Clinical research strategy for cN0 thyroid papillary carcinoma central lymph node dissection / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the pattern of central lymph node metastasis of cN0 single thyroid papillary carcinoma and provide clinical evidence-supported proof for central lymph node dissection.</p><p><b>METHODS</b>The performed thyroidectomy and bilateral central lymph node dissection for 150 patients with cN0 single papillary thyroid carcinoma. The bilateral central lymph nodes were divided into 4 parts: the cornu inferius cartilaginis thyroideae region of ipsilateral central area, the lower part of ipsilateral central area, the cornu inferius cartilaginis thyroideae region of contralateral central area, the lower part of contralateral central area on the baseline of 1 cm below the cornu inferius cartilaginis thyroideae. We analyzed the differences and influencing factors of lymph node metastasis in these 4 parts.</p><p><b>RESULTS</b>The lymph node metastasis rate in lower part of ipsilateral central area was the highest (56.7%), followed by the lower part of contralateral central area (28.0%), the cornu inferius cartilaginis thyroideae region of ipsilateral central area (17.3%), and the cornu inferius cartilaginis thyroideae region of contralateral central area (0). In the logistic analysis of multiple factors, invaded thyroid capsule was an independent factor for lymph node metastasis in both the cornu inferius cartilaginis thyroideae region of ipsilateral central area (β = 0.1835, χ(2) = 0.3102, P < 0.05) and lower part of contralateral area (β = 0.3166, χ(2) = 1.4640, P < 0.05). The patients' age ≥ 45 years (β = 0.5737, χ(2) = 6.5923) and invaded thyroid capsule (β = 0.4258, χ(2) = 3.4735) were independent factors for lower part of ipsilateral central area (both P < 0.05).</p><p><b>CONCLUSION</b>The cornu inferius cartilaginis thyroideae region of contralateral central area of cN0 single PTC patients could not be cleared routinely.</p>

Lateral neck lymph node metastasis in cN0 papillary thyroid carcinoma / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To study the pattern of lymph node spread in papillary thyroid carcinoma (PTC) with clinically negative node (cN0).</p><p><b>METHODS</b>A total of 106 patients with cN0 PTC who underwent total or subtotal thyroidectomy plus unilateral or bilateral lateral neck dissection (LND, level II-V or level I-V) at West China Hospital of Sichuan University between April 2004 and August 2010 were analyzed retrospectively.</p><p><b>RESULTS</b>The lateral neck lymph node metastasis in cN0 PTC was significantly associated with sex (male, P = 0.007), tumor stage (T3/T4, P = 0.006), tumor size (> 1 cm, P = 0.014) and the number of positive central lymph nodes (≥ 2, P < 0.001), but not with age and multifocal tumor. Level III (47/116, 40.5%) was the most prevalent metastatic site, followed by level IV (41/116, 35.3%), level II (18/116, 15.5%) and level V (2/29, 6.9%). Of the cases with lymph node metastases in level III and IV, 89.8% (79/88) of primary thyroid tumors existed in the lower and middle sites of the thyroid lobes, while in the cases with lymph node metastases in level II, 77.8% (14/18) of primary thyroid tumors in the upper sites of the thyroid lobes, and 83.3% of cases with level II metastases were accompanied with level III metastases. Two cases with level V metastases were accompanied with metastases in levels II, III and IV.</p><p><b>CONCLUSIONS</b>LND should be considered for cN0 PTC in male, with T3/T4 lesions and positive central lymph nodes ≥ 2, and the range of dissection should include level III and IV. Dissection of level II should be considered in cN0 PTC with primary tumor localized in the upper site of the thyroid lobe or with level III metastasis. Dissection of level V should be considered at present of metastases in level II, III, and IV. For cN0 PTC with tumor size < 1 cm, confined to the thyroid and without lymph node metastasis in the central compartment, LND is not recommended.</p>

Related factors of central lymph node metastasis in papillary thyroid carcinoma / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To study the related factors of central lymph node (CLN) metastasis in papillary thyroid carcinoma (PTC),the indications and the extent of central neck dissection (CND).</p><p><b>METHODS</b>A total of 153 cases treated between Jan. 2009 and Dec. 2010 was analysed retrospectively. Of the cases 28 males and 125 cases females, with a mean age of (44 ± 14) years. T1, T2, and T3 diseases accounted for 51, 10 and 81 cases, respectively; I, II, III and IV diseases for 88, 3, 26 and 36 cases, respectively. Multifocal tumors were found in 63 cases. The related clinicopathologic factors were analyzed, including sex, age, tumor size, extrathyroidal extension, and multifocal tumor.</p><p><b>RESULTS</b>All the cases had total/near total thyroidectomy and CND, of them 64 cases had unilateral neck dissection and 18 cases had bilateral neck dissection. CLN metastases existed in 68.6% (105/153) cases, 37.2% (57/153) for unilateral and 31.4% (48/153) for bilateral respectively. The rates of CLN metastasis were 86.6% (71/82) in cN1 cases and 47.9% (34/71) cN0 cases, respectively,and the rates of bilateral CLN metastases were 45.1% (37/82) in cN1 cases and 15.5% (11/71) in cN0 cases. Multivariate analysis showed that extrathyroidal extension (P = 0.002, OR = 3.502) was an independent risk factor for CLN metastasis and that lateral neck lymph node metastasis (P = 0.028, OR = 3.080), surrounding tissue invasion (P = 0.014, OR = 3.113), and maximum tumor diameter greater than 1 cm (P = 0.012, OR = 3.732) were independent risk factors for bilateral CLN metastases.</p><p><b>CONCLUSIONS</b>It is indicated that ipsilateral CND should be obligatory for PTC. Intraoperative frozen section examination should be routine. Bilateral CND should be conducted when ipsilateral CLN metastases accompanied by one of following issues such as more invasive tumor (surrounding tissue invasion, T3 or T4 disease), maximum tumor diameter greater than 1 cm, and lateral neck lymph node metastasis.</p>

Predictors of level V lymphatic metastasis in papillary thyroid carcinoma / 中华外科杂志

<p><b>OBJECTIVE</b>To study the predictors of level V metastasis in papillary thyroid carcinoma (PTC).</p><p><b>METHODS</b>The clinic data of 122 patients with PTC who underwent therapeutic lateral neck dissection between March 2004 and November 2010 was analyzed retrospectively. There were 31 male and 91 female patients. The median age at diagnosis was 38.5 years (ranging from 8 to 87 years). All the patients had undergone unilateral or bilateral lymph node dissection (II-VI or I-VI). Univariate analysis and multivariate analysis were performed using χ(2) test and binary Logistic regression test, respectively.</p><p><b>RESULT</b>The level V metastases was significantly associated with capsular invasion, extrathyroidal extension, preoperative distant metastasis, the size of primary, ipsilateral level IV lymph node metastasis and simultaneous metastases to ipsilateral level II, III and IV (χ(2) = 4.223 - 13.748, P < 0.05). Age, sex, tumor-multifocal, pTNM, central lymph node metastases ipsilateral level II lymph node metastases and ipsilateral level III lymph node metastases were not found to be associated with level V metastases (χ(2) = 0.882 - 3.167, P > 0.05). In multivariate analysis, extrathyroidal extension (OR = 8.32, 95%CI: 2.44 - 28.3, P = 0.001) and simultaneous metastases to ipsilateral level II, III and IV (OR = 7.81, 95%CI: 2.11 - 28.8, P = 0.002) were independent predictors of level V metastasis.</p><p><b>CONCLUSIONS</b>Extrathyroidal extension, simultaneous metastases to ipsilateral level II, III and IV are risk factors for level V lymph nodes metastases in PTC. Dissection of level V lymph nodes should be considered for PTC patients with extrathyroidal extension and simultaneous metastases to ipsilateral level II, III and IV.</p>

Sequential defunctionalization followed by thyroxine supplementation as preoperative preparation of hyperthyroid patients undergoing thyroidectomy / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Preparing hyperthyroid patients for thyroid surgery with a combination of antithyroid drugs and thyroxine has long been controversial because this combination usually results in only partial inhibition of thyroid function. We therefore used large doses of antithyroid drugs to completely inhibit the synthesis of thyroxine and render the thyroid gland defunctionalized. We then administered physiologic doses of thyroxine to inhibit thyroid-stimulating hormone secretion. We have named this treatment "sequential thyroid defunctionalization followed by thyroxine supplementation."</p><p><b>METHODS</b>Four hundred and seventy-one hyperthyroid patients seen at our hospital were divided into experimental and control groups. The control group was treated preoperatively with antithyroid drugs and iodine preparation. The experimental group was further divided into four subgroups and treated with "sequential thyroid defunctionalization followed by thyroxine supplementation". Each of the four subgroups received different doses of antithyroid drugs and thyroxine for differing time periods. Thyroid function was assessed at each stage of treatment, as were operative blood loss volumes and postoperative complications.</p><p><b>RESULTS</b>Compared to the control group, the four experimental groups showed less thyroid congestion and surface varices at surgery. Patients in subgroup A also had thyroid glands that were almost histologically normal. The mean operative blood loss volume of the experimental group was less than that of the control group (326 +/- 163) ml in the control group; (196 +/- 57) ml in subgroup A; (230 +/- 71) ml in subgroup B; (240 +/- 80) ml in subgroup C; and (312 +/- 97) ml in subgroup D). The postoperative complication rate of the experimental group was 8.64% (21/243) whereas that of the control group was 17.54% (40/228).</p><p><b>CONCLUSIONS</b>Sequential thyroid defunctionalization followed by thyroxine supplementation is effective in reducing the bleeding volume and postoperative complication rate in selected hyperthyroid patients undergoing thyroidectomy.</p>