Significance of lymph node metastasis in differentiated thyroid cancer

doi:10.1016/0002-9610(78)90209-X

The American Journal of Surgery

Volume 136, Issue 1, July 1978, Pages 107-112

https://doi.org/10.1016/0002-9610(78)90209-X Get rights and content

Abstract

In age-matched patients with differentiated carcinoma of the thyroid, the tumor recurred in 32 per cent of those with lymph node metastases and in 14 per cent of those without lymph node metastases. Twenty-four per cent of patients with nodal involvement at the initial examination died of thyroid cancer, whereas only 8 per cent of those without nodal involvement died of thyroid cancer.

In patients less than forty years old, there were no deaths in those without nodal metastases but there were three deaths (11 per cent) in patients with nodal metastases. In patients more than forty years old, nine (41 per cent) with nodal metastases died of tumor, and four (15 per cent) without nodal metastases died of tumor. In the presence of positive nodes the death rate was substantially greater in the older than in the younger patients. Nodal involvement has an adverse effect on prognosis, but appears to be less important than the age of the patient.

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Overall, well-differentiated thyroid cancer has a good prognosis, and mortality has changed minimally over the past several decades. The development of clinical guidelines is a result of an increasing emphasis on evidence-based medicine. The most recent American Thyroid Association guideline for patients with thyroid nodules was published in 2015. New studies in thyroidology are constantly being published, placing our evidence-based approach to thyroid disease in continuous refinement. Thus, it is critical for thyroid surgeons to be up-to-date to provide their patients with the highest level of care.
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The impact of clinically or radiologically detected nodal metastases on survival in patients with papillary thyroid cancer (PTC) is controversial but seems more important and relevant in older patients. The objective of this study was to determine the impact of clinically or radiologically detected nodal metastases on outcome in patients 45 years of age or older.
Retrospective analysis of 834 patients 45 years or older who underwent operation for PTC between 1986 and 2005.
With a median follow up of 77 months, the 5 year disease-specific survival (DSS) and recurrence-free survival (RFS) were 99% and 94%, respectively. Patients with clinically N+ nodes with pathologic confirmation were stratified into pN0/Nx, pN1a, and pN1b, respectively. Five-year DSS was 100%, 100%, and 91% for pN0/Nx, pN1a, and pN1b disease; P < .001. Patients with pN1b disease had poorer distant RFS compared with pN0/Nx and pN1a patients (84%, 99%, and 99%; P < .001). The presence of pN1b disease was an independent predictor of worse DSS and distant RFS on multivariate analysis, conferring a 10-fold increased risk of distant metastases and death. All cause-specific deaths were due to distant metastases.
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Radio-guided selective compartment neck dissection improves staging in papillary thyroid carcinoma: A prospective study on 345 patients with a 3-year follow-up
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Citation Excerpt :
The optimal treatment for PTC is still under debate, as is the management of occult lymphatic disease. Lymph node metastases are found in about 50% of patients affected by PTC32 and the presence of macrometastases at presentation increases the risk of locoregional recurrence.18,33-43 It is unclear, however, whether nodal metastases affect overall survival in patients with PTC, because it has been clearly shown only in elderly patients and those with bulky nodal disease.41,44-51
Prospective uncontrolled study to investigate in papillary thyroid carcinoma (PTC) patients: (1) Distribution of lymph node metastases within the neck compartments, (2) factors predicting lymph nodes metastases, and (3) disease recurrence after thyroidectomy associated with radio-guided selective compartment neck dissection (RSCND).
We studied 345 consecutive PTC patients operated on between February 2004 and October 2011 at the S. Anna University Hospital, Ferrara (Italy). Patients with cervical lymph node metastases on preoperative ultrasonography and fine needle aspiration cytology were excluded. All patients underwent total thyroidectomy associated with SLN identification followed by RSCND in the SLN compartment, without SLN frozen section.
In patients with lymph node metastases, metastatic nodes were not in the central neck compartment in 22.6% of the cases. The presence of infiltrating or multifocal PTC was a predicting factor for lymph nodes metastases. The median follow-up was 35.5 months. RSCND was associated with a false-negative rate of 1.1%, a persistent disease rate of 0.6%, and a recurrent disease rate of 0.9%. The permanent dysphonia rate was 1.3%.
RSCND associated with total thyroidectomy may improve: (1) the locoregional lymph node staging, and (2) the identification of the site of lymphatic drainage within the neck compartments. Thus, considering the high false-negative rate of sentinel lymph node biopsy (SLNB), a radio-guided technique in PTC patients may guide the lymphadenectomy (ie, RSCND) to increase the metastatic yield and improve staging of the disease rather than avoid prophylactic lymphadenectomy (ie, SLNB).
Management of Well-Differentiated Thyroid Cancer
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Citation Excerpt :
Yet there are other studies showing that cervical node metastases have an independently significant effect. Harwood's group47 also found that when matching for age, nodal metastasis also resulted in a worse survival prognosis, especially in older populations. Another study by Scheumann and colleagues51 confirmed a decrease in survival for node-positive patients, even when controlling for age, tumor invasion, and distant metastasis.
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Numerous studies in the past have mentioned various factors that influence the recurrence of papillary thyroid carcinoma, including age, tumor size, advanced stage, extrathyroidal extension, and distant metastasis, and attempts have been made to classify the disease into low-risk and high-risk group based on these clinicopathological factors. However, there has been relatively scarce study on patients with multiple recurrent papillary thyroid carcinoma. This study analyzed the risk factors associated with such cases.
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Patients were divided into 3 groups: group 1 (no recurrence, n = 380), group 2 (1 recurrence only, n = 21), and group 3 (multiple recurrences, n = 15). The univariate analysis on risk factors revealed tumor size greater than 2 cm, multifocality, clinical apparent lymph node metastasis to be risk factors associated with multiple recurrences of papillary thyroid carcinoma. A multivariate analysis performed on variables selected from univariate analysis demonstrated no significant risk factor. The 10-year disease-specific survival for 3 different patient groups (group 1, 2, and 3) was 100%, 100%, and 83.1%, respectively, and patients in more clinically advanced group demonstrated poorer prognosis (p < 0.001). The 10-year overall survival rate for the 3 patient groups was 93.9%, 100%, and 92%, respectively, and clinically advanced groups tended to show poorer overall survival rate as well (p = 0.046).
A more aggressive and extensive surgery, as well as closer follow up, is to be required when operating on patients with tumor size greater than 2 cm, multifocality, clinical apparent lymph node metastasis. The use of imaging modalities, such as ultrasonography and PET-CT scan, may be desirable when monitoring such patients.
Primary tumour characteristics predict the invasiveness of lymph node metastases in papillary thyroid carcinoma patients
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^☆: This work was supported in part by the Medical Research Service of the Veterans Administration and Academic Senate, University of California, San Francisco, California.

^☆☆: Presented at the Forty-Ninth Annual Meeting of the Pacific Coast Surgical Association, Newport Beach, California, February 19–22, 1978.

¹: From the Department of Surgery, Veterans Administration Hospital, and University of California, San Francisco, California.

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Scientific paperSignificance of lymph node metastasis in differentiated thyroid cancer☆,☆☆

Abstract

Am J Surg

Thyroid carcinoma: general considerations

Carcinoma of the thyroid gland: a statistical study of 390 patients

J Clin Endocrinol Metab

Changing clinical pathologic, therapeutic, and survival patterns in differentiated thyroid carcinoma

Ann Surg

Of origin, characteristics and behavior of thyroid cancer

J Clin Endocrinol Metab

Scientific paper
Significance of lymph node metastasis in differentiated thyroid cancer☆,☆☆