Pattern of regional metastases and prognostic factors in differentiated thyroid carcinoma.
ABSTRACT The meaning of nodal metastases in well-differentiated thyroid carcinoma is controversial. The Authors analyse the impact of lymphatic spread reviewing 1503 cases of well-differentiated thyroid carcinoma treated at the National Cancer Institute of Rome between 1988 and 2005, in order to detect significant prognostic factors through multivariate analysis. Overall, 462 cases of locally advanced well-differentiated thyroid carcinoma, were considered. A multivariate analysis of a subgroup, comprising 97 N+ consecutive cases of well-differentiated thyroid carcinoma, previously untreated, was performed to study prognostic factors for local (N+) and distant (M+) metastasis in well-differentiated thyroid carcinoma. Of the 97 cases, 88 were submitted to surgery for a large well-differentiated thyroid carcinoma, 9 for occult differentiated thyroid carcinoma. After surgery, 12 patients were lost to follow-up, 8 resulted pathologically negative, therefore only 77 cases of pN1 well-differentiated thyroid carcinoma were studied. Considering all cases of well-differentiated thyroid carcinoma, 10-year-overall survival was 58.7% for locally advanced well-differentiated thyroid carcinoma, compared to 94.8% in low stage cases. Neck dissection, margin infiltration and extra-capsular spread were significant prognostic factors. The Authors present a retrospective study of 77 patients with primary differentiated thyroid carcinoma, submitted to thyroidectomy and neck dissection aimed at analysing distribution of nodal metastases according to Robbins' levels classification and defining their prognostic value. All N1b cases, retrospectively reviewed (n. 77), presented clinical and histological evidence of neck nodes metastases from differentiated thyroid carcinoma; histological reports indicated tumour localisation and topographical distribution of metastases; papillary carcinoma was the most common type (72 cases), followed by follicular carcinoma (5 cases). Surgical treatment always comprised total thyroidectomy and 6(th) level dissection. Overall 52 cases were submitted to monolateral neck dissection, 25 to bilateral neck dissection. Treatment of the lateral neck was postero-lateral neck dissection (n. 53), selective lateral neck dissection (n. 20), modified radical and radical (n. 29). Cervical level IV was the most frequently involved (52%), extra-capsular spread of metastases was identified in 22% of the cases. Statistically significant prognostic factors for distant metastases and recurrence on the neck were follicular carcinoma (p < 0.01) and extra-capsular spread (p < 0.001). Age, pT, sex, number of positive nodal metastases, T-extension and the number of nodal positive levels were not significant. In the Authors' experience, histological grade of differentiation, wide tumour excision and neck dissection, in cases of N1b well-differentiated thyroid carcinoma, without residual disease (R1, R2), in the central and lateral neck, are determinant prognostic factors. Extracapsular spread in particular, was found to be a highly predictive factor either of distant metastasis or regional recurrence.
ACTA OTORHINOLARYNGOLOGICA ITALICA 2009;29:312-316
Pattern of regional metastases and prognostic
factors in differentiated thyroid carcinoma
Metastatizzazione linfonodale e fattori prognostici nel carcinoma differenziato
G. SPRIANO, P. RUSCITO, R. PELLINI, M. APPETECCHIA1, R. ROSELLI
Department of Otolaryngology, Head & Neck Surgery, 1 Endocrinology Unit, Regina Elena National Cancer Institute,
The meaning of nodal metastases in well-differentiated thyroid carcinoma is controversial. The Authors analyse the impact of lymphatic
spread reviewing 1503 cases of well-differentiated thyroid carcinoma treated at the National Cancer Institute of Rome between 1988 and
2005, in order to detect signifi cant prognostic factors through multivariate analysis. Overall, 462 cases of locally advanced well-differenti-
ated thyroid carcinoma, were considered. A multivariate analysis of a subgroup, comprising 97 N+ consecutive cases of well-differentiated
thyroid carcinoma, previously untreated, was performed to study prognostic factors for local (N+) and distant (M+) metastasis in well-
differentiated thyroid carcinoma. Of the 97 cases, 88 were submitted to surgery for a large well-differentiated thyroid carcinoma, 9 for
occult differentiated thyroid carcinoma. After surgery, 12 patients were lost to follow-up, 8 resulted pathologically negative, therefore only
77 cases of pN1 well-differentiated thyroid carcinoma were studied. Considering all cases of well-differentiated thyroid carcinoma, 10-
year-overall survival was 58.7% for locally advanced well-differentiated thyroid carcinoma, compared to 94.8% in low stage cases. Neck
dissection, margin infi ltration and extra-capsular spread were signifi cant prognostic factors. The Authors present a retrospective study of
77 patients with primary differentiated thyroid carcinoma, submitted to thyroidectomy and neck dissection aimed at analysing distribution
of nodal metastases according to Robbins’ levels classifi cation and defi ning their prognostic value. All N1b cases, retrospectively reviewed
(n. 77), presented clinical and histological evidence of neck nodes metastases from differentiated thyroid carcinoma; histological reports
indicated tumour localisation and topographical distribution of metastases; papillary carcinoma was the most common type (72 cases),
followed by follicular carcinoma (5 cases). Surgical treatment always comprised total thyroidectomy and 6th level dissection. Overall 52
cases were submitted to monolateral neck dissection, 25 to bilateral neck dissection. Treatment of the lateral neck was postero-lateral neck
dissection (n. 53), selective lateral neck dissection (n. 20), modifi ed radical and radical (n. 29). Cervical level IV was the most frequently in-
volved (52%), extra-capsular spread of metastases was identifi ed in 22% of the cases. Statistically signifi cant prognostic factors for distant
metastases and recurrence on the neck were follicular carcinoma (p < 0.01) and extra-capsular spread (p < 0.001). Age, pT, sex, number of
positive nodal metastases, T-extension and the number of nodal positive levels were not signifi cant. In the Authors’ experience, histological
grade of differentiation, wide tumour excision and neck dissection, in cases of N1b well-differentiated thyroid carcinoma, without residual
disease (R1, R2), in the central and lateral neck, are determinant prognostic factors. Extracapsular spread in particular, was found to be a
highly predictive factor either of distant metastasis or regional recurrence.
KEY WORDS: Thyroid carcinoma • Nodal metastases • Extra-capsular spread
Il signifi cato delle metastasi linfonodali nel carcinoma differenziato della tiroide è tuttora controverso. Gli Autori analizzano il valore pro-
gnostico della metastatizzazione linfonodale, mediante lo studio retrospettivo di 1503 casi di carcinoma differenziato della tiroide, trattati
presso l’Istituto Nazionale Tumori “Regina Elena” di Roma, nel periodo compreso tra il 1988 ed il 2005. In particolare è stato estrapolato
un sottogruppo di 77 casi di carcinomi sottoposti a tiroidectomia totale, svuotamento linfonodale ricorrenziale (6° livello) e svuotamen-
to linfonodale laterocervicale per metastasi linfonodali (pN1). Quest’ultimo è consistito in uno svuotamento selettivo postero-laterale
(livv. 2-5) in 53 casi, selettivo laterale (livv. 2-4) in 20 casi, radicale modifi cato o radicale in 29 casi. Il livello linfonodale maggiormente
interessato è risultato essere il 4° (52%). La metastatizzazione linfonodale extracapsulare è stata documentata nel 22% dei casi. Sono stati
analizzati mediante analisi multivariata i seguenti parametri: età, sesso, pT, istotipo, il numero di linfonodi, il/i livello/i cervicali coinvolti,
secondo la classifi cazione di Robbins, la diffusione metastatica extra-capsulare dei linfonodi. Sono risultati statisticamente signifi cativi per
la metastatizzazione a distanza e la recidiva linfonodale la variante follicolare (p < 0,01) ed il coinvolgimento extracapsulare delle meta-
stasi linfonodali (p < 0,001). Non sono per contro risultati signifi cativi l’età, il sesso, il numero di linfonodi metastatici, le dimensioni di T.
Nell’esperienza degli Autori l’extracapsularità linfonodale costituisce un importante parametro clinico predittivo del comportamento bio-
logico di un carcinoma tiroideo differenziato e localmente avanzato. Un corretto approccio chirurgico del tumore primitivo e delle stazioni
linfonodali cervicali laterali e del compartimento mediano è allo stato attuale determinante ai fi ni dell’esito oncologico della malattia.
PAROLE CHIAVE: Carcinoma tiroideo • Metastasi linfonodali • Metastasi extra-capsulari
Acta Otorhinolaryngol Ital 2009;29:312-316
Regional metastases and prognostic factors in thyroid carcinoma
From an analysis of the literature, the value of nodal me-
tastasis (N+) appears controversial: some reports consider
them as having a good prognostic impact on survival,
some relate them to higher rates of recurrences and sur-
vival decrease, while other Authors hold that the presence
of N+ is valueless from a prognostic point of view.
Its incidence in differentiated thyroid carcinoma (DTC)
is high, around 40-80% of the cases 1 2 and it varies in re-
lation to each histological variant: papillary carcinoma
80%, follicular and Hurtle cells carcinoma 10-15% 3-5.
In the present investigation, 97 cases of DTC nodal me-
tastases have been retrospectively examined, all homo-
geneously treated in the same Institution, by means of
thyroidectomy and neck dissection. The rates of regional
and distant recurrences were determined according to
histopathological evaluation of pathological variants and
nodal metastases were defi ned by levels, number, site and
extracapsular spread (ECS) 6.
Materials and Methods
A total of 1503 patients were treated for DTC at the Na-
tional Cancer Institute of Rome “Regina Elena” between
1988 and 2005. A sub-group of 97 patients with nodal
metastases in the lateral neck (N1b) was selected, who
had undergone total thyroidectomy and neck dissection,
unilateral or bilateral. Of these, 12 cases were excluded
from the study due to lack of information and 8 due to the
absence of nodal metastases at pathological examination.
Finally, therefore, 77 cases of nodal lateral metastases for
DTC were considered. The demographic characteristics
of the series were as follows: 30 male and 47 female, aged
between 18 and 77 years (mean 51).
According to the Shah risk group classifi cation, this series
was divided into two sub-groups : 33 patients ≤ 45 years
old (43%) and 44 > 45 years old.
All patients were submitted to total thyroidectomy. Patho-
logical fi ndings showed 72 papillary carcinomas (93%)
and 5 follicular carcinomas (7%).
Surgical treatment of the neck consisted of the 6th level
and lateral neck dissection as reported below:
selected neck dissection levels 2-5: 53 cases;
selected neck dissection levels 2-4: 20 cases;
modifi ed radical/radical neck dissection levels 1-5: 29
Lateral neck dissection was ipsilateral to the tumour side
in 52 cases and bilateral in 25, globally comprising over-
all 102 hemi-necks.
Nodal capsular infi ltration and tumour extension were ex-
amined. In case of primary multifocal tumour, nodal me-
tastases were considered ipsilateral in the event of its lo-
calization in the same side as the largest thyroid nodule.
All patients were submitted to post-operative 131I iodine
In the present series, clinical follow-up was performed in
the same Institution, for a period ranging between 4 and
16 years (median 7 years).
Pathological staging was performed following surgery,
according to the TNM (6th edn.) 7. Nodal extra-capsular
spread (ECS) was assessed in all the lymph nodes and cer-
vical levels were studied and divided according to Rob-
bins classifi cation 8.
Multivariate analysis of the prognostic factors, patient-
and tumour-related, has been carried out.
Papillary carcinoma was observed in 93% and follicular
caracinoma in 7% of the cases; ipsilateral metastases were
detected in 63 patients (82%) and bilateral metastases in
14 cases (18%). The pathological T-staging was: pT1
22%, pT2 31%, pT3 9% and pT4a 38%.
Nodal cervical metastases in the lateral neck were studied
considering the number of N+, of involved levels, the evi-
dence of nodal extra-capsular spread.
The mean number of metastatic nodes was 6.2 per patient
(ranging between 1 and 43). The mean number of cervical
levels involved was 2 (from 1 to 5) per patient. In the present
series, 45% had more than 3 metastatic nodes and 22% had
ECS in one or more lymph nodes. Examining the data col-
lected from our series, the 4th level resulted as that most
commonly involved (52%) (Table I), followed by the 3rd,
the 6 th, the 2nd, the 5th and fi nally the 1st level, with rates cor-
responding, respectively, to 45%, 43%, 38%, 8% and 4%.
As far as concerns the extension of the tumour inside the
gland, in the subgroup of 63 cases with ipsilateral metas-
tases, results showed:
one neoplastic nodule in the thyroid in 65% of cases;
more than one neoplastic nodule, in the same lobe, in
3% of cases.
Both thyroid lobes were involved in 31%.
A total of 8 out of 14 patients with bilateral metastases
presented multiple neoplastic nodules in the thyroid.
With regard to the histology variant, patients with follicu-
lar carcinoma developed 69% of recurrences after 6 years,
vs 18% with papillary carcinoma.
Considering cervical nodal involvement, bilateral metas-
tases were detected in 29% of cases, when the tumour was
located bilaterally in the gland, and in 13% of cases with a
monolateral location. In only one case was the metastasis
found contralaterally to the tumour.
At clinical follow-up, distant metastases (DM) were ob-
served in 8/77 cases (10%) and nodal recurrences (NR)
in 5/77 (6%).
As far as concerns the sub-group of 8 patients with DM, 5
had > 3 metastatic nodes and > 1 metastatic level involved
ECS was found in 7 out of 8 cases with DM and in 3 out
of 5 patients with NR.
G. Spriano et al.
Considering the group of distant metastases and nodal re-
currences together, i.e., 13 patients, ECS was detected in
10 cases (77%).
On the other hand, considering the subgroups positive to
ECS (17 cases) and negative to ECS (60 cases), in the
former, there were 10 cases of recurrences (nodal or dis-
tant metastases) (59%), and, in the latter, only 3 cases
with an incidence of 5%.
In order to determine the prognostic value of those fac-
tors, related to the tumour and to the patients, histology,
age, sex, tumour extension, side of lymph node metastas-
es, number of metastatic nodes and positive levels, ECS
were statistically analysed
Multivariate analysis of these data, focused on the risk of
NR and DM, in accordance with the Cox regression mod-
el 19, revealed as signifi cant adverse prognostic factors: the
follicular variant (p < 0.01) and the nodal extra-capsular
spread (p < 0.001).
The prevalence of DTC in females was confi rmed in the
present study 9-11 and the median age (51 years) was com-
parable to that reported in other larger series 10 12.
According to these data and considering the large number
of cases with only one metastatic neck level, in the present
series a fairly homogeneous uniformity in the distribution
of nodal metastases has been demonstrated in all cervi-
cal levels except the 1st and 5th 13 14. It probably means that
there is no progressive metastatic spread from the thyroid
to the cervical lymph nodes but that metastases do not fol-
low a regular path, skipping to different cervical levels.
At multivariate analysis, signifi cant prognostic fac-
tors were shown to be the follicular histology variant
(p < 0.01) 3 12 15 and, above all, ECS (p < 0.001). No refer-
ence to this peculiar prognostic factor has been found in
the literature, not even by those Authors, who reported the
negative impact, on prognosis, of nodal metastases 11 16-19.
Patients with thyroid cancer are usually stratifi ed into
low, intermediate and high risk categories on the basis of
prognostic factors which are related to the patient, to the
tumour and to the treatment 9 20 21.
Age, sex, size, nodal extra-capsular invasion and metas-
tases are well-defi ned prognostic factors 12 22.
The prognostic signifi cance of nodal involvement is still
Table I. Risk factors for regional and distant recurrence in the 77 patients.
Lymph nodes pN
No. positive nodes
No. Positive levels
No. patients Neck recurrence (%) Distant metastases (%)
Regional metastases and prognostic factors in thyroid carcinoma
debated in the literature; as in most retrospective analy-
ses, it is evaluated in the whole population, that includes
all thyroid tumours of any risk category. The statistical
weight of nodal involvement is consequently reduced due
to the dispersion arising from the included low and in-
termediate risk cases, which represent 80% of the entire
thyroid cancer population 23-25.
In the present study, which examined the advanced cases
only, the prognostic impact of nodal metastases resulted
highly signifi cant.
From our study, nodal extra-capsular spread was found to
be a highly predictive prognostic factor either of distant
metastasis or loco-regional recurrence.
In the literature, nodal metastasis is not considered as such
an important prognostic factor 1 9 10 26 27 and its treatment
still represents a major controversial issue. One of the
most adopted techniques in the past was “node picking”
or “berry picking” 28. This “limited” approach to nodal
metastases appears to have the advantage of low morbid-
ity and simplicity but it is accompanied by a high rate of
residual nodal disease. All the cases in the present series
were submitted to selected or modifi ed radical neck dis-
section. This, in the Authors’ opinion, is the only way to
achieve radical excision preserving the anatomy and the
function of the neck.
The correct surgical treatment of the primary thyroid tu-
mour and the cervical nodes of the central and lateral neck
represents, at the present time, the standard option in the
treatment of thyroid carcinoma, together with 131I ablation
and TSH-suppression treatment.
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Address for correspondence: Prof. G. Spriano, Divisione di
Chirurgia Testa e Collo, Istituto Nazionale Regina Elena, via Elio
Chianesi 53, 00144 Roma, Italy. E-mail: email@example.com
Received: November 3, 2009 - Accepted: November 15, 2009