Clin Exp Otorhinolaryngol.  2008 Mar;1(1):41-45. 10.3342/ceo.2008.1.1.41.

Is Routine Central Neck Dissection Necessary for the Treatment of Papillary Thyroid Microcarcinoma?

• Choi SJ
• Kim TY
• Lee JC
• Shong YK
• Cho KJ
• Ryu JS
• Lee JH
• Roh JL
• Kim SY

• KMID: 1486035
• DOI: http://doi.org/10.3342/ceo.2008.1.1.41

Abstract

OBJECTIVES
It remains unclear as to whether routine central neck dissection (CND) is necessary when performing surgery to treat patients with papillary thyroid microcarcinoma (PTMC). To determine the necessity for routine CND in PTMC patients, we reviewed the clinicopathologic and laboratory data of the patients of PTMC. METHODS: Between September 2001 and July 2005, 101 patients with PTMC and clinical N0 disease were retrospectively reviewed. The study cohort was devided into groups: the total thyroidectomy plus CND group (the CND group, N=48) and the total thyroidectomy without CND group (the no CND group, N=53). The serum stimulated thyroglobulin (Tg) levels were measured after surgery and prior to radioactive iodine ablation therapy (RAI) and at 6-12 months after RAI. Pathology, the Tg levels and recurrence data were compared between the 2 groups. RESULTS: Central nodal metastases were found in 18 of the 48 CND patients (37.5%). The incidence of Tg levels >5 ng/mL at RAI was higher in the no CND patients and in the 18 node-positive CND patients compared with the 30 node-negative CND patients (22-24% vs. 3%, respectively, P=0.020-0.058). The difference when performing a similar comparison using a >2 ng/mL Tg threshold level showed no significance (10-11% vs. 4%, respectively, P>0.1). Two of the no CND patients and one node-positive CND patient had recurrences in the thyroid bed or lateral neck during a mean follow-up of 24 months. CONCLUSION: The data showed that occult metastasis to the central neck is common in PTMC patients. A CND provides pathologic information about the nodal metastases, and it potentially provides guidance for planning the postoperative RAI. However, the long-term benefit of CND on recurrence and survival remains somewhat questionable.

Keyword

Papillary microcarcinoma; Central compartment; Neck dissection; Neoplasm metastasis; Thyroglobulin

MeSH Terms

Carcinoma, Papillary
Cohort Studies
Follow-Up Studies
Humans
Incidence
Iodine
Neck
Neck Dissection
Neoplasm Metastasis
Recurrence
Retrospective Studies
Thyroglobulin
Thyroid Gland
Thyroid Neoplasms
Thyroidectomy
Carcinoma, Papillary
Iodine
Thyroglobulin
Thyroid Neoplasms

Figure

• 

  Fig. 1 Serum TSH-stimulated Tg levels in patients either undergoing (CND) or not undergoing (no CND) central node dissection (CND). The ablation- and control-Tg levels were measured prior to radioactive iodine therapy (RAI) and at follow-up 6-12 months after RAI, respectively. The mean Tg levels were higher in the no CND and node-positive CND patients than in node-negative CND patients: ablation-Tg, 5.780 and 3.367 ng/mL vs. 1.059 ng/mL, P=0.054; control-Tg, 2.078 and 0.904 ng/mL vs. 0.447 ng/mL, P=0.319.

• 

  Fig. 2 Serum TSH-stimulated Tg levels prior to radioactive iodine therapy. The ablation-Tg levels were categorized as >5.0 ng/mL, 2.0-5.0 ng/mL and <2.0 ng/mL. The central neck dissection (CND) patients were analyzed as those with or without occult metastases to the central neck compartment.

• 

  Fig. 3 The serum TSH-stimulated Tg levels at follow-up 6-12 months after radioactive iodine therapy. The control-Tg levels were categorized as >2.0 ng/mL, 1.0-2.0 ng/mL and <1.0 ng/mL. The central neck dissection (CND) patients were analyzed as those with or without occult metastases to the central neck compartment.

Reference

1. Hedinger C, Williams ED, Sobin LH. The WHO histological classification of thyroid tumors: a commentary on the second edition. Cancer. 1989; 3. 01. 63(5):908–911. PMID: 2914297.

2. Harach HR, Franssila KO, Wasenius VM. Occult papillary carcinoma of the thyroid. A "normal" finding in Finland. A systematic autopsy study. Cancer. 1985; 8. 01. 56(3):531–538. PMID: 2408737.

3. Yamamoto Y, Maeda T, Izumi K, Otsuka H. Occult papillary carcinoma of the thyroid. A study of 408 autopsy cases. Cancer. 1990; 3. 01. 65(5):1173–1179. PMID: 2302665.

4. Bramley MD, Harrison BJ. Papillary microcarcinoma of the thyroid gland. Br J Surg. 1996; 12. 83(12):1674–1683. PMID: 9038540.

5. Wada N, Duh QY, Sugino K, Iwasaki H, Kameyama K, Mimura T, et al. Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg. 2003; 3. 237(3):399–407. PMID: 12616125.

6. Yokozawa T, Fukata S, Kuma K, Matsuzuka F, Kobayashi A, Hirai K, et al. Thyroid cancer detected by ultrasound-guided fine-needle aspiration biopsy. World J Surg. 1996; 9. 20(7):848–853. PMID: 8678961.

7. Hay ID, Grant CS, van Heerden JA, Goellner JR, Ebersold JR, Bergstralh EJ. Papillary thyroid microcarcinoma: a study of 535 cases observed in a 50-year period. Surgery. 1992; 12. 112(6):1139–1146. PMID: 1455316.

8. Strate SM, Lee EL, Childers JH. Occult papillary carcinoma of the thyroid with distant metastases. Cancer. 1984; 9. 15. 54(6):1093–1100. PMID: 6467135.

9. Mazzaferri EL, Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med. 1994; 11. 97(5):418–428. PMID: 7977430.

10. Harach HR, Franssila KO. Occult papillary carcinoma of the thyroid appearing as lung metastasis. Arch Pathol Lab Med. 1984; 7. 108(7):529–530. PMID: 6547312.

11. Rodriguez JM, Moreno A, Parrilla P, Sola J, Soria T, Tebar FJ, et al. Papillary thyroid microcarcinoma: clinical study and prognosis. Eur J Surg. 1997; 4. 163(4):255–259. PMID: 9161822.

12. Williams ED. Guest editorial: two proposals regarding the terminology of thyroid tumors. Int J Surg Pathol. 2000; 7. 8(3):181–183. PMID: 11493987.

13. Sugitani I, Fujimoto Y. Symptomatic versus asymptomatic papillary thyroid microcarcinoma: a retrospective analysis of surgical outcome and prognostic factors. Endocr J. 1999; 2. 46(1):209–216. PMID: 10426589.

14. Tisell LE, Nilsson B, Molne J, Hansson G, Fjalling M, Jansson S, et al. Improved survival of patients with papillary thyroid cancer after surgical microdissection. World J Surg. 1996; 9. 20(7):854–859. PMID: 8678962.

15. Kim TY, Kim WB, Kim ES, Ryu JS, Yeo JS, Kim SC, et al. Serum thyroglobulin levels at the time of ¹³¹I remnant ablation just after thyroidectomy are useful for early prediction of clinical recurrence in low-risk patients with differentiated thyroid carcinoma. J Clin Endocrinol Metab. 2005; 3. 90(3):1440–1445. PMID: 15613412.

16. Henry JF, Gramatica L, Denizot A, Kvachenyuk A, Puccini M, Defechereux T. Morbidity of prophylactic lymph node dissection in the central neck area in patients with papillary thyroid carcinoma. Langenbecks Arch Surg. 1998; 4. 383(2):167–169. PMID: 9641892.

17. Pereira JA, Jimeno J, Miquel J, Iglesias M, Munne A, Sancho JJ, et al. Nodal yield, morbidity, and recurrence after central neck dissection for papillary thyroid carcinoma. Surgery. 2005; 12. 138(6):1095–1100. PMID: 16360396.

18. Ito Y, Tomoda C, Uruno T, Takamura Y, Miya A, Kobayashi K, et al. Clinical significance of metastasis to the central compartment from papillary microcarcinoma of the thyroid. World J Surg. 2006; 1. 30(1):91–99. PMID: 16369721.

19. Menendez Torre E, Lopez Carballo MT, Rodriguez Erdozain RM, Forga Llenas L, Goni Iriarte MJ, Barberia Layana JJ. Prognostic value of thyroglobulin serum levels and ¹³¹I whole-body scan after initial treatment of low-risk differentiated thyroid cancer. Thyroid. 2004; 4. 14(4):301–306. PMID: 15142364.

20. Baudin E, Do Cao C, Cailleux AF, Leboulleux S, Travagli JP, Schlumberger M. Positive predictive value of serum thyroglobulin levels, measured during the first year of follow-up after thyroid hormone withdrawal, in thyroid cancer patients. J Clin Endocrinol Metab. 2003; 3. 88(3):1107–1111. PMID: 12629092.

21. Sawka AM, Thephamongkhol K, Brouwers M, Thabane L, Browman G, Gerstein HC. Clinical review 170: a systematic review and metaanalysis of the effectiveness of radioactive iodine remnant ablation for well-differentiated thyroid cancer. J Clin Endocrinol Metab. 2004; 8. 89(8):3668–3676. PMID: 15292285.

22. Hay ID, Thompson GB, Grant CS, Bergstralh EJ, Dvorak CE, Gorman CA, et al. Papillary thyroid carcinoma managed at the Mayo Clinic during six decades (1940-1999): temporal trends in initial therapy and long-term outcome in 2444 consecutively treated patients. World J Surg. 2002; 8. 26(8):879–885. PMID: 12016468.

23. Mazzaferri EL, Kloos RT. Clinical review 128: current approaches to primary therapy for papillary and follicular thyroid cancer. J Clin Endocrinol Metab. 2001; 4. 86(4):1447–1463. PMID: 11297567.

24. Wartofsky L, Sherman SI, Gopal J, Schlumberger M, Hay ID. The use of radioactive iodine in patients with papillary and follicular thyroid cancer. J Clin Endocrinol Metab. 1998; 12. 83(12):4195–4203. PMID: 9851751.