Elsevier

Surgery

Volume 159, Issue 6, June 2016, Pages 1557-1564
Surgery

Endocrine
Incidence of metastases from 524 patients with papillary thyroid carcinoma in cervical lymph nodes posterior to the sternoclavicular joint (level VIa): Relevance for endoscopic thyroidectomy

https://doi.org/10.1016/j.surg.2015.12.026Get rights and content

Background

Dissection of central cervical lymph nodes posterior to the sternoclavicular joint is unsatisfactory in endoscopic thyroid surgery via remote access because of the barrier posed by the sternoclavicular joint. The purpose of this study was to determine the incidence and risk factors of papillary thyroid carcinoma (PTC) metastasis to the area posterior to the sternoclavicular joint.

Methods

A total of 524 patients with PTC who underwent traditional thyroid surgery form January 2012 to December 2013 were analyzed retrospectively. Their cervical lymph nodes were harvested and divided into central cervical lymph nodes cranial to the sternoclavicular joint (VIb) and those nodes posterior to the sternoclavicular joint (VIa). The VIa status was correlated with clinicopathologic factors, including sex, age, clinical N classification, comorbid thyroid disease, tumor size, extrathyroidal extension, multifocality, tumor location, and central cervical lymph node metastasis.

Results

The VIa metastases were detected in 138 patients (26.3%; 138 of the 524). There were a mean 3.8 lymph nodes in VIa region, and the average number of metastatic lymph nodes was 0.5. Multivariate logistic regression revealed that cN1, extrathyroidal extension, VIb positivity, tumor size greater than 0.9 cm, and tumor location in the lower third of the thyroid lobe were factors associated with VIa metastasis.

Conclusion

Patients undergoing PTC with tumor location in the lower third of the thyroid lobe, a tumor size greater than 0.9 cm, extrathyroidal extension, or cN1 may be contraindicated for an endoscopic thyroidectomy.

Section snippets

Patients

A retrospective analysis was performed by the use of data collected prospectively from the database of the Head and Neck Surgery Department in Sir Run Run Shaw Hospital, Medical School of Zhejiang University. The study cohort comprised 524 consecutive patients scheduled to undergo standard, open transcervical thyroidectomy for primary PTC from January 2012 to December 2013. This study was approved by the Ethical Committee of Sir Run Run Shaw Hospital, Medical School of Zhejiang University. The

Patient characteristics

The 524 patients who underwent initial thyroidectomy for PTC included 128 men and 396 women, with a mean age of 43.6 years (range, 11–76) at time of first diagnosis. All patients were diagnosed with primary PTC by frozen section examination intraoperatively, with concomitant Hashimoto thyroiditis found in 54 patients. Overall, 3 different operative procedures were performed: (1) lobectomy (including isthmectomy and pyramidal lobectomy) with ipsilateral CND (right 157 patients, and left 137

Discussion

The role of CND (especially prophylactic) in primary surgery for PTC with cN0 is controversial. The consensus among surgeons in mainland China suggests that prophylactic CND (pCND) is indicated during the initial thyroidectomy.14 Major reasons include the following: (1) the estimated incidence of metastasis of the central lymph nodes has been reported to vary from 20 to 90%.15, 16 In our study, central lymph node metastases were confirmed in almost 50% of our 524 patients; these involved lymph

References (37)

  • S.W. Kang et al.

    Initial experience with robot-assisted modified radical neck dissection for the management of thyroid carcinoma with lateral neck node metastasis

    Surgery

    (2010)
  • A. Popadich et al.

    A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer

    Surgery

    (2011)
  • M. Ohgami et al.

    Scarless endoscopic thyroidectomy: breast approach for better cosmesis

    Surg Laparosc Endosc Percutan Tech

    (2000)
  • Y. Ikeda et al.

    Endoscopic thyroidectomy by the axillary approach

    Surg Endosc

    (2001)
  • H. Kitano et al.

    Endoscopic thyroid resection using cutaneous elevation in lieu of insufflation

    Surg Endosc

    (2002)
  • K. Shimazu et al.

    Endoscopic thyroid surgery through the axillo-bilateral breast approach

    Surg Laparosc Endosc

    (2003)
  • Y. Ileda et al.

    Comparative study of thyroidectomies: endoscopic surgery vs conventional open surgery

    Surg Endosc

    (2002)
  • Y.W. Koh et al.

    Endoscopic hemithyroidectomy with prophylactic ipsilateral central neck dissection via an unilateral axillo-breast approach without gas insufflation for unilateral micropapillary thyroid carcinoma: preliminary report

    Surg Endosc

    (2010)
  • Z. Li et al.

    Endoscopic lateral neck dissection via breast approach for papillary thyroid carcinoma: a preliminary report

    Surg Endosc

    (2011)
  • B. Seup Kim et al.

    Robotic modified radical neck dissection by bilateral axillary breast approach for papillary thyroid carcinoma with lateral neck metastasis

    Head Neck

    (2015)
  • S.E. Carty et al.

    Consensus statement on the terminology and classification of central neck dissection for thyroid cancer

    Thyroid

    (2009)
  • D.S. Cooper et al.

    Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer

    Thyroid

    (2009)
  • N.W. Thompson et al.

    The continuing development of the technique of thyroidectomy

    Surgery

    (1973)
  • N. Wada et al.

    Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection

    Ann Surg

    (2003)
  • Management guidelines for patients with thyroid nodules and differentiated thyroid cancer (2012 Chinese edition)

    Chinese J Clin Oncol

    (2012)
  • F. Arturi et al.

    Early diagnosis by genetic analysis of differentiated thyroid cancer metastases in small lymph nodes

    J Clin Endocrinol Metab

    (1997)
  • D.S. Cooper et al.

    Management guidelines for patients with thyroid nodules and differentiated thyroid cancer

    Thyroid

    (2006)
  • Supported by the major science and technology project of Zhejiang Province (grant no. 2012C13020-1), the Natural Science Foundation of Zhejiang Province (grant no. Y2110461), and the key project from the Health and Family Planning Commission of Zhejiang Province (grant no. 2015101112).

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