role of neck dissection for differentiated thyroid ca joint hospital surgical grand round ndh dr....
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Role of Neck Dissection for Differentiated Thyroid CA
Joint Hospital Surgical Grand Round NDH
Dr. Alex TSANG
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Background
Differentiated Thyroid CA refers to– Papillary thyroid CA– Follicular thyroid CA– Comprises almost 90% of all Thyroid CA
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Papillary Thyroid CA
Papillary thyroid cancers (PTC) =77% of thyroid malignancies
Strong propensity for regional nodal involvement.
Recent analysis which included > 33,000 patients with PTC, reports a 22% incidence of lymphatic involvement at initial operation
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Follicular Thyroid CA
Follicular thyroid cancers (FTC) less common Lower rate of lymphatic involvement In the same analysis only 2% with lymphatic
involvement
Zaydfudim V, Feurer ID, Griffin MR, et al. The impact of lymph node involvement on survival in patients with papillary and follicular thyroid carcinoma. Surgery 2008;144(6):1070–7 [discussion: 1077–8].
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Risk Factors associated with LN Metastasis
Fritze D, Doherty G. Surgical Management of Cervical Lymph Nodes in Differentiated Thyroid Cancer. Otolaryngol Clin N Am 43 (2010) 285–300
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Significance of LN Met
If LN Met +ve in initial OT– Locoregional Recurrence rate: higher
recurrence of DTC in 19% of patients with initially positive nodes and 2% in node-negative patients
Loh KC, Greenspan FS, Gee L, et al. Pathological tumor-node-metastasis (pTNM) staging for papillary and follicular thyroid carcinomas: a retrospective analysis of 700 patients. J Clin Endocrinol Metab 1997;82(11):3553–62.McHenry CR, Rosen IB, Walfish PG. Prospective management of nodal metastases in differentiated thyroid cancer. Am J Surg 1991;162(4):353–6.
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Significance of LN Met
If LN Met +ve in initial OT– Distant Met: higher
In a series stratified by tumor size, 0.7% of patients initially T1-T3N0 had distant metastases at diagnosis and 2.9% eventually developed distant spread. For T1-T3N1 patients, 8.5% had systemic involvement at diagnosis, and 15.1% later developed systemic disease.
Loh KC, Greenspan FS, Gee L, et al. Pathological tumor-node-metastasis (pTNM) staging for papillary and follicular thyroid carcinomas: a retrospective analysis of 700 patients. J Clin Endocrinol Metab 1997;82(11):3553–62.McHenry CR, Rosen IB, Walfish PG. Prospective management of nodal metastases in differentiated thyroid cancer. Am J Surg 1991;162(4):353–6.
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Significance of LN Met
If LN Met +ve in initial OT– Survival: inconclusive
Some studies showed no significant impact on survival if LN met +ve
Some studies showed worse long term survival (at least 14 years) if LN met +ve
So, knowing LN status helps to have more accurate staging which affect patients’ further management and prognosis.
Loh KC, Greenspan FS, Gee L, et al. Pathological tumor-node-metastasis (pTNM) staging for papillary and follicular thyroid carcinomas: a retrospective analysis of 700 patients. J Clin Endocrinol Metab 1997;82(11):3553–62.McHenry CR, Rosen IB, Walfish PG. Prospective management of nodal metastases in differentiated thyroid cancer. Am J Surg 1991;162(4):353–6.
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Cervical Lymphatics Anatomy
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Cervical lymphadenectomy of one or more lymph node groups
Selective Neck Dissection
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Two subtypes commonly encounter in surgery for DTC:
– Lateral neck dissection Level II-V
– Central compartment neck dissection
Level VI
Selective Neck Dissection
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Neck LN Dissection for DTC
DTCPTC FTC
LN + LN +LN - LN -
Senario 1 Senario 2 Senario 3 Senario 4
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Neck LN Dissection for DTC
DTCPTC FTC
LN + LN +LN - LN -
Senario 1 Senario 2 Senario 3 Senario 4
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Neck LN Dissection for PTC
Senario 1– For therapeutic neck dissection– Which type?
ALWAYS systemic compartment dissection for the involved compartment over berry-picking procedure
Davidson HC, Park BJ, Johnson JT. Papillary thyroid cancer: controversies in the management of neck metastasis. Laryngoscope 2008;118(12):2161–5.
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Neck LN Dissection for DTC
DTCPTC FTC
LN + LN +LN - LN -
Senario 1 Senario 2 Senario 3 Senario 4
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Neck LN Dissection for PTC
Senario 21. Total thyroidectomy and surveillance +/- re-
operation if LN recurrence appropriate for small, noninvasive, clinically node-
negative PTC
Cooper D, Doherty G, Haugen B, et. al. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. THYROID Volume 19, Number 11, 2009
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Neck LN Dissection for DTC
Senario 22. Total thyroidectomy and prophylactic central
compartment LN dissection advanced primary tumors extra-thyroidal extention High risk patient group: male, >45 year old Distant met
Cooper D, Doherty G, Haugen B, et. al. Revised American Thyroid Association Management Guidelines for Patients with Thyroid Nodules and Differentiated Thyroid Cancer. THYROID Volume 19, Number 11, 2009
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Benefits for prophylactic CCLND
unanticipated central metastases in 38% to 45% of patients with PTC
prevents compression or invasion of critical aerodigestive and neural structures
decreases lymphatic recurrence low levels of thyroglobulin which may
facilitate surveillance for recurrent disease
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Drawback for prophylactic CCLND
Uncertain about effect on overall survival Higher potential surgical complications
– Significantly higher temporary hypoPTH.– When compare with re-op in recurrence patients
vs prophylatic CCLND, significantly more permanent RLN palsy.
Fritze D, Doherty G. Surgical Management of Cervical Lymph Nodes in Differentiated Thyroid Cancer. Otolaryngol Clin N Am 43 (2010) 285–300
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Neck LN Dissection for DTC
DTCPTC FTC
LN + LN +LN - LN -
Senario 1 Senario 2 Senario 3 Senario 4
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Neck LN Dissection for FTC?
Senario 3– Therapeutic neck dissection is indicated
Senario 4– Not for prophylatics neck LN Dissection– Observation and re-operate if recurrence
as FTC had a lower risk of LN met
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Conclusion
PTC– Therapeutic systemic functional compartment
dissection if LN met is +ve.– Prophylactic CCLND in high risk group in expert
hands. FTC
– Therapeutic systemic functional compartment dissection if LN met is +ve.
– NOT for prophylatic neck LN dissection.
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The End
Questions?