Papillary thyroid microcarcinoma: A study of 900 cases observed in a 60-year period
Division of Endocrinology and Internal Medicine, Mayo Clinic and College of Medicine, Rochester, Minn, USA. Surgery
(Impact Factor: 3.38).
01/2009; 144(6):980-7; discussion 987-8. DOI: 10.1016/j.surg.2008.08.035
The study aims were to characterize patients with papillary thyroid microcarcinoma (PTM) and to describe post-surgical outcome.
Nine hundred PTM patients had initial treatment at Mayo Clinic during 1945-2004. Mean follow-up was 17.2 years. Recurrence and mortality details were derived from a computerized database.
Median tumor size was 7 mm; 98% were intrathyroidal. 273 patients (30%) had neck nodal involvement; 3 (0.3%) had distant metastases at diagnosis. Seven-hundred and sixty-five (85%) underwent bilateral lobar resection (BLR; total-, near-total, or bilateral subtotal thyroidectomy). Regional nodes were removed by either "node picking" (27%) or compartmental dissection (23%). Tumor resection was incomplete in 5 (0.6%). Radioiodine remnant ablation (RRA) was performed in 155 (17%). Overall survival did not differ from expected for an age and gender matched control group (P = .96); 3 patients (0.3%) died of PTM. None of the 892 patients with initial complete tumor resection developed metastatic spread during 20 postoperative years. Twenty-year and 40-year tumor recurrence rates were 6% and 8%, respectively. Higher recurrence rates were seen with multifocal tumors (P = .004) and node-positive patients (P < .001). Neither more extensive surgery nor RRA reduced recurrence rates compared to unilateral lobectomy.
More than 99% of PTM patients are not at risk of distant spread or cancer mortality. RRA after BLR did not improve postoperative outcome.
Available from: Giovanni Conzo
- "In a high percentage of cases, central or lateral lymph nodal metastases are observed without a demonstrated impact on survival, as well as the discordance between the rate of lymph node micrometastases and the low incidence of clinical recurrence, following TT without routine LD, is still subject of research. Nevertheless, it must be considered that, especially in older patients, lymphatic metastases may affect recurrence and survival rates . Multifocal primary tumor, infiltration of thyroid capsule, patient age (pediatric or geriatric population), tumor size, several oncogenes (p53, BRAF), are associated with node involvement and are considered the main risk factors for recurrence . "
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ABSTRACT: Introduction: Lymph nodal involvement in papillary thyroid cancers is very common, but the role of lymph node dissection is still controversial. Surgeons are consequently divided between opposed to and in favor of routine central neck dissection associated with total thyroidectomy. Methods: Clinical records of 210 patients undergoing from January 2000 to December 2006 total thyroidectomy without routine lymph node dissection were retrospectively evaluated. One hundred and ninety eight patients (94.2%) underwent radioiodine ablation as well, followed by Thyroid Stimulating Hormone suppression therapy. In patients with loco regional lymph nodal recurrence, central (VI) and ipsilateral (III-IV) lymph node dissection was performed. Results: Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent vocal fold paralysis were respectively 1.4% and 1.9%. After an 8-year mean follow-up, the rate of loco regional recurrence was 4.2%-9/210 patients. In these cases selective lymph node dissection was carried out without complications. Discussion: The role of neck dissection in papillary thyroid cancer management, is still subject of research and controversial regarding routine or therapeutic indications, surgical extension, its impact on local recurrence and survival. Conclusion: A low loco regional recurrence rate may be observed after total thyroidectomy without prophylactic lymph node dissection. Lymph nodal recurrences were more frequent in young male patients, sometime affected by follicular variant, in each case less than 2 cm. There is a general agreement about the extension of therapeutic lymph node dissection, while routine central neck dissection is still controversial and may be indicated in high risk patients. (C) 2014 Published by Elsevier Ltd on behalf of Surgical Associates Ltd.
International Journal of Surgery (London, England) 05/2014; 12. DOI:10.1016/j.ijsu.2014.05.010 · 1.53 Impact Factor
Available from: Claudio Gambardella
- "The high rate of micro and clinical nodal metastases is in contrast with the low incidence of clinical recurrence following TT without LD, and remains an "obscure" issue in oncology. According to recent studies, nodal metastases may affect recurrence and survival rates especially in older patients . Multifocal primary tumor, infiltration of thyroid capsule, patient age (pediatric or geriatric population), tumor size greater than 3 cm, several oncogenes (p53, BRAF), nodal metastases (number and size), as demonstrated in our series, are considered the main risk factors for local recurrence [16,23]. "
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The significance of nodal metastases, very common in papillary thyroid cancer, and the role of lymph node dissection in the neoplasm management, are still controversial. The impact of lymph node involvement on local recurrence and long-term survival remains subject of active research. With the aim to better analyze the predictive value of lymph node involvement on recurrence and survival, we investigated the clinico-pathological patterns of local relapse following total thyroidectomy associated with lymph node dissection, for clinical nodal metastases papillary thyroid cancer, in order to identify the preferred surgical treatment.
Clinical records, between January 2000 and December 2006, of 69 patients undergoing total thyroidectomy associated with selective lymph node dissection for clinical nodal metastases papillary thyroid cancer, were retrospectively evaluated. Radioiodine ablation, followed by Thyroid Stimulating Hormone suppression therapy was recommended in every case. In patients with loco regional lymph nodal recurrence, a repeated lymph node dissection was carried out. The data were compared with those following total thyroidectomy not associated with lymph node dissection in 210 papillary thyroid cancer patients without lymph node involvement, at preoperative ultrasonography and intra operative inspection.
Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent monolateral vocal fold paralysis were respectively 1.4 % (1/69) and 1.4% (1/69), similar to those reported after total thyroidectomy "alone". The rate of loco regional recurrence, with positive cervical lymph nodes, following 8 year follow-up, was 34.7% (24/69), higher than that reported in patients without nodal metastases (4.2%). A repeated lymph node dissection was carried out without significant complications.
Nodal metastases are a predictor of local recurrence, and a higher rate of lymph node involvement is expected after therapeutic lymph node dissection associated with total thyroidectomy. The prognostic significance of nodal metastases on long-term survival remains unclear, and more prospective randomized trials are requested to better evaluate the benefits of different therapeutic approaches.
BMC Surgery 10/2013; DOI:10.1186/1471-2482-13-S2-S3. · 1.40 Impact Factor
Available from: ncbi.nlm.nih.gov
- "Despite good overall prognosis of PTMC, recurrence of the disease after initial surgical cure remains a troublesome problem.9,12,13 According to the study by Hay, et al.,14 the recurrence within cervical lymph nodes was more than 80%. They noted "nodes beget nodes". "
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ABSTRACT: We evaluated whether the clinicopathological factors of papillary thyroid microcarcinoma (PTMC), especially tumoe size, are associated with subcinical central lymph node metastasis.
A total of 160 patients diagnosed with PTMC who underwent total thyroidectomy with bilateral central lymph node dissection were enrolled in this study. All patients were clinically lymph node negative PTMC. Patients were divided into 2 groups according to the size of tumor (≤5 mm vs. >5 mm). Clinicopathologic risk factors for subclinical central lymph node metastasis were analyzed.
Subclinical central lymph node metastasis was detected in 61 (38.1%). Patients with tumors ≤5 mm had a lower frequency of extrathyroidal extension, multifocality and subclinical central lymph node metastasis. On multivariate analysis, only male and tumor size >5 mm were independent predictors of subclinical central lymph node metastasis; age, multifocality, bilaterality, extrathyroidal extension, lymphvascular invasion and lymphocytic thyroiditis were not.
In this study, male and tumor size >5 mm were two independent predictive factors for subclinical central lymph node metastasis in PTMC. These are easier factors to assess before surgery than other factors when planning the central lymph node dissection. However, further long-term follow-up studies are needed to confirm the prognostic significance of subclinical central lymph node metastasis in PTMC.
Yonsei medical journal 09/2012; 53(5):924-30. DOI:10.3349/ymj.2012.53.5.924 · 1.29 Impact Factor
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