Journal List > J Korean Thyroid Assoc > v.7(2) > 1056554

Park, Lee, Bae, and Kang: Regional Lymph Node Metastasis in Papillary Thyroid Cancer

Abstract

Papillary thyroid cancer is a common endocrine cancer and commonly presents with lymph node metastases. It has been generally accepted that lymphatic drainage occurs from the thyroid primarily to the central lymphatic compartment and secondarily to the lateral compartment nodes. Recently, improvements in the resolution of imaging studies and the availability of highly sensitive thyroglobulin assays have highlighted the importance of identifying disease in the pre-operative assessment and dealing effectively with metastatic regional disease in order to prevent recurrence. However, there are limitations to diagnosing central lymph node metastases. With unreliable imaging modalities, prophylactic central lymph node dissection should be performed on all patients with papillary thyroid cancer. In comparison with the central compartment, prophylactic lateral node dissection has little or no effect on improving the prognosis of patients with papillary thyroid cancer. Therefore, lateral node dissection is recommended only as a part of the therapeutic procedure. The extension of lateral neck dissection is recommended a comprehensive selective neck dissection of levels IIa, III, IV, and Vb. The rich lymphatic supply of the thyroid gland coupled with the propensity for nodal metastases in papillary thyroid cancer require the modern thyroid surgeon to be familiar with the indications for and techniques of regional lymph node dissection.

References

1. Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA;2006; 295(18):2164–7.
crossref
2. Malterling RR, Andersson RE, Falkmer S, Falkmer U, Nilehn E, Jarhult J. Differentiated thyroid cancer in a Swedish county–long-term results and quality of life. Acta Oncol. 2010; 49(4):454–9.
3. Grodski S, Cornford L, Sywak M, Sidhu S, Delbridge L. Routine level VI lymph node dissection for papillary thyroid cancer: surgical technique. ANZ J Surg. 2007; 77(4):203–8.
crossref
4. Moo TA, McGill J, Allendorf J, Lee J, Fahey T 3rd, Zarnegar R. Impact of prophylactic central neck lymph node dissection on early recurrence in papillary thyroid carcinoma. World J Surg. 2010; 34(6):1187–91.
crossref
5. Enyioha C, Roman SA, Sosa JA. Central lymph node dissection in patients with papillary thyroid cancer: a population level analysis of 14,257 cases. Am J Surg. 2013; 205(6):655–61.
crossref
6. Caron NR, Clark OH. Well differentiated thyroid cancer. Scand J Surg. 2004; 93(4):261–71.
crossref
7. Ito Y, Tomoda C, Uruno T, Takamura Y, Miya A, Kobayashi K. et al. Ultrasonographically and anatomopathologically detectable node metastases in the lateral compartment as indicators of worse relapse-free survival in patients with papillary thyroid carcinoma. World J Surg. 2005; 29(7):917–20.
8. Mazzaferri EL, Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med. 1994; 97(5):418–28.
crossref
9. Simpson WJ, McKinney SE, Carruthers JS, Gospodarowicz MK, Sutcliffe SB, Panzarella T. Papillary and follicular thyroid cancer. Prognostic factors in 1,578 patients. Am J Med. 1987; 83(3):479–88.
10. Scheumann GF, Gimm O, Wegener G, Hundeshagen H, Dralle H. Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer. World J Surg. 1994; 18(4):559–67. discussion 67-8.
crossref
11. Ries L YJ, Keel G, Eisner M, Lin Y, Horner M. SEER Survival Monograph Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics, 2007 NIH Pub. No. 07-6215 edition. National Cancer Institute, SEER Program;Bethesda, MD:
12. Lundgren CI, Hall P, Dickman PW, Zedenius J. Clinically significant prognostic factors for differentiated thyroid carcinoma: a population-based, nested case-control study. Cancer. 2006; 106(3):524–31.
13. Beasley NJ, Lee J, Eski S, Walfish P, Witterick I, Freeman JL. Impact of nodal metastases on prognosis in patients with well-differentiated thyroid cancer. Arch Otolaryngol Head Neck Surg. 2002; 128(7):825–8.
crossref
14. Qubain SW, Nakano S, Baba M, Takao S, Aikou T. Distribution of lymph node micrometastasis in pN0 well-differentiated thyroid carcinoma. Surgery. 2002; 131(3):249–56.
crossref
15. Fernandez-Cruz L, Astudillo E, Pera C. Lymphography of the thyroid gland: is intraglandular dissemination of thyroid carcinoma possible? World J Surg. 1977; 1(5):647–54.
crossref
16. Eichhorn W, Tabler H, Lippold R, Lochmann M, Schreckenberger M, Bartenstein P. Prognostic factors determining long-term survival in well-differentiated thyroid cancer: an analysis of four hundred eighty-four patients undergoing therapy and aftercare at the same institution. Thyroid. 2003; 13(10):949–58.
crossref
17. Noguchi M, Earashi M, Kitagawa H, Ohta N, Thomas M, Miyazaki I. et al. Papillary thyroid cancer and its surgical management. J Surg Oncol. 1992; 49(3):140–6.
18. Cranshaw IM, Carnaille B. Micrometastases in thyroid cancer. An important finding? Surg Oncol. 2008; 17(3):253–8.
19. Noguchi S, Noguchi A, Murakami N. Papillary carcinoma of the thyroid. I. Developing pattern of metastasis. Cancer. 1970; 26(5):1053–60.
crossref
20. Ito Y, Miyauchi A. Lateral lymph node dissection guided by preoperative and intraoperative findings in differentiated thyroid carcinoma. World J Surg. 2008; 32(5):729–39.
crossref
21. Gimm O, Rath FW, Dralle H. Pattern of lymph node metastases in papillary thyroid carcinoma. Br J Surg. 1998; 85(2):252–4.
crossref
22. Machens A, Hinze R, Thomusch O, Dralle H. Pattern of nodal metastasis for primary and reoperative thyroid cancer. World J Surg. 2002; 26(1):22–8.
crossref
23. Machens A, Holzhausen HJ, Dralle H. Contralateral cervical and mediastinal lymph node metastasis in medullary thyroid cancer: systemic disease? Surgery. 2006; 139(1):28–32.
crossref
24. Machens A, Hauptmann S, Dralle H. Prediction of lateral lymph node metastases in medullary thyroid cancer. Br J Surg. 2008; 95(5):586–91.
crossref
25. Dralle H, Machens A. Surgical management of the lateral neck compartment for metastatic thyroid cancer. Curr Opin Oncol. 2013; 25(1):20–6.
crossref
26. Park JH, Lee YS, Kim BW, Chang HS, Park CS. Skip lateral neck node metastases in papillary thyroid carcinoma. World J Surg. 2012; 36(4):743–7.
crossref
27. Zhang L, Wei WJ, Ji QH, Zhu YX, Wang ZY, Wang Y. et al. Risk factors for neck nodal metastasis in papillary thyroid microcarcinoma: a study of 1066 patients. J Clin Endocrinol Metab. 2012; 97(4):1250–7.
28. Von Lanz T, Wachsmuth W. Praktische anatomie, hals. Berlin: Springer Verlag;1955; p.243–4.
29. Foldi M, Kubik S. Lehrbuch der lymphologie. Stuttgart: Fischer Verlag;1989; p.27–50.
30. Kim KM, Park JB, Bae KS, Kim CB, Kang DR, Kang SJ. Clinical prognostic index for recurrence of papillary thyroid carcinoma including intraoperative findings. Endocr J. 2013; 60(3):291–7.
crossref
31. Kouvaraki MA, Shapiro SE, Fornage BD, Edeiken-Monro BS, Sherman SI, Vassilopoulou-Sellin R. et al. Role of preoperative ultrasonography in the surgical management of patients with thyroid cancer. Surgery. 2003; 134(6):946–54. discussion 54-5.
32. Shimamoto K, Satake H, Sawaki A, Ishigaki T, Funahashi H, Imai T. Preoperative staging of thyroid papillary carcinoma with ultrasonography. Eur J Radiol. 1998; 29(1):4–10.
crossref
33. Ahn JE, Lee JH, Yi JS, Shong YK, Hong SJ, Lee DH. et al. Diagnostic accuracy of CT and ultrasonography for evaluating metastatic cervical lymph nodes in patients with thyroid cancer. World J Surg. 2008; 32(7):1552–8.
34. Hwang HS, Orloff LA. Efficacy of preoperative neck ultrasound in the detection of cervical lymph node metastasis from thyroid cancer. Laryngoscope. 2011; 121(3):487–91.
crossref
35. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL. et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009; 19(11):1167–214.
36. Kim E, Park JS, Son KR, Kim JH, Jeon SJ, Na DG. Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma: comparison of ultrasound, computed tomography, and combined ultrasound with computed tomography. Thyroid. 2008; 18(4):411–8.
crossref
37. Carty SE, Cooper DS, Doherty GM, Duh QY, Kloos RT, Mandel SJ. et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid. 2009; 19(11):1153–8.
38. Yi KH, Park YJ, Koong SS, Kim JH, Na DG, Ryu JS. et al. Revised Korean Thyroid Association management guidelines for patients with thyroid nodules and thyroid cancer. Endocrinol Metab. 2010; 25(4):270–97.
39. Hartl DM, Travagli JP. The updated American Thyroid Association Guidelines for management of thyroid nodules and differentiated thyroid cancer: a surgical perspective. Thyroid. 2009; 19(11):1149–51.
crossref
40. National Comprehensive Cancer Network. Clinical practice guidelines in oncology: thyroid carcinoma. [cited Nov 9, 2014] http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
41. British Thyroid Association and Royal College of Physicians. Guidelines for the management of thyroid cancer. 2nd ed. [cited Nov 9, 2014] http://www.british-thyroid-association.org/news/Docs/Thyroid_cancer_guidelines_2007.pdf. p.13–15.
42. Rotstein L. The role of lymphadenectomy in the management of papillary carcinoma of the thyroid. J Surg Oncol. 2009; 99(4):186–8.
crossref
43. Attie JN. Modified neck dissection in treatment of thyroid cancer: a safe procedure. Eur J Cancer Clin Oncol. 1988; 24(2):315–24.
crossref
44. Bardet S, Malville E, Rame JP, Babin E, Samama G, De Raucourt D. et al. Macroscopic lymph-node involvement and neck dissection predict lymph-node recurrence in papillary thyroid carcinoma. Eur J Endocrinol. 2008; 158(4):551–60.
45. Ito Y, Tsushima Y, Masuoka H, Yabuta T, Fukushima M, Inoue H. et al. Significance of prophylactic modified radical neck dissection for patients with low-risk papillary thyroid carcinoma measuring 1.1-3.0 cm: first report of a trial at Kuma Hospital. Surg Today. 2011; 41(11):1486–91.
46. Moreno MA, Edeiken-Monroe BS, Siegel ER, Sherman SI, Clayman GL. In papillary thyroid cancer, preoperative central neck ultrasound detects only macroscopic surgical disease, but negative findings predict excellent long-term regional control and survival. Thyroid. 2012; 22(4):347–55.
crossref
47. Chisholm EJ, Kulinskaya E, Tolley NS. Systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone. Laryngoscope. 2009; 119(6):1135–9.
crossref
48. Shan CX, Zhang W, Jiang DZ, Zheng XM, Liu S, Qiu M. Routine central neck dissection in differentiated thyroid carcinoma: a systematic review and meta-analysis. Laryngoscope. 2012; 122(4):797–804.
crossref
49. Zetoune T, Keutgen X, Buitrago D, Aldailami H, Shao H, Mazumdar M. et al. Prophylactic central neck dissection and local recurrence in papillary thyroid cancer: a meta-analysis. Ann Surg Oncol. 2010; 17(12):3287–93.
50. Perrino M, Vannucchi G, Vicentini L, Cantoni G, Dazzi D, Colombo C. et al. Outcome predictors and impact of central node dissection and radiometabolic treatments in papillary thyroid cancers < or =2 cm. Endocr Relat Cancer. 2009; 16(1):201–10.
51. Popadich A, Levin O, Lee JC, Smooke-Praw S, Ro K, Fazel M. et al. A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid Cancer. Surgery. 2011; 150(6):1048–57.
52. Giordano D, Valcavi R, Thompson GB, Pedroni C, Renna L, Gradoni P. et al. Complications of central neck dissection in patients with papillary thyroid carcinoma: results of a study on 1087 patients and review of the literature. Thyroid. 2012; 22(9):911–7.
53. Machens A, Hinze R, Lautenschlager C, Thomusch O, Dralle H. Thyroid carcinoma invading the cervicovisceral axis: routes of invasion and clinical implications. Surgery. 2001; 129(1):23–8.
crossref
54. Shaha AR. Revision thyroid surgery-technical considerations. Otolaryngol Clin North Am. 2008; 41(6):1169–83. x.
55. Lefevre JH, Tresallet C, Leenhardt L, Jublanc C, Chigot JP, Menegaux F. Reoperative surgery for thyroid disease. Langenbecks Arch Surg. 2007; 392(6):685–91.
crossref
56. Davies L, Welch HG. Thyroid cancer survival in the United States: observational data from 1973 to 2005. Arch Otolaryngol Head Neck Surg. 2010; 136(5):440–4.
57. Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant metastasis based on histologic varieties in differentiated carcinoma of the thyroid. Am J Surg. 1996; 172(6):692–4.
crossref
58. Hasney CP, Amedee RG. What is the appropriate extent of lateral neck dissection in the treatment of metastatic well-differentiated thyroid carcinoma? Laryngoscope. 2010; 120(9):1716–7.
crossref
59. Stack BC Jr, Ferris RL, Goldenberg D, Haymart M, Shaha A, Sheth S. et al. American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer. Thyroid. 2012; 22(5):501–8.
60. Hartl DM, Leboulleux S, Al Ghuzlan A, Baudin E, Chami L, Schlumberger M. et al. Optimization of staging of the neck with prophylactic central and lateral neck dissection for papillary thyroid carcinoma. Ann Surg. 2012; 255(4):777–83.
61. Roh JL, Park JY, Park CI. Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone. Ann Surg. 2007; 245(4):604–10.

Fig. 1.
Nodal levels with corresponding anatomic landmarks.
jkta-7-129f1.tif
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