Long-Term Outcomes After Lobectomy for Patients with High-Risk Papillary Thyroid Carcinoma.

BACKGROUND: Guidelines universally recommend total thyroidectomy for high-risk papillary thyroid carcinoma (PTC). However, in Japan, thyroid-conserving surgery had been widely applied for such patients until recently. We investigated long-term outcomes for this strategy. METHODS: A prospectively recorded database was retrospectively analyzed for 368 patients who had undergone curative surgery for high-risk PTC without distant metastasis between 1993 and 2013. High-risk PTC was defined for tumors showing tumor size > 4 cm, extrathyroidal extension, or large nodal metastasis ≥ 3 cm. RESULTS: Median age was 59 years and 243 patients were female. Mean duration of follow-up was 12.7 years. Lobectomy was conducted for 207 patients (LT group) and total or near-total thyroidectomy for 161 patients (TT group). The frequency of massive extrathyroidal invasion and large nodal metastasis was lower in the LT group than in the TT group. After propensity score matching, no significant differences were seen between groups for overall survival, cause-specific survival or distant recurrence-free survival. In the overall cohort, multivariate analysis identified age ≥ 55 years, large nodal metastasis, tumor size > 4 cm and massive extrathyroidal invasion as significantly associated with cause-specific survival, whereas extent of thyroidectomy was not. CONCLUSIONS: For patients with high-risk PTC without distant metastasis, curative surgery with lobectomy showed almost identical oncological outcomes compared to total thyroidectomy. The benefits of total thyroidectomy for high-risk PTC should be reevaluated in the future prospective studies.

Patient-Reported Outcomes in Patients with Low-Risk Papillary Thyroid Carcinoma: Cross-Sectional Study to Compare Active Surveillance and Immediate Surgery.

BACKGROUND: This cross-sectional study compared patient-reported outcomes of low-risk papillary thyroid carcinoma (PTC, T1N0M0) between patients who underwent active surveillance (AS) and those who received immediate surgery, METHODS: Using the State-Trait Anxiety Inventory, Short-Form 36 version 2, and a visual analog scale for neck symptoms, 249 patients under AS and 32 patients underwent immediate surgery were compared. To match the difference in time from the onset of treatment to the survey, we conducted propensity score matching. We also investigated factors affecting anxiety in patients under AS in multiple linear regression analysis. RESULTS: In the entire group, patients under AS had significantly longer time from the onset to the survey than patients underwent immediate surgery (7.9 vs. 4.0 years). After matching, AS group showed significantly better trait anxiety and mental component summary (MCS) compared to surgery group, while surgery group showed better role-social component summary. AS group also had significantly better MCS than the Japanese norm-based score. Surgery group displayed worse neck symptoms than AS group. Among AS group, trait anxiety and time from the onset were significant predictors of state anxiety. Compared with the group with < 5 years since starting AS, the group with ≥ 5 years of follow-up showed a significantly better state anxiety only in patients with better trait anxiety. CONCLUSIONS: Low-risk PTC patients under AS showed better trait anxiety and mental health than surgery group. After a certain period, the anxiety of patients under AS seems to be improved, especially in patients with better trait anxiety.

Correlation between low expression of protein disulfide isomerase A3 and lymph node metastasis in papillary thyroid carcinoma and poor prognosis: a clinicopathological study of 1,139 cases with long-term follow-up.

The incidence of papillary thyroid carcinoma (PTC) is increasing worldwide. The biomarkers to identify aggressive types of PTC are limited, illustrating the need to establish reliable novel biomarkers. Protein disulfide isomerase A3 (PDIA3) is a chaperone protein that modulates the folding of newly synthesized glycoproteins and stress-responsive proteins in the endoplasmic reticulum. Although the role of PDIA3 in various cancers such as breast, uterine cervix, head and neck, and gastrointestinal tract has been examined, its expression in thyroid cancer has not been reported. We retrospectively reviewed accumulated data with long-term follow-up of 1,139 PTC patients, and investigated the correlation between immunohistochemical expression of PDIA3 in PTC patients and clinicopathological features and prognosis. PDIA3 expression was significantly lower in PTCs compared to normal thyroid tissues (NTT; n = 80, p = 0.002). In PTCs, correlation between low PDIA3 expression and lymph node metastasis (p = 0.018) and the number of positive nodes (p = 0.004) was observed. Patients with low PDIA3 expression exhibited worse cause-specific survival compared to those with high PDIA3 expression (p = 0.013). Our findings indicate that low PDIA3 expression is related to poor clinical outcome in PTC patients, and that PDIA3 may potentially be a novel ancillary biomarker. Further clarification of the biological role of PDIA3 in PTC is warranted for the future clinical application.

The impact of COVID-19 on surgical procedures in Japan: analysis of data from the National Clinical Database.

BACKGROUND AND PURPOSE: The spread of COVID-19 has restricted the delivery of standard medical care to surgical patients dramatically. Surgical triage is performed by considering the type of disease, its severity, the urgency for surgery, and the condition of the patient, in addition to the scale of infectious outbreaks in the region. The purpose of this study was to evaluate the impact of the COVID-19 pandemic on the number of surgical procedures performed and whether the effects were more prominent during certain periods of widespread infection and in the affected regions. METHODS: We selected 20 of the most common procedures from each surgical field and compared the weekly numbers of each operation performed in 2020 with the respective numbers in 2018 and 2019, as recorded in the National Clinical Database (NCD). The surgical status during the COVID-19 pandemic as well as the relationship between surgical volume and the degree of regional infection were analyzed extensively. RESULTS: The rate of decline in surgery was at most 10-15%. Although the numbers of most oncological and cardiovascular procedures decreased in 2020, there was no significant change in the numbers of pancreaticoduodenectomy and aortic replacement procedures performed in the same period. CONCLUSION: The numbers of most surgical procedures decreased in 2020 as a result of the COVID-19 pandemic; however, the precise impact of surgical triage on decrease in detection of disease warrants further investigation.

Multifocality and Progression of Papillary Thyroid Microcarcinoma During Active Surveillance.

BACKGROUND: Prospective trials of active surveillance (AS) have shown low rates of progression in low-risk papillary thyroid microcarcinoma (PTMC; T1aN0M0). However, the significance of multifocality as a prognostic factor remains controversial. METHODS: Data from 571 patients (mean age, 53.1 years; 495 females) who underwent AS were reviewed. PTMC was unifocal in 457 patients (80.0%) and multifocal in 114 patients (20.0%), with 2-5 lesions each (261 tumors in total). Tumor progression was defined as tumor size enlargement ≥ 3 mm and/or development of clinically evident lymph node metastasis (LNM). RESULTS: After a mean duration of AS of 7.6 years, 53 patients (9.3%) showed tumor enlargement and 8 patients (1.4%) developed LNM. The 10-year progression rate was 13.1%. Age, sex, and calcification pattern did not differ significantly between uni- and multifocal diseases. However, anti-thyroglobulin antibody and/or anti-thyroid peroxidase antibody was more frequently positive with multifocal PTMCs (46.7%) than with unifocal disease (34.4%, p = 0.024). Patients with uni- and multifocal disease showed no significant differences in 10-year rate of tumor enlargement (11.4% vs. 14.8%), LNM development (1.1% vs. 2.4%), or progression (12.4% vs 15.9%). Multivariate analysis of predictors for progression showed multifocality was not a significant risk factor (odds ratio, 1.45; 95% confidence interval, 0.79-2.54; p = 0.22). Eventually, 9 patients (7.9%) with multifocal PTMCs underwent surgery and 7 needed total thyroidectomy, although 7 still showed T1N0M0 low-risk cancer. CONCLUSIONS: Even patients with multiple PTMCs (T1amN0M0) are good candidates for AS. Many patients can avoid total thyroidectomy and subsequent surgical complications.

Position paper from the Japan Thyroid Association task force on the management of low-risk papillary thyroid microcarcinoma (T1aN0M0) in adults.

The incidence of thyroid carcinoma has been increasing worldwide. This is interpreted as an increase in the incidental detection of papillary thyroid microcarcinomas (PTMCs). However, mortality has not changed, suggesting overdiagnosis and overtreatment. Prospective clinical trials of active surveillance for low-risk PTMC (T1aN0M0) have been conducted in two Japanese institutions since the 1990s. Based on the favorable outcomes of these trials, active surveillance has been gradually adopted worldwide. A task force on the management of PTMC in adults organized by the Japan Thyroid Association therefore conducted a systematic review and has produced the present position paper based on the scientific evidence concerning active surveillance. This paper indicates evidence for the increased incidence of PTMC, favorable surgical outcomes for low-risk PTMC, recommended criteria for diagnosis using fine needle aspiration cytology, and evaluation of lymph node metastasis (LNM), extrathyroidal extension (ETE) and distant metastasis. Active surveillance has also been reported with a low incidence of disease progression and no subsequent recurrence or adverse events on survival if conversion surgery was performed at a slightly advanced stage. Active surveillance is a safe and valid strategy for PTMC, because it might preserve physical quality of life and reduce 10-year medical costs. However, some points should be noted when performing active surveillance. Immediate surgery is needed for PTMC showing high-risk features, such as clinical LNM, ETE or distant metastasis. Active surveillance should be performed under an appropriate medical team and should be continued for life.

Video-assisted neck surgery (VANS) using a gasless lifting procedure for thyroid and parathyroid diseases: "The VANS method from A to Z".

PURPOSE: To describe and evaluate our video-assisted neck surgery (VANS) method for thyroid and parathyroid diseases. METHODS: We describe in detail the VANS method for enucleation, lobectomy, total (nearly total) thyroidectomy, and lymph node dissection for malignancy and Graves' disease. In collaboration with the Japan Society of Endoscopic Surgery (JSES), we evaluated several aspects of this method. The JSES evaluated the method for working-space formation and surgical complications, whereas we examined the learning curve of the surgeons, and the cosmetic satisfaction of the patients and the degree of numbness and pain they experienced. We also asked patients who underwent conventional surgery whether they would have selected VANS had it been available. RESULTS: The working space for 81.5% of the procedures in Japan was created using the gasless lifting method. The learning curve, considering both blood loss and operating time, decreased after 30 cases. Both factors improved for tumors smaller than 5 cm in diameter. Over 60% of the patients who underwent conventional surgery stated that they would have selected VANS, had it been available. Postoperative pain was worse after conventional surgery than after VANS, but neck numbness after VANS was more frequent than expected. CONCLUSIONS: The VANS method is a feasible, safe, and cost-effective procedure with clear cosmetic advantages over conventional surgery.

Cohort study exploring the effect of lenvatinib on differentiated thyroid cancer.

Lenvatinib is a molecular-targeting agent that was recently approved in Japan for treatment of curatively unresectable, radioactive iodine-refractory, progressive differentiated thyroid cancer (DTC). Because only a few Japanese patients have received lenvatinib in clinical trials, there are limited domestic data on its safety and efficacy or prognostic factors. Therefore, a prospective observational study has been designed to collect safety and efficacy data in at least 300 patients with curatively unresectable DTC receiving lenvatinib therapy (24 mg/day), in order to find predictors of antitumor activity and survival. Patients with progressive curatively unresectable DTC refractory to radioiodine therapy will be enrolled and the primary endpoint will be overall survival. This study is designed to estimate the 95% confidence intervals of the 1-year and 2-year survival rates with a two-sided width of less than 10%. Secondary endpoints will be the time to treatment failure, time to strategy failure, progression-free survival time with clinical progressive disease, response rate, quality of life, safety, and patient reports. The ultimate goal is to obtain information for developing evidence-based guidelines for treatment of DTC, including recommendations on patient selection, dosages, and duration of treatment. This study has been registered with the UMIN Clinical Trials Registry (UMIN000022243).

Clinicopathological significance of a solid component in papillary thyroid carcinoma.

AIMS: Solid variant of papillary thyroid carcinoma (SVPTC) is characterized by a solid component (SC) involving more than 50% of the tumour with the preservation of the classical cytological features of papillary thyroid carcinoma (PTC). However, the clinical significance of SC in PTC has been rarely examined. Herein, we investigated retrospectively the clinicopathological features of PTC with various degrees (10-85%) of SC (PTCSC). METHODS AND RESULTS: Patients with PTCSC (n = 27) were stratified into SC-major (SC > 50% of the tumour) and SC-minor (SC < 49%) groups. The clinicopathological parameters were compared to the well-differentiated PTC (WPTC) group (n = 47). Both SC-minor (n = 18) and SC-major (n = 9) groups had increased incidence of a large-sized tumour, extracapsular extension and a high recurrence rate, compared to WPTC. Disease-free survival (DFS) of both SC-minor and SC-major was shorter than that of WPTC (P = 0.035 and P = 0.016, respectively). Overall survival was similar among all the groups. Univariate analysis revealed that SC was associated significantly with a recurrence rate (P = 0.018). Using multivariate analysis, SC appeared to be associated with a recurrence rate with borderline significance (P = 0.055). CONCLUSIONS: Our findings indicate that the presence of SC in PTC, regardless of the proportion, is associated with adverse clinical parameters and a shorter DFS.

Natural History of Asymptomatic Papillary Thyroid Microcarcinoma: Time-Dependent Changes in Calcification and Vascularity During Active Surveillance.

BACKGROUND: Prospective trials of non-surgical observation have shown progression rates of only 5-10% in patients with asymptomatic papillary microcarcinoma (PMC). This study investigated time-dependent changes in calcification patterns and tumor vascularity on ultrasonography (US) to clarify the natural course of PMC. METHODS: We examined calcification patterns and tumor vascularity for 480 lesions in 384 patients. Calcification patterns were classified as: (A) none; (B) micro; (C) macro; or (D) rim. Tumor vascularity was classified as rich or poor via color Doppler US. RESULTS: After a mean of 6.8 years of observation, 29 lesions (6.0%) had increased in size. Mean age for initial calcification pattern was 52.1 years for A (n = 135), 54.2 years for B (n = 235), 56.3 years for C (n = 96), and 60.1 years for D (n = 14), and the incidence rates of tumor enlargement were 9.6, 5.5, 3.2, and 0%, respectively. The cumulative rate of upgrade in calcification pattern was 51.8% at 10 years. Lesions with initially rich vascularity (n = 70) had significantly higher rate of tumor enlargement than those with poor vascularity (n = 410); however, the majority of tumor (61.4%) with initially rich vascularity had decreased their blood supply during the follow-up. Multivariate analysis showed that strong calcification (C or D) and poor vascularity at last examination correlated significantly with non-progressive disease. CONCLUSIONS: PMCs in older patients showed significantly stronger calcification patterns and poorer vascularity. Both consolidation of calcification and loss of vascularity occurred in a time-dependent manner during observation and were significant indicators for non-progressive disease.

Tyrosine-kinase inhibitors to treat radioiodine-refracted, metastatic, or recurred and progressive differentiated thyroid carcinoma [Review].

Differentiated thyroid carcinoma (DTC) is generally indolent in nature and, even though it metastasizes to distant organs, the prognosis is normally excellent. In contrast, the overall survival (OS) of patients with radioactive iodine (RAI)-refractory and progressive metastases is dire, because no effective therapies have been available to control the metastatic lesions. However, recently, administration of tyrosine-kinase inhibitors (TKIs) has become a new line of therapy for RAI-refractory and progressive metastases. Previous studies have reported significant improvement regarding the progression-free survival rates of patients with metastatic lesions. However, TKIs cause various severe adverse events (AEs) that damage patients' quality of life and can even be life-threatening. Additionally, metastatic lesions may progress significantly after stopping TKI therapy. Therefore, it is difficult to determine who is a candidate for TKI therapy, as well as how and when physicians start and stop the therapy. The present review, created by Committee of pharmacological therapy for thyroid cancer of the Japanese Society of Thyroid Surgery (JSTS) and the Japan Association of Endocrine Surgeons (JAES) describes how to appropriately use TKIs by describing what we do and do not know about treatment using TKIs.

Histopathological analysis of anaplastic thyroid carcinoma cases with long-term survival: A report from the Anaplastic Thyroid Carcinoma Research Consortium of Japan.

The aim of this study was to clarify the histopathological features of anaplastic thyroid carcinoma in patients who achieved long-term survival. We reviewed 88 anaplastic thyroid carcinoma cases in which the patient survived less than 3 months (short-term survival), and 68 anaplastic thyroid carcinoma cases in which the patient survived more than one year (long-term survival) from the database of the Anaplastic Thyroid Carcinoma Research Consortium of Japan. We examined these cases both histologically and immunohistochemically. Six (6.8%) short-term survival cases and 27 (39.7%) long-term survival cases were considered not to be anaplastic thyroid carcinoma after central review. Of these, 12 were revised to papillary carcinoma with squamous cell carcinoma. In cases without chemotherapy, long-term survival was significantly more common if there was a pre-existing tumor, epithelial growth, or lymphocytic infiltration, and short-term survival was more common if neutrophilic infiltration was present. In cases with chemotherapy, long-term survival was significantly more common if epithelial growth or a squamous cell carcinoma component was present, whereas short-term survival was more common in cases with rhabdoid cells. Immunohistochemical results were not related to survival. Some long-term survival cases showed histological findings other than those typically associated with anaplastic thyroid carcinoma. The presence of a pre-existing tumor, epithelial growth, a squamous cell carcinoma component, no neutrophilic infiltration and lymphocytic infiltration may therefore be favorable prognostic factors in anaplastic thyroid carcinoma.

Prospective Evaluation of Zoledronic Acid in the Treatment of Bone Metastases from Differentiated Thyroid Carcinoma.

PURPOSE: The objectives of this study were to prospectively delineate the efficacy and safety of zoledronic acid for treating bone metastases (BM) from differentiated thyroid carcinoma (DTC), and to evaluate the relationships between levels of bone metabolic markers and occurrence of skeletal-related events (SREs). METHODS: This was a prospective, single-arm, single-center study. Nineteen patients with BM from DTC were assigned to receive zoledronic acid therapy every 4-5 weeks. Imaging studies for sites of BM were conducted every 6 months, and levels of bone metabolic markers, including serum bone-specific alkaline phosphatase (BAP) and urinary N-telopeptide of type I collagen (NTx), were assessed every 3 months. To evaluate the efficacy of zoledronic acid use, data of SREs were compared with those of 16 historical controls. RESULTS: SREs developed in eight patients (42 %), but metastatic spinal cord compression (MSCC) appeared in only one patient. Pain scores were ameliorated in five patients, but aggravated in six patients. Ten patients had stable disease, six showed progressive disease, and none showed partial or complete response during the observation period. Decreases in levels of bone metabolic markers were observed in ten patients for BAP and 15 for NTx. However, no significant correlations were identified between changes in bone metabolic marker levels and development of SREs. CONCLUSIONS: Zoledronic acid may offer a mainstay of multidisciplinary treatment for patients with BM for the purpose of reducing SREs. Levels of serum BAP and urinary NTx do not appear reliable as indicators of amelioration of BM symptoms.

Concept and design of a nationwide prospective feasibility/efficacy/safety study of weekly paclitaxel for patients with pathologically confirmed anaplastic thyroid cancer (ATCCJ-PTX-P2).

BACKGROUND: Anaplastic thyroid cancer (ATC) is one of the most aggressive malignancies in humans, often demonstrating resistance to multimodal therapeutic approaches. The median survival of ATC patients after initial diagnosis was reported to be <6 months due to the rapid progression of disease by dissemination and/or invasion. There have been several reports describing possible effective chemotherapies, but these studies might be biased by the nature of retrospective accumulations of clinical experiences, and thus reliable data concerning the efficacies of the treatment efforts are required. DESIGN: In 2009, we established the research organization Anaplastic Carcinoma Research Consortium Japan (ATCCJ) to investigate this highly malignant disease. Using this nationwide organization, we conducted a prospective clinical study to investigate the feasibility, safeness, and efficacy of chemotherapy with weekly paclitaxel for ATC patients. This trial is registered on the clinical trials site of the University Hospital Medical Information Network Clinical Trials Registry Web site (UMIN000008574). The study was started in 2012, and enrollment was closed in March 2014 after accumulating 71 patients from 28 registered institutes. The follow-up data will be available in April 2015. DISCUSSION: Important information concerning the management of this disease is expected to be revealed by this study. The concept and design of the study are described herein.

Chemotherapy for anaplastic thyroid cancer using docetaxel and cisplatin: report of eight cases.

Anaplastic thyroid carcinoma has a dismal prognosis and lacks an established therapeutic strategy. We have recently conducted chemotherapy with docetaxel and cisplatin as part of multimodal treatment for eight patients with anaplastic thyroid carcinoma. Docetaxel (75 mg/m2) and cisplatin (75 mg/m2) were administered on day 1 every 4 weeks for six courses. This chemotherapy was used as induction therapy in one patient, as therapy for distant metastases in five patients and as postoperative adjuvant therapy in two patients. Three patients showed partial responses and three patients showed stable disease. After excluding the two patients receiving the treatment as adjuvant therapy the response rate was 50 %. Grade 3 or 4 leukocytopenia occurred in seven patients (88 %), but these adverse events were tolerable. Chemotherapy with docetaxel and cisplatin may thus be feasible for anaplastic thyroid carcinoma.

Association between serum thyrotropin concentration and growth of asymptomatic papillary thyroid microcarcinoma.

BACKGROUND: Thyrotropin (TSH) is a known thyroid growth factor. Several studies have suggested its potential role in carcinogenesis and the progression of differentiated thyroid carcinoma. We have been conducting a prospective trial of nonsurgical observation for asymptomatic papillary thyroid microcarcinoma (PMC) since 1995. The aim of this study was to investigate whether serum TSH concentrations can be used to predict PMC growth. METHODS: This study examined 415 asymptomatic PMCs.Three hundred twenty-two patients decided to undergo nonsurgical observation by ultrasonography and were followed for ≥ 2 years. RESULTS: After a mean of 6.5 years of observation (range 2-22 years), 25 lesions (6 %) had increased in size, 377(91 %) showed no change and 13 (3 %) had decreased in size. Both baseline TSH and mean TSH during follow-up for PMC that increased in size did not differ significantly from those lesions that were unchanged or decreased in size. Increases in size were seen in 0 of 18 (0 %), 15 of 260(6 %), 10 of 126 (8 %), and 0 of 11 (0 %) for PMCs with baseline TSH <0.50, 0.50-1.99, 2.00-3.99, and ≥ 4.00 mIU/L, respectively. A logistic regression model analyzing the association between baseline TSH and outcome showed an odds ratio of 1.01 (95 % confidence interval [CI], 0.66-1.29). No significant correlations were apparent between mean TSH during follow-up and change in PMC volume (r = 0.019, p = 0.70). CONCLUSIONS: No significant association between TSH and tumor progression was verified during the nonsurgical observation trial for PMC. TSH is not a good predictor of PMC growth.

Anaplastic thyroid carcinomas incidentally found on postoperative pathological examination.

BACKGROUND: Anaplastic thyroid carcinoma (ATC) is occasionally found on postoperative pathological examination of patients with differentiated thyroid carcinoma (DTC). There is no general consensus on how we should treat these incidentally diagnosed ATC (incidental ATC). MATERIALS AND METHODS: A total of 675 patients with ATC were registered with the ATC Research Consortium of Japan. These patients were treated between 1995 and 2008 in 38 registered institutions. About 81 % of the ATC patients had common-type ATC and about 14 % had ATC co-existing with a metastatic DTC lesion. The remaining 5 % had incidental ATC. Among the patients with incidental ATC, we investigated 25 patients whose clinical data were fully available. We examined the clinical profile of incidental ATC, and the relationships between treatment and outcome in patients with incidental ATC. RESULTS: The tumor size was clearly smaller, and patients with extrathyroid invasion or distant metastasis were significantly fewer in incidental ATC than in common-type ATC. Most incidental ATC coexisted with papillary carcinoma. While the clinical course of incidental ATC was favorable compared with common-type ATC, half of the patients had disease-related deaths. The prognostic factors of incidental ATC were nearly the same as those of common-type ATC, but the tumor size alone was an independent factor on multivariate analysis. Regarding treatments, the outcome was more favorable in those who underwent curative resection, and the clinical course showed a slight improvement by the addition of external beam radiotherapy and/or chemotherapy after curative resection, but it did not reach statistical significance. CONCLUSION: Incidental ATC is the only curable type of ATC, and further studies are needed to establish the effectiveness of additional postoperative radiotherapy and/or chemotherapy in incidental ATC.

Surgical management of retropharyngeal nodes metastases from papillary thyroid carcinoma.

BACKGROUND: Papillary thyroid carcinoma (PTC) often metastasizes to the central and lateral neck lymph nodes, but rarely affects retropharyngeal nodes (RPN). METHODS: 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). RESULTS: 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. CONCLUSIONS: 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.

Metastatic thyroid tumors: ultrasonographic features, prognostic factors and outcomes in 29 cases.

PURPOSE: Metastatic thyroid tumors (MTT) are rare and have a poor prognosis. The aim of this retrospective study was to determine the diagnostic features and clinical outcomes of MTT. METHODS: The study subjects comprised 29 patients (age range, 37-78 years) diagnosed with MTT and treated during a 22-year period between 1987 and 2008 at a single tertiary oncology referral center. RESULTS: The primary cancer was breast cancer in 10 patients, lung cancer in six, digestive tract in six, kidney in three, head and neck in three and sarcoma in one patient. In seven patients, the diagnoses of primary cancer and MTT were synchronous. In 22 patients, the mean latency between the diagnosis of the primary cancer and MTT was 66 months (range 7 months-16 years). Based on ultrasonography (US), MTTs were classified into two categories: diffuse type (DT) (n = 9) and nodular type (NT) (n = 18). Eight patients who underwent thyroid surgery showed no survival benefit, but none needed tracheostomy. CONCLUSIONS: MTT should be considered for patients with a history of malignant disease. The findings from US are useful to diagnose MTT. Careful preoperative evaluation can avoid unnecessary thyroidectomy.