Is Level IIb Lymph Node Dissection Always Necessary in N1b Papillary Thyroid Carcinoma Patients?

Abstract

Introduction Papillary thyroid carcinoma (PTC) patients show a high rate of cervical lymphatic metastasis. However, there are no universal binding guidelines for the extent of lateral cervical lymph node dissection (LND) in such cases. In particular, the need for LND above the spinal accessory nerve (SAN) remains controversial. The present study examined whether level IIb lymph node (LN) dissection is always necessary in PTC patients with lateral cervical LN metastasis. Materials and Methods The study prospectively examined 167 PTC patients with lateral cervical LN metastasis who underwent modified radical neck dissection (MRND) in our institution from November 2005 to March 2007. The MRND was bilateral in 24 cases. All patients underwent level II, III, IV, and V LND. Levels IIa and IIb LNs were individually dissected in all cases. All LND was performed using strict leveling criteria by a single operating team. The patterns of lymphatic metastasis and potential risk factors for level IIb LN involvement were evaluated. Results The most common site of metastasis was level III (80.6% of cases), followed by level IV (74.9%) and II (55.5%). The metastasis rates in level IIa and IIb were 55.5% and 6.8%, respectively; all level IIb LN metastasis was accompanied by level IIa metastasis (p = 0.001). In addition, level IIb LN metastasis was found to be associated with the aggressiveness of lymphatic metastasis (i.e., the total number of metastatic LNs) (p \ 0.0001).Conclusions A level IIb LND should be performed when there is clinical or radiological evidence of lymphatic metastasis. In the absence of such evidence, the findings suggest that level IIb LND is not necessary in N1b PTC patients when there is no level IIa LN metastasis, or when the metastasis is not aggressive.Of all thyroid malignancies, papillary thyroid carcinoma (PTC) has the highest risk of cervical lymph node (LN) metastasis [1,2]. Cervical LN metastasis is the most significant prognostic factor for locoregional recurrences in patients with PTC [3][4][5]. However, cervical LN metastasis in such patients does not necessarily have an adverse affect on overall survival [2,6,7].Debate continues regarding the appropriate extent of surgery for cervical LN metastasis in PTC. Surgery can extend from selective dissection (i.e., ''berry picking'') to extensive neck dissection. Most investigators agree that prophylactic neck dissection is not necessary in pathologically negative neck nodes (N0). However, for pathologically positive neck nodes, some clinicians recommend radical neck dissection (RND), whereas others recommend selective dissection with limitations [8][9][10][11].The shoulder syndrome is a major postoperative sequela of RND [12]. Postoperative spinal accessory nerve (SAN) dysfunction can result from direct pressure or traction during surgery. Even when the SAN is

Low transverse incision for lateral neck dissection in patients with papillary thyroid cancer: improved cosmesis

“…These values are in accordance with the number of lymph nodes harvested from the hockey stick incision group (9.6, 5.6, and 29.3, respectively) and the results from a published data (mean 8.3–10.3, 6.2–6.6, and 31.1–31.5, respectively) [22–24]. In addition, the mean number of metastatic lymph nodes in the transverse incision group at neck levels II and V and the total lateral compartment were 2.4, 0.4, and 5.7, respectively, which were similar to both the mean number of metastatic lymph nodes in the hockey stick incision group (2.3, 0.6, and 6.5) and the published data (1.2–2.7, 0.3–1.9, and 4.6–4.8) [22–24]. These results suggest that surgical accessibility to the upper neck level is comparable between the single low transverse incision and the hockey stick incision in LND (Fig.…”

Sentinel Lymph Node Biopsy in Well Differentiated Thyroid Cancer

“…In keeping with the theory, Nogychi in a study of 68 patients after elective neck dissection, found 78% of nodal metastases in the paratracheal region and 22% in the jugular chain (Nogychi et al, 1987, as cited in Kelemen et al, 1998). Many groups have, however, reported that the risk of lymphatic metastases was greatest for the lateral nodal groups (level II, III and IV) ( Caron et al, 2006;Gimm et al, 1998;Lee et al, 2008;Roh et al, 2007Roh et al, , 2008Shah et al, 1990) while others have shown comparable rates of involvements in both the central cervical and lateral neck compartments (Machens et al, 2002).…”

A Case of Papillary Thyroid Carcinoma with Subclinical Lateral Lymph Node Metastasis Presenting as Recurrence

“…OLNM were confined to only one level in 53% of cases, which is within the range of various reports of 32% from Kupferman et al, 39% from Pingpank et al and 64% from Ducci et al [15][16][17] in therapeutic neck dissections. Lee et al and Sivanandan et al reported a lower rate of 18% [18,19]. This wide range between studies may be explained by the geographical variability, genetic changes in the tumour tissue (ras-, gsp-,p53-and p21-mutations), accuracy in the clinical and imaging diagnosis of the N0 necks and variability of the extent of neck dissection and pathological processes [20].…”

“…Level IIb OLNM were observed in a few (2.9%) and only in cases of invasion of the surrounding levels IIa and level III. In therapeutic ND, Lee et al found a low incidence of level IIb LNM (6.8%) although a higher level of III LNM up to 80% [18]. He concluded that level IIb ND should be performed only if there is clinical or radiological evidence of metastases at this level.…”