Central Compartment Lymph Node Research Articles

Sporadic Medullary Thyroid Carcinoma: Towards a Precision Medicine.

Medullary thyroid carcinoma (MTC) is a neuroendocrine malignant tumor originating from parafollicular C-cells producing calcitonin. Most of cases (75%) are sporadic while the remaining (25%) are hereditary. In these latter cases medullary thyroid carcinoma can be associated (multiple endocrine neoplasia type IIA and IIB) or not (familial medullary thyroid carcinoma), with other endocrine diseases such as pheochromocytoma and/or hyperparathyroidism. RET gene point mutation is the main molecular alteration involved in MTC tumorigenesis, both in sporadic and in hereditary cases. Total thyroidectomy with prophylactic/therapeutic central compartment lymph nodes dissection is the initial treatment of choice. Further treatments are needed according to tumor burden and rate of progression. Surgical treatments and local therapies are advocated in the case of single or few local or distant metastasis and slow rate of progression. Conversely, systemic treatments should be initiated in cases with large metastatic and rapidly progressive disease. In this review, we discuss the details of systemic treatments in advanced and metastatic sporadic MTC, focusing on multikinase inhibitors, both those already used in clinical practice and under investigation, and on emerging treatments such as highly selective RET inhibitors and radionuclide therapy.

Central Compartment Lymph Nodes Have Distinct Metastatic Patterns in Different Age Groups.

Background and PurposeCentral compartment lymph node metastasis (CLNM) is a manifestation of tumor aggressiveness and an indicator of tumor prognosis. The purpose of this study was to construct a nomogram for evaluating CLNM patterns in papillary thyroid carcinoma (PTC) in different age groups.MethodA total of 907 patients diagnosed with PTC from August 2014 to December 2018 were enrolled. A nomogram illustrating CLNM was generated using the results of multivariate logistic regression analysis.ResultsAccording to the best Youden index, we set the cut-off age at 45 years. Multivariate logistic regression analysis showed that in patients aged <45 years, large tumor size (P<0.05), extra-thyroid extension (P<0.05) and thyroglobulin level >40 ng/ml (OR=2.985, 95% CI 1.379-6.462; P<0.05) were independent risk factors; meanwhile, Hashimoto’s thyroiditis (OR=0.532, 95% CI 0.324-0.874; P<0.05) was a protective factor of CLNM. In the subgroup with age ≥45 years, large tumor size (P<0.05), extra-thyroid extension (P<0.05), unclear margin (OR=1.604, 95% CI 1.065-2.416; P<0.05), male gender (OR=2.009, 95% CI 1.257-3.212; P<0.05) were independent risk factors for CLNM. In the subgroup with age <45 years, an area under the curve (AUC) of 0.729 (95% CI 0.680-0.777); P<0.05) was obtained. In the ≥45 years subgroup, the AUC was 0.668 (95% CI 0.619-0.716; P<0.05).ConclusionCLNM of PTC in different age groups may have distinct patterns. Based on the potential risk factors for CLNM in patients with different age stratification, a user-friendly predictive model was established.

Factors associated with postoperative hypocalcemia following thyroidectomy in childhood.

Postoperative hypocalcemia is a frequent complication after thyroidectomy. Hypoparathyroidism may develop as transient (TtHP), with normalization within six months from surgery, or permanent (PtHP) if the patient requires replacement therapy. We analyzed factors associated with the development of postoperative hypoparathyroidism and in detail PtHP following thyroid surgery in a pediatric population. A retrospective multicenter study analyzing 326 patients was carried out. We recorded gender, age, tumor size, thyroiditis, extrathyroidal extension, lymph node dissection (central/lateral compartment, unilateral/bilateral), parathyroid autotransplantation, and histology. Additionally, calcium levels were acquired postoperatively. We analyzed pediatric patients ≤18 years who underwent thyroidectomy clustered into age groups (≤15 or>15). Patients' mean follow-up was 5.8 years (1-11 years). Postoperative hypoparathyroidism occurred in 36 (11.0%): 20 cases (6.13%) developed PtHP. Postoperative hypoparathyroidism was more frequent in younger patients (P=0.014), in larger tumors (P<0.001), in case of extrathyroidal extension (P=0.037), and in central compartment (P=0.020) and bilateral lymph node dissection (P=0.030). PtHP was more frequent in older patients (P=0.014), in case of thyroiditis (P<0.001), and extrathyroidal extension (P<0.001). Concerning the first postoperative calcium level measurement, in the postoperative hypoparathyroidism group, we registered a 8.17mg/dL value with 14% pre/postoperative decrease (ΔCa ), whereas in PtHP patient group calcium level was 7.91mg/dL with 16.7% ΔCa . The risk of postoperative hypoparathyroidism is related to younger age, tumor size, central compartment and bilateral lymph node dissection, extrathyroidal extension, and decrease in postoperative calcium levels. The risk of PtHP is related to older age, thyroiditis, extrathyroidal extension, and decrease in postoperative calcium levels.

Extension of Prophylactic Surgery in Medullary Thyroid Carcinoma. Differences Between Sporadic and Hereditary Tumours According to Calcitonin Levels and Lymph Node Involvement

IntroductionCurrently, there is no consensus on the indication of prophylactic surgery of the nodal compartments in the treatment of medullary thyroid carcinoma (MTC). The aim of our study was to perform a correlation study between preoperative calcitonin (basalCT) values and lymph node involvement to establish a criterion on which to base prophylactic surgery in these patients.Material and MethodsWe conducted an observational, retrospective and multicentre study with 29 hospitals. Patients over 18 years of age with a diagnosis of MTC with a pre-surgical calcitonin registry were included. The minimum surgery in all patients had to have been total thyroidectomy (TT) with central compartment lymph node dissection (CCLND). Receiver operating characteristic (ROC) curve analysis was used to establish basalCT cut-off values as predictors of postoperative lymph node involvement.ResultsA total of 244 patients were included. Baseline calcitonin (basalCT) was a good predictor of nodal involvement (AUC 0.718 and 95%CI 0.66–0.978). Heritability was identified as a preoperative factor correlated with baseline tumour CT values (p = 0.000). With a probability of lymph node involvement below 10%, new cut-off points were established. A prophylactic bilateral lateral lymph node dissection in sporadic tumours should be performed at a basalCT > 600 pg/mL; in the case of RET-mutated tumours this value would be 200 pg/mL.ConclusionThe baseline CT value is a good predictor of postoperative lymph node involvement in MTC, however, cut-off points should depent on the hereditary nature of the tumour.

Multifocal Diffuse Sclerosing Papillary Thyroid Carcinoma: A Rare Variant with Diagnostic Challenges

Diffuse sclerosing papillary thyroid carcinoma (DS PTC) is a relatively rare variant of papillary thyroid carcinoma. It is characterized by distinct histological features like scattered microscopic tumor islands, diffuse sclerosis, lymphocytic infiltration, numerous psammoma bodies, radiological features like snowstorm appearance and biologically aggressive behavior in the form of invasion and metastasis. A preoperative diagnosis is often challenging in the absence of nodules and scanty fine needle aspiration cytology sample. We describe a case of multifocal diffuse sclerosing variant of papillary thyroid carcinoma in a 29 year old young male who presented with a swelling in the right side of neck of 2 month duration in the absence of a visible thyroid swelling. Neck swelling was non tender, well defined, firm, not moving with deglutition. Laboratory studies showed normal thyroid function, neck ultrasound revealed heteroechoic right lobe with multiple punctate echogenic foci and enlarged right sided cervical nodes with echogenic foci, fine needle aspiration cytology of which was consistent with metastasis from papillary adenocarcinoma. Based on the above investigations, a total thyroidectomy with central compartment lymph node dissection and modified radical neck dissection of right side was performed. Histological analysis revealed Multifocal Diffuse Sclerosing variant of papillary Thyroid Carcinoma. Clinical and histological challenges usually occur when DS PTC present as diffuse thyroid enlargement, dispersed microscopic tumor islands, extensive fibrosis, abundant lymphocytic infiltration mimicking thyroiditis and when the fine needle aspiration cytology sample is non representative.

A Thyroid Ultrasound Image-based Artificial Intelligence Model for Diagnosis of Central Compartment Lymph Node Metastasis in Papillary Thyroid Carcinoma

Objective To establish an artificial intelligence model based on B-mode thyroid ultrasound images to predict central compartment lymph node metastasis(CLNM)in patients with papillary thyroid carcinoma(PTC). Methods We retrieved the clinical manifestations and ultrasound images of the tumors in 309 patients with surgical histologically confirmed PTC and treated in the First Medical Center of PLA General Hospital from January to December in 2018.The datasets were split into the training set and the test set.We established a deep learning-based computer-aided model for the diagnosis of CLNM in patients with PTC and then evaluated the diagnosis performance of this model with the test set. Result The accuracy,sensitivity,specificity,and area under receiver operating characteristic curve of our model for predicting CLNM were 80%,76%,83%,and 0.794,respectively. Conclusion Deep learning-based radiomics can be applied in predicting CLNM in patients with PTC and provide a basis for therapeutic regimen selection in clinical practice.

Prevalence of Central Compartment Lymph Node Metastases in Papillary Thyroid Micro-Carcinoma: A Retrospective Evaluation of Predictive Preoperative Features.

Simple SummaryThe present study focused on patients affected by stage pT1a papillary thyroid micro-carcinomas that were treated with surgery and central lymph node dissection. In this study, male sex, low age, and sub-capsular carcinoma localization resulted as independent predictive factors for central lymph node metastases.Papillary thyroid micro-carcinomas are considered relatively indolent carcinomas, often occult and incidental, with good prognosis and favorable outcomes. Despite these findings, central lymph node metastases are common, and are related to a poor prognosis for the patient. We performed a retrospective analysis on patients treated with surgery for stage pT1a papillary thyroid micro-carcinomas. One hundred ninety-five patients were included in the analyses. The presence of central lymph node metastases was identified and studied. A multivariate analysis employing binary logistic regression was used to calculate adjusted odds ratios with 95% confidence intervals of possible central lymph node metastases risk factors. In the performed multivariate analysis, male gender, younger age, and histopathological characteristics, such as a tumor sub-capsular localization, were significantly associated with central lymph node metastases in pT1a patients. Central compartment lymph node metastases are present in a non-negligible number of cases in patients with papillary thyroid micro-carcinoma undergoing surgical resection. Studying these factors could be an effective tool for predicting patients’ central lymph node metastases in papillary thyroid micro-carcinomas, defining a tailored surgical treatment in the future.

Utility and significance of clinical risk factor scoring model in predicting central compartment lymph node metastasis (CLNM) in patients with papillary thyroid cancer (PTC)

ABSTRACTObjectives:To establish and discuss the significance of a clinical risk factor scoring model in predicting central compartment lymph node metastasis (CLNM) (level VI) in patients with papillary thyroid cancer (PTC).Methods:A retrospective analysis was performed on 412 patients who underwent surgical treatment for PTC who were admitted to the Second Hospital of Hebei Medical University between July 2016 and May 2017, with the patients being divided into a CLNM group and a non-metastasis (NM) group. Risk factors such as sex, age, tumor diameter, capsular invasion, multifocality, and tumor location were recorded for scoring via maximum likelihood estimation (MLE)-based discriminant analysis. The scoring model was used for prospective analysis of CLNM in another 104 patients. Besides, the discriminant function that was developed using the risk factors based on the retrospective data derived from the 412 patients was evaluated by plugging the retrospective data in for specified variables, with a higher score indicating a greater risk of developing CLNM. Clinical diagnosis of CLNM was based on postoperative paraffin section pathology, which was adopted as the criterion to assess discriminative accuracy in the prospective and retrospective groups.Results:The discriminative accuracy of the scoring model was 71.8% in the retrospective group and 72.2% in the prospective group.Conclusions:The scoring model enables simplified, quantitative analysis of CLNM in PTC patients. The scoring model has clinical significance in that it provides a basis for the choice of operation, personalized postoperative treatment, and prognosis of PTC.

The Impact of Coexistent Hashimoto's Thyroiditis on Central Compartment Lymph Node Metastasis in Papillary Thyroid Carcinoma.

BackgroundHashimoto’s thyroiditis (HT) is the most prevalent inflammatory disorder of the thyroid gland. Current studies have reported the coexistence rate between HT and papillary thyroid carcinoma (PTC) is quite high. The objective of this study was to evaluate the impact of HT on the predictive factors of central compartment lymph node metastasis (CLNM) in PTC.MethodsA retrospective investigation was performed on PTC patients. They were subclassified into HT and non-HT groups. The results of preoperative neck ultrasound (US) examinations were reviewed. The clinical characteristics and the predictive value for CLNM were explored and compared between the two groups.ResultsA total of 756 patients were included in this study. There were more female patients (86.1%) in the PTC coexistent with the HT group than non-HT group. The patients with HT group had higher preoperative serum level of TSH. There was statistically significant difference between the HT patients and non-HT patients in nodular vascularization. Univariate and multivariate analyses showed that male, age ≤45 years old, tumor diameter >1 cm, and presence of suspicious central compartment lymph node on US, irregular nodular shape, multifocal carcinoma were independent predictive factors of CLNM in PTC patients. It was showed that male, age ≤45 years old, tumor diameter >1 cm, multifocality, and presence of suspicious central lymph node on US were risk factors for CLNM in non-HT patients. Only tumor diameter >1 cm and presence of suspicious central lymph node on US were independently correlated with CLNM in HT patients. The sensitivity of the multivariate model was 63.5%, and specificity was 88.9% for prediction CLNM in HT patients. For non-HT patients, the AUC was 80.6%, the sensitivity of the multivariate model was 64.5%, and specificity was 85.2%ConclusionPTC combined with HT is more common in women, and TSH level in HT group is higher than that in patients with PTC alone. Regardless of that HT is not a related risk factor of CLNM in PTC, our result suggested that different predictive systems should be used for HT and non-HT patients respectively to have a more accurate evaluation of CLNM in clinic.

Effect of Prophylactic Central Lymph Node Dissection on Locoregional Recurrence in Patients with Papillary Thyroid Microcarcinoma.

There is a consensus that central compartment lymph node dissection or modified radical lateral neck dissection should be performed in papillary thyroid microcarcinoma (PTMC) patients with lymph node metastases. Prophylactic central lymph node dissection (PCLND) in patients with clinically node-negative (cN0) PTMC to reduce locoregional recurrence (LRR) rate and improve prognosis remains controversial. The present study aimed to analyze the effect of PCLND on LRR and postoperative complications of PTMC in cN0 patients. We reviewed a cohort of patients with cN0 PTMC who underwent surgery between January 1997 and October 2019. The patients were divided into the PCLND and no lymph node dissection (NLND) groups. Kaplan–Meier curves were constructed to estimate 15-year locoregional recurrence-free survival rate of the two groups, and the difference was compared by the log-rank test. Three Cox regression models were performed to evaluate the correlation between PCLND and LRR. All patients underwent thyroidectomy, and 25 patients developed LRR; of whom, 23 underwent PCLND at initial surgery and 2 went without lymph node dissection. Cox regression analysis showed that PCLND had no effect on LRR. Postoperative hematoma and permanent recurrent laryngeal nerve injury did not occur in the NLND group, and their incidences were 0.5% and 0.3% in the PCLND group, respectively. PCLND had no significant correlation with LRR in patients with cN0 PTMC, and the absolute benefit for PTMC was small.

Serum Calcitonin-Negative Medullary Thyroid Carcinoma: A Case Series of 19 Patients in a Single Center.

IntroductionMedullary thyroid carcinoma (MTC) is a rare cancer that accounts for 5% of thyroid cancers. Serum calcitonin is a good biomarker for MTC, which is used for diagnosis, prognosis, and monitoring of recurrence. Calcitonin-negative MTC (CNMTC) is rare but confounds diagnostic and prognostic directions. This study introduces 19 cases of CNMTC in a single center.MethodFrom 2002 March to 2020 July, more than 76,500 patients had undergone thyroid surgery due to thyroid cancer at the Severance Hospital, and a total of 320 patients were diagnosed with MTC (0.4%). Serum calcitonin levels were obtained from every patient who was suspected with MTC. These patients had undergone either bilateral total thyroidectomy or unilateral thyroidectomy with central compartment lymph node dissection, and additional modified radical lymph node dissection if lateral lymph node metastasis was positive. Postoperative monitoring and out-patient clinic follow-up were performed with obtaining the serum calcitonin levels.ResultNineteen patients tested negative for calcitonin preoperatively (6%). The mean preoperative calcitonin level was 5.1pg/mL if undetectable level is regarded as 0pg/mL. Only two patients were males, and the female bias was significant (p = 0.017). No one except two patients with modified radical neck dissection showed central compartment lymph node metastasis. Every patient’s postoperative calcitonin level remained low. The median follow-up period was 71 months. There was no recurrence and only one fatality, and the overall survival rate was 95%.ConclusionSince incidence of CNMTC is not negligible, MTC should not be ruled out in the diagnostic phase even if serum calcitonin is negative in preoperative examination. We presented 19 cases of CNMTC whose prognosis in general were favorable. Markers of serum and immunohistochemical samples other than calcitonin should be actively examined.

Image Segmentation of Thyroid Nodule and Capsule for Diagnosing Central Compartment Lymph Node Metastasis.

Thyroid ultrasound (US) image segmentation is of great significance for both doctors and patients. However, it is a challenging task because of the low image quality, low contrast and complex background in each US image. In recent years, some researchers have done thyroid nodule segmentation tasks, but the results achieved are not particularly satisfactory. In this paper, we have broadened the targets of interest and included both thyroid nodules and capsules into our research scope. We propose a method that implements a C-MMDetection to detect and extract the region of interest (ROI), and a modified salient object detection network U2-RNet to segment nodules and capsules respectively. Experiments show that our method segments nodules and capsules in US images more effectively than other networks, which is very helpful for doctors to diagnose central compartment lymph node metastasis (CLNM).

Risk Benefit Analysis of Routine Thymectomy for Differentiated Thyroid Cancers: A Systematic Review.

Background Central compartment lymph node dissection (CLND) is a part of the surgical management of differentiated thyroid cancer (DTC). Therapeutic CLND is done to address clinically significant central compartment nodes in patients with DTC, while prophylactic CLND is performed in the presence of high-risk features in the absence of clinically significant neck nodes. Removal of thymus—unilateral or bilateral—during CLND to achieve complete clearance of level VI and VII lymph node stations and address thymic metastasis is debatable. Objective The present systematic review was conducted to summarize the evidence, delineating the role of thymectomy during CLND in patients with DTC. Methods Electronic databases of PubMed, Embase, and Cochrane were searched from their inception to July 2020 using keywords—thyroid neoplasms or tumors, thyroidectomy, and thymectomy—to identify the articles describing the role of thymectomy during CLND in DTC. A pooled analysis of surgicopathological outcomes was performed using metaprop command in STATA software version 16. Result A total of three studies and 347 patients—total thyroidectomy (TT) with bilateral thymectomy in 154, TT with unilateral thymectomy in 166, and TT alone in 27 patients with DTC—were included in the systematic review. The pooled frequency of thymic metastasis was a mere 2% in patients undergoing either unilateral or bilateral thymectomy. The routine addition of thymectomy does not result in better lymph node clearance. Unilateral and bilateral thymectomy were associated with high chances of transient hypocalcemia (12.0% and 56.1%, respectively). Conclusion Routine thymectomy is not warranted during CLND, considering minimal oncological benefit and high risk of postoperative hypocalcemia.

Thyroidectomy for Cancer: The Surgeon and the Parathyroid Glands Sparing.

Background: The diagnosis of thyroid cancer is continuously increasing and consequently the amount of thyroidectomy. Notwithstanding the actual surgical skill, postoperative hypoparathyroidism still represents its most frequent complication. The aims of the present study are to analyze the rate of postoperative hypoparathyroidism after thyroidectomy, performed for cancer by a single first operator, without any technological aid, and to compare the data to those obtained adopting the most recent technological adjuncts developed to reduce the postoperative hypoparathyroidism. Methods: During the period 1997–2020 at the Endocrine Surgery Unit of the Department of Clinical and Experimental Medicine of the University of Florence, 1648 consecutive extracapsular thyroidectomies for cancer (401 with central compartment node dissection) were performed. The percentage of hypoparathyroidism, temporary or permanent, was recorded both in the first period (Group A) and in the second, most recent period (Group B). Total thyroidectomies were compared either with those with central compartment dissection and lobectomies. Minimally invasive procedures (MIT, MIVAT, some transoral) were also compared with conventional. Fisher’s exact and Chi-square tests were used for comparison of categorical variables. p < 0.01 was considered statistically significant. Furthermore, a literature research from PubMed® has been performed, considering the most available tools to better identify parathyroid glands during thyroidectomy, in order to reduce the postoperative hypoparathyroidism. We grouped and analyzed them by technological affinity. Results: On the 1648 thyroidectomies enrolled for the study, the histotype was differentiated in 93.93 % of cases, medullary in 4% and poorly differentiated in the remaining 2.06%. Total extracapsular thyroidectomy and lobectomy were performed respectively in 95.45% and 4.55%. We recorded a total of 318 (19.29%) cases of hypocalcemia, with permanent hypoparathyroidism in 11 (0.66%). In regard to the literature, four categories of tools to facilitate the identification of the parathyroids were identified: (a) vital dye; (b) optical devices; (c) autofluorescence of parathyroids; and (d) autofluorescence enhanced by contrast media. Postoperative hypoparathyroidism had a variable range in the different groups. Conclusions: Our data confirm that the incidence of post-surgical hypoparathyroidism is extremely low in the high volume centers. Its potential reduction adopting technological adjuncts is difficult to estimate, and their cost, together with complexity of application, do not allow immediate routine use. The trend towards increasingly unilateral surgery in thyroid carcinoma, as confirmed by our results in case of lobectomy, is expected to really contribute to a further reduction of postsurgical hypoparathyroidism.

"Number of Foci Increases Risk of Central Compartment Lymph Node Metastasis in Papillary Thyroid Cancer"

"Number of Foci Increases Risk of Central Compartment Lymph Node Metastasis in Papillary Thyroid Cancer"

Is Performance of Routine Central Compartment Neck Dissection in cN0 Papillary Thyroid Cancers Really Useful? 10-Year Prospective Observational Study.

Central compartment nodes of neck are the first echelon nodes in papillary thyroid cancers (PTC). This study analyses the adverse parameters associated with central compartment nodal metastasis in cN0 PTC and also the usefulness of performing central compartment neck dissection routinely. A total of 236 patients with cNo PTC who underwent prophylactic central compartment neck dissection, from January 2008 to June 2017 in the Department of Oncology, Madurai Medical College, were included in study. Analysis of various adverse factors associated with central compartment nodal metastasis was made. Patients (46.18%) had metastatic nodes in the central compartment. Incidence of nodal metastasis increased with tumour size, capsular invasion, extrathyroidal extension, tracheal invasion and pulmonary metastasis. More than 50% patients did not have any of the statistically significant known adverse risk factors except for age and sex. Routine central compartment neck dissection has therapeutic value in PTC even in absence of known adverse factors and can be recommended in cases of clinically negative nodes. A meticulous dissection in experienced hands carries less complication rates as with thyroidectomy alone. In a resource limited country like ours, where the cost of re-surgery and radioiodine scans are high, a meticulous initial surgery incorporating central compartment neck dissection would really mean a difference.

A prospective randomized controlled trial to assess the efficacy and safety of prophylactic central compartment lymph node dissection in papillary thyroid carcinoma

BackgroundThe efficacy of prophylactic central compartment lymph node dissection for papillary thyroid carcinoma remains controversial. We performed a randomized controlled trial to evaluate the efficacy and safety of prophylactic central compartment lymph node dissection in patients with papillary thyroid carcinoma. MethodsIn this parallel-group randomized controlled trial, we assessed 101 patients aged 20 to 70 years with small/noninvasive papillary thyroid carcinoma and no clinical metastases or history of cervical surgery/radiation exposure. Randomization ran from April 2015 to November 2017. Data were collected between April 2015 and October 2020. Of the 101 enrolled patients, 50 underwent total thyroidectomy (TTx group) and 51 underwent total thyroidectomy as well as prophylactic central compartment lymph node dissection (TTx+pCND group). Surgical completeness, local recurrence, successful ablation, postoperative complication, and papillary thyroid carcinoma upstaging were compared between the 2 groups. ResultsNo patient showed structural recurrence after 46.6 ± 9.1 months of follow-up. Both groups had similar rates of surgical completeness and successful ablation. There was no difference in the incidence of complications. More patients were upstaged to pN1a in the TTx+pCND group compared to those in the TTx group (P < .05). ConclusionsProphylactic central compartment lymph node dissection detected more lymph node metastases but did not affect recurrence. The 2 groups showed similar outcomes with regard to surgical completeness, successful ablation, and complications. In conclusion, for small/noninvasive papillary thyroid carcinoma without clinical evidence of lymph node metastases, prophylactic central compartment lymph node dissection may not be required if total thyroidectomy is planned.

Concurrent Papillary Carcinoma of Thyroglossal Duct Cyst and Thyroid Isthmus, Beyond the Sistrunk Procedure

Introduction/Background: Papillary carcinoma (PC) originating from the thyroglossal cyst is a rare entity. It is even more uncommon to have concurrent thyroglossal duct cyst PC and papillary thyroid carcinomas (PTC). The surgical approach for such patients would involve a combination of a Sistrunk’s procedure and total thyroidectomy. We describe management of a patient found to have multi focal PC originating from a thyroglossal duct cyst and thyroid isthmus with extensive cervical lymph node metastasis. Clinical Case: 30-year-old male presented to PCP with palpable bilateral cervical adenopathy most prominent in the right supraclavicular region. Neck ultrasound confirmed multiple metastatic appearing nodes (largest 4cm) in the central, right and left lateral cervical compartments as well as a hypoechoic, TI-RADS category 5 right thyroid isthmus nodule. FNA of the cervical nodes confirmed metastatic PTC. Neck CT in addition to extensive cervical adenopathy revealed a 2 cm solid mass inferior to the central hyoid bone with infiltrative borders and calcifications suspicious for a primary tumor. Patient underwent total thyroidectomy with central compartment lymph node dissection, excision of thyroglossal cyst and bilateral modified radical neck dissections. Histopathology report revealed a 2.4 cm thyroglossal duct tumor and a 1.1 cm tumor in the thyroid isthmus, confirming two separate tumors both being classical variants of papillary thyroid carcinoma, with no lympho-vascular invasion and 8/53 positive lymph nodes. BRAF V600E mutation was positive. On follow up, the patient is doing well and has deferred adjuvant radioactive iodine treatment for 6 months for personal reasons. Clinical Lesson/ Conclusion: PC of the thyroglossal cyst with synchronous isthmic PTC merits total thyroidectomy and central compartment dissection in addition to the Sistrunk’s procedure, as the likelihood of local metastasis is high. Presence of BRAF V600E mutation has been identified as a predictor of more aggressive behavior in isolated PC of the thyroglossal duct cyst, suggesting a need for more than a Sistrunk’s procedure in such patients. Our patient, who presented with local lymph node metastasis supports this conclusion. Determining BRAF mutation status preoperatively may be a helpful strategy in planning the extent of surgery. Keywords Thyroglossal duct cyst, Papillary thyroid carcinoma, BRAF mutation

Carbon nanoparticle-guided intraoperative lymph node biopsy predicts the status of lymph nodes posterior to right recurrent laryngeal nerve in cN0 papillary thyroid carcinoma.

The lymph nodes in the right central compartment can be divided into 2 parts by the right recurrent laryngeal nerve (RLN), and there is a lack of an accurate and convenient method for assessing metastases in the lymph node posterior to the right recurrent laryngeal nerve (LN-prRLN) in cN0 thyroid papillary carcinoma patients. Patients diagnosed with cN0 thyroid papillary carcinoma and underwent intraoperative carbon nanoparticle-guided lymph node biopsy from January 2017 to November 2020 at the Center for Thyroid and Breast Surgery of Xuanwu Hospital were retrospectively analyzed. The intraoperative frozen section examination and postoperative LN-prRLN status should have been comprehensively recorded. The participants were divided into the LN-prRLN positive group and LN-prRLN negative group according to their recorded LN-prRLN status. In total, 189 cases (LN-prRLN positive group, n=30; LN-prRLN negative group, n=159) were included in the analysis. The univariate and multivariate regression analyses revealed that the number of metastatic lymph nodes during intraoperative lymph node biopsy was the potential predictor for LN-prRLN metastasis [odds ratio (OR): 1.320, 95% confidence interval (CI): 1.057 to 1.649, P=0.014]. The receiver operating characteristic (ROC) curve showed that the area under the curve (AUC) reached 0.7 upon a combined analysis of multiple lymph node statuses located at pre-laryngeal (Delphian), pre-tracheal, and para-tracheal lymph nodes ipsilateral to the tumor in predicting the metastasis of LN-prRLN, and the cut-off value was 0.5. Number of metastatic lymph nodes in intraoperative biopsy was an indicator of LN-prRLN metastasis in cN0 thyroid carcinoma patients. Patients staging in cN0 with negative intraoperative lymph node status might be considered not to require LN-prRLN dissection during central lymph nodes dissection.

Predictive factors for prolonged operative time of robotic thyroidectomy via bilateral axillo-breast approach: Analysis of 359 cases of differentiated thyroid cancer

ObjectiveThis study assessed the results of robotic thyroidectomy for differentiated thyroid cancer in early stage, to identify the predictive factors of operative time and complication rate. MethodsA patient cohort of 359 cases in total was involved in this retrospective study. The data of clinical characteristics and follow-up results were collected. ResultsThe cohort of patients involved was composed of 285 female patients and 74 male ones. The mean age was 34.91 ± 7.93 years old. The mean Body Mass Index (BMI) was 22.43 ± 3.47. The mean tumor size was 0.75 ± 0.56 cm, and the mean gland size was 4.68 ± 0.83 cm. Among all the specimen, the ratio of tumor invasion of gland capsule was 63/296, and the ratio of chronic thyroiditis was 110/249. 75 patients underwent total thyroidectomy + central compartment node dissection (CCND). 284 patients underwent Lobectomy + CCND. The ratio of central lymph node metastasis was 144/215 (40.1%). The mean number of lymph node dissected was 5.26 ± 4.09. The mean operative time was 96.53 ± 25.69 min. 21(5.8%) patients had hoarseness after operation. 22(29.3%) patients had hypocalcemia after total thyroidectomy. The inadvertent parathyroidectomy was found in 66(18.4%) cases. The surgical extent (unilateral/bilateral resection), BMI and gland size were found to have a significantly correlation with the operative time (p < 0.05) after multivariate analysis. ConclusionThe surgical extent, BMI and gland size are found to be independent risk factors of prolonged operative time of robotic thyroidectomy. However, these factors are not associated with a higher complication rate.