Some aspects of surgical strategies in patients with thyroid cancer with metastatic lesions of the neck lymph nodes

Abstract

Objective — to improve the surgical treatment of patients with thyroid cancer with metastatic lesions of the neck lymph nodes by means of an individual approach to diagnostics, intraoperative imaging, and choice of optimal surgical technique.
 Materials and methods. The analysis involved results of examinations and treatment of 749 patients. The following was taken into account: complaints, thyroid and lymph nodes ultrasound, thyroid hormones level, results of general clinical examinations. Levels of parathyroid hormone, vitamin D, magnesium, total and ionic calcium were determined at the preoperative stage. In some cases, computer tomography results were included. A fine‑needle aspiration (FNA) biopsy was performed to all patients. Women prevailed: 607 from 749 (81.0%; 95% CI 78.0—83.8). The mean age of the patients was 51.3% (45.6—59.1) years. The causes of disease included: colloid nodular goiter 566 (75.6%; 95% CI 72.3—78.6), nodular (adenomatous) goiter with follicular neoplasm 72 (9.6%; 95% CI 7.6—12.0), papillary carcinoma 54 (7.2%; 95% CI 5.5—9.3), suspicious for papillary thyroid carcinoma (according to the cytology results) 17 (2.3%; 95% CI 1.3—3.6), medullary carcinoma 12 (1.6%; 95% CI 0.8—2.8), anaplastic thyroid cancer 6 (0.8%; 95% CI 0.3—1.7), other tumors 22 (2.9%; 95% CI 1.8—4.4). Statistical processing of the obtained results was carried out by using the standard program package «Statistica 6.0 for Windows» (StatSoft, USA).
 Results. Surgical interventions were performed in 89 of 749 (11.9%; 95% CI 9.7—14.4) patients with malignant tumors of the thyroid gland. The variety of surgical procedures performed on the thyroid gland: thyroidectomy performed in 81 of 89 patients (91%; 95% CI 83.1—96.0), hemithyroidectomy in 8 of 89 patients (9.0%; 95% CI 4.0—16.9). The reasons for the hemithyroidectomy: in 2 of 89 patients (2.2%; 95% CI 0.3—7.9) the diagnosis was not confirmed by express histological examination with suspicion for papillary thyroid carcinoma. In 6 other cases, single micro adenocarcinomas that ranged in size from 0.4 to 0.8 mm were found, without invasion into the tumor capsule, which was confirmed during a planned pathological examination. Lymphodisection of the central tissue, as an addition to thyroidectomy, was performed by us in 76 of 89 cases (85.4%; 95% CI 76.3—92.0). Metastatic lesions of the central tissue during pathological examination were found in 29 (32.6%; 95% CI 23.0—43.3) patients with papillary carcinoma, in 5 with medullary cancer (5.6%; 95% CI 1.8—12.6), in 6 cases with anaplastic thyroid cancer (6.7%; 95% CI 2.5—14.1). In 11 patients (12.4%; 95% CI 6.3—21.0) due to the metastatic spread to the platysma of the lateral triangle of the neck, its excision was performed. In 9 (10%; 95% CI 4.7—18.3) patients were performed thyroidectomy with sheath‑fascial excision (removal) of the neck tissue. The precession method was used to visualize the upper laryngeal nerve in order to prevent traumatization. The upper parathyroid glands served as the first anatomical landmark of the recurrent nerve, which were identified in 72 (80.9%; 95% CI 71.2—88.5) patients. Temporary unilateral vocal fold paresis was observed in 3 (3.4%; 95% CI 0.7—9.5) patients. Wound drainage was carried out separately by leaving micro‑drainage, for active aspiration, which was evacuated in 2 days.
 Соnclusions. One of the main prerequisites for the high‑quality performance surgery of thyroid gland is the precise nature of surgical manipulations with careful observance of tactical and technical requirements for a surgeon: timely identify and precisely mobilize. The choice of the final surgical intervention on lymphatic collectors in thyroid cancer is directly dependent on the preoperative and intraoperative pathological examination. However, given the substantial proportion of metastatic lesions of the central zone lymph nodes (level VI), the technical complexity of repeated operative interventions in this area, it is recommended to perform a preventive removal of the central fiber.