

The aim of this study was to compare the feasibility and efficacy of robot-assisted laparoscopy with traditional laparotomy and conventional laparoscopy in a series of patients with locally advanced cervical cancer managed in our two institutions.

Methods

Twenty-two patients who underwent robot-assisted laparoscopy were compared with 20 patients who underwent adjuvant surgery by laparotomy and 16 who underwent conventional laparoscopy, before the arrival of the Da Vinci surgical system.

Results

There was no significant difference between the three groups in terms of body mass index, FIGO stage, or tumor histology. The complication rate was similar in the three groups of patients, although there was a trend towards more lymphatic complications in the robot-assisted subgroup managed medically. There was no significant difference in the recurrence rate between the robot-assisted laparoscopy, conventional laparoscopy and laparotomy groups (27.3%, 29.4% and 30%, respectively).

Conclusion

Robot-assisted laparoscopy is feasible after concurrent chemoradiation and brachytherapy in cases of locally advanced cervical cancer. This new surgical approach reduces hospital stay, and seems to result in less severe complications than conventional laparotomy without modifying the oncological outcome.     

Predictive factors of skip metastases to lateral neck compartment leaping central neck compartment in papillary thyroid carcinoma

Skip metastasis, referred to as leaping metastasis to the lateral neck without associated lymphadenopathy in the central compartment (level VI), can occur in patients with papillary thyroid carcinoma (PTC). However, there have been few studies on its predictive value in PTC patients. We reviewed the medical records of 90 patients who underwent simultaneous central and lateral neck lymph node dissection for the primary treatment of lymph node metastasis in the lateral neck of PTC patients. No patient was suspected of having metastasis in the central compartment by preoperative imaging study. The frequency of skip metastasis to the lateral neck compartment without central neck metastasis was 19% (17/90). The number of metastatic lymph nodes dissected in the lateral neck of patients with and without skip metastasis was 5.1±2.7 and 9.5±2.6, respectively (P<0.001). Skip metastasis was closely associated with significantly fewer lymphovascular invasion (P=0.009) and extracapsular spread (P=0.035). Skip metastasis can occur significantly frequently in PTC patients. The presence of lymphovascular invasion, extracapsular spread, and number of positive lymph nodes dissected were inversely correlated with skip metastasis.     

Plastic surgery for breast conservation therapy: How to define the volume of the tumor bed for the boost?

Purpose

To describe the procedure of definition of the boost volume using pre- and post-operative computed tomography (CT) and surgical clips in the tumor bed after oncoplastic surgical procedure.

Patients and methods

Thirty-one consecutive breast cancer patients who underwent simple lumpectomy or oncoplastic surgery were studied. All of them underwent pre- and post-operative CT scan in treatment position to evaluate the planning target volume (PTV) boost volume and define the primary tumor (gross tumor volume (GTV)) and tumor bed zones (CTV), with an overall margin of 5 mm in lateral and 10 mm in craniocaudal directions, corresponding to localization and setup uncertainties.

Results

Thirteem patients underwent simple lumpectomy and 18 oncoplastic surgery. The volumetric analysis showed that the intersection between GTV and CTV clips was significantly higher in patients with three and more clips (28.4% vs 3.14%; p < 0.001). In the case of patients with oncoplastic surgery, more than three clips were needed to define the tumor bed volume with accuracy. The number of clips was directly related to the exact definition of the boost volume.

Conclusions

The use of more than three clips allows better definition of the PTV boost volume after oncoplastic surgical procedure.     

Utility of FDG PET in patients with squamous cell carcinomas of the oral cavity

Background

The utility of ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in oral cavity cancer has received little attention in a clinician's perspective. We systematically evaluated the clinical roles of FDG PET in patients with oral cavity squamous cell carcinomas (SCCs).

Methods

Between August 2001 and February 2005, 82 new patients with resectable oral cavity SCCs underwent CT/MRI and FDG PET at initial staging and follow-up. The sensitivity and specificity of CT/MRI and FDG PET for neck metastases were compared with histopathologic reference of 67 patients who underwent neck dissection. The relationships between the maximal standardized uptake value (SUV) of primary tumors and clinicopathologic parameters, such as gender, age, tumor thickness, local invasiveness, T and N categories, tumor-node-metastasis stage, and histological grade, as well as with disease-free survival (DFS), were assessed.

Results

FDG PET was more sensitive than CT/MRI for detecting cervical metastases on a level-by-level basis (38/43 vs. 28/43; P = 0.002). Age, T and N categories, tumor thickness (>8 mm) and SUV (>5.0) were also significant variables of 3-year DFS in univariate analysis. T category was an independent determinant of DFS in multivariate analysis (P < 0.05). During a mean follow-up of 36 months, FDG PET correctly diagnosed locoregional recurrences in 20 patients, distant metastases in six and second cancers in five.

Conclusion

FDG PET may have potential roles in initial staging, survival prediction, and the detection of recurrences and second cancers.     

Contrast enhanced ultrasound should be the initial radiological investigation to characterise focal liver lesions

Introduction

Contrast enhanced ultrasound (CEUS) involves the administration of a microbubble contrast agent followed by a US scan to evaluate the liver lesion through all phases of enhancement. Although technical difficulty and operator dependence can be encountered, CEUS is thought to be superior to conventional US and CT. This study aims to determine how effective CEUS is at characterising focal liver lesions and to establish its role in the diagnostic algorithm.

Methods

All patients who underwent a liver CEUS performed by a single consultant radiologist were identified over a 5 year period. The CEUS report, CT, MRI and/or PET report, histopathology report and case notes were reviewed.

Results

127 patients were included. CEUS correctly identified 71 of 77 malignant lesions and all of the benign liver lesions. The sensitivity of CEUS for detecting and correctly characterising a malignant FLL is therefore 92% with a specificity of 100%.

Conclusion

Our study shows that CEUS has a high sensitivity and specificity for characterising focal liver lesions. CEUS has advantages over CT and MRI of a high degree of safety, good patient tolerance and often availability at the time of initial detection. We therefore suggest that CEUS should be used as the initial study in the characterisation of FLLs. The study should be followed, as appropriate, by CT and MRI or PET studies. Biopsy, with its risks of tumour seeding and false negative results should only be considered after review of the imaging studies and full MDT discussion.     

Surgery for melanoma metastases of the gastrointestinal tract: Indications and results

Aim

To assess survival, morbidity and mortality following therapeutic or palliative resection of gastrointestinal (GI) tract melanoma metastases.

Methods

A retrospective case series of 117 patients who underwent surgical resection of GI melanoma metastases between 1981 and 2005 was reviewed.

Results

The 117 patients underwent 142 operations for acute and/or sub-acute symptoms or for imminently symptomatic GI metastases detected radiologically. The intent of the surgery was palliative in 53 (37.3%) and therapeutic in 89 (62.7%) operations. The most common symptoms were due to anaemia (40.8%) or bowel obstruction (32.4%). The most frequently performed operation was small bowel resection (76.8%). Preoperative imaging and/or endoscopy were used in 83 cases, with computerised tomography (CT) being most frequent (85.5%). CT had a sensitivity of 68.8% when used alone to detect the presence of GI metastases in the study population. The mortality rate following GI resection was 1.4%, and 2.5% of patients had post-operative complications. Overall 5-year survival was 27%. On multivariate analysis, the presence of residual intraabdominal disease and the presence of non-GI metastases at the time of surgery or after surgery were the most significant prognostic indicators of survival.

Conclusions

Resection of GI melanoma metastases is safe, relieves symptoms and can achieve prolonged remission. In patients with limited disease, an aggressive surgical approach to symptomatic or imminently symptomatic GI melanoma metastases is warranted.     

Incidence and location of positive nonsentinel lymph nodes in head and neck melanoma

Background

The complex lymphatic drainage in the head and neck makes sentinel lymph node biopsy (SLNB) for melanomas in this region challenging. This study describes the incidence, and location of additional positive nonsentinel lymph nodes (NSLN) in patients with cutaneous head and neck melanoma following a positive SLNB.

Methods

A retrospective review was performed using a single institution prospective database. Patients with a primary melanoma in the head or neck with a positive cervical SLNB were identified. The lymphadenectomy specimen was divided intraoperatively into lymph node levels I–V, and NSLN status determined for each level.

Results

Of 387 patients with melanoma of the head and neck who underwent cervical SLNB, 54 had a positive SLN identified (14%). Thirty six patients (67%) underwent immediate completion lymph node dissection (CLND) of whom eight patients (22%) had a positive NSLN. The remaining 18 patients (33%) did not undergo CLND and were observed. Half of positive NSLNs (50%) were in the same lymph node level as the SLN and 33% were in an immediately adjacent level; only two patients were found to have NSLNs in non-adjacent levels. The only factor predictive of NSLN involvement was the size of the tumor deposit in the SLN>0.2 mm (p = 0.05). Superficial parotidectomy at CLND revealed metastatic melanoma only in patients with a positive parotid SLN.

Conclusions

A positive NLSN was identified in 22% of patients undergoing CLND after a positive SLNB. The majority of positive NSLNs are found within or immediately adjacent to the nodal level containing the SLN.     

Routine staging laparoscopy has no place in the management of colorectal liver metastases

Aims

Staging laparoscopy has been recommended in the management of patients with colorectal liver metastases prior to hepatectomy in order to reduce the incidence and associated morbidity of futile laparotomies. The utility of staging laparoscopy has not been assessed in patients undergoing CT, PET-CT and MRI as standard preoperative staging.

Methods

All patients undergoing attempted open hepatectomy for colorectal liver metastases between 1/4/2008 and 31/3/2012 were identified from a prospectively maintained research database. All patients who underwent futile laparotomy were identified, with demographics and operative notes subsequently analysed.

Results

A total of 274 patients underwent attempted open hepatectomy during the study period. At laparotomy 12 (4.4%) patients were found to have irresectable disease. There were no unifying demographic factors within the patients undergoing futile laparotomy.

Conclusions

With modern imaging, the potential yield of staging laparoscopy is low. Staging laparoscopy should not be used routinely, but may have a role in the case of specific clinical concerns.     

甲状腺乳头状癌颈部淋巴结转移特点及清扫策略

背景与目的：目前,在甲状腺癌颈淋巴结清扫方面存有较大分歧。该研究总结甲状腺乳头状癌淋巴结转移的特点,为择区淋巴结清扫提供理论依据。方法：回顾性分析2006年7月—2014年8月收治的462例甲状腺乳头状癌患者病历资料,分析其淋巴结转移规律及其影响因素,评判cN0标准的准确性。结果：全组患者均行患侧中央区(Ⅵ区)淋巴结清扫,320例行侧颈区淋巴结清扫术(Ⅱ～Ⅴ区)或择区淋巴结清扫(Ⅱ～Ⅳ区中的部分或全部),90例行对侧中央区淋巴结活检。73.2%(338/462)符合cN0标准,病理证实其中有184例淋巴结转移,cN0标准误诊率达60.9%。颈部淋巴结总转移率为65.4%(302/462),侧颈区淋巴结转移率为42.6%(197/462),“跳跃转移”率为13.1%(42/320),对侧中央区淋巴结转移率为50%(45/90)。男性、肿瘤累及腺叶上1/3、肿瘤T3或T4、多中心病灶是淋巴结转移的危险因素。肿瘤累及腺叶上1/3是喉前淋巴结转移及“跳跃转移”的危险因素。喉前淋巴结转移及中央区淋巴结2个以上转移者侧颈区淋巴结转移率显著增加(分别为85.7%和83.3%, P＜0.05)。结论：现行cN0标准不能作为确定淋巴结清扫范围的依据;甲状腺乳头状癌易发生淋巴结转移,其中Ⅵ区淋巴结转移率最高,依次为Ⅲ区、Ⅱ区、Ⅳ区、Ⅴ区;初次手术应常规清扫患侧中央区淋巴结,建议将Ⅵ区淋巴结送冰冻病理;当喉前淋巴结有转移或Ⅵ区2个以上淋巴结转移时,或肿瘤累及腺叶上1/3者,有必要行侧颈区(或择区)淋巴结清扫;对侧中央区淋巴结转移率较高,需予以重视;中央区淋巴结再分亚区具有重要意义,应深入研究。     

Impact of probe pressure variability on prostate localization for ultrasound-based image-guided radiotherapy

Purpose

To evaluate the impact of transabdominal probe pressure on prostate positioning with an intramodality ultrasound (US) image-guided-radiotherapy system and to quantify pressure variability over the treatment course.

Material and methods

8 prostate cancer patients (group A) and 17 healthy volunteers underwent 3 consecutive US images with increasing probe pressure levels, and 1 CT acquisition for the group A only. Prostate positions were compared after manual registration of the first US image contour projected on 2 others. Group A’s pressure levels were quantified by measuring skin-to-skin distances between corresponding CT–US images. The same methodology was used on paired CT/CBCT–US images acquired during treatments of 18 prostate cancer patients to determine whether the different pressure levels applied to the group A were close to the clinical practices and to quantify pressure variability along the treatment course.

Results

84% of 3D prostate displacements were above 2 mm for at least one pressure level. Probe pressures deliberately applied were similar to the ones observed clinically. The latter drastically varied between sessions.

Conclusion

Even with an intramodality system, probe pressure can impact prostate localization because of the pressure variability along the treatment course. Therefore, margins should be expanded from 0.5 to 1.2 mm to ensure treatment accuracy.     

Development of “extended radical retropubic prostatectomy”: A surgical technique for improving margin positive rates in prostate cancer

Aims

The objective of this study was to introduce a surgical approach called “extended radical retropubic prostatectomy (ERRP)” developed to reduce positive surgical margin rates in prostate cancer.

Methods

Modified surgical procedures in ERRP included apical dissection (division of the dorsal venous complex far distal to the prostatic urethral junction), excision of the bilateral neurovascular bundles (wide resection of structure between the exterior of the urethra and the rectal surface, which contains the neurovascular bundle), perirectal dissection (complete resection of perirectal tissue by dissecting the anterior rectal surface until the muscle layer of the rectum was encountered) and seminal vesicle excision (dissection that leaves seminal vesicles protected by Denonvilliers' fascia with the surrounding fatty and fascial coverings without pulling seminal vesicles from the prostate). This study included 127 consecutive patients who did not request the preservation of potency and underwent ERRP without any neoadjuvant therapies.

Results

Median value of preoperative serum prostate specific antigen in 127 patients was 18.1 ng/ml. Median operative time and estimated blood loss in these patients were 209 min and 744 ml, respectively. The pathological stage was diagnosed as pT2, pT3a, pT3b and pT4 in 51, 52, 20 and 4, respectively, while positive surgical margin was detected in 14 of the 127 patients. Furthermore, during the observation period of this study (median, 46 months), biochemical recurrence was detected in 11 of the 127 patients.

Conclusions

The ERRP technique could successfully decrease the positive surgical margin rate even in patients with comparatively adverse disease characteristics.     

Patterns of lymph node spread and its influence on outcome in resectable parotid cancer

Aim

To assess the metastatic topography of intraparotideal and neck lymph nodes in parotid cancer and its influence on tumour recurrence and survival.

Methods

The lymph node spread of 142 patients with primary parotid carcinoma treated from 1986 to 2006 was analysed. Disease-free survival (DFS) and overall survival (OS) were calculated. The role of the metastatic pattern as prognostic factors were univariately and multivariately analysed.

Results

A lateral, total or radical parotidectomy was performed in 19, 80 and 43 patients, respectively. A radical/radical-modified or selective neck dissection was performed in 68 and 74 patients, respectively. Eighty-seven neck dissection specimens were negative (pN0). Twelve patients had intraparotideal and cervical lymph node involvement (pPar+/pN+). In 24 patients only intraparotideal metastases were detected (pPar+/pN0). 19 patients only had cervical nodal involvement (pPar−/pN+). Twenty-five patients had occult locoregional lymph metastases (cN0/pN+). The median follow-up was 24.4 months. The disease-free survival rate was 81% at 5 years, and 62% at 10 years. By univariate analysis, R+ (p = 0.001), pT (p = 0.019), lymphangiosis carcinomatosa (p = 0.019), pN+ (p = 0.042), and extracapsular spread (p = 0.046) were prognostic for disease-free survival. Multivariate analysis revealed R+ as independent risk factor (p = 0.046). In pN+ patients, involvement of parotid lymph nodes (p = 0.013), nodes in neck level I (p < 0.0001) and IV (p = 0.005) were univariate risk factors. Multivariate analysis showed lymph node metastases in level I as independent risk factor (p = 0.022).

Conclusion

Total parotidectomy and radical-modified neck dissection is recommended as surgical treatment of parotid cancer and should be analysed in a prospective trial.     

The role of F-FDG PET/CT in detecting metastatic deposits of recurrent medullary thyroid carcinoma: A prospective study

Aim

To assess the diagnostic role of ¹⁸F-FDG PET/CT performed with a hybrid tomograph in the detection of tumoral deposits of recurrent medullary thyroid carcinoma (MTC).

Methods

Nineteen MTC patients with elevated serum calcitonin levels (58–1350 pg/ml) after first treatment were enrolled (11 F, 8 M, mean age 53.4 years, 14 sporadic MTC, 5 MEN-related MTC). All patients had previously undergone total thyroidectomy and lymphoadenectomy. When referred to us, they were studied with ultrasound (US), ¹⁸F-FDG PET/CT, ¹¹¹In-pentetreotide scan, and contrast-enhanced whole-body CT (c.e. CT). In 4 patients with equivocal abdominal findings at ¹⁸F-FDG PET/CT and/or at c.e. CT, laparoscopy was also performed.

Results

¹⁸F-FGD PET/CT depicted metastases in 15 patients, ¹¹¹In-pentetreotide in 8, c.e. CT in 11, US in 6. In 2 patients, liver micrometastases were detected at laparoscopy only. At a lesion-by-lesion analysis, ¹⁸F-FDG PET/CT visualized a total of 26 metastatic deposits, c.e. CT 18, ¹¹¹In-pentetreotide 12, US 8. Final diagnosis was obtained by cytological or surgical findings. Four patients with evidence of limited metastatic spread to neck/upper mediastinum were re-operated, and in 2 of them serum calcitonin levels normalized.

Conclusions

In our study, ¹⁸F-FDG PET/CT was the most sensitive imaging modality in detecting metastases in recurrent MTC patients with increased serum calcitonin levels. Moreover, ¹⁸F-FDG PET/CT was useful in some patients to plan a more accurate re-operation. From a diagnostic point of view, a multimodality imaging approach is recommended in recurrent MTC, especially based on the combination of c.e. CT and ¹⁸F-FDG PET/CT.