Central Compartment Lymph Node Research Articles

Usefulness of intraoperative determination of central lymph node metastasis by palpation in papillary thyroid cancer.

BackgroundThis study evaluated the usefulness of judgment of central lymph node (LN) metastasis by surgeon’s palpation in papillary thyroid cancer.MethodsThis study included 127 patients who underwent thyroidectomy and central compartment node dissection between October 2014 and February 2015. The criterion for suspicious LNs was hardness.ResultsOf the 20.5% (28/127) of suspicious for metastatic LNs according to surgeon determination, 92.8% (26/28) were confirmed to be metastatic in the final pathological examinations. Metastatic LNs were found in 38 (38.3%) of 99 patients without suspicious LNs, 29 of whom (76.3%) had micrometastases. The sensitivity, specificity, and positive and negative predictive values for the determination of LN metastasis by a surgeon were 40.6%, 96.8%, 92.9%, and 61.6%, respectively.ConclusionDetermination of central LN metastasis by a surgeon’s palpation may be useful to evaluate LNs owing to the high specificity and positive predictive values, especially in macrometastasis or high-risk LN disease.

The Number of Central Lymph Nodes on Preoperative Ultrasound Predicts Central Neck Lymph Node Metastasis in Papillary Thyroid Carcinoma: A Prospective Cohort Study

To evaluate the effectiveness of the number of central compartment lymph nodes (CLNs) on ultrasound (US) in predicting CLN metastasis (CLNM). We prospectively studied 309 papillary thyroid cancer (PTC) patients who underwent thyroidectomy with CLN dissection at our center from May 2017 to July 2017. The number and features of CLNs were evaluated preoperatively via US. All US examinations were performed using a Philips iU 22 or a GE Logiq 9 machine. Correlations between CLNs observed via preoperative US and amount of CLNM were evaluated. We found that ≥2 CLNs on the preoperative US was associated with CLNM (P < 0.01). For this feature, the sensitivity, specificity, and area under the curve (AUC) were 54.3%, 66.1%, and 0.61, respectively. The presence of both suspected metastasis and ≥2 CLNs on US had a specificity of 86.5%. In addition, ≥3 CLNs on preoperative US was associated with large-volume CLNM (>5 metastatic CLNs) (P < 0.01). For this feature, the sensitivity, specificity and AUC were 54.8%, 74.5% and 0.65, respectively. The presence of both suspected metastasis and ≥3 CLNs on US had a specificity of 84.9%. The presence of suspected metastasis and/or ≥3 CLNs had a sensitivity of 80.6%. Our results suggest that ≥2 and ≥ 3 CLNs on preoperative US may serve as ancillary preoperative markers for predicting CLNM.

Effect of perioperative application of glucocorticoid on postoperative hypoparathyroidism and hypocalcemia in patients with total thyroidectomy plus central compartment dissection

Objective: To evaluate the effect of glucocorticoid used in perioperative period of total thyroidectomy (TT) plus central compartment lymph node dissection (CCLND) or combining with lateral neck dissection on postoperative hypoparathyroidism (HPT) and hypocalcemia (HPC). Methods: The data of 117 patients with papillary thyroid carcinoma (PTC) undergone the surgeries in Tongren Hospital between Nov 2015 and Mar 2017 were retrospectively analyzed. There were 36 males and 81 females, and their ages ranged from 21 to 74 years old, average age of 47.8±12.5. TT and CCLND were performed in 81 (69.2%) patients, and TT, CCLND and unilateral or bilateral lateral neck dissection were performed in 36 (30.8%) patients. The patients were divided into 4 groups: Group A (40 patients), no glucocorticoid was applied; Group B (36 patients), 5 mg dexmethasone sodium phosphate was sprayed on the surface of wound on both sides of trachea during operation; Group C (21 patients), 40 mg methylprednisolone was applied by intravenous injection after operation, one time per day for 3 days; Group D (20 patients), 5 mg dexmethasone sodium phosphate was sprayed on the surface of wound on both sides of trachea during operation and 40 mg methylprednisolone were applied by intravenous injection after operation, one time per day for 3 days. Serum parathyroid hormone and calcium were tested before operation and at the 1(st), 2(nd) and 3(rd) day after operation. Spss19.0 was used to analyze the data. Results: There were statistically significant differences in the incidences of both no HPT and no HPC and the incidence of HPT alone between Group A and B (35.0% vs 61.1%, 15.0% vs 2.8%, χ(2) were 5.182 and 3.885, respectively, P<0.05), but not in the incidence of HPC alone between the two groups. There were statistically significant difference in the incidences of both no HPT and no HPC between Group A and D (35% vs 70.0%, χ(2)=6.530, P<0.05), but not in the incidences of HPT or HPC between the two groups. There were not statistically significant differences in the individual incidences between Groups A and C (P>0.05). There were statistically significant differences in the incidence of both no HPT and no HPC and the incidence of HPT alone between Groups B and C (61.1% vs 23.8%, 2.8% vs 23.8%, χ(2) were 7.402 and 6.229, respectively, P<0.05), but not in the incidence of HPC between the two groups (P>0.05). HPT and HPC often occurred on the 1(st) or 2(nd) day after operation. Permanent hypocalcemia did not occur in all cases. Conclusions: Intraoperative especially plus post-operative application of glucocorticoid can decrease the incidence of HPT after operation.

Detection of Papillary Thyroid Cancer Nodal Metastasis after Intravenous Administration of a Fluorescent Tracer Targeting MET

Background: Prophylactic central compartment lymph node dissection (PCLND) or watchful waiting are two currently used strategies in papillary thyroid cancer (PTC) treatment. Choosing between these two strategies for an individual patient is difficult due to low specificity of preoperative imaging modalities for central compartment nodal metastases. PCLND reduces recurrence rates but exposes pN0 patients to undesirable morbidity. Reoperation for local recurrence after watchful waiting is challenging and causes even higher morbidity rates. Since MET is overexpressed in PTC compared to normal thyroid tissue, we tested the feasibility of intraoperative molecular fluorescence guided imaging (MFGI) of EMI-137 (targeting MET) to improve detection of PTC nodal metastasis. MFGI may improve patient selection for CLND, ultimately reducing recurrence rates and morbidity in PTC.

Identifying risk factors for metastasis to the level VII lymph node in papillary thyroid carcinoma patients

BackgroundThe level VI lymph nodes are anatomically connected to the level VII lymph nodes and papillary thyroid carcinoma (PTC) can metastasis to both regions. The aim of this study was to identify clinicopathologic factors associated with level VII lymph node metastasis.MethodsBetween March 2015 and September 2016, a total of 275 consecutive patients were operated on for PTC with prophylactic level VII dissection at the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, ZheJiang, China. Patients with PTC were performed via video-assisted approach. Multivariate logistic regression analysis was performed to evaluate the associations between clinicopathologic factors.ResultsOf the 275 subjects enrolled in this study, 79 patients (28.73%) showed lymph node metastasis to the level VII. The multivariate logistic regression analysis showed ultrasonography-positive lymph nodes (p < 0.001), the location of primary carcinoma (p = 0.002) and hashimoto thyroiditis (HT) (p = 0.04) were associated with level VII lymph node metastasis.ConclusionsBased on the results of our study, we considered central-compartment lymph node dissection (CLND) as an integral strategy. On the basis of surgery safety, transcervical level VII lymph node dissection could be considered for PTC patients with high risk factors such as ultrasonography-positive lymph nodes, tumor located in middle and lower thirds of the thyroid lobe and the patients without HT. In future, prognostic significance of level VII lymph node dissection should be evaluated through long-term surveillance.

Transoral endoscopic thyroidectomy using the vestibular approach with an endoscopic retractor in thyroid cancer: experience with the first 132 patients.

Transoral endoscopic thyroidectomy using the vestibular approach (TOETVA) is a novel technique for thyroid cancer surgery. We aimed to review our initial experiences with TOETVA for the management of thyroid carcinoma, using retrospective analyses of a larger single-center case series. From September 2016 to April 2018, 132 patients with thyroid cancer underwent TOETVA. A three-port technique through the oral vestibule was used to perform endoscopic thyroidectomy with ipsilateral central compartment dissection using conventional laparoscopic instruments, and an endoscopic retractor that we developed. All patients had papillary thyroid carcinoma. Less-than total or total thyroidectomy with ipsilateral central compartment node dissection was performed (124 vs. 8). The mean operation time was 87.6min (range 56-213min). The average number of lymph nodes resected was 2.6 (range 1-12). Six patients experienced transient hoarseness, which was resolved within 3months. Most of the patients were discharged within 3days after surgery. In this large series from a single center, we found that TOETVA with the endoscopic retractor can be performed safely and radically in selected patients with thyroid cancer.

Risk factors predisposing for recurrent laryngeal nerve palsy following thyroid malignancy surgery: experience from a tertiary oncology centre.

Postoperative recurrent laryngeal nerve (RLN) palsy is one of the major morbidities encountered after thyroid surgery. The risk further increases when surgery is performed for thyroid malignancies. A retrospective study of patients who underwent hemi, total or completion thyroidectomy at our institute between June 2017 to May 2019 were analyzed. We assessed factors that predisposed to the development of RLN palsy. The study comprised of 228 patients. A total of 400 nerves were at risk. The RLN palsy rate was 6.8% (n = 27). On univariate and multivariate analysis, the risk of RLN palsy was seen most with pT4a tumor (OR = 8.5), gross extra-thyroidal extension (ETE) (OR = 3.5) and tracheo-esophageal groove (TEG) (OR = 2.8) involvement, followed by aggressive histopathology, and central compartment node positivity. pT4a tumors, gross ETE, and TEG involvement were the leading causes predisposing for the development of RLN palsy in our series.

Elective Central Compartment Lymph Node Dissection Does not Increase the Risk of Postoperative Hypoparathyroidism in Patients Treated for Differentiated Thyroid Cancer

SUMMARYAimThe aim of this study was to compare the incidence of postoperative hypoparathyroidism in two groups of patients who were treated for differentiated thyroid cancer.MethodsA retrospective analysis of 179 patients who were treated for differentiated thyroid cancer in our institution from January 2011 until December 2018 was performed. Only patients initially treated with total thyroidectomy and those who did not have preoperatively confirmed central compartment and lateral neck lymph node metastases were included in this study. Two main groups of patients were analysed. The patients who were treated with total thyroidectomy and elective central compartment lymph node dissection simultaneously were included in the first group. The patients who were treated only with total thyroidectomy were included in the second group. The rate of transitory and persistent postoperative hypoparathyroidism was compared between the two groups.ResultsA total of 117 patients (65.4%) underwent total thyroidectomy and elective central compartment lymph node dissection simultaneously (TT + CCLNd group). The remaining 62 patients (34.6%) underwent total thyroidectomy only (TT group). A total of 22.6% patients in the TT group developed postoperative hypoparathyroidism compared with 25.6% in the TT + CCLNd group. The rate of persistent hypoparathyroidism in the TT and TT + CCLNd groups was 3.2% and 6.0%, respectively. The difference in the rate of transient and persistent postoperative hypoparathyroidism was not statistically significant between the two groups. Within the TT + CCLNd group, 82.9% of patients underwent ipsilateral paratracheal lymph node dissection and 17.1% underwent bilateral paratracheal lymph node dissection. The rate of postoperative hypoparathyroidism was analysed in those two subgroups of patients and did not prove to be statistically significant.DiscussionWhile its impact on the local recurrence rate is still controversial, elective central compartment lymph node dissection could be a great tool for selection of patients who could profit from adjuvant radioiodine treatment. On the other hand, central compartment lymph node dissection could potentially increase the risk of hypoparathyroidism due to involuntary injury to parathyroid glands and/or their blood supply. Our study did not find a statistically significant difference regarding postoperative hypoparathyroidism between patients who underwent central compartment lymph node dissection compared with patients who underwent total thyroidectomy only. Our data are not in accordance with some of the previously published studies.ConclusionOur results demonstrated that elective central compartment lymph node dissection is a safe procedure and does not significantly increase the risk of postoperative hypoparathyroidism when it is performed simultaneously with total thyroidectomy.

Central Compartment Nodal Bulk: A Predictor of Permanent Postoperative Hypocalcaemia.

Central compartment clearance (CCC) for Papillary thyroid cancers (PTC) is one of the factors causing postoperative hypocalcaemia. We aimed to examine determinants of this major sequela. 41 patients treated for PTCs between 2014 and 2016 were studied. Surgical details, tumour and nodal characteristics, incidence of transient, temporary and permanent hypocalcaemia were noted. Central clearance was done bilaterally in 24 (58.5%) cases, ipsilaterally in 17 (41.6%). Central nodes were involved in 26 (63.4%) cases, unilaterally in 15 (36.6%), bilaterally in 11 (26.8%). Transient hypocalcaemia developed in 10 (24.4%) cases, temporary hypocalcaemia in 6 (14.6%) cases, and permanent hypocalcaemia in 2 (4.9%) cases. 17 (41%) patients were symptomatic. 9 (21.9%) patients received intravenous calcium. The only factor consistently associated with development of hypocalcaemia of all patterns, was the presence of matted central compartment nodes (p = 0.021). Matted nodes also related to a longer length of stay (p = 0.04) and requirement of intravenous calcium (p = 0.000). Extent of CCC, nodal yield, nodal positivity, perinodal extension, number of parathyroids identified, gender or pT size were not significantly associated. Symptomatic patients did not necessarily become permanently hypocalcaemic (p = 0.8). Patients requiring intravenous calcium were more likely to take oral calcium after discharge (p = 0.002). Postoperative hypocalcaemia is more likely in cases with bulky involved central nodes where extensive clearance is done. In routine CCC, even if done bilaterally, preservation of parathyroid function is possible. Permanent hypocalcaemia after CCC need not be taken as inevitable.

A Case Report of Familial Medullary Carcinoma Thyroid—Seldom Seen by Surgeons

Medullary thyroid carcinoma (MTC) constitutes around 5% of all thyroid cancers with a worse prognosis. It accounts for 13% of thyroid cancer–related deaths. Twenty-three-year-old male presented with 4-year history of progressively increasing thyroid swelling with similar family history. On examination, butterfly-shaped firm swelling of size 7 × 3 cm in the right and 7 × 4 cm in the left can be seen on the anterior aspect of neck with regular margins and nodular surface moving with deglutition extending from the thyroid cartilage to clavicle head and laterally beyond the sternocleidomastoid into the posterior triangle muscle. Pemberton’s sign is negative. CT neck showed enlarged both thyroid lobes with areas of cystic degeneration and 15 mm retrosternal extension of left lobe of thyroid with bilateral IB, II, and V lymphadenopathy. Serum calcitonin level was 4435 pg/ml. FNAC favoured the features of MTC. Total thyroidectomy with central compartment neck dissection was done. Intraoperative frozen sections of bilateral level III were found to be tumour-free, so proceeded with thyroid excision and central compartment neck dissection. Histopathology revealed MTC with bilateral multifocal capsular and lymphovascular invasion and metastatic foci in the right central compartment lymph node. Hence, early diagnosis in family members offers a higher likelihood of cure and long-term survival.

Evaluation of accuracy of one-step nucleic acid amplification (OSNA) in diagnosis of lymph node metastases of papillary thyroid carcinoma. Diagnostic study.

BackgroundThe incidence of node metastases in papillary thyroid carcinoma (PTC) is high, ranging from 20% to 90%. Prophylactic central lymph node compartment dissection (CLND), suggested from the latest guidelines for high-risk tumors, meets resistance due to the high incidence of postoperative complications. Recently, new molecular biologic techniques, such as One Step Nucleic Acid Amplification (OSNA), have spread widely, allowing to quickly isolate, amplify and quantify mRNA encoding for proteins selectively present in neoplastic cells, as Cytokeratine-19. The aim of this study is to evaluate the application of OSNA to intraoperative diagnosis of node metastases of PTC.MethodsWe included in the study patients with preoperative diagnosis of PTC; from each patient one or more lymph nodes were collected. To assess OSNA accuracy, each lymph node was divided into two halves: the first one was analysed with histopathological and immunohistochemical examination, whereas the second was studied with OSNA.ResultsTwenty-six lymph nodes from 13 patients were included in the study. Overall, OSNA sensitivity was 87.5%, specificity 94.4%, positive predictive value 87.5%, negative predictive value 94.4% and accuracy 92.8%.Discussion and conclusionOSNA is effective in detecting lymph node metastases of PTC. Considering the high risk of complications in CLND, and the uncertain prognostic value of lymph node metastases of PTC, OSNA seems to be a promising tool to identify intraoperatively patients who may benefit from CLND.

Right posterior paratracheal lymph nodes metastasis is one of the predictive factors in right-sided papillary thyroid carcinoma

BackgroundLymph nodes in the right paratracheal region are separated as anterior and posterior on the basis with right recurrent laryngeal nerve. Dissection of the right posterior paratracheal lymph nodes is sometimes overlooked during a central neck dissection. Therefore, this study was designed to assess the clinicopathologic risk factors and prognostic implication for recurrence related to the presence of right posterior paratracheal lymph nodes metastasis in patient with right-sided papillary thyroid carcinoma. MethodsRecords from 763 patients with papillary thyroid carcinoma who underwent total thyroidectomy with central neck dissection, including the right posterior paratracheal lymph nodes, between January 2007 and March 2015 were reviewed retrospectively. ResultsAmong 763 patients (120 men and 643 women; mean age 49.04 years) with right-sided papillary thyroid carcinoma, 127 exhibited right posterior paratracheal lymph nodes metastases. In multivariate analysis, central-compartment lymph nodes metastases (odds ratio 5.203; 95% confidence interval, 2.864–9.453) and lateral cervical lymph nodes metastases (odds ratio 3.668; 95% confidence interval, 2.375–5.667) were independently correlated with right posterior paratracheal lymph nodes metastases. Twenty-three patients (3.0%) showed loco-regional recurrence. The loco-regional recurrence rate was greater in the groups for males (P = .012), larger tumor size (>10 mm; P = .044), extrathyroidal extention (P = .002), and right posterior paratracheal lymph nodes metastasis (P < .001). ConclusionRight posterior paratracheal lymph nodes metastases are predictive factors of loco-regional recurrence, and these lymph nodes should be removed completely during a right central neck dissection in patients with right-sided papillary thyroid carcinoma with central or lateral cervical lymph node metastasis.

Synchronous primary cancer of the thyroid and breast

Background: The present case is of a synchronous primary classical thyroid carcinoma and primary ductal carcinoma of the breast in a 57 year old lady. Though the incidence of both thyroid cancer and breast cancer have been rising in recent years, it is very rare to find a single person with both of these cancers. Case summary: Patient underwent total thyroidectomy and right breast lump excision. Post operative histopathological examination identified papillary carcinoma thyroid, classical type, of the right lobe with metastasis to central compartment lymph nodes and invasive ductal carcinoma of the right breast. Now the patient is on regular follow up. Thus the aim of the current report was to improve the understanding of synchronous primary tumors of the thyroid and breast by presenting a review of the associated literature regarding breast and thyroid carcinoma. Conclusion: Although synchronous primary tumors of the thyroid and breast are very rare, they remain a possibility, therefore more attention should be paid to this cancer.

Risk factors analyses for lateral neck lymph node metastasis in papillary thyroid carcinoma

Objective:To study the risk factors for the lateral neck lymph node metastasis(LNM) in patients with papillary thyroid carcinoma(PTC).Method:Total 145 cases of papillary thyroid carcinoma patients were reviewed. These patients were divided into the following 2 groups: a lateral LNM-positive group and a lateral LNM-negative group.Clinical factors and tumor ultrasound characteristics were recorded, and the final pathology results were recorded as well. Result: Univariate and multivariate analyses indicated that primary tumor size(pathological diameter) >1.0 cm, upper portion location and lymph node metastasis in central neck were the three risk factors for lateral LNM of PTC(OR=6.250,4.881,5.222,P<0.05). The lymph node metastasis in the lateral neck was not correlated obviously with gender, age, capsuleinvasion, multifocality and tumor ultrasonic characteristics(including illdefined and irregular in shape, calcification, hypervascularized). The probability of lateral LNM was then calculated according to the number of risk factors present in each of the 145 patients, using the three factors. When two or more factors were present, the probability increased up to 38.1 %(95%CI23-53).Conclusion: The present study provides that lateral LNM occurs mainly in patients, with a tumor size(pathological diameter) diameter>1.0 cm, with the primary tumor located in the upper part of the lobe and positive central compartment lymph node metastasis. The risk increased up when at least two of the three factors were present. So it needs to pay attention to the high risk factors seriously which effect lateral neck lymph node metastasis in patients with PTC, combined with ultrasonic characteristics of lateral cervical lymph node or more meticulous evaluations, to establish the lymph node dissection individually.

The Learning Curve of Robotic Thyroid Surgery and the Avoidance of Temporary Hypoparathyroidism after Total Thyroidectomy and Concomitant Central Compartment Node Dissection: A Single Surgeon’s Experience

The aim of this study was to evaluate the learning curve of robotic thyroid surgery with regard to both operation time and temporary hypoparathyroidism using quantitative statistical analysis. A total of 194 patients who underwent total thyroidectomy and concomitant central compartment node dissection for papillary thyroid carcinoma by a single surgeon between December 2008 and September 2017 were enrolled. The learning curve for operation time was assessed using the cumulative sum (CUSUM) technique, and the number of procedures required to reduce the incidence of temporary hypoparathyroidism to less than 30% was determined using the CUSUM and risk-adjusted CUSUM (RA-CUSUM) techniques. The learning curve for operation time was divided into three phases: phase 1 (the initial learning period, 1st–19th cases), phase 2 (the challenging period, 20th–121st cases), and phase 3 (the competent phase, 122nd–194th cases). To reduce the incidence of temporary hypoparathyroidism to &lt;30% required 119 cases, and after adjustment for potential risk factors by RA-CUSUM analysis this extended to 173 cases. Technical proficiency for robotic thyroid surgery with respect to the avoidance of surgical complications probably requires a longer learning period than that required for operation time.

Magnetic Resonance Imaging Characteristics of Papillary Thyroid Carcinoma for the Prediction of Cervical Central Compartment Lymph Node Metastasis.

Cervical lymph node metastasis (LNM) is associated with local recurrence and distant metastasis in papillary thyroid carcinoma (PTC). This study was to assess magnetic resonance imaging (MRI) characteristics for predicting cervical LNM in PTC. A total of 119 patients with 154 PTC examined by MRI were assessed. According to inclusion and exclusion criteria, 78 subjects (78 tumors) were included in the final analysis. Conventional MRI findings and apparent diffusion coefficient were recorded. Descriptive statistics for LNM, sensitivity, specificity, and accuracy of various features were obtained. Multivariate logistic regression was performed for identifying independent variables for predicting LNM. Receiver operating characteristic curves were used to assess the diagnostic performance of the independent variables and model. There were 31 node-positive and 47 node-negative PTCs in this study. Node-positive patients significantly differed from the node-negative group in age (P = 0.039), long/short diameter of lymph nodes (both P < 0.001), lymph nodes cystic change (P = 0.005), tumor size (P < 0.001), poorly defined tumor margin in contrast-enhanced imaging (P < 0.001), and thyroid contour protrusion sign (P < 0.001). Satisfactory interobserver agreement was obtained between the 2 examiners (Cohen κ of 0.871 and 0.872). Thyroid contour protrusion sign and poorly defined tumor margin were identified as independent predictive factors of LNM in PTC (both P < 0.05), with area under the curves of 0.813 and 0.851, and accuracies of 0.810 and 0.838. When the independent factors were combined, the diagnostic performance was improved with an area under the curve of 0.944 and an accuracy of 0.884. Thyroid contour protrusion sign and poorly defined tumor margin in contrast-enhanced imaging could be 2 important predicted findings for cervical LNM in PTC.

Preoperative vitamin D deficiency is a risk factor for postoperative hypocalcemia in patients undergoing total thyroidectomy: retrospective cohort study.

The relationship between preoperative vitamin D deficiency and postoperative hypocalcemia in cases of total thyroidectomy (TT) is a matter of controversy and may vary according to geographical scenarios and populations. The objective here was to evaluate whether preoperative vitamin D deficiency was associated with postoperative symptomatic hypocalcemia in a population in South America. Retrospective cohort study on data from all patients undergoing total thyroidectomy, with or without central compartment lymph node dissection, from January 2014 to December 2017, at the A. C. Camargo Cancer Center. Patients with benign thyroid disease (Graves' disease, multinodular goiter or hyperthyroidism) or thyroid cancer who underwent primary total thyroidectomy with or without central compartment lymph node dissection were included. The exclusion criteria were simultaneous parathyroidectomy and conditions that could affect serum calcium levels. The data collected included patient demographics, thyroid pathology, extent of the surgical procedure and complications. Information on preoperative and postoperative calcium, parathyroid hormone (PTH) and vitamin D levels were retrieved from the medical records. 1,347 patients were assessed and postoperative hypocalcemia was diagnosed in 284 patients (21%). The vitamin D levels were considered deficient in 243 patients (18%). Postoperative hypocalcemia was diagnosed in 357 patients (31.5%). Multivariate analysis showed that central compartment dissection and preoperative total calcium and deficient vitamin D levels were significant risk factors for postoperative hypocalcemia. Deficient preoperative vitamin D levels were a significant risk factor for postoperative hypocalcemia. Preoperative oral supplementation should be considered, to minimize this risk.

Application of Carbon Nanoparticles in Endoscopic Thyroidectomy via Bilateral Areola Approach: Total Thyroidectomy Plus Central Lymph Node Dissection.

Background: The aim of this report was dual: (a) to describe the step-by-step standardized intraoperative percutaneous injection of carbon nanoparticles (CNPs) procedure for CNP-stained central compartment lymph nodes (CLNs) and passive display of parathyroid gland by CNP-stained thyroid in endoscopic thyroidectomy via bilateral areola approach (ETBAA) and (b) evaluation and outcomes of percutaneous injection of CNPs in total thyroidectomy plus CLN dissection through ETBAA. Materials and Methods: Video describes the technique of intraoperative percutaneous injection of CNPs for central compartment LNs identification, dissection, and parathyroid glands preservation in ETBAA for papillary thyroid cancer. Results: Supplementary video shows that after intrathyroid injection of CNPs, black carbon can be seen rapidly along the lymphatic vessels to the surrounding LNs. Parathyroid gland can be passive display when the thyroid is black and the parathyroid gland is normal in color. Intraoperative neuromonitoring (Medtronic® NIM-Response 3.0) was applied to identify recurrent laryngeal nerve and external branch of superior laryngeal nerve. No patient had any side effects of CNPs from 152 patients followed up for an average of 19.6 months (6-34 months). LNs were easily found under ETBAA. The accuracy of black-dyed LN in thyroid cancers was 95.9% (1016/1059). The number of parathyroid glands passive display was 69.9% (267/382). Conclusions: It is feasible to use CNPs to show CLNs in thyroid cancer during ETBAA. CNP suspension is safe for thyroidal injection.

The role of prophylactic central compartment lymph node dissection in elderly patients with differentiated thyroid cancer: a multicentric study

BackgroundProphylactic central neck lymph-nodes dissection is still a topic of major debate in Literature. There is a lack of randomized controlled trials proving advantages in its application in terms of overall survival and local recurrence. Due to the recent rapid increase of elderly population, differentiated tumor carcinoma diagnosis increased in patients over 65 years old. The aim of this study was to compare recurrence rate, complications rate and histological features of tumors in elderly population.MethodsA retrospective study was carried out collecting data from 371 patients with differentiated thyroid cancer without clinical evidence of lymph-nodes involvement in three Italian referral centers from 2005 to 2015. All patients were aged ≥ 65 years and were divided in two groups based on the performed surgery (total thyroidectomy alone or associated with central lymph-nodes dissection). Moreover, patients were stratified according to the age between 65 and 74 years old and over 75 years old.ResultsTotal thyroidectomy alone was performed in 184 patients (group A) and total thyroidectomy with prophylactic central neck dissection was performed in 187 cases (group B). There was a statistically significant difference in complications between the groups in terms of neck hematoma (0.5% group A vs 3.7% group B), temporary hypoparathyroidism (11.4% group A vs 21.4% group B), and temporary unilateral recurrent nerve injury (1.5% group A vs 6.4% group B). Lymph nodes recurrence rate was 9.2% in group A and 8.5% in group B, with no statistically significant difference. There was a statistically significant difference in patients over 75 years old in terms of temporary hypoparathyroidism (24% group A vs 11% group B), permanent hypoparathyroidism (2,7% group A vs 0,3% group B) and recurrent nerve injury (9,5% group A vs 2% group B).ConclusionsThe role of prophylactic central neck dissection is still controversial, especially in elderly patients, and an aggressive surgical approach should be carefully evaluated. The Authors reported a similar low recurrence rate between total thyroidectomy and total thyroidectomy associated with prophylactic central neck dissection, with increased postoperative complications in the lymphadenectomy group and in patients over 75 years old, advocating a tailored surgical approach in elderly population.

Correlation of Primary Tumour Size and Central Compartment Lymph Nodes Metastasis in Well Differentiated Thyroid Malignancies in a Tertiary Care Centre.

Central compartment lymph nodes are the first to be involved in thyroid carcinoma and associated with higher chances of recurrence. (1) Recurrence and revision surgery can be associated with a high risk of vocal cord paralysis and hypocalcemia. (2) However, the need for central compartment lymph nodes dissection routinely in all cases of thyroid malignancies is controversial considering the risk to recurrent laryngeal nerve and parathyroids. (3) The aim of the study was to evaluate the incidence of central compartment lymph nodes metastasis in well differentiated thyroid malignancy and their correlation with size of the primary tumour along with incidence of postoperative hypocalcemia and recurrent laryngeal nerve injury after central compartment lymph node dissection. Observational study 30 patients diagnosed as well-differentiated thyroid carcinoma after fine needle aspiration cytology and planned for total thyroidectomy and central compartment lymph node dissection in the Department of ENT at a tertiary care hospital in Mysuru were studied. After surgery, histopathological examination (HPE) of thyroid and lymph node specimen was done. Postoperatively, all patients were evaluated for hypocalcemia and recurrent laryngeal nerve injury. The incidence of central compartment lymph node metastasis after HPE was 66.6%. 80% cases with tumor size ≤ 1cm and 64% cases having tumor size > 1cm showed central compartment lymph node involvement. Overall Incidence of transient Hypocalcaemia was 40%. No case of recurrent laryngeal nerve palsy was observed. In well-differentiated thyroid malignancies we found a high incidence of central compartment lymph node involvement which was even higher with primary tumour of smaller size (≤ 1cm). We did not find any incidence of permanent hypocalcemia and recurrent laryngeal nerve injury. So based on our study we emphasize on elective central compartment lymph node clearance to avoid recurrence.