Total Thyroidectomy Without Prophylactic Central Cervical Lymph Node Dissection: Is It Oncologically Safe in Patients with Early-Stage Papillary Thyroid Carcinoma
Background: The necessity and the benefits of prophylactic central cervical lymph node dissection (PCLND) in clinically node negative patients with early-stage papillary thyroid carcinoma (PTC) remain controversial. Objective: to evaluate the safety of total thyroidectomy without PCLND in clinically node-negative early-stage PTC. Patients & Methods: 34 patients with T1 or T2 & N0 PTC were included in the study and submitted to total thyroidectomy without PCLND. Post-operatively, all patients received TSH suppression therapy & radio-active iodine (RAI) ablation. Any suspicious local neck recurrence during the follow up was confirmed cytologically and treated by RAI ablation. Results: The mean age was 42.1 years. 55.9% of patients were less than 45 years and 44.1% were 45 years old or more. Male to female ratio was 10:24. T1 was found in 14 cases & T2 in 20 cases. Total thyroidectomy was successfully done for all the cases. Central cervical lymph nodes sampling was done in 5 cases. Excised lymph nodes were found in 8 specimens; 5 cases with lymph node sampling (14.7%) and 3 cases (8.8%) with accidental lymph node excision during thyroidectomy. only 6 of these 8 patients (17.6%) showed positive metastasis (pN1). No recurrent laryngeal nerve injury was reported. In 12 patients (35.3%), temporary hypocalcemia was encountered. The mean follow up period was 34.6 months. There were 2 recurrences (5.9%); 1 in the central & 1 in the lateral neck compartment. All recurrences were treated by RAI ablation. No distant metastasis or mortality was reported. Conclusion: total thyroidectomy without PCLND in clinically node-negative early stage PTC is an excellent treatment option that gives adequate loco-regional control of the disease with low rate of surgical complications. Close follow up for longer periods is needed.
Tamer Abd-Elhafez El-Bakary,
Mohamed Aly Mlees,
Total Thyroidectomy Without Prophylactic Central Cervical Lymph Node Dissection: Is It Oncologically Safe in Patients with Early-Stage Papillary Thyroid Carcinoma, Journal of Surgery.
Vol. 5, No. 6,
2017, pp. 124-129.
Lundgren CI., Hall P., Dickman PW., & Zedenius J. Clinically significant prognostic factors for differentiated thyroid carcinoma: a populationed-based, nested case-control study. Cancer 2006; 106, 3: 524-531.
Eichhorn W., Tabler H., Lippold R., et al. Prognostic factors determining long term survival in well differentiated thyroid cancer: an analysis of four hundred eighty-four patients undergoing therapy and aftercare in the same institution. Thyroid 2003; 13 (10): 949-958.
Qubain SW., Nakano S., Baba M., et al. Distribution of lymph node micrometastasis in pN0 well-differentiated thyroid carcinoma. Surgery 2002; 131: 249-256.
Arturi F., Russo D., Giuffrida D., et al. Early diagnosis by genetic analysis of differentiated thyroid cancer metastases in small lymph nodes. J. Clin. Endocrinol. Metab. 1997; 82: 1638-1641.
Adam MA., Pura J., Goffredo P., et al. Presence and number of lymph node metastases are associated with compromised survival for patients younger than age 45 years with papillary thyroid cancer. J. Clin. Oncol. 2015; 33 (21): 2370-2375.
Nixon IJ., Wang LY., Ganly I., et al. Outcomes for patients with papillary thyroid cancer who do not undergo prophylactic central neck dissection. Br. J. Surg. 2016; 103 (3): 218-225.
Hughes DT., White ML., Miller BS., et al. Influence of prophylactic central lymph node dissection on prospective thyroglobulin levels and radioiodine treatment in papillary thyroid cancer. Surgery 2010; 148: 1100-1106.
Popadich A., Levin O., Lee JC., et al. A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer. Surgery 2011; 150: 1048-1057.
Hartl DM., Leboulleux S., Al Ghuzlan A., et al. Optimization of staging of the neck with prophylactic central and lateral neck dissection for papillary thyroid carcinoma. Ann. Surg. 2012; 255 (4): 777-783.
Lang BH., Ng SH., Lau LL., et al. A systematic review and meta-analysis of prophylactic central neck dissection and short term loco-regional recurrence in papillary thyroid carcinoma after total thyroidectomy. Thyroid 2013; 23: 1087-1098.
Shen WT., Ogawa L., Ruan D., et al. Central neck lymph node dissection for papillary thyroid cancer: comparison of complication and recurrence rates in 295 initial dissections and reoperations. Arch. Surg. 2010; 145 (3): 2720275.
Wdge SB., Byrd DR., Compton CC., et al. AJCC Cancer Staging Manual. 7th edition. New York, NY: Springer-Verlag; 2010.
The American Thyroid Association Surgery Working Group, American Association of Endocrine Surgeons, American Academy of Otolaryngology—Head and Neck Surgery, et al. Consensus Statement on the Terminology and Classification of Central Neck Dissection for Thyroid Cancer. Thyroid 2009; 19 (11): 1153-1158.
Grodski S., Cornford L., Sywak M., et al. Routine level VI lymph node dissection for papillary thyroid cancer: surgical technique. ANZ J. Surg. 2007; 77 (4): 203-208.
Brown AP., Chen J., Hitchcock YJ., Szabo A., et al. The risk of second primary malignancies up to three decades after the treatment of differentiated thyroid cancer. J. Clin. Endocrinol. Metab. 2008; 93 (2): 504-515.
Cooper DS., Doherty GM., Haugen BR., et al. Revised American association management guidelines for patients with thyroid nodule and differentiated thyroid cancer. Thyroid 2009; 19 (11): 1167-1214.
Machens A., Hinze R., Thomusch O., et al. Pattern of nodal metastasis for primary and reoperative thyroid cancer. World J. Surg. 2002; 26 (1): 22-28.
Sywak M., Cornford L., Roach P., et al. Routine ipsilateral level VI lymphadenectomy reduces postoperative thyroglobulin levels in papillary thyroid cancer. Surgery 2006; 140 (6): 1000-1005, discussion 1005-1007.
Moo TA., Umunna B., Kato M., et al. Ipsilateral versus bilateral central neck lymph node dissection in papillary thyroid carcinoma. Ann. Surg. 2009; 250 (3): 403-408.
Roh JL., Park JY., Rha KS., et al. Is central neck dissection necessary for the treatment of lateral cervical node recurrence in papillary thyroid carcinoma? Head Neck 2007; 29 (10): 901-906.
Shah MD., Hall FT., Eski SJ., et al. Clinical course of thyroid carcinoma after neck dissection. Laryngoscope 2003; 113 (12): 2102-2107.
Wang TS., Dubner S., Sznyter LA., & Heller KS. Incidence of metastatic well-differentiated thyroid cancer in cervical lymph nodes. Archives of Otolaryngology-Head and Neck Surgery 2004; 130 (1): 110-113.
Wang TS., Evans DB., Fareau GC., et al. effect of prophylactic central compartment neck dissection on serum thyroglobulin and recommendations for adjuvant radioactive iodine in patients with differentiated thyroid cancer. Ann. Of Surg. Oncol. 2012; 19 (13): 4217-4222.
Yuan J., Zhao G., Du J., Chen X., et al. To identify predictors of central lymph node.
Metastasis in patients with clinically node-negative conventional papillary thyroid carcinoma. Int. J. Endocrinol. 2016; article ID 6109218, 1-6.
Calo PG., Lombardi CP., Podda F., et al. Role of prophylactic central neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of regional recurrence. Updates Surg. 2017; 69: 241-248.
Ito Y., Hirokawa M., Uruno T., Kihara M., et al. prevalence and biological behavior of variants of papillary thyroid carcinoma: experience at a single institute. Pathology 2008; 40 (6): 617-622.
Haigh PI. Follicular thyroid carcinoma. Curr. Treat. Options Oncol. 2002; 3 (4): 349-354.
Garcia-Rostan G. & Sobrinho-Simoes M. Poorly differentiated thyroid carcinoma: an evolving entity. Diagn. Histopathol. 2011; 17: 114-123.
Ibrahimpasic T., Ghossein A., Carlson DL., et al. Outcomes in patients with poorly differentiated thyroid carcinoma. J. Clin. Endocrinol. Metab. 2014; 99: 1245-1252.
Stulak JM., Grant CS., Farley DR., et al. Value of preoperative ultrasonography in the surgical management of initial; and reoperative papillary thyroid cancer. Arch. Surg. 2006; 141 (5): 489-494, discussion 954-955.
Kouvaraki MA., Shapiro SE., Fornage BD., et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery 2003; 134 (6): 946-954, discussion 954-955.
Danese D., Sciacchitano S., Farsetti A., et al. Diagnostic accuracy of conventional versus sonography-guided fine needle aspiration biopsy of thyroid nodules. Thyroid 1998; 8: 15-21.
Cesur M., Corapcioglu D., Bulut S., et al. Comparison of palpation guided fine needle aspiration biopsy to ultrasound guided fine needle aspiration biopsy in the evaluation of thyroid nodules. Thyroid 2006; 16: 555-561.
Degirmenci B., Haktanir A., Albayrak. et al. Sonographically guided fine needle biopsy of thyroid nodules: the effects of nodule characteristics, sampling technique, and needle size on the adequacy of cytological material. Clin. Radiol. 2007; 62: 798-703.
Hegedus L. Clinical practice. The thyroid nodule. N. Engl. J. Med. 2004; 351 (17): 1764-1771.
Said M., Fujimoto M., Franken C., et al. Preferential use of total thyroidectomy without prophylactic central lymph node dissection of early-stage papillary thyroid cancer: oncologic outcomes in an integrated health plan. Prem. J. 2016; 20 (4): 22-26.
Islam S., Al-Maqbali T., Howe D. & Campbell J. Hypocalcemia following total thyroidectomy: early post-operative parathyroid hormone assay as a risk stratification and management tool. J. Laryngology & Otology 2014; 128: 274-278.
Sousa Ade A., Salles JM., Soares JM. et al. Predictor factors for post-thyroidectomy hypocalcemia. Rev. Col. Bras. Cir. 2012; 39 (6): 476-482.
Karamanakos SN., Markou KB., panagopoulos K., et al. Complications and risk factors related to the extent of surgery in thyroidectomy. Results from 2043 procedures. Hormones 2010; 9: 318-325.
Rosato L., Avenia N., Bernante P., et al. Complications of thyroid surgery: analysis of a multicentric study on 14934 patients operated on in Italy over 5 years. World J. Surg. 2004; 28: 271-276
Lombardi CP., Raffaelli M., Princi P., et al. Parathyroid hormone levels 4 hours after surgery do not accurately predict post-thyroidectomy hypocalcemia. Surgery 2006; 140: 1016-1025.
Coelho SM., Buescu A., Corbo R., et al. Recurrence of papillary thyroid cancer suspected by high anti-thyroglobulin antibody levels and detection of peripheral blood thyroglobulin mRNA. Arq. Bras. Endocrinol. Metabol. 2008; 52 (8): 1321-1325.