Central Neck Dissection In Patients Research Articles

The Oncologic Outcomes of Bilateral Central Lymph Node Dissection in Unilobar Papillary Thyroid Cancer and Its Risks: A Prospective Cohort Study.

Background Indications for performing a prophylactic central neck dissection (pCND) in papillary thyroid cancer (PTC) remain controversial. Thyroidectomy and central neck dissection (CND) are often recommended in all cases with proven differentiated thyroid cancer (DTC) and clinically positive lymph nodes (LNs), as well as in high risk for micro-metastasis patients with T3-T4 tumors or established metastatic nodes in the lateral compartments. Aims The aims of this study were to ascertain the role of performing bilateral central LN dissection in unilobar PTC in improving the oncological outcomes and outline the risks involved. Methods This was a department-based, prospective cohort study. We included all 20 patients who had unilobar PTC and underwent total thyroidectomy with bilateral CND. A postoperative histopathological analysis was used to identify metastatic central LNs. Results Twenty total thyroidectomies plus bilateral CNDs were performed, of which 10 were prophylactic bilaterally (those with N0), and all 20 were prophylactic on the contralateral side of PTC. Conventional risk factors (age, tumor size, and extrathyroidal extension)were notassociated with performing a pCND. The presence of unilobar PTC by preoperative FNAC was the only factor associated with performing bilateral CND. Positive ipsilateral LNs were retrieved in 55% of CNDs, while positive contralateral LNs were retrieved in only 15% of the patients. Conclusions The incidence of contralateral cervical LN metastasis in patients with unilateral PTC is low, while there is clear evidence of postoperative morbidity from routine contralateral CND in unilobar PTC. Contralateral CND in patients with unilobar PTC may be reserved for high-risk patients: males, those aged ≤45 years, tumors larger than 1.0 cm, and cases with extrathyroidal extension and micro-calcification on ultrasound.

Sporadic noninvasive medullary thyroid neoplasm: A desmoplasia-negative unifocal nonmetastatic tumor cured by hemithyroidectomy

BackgroundThe absence of primary tumor desmoplasia, a marker of node metastases, on frozen section may help reduce the extent of surgery without compromising the biochemical cure. We aimed to clarify whether hemithyroidectomy with diagnostic ipsilateral central neck dissection can replace total thyroidectomy with routine central neck dissection in patients with sporadic medullary thyroid cancer. MethodsWe retrospectively evaluated data collected from patients who had undergone primary neck surgery for hypercalcitoninemic sporadic medullary thyroid cancer between January 2017 and December 2022 at one institution. ResultsOf the 25 patients we examined, 19 had desmoplasia-negative and 6 desmoplasia-positive primary thyroid tumors on frozen section. The desmoplasia-negative patients had undergone less surgery with fewer nodes removed than the desmoplasia-positive patients (medians of 6 vs 31 nodes, P < .001). The desmoplasia-negative patients had predominantly undergone hemithyroidectomy with ipsilateral central neck dissection. None of the desmoplasia-negative tumors was multifocal (0 of 19 desmoplasia-negative vs 2 of 6 desmoplasia-positive or 0% vs 33%, P = .050) or node-positive (0 of 19 vs 6 of 6 patients or 0% vs 100%; medians of 0 vs 3.5 node metastases; both P < .001). Despite limited surgery, all desmoplasia-negative patients attained and maintained biochemical cure. ConclusionHemithyroidectomy combined with diagnostic ipsilateral central neck dissection is a viable risk-reducing and curative strategy for desmoplasia-negative and node-negative, nonmetastatic unifocal tumors, for which we propose the term sporadic noninvasive medullary thyroid neoplasm (SNMTP).

Comparative Study between Total Thyroidectomy with Ipsilateral versus Bilateral Prophylactic Central Neck Dissection in Patients with Clinically Node – Negative Papillary Thyroid Carcinoma. A Meta-Analysis

Abstract Background Papillary thyroid carcinoma (PTC) accounts for &amp;gt; 80% of all thyroid malignancies. It is generally slow-growing and the overall prognosis is excellent, with 5-year, 10-year, and 20-year survival rates of 94%, 89%, and 87%, respectively. Aim of the Work The aim of this study is to compare between unilateral PCND and bilateral PCND in patients with clinically unifocal cN0 PTC using meta-analysis approach Methodology A Systemic review and meta-analysis Study was performed after the data extraction process. Five studies comparing the out-comes of unilateral PCND and bilateral PCND procedures in adult patients with PTC CN0 were included in this study. The publicly available literature on PubMed, and, the Web of Knowledge, and the China Journal Net, EMBASE, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry. Published from January 2005 to December 2020 concerning TT plus ipsilateral PCND versus TT plus bilateral PCND for PTC CN0 will be retrieved by searching the national and international online databases. Results The result of our study revealed that: Bilateral central neck dissection had higher insignificant operative time than ipsilateral one, bilateral central neck dissection had higher overall significant complications rate than ipsilateral one, bilateral central neck dissection had higher significant permanent hypo PTH and insignificant hematoma, seroma, and transient hypo PTH rate than ipsilateral one, ipsilateral central neck dissection had higher insignificant PRLNP, TRLNP rate nearly equal with bilateral one, ipsilateral CND appears to be sufficient in patients with tumors&amp;lt;1 cm as bilateral central neck dissection had higher insignificant tumor size than ipsilateral one, there was no statistically significant difference found between unilateral PCND and bilateral PCND regarding rate of recurrence. Conclusion We suggest that, ipsilateral central neck dissection may be a reasonable surgical option for prophylactic CND in unilateral PTC with clinically negative lymph nodes because of its lower rates of contralateral paratracheal node metastasis and transient hypoparathyroidism and lower complications than bilateral pCND. and effective for selected patients undergoing a total thyroidecto- my for cN0 unilateral PTC.

Hemithyroidectomy and ipsilateral central neck dissection for T1 low-risk papillary thyroid cancer: single-institution retrospective observational study.

The aim of this study was to report the rationale and selection criteria for hemithyroidectomy and ipsilateral central neck dissection in patients with selected papillary thyroid cancer and to report the surgical and oncological outcomes. Single-institution retrospective observational study. The clinical records of patients with a histopathological diagnosis of low-risk pT1 papillary thyroid cancer who underwent hemithyroidectomy with or without ipsilateral central neck dissection between March 2000 and April 2018 at a tertiary referral center were retrospectively reviewed. Demographic, clinical, and histopathological data were collected. During the study period, 176 patients underwent hemithyroidectomy for PTC. Thirteen patients (13/176, 7.39%) were lost to follow-up and 74 patients (74/163 45.40%) underwent completion thyroidectomy within 1 month because they were classified intermediate ATA initial risk based on definitive pathology. The final study group was composed of 89 patients, who had a median follow-up of 5.3 years. The mean follow-up was 6.3 years (range: 36-207 months). Eighty-four patients (94.38%) did not experience recurrence in the follow-up period. A total of 5/89 patients (5.62%) underwent delayed completion thyroidectomy with or without neck dissection for recurrent malignancy in the residual lobe (3/5) or regional lymph nodes (2/5). The median time from surgery to recurrence was 24.8 months (range: 6-60). The follicular variant was an independent risk factor for recurrence. Hemithyroidectomy with or without prophylactic ipsilateral central neck dissection is a valuable treatment option in selected low-risk papillary thyroid cancers and ensures a low risk of recurrence. Prophylactic ipsilateral central compartment dissection could have a role in improving cancer staging, and accurate ultrasonographic follow-up is essential to identify local recurrence.

Risk of hypocalcemia after total thyroidectomy and bilateral central neck dissection in patients with well differentiated thyroid carcinoma.

Background: Hypocalcaemia is a grave complication after thyroid surgery with signs ranging from paresthesia up to laryngospasm. Avoiding this complication is mandatory to avoid lifelong calcium and vitamin D supplements. Aim of the work: to assess the risk of hypocalcaemia after thyroid surgery and the factors contributing to it. Patients and methods: this study was conducted on 50 patients with well differentiated thyroid carcinoma admitted to Sayed Galal hospital and they were divided into 3 groups: A, B and C. Results: Group B patients had transient hypocalcaemia and PTH levels were in normal range, thus suffering from parathyroid dysfunction. Calcium levels returned to normal range after a mean of 15.5 days. Group C patients remained hypocalcemic for over six months and PTH levels were below normal range thus defining absolute hypoparathyroidism. In terms of age, gender, tumor size and stage, group C patients were older, had no female prevalence, had slightly larger tumors and presented at late stages. Preoperative calcium levels were not a risk factor as group C patients had the highest mean of ionized calcium and group B patients had lower mean of total calcium level than those of group C. Conclusion: The most important risk factor for post-thyroidectomy hypocalcaemia is the surgical technique. Meticulous dissection to preserve the blood supply to the parathyroid glands and careful handling of the parathyroid tissue are equally important to preserving the parathyroids themselves. Other risk factors include older age, large tumors and late stages.

Performing Central Neck Dissection in Patients with Papillary Thyroid Carcinoma with Clinically Node Negative, Benefits and Drawbacks: A Comparative Study

Context: central neck dissection in addition to total thyroidectomy as a management procedure of patients with papillary carcinoma of the thyroid [PTC] was previously found to decrease the incidence of lymph node recurrence and allow and accurate PTC surgical staging that allow making a better decision regarding adjuvant radioactive iodine (RAI) ablation. But recently, central neck dissection in patients with clinical and radiological evidences of negative cervical lymph nodes was found to have many post-operative complications. Aim: to assess benefits, complications and drawbacks of performing central neck dissection by in PTC patients. Patients and methods: This is a prospective randomized study which included 70 PTC patients who was subjected to total thyroidectomy with or without neck dissection; all included patients have clinically negative cervical lymph nodes, 40 (60%) underwent total thyroidectomy in addition to central neck dissection and 30 (40%) patients were subjected to only total thyroidectomy without central neck dissection. We followed our patients for five years to detect recurrence, RFS and OS rates. Results: We found that operative time was longer in patients underwent central block dissection (p=0.049). Recurrence free survival and overall survival rates were not significantly different among both included groups, which denoted that central block neck dissection has no survival benefits in PTC patients. Conclusions: We have concluded that performing central neck dissection in PTC with clinically and radiologically negative lymph nodes has no benefits in increasing patients’ survival or decreasing recurrence rate and might lead to prolongation of operation time, increasing post-operative morbidity.

Sentinel Lymph Node Biopsy in Thyroid Cancer.

Prophylactic central neck dissection in patients with papillary thyroid carcinoma is controversial. Sentinel node biopsy might be an adjunct to optimize surgical treatment for these patients. Earlier studies reported inconsistent detection rates and diagnostic value of this technique, and the role of sentinel lymph node biopsy in thyroid cancer needs to be established. During a single-center prospective interventional study between 2010 and 2017, sentinel lymph node biopsy using 99mTc-nanocolloidal albumin tracer was performed on patients undergoing thyroid surgery for suspected thyroid cancer by fine needle aspiration cytology. All eligible patients without clinical lymph node involvement were invited to participate. Central neck dissection was performed on all patients after the detection of sentinel lymph nodes. Ninety-six patients participated in the study. The detection rates of the sentinel node were 67% and 45% by scintigraphy and intraoperative gamma probe, respectively. The detection rate was not associated with Bethesda score, malignancy, or presence of lymph node metastases. Sensitivity, negative predictive value, and accuracy were 80%, 97%, and 98%, respectively, for the sentinel node to represent the status of lymph node metastasis in the central neck compartment. The false negative rate was 20%. Sentinel lymph node biopsy had a low detection rate and only moderate sensitivity in patients with suspected thyroid carcinoma and is not a useful adjunct to surgery in the context of current treatment concepts.

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.

Local lymph node recurrence after central neck dissection in papillary thyroid cancers: A meta analysis

BackgroundProphylactic central neck dissection (CND) at the time of total thyroidectomy (TT) remains controversial in clinically node-negative (cN0) papillary thyroid carcinoma (PTC). This systematic review and meta-analysis was performed to compare the local recurrence between patients who underwent TT plus CND and those who underwent TT alone. MethodsThe publicly available literature published from January 1990 to October 2017 concerning TT plus prophylactic CND versus TT for PTC was retrieved by searching the national and international online databases. Meta-analysis was performed after the data extraction process. ResultsTwenty-five studies with comparison between TT+CND and TT alone were eligible and included in this meta-analysis. For both PTC and papillary thyroid microcarcinoma (PTMC), the overall recurrence in TT+CND group was significantly lower than that in TT alone group. The central compartment recurrence was significantly higher in TT alone group than TT+CND group (OR=3.41, 95% Cl [2.00∼5.80], P<0.00001), while no significant difference of lateral compartment recurrence was observed between the two groups (OR=1.19, 95%Cl [0.81∼1.77], P=0.38). We compared ipsilateral CND+TT with TT alone and found that the recurrence was not significantly different between the two groups (OR=1.44, 95%Cl [0.74∼2.81], P=0.28). On the other hand, bilateral CND+TT showed significantly low recurrence (OR=2.48, 95%Cl [1.75∼3.53], P<0.00001). ConclusionsThe addition of CND to TT resulted in a greater reduction in risk of local recurrence than TT alone, especially preventing central neck recurrences. Additionally, we discovered that bilateral CND in patients with PTC>1cm was necessary.

Sentinel Lymph Node Biopsy as a Guide for Central Neck Dissection in Patients with Suspicious Thyroid Nodule and Negative Cervical Lymphadenopathy

Background: Routine prophylactic central compartment neck dissection in patients with differentiated thyroid carcinoma is not always accepted as a standard management of occult metastasis due to the risk of hypocalcaemia and recurrent laryngeal nerve injury. Aim: To evaluate the accuracy of using sentinel lymph node biopsy as a guide in identifying occult cervical LN metastases early and thus to avoid the morbidity associated with routine unnecessary central lymph node dissection. Patients and methods: A prospective study was conducted in the period between April 2015 and January 2017 in Ain Shams University Hospitals, General Surgery Department, Endocrine Surgery Unit, Cairo, Egypt. The study included fifty two patients who had at least one suspicious thyroid nodule and not accompanied by clinical or radiological cervical LN. The patients underwent sentinel lymph node biopsy via intra-tumoral injection of methylene blue dye 1%, followed by tracking the lymphatics till the sentinel LN then total thyroidectomy and central LN dissection. Results: The study included 52 patients with suspicious thyroid nodule, 11 males and 41 females with mean age 41±6.7 (26-65). Co-morbid conditions included DM, HTN and ISHD. Size of nodules ranged from 0.8- 5.6 cm (1.9± 0.6) and most nodules were confined to one lobe (65.4%). After the final paraffin pathology 24 nodules were found to be benign and 28 proved malignant. SLNs were identified in 21 of 28 malignant cases (75%); number of sentinel LNs detected was 0-6 (2.8±1.9) and size ranged from 0.1- l.6 cm. 18 of identified SLN were positive for metastasis and 10 were negative while non SLN were positive in 15/28 and negative for 13/28. Thus, the sensitivity, specificity, negative predictive values, positive predictive values and accuracy of SLN biopsy were 85.7%, 100%, 70%, 100%, and 75%, respectively. Post-operative complications included temporary hypocalcaemia in 3 patients and extensive laryngeal edema in 1 patient needing prolonged intubation more than one day then recovered. Conclusion: SLN biopsy for patients with differentiated thyroid carcinoma and negative LNs clinically and radiologically is an accurate and noninvasive means to identify subclinical lymph node metastasis and so can be used as a guide to determine the need for zone 6 LN dissection.

Lateral lymph node recurrence after total thyroidectomy and central neck dissection in patients with papillary thyroid cancer without clinical evidence of lateral neck metastasis

BackgroundThis study analyzed the incidence, pattern, and predictive factors for lateral lymph node (LN) recurrence in patients with papillary thyroid cancer (PTC) without clinical evidence of lateral LN metastasis. MethodsA retrospective analysis was performed on 246 patients with PTC who underwent total thyroidectomy and central neck dissection from 2004 to 2010. None of the patients had clinical evidence of lateral LN metastasis at the time of diagnosis. Predictive factors for lateral LN recurrence were evaluated using the chi-square test. Binary logistic regression was used for the multivariate analysis. Recurrence-free survival rates were estimated by the Kaplan–Meier and Cox regression methods. ResultsOf the 246 patients, 11 (4.5%) developed lateral LN recurrence with a median follow-up of 49months. In the multivariate analysis, tumor size >1cm (odds ratio [OR], 8.14; 95% confidence interval [CI], 1.01–65.68; p=0.049) and central LN metastasis (OR, 10.59; 95% CI, 1.32–85.17; p=0.026) were independent predictive factors of lateral LN recurrence. Especially, extranodal extension of a metastatic central LN (OR, 38.82; 95% CI, 5.71–264.10; p<0.001) was an independent predictor of lateral LN recurrence. ConclusionsTumor size and central LN metastasis were independent predictors of lateral LN recurrence in patients with PTC without initial clinical lateral neck metastasis who underwent total thyroidectomy and central neck dissection. Close surveillance may be necessary for early detection of lateral LN recurrence in PTC patients with tumor size ⩾1cm, and central LN metastasis with extranodal extension.

Potential role for carbon nanoparticles to guide central neck dissection in patients with papillary thyroid cancer

The purpose of this study was to investigate the use and clinical utility of carbon nanoparticles as a lymph node tracer in the central neck lymph node dissection of patients with papillary thyroid cancer. One hundred forty consecutive patients were divided into a carbon nanoparticle group (n=70) and a control group (n=70). All patients underwent total or near-total thyroidectomy with bilateral central neck dissection. The carbon nanoparticle and control groups had different rates of metastatic lymph nodes (P=.017), total detected numbers of lymph nodes (P=.0001), total numbers of dissected lymph nodes <5mm(P=.0001), and numbers of metastatic lymph nodes <5mm(P=.0001). Of the 682 lymph nodes dissected in the carbon nanoparticle group, 579 (85%) were stained black, and of these, 147 (25%) were metastatic lymph nodes. There were 63 metastatic lymph nodes <5mm among the black-stained metastatic lymph nodes, while there were 12 non-black-stained metastatic lymph nodes <5mm. Of the total number of metastatic lymph nodes (n=193), 147 (76%) were stained black. Moreover, pathologic results revealed that 5 accidental parathyroid resections occurred in the carbon nanoparticle group, compared with 14 in the control group (P=.046). Carbon nanoparticles might help to detect lymph nodes and increase the number of metastatic lymph nodes visualized and preserved. Therefore, use of carbon nanoparticles may reflect the metastatic condition of the central neck and have the potential to protect parathyroid glands.

Pathologic features of metastatic lymph nodes identified from prophylactic central neck dissection in patients with papillary thyroid carcinoma.

The importance of pathologic features of metastatic lymph nodes (LNs), such as size, number, and extranodal extension, has been recently emphasized in patients with papillary thyroid carcinoma (PTC). We evaluated the characteristics of metastatic LNs identified after prophylactic central neck dissection (CND) in patients with PTC. We performed a retrospective review of 1,046 patients who underwent unilateral or bilateral thyroidectomy with ipsilateral prophylactic CND. We reviewed the characteristics of the metastatic LNs and analyzed their correlation to the clinicopathologic characteristics of the primary tumor. Cervical LN metastasis after prophylactic CND was identified in 280 out of 1046 patients (26.8%). The size of metastatic foci (≥2mm) was independently correlated with primary tumor size (≥1cm) (p=0.016, OR=1.88). Primary tumor size (≥1cm) was also correlated to the number of metastatic LNs (≥5) (p=0.004, OR=3.14) and extranodal extension (p=0.021, OR=2.41) in univariate analysis. The size of the primary tumor affects pathologic features of subclinical LN metastasis in patients with PTC. Patients with primary tumors ≥1cm have an increased risk of larger LN metastases (≥2mm), an increased number of LN metastases (≥5), and a higher incidence of ENE, which should be considered in decision for prophylactic CND.

Predictive factors of contralateral paratracheal lymph node metastasis in unilateral papillary thyroid carcinoma

BackgroundMost of unilateral papillary thyroid carcinoma (PTC) metastasize to ipsilateral paratracheal lymph nodes (LNs) while some had contralateral paratracheal LN involved. The aim of this study was to analyze the predictive factors of contralateral paratracheal LN metastasis in unilateral PTC. MethodsData on 332 patients with unilateral PTC who underwent total/near total thyroidectomy and bilateral central neck dissection (CND) with/without lateral neck dissection were collected retrospectively. Patients' demographics, the extent of surgeries, and the pathological status of LNs and primary tumor were analyzed. ResultsA total of 332 patients (67 male and 265 female) were included. Contralateral paratracheal LN metastasis was found in 68 (68/332, 20.5%) patients. Tumor size (>1 cm) (P < .001), capsular/extracapsular invasion (P < .001), pretracheal/prelaryngeal LN metastasis (P < .001), lateral neck LN metastasis (P < .001) and ipsilateral paratracheal LN metastasis (P < .001) was significantly associated with contralateral paratracheal LN metastasis on univariate analysis. Multivariate analysis showed that tumor size (>1 cm) (P = .013), capsular/extracapsular invasion (P = .009), pretracheal/prelaryngeal LN metastasis (P = .021) and lateral neck LN metastasis (P = .002) were independent risk factors of contralateral paratracheal LN metastasis. ConclusionPrimary tumor size >1 cm, capsular/extracapsular invasion, pretracheal/prelaryngeal LN metastasis and lateral neck LN metastasis are predictive factors of contralateral paratracheal LN metastasis in unilateral PTC, which may help to determine the optimal extent of CND in patients with PTC.

Risk factor analysis for central nodal metastasis in papillary thyroid carcinoma.

Lymph node involvement is associated with recurrence in papillary thyroid carcinoma (PTC). The central neck compartment (level VI) lymph nodes are at the greatest risk of metastases from PTC, but the role of central neck dissection (CND) remains controversial, particularly in PTC without clinical cervical lymph node metastasis (cN0). The present study aimed to identify risk factors of central cervical nodal metastasis and the safety of CND in patients with cN0 PTC. The current study retrospectively investigated 389 patients who had been followed up for 12.0–25.5 months after surgery, and were divided into positive or negative lymph node involvement groups according to the pathological results subsequent to this surgery. Univariate and multivariate analyses were used to study the risk factor of central node involvement. The mean tumor size was 0.71±0.35 cm (range, 0.1–2.0 cm). There was no significant difference in the rate of central lymph node involvement based on age (<45 or ≥45 years) or tumor focality (unifocal or multifocal). However, there were significant differences based on gender, extra-thyroid invasion and tumor size (P<0.05). The incidence of transient hypoparathyroidism and transient vocal cord paralysis following CND was 12.34 and 4.11%, respectively. No patient experienced permanent hypoparathyroidism or vocal cord paralysis. One patient (1/389; 0.23%) experienced disease recurrence during the follow-up. A larger tumor size and the male gender were significantly associated with the central nodal metastasis rate for cN0 PTC with a tumor size of <2.0 cm. CND for cN0 PTC patients was safe and the tumor-associated recurrence rate following CND plus total thyroidectomy was low. The present study suggests that CND should be conducted for male cN0 PTC patients with a larger tumor size (≥0.5 cm).

BRAF mutation in papillary thyroid cancer: A cost-utility analysis of preoperative testing

Papillary thyroid carcinoma (PTC) with BRAF mutation carries a poorer prognosis. Prophylactic central neck dissection (CND) reduces locoregional recurrences, and we hypothesize that initial total thyroidectomy (TT) with CND in patients with BRAF-mutated PTC is cost effective. This cost-utility analysis is based on a hypothetical cohort of 40-year-old women with small PTC [2cm, confined to the thyroid, node(-)]. We compared preoperative BRAF testing and TT+CND if BRAF-mutated or TT alone if BRAF-wild type, versus no testing with TT. This analysis took into account treatment costs and opportunity losses. Key variables were subjected to sensitivity analysis. Both approaches produced comparable outcomes, with costs of not testing being lower (-$801.51/patient). Preoperative BRAF testing carried an excess expense of $33.96 per quality-adjusted life-year per patient. Sensitivity analyses revealed that when BRAF positivity in the testing population decreases to 30%, or if the overall noncervical recurrence in the population increases above 11.9%, preoperative BRAF testing becomes the more cost-effective strategy. Outcomes with or without preoperative BRAF testing are comparable, with no testing being the slightly more cost-effective strategy. Although preoperative BRAF testing helps to identify patients with higher recurrence rates, implementing a more aggressive initial operation does not seem to offer a cost advantage.

Intraoperative frozen section for the evaluation of extrathyroidal extension in papillary thyroid cancer.

We investigated extrathyroidal extension (ETE) through frozen biopsy for intraoperative decision making in patients with papillary thyroid cancer (PTC). During the period of the study an operation was performed in 268 patients with PTC and ETE was evaluated using intraoperative frozen biopsies of thyroid tissue. Extrathyroidal extension was confirmed in 54 patients (20 %) on frozen biopsy. Fifty-three patients among 54 patients showing ETE on frozen biopsy were confirmed on permanent pathologic analysis. Accordingly, frozen biopsy had a sensitivity of 66 %, a specificity of 99 %, a positive predictive value of 98 %, and a negative predictive value of 87 %. Tumor size (OR 4.373; CI 2.257-8.475, p = <0.001) was an independent factor for predicting ETE on frozen biopsy. Intraoperative frozen biopsy can be an useful tool in identifying the presence of ETE. It can also help the operator decide the extent of surgery and central neck dissection in patients with PTC.

Intraoperative Frozen Biopsy for the Evaluation of Extrathyroidal Extension in Papillary Thyroid Cancer

Objectives: We investigated extrathyroidal extension (ETE) through frozen biopsy for intraoperative decision-making in patients with papillary thyroid cancer (PTC). Methods: During the period of the study an operation was performed in 268 patients with PTC and ETE was evaluated using intraoperative frozen biopsies of thyroid tissue. Results: ETE was confirmed in 54 patients (20%) on frozen biopsy. Fifty-three patients among 54 patients showing ETE on frozen biopsy were confirmed on permanent pathologic analysis. Accordingly, frozen biopsy had a sensitivity of 66%, a specificity of 99%, a positive predictive value of 98%, and a negative predictive value of 87%. Tumor size (odds ratio 4.373; confidence interval 2.257-8.475, P &lt; .001) was an independent factor for predicting ETE on frozen biopsy. Conclusions: Intraoperative frozen biopsy can be a useful tool in identifying the presence of ETE. It can also help the operator decide the extent of surgery and central neck dissection in patients with PTC.

Routine prophylactic central neck dissection for low-risk papillary thyroid cancer is not cost-effective.

The role of routine prophylactic central neck dissection (CND) in papillary thyroid cancer (PTC) remains controversial. The aim of this study was to evaluate the cost utility of the addition of routine CND in patients with low-risk PTC compared with total thyroidectomy (TT) alone. A Markov model for low-risk PTC was constructed with a treatment algorithm based on the American Thyroid Association guidelines for well-differentiated thyroid carcinoma. Utilities and outcome probabilities were derived from published medical literature. US 2010 costs were examined from a society perspective using Medicare reimbursement rates and opportunity loss based on published US government data. Monte Carlo simulation and sensitivity analysis were used to examine the uncertainty of probability, cost and utility estimates. Initial TT alone is more cost-effective than TT with CND, resulting in a cost savings of US $5763 per patient with slightly higher effectiveness per patient (0·03 QALY) for a cost savings of $285 per QALY. Sensitivity analysis shows that TT alone offers no advantage when radioactive iodine (RAI) becomes more detrimental to a patient's state of health, when the incidence of non-neck recurrence increases above 5% in patients undergoing TT alone or decreases below 3·9% in patients undergoing TT with CND or when the rate of permanent hypocalcaemia rises above 4%. TT with CND is not a cost-effective strategy in low-risk PTC. Initial TT alone is favourable because of the low complication rates and low recurrence rates associated with the initial surgery. Alternative strategies such as unilateral prophylactic neck dissection require additional study to assess their cost-effectiveness.

Sentinel lymph node biopsy using blue dye as guidance for central neck dissection in patients with clinically node-negative papillary thyroid carcinoma

Background Sentinel lymph node biopsy has recently been used to detect occult lymph node metastases. Occult lymph node metastasis of papillary thyroid carcinoma (PTC) can be detected by sentinel lymph node (SLN) biopsy, but studies in larger patient cohorts undergoing complete central neck dissection are required to assess the diagnostic accuracy of SLN. Materials and methods A total of 25 consecutive patients with clinically and ultrasonographically node-negative PTC were enrolled and underwent sentinel lymph node biopsy. After injection of 0.2-0.3 ml methylene blue around the tumor or 0.5-1.0 ml into the thyroid nodule, blue-stained SLNs were collected from the central compartments. Results SLNs were identified in 21 of 25 patients (84%); of these, 14 SLNs were positive and seven SLNs were negative by hematoxylin and eosin staining. The false-negative rate was detected in two patients (8%), identified by immunohistochemical staining. The non-SLNs were positive in five patients (20%) from positive SLN patients, and no positive non-SLNs were present in negative SLN patients. Conclusion SLN biopsy in patients with PTC without gross clinical or ultrasonographical lymph node involvement was able to detect occult metastasis and may have the potential to select patients who require central neck dissection using methylene blue dye technique in PTC, and it is a safe and technically feasible procedure.