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Int Surg 2010;95:142-146
Lymph Node Surgery in Papillary
Thyroid Carcinoma
Derya Karakoc \ Arif Ozdemir
1 Lecturer
2
2
of General Surgery, and Professor of General Surgery, Department of General Surgery, Hacettepe
University Medical School, Ankara, Turkey
Papillary thyroid carcinoma is the most common type of thyroid cancer, and cervical
lymph node metastasis of the disease is high. Lymph node surgery of the papillary
thyroid carcinoma is controversial because of the good prognosis of the disease.
Although controversy continues on prophylactic lymph node dissection, therapeutic
lymph node dissection is recommended in all guidelines for patients who have known
lymph node metastases.
Key words: Papillary thyroid carcinoma- Lymph node- Surgery
P type of thyroid cancer. It represents 75% of all
detectable lymph node metastasis occurs in around
4
15% to 30% of cases. Occult lymph node metastasis
entiated
sis in clinically node-negative patients is 50%,5 and
apillary thyroid carcinoma is the most common
thyroid malignancies and more than 90% of differ­
1
thyroid cancers.
An increase in the
is reportedly as high as 90%. Lymph node metasta­
incidence of papillary thyroid carcinoma during
2
lymph node metastasis in papillary thyroid micro­
Management of the papillary thyroid carcinoma is
carcinoma 10 mm or less in diameter, occurs at 15%
6 s
to 50%. -
past decades has increased interest in the disease.
controversial because of the lack of prospective
carcinoma, which is defined as papillary thyroid
randomized studies and the excellent prognosis of
the disease. The cause-specific 10-year survival rate
for papillary thyroid carcinoma is 95%.3 Despite
slow tumor growth and a good prognosis, the major
challange involves controlling locoregional recur­
rence. This is why lymph node surgery is considered
important in the treatment of papillary thyroid
carcinoma.
The incidence of cervical lymph node metastasis
is high in papillary thyroid carcinoma. Clinically
Effects of Lymph Node Metastases on
Recurrence and Survival
Patients
who
have
lymph
node
metastases
at
presentation have a higher incidence of recurrent
disease in the cervical region.9 The presence of
metastatic nodes at the time of initial examination is
associated with a 10-fold increase in the risk of
1°
developing a nodal recurrence.
Cervical recur-
Reprint requests: Derya Karakoc, MD, Hacettepe Universitesi Tip Fakultesi, Gene! Cerrahi AD 06100, Sihhiye, Ankara, Turkey.
Tel.: +9 0 312 305 1676, +9 0 532 562 5747; Fax: +9 0 312 385 4983; E-mail: [email protected]
142
Int Surg 2010;95
KARAKOC
LYMPH NODE SURGERY IN PAPILLARY THYROID CARCINOMA
renee is seen in 20% of patients with low-risk
reported in the literature. In most cases, retropha­
papillary thyroid carcinoma and in 60% of those
ryngeal metastasis is associated with other cervical
the tumor, male gender, and older age are among
normal pattern of lymph flow secondary to these
with high-risk diseaseY Extrathyroidal extension of
the factors that contribute to recurrence of the
disease
in
the
presence
of
nodal
metastases.12
Residual metastatic lymph nodes that remain after
initial therapy
are the most
subsequent recurrence.13•14
common cause of
It remains controversial whether the presence of
lymph node metastases, either overt or occult, has
an impact on prognosis. Traditionally, it has been
suggested that the presence of regional metastases
has no effect on survival.15•16 However, studies have
reported
that
lymph
node
metastases
decrease
survival, and this is even prominent among elderly
patients.17•18
the
estimated
lymphatic
drainage of
thyroid carcinoma is central cervical compartment
metastasis followed by lateral cervical compartment
metastasis. However, the metastatic pathways may
be unpredictable, and skip metastasis may occur.
For papillary thyroid carcinoma, central nodal
metastasis was found to be 76%, lateral nodal
the
Age, sex, tumor size, and histopathologic properties
of the tumor are among the most studied parameters
predicting lymph node involvement of the papillary
thyroid carcinoma.
Although age younger than
20 years and older than 45 years, male gender, and
increasing tumor size are proposed to predict lymph
node metastasis, absence of the tumor capsule and
perithyroidal extension are believed to be more
clinicopathologic
primary tumor size.2° For papillary thyroid micro­
carcinoma, central and lateral nodal metastases were
found in 64% and 45%, respectively, with a 5% skip
American Joint Comittee on Cancer and the Amer­
Neck Surgery25:
metastasis may be seen in 30% of patients.
Level III:
For central lymph node metastasis, pretracheal
frequent
paratracheal lymph node metastasis, and for lateral
than
upper
level
ones.
Level IV:
Tumor
position of the metastatic spread. Tumors in the
the spinal accessory nerve.
Lymph nodes that are located lateral to
the spinal accessory nerve.
Lymph nodes that are located between
the levels of the hyoid bone and the
This level is the
middle jugular region.
Lymph nodes that are located between
the level of the cricoid cartilage and the
clavicle.
position within the thyroid gland may affect the
isthmus, middle, and lower parts of the gland
Lymph nodes that are located medial to
cricoid cartilage.
than
lymph node metastasis, mid-lower level nodes are
Lymph nodes that are located above the
level of the hyoid bone to the base of
region.
Level IIA:
metastasis rate.5 Contralateral central lymph node
19%. Bilateral lymph node
Submental and submandibular lymph
nodes.
the skull. This level is the upper jugular
Level liB:
frequent
be
ican Academy of Otolaryngology and Head and
was found to be increased with an increase in
more
to
The most widely used cervical lymph node classi­
lateral compartments, and contralateral involvement
is
found
fication system is based on recommendations by the
Level II:
was found to occur at 7%.19 Contralateral metastasis
metastasis
is
Surgical Anatomy of Cervical Lymph
rates were reportedly 13% and 3% for central and
metastasis is 5% to
parameter
Node Compartments
Level I:
more
of
Predictive Factors for Lymph Node Metastases
metastasis was found to be 65%, and skip metastasis
node
alteration
other metastases?1•22
no
The thyroid gland is located in the central neck, and
lymph
representing
predictive of lymph node metastasis.24
lymphatic drainage follows venous drainage of the
so
likely
important. 23 For papillary thyroid microcarcinoma,
Pattern of Lymph Node Metastases
gland,
metastases,
This
is
the
lower jugular
region.
Level V:
Lymph nodes that are located in the
metastasize most often to the central nodes, and
posterior triangle. This level also in­
often to the ipsilateral lateral nodes.
Lymph nodes that are located in the
tumors in other parts of the gland metastasize most
Retropharyngeal nodes represent a rare site of
nodal metastasis in thyroid cancer. Few cases are
Int Surg 2010;95
cludes the supraclavicular lymph nodes.
Level VI:
central area, posterior and inferior to
the thyroid gland and adjacent to the
143
KARAKOC
LYMPH NODE SURGERY IN PAPILLARY THYROID CARCINOMA
trachea and esophagus. This compart­
ment includes the pretracheal nodes,
paratracheal nodes, precricoid
node
Berry Picking: In this procedure, only suspicious
enlarged lymph nodes are removed. This
and
procedure has lost its popularity.
(Delphian), perithyroidal nodes, and
lymph nodes along the recurrent laryn­
geal nerve.
Level
VII:
These are
the superior mediastinal
lymph nodes.
Central Compartment: Includes level VI lymph
nodes.
Lateral Compartment: Includes level II to level IV
lymph nodes.
tried for papillary thyroid cancer.26 Methylene blue,
isosulfan blue, patent blue, or radiocolloid may be
�
sentinel lymph node biopsy can guide com art­
lymph nodes in the neck. During the procedure, the
sternocleidomastoid muscle,
the internal jugular
vein, and the spinal acceessory nerve are removed.
This procedure was first described in 1906; later it
was modified because of the unwanted cosmetic
results and shoulder dysfunction caused by sacrifice
of the spinal accessory nerve.
Mod ified Radical Neck Dissection: Is also called
functional neck dissection. In this procedure, the
sternocleidomastoid muscle, internal jugular vein,
carotid artery, vagus, phrenic and spinal accessory
submandibular
salivary glands
are
preserved to decrease the morbidity of the radical
neck dissection.
Type I:
Preservation of the spinal accessory nerve.
Type II:
Preservation of the spinal accessory nerve
and internal jugular vein.
Type III:
Sentinel lymph node biopsy, which is used fre­
quently for breast cancer and melanoma, has been
ment-oriented cervical lymph node dissection?
Radical Neck Dissection: Includes the removal of all
and
Sentinel Lymph Node Biopsy: The sentinel lymph node
is defined as the first lymph node draining a tumor.
used to perform the procedure. When positive,
Types of Cervical Lymph Node Dissection
nerves,
Newer surgical approaches
Preservation of the spinal accessory nerve,
internal jugular vein, and sternocleido­
mastoid muscle.
Selective Neck Dissection: Preserves some lymph
node groups. The procedure has 2 subgroups for the
treatment of papillary thyroid carcinoma.
Central Compartment Lymph Node Dissection: In this
procedure, the lymph nodes and the soft tissues in
level VI are removed. During the procedure, the
recurrent laryngeal nerve is preserved.
Lateral Compartment Lymph Node Dissection: In this
procedure, the lymph nodes and the soft tissues
from the lateral wall of the carotid sheath to the
trapezius muscle and from the subclavian vein
inferiorly to the hypoglossal nerve superiorly are
excised. During the procedure, levels IIA, III, IV, and
V are removed. In patients with obvious metastatic
Video-Assisted Cervical Lymph Node Dissection: This
technique has been proposed for better cosmetic
outcorne?8 However, experience with this proce­
dure is very limited, and the oncologic outcome is
controversial. New data are needed for long-term
results of this procedure.
Surgical Strategy
Prophylactic lymph node dissection
Prophylactic lymph node dissection is dissection of
the cervical lymph nodes with no evidence of lymph
node metastasis. The role of prophylactic lymph
node dissection in the management of papillary
thyroid carcinoma is highly controversial because
the effect of lymphatic metastasis on survival is
controversial, and potential surgical complications
are not few.
Prophylactic lymph node dissection may not be
preferred because the nodal recurrence rate may not
be different between the lymph node dissection and
no-dissection groups.5•29 On the other hand, pro­
phylactic central cervical lymph node dissection is
advised by the European Thyroid Association, the
British
Thyroid
Association,
and
the
American
Thyroid Association.30•31 One potential benefit of
routine central cervical lymph node dissection may
be the accurate staging of the tumor, which may
guide subsequent treatment and follow-up. The
procedure may decrease the recurrence of papillary
thyroid carcinoma, improve disease-specific surviv­
al, and significantly reduce levels of serum thyro­
globulin, increasing the rate of athyroglobulinemia.32
However, it should be remembered that the rate of
permanent hypothyroidism and unintentional per­
manent nerve injury is higher when cervical lymph
disease at level VI, levels VI and VII can also be
node dissection is performed with total thyroidecto­
removed.
my than with total thyroidectomy alone.32
144
Int Surg 2010;95
KARAKOC
LYMPH NODE SURGERY IN PAPILLARY THYROID CARCINOMA
In
the
process
of
surgical
decision
making,
3.
Hay 10, Thompson GB, Grant CS, Bergstralh EL Dvorak CE,
possible benefits should always be weighed against
Gorman CA et al. Papillary thyroid carcinoma managed at the
potential morbidity. Because survival is favorable
Mayo Clinic during six decades
for papillary thyroid carcinoma, local recurrence is
in initial therapy and long term outcome in
considered an important parafY1eter for long-term
tively treated patients. World J Surg
follow-up.
The
impact
of
central
compartment
4.
recurrence differs from that of the lateral compart­
ment.
Reoperation
for recurrence
temporal trends
2444
consecu­
2002;26(8):879-885
Shaha AR, Shah JP, Loree TR. Patterns of nodal and distant
metastasis based on histologic varieties in differentiated
in the lateral
compartment can be performed more easily than
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Wada N, Duh QY, Sugino K, Iwasaki H, Kameyama K,
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Schonberger L Marienhagen L Agha A, Rozeboom S,
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32
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Bachmeier E, Schlitt H et al. Papillary microcarcinoma and
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in the central compartment may be a complicated
Prophylactic
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lymph
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papillary
dissection
thyroid
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Sakorafas GH, Giotakis L Stafyla V. Papillary thyroid
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