Surgical complications after thyroid surgery performed in a cancer hospital.

OBJECTIVE: This study evaluates the incidence and risk factors of complications in patients submitted to thyroidectomy in a cancer hospital with residency training. STUDY DESIGN: A retrospective chart and complications review of 1020 patients (1990-2000) underwent to thyroidectomy. RESULTS: At our cancer hospital, 1020 patients underwent thyroidectomy. The main postoperative complications consisted of transient hypocalcemia in 134 (13.1%) patients, permanent hypocalcemia in 26 (2.5%) patients, transient vocal cord palsy in 14 (1.4%) patients, and permanent vocal cord palsy in 4 (0.4%) patients. The type of thyroidectomy, neck dissection, and paratracheal lymph node dissection were significantly associated with transitory and permanent hypocalcemia. CONCLUSION: Thyroid surgery can be performed safely in a surgical residency training program under direct supervision of an experienced surgeon with little morbidity to the patients. Hypocalcemia is the most significant complication. Neck and paratracheal lymph node dissections were the most significant predictors of hypocalcemia in patients who underwent total thyroidectomy.     

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.     

Hypocalcemia following total thyroidectomy: early factors predicting long-term outcome

Hypocalcemia following total thyroidectomy (TT) must be considered permanent in patients requiring calcium replacement after one year. The aim of this study was to identify early risk factors predicting long-term outcome of postoperative hypocalcemia. Among 453 patients who underwent TT from January 1998 to May 2003, a cross-sectional study between 44 patients with transient hypocalcemia (9.7%) and 3 patients with permanent hypocalcemia (0.7%) was carried out. Both low serum calcium level (< 8 mg/dl) and high serum phosphorus level (> 4.5 mg/dl), measured on postoperative day 7, were predictive for outcome. Central neck lymph node dissection, performed for thyroid carcinoma, also correlated with outcome. Serum phosphorus level > 4.5 mg/dl on postoperative day 7 resulted the only independent factor predicting permanent hypoparathyroidism. Therefore indication for central dissection would be very strict. When serum phosphorus level is unfavorable a correct replacement therapy is mandatory to prevent the consequences of permanent hypocalcemia.     

Parathyroid hormone: A sensitive predictor of hypocalcemia following total thyroidectomy

OBJECTIVE: To investigate whether monitoring parathyroid hormone (PTH) could predict hypocalcemia following total thyroidectomy or other bilateral thyroid manipulations. STUDY DESIGN AND SETTING: Forty patients undergoing total thyroidectomy as well as other bilateral thyroid procedures were prospectively enrolled. PTH levels were measured preoperatively and 30 minutes postoperatively. Calcium levels were measured preoperatively and every 8-12 hours for the first 72 postoperative hours. Changes in PTH levels as well as symptoms of hypocalcemia were correlated with postoperative hypocalcemia. RESULTS: Hypocalcemia developed in 13/40 patients (32.5%), mainly those patients undergoing total thyroidectomy in conjunction with paratracheal neck dissections. The respective sensitivity and specificity of a drop in PTH for detecting hypocalcemia was 92% and 66% (50% drop), 23% and 75% (75% drop), and 46% and 100% (drop below normal range). CONCLUSIONS: A 50% drop in PTH levels 30 minutes following bilateral thyroid procedures is a sensitive predictor of hypocalcemia. A drop of 75% is a highly specific indicator of postoperative hypocalcemia, though not highly sensitive. EBM RATING: C-4.     

Nodal yield, morbidity, and recurrence after central neck dissection for papillary thyroid carcinoma

BACKGROUND: The role of central neck dissection (CND) in differentiated thyroid cancer remains controversial. This study aims at elucidating the potential benefits and drawbacks of CND associated to total thyroidectomy in papillary cancer. METHODS: Protocols of patients undergoing total thyroidectomy and CND for papillary cancer were reviewed. The following data were recorded: macroscopic appearance of central nodes; nodes obtained at operation; number of metastatic nodes and parathyroid glands incidentally resected; metastases, age, completeness, invasiveness, size score; postoperative s-Ca; complications; and recurrences. Differences between therapeutic (gross nodal involvement) and prophylactic (no apparent node involvement) CNDs were studied. RESULTS: Forty-three patients (mean age, 52 +/- 17 years) were studied. A mean of 8.4 +/- 6.6 nodes were resected per patient. A 60% prevalence (26/43) of presence of nodal involvement (N+) was found with no difference between low- and high-risk patients. Twenty-five (60%) patients developed transient hypocalcemia, which was associated with incidental parathyroidectomy, number of nodes resected, and thymectomy. Two patients (4.6%) developed permanent hypoparathyroidism and 3 (7%), transient vocal cord paralysis. Parathyroid glands were found in 19% of the specimens. At follow-up, there were no central neck recurrences, but 5 patients developed lateral recurrences despite treatment with I(131). All 5 patients had had therapeutic CND with 6 or more metastatic nodes obtained in the CND specimen. No lateral neck recurrences were observed after prophylactic CND or in patients with < 6 nodes involved. CONCLUSIONS: CND prevents central neck recurrences. Morbidity of bilateral CND is significant, and its systematic implementation in the absence on gross nodal involvement requires reassessment.     

Is Thymectomy Worthwhile in Central Lymph Node Dissection for Differentiated Thyroid Cancer?

Background

Clinical guidelines edited in 2006 by the American Thyroid Association (ATA) and stated in the European Thyroid Association Consensus (ETA) recommend routine central lymph node dissection (level VI neck dissection) in addition to thyroidectomy for the surgical treatment of differentiated thyroid cancer. This central dissection increases the incidence of postoperative hypocalcemia, which is related to the resection or devascularization of the inferior parathyroids together with bilateral thymectomy. Some authors perform unilateral thymectomy in order to minimize this complication. Our aim was to study the benefit/risk (incidence of thymic lymph node metastases versus postoperative hypocalcemia) of both procedures.

Methods

We retrospectively reviewed the records of 138 patients who underwent total thyroidectomy with central neck lymph node dissection for differentiated thyroid cancer between 2004 and 2007. Bilateral thymectomy was performed in 45 patients (group 1, 15 males and 30 females) and unilateral thymectomy was performed in 93 patients (group 2, 27 males and 66 females). Forty-two papillary and 3 medullary cancers were found in group 1, and 75 papillary, 2 follicular, and 17 medullary cancers were found in group 2. The presence of thymic metastases at pathology and the occurrence of postoperative hypocalcemia were reviewed.

Results

Two cases of papillary thymic metastases were found in group 1. These were lymph node micrometastases localized in the ipsilateral side of the primary tumor in both cases. Transient hypocalcemia was significantly more frequent (P < 0.001) in group 1 than in group 2: 16 patients (35.5%) versus 10 (10.7%). There was one case of permanent hypocalcemia in group 1 after the follow-up period.

Conclusions

Bilateral thymectomy risk outweighs any likely carcinologic benefit. We do not recommend routine bilateral thymectomy during central neck dissection for differentiated thyroid cancer.     

Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone

OBJECTIVE: To investigate the pattern of nodal metastasis, morbidity, recurrence rates of papillary thyroid carcinoma (PTC), and parathyroid hormone (PTH) responses following neck dissection (ND) plus total thyroidectomy (TT). SUMMARY BACKGROUND DATA: While hypoparathyroidism develops after TT plus ND, little is known of postoperative PTH response. METHODS: Of 155 PTC patients, 82 underwent TT plus bilateral central ND with/without lateral ND, while 73 underwent TT alone. The nodal metastasis pattern was determined and the recurrence, morbidity, and postoperative levels of serum calcium and PTH were compared between 2 groups. RESULTS: Of the 82 node dissection patients, metastatic nodes were present in the central neck of 51 (62.2%) and the lateral neck of 21 (25.6%) patients, most frequently in the ipsilateral and pretracheal central nodes and lateral jugular nodes. Four regional recurrences (2.6%) were found in 3 patients of the no node dissection group and one of the node dissection group (P = 0.37) during the follow-up lasting a mean 52 months. Overall morbidity and hypocalcemia was higher in the node dissection group than the no node dissection group (41 of 82, 50%; vs. 9 of 73, 12.3%; P < 0.001; 25 of 82, 30.5%; vs. 7 of 73, 9.6%; P = 0.001). Serum PTH levels significantly decreased immediately postoperatively in the node dissection group and remained low for several weeks thereafter. CONCLUSIONS: Serum PTH levels were significantly reduced following ND in PTC patients. Our data suggest that, when performing therapeutic ND plus TT, particular effort should be made to preserve the parathyroid glands and to monitor their function.     

221例甲状腺癌的外科治疗体会

目的 探讨甲状腺癌的诊断和外科治疗方法。方法 回顾性分析我院2003年1月-2007年12月间收治的221例甲状腺癌患者的临床资料。甲状腺次全切除161例，甲状腺全切57例，姑息性手术3例。除3例行姑息性手术外其余所有患者均常规颈部中心区淋巴清扫。结果 术后病理检查证实有淋巴转移者为40．3％（89／221）。术后并发症包括5例短暂喉返神经麻痹，37例短暂低血钙抽搐，1例永久性甲状旁腺功能低下，2例术后颈部血肿。本组患者术前B超检查均发现甲状腺内实性或囊实性低回声结节，其中结节内伴微钙化灶者79例（35．7％）。获得随访187例患者，随访率为84．6％，随访6月～5年，除未分化癌患者术后7月死亡，其余患者均存活。结论 患侧甲状腺＋峡部＋对侧甲状腺大部分切除＋中心区淋巴清扫是甲状腺癌的主要手术方式，术前高频B超检查提示甲状腺结节内沙砾微钙化灶对甲状腺癌的术前诊断有重要意义。     

Central Cervical Nodal Metastasis from Papillary Thyroid Microcarcinoma: Pattern and Factors Predictive of Nodal Metastasis

Background  Although several factors are thought to predict the occurrence of lymph node metastases from papillary thyroid microcarcinoma (PTMC), the pattern of nodal metastasis has been rarely studied. We evaluated the pattern and factors predictive of central cervical metastasis from PTMC. Methods  Seventy-two patients with PTMC underwent total thyroidectomy and central neck dissection, including three who underwent therapeutic modified radical neck dissection. Lymph node involvement was analyzed by neck subsite, and clinicopathologic variables predictive of nodal metastasis were determined. Results  Central and lateral nodal metastases were found in 29 (40.3%) and 3 (4.2%) patients, respectively, and ipsilateral paratracheal, pretracheal, superior mediastinal, and contralateral paratracheal lymph node metastases in 27 (37.5%), 8 (11.1%), 4 (5.6%), and 1 (1.4%), respectively. Sex, age, tumor size, multifocality, bilaterality, extracapsular invasion, lymphovascular invasion, and MACIS (metastases, age, completeness of resection, invasion, size) for central node metastasis were not predictive of metastasis (P > .1). Temporary and permanent hypocalcemia was observed in 17 (23.6%) and 1 (1.4%) patients, respectively, and transient vocal fold paralysis in 1 (1.4%). Conclusion  Despite the absence of palpable neck nodes, PTMC is associated with a high rate of central lymph node metastasis to ipsilateral and pretracheal subsites. No clinicopathologic factor predicted nodal metastasis. In patients with PTMC involving one lobe and positive nodes, neck dissection may exclude the contralateral side.     

Complications associated with different surgical approaches to differentiated thyroid carcinoma

Introduction: With the good prognosis associated with differentiated carcinoma, the morbidity and mortality of different surgical approaches are of crucial importance. Methods: At the Department of Surgery (Virchow Klinikum Berlin), 139 patients who underwent surgery for differentiated thyroid carcinoma between 1979 and 1994 were reviewed, focussing on postoperative complications. In 113 and 18 patients, respectively, primary and completion thyroidectomy was performed. In five patients, less than total thyroidectomy and in three patients only palliative surgery was carried out. We performed thyroidectomy without systematic lymphadenectomy (LAD) in 70 patients (51.1%). In 15 patients (10.8%), lymphadenectomy of the lateral compartment and, in 53 patients (38.1%), central LAD was performed. LAD did not significantly influence survival time in either follicular (n = 42) or papillary carcinoma (n = 97). Results: No patient died because of postoperative complications. Permanent laryngeal nerve palsy occurred in no patients after thyroidectomy without LAD, in one patient after central LAD (1.9%) and in one patient after lateral LAD (6.7%). Transient laryngeal nerve palsy was seen in ten patients [six (8.6%) after thyroidectomy only, two (3.7%) after central LAD and two (13.3%) after lateral LAD] (P = 0.19). Hypocalcemia was distributed equally within the LAD groups: total transient hypocalcemia could be recorded in 54 patients (38.8%), but permanent hypocalcemia occurred only in one patient (0.7%). Postoperative recovery was delayed in patients when a more radical approach was used (P = 0.03). Conclusion: The magnitude of the benefit of LAD in therapy for differentiated thyroid carcinoma is still controversial. This more radical approach is not necessarily accompanied, however, by higher morbidity and mortality. Received: 30 January 1998 Accepted: 18 July 1998     

Is it possible to intraoperatively modulate the extent of thyroidectomy in small papillary thyroid carcinoma?

BackgroundThyroid lobectomy is the preferred option for small, unifocal papillary thyroid carcinoma. Involvement of the central neck lymph nodes is an indication for total thyroidectomy plus central neck dissection. We aimed to verify if frozen section examination of ipsilateral central neck nodes can identify the subgroup of patients scheduled for thyroid lobectomy intraoperatively who could benefit of more extensive initial operative treatment.MethodsNinety-four consenting patients with clinically unifocal cN0 papillary thyroid carcinoma underwent thyroid lobectomy plus ipsilateral central neck dissection with frozen section examination. If the frozen section examination was positive for metastases, a completion thyroidectomy and a bilateral central neck dissection were accomplished during the same procedure.ResultsFrozen section examination identified occult nodal metastases in 25 of the 94 patients who then underwent immediate completion thyroidectomy and bilateral central neck dissection. Overall, central neck node metastases were found at final histology in 35 cases: occult micrometastases were observed in additional 9 patients and nodal metastases ≥2 mm in additional 1 patient.ConclusionIntraoperative assessment of nodal status obtained with ipsilateral central neck dissection and frozen section examination is able to change the extent of thyroidectomy in about one-fourth of patients scheduled for thyroid lobectomy. Frozen section examination appears a safe and effective strategy to decrease the need of a second-step completion procedure and, theoretically, the risk of recurrence.     

Is central neck dissection necessary for the treatment of lateral cervical nodal recurrence of papillary thyroid carcinoma?

BACKGROUND: Although the pattern of cervical lymph node metastases from papillary thyroid carcinoma (PTC) has been described, little is known about the pattern of lateral cervical nodal recurrence. The aim of this study was to establish the optimal strategy for neck dissection in patients who underwent reoperation for lateral cervical recurrence of PTC. METHODS: We reviewed the records of 22 patients who underwent neck dissection for lateral nodal recurrence of thyroid cancer between 2002 and 2004. Eight patients had thyroid remnants or recurrent tumors in the bed and 6 had undergone lateral neck dissection prior to referral. Patients underwent comprehensive dissection of the posterolateral and ipsilateral (n = 10) or bilateral (n = 12) central neck. The pattern of nodal recurrence and postoperative morbidity were analyzed. RESULTS: All patients had lateral compartment involvement, 91% at mid-lower, 45% at upper, and 18% at posterior sites. Central nodes were involved in 86% of patients: 82% at ipsilateral paratracheal, 32% at pretracheal, 27% at superior mediastinal, and 2 patients at contralateral sites. Skip lateral recurrence with no positive central nodes was rarely observed (14%). Postoperative vocal cord palsy (n = 1) and hypoparathyroidism (n = 5) developed only in patients undergoing bilateral central compartment dissection. CONCLUSIONS: The inclusion of comprehensive ipsilateral central and lateral neck dissection in the reoperation for patients with lateral neck recurrence of PTC is an optimal surgical strategy.     

全甲状腺切除加功能性颈淋巴结清扫治疗甲状腺乳头状癌172例

目的 探讨甲状腺乳头状癌颈淋巴结转移模式以及全甲状腺切除+功能性颈淋巴结清扫术在甲状腺乳头状癌治疗中的作用.方法 回顾性分析一期全甲状腺切除+功能性颈淋巴结清扫术治疗的172例甲状腺乳头状癌患者的临床和病理资料.结果 172例患者的219侧功能性颈淋巴结清扫结果提示颈淋巴结转移率依次为Ⅵ区(96.3%)、Ⅳ区(78.5%)、Ⅲ区(62.1%).肿瘤浸润甲状腺被膜者颈淋巴结转移率明显增高(P＜0.05).124例术后1 d血清甲状旁腺素(15.87±8.03)pg/ml较术前(37.68±15.0)pg/ml显著降低(P＜0.01).患者5年、10年和15年的生存率分别为(98.83±0.82)%、(98.23±1.02)%和(96.42±1.43)%.结论 术中快速冰冻切片是确定Ⅵ区淋巴结病理状态的可靠方法.准确掌握全甲状腺切除+功能性颈淋巴结清扫术的适应证,术后患者可获得长期生存.     

Greater local recurrence occurs with "berry picking" than neck dissection in thyroid cancer

Managing cervical lymph node metastases in well-differentiated thyroid cancer with either "berry picking" (BP) or anatomic neck dissection (AND) has not been shown to alter survival. Nevertheless local control of thyroid cancer is important. The purpose of this study is to determine whether the local recurrence rate of well-differentiated thyroid cancer is equivalent with BP versus AND. A retrospective analysis revealed 41 patients with well-differentiated thyroid cancer and cervical node metastases seen by a single surgeon from 1985 to 2002. A total of 83 initial and repeat neck operations were performed (nine BPs, 30 central neck dissections, and 44 modified radical neck dissections). Recurrence of cancer, intervention for recurrence, and complications of the BP and AND groups were evaluated. All nine (100%) patients undergoing a limited BP operation had local recurrence of cancer. Only three of the 32 (9%) patients undergoing an initial formal neck operation had local recurrence of tumor. The recurrences after BP (100%) were significantly greater than the recurrences after AND (9%) (P < 0.001). The incidence of surgical complications with BP and AND was not different. Six of 32 (19%) initial formal neck dissection patients and four of nine (44%) BP patients had surgical complications. We conclude that BP is associated with greater local recurrence of thyroid cancer. Patients with nodal metastases should be managed with ANDs.     

Prospective Identification of Chyle Leakage in Patients Undergoing Lateral Neck Dissection for Metastatic Thyroid Cancer

Background Lateral neck dissection for metastatic thyroid cancer includes the lower jugular nodes, but there has been little study of chyle leakage. We therefore prospectively examined chyle leakage that occurred during and after lateral neck dissection in treatment of thyroid cancer. Methods A total of 82 consecutive patients underwent 96 lateral neck dissections for metastatic differentiated thyroid cancer—42 in the right neck, 26 in the left neck, and 14 in both. All patients were monitored for intraoperative and postoperative chyle leakage. All postoperative drainage fluid and serum were chemically analyzed for triglycerides and cholesterol for early identification of chyle leakage. Results Intraoperative chyle leakage was observed during 5 of the 96 neck dissections (5.2%), all on the left side and all controlled by suturing chyle fistula, thus avoiding postoperative leakage. Postoperative chyle leakage was observed in 8 of the 96 neck dissections (8.3%), 5 in the right and 3 in the left neck. The mean peak triglyceride concentration of drainage fluid was significantly higher in patients with chyle leakage than in those without (309 vs 42 mg/dl, P < 0.001). To stop leakage, 2 patients underwent reoperations. Chyle leakage stopped within 5–62 days (mean 18 days) after surgery. Conclusions Chyle leakage related to lateral neck dissection for thyroid cancer is uncommon but may occur more frequently than reported previously, even in the right neck. Our findings may guide thyroid surgeons in both careful neck dissection in at-risk areas and proper postoperative management.     

Differentiated thyroid cancer: determinants of disease progression in patients <21 years of age at diagnosis: a report from the Surgical Discipline Committee of the Children''s Cancer Group.

OBJECTIVE: This study was done to define the extent of disease and evaluate the effect of staging and treatment variables on progression-free survival in patients with differentiated thyroid carcinoma who were less than 21 years of age at diagnosis. SUMMARY BACKGROUND DATA: Differentiated thyroid cancer in young patients is associated with early regional lymph node involvement and distant parenchymal metastases. Despite this, the overall long-term survival rate is greater than 90%, which suggests that biologic rather than treatment factors have a greater effect on outcome. METHODS: Variables analyzed for their impact on progression-free survival in a multi-institutional cohort of 329 patients included age, antecedent thyroid irradiation, extrathyroidal tumor extension, size, nodal involvement, distant metastases, technique of thyroid surgery and lymphatic dissection, initial treatment with 131Iodine, residual cervical disease, and histopathologic subtype. Surgical complications were correlated with the specific procedures completed on the thyroid gland or cervical lymphatics. RESULTS: The overall progression-free survival rate was 67% (95%, CI: 61%-73%) at 10 years with 2 disease-related deaths. Regional lymph node and distant metastases were present in 74% and 25% of patients, respectively. Progression-free survival was less in younger patients (p = 0.009) and those with residual cervical disease after thyroid surgery (p = 0.001). Permanent hypocalcemia was more frequent after total or subtotal thyroidectomy (p = 0.001) while wound complications increased after radical neck dissections (p < 0.00001). CONCLUSIONS: The progression-free survival rate was better after a complete resection and in older patients. Progression-free survival rate was the same after lobectomy or more extensive thyroid procedures, but comparison was confounded by the increased use of total or subtotal thyroidectomy in patients with advanced disease. The risk of permanent hypocalcemia increased when total or subtotal thyroidectomy was done. Thyroid lobectomy alone may be appropriate for patients with small localized lesions while total or subtotal thyroidectomy should be considered for more extensive tumors.     

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.     

Selective neck dissections for squamous carcinoma of the upper aerodigestive tract: patterns of regional failure.

BACKGROUND: Surgeons have been using selective neck dissections in the treatment of squamous carcinoma of the upper aerodigestive tract for over 20 years. To date, no data is available that can answer the question "What are the patterns of failure in the neck following a selective neck dissection and is a selective neck dissection a reliable procedure for metastatic disease?" METHODS: To answer this question, the medical records of all patients with squamous carcinoma of the oral cavity, oropharynx, larynx, and hypopharynx treated at The University of Texas M. D. Anderson Cancer Center from January 1, 1985-December 31, 1990, with a selective neck dissection were reviewed. Five hundred seventeen neck dissections were analyzed: suprahyoid (41), supraomohyoid (284), and anterolateral (192). The end point of the study was regional failure and survival. RESULTS: Regional recurrence in patients treated with a suprahyoid dissection was 43% with pathologically positive nodes. The regional recurrence in the patients treated with a supraomohyoid neck dissection was 1.9% with pathologically negative nodes, 35.7% with path N1 without postoperative radiation therapy, and 5.6% with postoperative radiation therapy. The neck staged pathologically N2B failed with and without postoperative radiation, 8.3% and 14%, respectively. Thirteen percent of the anterior/lateral neck dissections failed regionally. If multiple pathologically positive nodes (N2B) were present, the regional failure with postoperative radiation was 30% and 33.3% without postoperative radiation. CONCLUSION: The results of this retrospective study suggest that a selective neck dissection is a satisfactory staging procedure and is a definitive operation if all the nodes are pathologically negative. However, if a node is found to be invaded with cancer, the use of postoperative radiation is advisable.     

Role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence

Prophylactic central neck dissection in clinically node-negative patients remains controversial. The aim of this multicenter retrospective study was to determine the rate of metastases in the central neck in clinically node-negative differentiated thyroid cancer patients, to examine the morbidity, and to assess the risk of regional recurrence in patients treated with total thyroidectomy with concomitant bilateral or ipsilateral central neck dissection compared with those undergoing total thyroidectomy alone. 258 consecutive clinically node-negative patients were divided into three groups according to the procedures performed: total thyroidectomy only (group A), total thyroidectomy with concomitant ipsilateral central neck dissection (group B), and total thyroidectomy combined with bilateral central neck dissection (group C). Mean operative time and postoperative stay were shorter in Group A (p < 0.01). The incidence of postoperative transient hypoparathyroidism was lower in Group A (p = 0.03), whereas no differences in the incidence of permanent hypoparathyroidism and nerve palsy were present. Postoperative radioactive iodine administration was higher in group B and particularly C (p = 0.03) compared with group A. There were no statistically significant differences in terms of regional recurrence. Differentiated thyroid cancer has a high rate of central lymph node metastasis even in clinically node-negative patients; in the present study there was no statistically significant difference in the rates of locoregional recurrence between the three modalities of treatment. Total thyroidectomy appears to be an adequate treatment for clinically node-negative differentiated thyroid cancer. Prophylactic central neck dissection might be considered for differentiated thyroid cancer patients with large tumor size or extrathyroidal extension.     

The value of intraoperative pentagastrin testing in medullary thyroid cancer

BACKGROUND: The decrease of calcitonin levels after curative operation in patients with medullary thyroid cancer is characterized by individual variation; therefore, intraoperative calcitonin measurements to evaluate the completeness of the resection seem to not be feasible. The aim of this study was to evaluate whether an intraoperative pentagastrin test after thyroidectomy and central neck dissection is useful to predict lymph node involvement of the lateral neck. METHODS: A group of 30 consecutive patients underwent primary surgery. After thyroidectomy and dissection of the central lymph node compartment, an intraoperative pentagastrin test was performed. Biochemical and histologic data were compared retrospectively. RESULTS: Of the group, 20 patients (67%) showed no, or only central neck lymph node, involvement and no increase in calcitonin after intraoperative stimulation. Lymph node involvement was documented histologically in the lateral neck of 10 patients (33%), and 8 patients showed an increase of calcitonin as an indication of lymph node involvement. In two patients, each with 1 single micrometastasis in the lateral neck, the intraoperative pentagastrin test was negative. CONCLUSIONS: Intraoperative calcitonin monitoring after pentagastrin stimulation seems promising in predicting lymph node involvement of the lateral neck to aid selection of patients for lateral lymph node dissection. The development of a highly sensitive, quick calcitonin assay is imperative.