Impact Of Lymph Node Metastasis Research Articles

Mapping the lymph node metastasis landscape: A bibliometric Odyssey of papillary thyroid carcinoma publications (2012–2022)

ObjectiveLymph node metastasis in papillary thyroid carcinoma (PTC) has become an area of great interest in the study of thyroid diseases. The aim of this study was to elucidate the research trends and impact of lymph node metastasis of PTC in the study of thyroid diseases through a comprehensive bibliometric analysis. MethodsWe conducted an extensive bibliometric review of the literature on lymph node metastasis in PTC using the Web of Science Core Database (WOSCC), which included approximately 3292 publications from 2012 to 2022. Data analysis and visualization were performed, using advanced bibliometric tools including VOSviewer, CiteSpace, and bibliometrix R software packages. ResultsA total of 3292 publications from 81 one countries were identified. The analysis showed a pattern of growth in the number of publications per year from 2012 to 2022, with China having the highest number of papers. Outstanding contributions were made by China, Korea, USA, Italy and Japan, with Thyroid being the most important journal. The author who published the most papers was Jingqiang Zhu. The institutions that published the most papers were Shanghai Jiao Tong University and Yonsei University. The analysis found that prognosis, recurrence, and ultrasound were the keywords with the highest frequency of occurrence in addition to those related to the title of this article. ConclusionOur bibliometric analysis outlines the current state of research on lymph node metastasis in PTC, highlighting significant contributions, trends, and future research directions.

Appendiceal Neuroendocrine Neoplasms: an Update for 2023.

To summarize the literature from the last 5years on treatment of appendiceal neuroendocrine neoplasms (aNEN). Furthermore, to evaluate the prognostic significance of lymph node metastases, indications for adjuvant treatment, and challenges of the current follow-up regimen. Simple appendectomy is sufficient in tumors < 1cm while extended surgery is indicated in tumors > 2cm. In a multicenter study of aNENs measuring 1-2cm, extended surgery offered no significant prognostic advantage and is now limited to incomplete tumor resection or high-grade G2 or G3 aNEN. Follow-up remains debatable, as the use of imaging and biomarkers lacks validation. While surgical procedure is well established in aNEN tumors < 1cm and > 2cm, the need for extended surgery in aNEN tumors 1-2cm is questionable. Future studies should address the prognostic impact of lymph node metastases and the optimal design and duration of follow-up.

Long-term efficacy of lobectomy for stage T1 papillary thyroid carcinoma with varying degrees of lymph node metastasis.

The presence of lymph node metastasis (LNM) is frequently observed in papillary thyroid carcinoma (PTC), and most clinical guidelines recommend total thyroidectomy. However, the impact of LNM on specific types of locoregional recurrence remains uncertain, particularly for stage T1 PTC. The present retrospective cohort study enrolled patients diagnosed with stage T1 PTC between 2008 and 2015. Propensity score matching was performed in patients with lobectomy accompanied by varying degrees of LNM. Logistic regression analysis was performed to compare the effect of LNM on relapse types, and Kaplan-Meier method was utilized to calculate recurrence-free survival. The study cohort comprised 2,785 patients who were followed up for an average duration of 69 months. After controlling follow-up time and potential prognostic factors, we include a total of 362 patients in each group. Recurrence rates in the N0, N1a, and N1b groups were found to be 2.5%, 9.7%, and 10.2% respectively. Notably, group N1a versus group N0 (P=0.803), N1b group versus N0 group (P=0.465), and group N1b versus group N1a (P=0.344) had no difference in residual thyroid recurrence. However, when considering lymph node recurrence, both N1a(P=0.003) and N1b(P=0.009) groups showed a higher risk than N0 group. In addition, there was no difference in lymph node recurrence between N1b group and N1a group (P=0.364), but positive lymph node (PLN) and lymph node positive rate (LNPR) demonstrated a strong discriminatory effect (P<0.001). Lobectomy may be more appropriate for patients with unilateral stage T1 PTC in the low LNPR group.

Chapter 5: Surgery for Neck in Well-differentiated Thyroid Cancers

ABSTRACT Thyroid cancers frequently metastasize to neck nodes. However, most of these are occult micrometastases with no impact on survival, while only a small percentage have clinically apparent neck nodes. The impact of nodal metastases on overall survival is very low, as compared to other head-neck sites and pathologies. Hence the surgical management of neck nodes has to be balanced with the likely morbidity of these procedures. This narrative review deals with the management of neck nodal metastasis of well differentiated thyroid cancers.

Impact of Nodal Metastasis on Survival in Clear Cell Sarcoma

Aim: Clear Cell Sarcoma (CCS) of soft tissue is a high-grade malignancy that often occurs on the distal extremities. The five-year overall survival is reported to be around 40%. Lymph node metastasis, that is categorized into stage IV in the latest American Joint Committee on Cancer (AJCC, 8th edition) staging system, is characteristic in CCS. We here focused on the impact of nodal metastasis on prognosis in CCS. Methods: We performed a retrospective analysis of 37 patients with CCS who were treated between 1982 and 2023. This study investigated age, gender, tumor size, tumor location, AJCC stage (7th and 8th edition), presence of lymph node or distant metastasis, presence of surgery, chemotherapy, radiotherapy, and surgical margin. Statistical analysis was conducted to evaluate the impact of each factor on survival. Results: In our cohort, tumor location, tumor size, and stage were significant prognostic factors. Notably, the disease-Specific Survival (DSS) in patients with nodal and/or distant metastasis was significantly shorter than those with no metastasis while DSS in the patients with nodal metastasis was not significantly different from those with distant metastasis. Conclusion: Consistent with the latest AJCC 8th edition in which nodal and distant metastasis are both categorized into stage IV, there was no difference in DDS between nodal metastasis and distant metastasis in CCS in the present study. This result highlights the importance of nodal metastasis in CCS.

Lymph node metastases and recurrence in pancreatic neuroendocrine neoplasms

BackgroundThe impact of lymph node metastasis on survival in pancreatic neuroendocrine neoplasms as well as their best surgical treatment is controversial. We aimed to determine the frequency and prognostic impact of lymph node involvement in pancreatic neuroendocrine neoplasms. MethodsPatients undergoing pancreatic resections for pancreatic neuroendocrine neoplasms between 2001 and 2019 were retrospectively analyzed based on a prospective database. Clinicopathological parameters and perioperative outcome were assessed. Overall and disease-free survival was analyzed. Subgroup analysis was performed for sporadic, nonfunctional pancreatic neuroendocrine neoplasms without distant metastases and ≥4 analyzed lymph nodes. ResultsOf 605 surgically resected pancreatic neuroendocrine neoplasms, 55% were G1, 36% were G2, and 9% were G3 differentiated. At the time of resection, 34% of patients had lymph node metastasis, and 16% had distant metastases. For subgroup analysis, 314 patients were analyzed. Lymph node metastases occurred in 36% of patients and were most frequent in G3 patients (67%). An increase in tumor size and advancement was associated with higher rates of lymph node metastasis, and disease-free survival was significantly impaired. Significant differences in disease-free survival were observed between 1 and 3 (5-year disease-free survival 52%) and ≥4 positive lymph nodes (5-year disease-free survival 28%), as well as when G3 tumors were excluded. In multivariable analysis, grading, tumor stage, and especially lymph node metastases as well as the proposed pN1 and pN2 categories were confirmed as independent predictors of recurrence. ConclusionThe presence and extent of lymph node involvement has considerable prognostic impact in pancreatic neuroendocrine neoplasms. This study, for the first time, validated the proposed pN2 stage for well-differentiated pancreatic neuroendocrine neoplasms.

Clinical implications of lymphadenectomy for invasive ductal carcinoma of the body or tail of the pancreas.

AimThe appropriate extent of lymphadenectomy for pancreatic cancer of the body/tail has not been standardized worldwide. The present study evaluated the optimal extent of harvesting lymph nodes.MethodsPatients who underwent distal pancreatectomy for invasive ductal carcinoma of the pancreas between 2007 and 2018 were retrospectively reviewed. Patients were subclassified into three groups depending on the tumor location: pancreatic body (Pb), proximal pancreatic tail (Ptp), and distal pancreatic tail (Ptd). The pancreatic tail was further divided into even sections of Ptp and Ptd. Patterns of lymph node metastasis and the impact of lymph node metastasis on the prognosis were examined.ResultsA total of 120 patients were evaluated. Fifty‐eight patients had a tumor in the Pb, 38 in the Ptp, and 24 in the Ptd. No patients with a Ptd tumor had metastasis beyond the peripancreatic and splenic hilar lymph nodes (LN‐PSH). All patients with metastasis to the lymph nodes along the common hepatic artery (LN‐CHA) or along the left lateral superior mesenteric artery (LN‐SMA) also had metastasis to the LN‐PSH. Recurrence after surgery occurred significantly earlier in this population. In a multivariate analysis, metastasis to the LN‐CHA or LN‐SMA (hazard ratio [HR] 3.3; P = .04) was an independent risk factor for overall survival. Furthermore, high levels of preoperative serum CA19‐9 (HR 10.9; P = .013) were a predictive factor for metastasis to the LN‐CHA or LN‐SMA.ConclusionsMetastasis to the LN‐CHA or LN‐SMA was rare but a significant prognostic factor in patients with pancreatic body/tail cancer.

Fasting serum glucose and lymph node metastasis in non-diabetic PTC patients: a 10-Year multicenter retrospective study.

Background: Mostly current studies are limited to the impact of lymph node metastasis(LNM) on the prognosis of papillary thyroid cancer(PTC) or the impact of glucose metabolism on the occurrence of PTC, but no one has paid attention to the connection between fasting serum glucose(FSG) and LNM. The purpose of our study was to explore the relationship between FSG and LNM in non-diabetic PTC patients.Methods: In this study, we performed a multicenter, retrospective study on 6034 non-diabetic patients with PTC. The associations of FSG with three types of LNM including central lymph node metastasis (CLNM), lateral cervical lymph node metastasis (LLNM) and both were estimated.Results: Compared with PTC patients without LNM, those with LNM had higher FSG. We also found that FSG was associated with tumor extension, maximum tumor diameter and TSH. In order to further explore the association between FSG and different types of LNM, we analyzed three groups of data separately. Our study reveals that by comparing FSG between patients without LNM and patients with three LNM types, it was statistically different in the PTC patients with CLNM and the PTC patients with CLNM combined with LLNM.Conclusion: Our study provides evidence for the association of FSG and LNM in non-diabetic PTC patients, with a gradual increase in FSG over the course of the PTC from no lymph node metastasis to CLNM combined with LLNM. Meanwhile, higher FSG is a risk factor for CLNM and CLNM combined with LLNM. In the future, FSG might be used as an indicator for lymph node dissection in PTC patients. However, larger relative studies are needed.

Impact of Lymph Node Metastases Around the Superior Mesenteric Artery on Postoperative Outcomes of Pancreatic Head Cancer

The neural plexus and lymph nodes around the superior mesenteric artery (LN#14), are the most frequent sites involved by pancreatic head cancer. However the influence of metastases to LN#14 on patients' prognosis has rarely been evaluated. The patients who underwent pancreatectomy for pancreatic head cancer between January 2010 and December 2018 were selected. The patients with nodal metastases were classified into an LN#14 + or LN#14-group according to LN#14 metastasis. Clinical and pathological characteristics and prognosis were compared between the two groups. In total, 99 patients underwent pancreatectomy. Ninety-four patients were positive for lymph node metastases and 14 and 80 were classified as LN#14 + and LN#14 - , respectively. Postoperative median overall survival (OS) of the LN#14 + and LN#14 - groups was 10.2 and 31.1months, respectively (P < 0.001). Median OS of the LN#14 + group was worse than that of patients with ≥ 4 metastatic nodes in the LN#14 - group (n = 35, 24.7months, P = 0.002). In multivariate analysis, LN#14 + (hazard ratio [HR] = 3.89, 95% confidence interval [CI], 1.64-8.86) was one of the independent predictors of worse OS. It might be feasible to recognize LN#14 metastases as an important prognostic factor independently from other regional lymph node metastases.

A Case of Intrathyroidal Spread of Papillary Thyroid Carcinoma

Papillary thyroid carcinoma (PTC) typically has a good prognosis, but it frequently metastasizes to the regional lymph nodes. Although survival impact of lymph node metastasis is not clear, complementary treatment is generally added after surgery when lymphatic metastasis exists. Several previous studies have reported that the multifocal PTC is associated with poor prognosis and requires selective neck dissection to prevent regional lymph node metastasis, but they are under controversy. In this study, we present a 24-year-old female patient, diagnosed as PTC with intrathyroidal spread and regional lymph node metastases. Intrathyroidal spread of PTC can only be observed microscopically and is believed to have the similar origin of unicentric multifocal PTC. As multifocal PTC is highly associated with regional lymph node metastasis and requires an additional treatment, PTC with intrathyroidal spread may follow a similar clinical course and treatment plan. Here we report the case with a brief literature review and expect its attribution to further academic interest of treatment choice. Key Words: Intrathyroidal spread, Lymphatic metastasis, Papillary thyroid carcinoma, Prognosis

Prognostic impact of lymph node metastasis along the left gastric artery in esophageal squamous cell carcinoma

BackgroundAlthough the incidence of lymph node (LN) metastasis (LNM) along the left gastric artery is high, its relationship with the prognosis in postoperative patients with esophageal squamous cell carcinoma (ESCC) is rarely reported. This study clarified the prognostic impact of LNM along the left gastric artery in postoperative patients with ESCC.MethodsThis study assessed data of 1521 patients with ESCC who underwent esophagectomy at the Sun Yat-sen University Cancer Center between March 1992 and March 2012. A chi-squared test and Mann-Whitney U test were used to explore the preliminary correlation between clinical factors and LNM along the left gastric artery. Univariate and multivariate Cox regression analyses were used to assess whether LNM along the left gastric artery was an independent predictor of overall survival. Kaplan–Meier analysis and the log-rank test were used to present a classifying effect based on LN status.ResultsLNM was observed in 598 patients (39.3%) and was found along the branches of the left gastric artery in 256 patients (16.8%). The patients were classified into two groups based on the presence of LNM along the left gastric artery. Patients without LNM along the left gastric artery had better cancer-specific survival than those with positive LNs (P < 0.001).ConclusionsThis study indicated that LNM along the left gastric artery was an important independent prognostic factor for long-term survival among ESCC patients (P = 0.011).

Prognostic value of the lymph node metastasis in patients with ampulla of Vater cancer after surgical resection

Backgrounds/AimsPatients with Ampulla of Vater cancer have a better prognosis than those with other periampullary cancers. This study aimed to determine the prognostic impact of lymph node metastasis on survival in patients with ampulla of Vater cancer after surgical resection.MethodsFrom 1991 to 2016, we retrospectively reviewed data on 104 patients with ampulla of Vater cancer who had received pancreaticoduodenectomy. Clinicopathologic factors such as lymph node ratio (LNR) and number of metastatic lymph nodes that influence survival were statistically analyzed.Results5-year survival rate after resection was 57.8%. Mean number of retrieved and metastatic lymph nodes was 13 and 0.95, respectively. In patients with lymph node metastasis, the median number of metastatic lymph nodes and was 1, and the mean LNR was 0.18. LNR >0.2 was a significant prognostic factor for overall survival. Patients with 0 or 1 metastatic lymph nodes had better survival than those with ≥2 metastatic lymph nodes. Univariate analysis revealed that histologic differentiation of tumor, lymph node metastasis, and T stage were significant prognostic factors for overall survival. Multivariate analysis revealed that tumor differentiation and number of metastatic lymph nodes were independent prognostic factors for survival.ConclusionsPancreaticoduodenectomy is an appropriate surgical procedure with acceptable long-term survival for ampulla of Vater cancer. Patients with LNR >0.2 and ≥2 positive lymph node metastasis had a poor survival. Tumor differentiation and ≥2 metastatic lymph nodes were independent significant prognostic factors for overall survival. Curative resection with lymph node dissection might control lymph node spread and enhance survival outcomes.

Metastasis to lymph nodes around the vascular tie worsens long-term oncological outcomes following complete mesocolic excision and conventional colectomy for right-sided colon cancer.

Oncologic outcomes after complete mesocolic excision (CME) in colon cancer are under investigation. The aim of our study was to compare CME and conventional colectomy (CC) in terms of pathological and oncological outcomes for right colon cancer and to evaluate the impact of lymph node metastasis around the vascular tie on survival. Consecutive patients with right colon cancer who had CME or CC between January 2011 and August 2018 at two specialized centers in Turkey were included. Statistical analyses were performed with respect to demographic characteristics, operative and pathologic outcomes, harvested and metastatic lymph nodes around the vascular tie (LNVT), recurrences, and survival. There were 91 patients in the CME group (58 males, mean age 64 ± 16years) and 192 patients in the CC group (96 males, mean age 66 ± 14years). The mean number of harvested lymph nodes (CME: 42 ± 15 vs CC: 34 ± 13, p = 0.01) and LNVT were higher in the CME group (CME: 3.2 ± 2.2 vs CC: 2.4 ± 1.6, p = 0.001). LNVT metastases were 7.7% and 8.3% in the CME and CC groups, respectively (p = 0.85). Three-year overall and disease-free survival rates were 96.4% and 90.9% in the CME group and 90.4% and 87.6% in the CC group in stage I-III patients (p > 0.05). In stage III patients, the 3-year overall survival (92.5% vs 63.5%, p = 0.03) and disease-free survival (85.6% vs 52.1%, p = 0.008) were significantly better in LNVT-negative patients than in LNVT-positive patients. LNVT metastasis seems to be the key factor associated with poor disease-free and overall survival in right colon cancer regardless of the radicality of surgery.

Incidence and prognostic impact of lymph node metastasis in gastric cancer: Deep inside of signet ring cell histotype

Incidence and prognostic impact of lymph node metastasis in gastric cancer: Deep inside of signet ring cell histotype

Nodal disease burden and outcome of medullary thyroid carcinoma.

Medullary thyroid carcinoma (MTC) is a rare malignancy with high incidence of cervical lymph node (CLN) metastasis. We investigated the impact of nodal disease burden on survival. We searched the National Cancer Database for MTC patients treated surgically. Impact of nodal metastasis on survival was analyzed using Cox univariable and multivariable regression. We identified 2627 patients from 2004 to 2015. Positive CLNs were identified in 1433 (54.5%), and 542 (20.6%) had >10 CLN+. Overall survival was 94.5% and 89.6% at 3 and 5 years. Patients with 11 to 20 CLN+ had significantly worse survival than patients with 1 to 10 CLN+ in univariable and multivariable analyses (HR = 3.56 (2.31-5.50) vs 2.26 (1.60-3.20); P < .0001). The ratio of positive to dissected CLN was associated with overall survival. Higher burden of nodal disease is associated with worse survival in MTC. The number of positive nodes could be a valuable prognosticator in addition to the current staging system.

The impact of lymph node metastases and right hemicolectomy on outcomes in appendiceal neuroendocrine tumours (aNETs)

IntroductionEuropean Neuroendocrine Tumour Society (ENETS) recommends managing appendiceal neuroendocrine tumours (aNET) with appendicectomy and possibly completion right hemicolectomy (CRH). However, disease behaviour and survival patterns remain uncertain. Materials and methodsWe retrospectively assessed the impact of lymph nodes and CRH on outcomes, including survival, in all aNET patients diagnosed between 1990 and 2016. Results102 patients (52F, 50 M), median age 39.4 (range 16.3–81.1) years, were diagnosed with aNET. Mean tumour size was 12.7 (range 1–60) mm, most sited in appendiceal tip (63%). Index surgery was appendicectomy in 79% of cases while the remainder underwent colectomy. CRH performed in 30 patients at a median 3.2 (range 1.4–9.8) months post-index surgery yielded residual disease in nine: lymph nodes (n = 8) or residual tumour (n = 1). Univariate logistic regression showed residual disease was significantly predicted by tumour size ≥2 cm (p = 0.020). Four patients declined CRH, but did not suffer relapse or reduced survival. One patient developed recurrence after 16.5 years of follow-up and another patient developed a second neuroendocrine tumour after 18.8 years follow-up. There were 5 deaths; one being aNET-related. 5-year and 10-year overall survival were 99% and 92% respectively; 5-year and 10-year relapse-free survival were 98% and 92% respectively. Only 5-year relapse-free survival was affected by ENETS stage (p = 0.002). ConclusionaNETs are indolent with very high rates of overall and relapse-free survival. Recurrence is rare, and in this series only occurred decades later, making a compelling case for selective surveillance and follow-up. The significance of positive lymph nodes and the necessity for completion right hemicolectomy remain unclear.

Lymph node metastasis in extremity chondrosarcomas: A series of four cases.

Background:Primary bone sarcomas mainly metastasize through haematogenous route and rarely through lymph nodes due to paucity of lymphatic channels in the bone (1). Nodal spread in chondrosarcoma is extremely rare and there are two reported cases in literature including one previously published by our institute (3, 5).Aims and Objectives:We present a series of chondrosarcoma cases (primary tumour located in the scapula, proximal femur, proximal humerus and pelvis), presenting with lymph node metastasis, treated at our institute. We assessed the oncological outcome of these cases and the impact of nodal metastasis on survival.Materials and Methods:Between January 2006 and December 2015, 243 patients of extremity and pelvic chondrosarcoma were operated at our institute. These cases were retrieved from a prospectively maintained database. Four (1.6%) of these patients developed lymph node metastasis. Clinical and radiological details of these cases were retrieved from electronic medical records and case files. Histopathology of the primary chondrosarcoma lesion and nodal metastasis was reconfirmed by a pathologist specializing in sarcomas.Conclusion:Lymph node metastasis though extremely rare in primary osseous chondrosarcoma, definitely affects their survival adversely. The rarity of the occurrence of lymph node metastasis in primary osseous tumors, especially chondrosarcoma highlights the need for multi institutional studies to pool knowledge and evaluate the prognostic significance and etiopathogenesis of lymph node metastasis in primary bone chondrosarcoma.

Tumor sidedness influences prognostic impact of lymph node metastasis in colon cancer patients undergoing curative surgery

This study aimed to evaluate prognostic impacts of the number of lymph nodes (LNs) examined and LN ratio on cancer-specific mortality after surgery in patients with right-sided colon cancer (RCC) or left-sided colon cancer (LCC) using the Surveillance, Epidemiology, and End Results database. Number of LNs examined and LN ratio were treated as categorical and/or continuous. Competing risks proportional hazards regressions adjusted by propensity score were performed. All included patients had stage I, II, or III disease, and 45.1% of them had RCC. RCC and LCC patients with high level of LNs examined had better prognosis after segmental resection or hemicolectomy. RCC and LCC patients with higher LN ratio had worse prognosis regardless of surgery. Survival benefit of having high level of LNs examined was observed in RCC patients with stage I, II, or III disease, but only in LCC patients with stage II disease. Both higher LN ratio and high level of LN were negative prognostic factors for cancer-specific mortality in stage III patients regardless of tumor sidedness. In conclusion, RCC patients in various conditions had worse or comparable prognosis compared to their LCC counterparts, which reflected the severity of LN metastasis.

Influence of the New FIGO Classification for Cervical Cancer on Patient Survival: A Retrospective Analysis of 265 Histologically Confirmed Cases with FIGO Stages IA to IIB

Objective: At the end of the year 2018, a new FIGO classification for cervical cancer was published, mainly revising stage IB and introducing a new stage IIIC, which includes irrespectively of tumor size and local spread all patients with lymph node metastasis. Methods: We retrospectively analyzed all cases of cervical cancer stage I to IIB who underwent surgery as primary treatment at our institution from 2000 until 2016 and therefore had a histological confirmation of tumor stage. We reclassified all histologies according to the new FIGO classification and calculated outcome according to the new stages. Results: Out of 265 patients, 146 (55%) patients were reclassified into a higher FIGO stage. Most changes appeared within stage IB and from any stage to stage IIIC1. Kaplan-Meier curves for new stages showed a significant difference in disease-free survival (DFS) and overall survival (OS) between stages I versus II versus III (log-rank test, both p < 0.001). Overall, patients that were upstaged had a significant worse DFS (p = 0.012) and OS (p = 0.008) than patients whose stage did not change. Similar observations were made within sub-stages, when node-positive IB or IIB tumors were upstaged to IIIC tumors. Conclusion: The new FIGO classification for cervical cancer reflects the strong impact of lymph node metastases on survival and is a clear improvement compared to the old FIGO classification with regard to risk stratification.

Nodal Disease Burden and Outcome of Medullary Thyroid Carcinoma

BACKGROUND Medullary thyroid carcinoma (MTC) is a rare malignancy with high incidence of cervical lymph node (CLN) metastasis. We investigated the impact of nodal disease burden on survival. METHODS We searched the National Cancer Database for MTC patients treated surgically. Impact of nodal metastasis on survival was analyzed using Cox univariable and multivariable regression. RESULTS We identified 2627 patients from 2004 to 2015. Positive CLNs were identified in 1433 (54.5%), and 542 (20.6%) had >10 CLN+. Overall survival was 94.5% and 89.6% at 3 and 5 years. Patients with 11 to 20 CLN+ had significantly worse survival than patients with 1 to 10 CLN+ in univariable and multivariable analyses (HR = 3.56 (2.31-5.50) vs 2.26 (1.60-3.20); P < .0001). The ratio of positive to dissected CLN was associated with overall survival. CONCLUSIONS Higher burden of nodal disease is associated with worse survival in MTC. The number of positive nodes could be a valuable prognosticator in addition to the current staging system.