Cervical Node Dissection Research Articles

Poorly differentiated thyroid carcinoma: a retrospective clinicopathological study.

Poorly differentiated thyroid carcinoma (PDTC) is an independent thyroid cancer histotype. In spite of its scarcity, it represents the main cause of death from non-anaplastic follicular cell-derived thyroid cancer. However, given the newness of this entity, few data are available on its clinical behaviour and no explicit consensus sets its treatment. To report the experience of a tertiary medical centre in morocco with PDTC over a period of 7 years. Retrospective study selecting all patients treated for thyroid carcinoma in Nuclear Medicine Department of a tertiary medical centre in Casablanca over seven years period. Patient's files were reviewed for background data, clinico-pathological characteristics, treatment and outcome. Seven patients were included in the study. Patient's average age was 60 years old (30-81) including six women and one man. All patients underwent a total thyroidectomy completed by cervical lymph node dissection in 57% of cases. Mean primary tumour size was 4cm (1-9cm). Patients were classified pT3 in 70% of cases, pT1 and pT2 in 15% each. Vascular invasion was found in 85% of cases. Pathological subtypes found were “insular carcinoma” in 85% of cases. Radioiodine therapy (RIT) was indicated in all cases. Follow-up period ranged between 10 months and 6 years. It showed a complete remission in 57% of cases, persistent disease in 28% of cases and a progressive disease in 15% of cases with a local recurrence. To date, the survival rate is 85%. PDTC is an aggressive thyroid cancer histotype. Treatment remains surgical followed by RIT if the tumour is radioavid. Multimodality therapy is indicated depending on the case and close monitoring is always indicated given the high risk of relapse.

P45. New method of brachytherapy catheter stabilization in proximal trachea

The authors describe the therapeutic management of a patient with implantation intratracheal metastasis of carcinoma of the base of tongue and carcinoma in the left lower lobe. In autumn 2012 the 50-year-old man with negative past medical history underwent surgical resection of squamous cell carcinoma of the tongue’s basis including right-sided cervical lymph node dissection, followed by postoperative radiotherapy. In November 2013 patient appeared in the hospital with chest pain. Following diagnostic methods revealed implantation intratracheal metastasis of the base of tongue and squamous cell carcinoma in the left lower lobe. The combination of brachytherapy, in which bronchial afterloading catheter was fixed via Novatech-Dumon stent to tumor´s bearing, and lower left lobectomy achieved complete remission of cancer.

Prognostic significance of the number of positive lymph nodes, number of involved regions and metastatic lymph node ratio in hypopharyngeal cancer

To explore the relationship between positive lymph node number, involved region, positive lymph node ratio and the prognosis of patients with hypopharyngeal cancer. Clinicopatological data of 81 patients with hypopharyngeal squamous cell carcinoma who underwent hypopharyngectomy and cervical lymph node dissection from January 2000 to December 2005 in our hospital were analyzed retrospectively. The relationship between positive lymph node number, involved region, positive lymph node ratio and the prognosis was analyzed. The rate of lymph node metastasis was 79.0% (64/81) in the 81 patients with hypopharyngeal cancer. Of which, the rates of unilateral metastasis and bilateral metastasis were 82.9% (53/64) and 17.1% (11/64), respectively. The rate of lymph node metastasis was increasing with advancing tumor stage. The median survival times were 81, 51 and 26 months in the patients with 0, 1-3 and ≥ 4 positive lymph nodes, respectively (P < 0.001), 84, 45 and 23 months in patients with 0, 1-2 and ≥ 3 involved regions, respectively (P < 0.001), and 84, 51 and 17 months in patients with positive lymph node ratio of 0, <10% and ≥ 10%, respectively (P < 0.001). Multivariable analysis showed that positive lymph node ratio, extracapsular infiltration, T classification and treatment modality were independent prognostic factors (P = 0.002). Positive lymph node ratio is an independent prognostic factor for hypopharyngeal cancer.

Applicability of the swine model for training surgery – cervical lymph node dissection

Abstract But de la presentation The surgical neck dissection is the primary resource for the treatment of the head and neck cancer with cervical metastasis, representing a major challenge for the surgeon. The objective of this study is to compare the swine cervical anatomy with human and present the possibility of applying the swine model in experimental surgery in the field of cervical lymph node dissection. Materiel et methodes The authors performed several sessions of experimental neck dissection, highlighting technical and anatomical aspects involving the cervical lymph node dissection. We conducted a literature search about swine cervical anatomy and research in surgical techniques applied to porcine model of experimental surgery. Resultats Anatomical similarities led perform cervical lymph node dissection in swines with successfully. However, the level of cervical lymph node dissection in swine model have some particularities: – the lower limit should be set through the subclavian muscle; – the level V is very extensive; – levels III and IV show little tissue volume; – access to level II is very difficult by the location of the angle of the jaw; – level I is quite similar to the human model. Conclusion After several sessions of neck dissection in swines, we conclude that swine model is valid for training in cervical lymph node dissection.

Intraoperative ultrasonography is useful in surgical management of neck metastases in differentiated thyroid cancers.

Differentiated thyroid carcinomas are the most common malignancies of endocrine organs. Metastases to cervical lymph nodes occur in 20-50% of cases. Recurrence and survival rates are closely related to the type of surgery performed. High-resolution ultrasonography (USG) is a sensitive imaging method used to detect occult lymph node metastases in patients with thyroid cancer. We evaluated how intraoperative USG affected surgical success. This was a retrospective study comparing two groups of patients with thyroid carcinoma who underwent cervical lymph node dissection. A total of 101 patients (33 males and 68 females) were included. Group 1 included 53 patients who underwent surgery with intraoperative USG guidance. Group 2 included 48 patients who underwent surgery without the use of USG. All patients were followed up (mean 23 months; range 5-44 months) with thyroglobulin measurements and USG evaluations. Group 1 (intraoperative USG) had a residual/recurrent tumor rate of 1.9% (1/53 patients). Group 2 had a residual/recurrent tumor rate of 12.5% (6/48 patients). A statistically significant difference appeared between the residual/recurrent tumor rates in Groups 1 and 2 (p<0.05). In addition to its classical use in diagnosis and follow-up, intraoperative use of high-resolution USG can improve surgical success and may decrease the number of residual/recurrent tumors encountered during follow-up.

Parasitic thyroid nodules: cancer or not?

SummaryIn 2006, a 58-year-old woman presented with thyrotoxicosis. She had undergone left hemithyroidectomy 14 years before for a benign follicular adenoma. Ultrasound imaging demonstrated bilateral cervical lymphadenopathy with enhanced tracer uptake in the left lateral neck on a Technetium-99m uptake scan. Fine-needle aspiration biopsy of a left lateral neck node was insufficient for a cytological diagnosis; however, thyroglobulin (Tg) washings were strongly positive. The clinical suspicion was of functionally active metastatic thyroid cancer in cervical lymph nodes. A completion thyroidectomy and bilateral cervical lymph node dissection were performed. Histology demonstrated benign multinodularity in the right hemithyroid, with bilateral reactive lymphadenopathy and 24 benign hyperplastic thyroid nodules in the left lateral neck that were classified as parasitic thyroid nodules. As there had been a clinical suspicion of thyroid cancer, and the hyperplastic/parasitic thyroid tissue in the neck was extensive, the patient was given ablative radioactive iodine (3.7 GBq). After 2 years, a diagnostic radioactive iodine scan was clear and the serum Tg was undetectable. The patient has now been followed for 7 years with no evidence of recurrence. Archived tissue from a left lateral neck thyroid nodule has recently been analysed for BRAF V600E mutation, which was negative.Learning points Thyrotoxicosis due to functional thyroid tissue in the lateral neck is very rare and may be due to metastatic thyroid cancer or benign parasitic thyroid tissue.Parasitic thyroid nodules should be considered as a differential diagnosis of lateral neck thyroid deposits, particularly where there is a history of prior thyroid surgery.Parasitic thyroid nodules may occur as a result of traumatic rupture or implantation from a follicular adenoma at the time of surgery.The use of ablative radioactive iodine may be appropriate, as resection of all parasitic thyroid tissue can prove difficult.BRAF mutational analysis of parasitic thyroid tissue may provide extra reassurance in the exclusion of papillary thyroid carcinoma.

Treatment of c-kit positive adenoid cystic carcinoma of the tongue: A case report

Adenoid cystic carcinoma (ACC) or ‘cylindroma’ is a malignant tumor that often occurs in the areas of the head and neck, affecting the secretory glands and the major and minor salivary glands. The present study describes a case of a patient who presented with a posterior tongue lesion. The case is of a 71-year-old female with an asymptomatic volume growth of the posterior left tongue perceived 8 months prior, and neoplastic cells positive for c-kit. A computed tomography of the head and neck showed asymmetry of the base of the tongue, which was enlarged in the left portion. A physical examination revealed a nodule on the posterior left tongue of ~3 cm in diameter, while the cervical lymph node chain had a normal size and consistency. Surgical exeresis of the tongue lesion and cervical lymph node dissection were performed. Subsequent to surgical removal of the cancer cells and adjuvant radiotherapy, the patient showed excellent health, although the follow-up remains in progress. ACC, one of the most biologically destructive tumors of the head and neck, is locally aggressive and gives rise to distant metastases. The tongue is the place of origin in 3.4–17.1% of cases. The treatment for ACC consists of primary surgical resection with adjuvant radiotherapy. To prevent the risk for distant metastasis, it is necessary to remove the first echelon nodes and monitor the patient with a long-term follow-up.

Myxofibrosarcoma of the thyroid gland

IntroductionMyxofibrosarcoma of the thyroid is exceptional: a Medline search found a single case report. We report a new case which raised diagnostic and therapeutic problems. ObservationWe report the case of a 74-year-old woman who presented with swelling of the left thyroid lobe and ipsilateral cervical lymphadenopathy. Total thyroidectomy with cervical lymph-node dissection was performed. Histological analysis diagnosed myxofibrosarcoma. Evolution was marked by rapid local recurrence, and chemotherapy based on doxorubicin and ifosfamide was introduced. Discussion/conclusionHead and neck myxofibrosarcoma is rare. MRI is essential and should always precede treatment. Diagnosis is histological. There is elevated risk of local recurrence after resection, accompanied by worsening tumor grade, whence the need for accurate diagnosis, appropriate treatment and regular MRI follow-up.

Effects of neoadjuvant chemoradiotherapy on postoperative morbidity and mortality associated with esophageal cancer

We compared the surgical outcomes between 114 patients who did not receive neoadjuvant therapy (group 1) and 92 others who received neoadjuvant chemoradiotherapy (nCRT) (group 2), and assessed the preoperative and surgical factors that influence postoperative morbidity to determine the impact of nCRT on morbidity and mortality after esophagectomy via cervical, right transthoracic, and abdominal approaches. The overall postoperative morbidity rates were 44.7% and 55.4% in groups 1 and 2, respectively (P = 0.13). Rates of anastomotic leak (8.8% vs. 16.3%; P = 0.10), pneumonia (9.6% vs. 13.0%; P = 0.44), recurrent nerve palsy (15.8% vs. 10.9%; P = 0.31), and all other complications did not significantly differ between the groups. Multivariable analysis revealed cervical lymph node dissection (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.01-3.84; P = 0.047) as the sole independent covariate for overall morbidity. Furthermore, a history of cardiovascular disease (OR, 2.90; 95% CI, 1.03-8.24; P = 0.045), the retrosternal reconstruction route (OR, 15.15; 95% CI, 3.56-62.50; P = 0.0002), and a longer surgical duration (OR, 1.01; 95% CI, 1.002-1.02; P = 0.01) were independent covariates for anastomotic leakage, and advanced age (OR, 1.08; 95% CI, 1.01-1.15; P = 0.02) and lower body mass index (OR, 1.16; 95% CI, 1.01-1.33; P = 0.04) were independent covariates for pneumonia. However, whether or not patients received nCRT was irrelevant. We found that nCRT is safe for three-incision esophagectomy and it does not increase the incidence of postoperative morbidity and mortality relative to esophagectomy alone.

Effect of number and ratio of positive lymph nodes in hypopharyngeal cancer

The number and ratio of positive lymph nodes are important prognostic factors in gastric cancer, but there is little data reported in hypopharyngeal cancer. Medical data from 81 patients with hypopharyngeal cancer undergoing radical hypopharyngectomy and cervical lymph node dissection were reviewed. The median survival time was 84, 54, 30, and 13 months in patients with N0, N1, N2, and N3, respectively, and 84, 51, and 17 months with positive lymph node ratios (N ratio) 0, <10%, and >10%, respectively. Of the 24 N1 patients, the 20 patients that had an N ratio <10% had a better prognosis than the 4 patients with an N ratio >10%. Similar data was seen for the N2 patients. Tumor (T) classification, adjuvant therapy, and N ratio were independent prognostic factors in multivariate analysis. The positive lymph node ratio is complementary to the current N classification system.

Thoracoscopic and laparoscopic radical esophagectomy with lateral-prone position.

With 20 years of development, minimally-invasive treatment for esophageal cancer has been widely spread. However, surgeons have not reached consensus about the optimal minimally-invasive operation method, or whether the effect of radical lymph nodes dissection is comparable to the traditional open procedure. Thoracoscopic esophagectomy with lateral-prone position combines the advantages of both lateral position (allowing quick conversion to open procedure) and prone position (good visual area and complete lymphadenectomy). Together with laparoscopic abdominal lymphadenectomy, gastric tube formation and jejunostomy, this approach provides an easier way for minimally-invasive radical esophagectomy. In this article, approaches for thoracoscopic esophagectomy with lateral-prone position and total mediastinal lymphadenectomy, combined with totally laparoscopic gastric mobilization, abdominal lymphadenectomy, gastric tube formation and jejunostomy, will be presented by video instructions. All the procedures were under the rule of radical lymphadenectomy. Cervical lymph nodes dissection and esophago-gastrostomy were the same as those in open procedure, which will not be discussed here.

Pseudoaneurisma de la arteria cervical transversa tras esofagectomía McKeown

The patient is a 52-year-old male diagnosed with adenocarcinoma of the distal esophagus in Barrett’s esophagus, cT3N+M0. He was treated with neoadjuvant radiotherapy and chemotherapy as well as esophagectomy with three-field lymph node dissection following the McKeown technique. Thirty days after being discharged from the hospital, he was diagnosed with a left laterocervical mass. Ultrasound demonstrated a vascular tumor formation. Further study with CT angiography (Fig. 1) revealed a partially thrombotic pseudoaneurysm of the left transverse cervical artery. Selective embolization was performed (Fig. 2), which provided satisfactory improvement. Although pseudoaneurysm of the transverse cervical artery is an uncommon complication, it should be considered after cervical lymph node dissection. c i r e s p . 2 0 1 4 ; 9 2 ( 4 ) : e 1 5

Thyroid Cancer

Thyroid cancer is rapidly increasing in incidence, but the mortality rate remains flat. Debate has arisen over the need to detect or treat most thyroid cancers early, given their favorable natural history. The appropriate extent of surgery for thyroid cancer is also controversial: some researchers advocate partial and others total thyroidectomy; some advocate prophylactic central cervical lymph node dissection, whereas others only rarely recommend lymphadenectomy. Although radioactive iodine is effective, its appropriate use and dosage remain controversial. In addition, molecular analysis of thyroid cancer is frequently used for diagnostic purposes involving preoperative fine-needle biopsy specimens as well as to define targetable pathways altered in the disease to guide clinical trials of drug therapy for advanced thyroid cancers.

Analysis of the factors that have an effect on hypocalcemia following thyroidectomy.

The incidence of and risk factors for hypocalcemia following thyroidectomy were evaluated in this study. One hundred and ninety thyroidectomy patients were evaluated retrospectively for factors that might contribute to postoperative hypocalcemia; age, hyperthyroidism, malignancy, the extent of surgery (total/near total/subtotal thyroidectomy), cervical lymph node dissection, and incidental parathyroidectomy. The rate of transient hypocalcemia/hypoparathyroidism was 19.47%, with a permanent hypoparathyroidism rate of 4.74%. Factors affecting the development of transient hypocalcemia were found as being operated for hyperthyroidism, and use of total thyroidectomy as the surgical method. Total thyroidectomy increased the risk of postoperative hypocalcemia by 3.16 fold. Patients undergoing operations for hyperthyroidism had a 2.3 fold increase, and those undergoing total thyroidectomy had a 3.16 fold risk of postoperative hypocalcemia. Hyperthyroidism surgery and total thyroidectomy lead to a higher risk of developing early postoperative or transient hypocalcemia. According to our results, no significant relationship could be established between any of the study parameters and persistent hypocalcemia.

Cervical Lymph Node Dissection in Papillary Thyroid Cancer: Pattern and Predictive Factors of Regional Lymph Node Metastas

Background: Papillary thyroid carcinoma (PTC) exhibits a high index of cervical lymphatic dissemination. Methods: Retrospective study of 101 cases of PTC subjected to total thyroidectomy associated with cervical lymph node dissection. Results: The incidence of neck metastasis was 50.5%, and all the metastases wereipsilateral to the primary tumor. Although the participants with metastases (N+) hadmore dissected lymph nodes than the group without metastases (p = 0.01), the lymphnode size was not a determinant of malignancy (p=0.34). Uni and multivariate analyses showed tumor size ≥ 1.0 cm, angiolymphatic invasion, and multicentric diseases were associated with lymphatic dissemination (p < 0.05). Conclusions: Factors predictive of cervical lymph node metastasis were tumor size ≥ 1.0cm, multicentric disease and angiolymphatic invasion. All the metastases wereipsilateral to the primary tumor. Lymph node size was not a reliable predictor of thepresence or absence of metastasis.

Medullary thyroid carcinoma with ectopic adrenocorticotropic hormone syndrome.

Ectopic adrenocorticotropic hormone (ACTH) syndrome is caused most frequently by a bronchial carcinoid tumor or by small cell lung cancer. Medullary thyroid carcinoma (MTC) is a rare etiology of ectopic ACTH syndrome. We describe a case of Cushing syndrome due to ectopic ACTH production from MTC in a 48-year-old male. He was diagnosed with MTC 14 years ago and underwent total thyroidectomy, cervical lymph node dissection and a series of metastasectomies. MTC was confirmed by the pathological examination of the thyroid and metastatic mediastinal lymph node tissues. Two years after his last surgery, he developed Cushingoid features, such as moon face and central obesity, accompanied by uncontrolled hypertension and new-onset diabetes. The laboratory results were compatible with ectopic ACTH syndrome. A bilateral adrenalectomy improved the clinical and laboratory findings that were associated with Cushing syndrome. This is the first confirmed case of ectopic ACTH syndrome caused by MTC in Korea.

Prognostic Significance of the Number of Metastatic Lymph Nodes to Stratify the Risk of Recurrence

Prophylactic dissection facilitates identification of central lymph node (LN) metastasis in patients with papillary thyroid cancer (PTC). Because most staging systems do not stratify risks by the number of LN metastases, postoperative treatments vary among different institutions. Therefore we investigated the significance of number of LN metastases in risk stratification for recurrence in PTC. A retrospective review was performed for 3,305 patients who had undergone thyroidectomy at Ajou University Hospital. A total of 2,462 patients (73.5 %) underwent total thyroidectomy, and another 3,152 (94.1 %) underwent central LN dissection. Lateral cervical LN dissection had been performed in 420 patients (12.5 %). There were 115 patients with recurrence (3.4 %). Recurrence-free rates were 94.6 % at 5 years and 89.4 % at 10 years. On univariate analysis, prognostic factors for recurrence were extent of thyroidectomy, tumor size, capsular invasion, T stage, N stage, number of LN metastasis, TNM stage, and radioactive iodine (RAI) therapy. On multivariate analysis, number of LN metastasis and N stage were significant prognostic factors for recurrence. Recurrence-free rate was significantly different between patients with 0-1 LN and those with 2 or more LN. Number of metastatic LN was a significant prognostic factor, in addition to the N stage. Therefore, number of metastatic LN must be considered for postoperative staging system to tailor treatment and follow-up recommendations. In addition, patients with ≥2 metastatic LN may benefit from total thyroidectomy and RAI therapy with postoperative follow-up with serum thyroglobulin.

Invited Commentary

The debate about the extent of lymph node dissection for cancer of the thoracic esophagus has occupied esophageal surgeons for decades. In the early 1980s, Japanese surgeons proposed that nodal dissection should be extended to a “third field” that includes the nodes along both recurrent nerves and a cervical node dissection. Despite promising results, wider implementation of the technique in the West was impeded by concerns about its seemingly higher morbidity and unproven survival benefit. The lack of adequately powered randomized trials or well-conceived metaanalyses sustained the controversy.

Application of selective neck lymphadenectomy in papillary thyroid carcinoma

Objective To explore the rule of papillary thyroid carcinoma lymph node metastasis,and provide the basis for cervical lymph node dissection in papillary thyroid carcinoma selective node.Methods The clinical data and follow-up results of 50 cases with thyroid papillary carcinoma were retrospectively analyzed.Results Average number of selective neck dissection was 4.2 cases,lymph node metastasis in 19 cases (38.0％),6 cases had postoperative complications(12.0％).The patients were followed-up for 4 years without recurrence or metastasis of thyroid cancer.4 cases during the follow-up period appeared neck lymph node metastasis,accounted for 8.0％.Conclusion Primary radical combined with selective neck dissection is an effective procedure for the treatment of Ⅰ,Ⅱ stage of thyroid papillary carcinoma. Key words: Lymph node excision; Thyroid neoplasms

The Value of F-18 FDG PET for Planning Treatment and Detecting Recurrence in Malignant Salivary Gland Tumors: Comparison with Conventional Imaging Studies.

To assess the value of F-18 FDG PET/CT for detecting cervical lymph node (LN) metastasis and recurrence, as well as planning treatment, and to compare the accuracy of PET/CT with conventional imaging studies (CIS) in patients with malignant salivary gland tumor (SGT). Staging and follow-up PET/CT for SGT were retrospectively reviewed. Enhanced CT and/or MRI of the neck were performed within 1month of PET/CT. Final diagnosis was based on histology from cervical LN dissection and biopsy or a minimum 6months of clinical and imaging follow-up. We compared the performance of PET/CT in initial cervical LN staging and recurrence detection with that of CIS. A total of 184 PET/CT exams of 66 patients were included, and 34 initial staging and 150 surveillance PET/CT exams were performed. The initial cervical LN detection sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were 60.9%, 89.2%, 84.0%, 56.0%, and 91.0% for visual analysis on PET/CT, 39.1%, 95.0%, 84.8%, 64.3%, and 87.4% for semiquantitative analysis on PET/CT, and and 43.5%, 94.1%, 84.8%, 62.5%, and 88.1% for CIS. The sensitivity of visual analysis on PET/CT was significantly higher than that of semiquantitative analysis on PET/CT and CIS (p = 0.0009 and 0.0086). In 5 of 34 initial staging patients (14.7%), the treatment plan was changed from curative surgery to palliative therapy. The performance of follow-up PET/CT showed no significant difference compared with CIS. PET/CT showed comparable performance with CIS for cervical LNs staging. Initial PET/CT changed treatment plans in 14.7% of patients. However, PET/CT offered no additional advantage for detecting locoregional recurrence.