VI Lymph Node Research Articles

8788 Implications of NTRK gene fusion in Papillary thyroid cancer

Abstract Disclosure: W. Medina-Torres: None. L. El Musa Penna: None. J. Segarra-Villafane: None. L.R. Sepulveda-Garcia: None. Z. Maisonet -Feliciano: None. I.C. Arroyo: None. M. Ramirez: None. M. Alvarado: None. L.A. Gonzalez-Rodriguez: None. V.J. Carlo: None. Thyroid cancer (TC) is the most common endocrine cancer. Papillary thyroid carcinoma (PTC) is the predominant contributor of this occurrence, comprising approximately 80% of all thyroid carcinomas. PTC has a good prognosis with a 5-year survival rate of more than 90% after resection. Nonetheless, factors such as tumor size, multifocality, nodal and distant metastases, characterize more aggressive cases including tall cell variant, columnar cell variant, and hobnail variant Aside from staging parameters, PTC behavior is mostly determined by morphologic variant. This is the case of 31 y/o female without known past medical history who was evaluated at endocrinology clinic due to a fine needle thyroid aspiration (FNA) positive for PTC, tall cell variant. Total thyroidectomy with central compartment dissection was performed. Pathology report presented a main tumoral mass of 3 cm but permeating multinodular pattern involving the entire gland with focal extrathyroidal extension, positive margins and six level VI positive lymph nodes. As per report, the tumor presented both papillary and follicular patterns of growth and other findings including oncocytic change, foci of clear cell change, low mitotic rate, and most notably "reverse polarization”. This pattern has the pathological features suggestive of the novel NTRK gene fusion mutation. The patient was treated with radioactive iodine (RAI) and one year post treatment there was evidence of elevated Thyroglobulin level at 904 ng/mLand thyroglobulin Ab at 2.48 IU/mL. A WBS +SPECT was done resulting in small uptake at left posterior thyroid bed and pulmonary intake. A chest CT revealed multiple bilateral sub centimeter nodules. Based on this result, a second course of RAI was given. Follow up neck ultrasound and chest CT presented persistent left level VI lymph nodes, increased amount of bilateral sub-centimeter pulmonary nodules and new thoracic(T11) lesion. FNA of left neck lymph nodes were positive for metastatic PTC for which left neck dissection was performed. Evaluation for actionable somatic mutations was requested based on resistance behavior, remarkable for TRIM33-NTRK1 chromosomal rearrangement. Patient was evaluated by Oncology service who started Larotrectinib treatment since it was approved for NTRK driven malignancies. Six-month post therapy patient achieved clinical and biochemical improvement. In the thyroid, NTRK-driven malignancies are rare and aggressive but treatable, in the evolving genomic era. As reviewed in the literature, NTRK fusion-positive TC exhibits distinctive clinicopathological features that could aid in identifying potential patients. Thus, in such patients who have PTC with non-classic pathologic patterns, specific molecular profile of the main tumor may have significant prognostic value that must be integrated into stratification system in order to provide target therapy on time. Presentation: 6/3/2024

8390 It's not Cancer: Establishing the Diagnosis of Hyaline Trabecular Tumor

Abstract Disclosure: R.A. Zielinski: None. M. Khalifa: None. M. Dillon: None. M. Kaur: None. Background: Hyaline trabecular tumor (HTT) is a rare benign follicular thyroid neoplasm characterized by extensive intra-trabecular hyaline stromal material. Resemblances to other follicular neoplasms create difficulty in distinguishing HTT from its more nefarious counterparts such as medullary thyroid cancer (MTC) and papillary thyroid cancer (PTC).Clinical Case:Our patient is a 56-year-old female with Hashimoto’s thyroiditis diagnosed in her twenties who has been on different strengths of levothyroxine based on her fluctuating TSH. A thyroid ultrasound done to evaluate left-sided neck fullness on physical exam showed a solid, hypoechoic 2.3 cm x 1.4 x 0.9 cm left middle thyroid nodule without calcifications (TI-RADS 4) and benign-appearing lymph nodes, the largest of which was 1.5 cm at level 1B. Cytology from a thyroid FNA biopsy was suspicious for PTC, Bethesda category IV. A thyrosure genetic panel was negative for genetic mutations. FNA biopsy of the 1.5 cm lymph node was negative for malignancy. The patient was referred for thyroid lobectomy but instead elected to undergo total thyroidectomy with level VI lymph node dissection. Pathology revealed a 2.2 cm HTT in the left lobe, scattered psammoma bodies in adjacent soft tissue, and a 0.2 cm multifocal papillary microcarcinoma in the right lobe. The microcarcinoma had negative margins, no lymphatic or vascular invasion, and 7/7 benign level VI lymph nodes; staging it as pT1aN0. Immunohistochemistry staining was positive for TTF-1 and thyroglobulin and negative for calcitonin, chromogranin, and synaptophysin. Post-thyroidectomy she was started on Tirosint 175 mcg daily with good response. No I-131 treatment was pursued due to the microcarcinoma being categorized as low risk.Discussion and Conclusion: HTT is a benign neoplasm and management is usually conservative with surgical excision. The diagnosis of HTT by cytology alone is challenging due to the presence of nuclear clearing, grooves and intranuclear pseudo-inclusions that may be mistaken for PTC or MTC. Cell membrane immunoreactivity of MIB1 monoclonal to Ki67 and the molecular identification of the novel PAX8-GLIS1 or PAX8-GLIS3 fusions may aid in making the correct diagnosis.

Elevations of neutrophil-to-lymphocyte ratio and C-reactive protein over time as a precursor to anaplastic transformation of papillary thyroid carcinoma: a case report

BackgroundPapillary thyroid carcinoma rarely undergoes anaplastic transformation. Some risk factors for anaplastic transformation of thyroid cancer are known, but such transformation is difficult to predict in practice. We report a case demonstrating elevations of neutrophil-to-lymphocyte ratio (NLR) and C-reactive protein (CRP) over time as a precursor to anaplastic transformation of thyroid carcinoma.Case presentationThe patient was an 89 year-old woman with a history of chronic aortic dissection. She was referred to our department after her local doctor detected thyroid nodules. She had previously been found to have multinodular goiter and enlarged left cervical lymph nodes on computed tomography. Her chief complaint was cervical discomfort and hoarseness. Blood tests revealed: white blood cells (WBCs), 4900 /µL; CRP, 0.29 mg/dL; neutrophils, 64.4%; and lymphocytes, 25.4%. A 21 mm mass was identified in the upper left lobe. Left III (16 mm) and left VI (16 mm) lymph node were enlarged on ultrasonography. Fine-needle aspiration cytology diagnosed malignant papillary carcinoma. However, due to the advanced age and medical history of the patient, a non-surgical policy was implemented. The primary tumor grew to 4 cm in diameter by 9 months after diagnosis, and blood tests showed: WBC, 7700 /µL; CRP, 0.18 mg/dL; neutrophils, 65.3%; and lymphocytes, 22.3%. By 10 months after diagnosis, the tumor had increased rapidly in diameter to 8 cm, with blood tests showing: WBC, 6500 /µL; CRP, 1.01 mg/dL; neutrophils, 68.2%; and lymphocytes, 19.3%. Anaplastic transformation of papillary thyroid carcinoma was diagnosed, and the patient was placed on treatment under a policy of best supportive care. Multiple lung metastases appeared 11 months after diagnosis, and blood test results showed: WBC, 13,300 /μL; CRP, 11.28 mg/dL; neutrophils, 93.6%; and lymphocytes, 2.3%. Unfortunately, the patient died of disease progression 63 days after identification of undifferentiated metastasis.ConclusionsChances to see the natural history of anaplastic transformation of thyroid cancer are rare. Elevations in NLR and CRP over time may be precursors to anaplastic transformation.

Preventive central neck lymph node dissection as a stage in the treatment of papillary thyroid cancer

Relevance: The need of prophylactic cervical lymph node dissection for the detection of low grade thyroid cancer remains debatable since preoperative examination does not always allow determining the involvement of a group VI regional lymph collector.Objective: to evaluate the frequency of group VI nodes involvement with clinical N0–Nx based on the results of a morphological examination after performing a preventive central neck lymph node dissection.Materials and methods: the study included 295 patients who underwent surgery from 2016 to 2022 for papillary thyroid cancer with cT1–T2, N0–Nx. There were 11.5 % of men included (n = 34) and 88.5 % of women (n = 261). Of these, 40.7 % (n = 120) were less than 55 years old. All patients underwent surgical treatment which included thyroidectomy or hemithyroidectomy with cervical lymph node dissection.Results: The study included 295 patients with cT1 — 247 (83.7 %) and cT2 — 48 (16.3 %). Pathomorphological examination changed the T index in some patients: pT1 was found in 80.3 % of cases (n = 237); рТ2 — in 9.2 % (n = 27); рТ3 — in 10.5 % (n = 31). Central neck lymph nodes involvement was detected in 77 (26.1 %) out of 295 patients. There was a correlation between the frequency of metastases detection and the size of the primary tumor: 22.8 % (n = 54) of metastases with pT1, 33.3 % (n = 9) with pT2, and 45.2 % (n = 14) with pT3. Transient hypocalcemia was found in 32 % of patients with pT1, 69 % with pT2, and 84 % with pT3. Two patients had unilateral transient paresis of the larynx.Conclusions: Our analysis demonstrates that the preventive central neck lymph node dissection in patients with low grade thyroid cancer is an important component of surgical treatment, which allows to improve the treatment results with a possible subsequent reduction in the risk of distant progression. In this study 77 (26.1 %) of 295 patients had metastases in the lymph nodes of the central neck. The number of postoperative complications affecting the quality of life of patients was acceptable with 0.67 % of paresis of the larynx and 39 % of mild hypocalcemia.

A New Transoral Vestibulum Single Incision Endoscopic-Assisted Thyroidectomy with Gasless.

We developed a novel method for thyroidectomy using a single-incision oral vestibular approach. To assess its advantages and disadvantages, we compared the perioperative parameters of this approach with those of transoral three-incision thyroidectomy and trans-areolar thyroidectomy. In a study of 136 papillary thyroid carcinoma patients (2016-2018), precise thyroidectomy and neck dissection were conducted. Among them, 52 chose single-incision oral vestibular approach, 33 chose three-incision variant, and 51 underwent trans-areolar thyroidectomy. Perioperative aspects of the transoral single-incision group were compared with those of transoral three-incision group, and transthoracic group. In the cohort, meticulous tumor level VI lymph node dissection was performed, achieving intended resection extent with one case requiring a switch from transoral to transthoracic approach. No nerve palsy occurred in the transoral group. Thyroidectomy duration varied significantly across groups. Transoral single-incision had a shorter duration than transoral three-incision and longer than transthoracic. Minor differences were observed in blood loss and drainage. Perioperative factors like hematoma, infection, hypocalcemia, et al., remained consistent. Notably, no tumor recurrence was observed in this study. This new transoral video-assisted neck surgery (TOVANS) method for thyroidectomy without gas insufflation approach did not increase the surgical complexity compared with the transoral vestibular three-incision thyroidectomy and the trans-areolar thyroidectomy. 3 Laryngoscope, 134:2976-2984, 2024.

Preliminary analysis of neuroprotective effects of capillary fascia preservation recurrent laryngeal nerve anatomical method in right level Ⅵ dissection

Objective: To investigate the application and effect of capillary fascia preservation between the recurrent laryngeal nerve (RLN) and common carotid artery (fascia preservation method) in nerve protection when dissecting right level Ⅵ lymph nodes for patients with papillary thyroid carcinoma. Methods: A retrospective cohort study enrolling 195 patients with papillary thyroid carcinoma undergoing right level Ⅵ lymph node dissection in Beijing Tongren Hospital from March 2021 to August 2022 was carried out. The RLN was dissected by fascia preservation method in study group and by routine method in control group. The intraoperative electrical signal amplitude of the RLN, the number of dissected lymph nodes, and the postoperative complications were recorded and analyzed. Results: A total of 195 patients (study group: 94 cases, control group: 101 cases) were collected. There were 71 males and 124 females, with the median age of 32 (39, 51) years. In the study group, the total number of right level Ⅵ lymph nodes was significantly larger than the number of right Ⅵa level lymph nodes [8 (6, 11) vs 6 (4, 8), P<0.001]. There were no significant differences between the two groups in the number of level Ⅵa or level Ⅵb lymph nodes [Ⅵa: 6 (4, 8) vs 5 (3, 7), P=0.373; Ⅵb: 3 (1, 4) vs 2 (1, 4), P=0.337] and metastasis rate [Ⅵa: 51.1% (48/94) vs 52.5% (53/101), P=0.844; Ⅵb: 12.8% (12/94) vs 15.8% (16/101), P=0.541]. The ratio of electromyography (EMG) amplitude R2 in lower level Ⅵ and entry into larynx (grouped as>90%, 50%~90%,<50%) in the study group was significantly higher than that in the control group (P<0.001). No significant differences were detected between the two groups in temporary RLN paralysis [1.1% (1/94) vs 2.0% (2/101), P=1.000]. Conclusions: Fascia preservation method can decrease the stimulus and traction to RLN and preserve the capillary network serving RLN. It can thoroughly dissect lymph nodes and decrease the injury of RLN.

Patterns of lymph node metastasis in level IIB and contralateral level VI for papillary thyroid carcinoma with pN1b and safety of low collar extended incision for neck dissection in level II

ObjectiveTo explore relevant clinical factors of level IIB and contralateral level VI lymph node metastasis and evaluate the safety of low-collar extended incision (LCEI) for lymph node dissection in level II for papillary thyroid carcinoma (PTC) with pN1b.MethodA retrospective analysis was performed on 218 patients with PTC with pN1b who were treated surgically in the Head and Neck Surgery Center of Sichuan Cancer Hospital from September 2021 to May 2022. Data on age, sex, body mass index (BMI), tumor location, maximum tumor diameter, multifocality, Braf gene, T staging, surgical incision style, and lymph node metastasis in each cervical subregion were collected. The chi-square test was used for comparative analysis of relevant factors. All statistical analyses were completed by SPSS 24 software.ResultEach subgroup on sex, age, BMI, multifocality, tumor location, extrathyroidal extension, Braf gene, and lymphatic metastasis in level III, level IV, and level V had no significant difference in the positive rate of lymph node metastasis in level IIB (P > 0.05). In contrast, patients with bilateral lateral cervical lymphatic metastasis were more likely to have level IIB lymphatic metastasis than those with unilateral lateral cervical lymphatic metastasis, with a statistically significant difference (P = 0.000). In addition, lymph node metastasis in level IIA was significantly associated with lymph node metastasis in level IIB (P = 0.001). After multivariate analysis, lymph node metastasis in level IIA was independently associated with lymph node metastasis in level IIB (P = 0.010). The LCEI group had a similar lymphatic metastasis number and lymphatic metastasis rate in both level IIA and level IIB as the L-shaped incision group (P > 0.05). There were 86 patients with ipsilateral central lymphatic metastasis (78.2%). Patients with contralateral central lymphatic metastasis accounted for 56.4%. The contralateral central lymphatic metastasis rate was not correlated with age, BMI, multifocality, tumor invasion, or ipsilateral central lymphatic metastasis, and there was no significant difference (P > 0.05). The contralateral central lymphatic metastasis in males was slightly higher than that in females, and the difference was statistically significant (68.2% vs. 48.5%, P = 0.041).ConclusionLymphatic metastasis in level IIA was an independent predictor of lymphatic metastasis in level IIB. When bilateral lateral cervical lymphatic metastasis or lymph node metastasis of level IIA is found, lymph node dissection in level IIB is strongly recommended. When unilateral lateral cervical lymphatic metastasis and lymphatic metastasis in level IIA are negative, lymph node dissection in level IIB may be performed as appropriate on the premise of no damage to the accessory nerve. LCEI is safe and effective for lymph node dissection in level II. When the tumor is located in the unilateral lobe, attention should be given to contralateral central lymph node dissection because of the high lymphatic metastasis rate.

Intrathyroidal Thymic Carcinoma: A Retrospective Case Series Study.

Intrathyroidal thymic carcinoma (ITC) is a rare low-grade malignant thyroid tumor. There is neither sufficient understanding of this tumor nor its clinical treatment. This study is to explore the clinicopathological features, treatment, and prognosis of ITC and thereby provide a reference for the diagnosis and treatment of the disease. The clinical, pathological, therapeutic, and prognostic data of 13 patients with ITC were retrospectively analyzed. The case series comprised 7 males and 6 females, with an average age of 51.9 ± 10.1years. After surgical resection, all patients received post-operative neck radiotherapy at dosages of 60-66 Gy. Five patients with level VI lymph node metastasis additionally received 6 courses of cisplatin chemotherapy. All patients were followed-up for 21-132months (median = 66months), and all of them survived without recurrence or metastasis. The diagnosis of ITC depends mainly on pathological and immunohistochemical results, particularly CD5 positive staining. Surgical resection is the preferred primary treatment modality which can be supplemented with radiotherapy and chemotherapy to reduce the risk of recurrence and metastasis.

309 Sonograhic Appearances of Hobnail Thyroid Carcinoma: A Rare Tumour

Abstract Background Hobnail papillary thyroid carcinoma is a rare, recently described papillary thyroid carcinoma variant, with potential for a more aggressive clinical course of disease and poorer prognosis1. The ultrasound features of papillary thyroid carcinoma variants can differ from known traditional features1 and the specific sonographic findings of the hobnail variant itself have not been previously described in the literature. Case report A 53-year-old man presented with a left thyroid mass. The ultrasound features of this mass included a predominantly cystic appearance with mobile internal echoes, vascularised internal septations, and murally based solid material. These ultrasound features were deemed benign by classification standards, which led to the patient being managed with active surveillance and interval imaging. However, the mass grew quickly, and the patient underwent diagnostic hemithyroidectomy which led to hobnail variant papillary thyroid carcinoma being found on pathology. Given that papillary thyroid carcinoma variants can lead to aggressive disease, the patient underwent completion thyroidectomy and level VI lymph node clearance, on multidisciplinary team recommendation. Discussion The ultrasound features of the hobnail variant of papillary thyroid carcinoma have not been previously described in detail in the literature and, in this case, are features that would be deemed benign by classification standards. The rapid growth of the mass is what led to clinical suspicion of malignancy and resulted in diagnosis. Therefore, careful clinical correlation is advised in order to discern this difficult diagnosis and to facilitate appropriate treatment.

Clinical advantages and neuroprotective effects of monitor guided fang's capillary fascia preservation right RLN dissection technique.

ObjectiveTo investigate the feasibility and advantages of Fang’s capillary fascia preservation right recurrent laryngeal nerve (RLN) dissection technique (F-R-RLN dissection) with preservation of the capillary network and fascia between the RLN and common carotid artery for greater neuroprotective efficiency compared with traditional techniques.MethodsWe retrospectively analyzed 102 patients with papillary thyroid carcinoma undergoing right level VI lymph node dissection in our department from March 2021 to January 2022. Sixty patients underwent F-R-RLN dissection (the experimental group) and 42 patients underwent standard dissection (the control group). The intraoperative electrical signal amplitude ratios of the RLN, the number of dissected lymph nodes, and the preservation rates of the parathyroid glands were recorded and compared between the two groups.ResultsThe electrical signal amplitude ratio of the lower neck part point of the RLN to the upper laryngeal inlet point in the experimental group was significantly lower than the ratio in the control group (p = 0.006, Z-score = -2.726). One patient suffered transient RLN paralysis in both groups, but this resolved within 1 month after operation. There were no significant differences between the two groups in terms of the number of level VIa or level VIb lymph nodes dissected, nor in the rate of preservation of the parathyroid glands.ConclusionsF-R-RLN dissection is a thorough dissection technique that is effective at preventing an electrical signal amplitude decrease in the RLN, and at preventing RLN paralysis by preserving its blood supply.

Endoscopic thyroidectomy via the combined trans-oral and chest approach for cT1-2N1bM0 papillary thyroid carcinoma.

Recent years there have been witnessed considerable advances in endoscopic selective lateral neck dissection (LND). However, dissection of lymph nodes at level IV and level VI via the chest approach is inherently challenging. In this study, we used combined trans-oral and chest approach for endoscopic thyroidectomy in patients with cT1-2N1bM0 papillary thyroid carcinoma (PTC). Clinical characteristics and surgical outcomes of ten patients with cT1-2N1bM0 PTC who underwent endoscopic thyroidectomy via combination of trans-oral and chest approach between September 2020 and September 2021 were retrospectively reviewed. All 10 patients successfully underwent total thyroidectomy and selective LND via chest approach, while central neck dissection (CND) and supplementary dissection of lymph nodes at level IV were performed via the trans-oral approach. The mean number of positive/retrieved level II, III-IV, and VI lymph nodes were 0.6 ± 1.0/9.8 ± 5.0, 4.6 ± 2.8/23.1 ± 4.7, and 4.9 ± 3.4/10.3 ± 4.6, respectively. Four patients developed transient hypoparathyroidism which spontaneously resolved within 1month. Five patients developed numbness of lateral neck and ear and one patient experienced limb lift restriction. No other complications or tumor recurrence occurred during follow-up. It is feasible to perform total thyroidectomy, CND, and selective LND via combined trans-oral and chest approach, and satisfactory short-term outcomes were observed in this cohort. This approach may offer one more option for cT1-2N1bM0 PTC patients, especially those in whom metastatic lymph nodes at level IV or level VI are detected by preoperative examination.

Risk Benefit Analysis of Routine Thymectomy for Differentiated Thyroid Cancers: A Systematic Review.

Background Central compartment lymph node dissection (CLND) is a part of the surgical management of differentiated thyroid cancer (DTC). Therapeutic CLND is done to address clinically significant central compartment nodes in patients with DTC, while prophylactic CLND is performed in the presence of high-risk features in the absence of clinically significant neck nodes. Removal of thymus—unilateral or bilateral—during CLND to achieve complete clearance of level VI and VII lymph node stations and address thymic metastasis is debatable. Objective The present systematic review was conducted to summarize the evidence, delineating the role of thymectomy during CLND in patients with DTC. Methods Electronic databases of PubMed, Embase, and Cochrane were searched from their inception to July 2020 using keywords—thyroid neoplasms or tumors, thyroidectomy, and thymectomy—to identify the articles describing the role of thymectomy during CLND in DTC. A pooled analysis of surgicopathological outcomes was performed using metaprop command in STATA software version 16. Result A total of three studies and 347 patients—total thyroidectomy (TT) with bilateral thymectomy in 154, TT with unilateral thymectomy in 166, and TT alone in 27 patients with DTC—were included in the systematic review. The pooled frequency of thymic metastasis was a mere 2% in patients undergoing either unilateral or bilateral thymectomy. The routine addition of thymectomy does not result in better lymph node clearance. Unilateral and bilateral thymectomy were associated with high chances of transient hypocalcemia (12.0% and 56.1%, respectively). Conclusion Routine thymectomy is not warranted during CLND, considering minimal oncological benefit and high risk of postoperative hypocalcemia.

Pathological Level VI Lymph Node Metastasis in Clinical N3b Pyriform Sinus Squamous Cell Carcinoma.

The frequency of metastasis to level VI lymph nodes in advanced pyriform sinus squamous cell carcinoma (PSSCC) is unknown. We intended to analyze the clinical features and pathological presence or absence of level VI lymph node metastasis in patients with PSSCC. The data of 270 patients with previously untreated hypopharyngeal squamous cell carcinoma from 2006 to 2016 were obtained. Patients who underwent pharyngolaryngectomy for the pyriform sinus subsite with a curative intent with level VI dissection were included. We retrospectively analyzed the clinical Tumor-Node (TN) status (TNM classification of malignant tumors, eighth edition) and the presence or absence of pathological level VI lymph node metastasis. A total of 34 patients were included. Eight patients (24%) had pathological level VI lymph node metastasis. The rate of pathological level VI lymph node metastasis was directly proportional to the clinical N status (P = .0002, Chi-square test for trend). In all, 5 patients with cN2b- 3 were classified as cN3b. Ipsilateral pathological level VI lymph node metastasis was observed in 1 patient, and bilateral metastasis was observed in 3 patients. There was no association between clinical T status or pyriform sinus apex invasion and pathological level VI metastasis (both P > .99, Fisher's exact test). PSSCC with cN3b is prone to bilateral level VI metastasis. We recommend that patients with PSSCC with cN3b should undergo bilateral level VI lymph node dissection.

Thyroid Paraganglioma- An Unusual Head and Neck Tumour

Paragangliomas are neuroendocrine tumour originating from the neural crest-derived paraganglia with majority arising from the head and neck. (1)Thyroid paraganglioma are exceedingly rare neuroendocrine tumours accounting for <0.1% of thyroid malignancy (1)We present a 57 years old gentleman who was referred to ENT surgeon following discovery of a two month history of lump on his left neckIt has not changed in size and not caused any symptoms such as anxiety, sweats, palpitations, dizziness or unexplained headaches. He has a Past medical history of epilepsy following a Road traffic accident 28 years ago leaving him seizure prone. He has no family history of neuroendocrine tumours His ultrasound scan of his thyroid gland showed a 25 x 23 x 15mm lesion lying anteriorly within the left thyroid lobe. There are two highly reflective foci which could represent microcalcification. It was classified as U5 lesion He proceeded with fine needle aspiration which confirmed carcinoma of the left thyroid gland with no clear differentiation between follicular or papillary carcinoma. He undergone a total thyroidectomy and left central level VI lymph node dissection His histology confirmed a thyroid paraganglioma staining strongly positive for neuroendocrine markers (Synaptophysin and chromogranin) while S-100 shows positivity in the sustentacular cells. He was referred for genetic testing which demonstrate no evidence of mutation in FH, SDHAF2, SDHB/C/D, RET, MAX, TMEM127 and VHL gene. He was commenced on levothyroxine replacement at a dose of 150micrograms OD. His urine metanephrines is 178.1pmol/L (0-510), urine normetanephrines 192.9pmol/L (0-1180) and 3-methoxytyramine <75pmol/ L (0-180) (all normal). His MRI neck revealed no synchronous tumour. He continues to be followed up under our endocrine clinic.Conclusion: Due to the rarity of these tumours, their natural history is mostly unknown. Nevertheless, postoperative surveillance should include plasma or urinary metanephrines and ultrasonography.

Construction and verification of lymph node metastasis model of cN0 stage thyroid micropapillary carcinoma and discussion of surgical methods

Objective:To construct and verify a model of lymph node metastasis in cN0 stage thyroid micropapillary carcinoma. To explore the significance of thyroid gland lobectomy combined with prophylactic zone Ⅵ lymph node dissection in cN0 stage thyroid micropapillary carcinoma surgery. Methods:The clinical data of 670 patients with cN0 stage thyroid micropapillary carcinoma and area Ⅵ lymph node dissection were collected. All patients underwent the affected thyroid gland lobe±isthmus resection+ area Ⅵ lymphadenectomy on the same side. Logistic regression model was constructed by gender, age, size of thyroid papillary carcinoma, whether it was multifocal, whether it was encroaching on the membrane, and whether the lymph nodes in the central area were metastasized, and displayed by nomogram. Discrimination and prediction accuracy were evaluated by C-index, calibration curve and ROC curve. An internal validation group was used to test the fitted model. Analyze the lymph node metastasis trend according to the largest tumor diameter. Follow-up analysis of the reoperation was conducted to evaluate the effect of initial surgery. Results:The rate of lymph node metastasis in area Ⅵ was 36.7%. Multiple regression analysis included three variables. The largest tumor diameter（P<0.001）, male（P<0.001） and young（P<0.001） were the main independent risk factors for lymph node metastasis. Conclusion:The reoperation rate of thyroid gland lobectomy combined with prophylactic zone Ⅵ lymph node dissection was low, and this surgical method might be safe and reliable for the treatment of cN0 stage thyroid micropapillary carcinoma, and it is worthy of promotion.

Role and extent of neck dissection for neck lymph node metastases in differentiated thyroid cancers

Differentiated thyroid cancers (DTC) consist of 95% of thyroid tumors and include papillary thyroid cancer (PTC), follicular thyroid cancer (FTC), and Hurthle cell thyroid cancer (HTC). Rates of lymph node metastases are different depending on histologic subtypes and <5% in FTC and between 5% and 13% in HTC. Lymph node metastasis is more frequent in PTC and while rate of clinical metastasis can be seen approximately 30% rate of routine micrometastasis can be seen up to 80%.Lymph node metastasis of DTC mostly develops first in the Level VI lymph nodes at the central compartment starting from the ipsilateral paratracheal lymph nodes and then spreading to the contralateral paratracheal lymph nodes. Spread to the Level VII is mostly after Level VI invasion. Subsequent spread is to the lateral neck compartments of Levels IV, III, IIA, and VB and sometimes to the Levels IIB and VA. Occasionally skip metastasis to the lateral neck compartments develop without spreading to the central compartments and this situation is more frequent in upper pole tumors.Although application of prophylactic central neck dissection (pCND) in DTC increases the rate of complication, due to its unclear effects on oncologic results and quality of life, the interest to the pCND is decreasing and debate on its surgical extent is increasing. pCND is not essential in DTC and characteristics of patient and tumor and experience of surgeon should be considered when deciding for pCND. Due to lower complication rate of one sided pCND compared to bilateral central neck dissection (CND), low possibility of contralateral central neck metastasis and low risk of recurrence, application of one-sided CND is logical. Although therapeutic CND (tCND) is the standart treatment when there is a clinically involved lymph node, extent of dissection is a matter of debate. A case-based decision for the extent of tCND can be made by considering patient and tumor characteristics and experience of the surgeon.Due to the higher complication risk of bilateral CND, unilateral tCND can be performed if there is no suspicious lymph node on the contralateral side and bilateral tCND can be applied when there is a suspicion for metastasis only on the contralateral side or there are features for risk of metastasis to the contralateral side. In patients with clinical central metastasis owing to intra-operative pathology results by frozen section procedure are compatible with post-operative pathology results, when there is a suspicion for contralateral metastasis, a decision for one- or two-sided dissection can be made using frozen section procedure. In DTC, it can be stated that there is a consensus in the literature about not performing prophylactic lateral neck dissection (LND), but performing therapeutic LND (tLND). In addition, there is a debate on the extent of tLND.In a meta-analysis about lateral metastasis, the rates of metastasis to the Levels IIA, IIB, III, IV, VA, and VB were 53.1%, 15.5%, 70.5%, 66.3%, 7.9%, and 21.5%, respectively. Ultrasonography (USG) is an effective procedure for detection of cervical nodal metastasis on lateral compartment. Pre-operative imaging with USG and/or combination with the fine needle aspiration biopsy (cytology/molecular test/Thyroglobulin test) can allow pre-operative detection and verification of lateral lymph node metastasis.Extent of tLND can be determined to minimize morbidity considering pre-operative USG findings, pre-operative tumor and clinical features of lateral metastasis. Especially in the presence of limited lateral metastases, limited selective LND such as Levels III, IV or Levels IIA, III, IV can be applied according to the patient. Levels IIB and VB should be added to the dissection in the presence of metastases in these regions. In cases that increase the risk of Level IIB involvement, such as presence of metastasis at Level IIA, extranodal tumor involvement, presence of multifocal tumor, and in cases that increase the risk of Level VB involvement such as macroscopic extranodal spread, and simultaneous metastases at Levels II, III, IV; Levels IIB and VB can be added to dissection material. Levels I and VA should be added to the dissection in the presence of clinically detected metastases.

Ultrasound diagnosis of cervical lymph node metastases in patients with first diagnosed papillary thyroid cancer and in patients previously treated surgically and admitted for radioactive iodine therapy

Purpose of the study. To evaluate the potentialities of ultrasound method in diagnosing cervical lymph node metastasis in patients with first diagnosed papillary thyroid cancer (group 1) and in patients previously treated surgically at different clinics of the Russian Federation and subsequently admitted to the A.F.Tsyb Medical Radiological Research Center — Branch of the National Medical Research Radiological Center to receive radioactive iodine therapy (group 2).Patients and methods. Patients with PTC were divided into two groups. Group 1 included 649 patients with first diagnosed PTC. All the patients underwent thyroidectomy and level VI lymph node neck dissection at the clinic of the A.F.Tsyb Medical Radiological Research Center — Branch of the National Medical Research Radiological Center. Of these patients, 92 patients underwent cervical lymph node dissection including levelsII–III–IV and 9 patients underwent cervical lymph node dissection including level VB. Group 2 consisted of 2875 patients who had previously received surgery at different clinics of the Russian Federation. Subsequently, they were admitted to our institution to receive radioactive iodine therapy. In 291 of these patients, cervical lymph node metastases were found and reoperations were performed: in 89 cases at level VI, in 170 cases at levels II–III–IV and in 32 cases at level VB. The detected metastases were verified histologically.Results. Histology confirmed the presence of nodal metastasis in 57.6% of 649 patients in group 1, and in 10.1% of 241 patients in group 2. In group 1, the incidence of metastatic disease in level VI nodes was 73% and in group 2, it was 30.6%. Metastases in levels II–III–IV were noted in 24.6% of patients in group 1, and in 58.4% of patients in group 2. Level VB metastasis was found in 2.4% of patients in group 1, and in 11% of patients in group 2. Multiple metastases were detected in 75.4% of patients in group 1, and in 20.3% of patients in group 2.Conclusion. Central lymph node metastasis was observed in 73% of patients who were first diagnosed with PTC and treated with thyroidectomy and prophylactic level VI cervical lymph node dissection. In group 2, solitary metastases to lateral lymph nodes occurred more frequently after surgical treatment for PTC, which suggested that the primary treatment was insufficiently radical.

SUN-474 An Unusual Case of Poorly Differentiated Thyroid Carcinoma with an Excellent Prognosis

Background: Poorly differentiated thyroid carcinoma (PDTC) is a rare and aggressive subtype with morphological/behavioral features between differentiated thyroid carcinoma (DTC) and anaplastic thyroid carcinoma (ATC). Clinical case: A 43-year-old female presented with 3 cm right thyroid mass noted on US neck. FNA biopsy showed undifferentiated carcinoma, large cell type. Additional immune-stains were suggestive of ATC. Pre-surgery non-stimulated thyroglobulin (NSTG) was 311 (RR 0–55 ng/dl). Pathology post-total thyroidectomy with bilateral level VI lymph node dissection showed a 3.2 x 2.5 x 2.5 cm carcinoma with vascular and capsular invasion. Most of the mass consisted of very atypical pleomorphic cells, mitosis was difficult to find. The tumor did not show the widely invasive-destructive pattern commonly seen in ATC. An adjacent differentiated component showed predominantly follicular pattern and was described as dedifferentiated follicular carcinoma. All lymph nodes were negative for metastatic disease. Post-surgery NSTG was <0.2 (RR <0.1ng/ml as athyreotic), stimulated TG was 2.22 with negative TG antibodies. Four months later, she received 193.5 mCi radioactive iodine (RAI) therapy. The post-therapy scan showed no Iodine-131 avid uptake in neck or distant metastasis. Neck imaging and TG levels done periodically showed no structural or biochemical evidence of recurrence. Currently the patient is cancer-free for 14 years since diagnosis with no need for additional therapies. Discussion: PDTC accounts for 1–15% of all thyroid cancers. Although PDTC is rare, it is a clinically significant histological diagnosis as it represents the main cause of death from non-anaplastic follicular cell-derived thyroid carcinoma. The Turin proposal published in 2007 suggested three criteria for the diagnosis of PDTC which included the pattern of growth and high-grade features. PDTC presents more frequently with locally invasive extra-thyroidal disease, metastasis to regional lymph nodes and distant organs compared to DTC. Despite the capacity to have RAI uptake, there has been no evidence of significant improvement in survival due to tumor heterogeneity in differentiation. Recent data suggest that age more than 45 years, tumor size more than 4cm, extra-thyroidal extension, higher pathological T stage, positive margins, and distant metastasis predict worse prognosis. Conclusion: Our patient showed an excellent response to therapy in spite of having PDTC with positive margins. We hypothesize that this could be likely due to young age at the time of diagnosis, early detection of tumor while it was localized in the thyroid without distant metastasis as well as heterogeneity in the tumor with differentiated cells that are responsive to RAI. We conclude that with early detection, timely surgery, and adjuvant therapy, excellent prognosis can be achieved in patients with PDTC.

Identifying risk factors for metastasis to the level VII lymph node in papillary thyroid carcinoma patients

BackgroundThe level VI lymph nodes are anatomically connected to the level VII lymph nodes and papillary thyroid carcinoma (PTC) can metastasis to both regions. The aim of this study was to identify clinicopathologic factors associated with level VII lymph node metastasis.MethodsBetween March 2015 and September 2016, a total of 275 consecutive patients were operated on for PTC with prophylactic level VII dissection at the Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, ZheJiang, China. Patients with PTC were performed via video-assisted approach. Multivariate logistic regression analysis was performed to evaluate the associations between clinicopathologic factors.ResultsOf the 275 subjects enrolled in this study, 79 patients (28.73%) showed lymph node metastasis to the level VII. The multivariate logistic regression analysis showed ultrasonography-positive lymph nodes (p < 0.001), the location of primary carcinoma (p = 0.002) and hashimoto thyroiditis (HT) (p = 0.04) were associated with level VII lymph node metastasis.ConclusionsBased on the results of our study, we considered central-compartment lymph node dissection (CLND) as an integral strategy. On the basis of surgery safety, transcervical level VII lymph node dissection could be considered for PTC patients with high risk factors such as ultrasonography-positive lymph nodes, tumor located in middle and lower thirds of the thyroid lobe and the patients without HT. In future, prognostic significance of level VII lymph node dissection should be evaluated through long-term surveillance.

Prediction of cervical lymph node metastases in papillary thyroid microcarcinoma by sonographic features of the primary site.

ObjectiveTo study the sonographic features of the primary site of papillary thyroid microcarcinoma (PTMC) for the prediction of cervical lymph node metastasis during preoperative diagnosis.MethodsA total of 710 PTMC patients between 2013 and 2016 with a diagnosis of cervical lymph node metastases were reviewed. We analyzed the sonographic features of the PTMC primary site to predict ipsilateral or central lymph node metastases in univariate and multivariate models. The ratio of abutment/perimeter of the PTMC primary site was utilized to evaluate cervical lymph node status.ResultsRegarding clinical characteristics, multifocality and extrathyroidal extension were associated with cervical lymph node involvement. In the multivariate regression model, calcification and the abutment/perimeter ratio of lesions were evaluated as independent factors in level VI, ipsilateral or skip cervical lymph node metastases. The cut-off value of the ratio of abutment/perimeter of the PTMC primary site (25%) was significantly correlated with cervical lymph node metastases (P = 0.000). ConclusionsIndependent sonographic features, including lesion size, lesion location, calcification, and the ratio of abutment/perimeter of the primary site, were associated with cervical lymph node metastases in PTMC patients.