Lateral Cervical Lymph Node Metastasis Research Articles

Right Central Lymph Node Dissection in Thyroidectomy: Can Endoscopic Chest-Breast Approach Be Used?

Background: The purpose of this research was to investigate the feasibility and strategies of right central lymph node dissection (CLND) in endoscopic thyroidectomy through chest-breast approach. Materials and Methods: Retrospective analysis on the conduction of 68 cases of endoscopic thyroidectomy through chest-breast approach with right side CLND (endoscopic group) and 31 cases of thyroidectomy through low-neck collar cervical approach with right side CLND (open group) from July 2014 to February 2019. The intraoperative and postoperative data were compared between the two groups. Results: All the surgeries in open group were successfully completed as well as the endoscopic group without any intraoperative conversion into open surgery. There were no difference in sizes of tumor, incidence of lymph node metastasis, number of dissected and metastatic lymph nodes, and postoperative hospitalization days between the two groups. Temporal hypoparathyroidism occurred in both groups with endoscopic group to be 24 cases and open group to be 15 cases but no case in both groups suffering from permanent hypoparathyroidism, recurrent laryngeal nerve injury, lymphatic leakage, or death. One case in endoscopic group was treated with secondary surgery for lateral cervical lymph node metastasis and no evidence of recurrence or metastasis was found in other cases during postoperative follow-up. Conclusions: With strict control in surgical indications and contraindications, endoscopic surgery is safe and feasible for selected cases with the same effect as open surgery on dissection of lymph nodes in the right central region, which is in line with the principle of radical treatment of tumors.

RET Proto-oncogene Gene Mutation Is Related to Cervical Lymph Node Metastasis in Medullary Thyroid Carcinoma.

RET proto-oncogene (RET) mutations were proved to be related to the development of medullary thyroid carcinoma (MTC). We aimed to analyze the role of RET mutations in cervical lymph node metastasis in patients with MTC. Forty-nine patients with preoperatively diagnosed MTC by fine-needle aspiration cytology (FNAC) who underwent bilateral total thyroidectomy with cervical lymphadenectomy were included. Postoperative RET gene test and pathological analysis were performed with the surgical specimens; serum calcitonin (Ctn) and carcinoembryonic antigen (CEA) levels were tested pre- and postoperatively, to evaluate the association between RET mutations and cervical lymph node metastasis in MTC. In these 49 patients, the RET mutation rates of Exon 11, Exon 10, Exon 11&13, Exon 13, and Exon 16 were 20.4%, 4.1%, 38.8%, 22.4%, and 0%, respectively. The lymph node metastasis rates of patients with RET mutation in the central and lateral compartments were 71.4% and 64.3%, respectively, versus 28.6% and 14.3% of patients without RET mutation. The preoperative basal serum levels of Ctn (234.8 ± 188.4 vs. 44.4 ± 27.5, p< 0.01) and postoperative Ctn (49.8 ± 86.4 vs. 3.7 ± 2.2, p= 0.001) in MTC patients with RET mutations were significantly higher than those in MTC patients without RET mutation. In addition, the preoperative (50.2 ± 76.7 vs. 7.4 ± 6.8, p= 0.001) and postoperative serum levels of CEA (13.2 ± 19.5 vs. 1.3 ± 1.6, p< 0.01) in MTC patients with RET mutations were significantly higher than those in MTC patients without RET mutation (p< 0.05). RET mutation was related to cervical lymph node metastasis in patients with MTC, especially the mutation in Exon 11&13. Patients with RET mutation in Exon 11&13 might be regarded as the predictor for prophylactic ipsilateral total cervical lymphadenectomy even without clear evidence of lateral cervical lymph node metastasis.

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.

BRAFV600E/telomerase reverse transcriptase protein expression in lung metastasis of papillary thyroid carcinoma and clinical significance

Objective To investigate the protein expression of BRAFV600E/telomerase reverse transcriptase (TERT) in patients with papillary thyroid cancer (PTC) and its correlation with lung metastasis. Methods The tumor tissues of 716 patients with PTC were collected. The expression of BRAFV600E and TERT was detected by immunohistochemistry, and their clinical pathological features were analyzed. Results In tumor tissues of these PTC patients, 62.3% (446/716) expressed BRAFV600E protein, 30.9% (221/716) expressed TERT protein, and 18% (129/716) co-expressed BRAFV600E and TERT proteins. Multivariate analysis revealed that special subtype of papillary carcinoma, maximal diameter of tumor, lateral cervical lymph node metastasis, and co-expression of BRAFV600E/TERT proteins were independent risk factors of PTC lung metastasis. Tumor maximum diameter, lateral cervical lymph node metastasis and co-expression of BRAFV600E/TERT proteins had a high diagnostic accuracy [area under curve (AUC)>0.7] in predicting lung metastasis in PTC patients. Conclusion The specific subtype of papillary carcinoma, tumor maximum diameter, lateral cervical lymph node metastasis and co-expression of BRAFV600E/TERT proteins were independent risk factors for PTC pulmonary metastasis. Key words: Papillary thyroid carcinoma; Lung metastasis; BRAFV600E; Telomerase reverse transcriptase

Abstract 2767: Expression of defensin-associated genes may be correlated with lymph node metastasis of early stage tongue cancer

Abstract OBJECTIVES: Appropriate patient selection for elective neck dissection in N0 tongue cancer has been controversial, while there has been no genetic consideration so far. We aimed to analyze genetic difference between early and late cervical lymph node metastasis in oral tongue cancer patients using the Seoul National University Hospital (SNUH) cancer cohort and cancer genome atlas (TCGA) data, and to suggest genetic background for choosing eligible patient for elective neck dissection. METHODS: A total of 35 cases with RNAseq in SNUH cancer cohort with tongue cancer were also enrolled in this study. To investigate gene expression in early cervical lymph node metastasis, genomic data of following 2 groups was compared; 1) N0 group: T1/2 and N0, 2) N+ group: T1/2 and N+. Differentially expressed genes (DEGs) were extracted using R and limma package in bioconductor program. Gene ontology and pathway enrichment analysis were performed using DAVID online tool. Immune cell infiltration was analyzed using CIBERSORT online program. Additionally, 70 cases with matched RNAseq data of primary tumor and clinical TCGA data were analyzed to validate the role of DEGs. RESULTS: N0 and N+ groups showed no difference in age, gender, size and thickness of tumor, and nearest resection margin. In addition, there was no significant difference in 22 types of immune cell infiltration. A total of 51 DEGs were identified, and 14 genes were significantly upregulated and 37 genes were significantly downregulated (p&amp;lt;0.01, fold-change &amp;gt;2). Significant genes were PLA2G4D, NELL2, PCOLCE2, PI3, and PLA2G3. On KEGG pathway analysis, calcium, muscle contraction, and arachidonic acid metabolism-related pathway was significantly correlated. The most significant difference was found in 6 genes as follows; DEFB4A, SPRR2B, DEFB103B, SPRR2G, DEFB4B, FAM25A.DEFB which was the most significantly difference in expression was associated with ‘antibiotic’, ‘antimicrobial’, ‘beta defensing type’, defense reponse to bacterium’, and ‘defensin’. In TCGA data, DEFB4A and DEFB103B were more highly expressed in N0 group than N+ group, although it did not attain significant significance. CONCLUSIONS: Defensin (DEFB4A, DEFB103B, DEFB4B) may be a novel biomarker for early regional metastasis in T1/2 tongue cancer. Considering that defensin can be detected in saliva, simple saliva test for prediction of metastasis can be developed in the future. Note: This abstract was not presented at the meeting. Citation Format: Doh Young Lee. Expression of defensin-associated genes may be correlated with lymph node metastasis of early stage tongue cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2767.

Analysis of the relationship between ultrasonographic features and cervical lymph node skip metastasis of papillary thyroid micro-carcinoma

Objective: To investigate the correlation between cervical lymph node skip metastasis with ultrasonographic characteristics of papillary thyroid micro- carcinoma (PTMC). Methods: We reviewed ultrasonographic features of 385 primary PTMC and cervical lymph node metastasis, confirmed by pathology in Tianjin Medical University Cancer Institute and Hospital, to evaluate the efficacy of ultrasonography in the diagnosis of cervical lymph node metastasis of PTMC patients. The relationship between ultrasonographic features of primary lesions and skip metastasis of cervical lymph nodes was analyzed by χ(2) test and multiple factor Cox regression. Results: Among the 385 cases of PTMC patients with cervical lymph node metastasis, 231 cases were central lymph node metastasis alone, 31 cases were lateral cervical lymph node metastasis alone, 123 cases were both central and lateral cervical lymph node metastasis. Among the 354 cases without skip metastasis of cervical lymph nodes, 48 cases were level Ⅱ, 92 cases were level Ⅲ, 83 cases were level Ⅳ, 9 cases were level Ⅴ, 354 cases were level Ⅵ. Among the 31 cases with skipping metastasis of cervical lymph nodes, 12 cases were level Ⅱ, 14 cases were level Ⅲ, 14 cases were level Ⅳ, 1 case was level Ⅴ. The sensitivity and specificity of preoperative ultrasonography in the diagnosis of central cervical lymph node metastasis were 46.3% and 66.7%, respectively, and those of lateral cervical lymph node were 91.0% and 87.8%, respectively. Univariate analysis showed that the abutment/perimeter, diameter and location of PTMC were significantly associated with skip metastasis (P<0.05), multivariate analysis showed that abutment/perimeter and location of PTMC were significantly associated with skip metastasis (P<0.05). Conclusions: The sensitivity and specificity of preoperative ultrasound diagnosis for lateral cervical lymph node metastasis of PTMC is higher than that of central metastasis. PTMC with abutment/perimeter ≥1/4 and upper portion location are prone to skip metastasis.

Clinical analysis of risk factors for lateral cervical lymph node metastasis in stage cN0 papillary thyroid carcinoma and preventive dissection

Objective To discuss the clinical characteristics for lateral cervical lymph node metastasis in stage cN0 papillary thyroid microcarcinoma and significance and feasibility of preventive dissection, and provide reference for clinical treatment. Methods Reviewd the clinical data of 191 patients with stage cN0 papillary thyroid microcarcinoma patients from Jul. 2011 to Dec. 2016 underwent surgery in the Department of General Surgery of Lianyungang Oriental Hospital. Assessed the need for preventive cervical lymph node dissection.Chi-square test and logistic regression were used to analyze the relationship between cervical lymph node metastasis and gender, age, tumor number, tumor size, capsule infiltration, single and bilateral tumors, Hashimoto′s disease, and central lymph node metastasis. Results The positive rate of cervical lymph node metastasis in papillary thyroid microcarcinoma was 27.9% (50/191). Univariate analysis showed that the metastasis of the cervical lymph nodes was associated with infiltration of the capsule, Hashimoto disease, and CLN metastasis (all P<0.05). Multivariate logistic regression analysis showed that the capsule infiltration (OR=7.563, P=0.000), Hashimoto′s disease (OR=4.635, P=0.003), and central lymph node metastasis (OR=3.075, P<0.001) were able to be independent risk factors for cervical lymph node metastasis. When the positive number of lymph node metastasis in the central region was ≥ 2, the positive rate of cervical lymph nodes was significantly increased (P<0.001). Eleven patients (5.8%) had temporary recurrent laryngeal nerve palsy, 29 patients (15.1%) had transient hypoparathyroidism, and no patients with permanent recurrent laryngeal nerve palsy and hypoparathyroidism. Conclusions The removal of the cervical lymph nodes helps to accurately classify the tumor and assess the risk.It is important to choose the postoperative treatment follow-up plan for patients.For patients with capsule infiltration, Hashimoto′s disease, and central lymph node metastasis, cervical lymph node dissection should be routinely performed. Key words: Surgical procedures, operative; Parathyroid glands; Neck dissection; Papillary thyroid microcarcinoma; Prophylactic lateral cervical lymph node dissection

Predictive factors for central lymph node and lateral cervical lymph node metastases in papillary thyroid carcinoma.

Central lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC) is common. But the association between primary tumor characteristics and specific features of metastatic lymph nodes in PTC has not been fully identified. Determining risk factors for LNM may help surgeons determine rational extent of lymph node dissection. Data from 432 patients who underwent thyroidectomy with cervical lymph node dissection for PTC were retrospectively analyzed. The relationships between LNM to central compartment or lateral compartment and clinicopathologic factors were analyzed. Cox regression model was used to determine the risk factors for recurrence-free survival (RFS). Central lymph node metastasis (CLNM) and lateral lymph node metastasis (LLNM) were found in 216 (50.0%) and 65 (15.0%) patients, respectively. In the multivariate analysis for CLNM, patients < 45years of age (OR 2.037, 95% CI 1.388-2.988, P < 0.001), extrathyroidal invasion (OR: 2.144, 95% CI 0.824-5.457, P = 0.011), vascular invasion (OR 13.817, 95% CI 1.694-112.693, P = 0.014), LLNM (OR 2.851, 95% CI 1.196-6.797, P = 0.014) and TNM Stage III-IV (OR 465.307, 95% CI 113.903-1900.826, P < 0.001) were independent predictors for high prevalence of CLNM. In the multivariate analysis for LLNM, tumor size more than 1cm (OR 3.474, 95% CI 1.728-6.985, P < 0.001) and CLNM (OR 5.532, 95% CI 2.679-11.425, P < 0.001) were independent predictors for high prevalence of LLNM. Moreover, tumor with T3-T4 stage, extrathyroidal invasion and CLNM were the significant factors related to the RFS. For patients with pre-operative risk factors of LNM, an accurate preoperative evaluation of central compartment or lateral compartment is needed to find suspicious lymph nodes. And prophylactic lymph node dissection should be performed in patients with high risk of CLNM. Moreover, we suggest performing close follow-up for patients with high risk of RFS.

Expression of NF2 Modulates the Progression of BRAFV600E Mutated Thyroid Cancer Cells.

BackgroundWe previously reported the frequent neurofibromatosis 2 (NF2) gene mutations in anaplastic thyroid cancers in association with the BRAFV600E mutation. We aimed to investigate the role of NF2 in thyroid cancer with BRAF mutation.MethodsTo identify the function of NF2 in thyroid cancers, we investigated the changes in cell proliferation, colon formation, migration and invasion of thyroid cancer cells (8505C, BHT101, and KTC-1) with BRAFV600E mutation after overexpression and knock-down of NF2. We also examined how cell proliferation changed when NF2 was mutagenized. Human NF2 expression in papillary thyroid carcinoma (PTC) was analyzed using the The Cancer Genome Atlas (TCGA) data.ResultsFirst, NF2 was overexpressed in 8505C and KTC-1 cells. Compared to control, NF2 overexpressed group of both thyroid cancer cells showed significant inhibition in cell proliferation and colony formation. These results were also confirmed by cell migration and invasion assay. After knock-down of NF2 in 8505C cells, there were no significant changes in cell proliferation and colony formation, compared with the control group. However, after mutagenized S288* and Q470* sites of NF2 gene, the cell proliferation increased compared to NF2 overexpression group. In the analysis of TCGA data, the mRNA expression of NF2 was significantly decreased in PTCs with lateral cervical lymph node (LN) metastasis compared with PTCs without LN metastasis.ConclusionOur study suggests that NF2 might play a role as a tumor suppressor in thyroid cancer with BRAF mutation. More studies are needed to elucidate the mechanism how NF2 acts in thyroid cancer with BRAF mutation.

Lobectomy Is Feasible for 1-4 cm Papillary Thyroid Carcinomas: A 10-Year Propensity Score Matched-Pair Analysis on Recurrence.

Current guidelines allow lobectomy as treatment for 1-4 cm papillary thyroid carcinomas (PTCs), as previous studies reported no clear survival advantages for total thyroidectomy (TT). However, data on recurrence based on surgical extent are limited. This study enrolled 2345 patients with 1-4 cm PTC. Those with lateral cervical lymph node metastasis or initial distant metastasis were excluded. Disease-free survival (DFS) was compared after 1:1 propensity score matching by age, sex, tumor size, extrathyroidal extension, multifocality, and cervical lymph node metastasis. Lobectomy was performed in 383 (16.3%) and TT in 1962 (83.7%) patients. In the matched-pair analysis (381 patients in each group), no significant difference in DFS was observed during the median follow-up of 9.8 years (hazard ratio [HR] = 1.35 [confidence interval (CI) 0.40-1.36], p = 0.33). When stratified by tumor size, DFS did not differ between the group with 1-2 cm tumors and that with 2-4 cm tumors (HR = 1.57 [CI 0.75-3.25], p = 0.228; HR = 0.93 [CI 0.30-2.89], p = 0.902, respectively). Multivariate analysis showed that the surgical extent did not play an independent role in structural persistent/recurrent disease development (HR = 1.43 [CI 0.72-2.83], p = 0.306). Patients with 1-4 cm PTCs who underwent lobectomy exhibited DFS rates similar to those who underwent TT after controlling for major prognostic factors. This supports the feasibility of lobectomy as initial surgical approach for these patients and emphasizes that tumor size should not be an absolute indication for TT.

Correlation analysis and clinical significance of lymph node metastasis in right recurrent laryngeal nerve of papillary thyroid carcinoma

Objective To explore the correlation factors and clinical significance of lymph node metastasis in right recurrent laryngeal nerve of thyroid papillary carcinoma (PTC). Methods Ninty-eight consecutive patients with PTC who were underwent total thyroidectomy with routine central lymph node dissection in the Second People′s Hospital of Hefei from January 2015 to August 2017 were analyzed. The right paratracheal lymph nodes in the central compartment lymph nodes were divided into the level Ⅵ-A (anterior) and level Ⅵ-B (posterior, that was lymph node posterior to recurrent laryngeal nerve) compartments by recurrent laryngeal nerve. The lymph node metastasis of Ⅵ-B area during central compartment lymph node dissection was analyzed. We drew the receiver-operating characteristic curve (ROC) for right neck Ⅵ-A number of lymph node metastasis, and calculated the area under the curve (AUC) and Youden index. Results Among 98 cases, 16 cases occurred Ⅵ-B district lymph node metastasis (16.33%). Single factor analysis results showed that lymph node metastasis in Ⅵ-B area of PTC patients were related to the tumor size (χ2=12.864, P 0.05). Lymph node metastasis in Ⅵ-B area of PTC patients were related to the number of right neck Ⅵ-A area lymph node metastasis. When the number of right neck Ⅵ-A metastatic lymph nodes was 2.5, the sensitivity and specificity were 70.60% and 70.00% respectively, AUC was 0.754, and Youden index was 0.406. Conclusion For patients with PTC, primary tumor diameter >1 cm, tumor extracapsular invasion, Ⅵ-A area lymph node metastasis, multiple tumor and lateral cervical lymph node metastasis were the predictive factors for the lymph node metastasis in Ⅵ-B area. When the number of right neck Ⅵ-A area metastatic lymph nodes was greater than 3, we should dissect Ⅵ-B area. Key words: Thyroid neoplasms; Papilloma; Lymphatic metastasis; Lymph node posterior to right recurrent laryngeal nerve

PAPILLARY THYROID CARCINOMA IN CHILDREN AND ADOLESCENTS, RESULTS OF TREATMENT OF 215 PATIENTS: FACTORS PREDICTING DISTANT METASTASES AND RECURRENCE OF THE DISEASE

We evaluated the results of treatment of 215 pediatric patients with papillary thyroid carcinoma (PTC). Median age at diagnosis was 14 (5 - 18 y.o). Thyroidectomy performed in 105, subtotalthyroidectomy in 8, lobectomy - in 102, additional lymph node dissection - in 169, radioiodine ablation/ therapy - in 102 patients. Follicular variant PTC was found in 41 (19%), solid - in 37 (17%), diffuse sclerosing - in 3 (1%), the remaining had a classical PTC with mainly papillary (90; 42%) or follicular (44; 21%) pattern. 21% had multifocal PTC, 4,6% - extrathyroidal extension, 62% - regional lymph node metastases, 12% - lung metastases. The follow up was 95 months (6 - 301 mo). All patients are alive. Recurrence of PTC occurred in 37 (17%): 7 - thyroid remnant, 26 - cervical lymph nodes, 4 - distant lung metastases. Prognostic factors for distant metastases were young age at diagnosis &lt;12 years old (OR 3.4, р &lt;0.022), tumor size more then 3 cm (OR 3.2, р &lt;0.027) and lateral cervical lymph node metastases (OR 21.39, р &lt;0.0001). Risk of recurrence was higher in multifocal PTC (OR 2.4, р &lt;0.009), regional lymph node metastases (OR 7.4, р &lt;0,008) and distant metastases (OR 3.2, р &lt;0,01). The highest risk of relapse had the patients with solid variant of PTC. Radical surgery diminished the risk of relapse (OR 0.3, р &lt;0.002). There was no evidence of impact of radioiodine therapy on risk of recurrence (р=0.66).

LpMab-23-recognizing cancer-type podoplanin is a novel predictor for a poor prognosis of early stage tongue cancer.

PurposeWe report that the reactivity of a novel monoclonal antibody LpMab-23 for human cancer-type podoplanin (PDPN) is a predictor for a poor prognosis of tongue cancer.Patients and MethodsThe association between LpMab-23-recognizing cancer-type PDPN expression and clinical/pathological features were analyzed on 60 patients with stage I and II tongue cancer treated with transoral resection of the primary tumor.ResultsIn the mode of invasion, the LpMab-23-dull/negative cases were significantly larger in cases with low-grade malignancies and without late cervical lymph node metastasis, than in cases with high-grade malignancies and the metastasis. In the high-grade malignant cases, LpMab-23-positive cases were significantly larger than LpMab-23-dull/negative cases. The Kaplan–Meier curves of the five-year metastasis-free survival rate (MFS) were significantly lower in the LpMab-23 positive patients than in LpMab-23 dull/negative patients. The LpMab-23-dull/negative cases showed the highest MFS in all of the clinical/pathological features and particularly, the MFS of the LpMab-23 positive cases decreased to less than 60% in the first year. In the Cox proportional hazard regression models a comparison of the numbers of LpMab-23 dull/negative with positive cases showed the highest hazard ratio with statistical significance in all of the clinical/pathological features.ConclusionsLpMab-23 positive cases may be considered to present a useful predictor of poor prognosis for early stage tongue cancer.

Study on the relationship between ultrasonographic features of papillary thyroid carcinoma and central cervical lymph node metastasis

Objective: To investigate the correlation between ultrasonographic features of papillary thyroid carcinoma and central cervical lymph node metastasis. Methods: We retrospectively analyzed 486 patients with papillary thyroid carcinoma(PTC), pathologically confirmed after surgery in Tianjin Medical University Cancer Institute & Hospital. All patients were divided into central cervical lymph node metastasis group and non-metastasis group. No lateral cervical lymph node metastasis was found in preoperative ultrasonography and postoperative pathology. The characteristics of the ultrasound was observed and analyzed. Results: 297 out of 486 patients with papillary thyroid carcinomahad central metastasis, and the other 189 cases did not. Take pathology results as a standard, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy rate of preoperative ultrasound diagnosis in PTC patients with central cervical lymph node metastasis were 35.3%, 88.6%, 83.2%, 47.4%, 56.6%, respectively. Univariate analysis showed that multi-focus, taller-than-wide, diameter>1 cm, located in the lower pole, ill-defined margin, hypoechogenicity, micro-calcification, capsule invasion more than 1/4 perimeter of papillary thyroid carcinoma were significantly associated with central cervical lymph node metastasis (all P<0.05). Multivariate analysis showed that diameter>1 cm, micro-calcification, capsule invasion more than 1/4 perimeter of papillary thyroid carcinoma became independent risk factors of central cervical neck lymph node metastasis (all P<0.05). Conclusions: Preoperative description of ultrasonographical features has important value to assess central cervical lymph node metastasis in patients with papillary thyroid carcinoma. More information could be provided for clinical treatment. When the papillary thyroid carcinoma presented as diameter>1 cm, micro-calcification, and capsule invasion more than 1/4 perimeter of, there will be a greater risk of central cervical lymph node metastasis, and we shall suggest prophylactic central lymph cervical node dissection.

Preoperative Clinical and Sonographic Predictors for Lateral Cervical Lymph Node Metastases in Sporadic Medullary Thyroid Carcinoma.

Total thyroidectomy and cervical lymph node (LN) dissection is generally recommended in patients with medullary thyroid carcinoma (MTC). However, there is no clear evidence for whom to perform prophylactic lateral neck dissection in MTC patients without evident lateral cervical lymph node (LCLN) metastasis in preoperative images. This study evaluated the preoperative features for predicting the LCLN metastasis of MTC. The study included 26 MTC patients with LCLN metastasis at initial surgery (N1b group) and 47 MTC patients without any LN metastasis or recurrence of disease (N0-NED group). The association between LCLN metastasis and preoperative clinical and sonographic characteristics (size, location, solid component, shape, margin, echogenicity, calcification, and subcapsular location of the tumor) were evaluated. There were no significant differences in age and sex between the N1b and N0-NED groups. Preoperative serum levels of calcitonin >65 pg/mL were associated with LCLN metastasis (p < 0.001). In preoperative neck ultrasonography (US), patients in the N1b group were more commonly found with a larger tumor (>1.5 cm) of irregular shape with a spiculated margin and a subcapsular location than those in the N0-NED group (p = 0.029, p < 0.001, p < 0.001, and p < 0.001, respectively). Increases in the number of these LCLN metastasis-related features were significantly associated with higher risk for LCLN metastasis (p < 0.001). The presence of two or more predictors was an appropriate cutoff point for predicting LCLN metastasis of MTC with 73.1% sensitivity and 91.5% specificity. MTC tumors with high preoperative calcitonin levels (>65 pg/mL), larger size (>1.5 cm), irregular shape, spiculated margins, and subcapsular locations in the neck US are at higher risk for LCLN metastasis. MTC patents with fewer than two predictors might be suitable for treatment without prophylactic LCLN dissection.

Outcome of Thyroid Carcinoma Showing Thymus-Like Differentiation in Patients Undergoing Radical Resection.

Carcinoma showing thymus-like differentiation (CASTLE) is a rare malignant tumor of the thyroid. It is difficult to diagnose, and there is no universally recognized therapeutic regimen. This study aims to define the clinicopathological features and discuss the optimal management of CASTLE. We retrospectively analyzed six patients with CASTLE who accepted surgery at the First Hospital of China Medical University between January 2010 and December 2015. The six patients (three women and three men) had median age of 53years (range 47-61years). All patients presented with a slow-growing, painless neck mass; three patients also had hoarseness. All tumors were located in middle-lower or lower lobe, and two tumors extended to the substernal region. All patients underwent radical surgery without postoperative radiotherapy or chemotherapy. Five patients had extrathyroidal extension and two had lymph node metastasis. All six tumors were positive for CD5 and negative for thyroglobulin (Tg) and thyroid transcription factor (TTF)-1. Median follow-up was 32months (range 23-81months). Lateral cervical lymph node metastasis occurred in one patient at 26months after initial treatment. CASTLE is a rare, aggressive malignant tumor of the thyroid. Ultrasound, computed tomography, and fine-needle aspiration biopsy may not be sufficient to establish the diagnosis preoperatively; pathological examination and immunohistochemistry, particularly positive CD5 staining, are necessary to establish the diagnosis. Patients with CASTLE can yield a favorable outcome after radical surgery.

Correlation analysis of the clinical and sonographic characteristics of papillary thyroid microcarcinomas with its aggressiveness

Objective To compare the clinical and sonographic characteristics of aggressive and nonaggressive papillary thyroid microcarcinomas (PTMC) in order to improve the preoperative predictive value of aggressive PTMC. Methods A total of 309 patients with PTMC from January 2014 to December 2016 were included in this study. Patients with lymphatic metastasis, extrathyroidal invasion, reccurence, distant metastasis and death were classified into aggressive PTMC group, and patients without above characteristics were classified into nonaggressive group. Clinical and sonographic features were reviewed and compared between the two groups. Results Among the 309 patients, 76 cases (24.6%) were aggressive PTMC, and 233 cases (75.4%) were nonaggressive. Patients were younger and larger cancerous nodules, microcalcification, capsular inconnection and multifocality were seen more frequently in aggressive PTMC group compared with nonaggressive group. The best cut-off value of age and diameter were 44.5 years and 0.66 cm respectively. Advanced age was the protective factor and larger tumor size and multifocality were independent risk factors for PTMC aggressiveness. The capsular invasion was related with the lateral cervical lymph node metastasis while other features were not. Conclusions Extra attention should be paid to patients with age 0.66 cm and multifocal cancerous nodules because their PTMCs are more likely to be aggressive. Thyroid capsule adjacent to the cancerous nodule should be observed carefully. If there is interruption in the capsule, lateral cervical lymph nodes should be carefully examed. Key words: Ultrasonography; Papillary thyroid microcarcinomas; Aggressiveness; Clinical characteristics

Clinical significance of lymphatic metastasis between sternocleidomastoid and sternohyoid muscle in papillary thyroid cancer

Objective: To explore the clinical significance of metastasis of lymph nodes between sternocleidomastoid and sternohyoid muscle (LNSS) in papillary thyroid cancer (PTC). Methods: A total of 175 patients with PTC who underwent thyroidectomy with LNSS dissection were retrospectively analyzed. Univariate and multivariate Logistic regression analyses were used to determine the independent risk factors for LNSS metastasis in PTC. Results: The rate of detectable LNSS was 70.9% (124/175) and metastasis rate was 7.4% (13/175). Of 13 cases with LNSS metastasis, 10 with the coexistence of cervical lymph node metastasis. Univariate Logistic regression analysis showed that multiple focal cancer, tumor located in the lower pole of thyroid, belt-shaped muscle invasion, lateral cervical lymph node metastasis, cN+ , the number of cervical lymph nodes with metastasis and the number of lymph nodes with metastasis in level Ⅳwere the risk factors for LNSS metastasis (P<0.05). Multivariate Logistic regression analysis suggested that tumor located in the lower pole of thyroid and the number of cervical lymph nodes with metastasis >6 were the independent risk factors for LNSS metastasis (P<0.05). Given the number of cervical lymph nodes with metastasis as a predictor for the LNSS metastasis, the sensitivity was 92.3%, the specificity was 66.7% and the accuracy rate was 68.6%. Conclusions: LNSS metastasis is commom in PTC, with a metastasis rate of 7.4%. PTC in the lower pole of thyroid and the number of cervical lymph nodes with metastasis > 6 are independent risks for LNSS metastasis.

Lack of Efficacy of Radioiodine Remnant Ablation for Papillary Thyroid Microcarcinoma: Verification Using Inverse Probability of Treatment Weighting.

Most of the increase in thyroid cancer in recent decades has been due to papillary thyroid microcarcinoma (PTMC). We evaluated the efficacy of radioiodine remnant ablation (RRA) in patients with PTMC. This historical cohort study included 1932 PTMC patients without lateral cervical lymph node (LN) or distant metastasis who underwent total thyroidectomy (TT) during the median 8.3years of follow-up. The clinical outcomes of patients with or without RRA were compared using weighted logistic regression models with the inverse probability of treatment weighting (IPTW) method and considering risk factors, including age, sex, primary tumor size, extrathyroidal extension, multifocality, and central cervical LN metastasis. The median primary tumor size of the RRA group was significantly larger than that of the no-RRA group (0.7 vs. 0.5cm, P<0.001). There were significantly more patients with multifocality, extrathyroidal extension, and cervical LN metastasis in the RRA group compared with the no-RRA group. There was no significant difference in recurrence-free survival between the two groups (P=0.11). Cox proportional-hazard analysis with IPTW by adjusting for clinicopathological risk factors demonstrated no significant difference in recurrence of PTMC according to RRA treatment (hazard ratio [HR] 2.02; 95% confidence interval [CI] 0.65-6.25; P=0.2). RRA had no therapeutic effect on the clinical outcomes of patients with PTMC who underwent TT. Surgical treatment without RRA could be applicable for patients with PTMC if there is no evidence of lateral cervical LN metastasis or distant metastasis.

Needle-Assisted Endoscopic Lateral Neck Dissection Through Bilateral Areola Approach for Papillary Thyroid Carcinoma Patients

Introduction: Needle-assisted endoscopic lateral neck dissection through the bilateral areola approach is a technique of selective neck dissection for levels IIA, IIB, III, IV, VB, and VI lymph nodes. This technique has a cosmetic effect on patients with N1b papillary thyroid carcinoma (PTC). Methods/Case Presentation: In January 2016, a 26-year-old female patient was found to have PTC with right lateral cervical lymph node metastasis by fine-needle aspiration. It was found to be clinical stage I cT1bN1bM0. After CT scan and ultrasonography inspection, we decided to perform total thyroidectomy and right lateral neck dissection through the bilateral areola approach. Incisions were made at the bilateral areola with a 5-mm trocar and a 10-mm trocar was inserted into the right breast margin at the 4 o'clock position. Needle-assisted instruments directly approached the surgery region through the neck skin. We built up an operating space by the liquid–gas method with 6 mmHg CO2 and suture suspension to maintain the spaces. Using needle-assisted instruments, the external jugular vein was separated primarily and was protected well. Then we anatomized the anterior border of the sternocleidomastoid to show the carotid triangle, including the posterior belly of the digastric muscles, hypoglossal nerve (XII), and accessory nerve (XI), and dissected the levels IIA, IIB, and III lymph nodes at the same time. Furthermore, the level IV lymph node was dissected after exposing the venous angle and ligating the lymphatic duct at the intermuscular approach. For identifying the transverse cervical artery and cervical nerves, we returned to level V to remove the specimen and complete the lateral neck dissection. Finally, the recurrent laryngeal nerves, parathyroids, and other important structures mentioned previously were taken on completely. Three drainage tubes were placed in the neck. This surgery left minimal scars on the neck, and the cervical sensory nerves were properly preserved. Results/Discussion: The patient received treatment after surgery in the hospital for 5 days without postoperative complications. Needle-assisted endoscopic lateral neck dissection through the bilateral areola approach for PTC patients can obtain significant cosmetic results and also minimal invasion for young PTC patients with lateral lymph node metastasis. Conclusions: Needle-assisted endoscopic lateral neck dissection through the bilateral areola approach is considered for N1b papillary thyroid carcinoma without mediastinal metastasis. It is an excellent option for young patients that gives better cosmetic effect and minimal invasion. No competing financial interests exist. Runtime of video: 8 mins 30 secs