Surgery For Papillary Thyroid Carcinoma Research Articles

Correlation of minimal extrathyroidal extension with pathologic features of lymph node metastasis in patients with papillary thyroid carcinoma.

The impact of minimal extrathyroidal extension (mETE) to the prognosis of patients with papillary thyroid carcinoma (PTC) is controversial. In this study, we investigated whether mETE is related to the aggressive biology of metastatic lymph node (LN) in patients with PTC. A retrospective review of 369 patients who had biopsy-confirmed cervical LN metastasis after initial surgery for PTC was conducted. The correlations of mETE with the specific features of metastatic LNs such as the LN size, number, LN ratio, and presence of extranodal extension (ENE) were statistically analyzed. Size of the primary tumor (≥1 cm) had independent correlations to mETE (HR = 5.750). While mETE was related to number of metastatic LNs (≥5), LN ratio (≥0.31) and ENE in univariate analysis, only ENE (HR = 2.322) was independently correlated to mETE in our series. Along with mETE, size of primary tumor (≥1 cm) had significant impact on ENE (HR = 2.107). Minimal ETE particularly those with larger primary tumor (≥1 cm) may be still considered as a significant factor regarding the management of cervical LNs in patients with PTC.

Role of BRAF V600E mutation as an indicator of the extent of thyroidectomy and lymph node dissection in conventional papillary thyroid carcinoma

The extent of surgery for papillary thyroid carcinoma (PTC) is associated strongly with disease persistence, recurrence, and mortality. It is difficult, however, to determine the optimal extent for surgery. The BRAF mutation is well known for its diagnostic and prognostic value in PTC. Among the variants of PTC, the clinical importance of the BRAF mutation has been associated particularly with conventional PTC. The goal of this study was to clarify the role of the BRAF mutation as a determinant for the operative extent in conventional PTC. Histopathology and BRAF mutation status of 3,019 patients with conventional PTC were analyzed. With regard to the extent of surgery in PTC, focus was given to the factors of tumor bilaterality, central lymph node metastasis (CLNM), and lateral lymph node metastasis. In addition, the prognostic impact of BRAF mutation on loco-regional recurrence was investigated. The BRAF mutation was found to be an independent indicator of tumor bilaterality (odds ratio [OR] 1.484, P = .010); however, it was not an independent indicator of CLNM (OR 1.167, P = .254) or lateral lymph node metastasis (OR 0.647, P = .384). Moreover, it was not an independent indicator of CLNM in either the therapeutic or prophylactic central neck dissection. Finally, BRAF mutation positivity did not increase the risk of loco-regional recurrence (adjusted hazard ratio = 0.829, P = .523). The BRAF mutation is a possible indicator for determining the extent of thyroidectomy required but not for the extent of lymph node dissection and prognosis in patients with conventional PTC.

THERAPY OF ENDOCRINE DISEASE: Central neck dissection: a step forward in the treatment of papillary thyroid cancer

Since its introduction in the '70s and '80s, CND for papillary cancer is here to stay. Compartment VI should always be explored during surgery for papillary thyroid carcinoma (PTC) for obvious lymph node metastases. These can be easily spotted by an experienced surgeon or, eventually, by frozen section. No doubt, obvious nodal disease in the Delphian, paratracheal and subithsmic areas should be dissected in a comprehensive manner (therapeutic central neck dissection), avoiding the selective removal of suspicious nodes. Available evidence for routine prophylactic CND is not completely satisfactory. Our group's opinion, however, is that it reduces or even eliminates the need for repeat surgery in the central neck, better defines the extent (and stage) of the disease and provides a further argument against routine radioiodine ablation. Thus, PTC is becoming more and more a surgical disease that can be cured by optimized surgery alone in the majority of cases. Prophylactic CND, however, involves a higher risk for the parathyroid function and should be skilfully performed, preferably only on the same side as the primary tumour and preserving the cervical portion of the thymus.

Review of survival rates 20-years after conservative surgery for papillary thyroid carcinoma

IntroductionA less extensive thyroidectomy could be used for patients in the low risk group. ObjectiveTo perform a critical follow-up after lobectomy with isthmusectomy for the treatment of papillary thyroid carcinoma in patients with a single nodule limited to the periphery of the lobe. MethodsThirty-one patients with thyroid papillary carcinoma operated on till 1993 were selected. They had undergone lobectomy with isthmusectomy. This is a retrospective cohort study in which the oncological outcome (contralateral and regional recurrence) and the reoperation complications (recurrent nerve paralysis/paresis and hypoparathyroidism) were evaluated. Descriptive analysis was employed. ResultsIn the last decade (2003–2013), 6 (20%) contralateral recurrences were observed in the remaining lobe and in 1 of these cases (3%), contralateral lymph node metastases were noted. A completion thyroidectomy plus lymphadenectomy was performed, without modification of global survival. ConclusionBecause of the rate of 20% of contralateral recurrence after a 20-year follow-up, we suggest modification of the surgical paradigm for total thyroidectomy as an initial therapy.

Surgical Management of Familial Papillary Thyroid Microcarcinoma: A Single Institution Study of 94 Cases.

Familial papillary thyroid carcinoma (familial PTC) is well known to present with aggressiveness; however, the characteristics and the prognostic outcomes of familial papillary thyroid microcarcinoma (familial micro-PTC) are not well established. The overall aim of this study was to analyze the clinicopathological outcomes of familial micro-PTC. Between 1996 and 2006, 2071 patients underwent thyroid surgery for papillary thyroid carcinoma. The clinicopathological outcomes for familial PTC and sporadic PTC were compared, and familial micro-PTC data were sub-analyzed. There were significant differences in multifocality, bilaterality, extent of surgery, and recurrence between familial PTC and sporadic PTC (p<0.05). There was no significant difference in the number of affected family members in the familial PTC group. In patients with familial micro-PTC, less aggressiveness was noted in multifocality, extrathyroidal invasion, tumor stage at time of initial surgery, central lymph node metastasis, and recurrence than in those with familial PTC tumors>1 cm in diameter (p<0.05). The multivariate analysis including recurrence showed no significant difference between familial micro-PTC patients and sporadic micro-PTC patients. When familial PTC was compared with sporadic PTC, our results support the recommendation for more invasive familial PTC surgery. However, familial micro-PTC outcomes differed from familial PTC tumors>1.0 cm in diameter. It was similar to sporadic micro-PTC, illustrating that familial micro-PTC is less aggressive and that a less invasive surgical treatment could be considered.

Effects of endocrine therapy on the prognosis of elderly patients after surgery for papillary thyroid carcinoma.

Papillary thyroid carcinoma (PTC) is a common thyroid malignancy. Elderly patients have more severe disease and more complications following postoperative endocrine therapy to control thyroid-stimulating hormone (TSH) levels. We aimed to identify optimal postoperative serum TSH levels in elderly patients to prevent recurrence and metastasis and minimize complications. This retrospective cohort study collected data of 87 consecutive elderly patients (age >75) who underwent surgery for PTC with postoperative levothyroxine therapy (50-150 μg/d) between January 2006 and June 2008 and were followed until 2013. After 24 patients with TSH fluctuations and incomplete data were excluded, 73 patients were grouped based on postoperative TSH levels: Group A, 0.3-0.5 mIU/mL; Group B, 0.1-0.3 mIU/mL; and Group C <0.1 mIU/mL (n = 24, 25, 24, respectively). Subjects' baseline, preoperative data, postoperative complications and 1-, 3- and 5-year follow-up data were compared between groups. No significant differences in gender, age (median age of 80 years old), surgery type or clinical characteristics were found between groups (all p value >0.05). Postoperatively, all subjects had normal ECG and neck ultrasound, no osteoporosis, and no differences in survival rate or metastasis. Five-year follow-up revealed significant differences in development of arrhythmias, osteoporosis, insomnia and anxiety between Groups B (0.1-0.3 mIU/mL) and C (<0.1 mIU/mL) compared to Group A (0.3-0.5 mIU/mL). Postoperative incidence of PTC recurrence and metastasis remained stable in elderly patients undergoing thyroid surgery and endocrine therapy but complications increased significantly with increasing TSH levels. Controlling TSH to lower limits of normal may help prevent PTC recurrence and metastasis and reduce complications in this high-risk population.

A prospective randomized study of FOCUS harmonic scalpel in the opening papillary thyroid carcinoma surgery

Objective To evaluate effectiveness of application with FOCUS harmonic scalpel in papillary thyroid carcinoma (PTC) surgery. Methods 110 patients with PTC between June 2013 and December 2013 were divided into two groups randomly as harmonic scalpel group (group H) and conventional group (group C). Incision length, operative time, estimated blood loss, drainage volume within 24 h, in the second 24 h and in total after operation, the number of lymph node retrieval, post-operative complication and hospital stay were compared between two groups. Results There is significant different in factors of incision length [(5.5±0.4) cm in group H and (6.6±0.5) cm in group C (P 0.05). Conclusion FOCUS harmonic scalpel could reduce incision length, operative time, estimated blood loss in PTC surgery. Key words: Harmonic scalpel; Papillary thyroid carcinoma; Surgery

Robotic thyroid surgery for papillary thyroid carcinoma: lessons learned from 100 consecutive surgeries.

To evaluate the feasibility and safety of robotic thyroidectomy using the da Vinci surgical system. Between July 2008 and April 2011, the data revealed an initial series of 100 consecutive patients who underwent robotic thyroidectomy with the da Vinci-S surgical system using the bilateral axillo-breast approach for thyroid cancer. Prospectively collected data were analyzed retrospectively. There were 88 cases of total thyroidectomy, 11 cases of lobectomy, and 1 case of total thyroidectomy with modified radical neck dissection. There was no conversion. The mean total operation time was 287.15±45.19 minutes for total thyroidectomy and 236.27±48.98 minutes for lobectomy. Nineteen patients experienced transient hypocalcemia and 3 patients experienced transient vocal fold palsy. All of the patients recovered within 3 months. Robotic thyroid surgery for patients with thyroid malignancy is safe and results in fewer postoperative complications than open thyroid surgery.

Correlation between the BRAF V600E mutation status and the clinicopathologic features of papillary thyroid carcinoma.

This study sought to investigate the correlations of V-raf murine sarcoma viral oncogene homolog B1 (BRAF) gene mutations with the clinicopathologic features of papillary thyroid carcinoma and central lymph node metastasis. We retrospectively analyzed the 2-year medical records of patients who underwent surgery for papillary thyroid carcinoma. After screening, the records of 126 patients who met the study requirements were used to assess the characteristics associated with the BRAF V600E gene mutation. The BRAF mutation incidence rate among patients with papillary thyroid carcinoma was 69.0% (87/126). Univariate analysis revealed that the BRAF mutation status was correlated significantly with both tumor size and lymph node metastasis (P < 0.05). Multivariate analysis revealed a significant correlation between lymph node metastasis and BRAF mutation status (P < 0.05). When the tumor diameter was ≤10 mm, the BRAF mutation status had no effect on lymph node metastasis (P > 0.05). When the tumor diameter was >10 mm, the incidence of lymph node metastasis was significantly higher among BRAF mutation-positive patients than among BRAF mutation-negative patients (P < 0.05). BRAF gene mutations independently predicted central lymph node metastasis in patients with papillary thyroid carcinoma. For patients preoperatively diagnosed to be BRAF mutation-positive, the importance of central lymph node dissection should be emphasized because the tumor diameter increases; regional lymphatic and adipose tissue dissection should be routinely conducted. However, in mutation-negative patients with tumor diameters of ≤5 mm, the need for central lymph node dissection should be re-examined.

Comparison of T stage, N stage, multifocality, and bilaterality in papillary thyroid carcinoma patients according to the presence of coexisting lymphocytic thyroiditis

Purpose: This study aimed to assess the relationship between coexisting lymphocytic thyroiditis and T-N stages of papillary thyroid carcinoma (PTC) by histopathological analysis. Materials and methods: The study included 653 patients who underwent thyroid surgery for PTC at our hospital. Each case was classified as either Hashimoto’s thyroiditis (HT), non-Hashimoto type of lymphocytic thyroiditis (NHLT), or normal according to the histopathology of thyroid parenchyma. Patient age, gender, surgical modality, location, T stage, N stage, multifocality and bilaterality were compared according to the histopathology. Results: The prevalence of coexisting lymphocytic thyroiditis was 25.8% (169/653); HT (7.5%, 49/653) and NHLT (18.3%, 120/653). There were no significant differences in T stage, N stage, multifocality and bilaterality with regard to coexisting lymphocytic thyroiditis, regardless of whether HT and NHLT were considered collectively or discretely. Primary tumor size (p < 0.0001), location (p = 0.0011), N stage (p < 0.0001), multifocality (p < 0.0001) and bilaterality (p < 0.0001) differed significantly according to T stage, and gender (p = 0.0193), primary tumor size (p < 0.0001), T stage (p < 0.0001), multifocality (p < 0.0001) and bilaterality (p < 0.0001) differed significantly according to N stage. Conclusions: PTC patients with coexisting lymphocytic thyroiditis did not differ from those with normal parenchyma in terms of T stage, N stage, multifocality and bilaterality.

Clinical application of carbon nanoparticles in surgery for papillary thyroid carcinoma in young patients

To investigate the number of dissected lymph nodes and the incidence of injury to parathyroid glands during surgery for papillary thyroid carcinoma (DTC) in young patients. This study collected clinicopathological data of 51 young patients with PTC. Of the 51 patients, 18 patients were classified into carbon nanoparticles group (CNP group) and 33 patients into traditional surgical group (TS group). The number of dissected lymph nodes and the incidence of injury to parathyroid glands were analyzed using Wilcoxon rank sum test and chi-square test. There were 16 males and 35 females, with a male/female ratio of 1: 2.19. The age ranged from 14 to 29 (25 ± 3.9) years. There was no statistically significant difference in age, gender, T-classification, TNM stage and surgical procedures between two groups (P > 0.05). The total number of dissected lymph nodes in CNP group was higher than that in TS group (Z = -2.258, P < 0.05) . However, significant difference in the total number of metastatic lymph nodes between the two groups was not found (Z = -0.396, P > 0.05). In level VI, the detected lymph node number of group CNP was higher than that of TS group (Z = -2.461, P < 0.05) but there was no significant difference in the detected number of metastatic lymph nodes (Z = -1.396, P > 0.05) . The rates of injury to parathyroid gland were 5.5% in CNP group and 18.2% in TS group, respectively (χ(2) = 1.568, P > 0.05). Carbon nanoparticles could be an effective lymph nodes tracer applying to PTC operation in young patients.

Surgical management of retropharyngeal nodes metastases from papillary thyroid carcinoma.

Papillary thyroid carcinoma (PTC) often metastasizes to the central and lateral neck lymph nodes, but rarely affects retropharyngeal nodes (RPN). We retrospectively reviewed 12 patients (three men, nine women) with PTC who underwent dissection of RPN metastases between 1994 and 2012. Mean age at dissection was 65 years (range 23-77). Dissection was performed with the initial surgery for PTC in eight patients, while the remaining four patients underwent dissection as secondary surgery. RPN metastases arose from an ipsilateral primary in nine patients, bilateral in two, and contralateral in one, with primaries located at the superior pole of the thyroid lobe in nine patients. All patients showed simultaneous or previous lymph node metastases in the upper jugular chain. A transcervical approach was applied for RPN dissection in 11 patients, while a transcervical-transparotid approach was applied in the remaining patient. No patients needed mandibulotomy or showed severe complications. Median duration of follow-up after RPN dissection was 48 months (range 3-206). No recurrences in the retropharyngeal space were identified. Two patients died of the disease, one died from other carcinoma, and five survived with distant metastases from PTC. The remaining four patients remain free of the disease as at the time of writing. If lymph node metastases are identified in the upper jugular chain, the possibility of RPN metastases should be checked. Most RPN metastases from PTC can be dissected safely without mandibulotomy. In particular, low-risk patients can expect favorable outcomes.

Association between TNM staging system and histopathological features in patients with papillary thyroid carcinoma.

We aimed to assess the validity of the American Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) staging system in patients with papillary thyroid carcinoma (PTC) by evaluating the relationships between clinicopathologic factors and TNM stage using histopathological specimens and electronic medical records. We enrolled 733 consecutive patients who had undergone thyroid surgery for PTC between 2010 and 2013. Clinical data were obtained from electronic medical records. TNM stages, multifocality, and bilaterality were analyzed after review of histopathological specimens by applying the AJCC TNM staging system. Multiple statistical analyses were performed to evaluate the correlation between the AJCC TNM staging system and the clinicopathologic factors. Of the 733 patients, there were T stage including T1a (46.9 %, 344/733), T1b (12.6 %, 92/733), T2 (2.0 %, 15/733), T3 (38.1 %, 279/733), T4a (0.4 %, 3/733), and T4b (0 %, 0/733), N stage including N0 (58.9 %, 432/733), N1a (24.3 %, 178/733), and N1b (16.8 %, 123/733), and multiplicity including multifocality (31.1 %, 228/733) and bilaterality (23.7 %, 174/733). There was a significant association between the PTC primary tumor size and T stage, N stage, multifocality, and bilaterality (p < 0.0001). Multifocality, bilaterality, and the presence of nodal metastasis were most frequently seen in patients with T3 stage (p < 0.0001). In multivariate logistic regression analyses, T and N stages were independent predictors of multiple PTCs. The PTC primary tumor size had a significant association with the T and N stages of the AJCC TNM staging system, and these factors were independent predictors of multifocality and bilaterality.

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.

Shorter Distance Between the Nodule and Capsule has Greater Risk of Cervical Lymph Node Metastasis in Papillary Thyroid Carcinoma

The purpose of this study was to assess the relationship between different sonographic features of papillary thyroid carcinoma (PTC) on high-frequency ultrasound and cervical lymph node metastasis (CLNM). We enrolled 548 patients who underwent initial surgery for PTC between May 2011 and December 2012 in our hospital at diagnosis. The sonographic features of 513 PTC nodules in 513 eligible patients, who had single PTC nodules in their thyroid glands, were retrospectively investigated. All patients with a suspect malignant nodule (d<0.5cm) among multiple nodules were initially diagnosed by fine-needle aspiration biopsy (FNAB) to ascertain if the suspect nodule was PTC. The final diagnosis of all the thyroid nodules and existence of CLNM were based on postoperative pathology. Patients were divided into two groups: a positive group with CLNM (224 nodules) and a negative group without CLNM (289 nodules). The following factors were investigated: gender, age, echogenicity, echotexture, size, shape, location, margin, contour, calcification morphology, distance between the nodule and pre- or post-border of the thyroid capsule, vascularity and the differences between the two groups. Correlation analysis showed that shorter distances between the nodule and pre- or post- border of thyroid capsule resulted in greater risk of CLNM (Spearman correlation coefficient=-0.22, p<0.0001). The significant factors in multivariate analysis were age<45yrs, larger size (d>1cm), "wider than tall" shape, extrathyroid extension and mixed flow (internal and peripheral) (p<0.05, OR=0.406, 2.093, 0.461, 1.610, 1.322). Significant sonographic features of PTC nodules in preoperative high-frequency ultrasound are crucial for predicting CLNM.

CA19-9-producing lung metastasis after surgery for papillary thyroid carcinoma: report of a case

Measuring tumor marker levels following cancer treatment can be useful. Although serum thyroglobulin is a useful marker after total thyroidectomy for papillary thyroid carcinoma (PTC), it is not a reliable marker for patients with a high titer of anti-thyroglobulin antibodies or when transformation to undifferentiated carcinoma has occurred. The female patient in this case report underwent total thyroidectomy and oral I-131 therapy for PTC at the age of 47 years, followed by cervical lymph node and lung resections for metastases, 3 and 11 years later, respectively. She also received oral I-131 therapy and external beam radiotherapy for mediastinal lymph node metastases. The lymphadenopathy lesions progressed and multiple lung metastases were detected when she was 61 years of age. She died at the age of 62 years. The serum CA19-9 level had gradually increased in association with enlargement of the recurrent lesions and immunostaining of CA19-9 in the pulmonary metastasis was intense. Thus, we consider that measuring the level of serum CA19-9 is an effective tool for evaluating disease status after surgery for PTC.

Does Extracapsular Extension Impact the Prognosis of Papillary Thyroid Microcarcinoma?

Extracapsular (EC) extension is a pejorative factor in papillary thyroid carcinoma (PTC). However, the impact of EC extension in microcarcinoma (micro-pT3) remains controversial, and all pT3 patients are currently considered to be at high risk of recurrence. This study sought to determine the risk of recurrence in patients with micro-pT3 and to compare their outcomes with other pT3 (macro-pT3) and low-risk patients. All consecutive patients who received surgery for PTC in our department from January 1978 to December 2011 were included in this study. We compared three patient groups: micro-pT3 (≤10 mm with EC extension), macro-pT3, and low risk, including pT1a-b s N0-x, pT1a-b m N0-x, and pT2 N0-x. Total thyroidectomy was performed with lymph node (LN) dissection in most cases, and radioiodine therapy was administered as needed. The median follow-up period was 6.7 years. A total of 2,482 patients were included in this study, including 178 micro-pT3 patients, 533 macro-pT3 patients, and 1,771 low-risk PTC patients. Recurrence was documented in 14 (7.9 %) micro-pT3 patients, 124 (23.3 %) macro-pT3 patients, and 36 (2 %) low-risk PTC patients. The micro-pT3 patients with LN metastases (N1) demonstrated a higher recurrence rate than the N0-x patients (14.8 vs. 4.8 %; p < 0.01), whereas the risk of recurrence among the T2 N0-x (5 %) and micro-pT3 N0-x (4.8 %) patients was similar (p = 0.95). Micro-pT3 N1 patients are at high risk of recurrence and should be treated aggressively. Because the outcomes of the micro-pT3 N0-x patients were similar to those of the low-risk PTC patients (pT2 N0-x), we suggest that micro-pT3 N0-x should be treated in a similar manner, with low-dose iodine-131 and recombinant human thyrotropin.

BRAFV600E Mutation Analysis in Papillary Thyroid Carcinoma: Is it Useful for all Patients?

The BRAF(V600E) mutation has been adopted as a prognostic factor in papillary thyroid carcinoma (PTC). However, it remains unclear whether routine BRAF mutation analysis is useful in establishing a prognosis for PTC patients. In the present study we investigated BRAF mutation analysis in a large number of PTC patients with long-term follow-up. We enrolled 766 patients from our hospital who underwent initial surgery for PTC without distant metastasis at diagnosis between 1996 and 2001, and whose BRAF mutation of primary lesions could be analyzed. The average age and follow-up period were 51years and 130months, respectively. To date, 77 (10%) and 37 (5%) patients have developed lymph node and distant recurrence, respectively, and 10 (1%) have died of PTC. The BRAF mutation was positive in 281 patients (37%), and it had no prognostic impact on lymph node recurrence-free (LNRFS) (p=0.700), distant recurrence-free (DRFS) (p=0.696), and cause-specific (CSS) (p=0.125) survival in our entire series. However, CSS of BRAF mutation-positive high-risk patients based on AMES (p=0.030), MACIS (score >6) (p=0.017), the UICC stage (IVa) (p=0.021), CIH classification (Sugitani et al. Surgery 135:139-148, 2004) (p=0.015), and our own classification system (Ito et al. World J Surg 34:2570-2580, 2010) (p=0.010) were significantly poorer than CSS of mutation-negative high-risk patients. The BFAF mutation did not affect CSS of non-high-risk patients, although the incidence of the BRAF mutation did not significantly differ between high-risk and non-high-risk groups based on these classification systems. The BRAF mutation was not related to LNRFS and DRFS in the subsets of high-risk and non-high-risk patients. BRAF mutation analysis is useful in estimating the CSS of high-risk PTC patients based on the representative classification systems. It was not related to the prognosis in non-high-risk patients, at least those living in Japan.

Airtight Tracheocutaneostomy After Window Resection of the Trachea for Invasive Papillary Thyroid Carcinoma: Experience of 109 Cases

There are some tracheal surgeries for invasive papillary thyroid carcinoma (PTC) requiring tracheal resection. We create an airtight tracheocutaneostomy (TCS) by suturing the tracheal hole to the skin when window resection of the trachea is required. Here, we present the outcomes of PTC patients who underwent surgery with airtight TCS. We enrolled 109 patients (18 males and 91 females) who underwent initial surgery for PTC and TCS after partial window resection of the trachea between 1987 and 2010. The average patient age was 61 and the average follow-up was 99months. The TCS was closed using a local skin flap 3-6months after surgery in 78 patients, and it closed spontaneously in 13 patients. The TCS of the remaining 18 patients was not closed for various reasons, such as a poor general condition, permanent bilateral vocal cord paralysis, and loss to follow-up. None of the 109 patients showed any serious complications of TCS. Minor wound infection, partial skin necrosis, granulation, and air leakage were observed in 12 (11%), 2 (2%), 7 (6%), and 4 (4%) patients, respectively. Infection was more likely to occur in patients whose cricoid cartilage was resected (p=0.0456). Although macroscopically curative surgery was performed for all patients, 38 patients (35%) had a suspiciously positive margin in the resected tracheal mucosa. Five margin-positive (13%) and five margin-negative (7%) patients showed excision site recurrence, but the margin status did not directly affect the prognosis. External beam radiation therapy (EBRT) (50-60Gy) was administered to nine patients, none of whom showed excision site recurrence, although eight were microscopically margin-positive. Among various clinicopathological features, tumor size >4cm and age ≥60years were significant (p=0.0281) and marginal (p=0.0771) predictors of excision site recurrence on univariate analysis. On multivariate analysis, age ≥60years (p=0.0484) and tumor size >4cm (p=0.0763) were independent and marginal predictors of excision site recurrence, respectively. To date, 14 and 17 patients have shown lymph node and distant recurrence, respectively, and nine have died of PTC. Tracheocutaneostomy is a safe surgical technique after partial window resection of the trachea, although we have to be careful of infection when resecting the cricoid cartilage. Large tumor size and old age are risk factors for excision site recurrence. EBRT may be useful to prevent excision site recurrence, especially in patients with a suspected positive margin.

Clinical characteristics of papillary thyroid microcarcinoma less than or equal to 5 mm on ultrasonography

Management of papillary thyroid microcarcinoma sized ≤5mm identified on ultrasonography is controversial. In this study, we evaluated the clinical characteristics of papillary thyroid microcarcinoma sized ≤5mm on ultrasonography in comparison to those >5mm and sought to present rationales for optimal management in papillary thyroid microcarcinoma ≤5mm. The medical records of 396 patients who underwent surgery for papillary thyroid carcinoma between 2009 and 2011 were retrospectively analyzed. The patients were grouped into A (≤5mm, n=132) or B (>5mm, n=264) and the clinicopathologic characteristics of the patients were reviewed and compared between the two groups. Tumor capsular invasion (45.5 vs. 59.8%, p=0.007) and cervical lymph node metastasis (18.2 vs. 29.2%, p=0.018) were more frequent in group B. Nonetheless, group A presented lymph node metastasis in 42.3% of multifocal cases showing no difference to that of group B (41.5%, p=0.946) and also included five cases (3.8%) of lateral neck metastasis. Multifocality was the only predictive factor for lymph node metastasis in group A (p<0.001). Over half (55.3%) of the patients of group A were diagnosed with papillary carcinoma in private clinics; however, only 5.5% of these patients underwent assessment of lateral neck lymph nodes initially. In conclusion, higher risk of cervical lymph node metastasis should be considered in evaluation and surgical decision of papillary thyroid microcarcinoma ≤5mm identified on ultrasonography with multifocality. Evaluation of the cervical lymph nodes including the lateral neck should not be overlooked when suspicious thyroid nodule suggesting malignancy sized ≤5mm shows multifocal lesions.