Lateral Neck Recurrence Research Articles

Lateral neck dissection for the treatment of synchronous and metachronous lateral neck metastasis of N1b papillary thyroid cancer.

Metachronous lateral neck recurrence after thyroidectomy for N1b papillary thyroid cancer is accompanied by high morbidity and increased difficulty of reoperation. From the perspective of recurrence, the objective of this study was to compare patients who underwent metachronous lateral neck dissection (mLND) despite initial thyroidectomy and patients who underwent synchronous lateral neck dissection (sLND) for papillary thyroid cancer and analyze the risk factors for recurrence after mLND. This retrospective study involved 1,760 patients who underwent lateral neck dissection for papillary thyroid cancer at the Gangnam Severance Hospital, a tertiary medical center in Korea, from June 2005 to December 2016. The primary outcome was structural recurrence, and secondary outcome measures were risk factors of recurrence in the mLND group. A total of 1,613 patients underwent thyroidectomy and sLND at diagnosis. In 147 patients, thyroidectomy alone was performed at the time of diagnosis, and mLND was performed when recurrence to the lateral neck lymph node was confirmed. During a median follow-up of 102.1 months, 110 (6.3%) patients experienced a recurrence. There was no significant difference in the recurrence between the sLND and mLND groups (6.1% vs 8.2%, P=.32). The period from lateral neck dissection to recurrence was longer in the mLND group than in the sLND group (113.6 ± 39.4 months vs 87.0 ± 33.8 months, respectively, P<.001). Age ≥50 years (adjusted HR=5.209, 95% CI=1.359-19.964; P=.02), tumor size >1.45cm (adjusted HR=4.022, 95% CI=1.036-15.611; P=.04), and lymph node ratio in the lateral compartment (adjusted HR=4.043, 95% CI=1.079-15.148; P=.04) were independent variables predictive of recurrence after mLND. mLND is suitable for treating lateral neck recurrence in patients with N1b papillary thyroid cancer who previously underwent thyroidectomy. Lateral neck recurrence after treatment in patients who underwent mLND was predicted by age, tumor size, and lymph node ratio in the lateral compartment.

Risk stratification of lateral neck recurrence for patients with pN1a papillary thyroid cancer

BackgroundLateral neck is not recommended for dissection in patients with pN1a papillary thyroid cancer (PTC), but its recurrence risk has not been well stratified. We aimed to develop a risk stratification system for lateral neck recurrence in patients with pN1a PTC.MethodsPatients with pN1a PTC who underwent thyroidectomy and unilateral central compartment dissection from 2000–2016 were enrolled. The association between number of central lymph node metastases (CLNMs) and lateral neck recurrence was comprehensively assessed using a Cox proportional hazards model with restricted cubic spline. Stratification was then performed based on CLNMs and other significant risk factors selected by multivariate analysis. Lateral neck recurrent-free survival (LRFS) rate of each stratification was estimated with Kaplan–Meier curve and comparison was performed using log-rank test.ResultsNinety-six (3.8%) lateral neck recurrences were identified during a median follow-up of 62 months among a total of 2500 admitted cases. An increasing number of CLNMs was associated with compromised LRFS for up to 6 CLNMs (P < 0.001), and CLNMs > 3 indicated significantly worse 5-year LRFS than that of CLNM ≤ 3 (90.6% vs. 98.1%, P < 0.001). When stratification with CLNMs and primary tumor size (selected by multivariate analysis, HR (95%CI) = 4.225(2.460–7.256), P < 0.001), 5-year LRFS rates of high- (CLNMs > 3 and primary tumor size > 2 cm), intermediate- (CLNMs > 3 and primary tumor size 1–2 cm) and low-risk (primary tumor size ≤ 1 cm or CLNMs ≤ 3) groups were 78.5%, 90.0% and 97.9%, respectively (P < 0.05).ConclusionsThe number of CLNMs combined with primary tumor size seems to effectively stratify lateral neck recurrence risk for patients with pN1a PTC.

Establishment of model to predict lateral neck recurrence of central lymph node metastasis in papillary thyroid carcinoma

Objective: To explore the risk factors for lateral neck recurrence of central lymph node metastasis (CLMN) in papillary thyroid cancer (PTC), and to construct a model to predict the recurrence. Methods: The records of 245 consecutive PTC patients with CLMN underwent surgical treatment from 1996 to 2009 in our department were retrospectively reviewed. The threshold value of CLNM number is determined by ROC curve. The risk factors for lateral neck recurrence were determined by using Cox regression model. The identified risk factors were incorporated into a nomogram model to predict the risk of lateral neck recurrence. Results: A total of 245 patients were enrolled in the study, among them, 32 cases occurred lateral neck lymph node recurrence and 4 cases were dead of thyroid carcinoma. Multivariate analysis revealed that primary tumor size, extrathyroidal extension, the number of metastatic CLNM >3 were independent risk factors of lateral neck recurrence (P<0.05), lateral neck recurrence was a risk factor of disease-free survival(P<0.05). The nomogram model of predicting the lateral neck recurrence was further established based on the above 3 independent risk factors, the area under the receiver operating characteristic (ROC) curve of which was 0.790. Conclusions: The nomogram model based on the independent risk factors of LN recurrence can be helpful to screen the papillary thyroid carcinoma patients with high risk of lateral neck recurrence, and provide more guidance for clinical treatment.

Extended Level IV Neck Dissection for Limited Prophylactic Clearance of Level V in Node-Positive Papillary Thyroid Carcinoma: a Homogenous Study Population.

There is near consensus that prophylactic lateral neck dissection has no role in the management of differentiated thyroid cancer, but the extent of lateral neck dissection in differentiated thyroid cancer remains controversial, especially whether level V should be addressed or not. There is lot of heterogeneity in reporting of the management of level V in papillary thyroid cancer. We at our Institute address the lateral neck positive papillary thyroid cancer with selective neck dissection involving levels II-IV, performing extended level IV dissection with inclusion of the triangular area delineated by the sternocleidomastoid muscle, the clavicle, and the perpendicular line drawn to the clavicle from the point where the horizontal line at the level of cricoid cuts the posterior border of sternocleidomastoid muscle. Retrospective analysis of the departmental data set related to thyroidectomy with lateral neck dissection from 2013 to mid-2019 for papillary thyroid cancer, was carried out. Patients with recurrent papillary thyroid cancer were excluded as were patients with involvement of level V. Data related to the demography of patients, histological diagnosis, and postoperative complications were compiled and summarized. Note was made of the incidence of ipsilateral neck recurrence and the neck level involved with recurrence noted. Data was analyzed for fifty-two patients of non-recurrent papillary thyroid cancer who had undergone total thyroidectomy and lateral neck dissection involving levels II-IV, with extended dissection at level IV. It should be noted that none of the patients had clinical involvement of level V. Only two patients had lateral neck recurrence, both the recurrences were in level III, one on the ipsilateral side and the other on the contralateral side. Recurrence in the central compartment was noted in two patients, with one of these patients also having ipsilateral level III recurrence. One of the patients had distal metastasis to the lungs. Transient paresis of the unilateral vocal cords was noted in seven patients which got resolved within 2months in all of them. Transient hypocalcemia was noted in four patients. Although our series has a small sample size with limited follow-up, it is one of the few studies in which prophylactic level V dissection has been studied in a homogenous study population of non-recurrent papillary thyroid cancer. Our study has shown that prophylactic dissection of level V may have a limited role, but further large multi-institutional studies need to be carried out to come up with a definite answer.

Routine Prophylactic Central Neck Dissection May Not Obviously Reduce Lateral Neck Recurrence for Papillary Thyroid Microcarcinoma

Background: The role of routine prophylactic central compartment neck dissection (pCCND) for papillary thyroid microcarcinoma (PTMC) remains controversial. The lateral neck recurrence-free survival (LRFS) advantages achieved by pCCND are still under investigation. Methods: The records of 2,074 consecutive patients with papillary thyroid carcinoma (PTC) at the time of surgery from 1996 to 2009 were retrospectively reviewed. A total of 611 consecutive patients were included in the final analyses. We used R version 3.5.1 to match patients with total thyroidectomy (TT)/lobectomy + pCCND with patients with TT/lobectomy alone and analyzed the following factors with a potential influence: age at diagnosis, sex, extrathyroid extension, and primary tumor multifocality and bilaterality. LRFS was analyzed. Moreover, the data were reanalyzed after separating the pairs of patients with pN1a from those with pN0. Results: We were able to select 159 pairs sharing the major prognostic risk factors as listed. Overall, there was no difference in the LRFS, although patients with pCCND more often had recurrence. Moreover, the central lymph node metastasis status had no significant influence on the risk of recurrence. Conclusion: Routine pCCND was not a protective factor for LRFS in PTMC patients with cN0. The difference in LRFS between pN0 and pN1a was not statistically significant (p > 0.05).

Comprehensive Lateral Neck Dissection in Papillary Thyroid Carcinoma may Reduce Lateral Neck Recurrence Rates.

To Identify predictors of recurrent disease following lateral neck dissection (LND) for papillary thyroid carcinoma (PTC). A retrospective review of patients who underwent first-time LND for PTC at our institution (2000-2015) was performed. Medical records were examined for biopsy or pathologically proven lateral neck recurrence. Differences between the groups with and without recurrence were compared. All LNDs were then classified in to two groups: "comprehensive" (CND), involving levels IIa-Vb at minimum, or "selective", labelling less extensive dissection (SND). Four hundred nine patients underwent 467 LNDs. Surveillance data were available for 317 patients who underwent 362 LNDs (mean age 45 ± 16; range 18-88). The median follow-up was 64 ± 48 months (range 3-197). Recurrence was detected in 71 lateral necks (20%). The total number of lymph nodes was greater in the group without recurrence compared to those with recurrence (23 vs. 19, p = 0.02). Among patient demographics, radioactive iodine treatment, primary tumor characteristics and characteristics of nodal metastases, only an older patient age (mean 50 vs. 43 years) was associated with lateral neck recurrence (p < .01). CND was performed in 102 lateral necks and SND in 143 necks. There were 12 recurrences recorded in the CND group (12%) vs. 31 in the SND group (22%, p = .04). The majority of recurrences (70%) involved levels included in the original dissection. Younger patients, more extensive dissection and a higher total number of lymph nodes removed are associated with a lower incidence of lateral neck recurrence after LND for papillary thyroid carcinoma.

Treatment of lateral neck papillary thyroid carcinoma recurrence after selective lateral neck dissection

There is a paucity of data regarding optimal treatment options and outcomes for recurrent disease after lateral neck dissection in patients with papillary thyroid carcinoma. Retrospective review of patients who underwent either percutaneous ethanol injection or surgery for first-time ipsilateral recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma was performed. Follow-up data were available for 54 patients with recurrences in 57 lateral necks treated by either percutaneous ethanol injection (n = 32) or surgery (n = 25). Tumor burden at the time of lateral neck recurrence differed between the groups including the largest lymph node diameter (mean: 13 mm vs 18 mm, P < .01) and the mean number of metastatic lymph nodes identified on ultrasound (1.3 vs 1.9, P = .04). Each modality alone achieved similar estimated rates of disease control at 36 months (75% for percutaneous ethanol injection and 74% for surgery, P = .8) with similar number of reinterventions (1.8 for percutaneous ethanol injection, 1.6 for surgery, P = .6). Both ethanol ablation and surgery can achieve disease control in the majority of patients with recurrences after ipsilateral lateral neck dissection for papillary thyroid carcinoma. Ethanol ablation, when used for treatment of a single small lymph node, can result in outcomes that are similar to reoperative surgery for larger and multiple lymph nodes.

Long-Term Outcomes of Lateral Neck Dissection in Patients with Recurrent or Persistent Well-Differentiated Thyroid Cancer.

Well-differentiated thyroid carcinoma (WDTC) has a high predilection for regional metastatic spread. Rates for WDTC lateral neck recurrence are reported to be as high as 24% in patients after initial thyroidectomy, lateral neck surgery, and adjuvant radioactive (RAI) iodine treatment. The objective of the study was to evaluate the efficacy, safety, and long-term outcome of comprehensive lateral neck dissection (LND) of levels II-V for recurrent or persistent WDTC in a tertiary referral center. This study retrospectively analyzed the standardized approach of LND for recurrent WDTC in the lateral neck compartment. Survival was analyzed by Cox regression analysis. Three hundred and seven patients underwent 429 LND for cytopathology-confirmed lateral neck recurrent WDTC at the University of Texas MD Anderson Cancer Center between 1994 and 2012. The vast majority (90%) of patients were originally treated elsewhere. Multilevel lateral neck dissection had been originally performed in 80% of patients, with 17% having undergone at least two previous operations. Two hundred and sixty-seven (87%) patients had previous RAI. The most common levels of recurrence were levels III and IV (33% and 33%, respectively). Postoperative complications were seen in 7% of patients. Median follow-up was 7.2 years. In-field lateral neck control was 96% at 10 years. Overall lateral neck regional control, overall survival (OS), and disease-specific survival (DSS) at 10 years was 88%, 78%, and 91%, respectively. When stratifying by age (<24 years, 24-50 years, and >50 years), OS and DSS was significantly better in patients <50 years (OS: p < 0.001; DSS: p < 0.001). However, there was worse overall lateral neck control in the younger group (<24 years; p = 0.04). Regional recurrence after salvage LND occurred within a median time interval of 20.0 months (2.9-121.3 months), of which 2% (8/429) developed in-field lateral neck recurrences. Of those with any lateral neck recurrence after salvage LND, 24/30 (80%) patients successfully underwent another LND, resulting in an ultimate 98% lateral neck regional control rate. Expert comprehensive LND of levels II-V is associated with few perioperative complications and results in very high in-field regional control rate and ultimate lateral neck control in recurrent/persistent WDTC.

Risk Factors for Lateral Neck Recurrence of N0/N1a Papillary Thyroid Cancer.

Current guidelines advocate no prophylactic dissection of the lateral neck compartment for papillary thyroid carcinoma (PTC) without clinical evidence of lateral neck metastasis (cN1b). However, lateral neck recurrence can affect patient treatment outcomes and quality of life. Therefore, this study examined the risk factors for lateral neck recurrence after the definitive treatment of PTC without cN1b. The study enrolled 1928 consecutive patients who underwent total thyroidectomy between 2006 and 2012 for PTC without cN1b. Logistic regression analysis was used to identify the relationship of clinicopathologic factors with lateral neck recurrence. Uni- and multivariate Cox-proportional hazards regression analyses were used to identify factors predictive of lateral neck recurrence-free survival (LRFS). During a median follow-up period of 94 months (range, 24-133 months), lateral neck recurrence occurred in 47 patients (2.4%). Binary logistic regression showed that tumor size (>2cm), multifocality, clinical central neck metastasis (cN1a), number of positive lymph nodes (LNs, >5), and LN ratio (>0.5) were significantly associated with lateral neck recurrence (P<0.05). Multivariate analyses showed that multifocality (hazards ratio [HR], 2.338; 95% confidence interval [CI], 1.126-4.858; P=0.023), cN1a (HR, 5.301; 95% CI, 2.416-11.630; P<0.001), LN ratio (HR, 2.628; 95% CI, 1.228-5.626; P=0.013), extranodal extension (HR, 2.570; 95% CI, 1.063-6.213; P=0.036), and MACIS (distant metastasis, patient age, completeness of resection, local invasion and tumour size) score (HR, 2.513; 95% CI, 1.211-5.216; P=0.013) were independent factors for LRFS. Lateral neck recurrence after thyroidectomy is predicted by the clinicopathologic factors of multifocality, cN1a, LN ratio, extranodal extension, and MACIS score in N0/N1a PTC patients.

Prognostic Implications of Lymph Node Yield in Central and Lateral Neck Dissections for Well-Differentiated Papillary Thyroid Carcinoma.

The aim of this study was to evaluate the relationship between lymph node yield (LNY) from central (CND) and lateral (LND) neck dissections and risk of recurrence in patients undergoing primary surgery for well-differentiated papillary thyroid carcinoma (WDPTC). Clinical data were reviewed from all patients with biopsy-proven WDPTC who underwent primary total thyroidectomy with CND or LND at the authors' institution from 2005 to 2009. Patient demographics and tumor characteristics were obtained, and clinical data with at least five-year follow-up were used. Within the CNDs and LNDs, total number of nodes removed (LNY), total positive nodes removed, and the ratio of positive lymph nodes to LNY were determined. One hundred fifty-two patients were included in the study, with average follow-up of 69 months. Of 125 patients who underwent CND, 20 had central neck disease recurrence. The LNY of patients with central neck recurrence was significantly less than those who had no recurrence (2.5 vs. 10.3; p < 0.0001). Of 71 patients who underwent LND, 23 had ipsilateral lateral neck disease recurrence. The LNY of patients with lateral neck recurrence was significantly less than those who did not recur (10.5 vs. 24.6; p < 0.0001). Higher rates of recurrence were associated with smaller LNY in both groups. For both groups, lower LNY remains predictive of recurrence on multivariate analysis controlling for pT stage, pN stage, American Joint Committee on Cancer stage, and radioactive iodine treatment. Higher LNY in CNDs and LNDs is associated with lower rates of papillary thyroid carcinoma recurrence in the central and lateral neck. To minimize the risk of recurrence and the need for secondary therapy with revision surgery and/or radiation, surgeons should perform thorough, compartment-oriented CNDs and LNDs when nodal surgery is undertaken.

Lateral neck recurrence from papillary thyroid carcinoma: Predictive factors and prognostic significance.

The aim of this study was to identify any possible predictive factors of lateral neck recurrence in patients with papillary thyroid carcinoma with no ultrasonographic and/or cytological evidence of lymph node metastasis at time of diagnosis. The influence of lateral neck recurrence on survival was also investigated. Observational retrospective study. Retrospective review of clinical records of 610 patients surgically treated for papillary thyroid carcinoma with clinically negative lymph nodes at the Otolaryngology Unit of the Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy, from January 1984 to December 2008. Lateral neck recurrences were ipsilateral to the primary tumor in all cases and were associated with the occurrence of more aggressive histological variants and central neck metastasis. Lateral neck recurrences were more frequently observed in patients with distant metastases and were associated with a reduced disease-specific survival. Lateral neck compartment ipsilateral to the tumor was the most common site of recurrence, with about half of cases appearing in the first 28 months of follow-up. In patients with papillary thyroid carcinoma, detection of lateral neck metastases prior to first surgery is crucial to surgical planning. Aggressive histological variants and postsurgical evidence of lymph node metastasis from papillary thyroid carcinoma in central neck compartment are associated with a higher risk of lateral neck recurrence. In these patients, a closer postsurgical ultrasound surveillance of the lateral neck compartments seems worthwhile. 4.

Short call abstracts.

Short call abstracts.

Recurrence pattern after conservative surgery for papillary thyroid carcinoma.

Risk-based treatment represents the optimal management strategy for papillary thyroid carcinoma; however, the optimal extent of thyroidectomy and neck dissection remains controversial. This study aims to clarify the pattern of recurrence after conservative surgery in patients with papillary thyroid carcinoma. We retrospectively reviewed 93 patients with papillary thyroid carcinoma treated with conservative surgery. We analyzed recurrence rate, recurrence pattern, risk factors for recurrence, salvage treatment, and disease-free survival (DFS) in patients stratified according to risk. The recurrence rate was significantly lower in the low-risk group compared with the high-risk group (14% vs 34%; p<0.01). The recurrence pattern also differed between the two groups, with ipsilateral lateral neck recurrence being more common in the low-risk group (9%), while contralateral lateral neck recurrence was more common in the high-risk group (18%). Patients with contralateral thyroid lobe metastasis and/or direct contralateral thyroid lobe invasion showed a significantly higher rate of contralateral lateral neck metastasis than patients negative for both these features. The overall 5-year DFS was 81% in all patients. Advanced T and N classification, large primary tumor (≥4cm), extrathyroidal invasion, and high-risk group were significantly associated with poorer 5-year DFS in univariate analysis. Conservative surgery may represent a good treatment option for patients with low-risk papillary thyroid carcinoma. Tumor recurrence patterns differ between risk groups, with contralateral thyroid lobe lesions and direct contralateral lobe invasion being risk factors for contralateral lateral neck recurrence.

Observation of clinically negative central compartment lymph nodes in papillary thyroid carcinoma

The role of prophylactic central neck dissection in the management of papillary thyroid cancer (PTC) is controversial. We report our experience of an observational approach to the cN0 neck in PTC. We reviewed 1,129 patients with PTC who had total thyroidectomy between 1986 and 2005. In that group, 470 patients were pN1; 384 had benign nodes removed (pN0); and the remaining 275 had no nodes removed (pNx). The pNx group formed the cohort for this study. With a median follow-up of 70 months, the 10-yr disease-specific survival was 100%. We found 4 patients who had evidence of radioactive iodine uptake on scans performed during follow-up without diagnostic cytology. All subsequently received radioactive iodine and are considered disease free. Three patients had biopsy-proven lateral-neck recurrence and underwent neck dissection; 1 patient developed a low-level thyroglobulin suspicious for recurrence; and 1 patient had a subcentimeter level VI node suspicious for recurrence, which has been observed. Therefore, the rate of structural recurrence in the central neck was 0.4% (1/275), and the rate of reoperation on the central neck was0. Our results suggest that properly selected patients can be managed safely with observation of the central neck rather than prophylactic central neck dissection, which has a higher complication rate.

Number of lymph nodes removed during modified radical neck dissection for papillary thyroid cancer does not influence lateral neck recurrence

This study examines the relationship between the number of lymph nodes removed during modified radical neck dissection and the incidence of disease recurrence. A retrospective review of 117 patients with papillary thyroid cancer and lateral neck involvement (levels 2-5) who underwent modified radical neck dissection was performed. Data were analyzed for patient demographics, operative procedure, lymph node involvement, complications, radioactive iodine therapy, and disease recurrence. Of 117 patients who underwent modified radical neck dissection, the median follow-up of the entire study group was 25 months (range, 1-256 months). Recurrent disease was found in 8% of patients, with a median time to recurrence of 35 months. The median number of lymph nodes removed during modified radical neck dissection was similar in recurrent and nonrecurrent patients (P = .78). There was also no difference in the median number of positive lymph nodes removed (P = .14) between these 2 groups. On multivariate analysis, however, the number of positive lymph nodes (odds ratio, 1.16 [95% confidence interval, 1.01-1.34]) and tumor size (odds ratio, 1.60 [95% confidence interval, 1.03-2.49]) were independent predictors of recurrence of disease after modified radical neck dissection. Recurrence of papillary thyroid cancer after modified radical neck dissection is unrelated to the number of lymph nodes removed. This study suggests that attempts to maximize the number of lymph nodes removed during modified radical neck dissection for papillary thyroid cancer may not be necessary.

Sentinel Lymph Node Biopsy for Papillary Thyroid Cancer: Commentary on the efficacy of Lateral Neck Sentinel Lymph Node Biopsy in Papillary Thyroid Carcinoma by Se Kyung Lee et al.

In their article on the efficacy of lateral neck sentinel lymph node (SLN) biopsy in papillary thyroid carcinoma, Dr. Kim’s group has detailed an impressive series of lateral neck SLN assessments for papillary thyroid cancer [1]. In their 94 patients, they were able to identify sentinel nodes in 60 (64%). In 19 of these patients, the sentinel node contained papillary thyroid cancer, leading the surgeons to perform a compartment-oriented neck dissection. They did not perform lateral neck dissection on the patients with negative sentinel node biopsies, and so sensitivity estimates are not available. Sentinel node biopsy has been a marked advance in the management of patients with breast cancer and melanoma, because it allows accurate staging of patients with minimal morbidity. This technique has resolved the morbidity of routine axillary dissection for breast cancer, and the controversy of whether or not to perform prophylactic dissections for melanoma. However, this has not yet found a place in the therapy for thyroid cancer. In my opinion, there are several reasons for this: (1) sentinel node biopsy in the confined area of the neck is technically challenging; (2) the most common node basin for papillary thyroid cancer metastasis is the level 6 nodes, an area that has already been exposed during thyroidectomy and can be dissected with limited additional morbidity; (3) ultrasound evaluation of the lateral neck is sensitive for identification of nonpalpable node metastases; and (4) lateral neck recurrence is uncommon after effective adjuvant treatment with radioiodine. The contribution by this group has effectively answered some of these issues. Using the sentinel node biopsy after thyroidectomy to assess the lateral neck, rather than just the first sentinel node that is usually in the central neck, they have resolved some of the technical issues caused by the proximity of the radiotracer injection to the nodes in question. In addition, assessing only the lateral neck nodes focused the procedure on the nodes that would not otherwise be directly accessible during the thyroidectomy. A remaining question in this area is the comparison of preoperative ultrasound evaluation of the lateral neck to the intraoperative sentinel node biopsy assessment. Unfortunately, it does not appear that this series of patients had preoperative ultrasound node mapping in order to delineate this. However, this should be a part of any further reports on this subject. Finally, the issue of whether it is important to remove these small amounts of disease, or whether they can be effectively managed by radioiodine therapy, will require careful clinical study.

Distant, Solitary Skeletal Muscle Metastasis in Recurrent Papillary Thyroid Carcinoma

Papillary thyroid cancer (PTC) is the most common differentiated thyroid carcinoma. Metastases usually occur in regional lymph nodes or to lungs. Distant metastases to skeletal muscle are rare. Here, we report a patient with a solitary metastasis to skeletal muscle. A 31-year-old woman was found on routine physical examination to have a 1-cm nodule in the right thyroid lobe. The patient underwent endoscopic total thyroidectomy with central cervical lymph node dissection in April 2008. Pathological analysis showed a 1.5 × 0.9 cm PTC in the right thyroid lobe with extension into perithyroidal soft tissue and lymph node involvement (all six central lymph nodes examined were positive). After surgery, she received 100 mCi of radioactive iodine. Subsequently, the patient was found to have a lateral neck recurrence and, therefore, underwent right unilateral modified radical neck dissection followed by additional radioactive iodine ablation. In February 2010, her serum thyroglobulin was 19.4 ng/mL, but the neck ultrasound was negative. However, a fluorodeoxyglucose (FDG) positron emission tomography scan showed focal FDG uptake in the vastus medialis muscle of the right distal femur. A 0.9 × 0.5 cm, well-defined, whitish mass in the vastus medialis muscle was confirmed on histopathology to be metastatic PTC. Here, we report an adult woman who presented with a thyroid nodule that was noted to be PTC on histopathology after total thyroidectomy. Almost 2 years later, she was noted to have had focal FDG uptake consistent in the region of the right femur. A solitary metastasis of PTC in the right vastus medialis muscle was resected. A MEDLINE (Medical Literature Analysis and Retrieval System Online) search showed that this is only the third report of PTC with a distant, solitary skeletal muscle metastasis. Distant skeletal metastasis in PTC is very rare. Until the availability of FDG to detect skeletal metastasis of PTC, they may have been more difficult to discern.

Video-Assisted Thyroidectomy for Papillary Thyroid Carcinoma

Background. The results of video-assisted thyroidectomy (VAT) were evaluated in a large series of patients with papillary thyroid carcinoma (PTC), especially in terms of completeness of the surgical resection and short-to-medium term recurrence. Methods. The medical records of all patients who underwent video-assisted thyroidectomy for PTC between June 1998 and May 2009 were reviewed. Results. Three hundred fifty-nine patients were included. One hundred twenty-six patients underwent concomitant central neck node removal. Final histology showed 285 pT1, 26 pT2, and 48 pT3 PTC. Lymph node metastases were found in 27 cases. Follow-up was completed in 315 patients. Mean postoperative serum thyroglobulin level off levothyroxine was 5.4 ng/mL. Post operative ultrasonography showed no residual thyroid tissue in all the patients. Mean post-operative 131I uptake was 1.7%. One patient developed lateral neck recurrence. No other recurrence was observed.

Is central neck dissection necessary for the treatment of lateral cervical nodal recurrence of papillary thyroid carcinoma?

Although the pattern of cervical lymph node metastases from papillary thyroid carcinoma (PTC) has been described, little is known about the pattern of lateral cervical nodal recurrence. The aim of this study was to establish the optimal strategy for neck dissection in patients who underwent reoperation for lateral cervical recurrence of PTC. We reviewed the records of 22 patients who underwent neck dissection for lateral nodal recurrence of thyroid cancer between 2002 and 2004. Eight patients had thyroid remnants or recurrent tumors in the bed and 6 had undergone lateral neck dissection prior to referral. Patients underwent comprehensive dissection of the posterolateral and ipsilateral (n = 10) or bilateral (n = 12) central neck. The pattern of nodal recurrence and postoperative morbidity were analyzed. All patients had lateral compartment involvement, 91% at mid-lower, 45% at upper, and 18% at posterior sites. Central nodes were involved in 86% of patients: 82% at ipsilateral paratracheal, 32% at pretracheal, 27% at superior mediastinal, and 2 patients at contralateral sites. Skip lateral recurrence with no positive central nodes was rarely observed (14%). Postoperative vocal cord palsy (n = 1) and hypoparathyroidism (n = 5) developed only in patients undergoing bilateral central compartment dissection. The inclusion of comprehensive ipsilateral central and lateral neck dissection in the reoperation for patients with lateral neck recurrence of PTC is an optimal surgical strategy.