Central and lateral lymph node metastases are quite common in patients with papillary thyroid carcinoma, and the predictors for those metastases have been well studied. Right upper paraesophageal lymph node metastasis has rarely been studied. The aim of this study was to identify the clinicopathological characteristics that may be risk factors for right upper paraesophageal lymph node metastasis in patients with papillary thyroid carcinoma.
This was a prospective observational study of 243 patients with papillary thyroid carcinoma (PTC) who underwent total thyroidectomy and comprehensive central lymph node dissection with or without lateral lymph node dissection between April 2008 and January 2010. The clinicopathologic findings from these patients were investigated and the patterns of lymph node metastasis were analyzed in the patients who had right upper paraesophageal lymph node disease.
Of the 243 patients undergoing lymph node dissection, 14 had right upper paraesophageal lymph node metastases. Two of these patients had right upper paraesophageal lymph node metastasis only, without central compartment metastasis. Univariate analysis of clinicopathologic findings showed that right upper paraesophageal lymph node metastasis had significant association with larger primary tumors, multifocal tumors, extrathyroid extension, and lymphatic invasion (p <0.05 for each factor).
Although there were no independent predictors of right upper paraesophageal lymph node metastasis, it can be the only site of metastasis without other compartmental metastasis. Therefore, during surgery for patients with central or lateral lymph node metastases from PTC, it may be helpful to examine the right upper paraesophageal lymph nodes.
Paraesophageal lymph node; Thyroid cancer; Papillary thyroid carcinoma
Background. The results of video-assisted thyroidectomy (VAT) were evaluated in a large series of patients with papillary thyroid carcinoma (PTC), especially in terms of completeness of the surgical resection and short-to-medium term recurrence. Methods. The medical records of all patients who underwent video-assisted thyroidectomy for PTC between June 1998 and May 2009 were reviewed. Results. Three hundred fifty-nine patients were included. One hundred twenty-six patients underwent concomitant central neck node removal. Final histology showed 285 pT1, 26 pT2, and 48 pT3 PTC. Lymph node metastases were found in 27 cases. Follow-up was completed in 315 patients. Mean postoperative serum thyroglobulin level off levothyroxine was 5.4 ng/mL. Post operative ultrasonography showed no residual thyroid tissue in all the patients. Mean post-operative 131I uptake was 1.7%. One patient developed lateral neck recurrence. No other recurrence was observed.
Ultrasound is considered the best diagnostic method for the detection of metastatic cervical lymph nodes (LNs) in patients with papillary thyroid carcinoma (PTC). According to current guidelines, all patients undergoing thyroidectomy for malignancy should undergo preoperative neck ultrasound of the thyroid and central and lateral neck LNs, followed by fine needle aspiration of suspicious LNs. Cervical LN involvement determenes the extent of surgery. Complete surgical resection disease at the initial operation decreases likelihood of future surgery for recurrent disease and may impact survival. We use a new technique, B-flow imaging (BFI), recently used for evaluation of thyroid nodules, to estimate the presence of BFI twinkling signs (BFI-TS), within metastatic LNs in patients with PTC.
Between September 2006 and December 2012, 304 patients with known PTC were examined for preoperative sonographic evaluation with gray-scale US, color Doppler US and BFI. Only 157 with at least one metastatic LN were included in our study. All patients included underwent surgery, and the final diagnosis was based on the results of histologic examination of the resected specimens. The following LN characteristics were evaluated: LN shape, abnormal echogenicity, the absent of hilum, calcifications, cystic appearance, peripheral vascularization and the presence of BFI-TS.
A total of 767 LNs were analyzed. 329 out of 767 were metastatic, according to the histopathologic findings. BFI-TS, showed 99.5% specificity and 81,5% sensitivity. We detected BFI-TS in 6 metastatic LNs that were negative to the other conventional US features.
Our results indicate that the BFI-TS has a diagnostic accuracy higher than the other conventional sonographic signs. Our findings suggest that BFI can be helpful in the selection of suspicious neck LNs that should be examined at cytologic examination or open biopsy for accurate preoperative staging and individual therapy selection.
In selected patients, video-assisted thyroidectomy can be considered a safe and validated procedure offering significant advantages over conventional surgery, with no additional morbidity. Aim of this study was to evaluate the results obtained in a series of patients selected for video-assisted thyroidectomy over a 10-years period. All patients who underwent video-assisted thyroidectomy from June 1998 to June 2009 were considered. The eligibility criteria for video-assisted thyroidectomy are: thyroid nodules ≤ 35 mm; estimated thyroid volume < 30 ml; no previous conventional neck surgery and/or radiation therapy; small, low-risk papillary thyroid carcinoma. A total of 1363 video-assisted thyroidectomies were attempted in the time period considered. Conversion to the conventional procedure was necessary in 7 cases. Thyroid lobectomy was successfully performed in 157 cases, total thyroidectomy in 1175, and completion thyroidectomy in 24. In 126 patients, the central neck nodes were removed through the same access. Simultaneous video-assisted parathyroidectomy, for a parathyroid adenoma, was performed in 42 patients. Pathological studies showed benign disease in 986 cases, papillary thyroid carcinoma in 368 cases, C-cells hyperplasia in 1 case, and medullary microcarcinoma in 1 patients with RET germline mutation. Post-operative complications included 27 transient and 1 definitive recurrent laryngeal nerve palsy, 230 transient hypocalcemia, 10 definitive hypoparathyroidism, 4 postoperative hematoma and 5 wound infection.
Thyroidectomy; Minimally invasive thyroidectomy; Endoscopic thyroidectomy
Prophylactic central neck dissection (CND) remains controversial in papillary thyroid carcinoma (PTC). Because postsurgical stimulated thyroglobulin (sTg) level is a good surrogate for recurrence, the study aimed to evaluate the impact of prophylactic CND on preablative and postablative sTg levels after total thyroidectomy.
Of the 185 patients retrospectively analyzed, 82 (44.3%) underwent a total thyroidectomy and prophylactic CND (CND-positive group) while 103 (55.7%) underwent total thyroidectomy only (CND-negative group). All patients had no preoperative or intraoperative evidence of lymph node metastases. Clinicopathological characteristics, postoperative outcomes, and preablative and postablative sTg levels were compared between the two groups. Preablative sTg level was taken at the time of radioiodine ablation, while postablative sTg level was taken 6 months after ablation. A multivariable analysis was conducted to identify factors for preablative athyroglobulinemia (sTg < 0.5 μg/L).
Relative to the CND-negative group, the CND-positive group had larger tumors (15 mm vs. 10 mm, P < 0.005), more extrathyroidal extension (26.8% vs. 14.6%, P < 0.003), more tumor, node, metastasis system stage III disease (32.9% vs. 9.7%, P < 0.001), and more temporary hypoparathyroidism (18.3% vs. 8.7%, P = 0.017). Fourteen patients (17.1%) in the CND-positive group were upstaged from stages I/II to III as a result of prophylactic CND. The CND-positive group experienced lower median preablative sTg (<0.5 μg/L vs. 6.7 μg/L, P < 0.001) and a higher rate of preablative athyroglobulinemia (51.2% vs. 22.3%, P = 0.024), but these differences were not observed 6 months after ablation. Prophylactic CND was the only independent factor for preablative athyroglobulinemia.
Although performing prophylactic CND in total thyroidectomy may offer a more complete initial tumor resection than total thyroidectomy alone by minimizing any residual microscopic disease, such a difference becomes less noticeable 6 months after ablation.
The aim of this study was to evaluate the clinicopathologic characteristics of papillary thyroid cancer with thyroiditis, and to determine the rate of its complications for it.
A retrospective review of 1,247 patients with papillary thyroid cancer who underwent primary thyroidectomy was performed. Among them, 316 patients had thyroiditis (group I) while 931 patients had no thyroiditis (group II), as reflected in the final pathologic reports. The two groups' clinicopathologic results and rate of complications were compared.
Female gender, preoperative hypothyroidism, total thyroidectomy, no extrathyroid extension, no lymphovascular invasion, and no perineural invasion were associated with group I. More central lymph nodes were removed in group I than in group II, but there were fewer central lymph nodes with metastasis in group I than in group II. For the lateral lymph nodes, the two groups had the same numbers of removed nodes and nodes with metastatic tumor. Multivariate analysis revealed female predominance, more cases of preoperative hypothyroidism, more dissected lymph nodes, and fewer lymph nodes with metastasis in group I. Among the patients who underwent lobectomy, postoperative hypothyroidism occurred more in group I than in group II (P < 0.001). There was no difference in postoperative complications between the two groups.
Papillary thyroid cancer with thyroiditis showed less aggressive features. Postoperative hypothyroidism occurred more in the patients with thyroiditis.
Thyroiditis; Papillary thyroid cancer; Hypothyroidism
Papillary thyroid microcarcinoma (PTMC) is defined as a papillary thyroid carcinoma less than or equal to 1.0 cm in size. Independent prognostic factors for clinical recurrence of PTMC have not been clearly delineated.
Clinicopathological parameters predicting PTMC recurrence were determined by retrospective analysis of 307 patients.
Of the 293 patients eligible for analysis, 14 (5%) had recurrence during a median follow-up time of 65 months. Recurrence was observed in 8 of 166 patients (0.5%) treated with total or near-total thyroidectomy; gender (P = 0.02) and presence of lateral cervical node metastases at initial surgery (P = 0.01) were associated with recurrence. Six of the 127 patients (0.5%) treated with hemi- or subtotal thyroidectomy experience recurrences, but no significant prognostic factor for recurrence was identified. Multivariate Cox-regression analysis showed that gender and cervical lymph node metastasis were significant variables
PTMC showed very diverse disease extent and could not be regarded as indolent, relatively benign disease based on the primary tumor size. The extent of surgery should be based on prognostic parameters, such as gender and lateral neck node metastasis, in patients with PTMC.
Endoscopic thyroidectomy has been applied prudently to malignant thyroid tumors. The purpose of our study was to compare the surgical outcomes of endoscopic thyroidectomy (ET) and conventional open thyroidectomy (COT) for micropapillary thyroid carcinoma.
From October 2002 to December 2008, 78 patients underwent unilateral lobectomy and isthmectomy with central lymph node dissection for papillary thyroid microcarcinoma. Of these, 37 patients underwent ET and 41patients COT. Surgical outcomes, including operation time, number of retrieved lymph nodes, postoperative complication rate and patients’ satisfaction with the cosmetic results, were analyzed.
The mean age of the patients was 42.3 ± 7.6 years in the ET group and 49.0 ± 10.8 years in the OT group (P = 0.003). The operation time was shorter in the COT group (112.3 ± 14min) than in the ET group (138.4 ± 36.9 min, P< 0.01). However, there were no significant differences in tumor size (0.5 ± 0.231vs. 0.41 ± 0.264cm, P = 0.116), number of retrieved lymph nodes (3.63 ± 2.1vs. 3.82 ± 3.28, P = 0.78) or postoperative hospital stay (3.35 ± 0.94vs. 3.17 ± 1.16 days, P = 0.457). Patients in the ET group experienced more pain than those in the COT group at 1 and 7 days after the operation as evaluated by a visual analog scale (P = 0.037, 0.026). Cosmetically, patients in the ET group were very satisfied with the operative procedure according to the questionnaire we used (1.43 ± 0.55vs. 3.21 ± 0.72, P< 0.001). The mean follow-up period was 54.3 months in the ET group and 47.4 months in the COT group, and each group exhibited one case of tumor recurrence detected at the other thyroid lobe within 2 years.
Large series of prospective studies and long-term follow-up are needed, but the results of ET using the axillary approach for micropapillary thyroid carcinoma were not inferiortothose using COT, and it might be a safe and feasible procedure with good cosmetic results.
Endoscopic thyroidectomy; Conventional open thyroidectomy; Micropapillary thyroid carcinoma
The impact of metastasized cervical lymph nodes (CLN) identified on central neck dissection (CND) on the recurrence/persistence of papillary thyroid cancer (PTC) and the extent of CND needed to reduce recurrence/persistence have not been firmly established. To assess the impact of CLN metastasis and BRAF mutation on the recurrence/persistence of PTC and the potential of BRAF mutation in assisting CND, we analysed data of 379 consecutive patients with PTC who underwent thyroidectomy with (n=243) or without CND (n=136) at a tertiary-care academic hospital during the period 2001–2010 for their clinicopathological outcomes and BRAF mutation status. Increasingly aggressive tumor characteristics were found as the extent of CND was advanced following conventional risk criteria from non-CND to limited CND to formal CND. Disease recurrence/persistence rate also sharply rose from 4.7% to 15.7% and 40.5% in these CND settings respectively (P<0.0001). CLN metastasis rate rose from 18.0 to 77.3% from limited CND to formal CND (P<0.0001). An increasing rate of BRAF mutation was also found from less to more extensive CND. A strong association of CLN metastasis and BRAF mutation with disease recurrence/persistence was revealed on Kaplan– Meier analysis and BRAF mutation strongly predicted CLN metastasis. CLN metastases found on CND are closely associated with disease recurrence/persistence of PTC, which are both strongly predicted by BRAF mutation. Current selection of PTC patients for CND is appropriate but higher extent of the procedure, once selected, is needed to reduce disease recurrence, which may be defined by combination use of preoperative BRAF mutation testing and conventional risk factors of PTC.
papillary thyroid cancer; neck dissection; BRAF mutation; lymph node metastasis; thyroid cancer recurrence
The indications and extent of cervical lymph node dissection in papillary thyroid carcinoma (PTC) are still being debated. The aim of this study was to analyze the patterns of cervical lymph node metastasis in the lateral and central compartment and related factors and suggest the optimal extent of lateral and central neck dissection for PTC patients with clinical lateral lymph node metastasis.
We retrospectively analyzed 72 patients with unilateral PTC who underwent therapeutic lateral neck dissections with concomitant total thyroidectomy and central neck dissection between January 2001 and December 2009.
The 72 patients underwent 79 sides of therapeutic lateral neck dissection. The most frequent metastatic level in the ipsilateral lateral compartment was level IV (75.0%), followed by level III (69.4%), level II (56.9%) and level V (20.8%). Multiple level metastases were common (77.8%) and were correlated with tumor size (≥ 10 mm). The central compartment lymph node metastasis rate was 87.5%, including 26.4% of contralateral central compartment metastases.
In PTC patients with clinical lateral lymph node metastasis, the optimal extent of lateral and central neck dissection should include levels II, III, IV and V as well as the bilateral central compartment.
Papillary thyroid carcinoma; Lateral neck dissection; Lymph node metastasis; Central neck dissection
Papillary thyroid carcinoma presenting as isolated cervical lymphadenopathy with clinically and histologically normal thyroid gland is rarely reported.
We report a case of 31 years old female who presented with a left cervical mass and clinically normal thyroid gland. After inconclusive FANC, excision biopsy of her cervical lymph nodes revealed metastatic papillary thyroid carcinoma. The patient subsequently underwent total thyroidectomy with bilateral lymph node dissection. Interestingly pathological examination showed no primary carcinoma in the gland. Postoperative radioactive iodine scan revealed no other metastasis.
Total thyroidectomy is the next best step despite clinically and radiologically normal appearing thyroid gland once cervical lymph nodes are proven to be metastatic in nature followed by a RAI therapy to treat occult foci of PTC.
papillary thyroid micro carcinoma (PTMC); fine needle aspiration cytology (FNAC); computed tomography (CT); papillary thyroid carcinoma (PTC)
Prophylactic central neck dissection in papillary thyroid cancer is controversial. In this retrospective cohort study, the aim was to assess possible advantages of prophylactic central neck dissection with total thyroidectomy in cN0 papillary thyroid cancer. A total of 244 consecutive patients with papillary thyroid cancer, without clinical and ultrasound nodal metastases (cN0), were evaluated out of 1373 patients operated for a thyroid disease at the Istituto Europeo di Oncologia, Milan, Italy from 1994 to 2006. Of these 244 patients, 126 (Group A) underwent thyroidectomy with central neck dissection, while 118 (Group B) underwent thyroidectomy alone. Demographic, clinical and pathological features were analysed. Overall recurrence rate was 6.3% (8/126) in Group A and 7.7% (9/118) in Group B, with a mean follow-up of 47 (Group A) and 64 (Group B) months. In Group A patients, 47% were pN1a and all patients with recurrence had nodal involvement (p = 0.002). Survival rate did not differ in the two groups. Nine patients were lost to follow-up. Group A patients were older and their tumours were larger in size; according to the pT distribution, a higher extra-capsular invasion rate was observed. The two groups were equivalent as far as concerns histological high risk variants and multifocality. Nodal metastases correlated with stage: pT1-2 vs. pT3-T4a, p = 0.0036. A lower risk of nodal metastases was related to thyroiditis (p = 0.0034). In conclusion, central neck metastases were predictive of recurrence without influencing prognosis. From data obtained, possible greatest efficacy of central neck dissection in pT3-4 papillary thyroid cancer without thyroiditis is suggested.
Thyroid; Papillary thyroid cancer; Nodal metastases; Central neck dissection
Papillary carcinoma is the most common differentiated malignant thyroid neoplasm. The biological course of this cancer is typically indolent with a protracted clinical course. Metastases commonly occur in regional lymph nodes, and distant metastasis is a late and rare occurrence. We report a patient who presented with cerebellar metastasis prior to the diagnosis of papillary thyroid carcinoma and review the literature of brain metastasis from papillary thyroid carcinoma.
A 75-year old female presented at the emergency room with progressive dizziness, headache and vomiting, where a brain CT and MRI showed a posterior cerebellar tumor. Surgical resection revealed papillary carcinoma consistent with thyroid origin. Subsequent ultrasound and CT-scan revealed a thyroid nodule, after which the patient underwent total thyroidectomy. Pathologic evaluation was consistent with papillary thyroid carcinoma.
Brain metastasis may rarely be the initial presentation of papillary thyroid carcinoma. Solitary brain metastasis can completely be resected with better prognosis.
The significance of nodal metastases, very common in papillary thyroid cancer, and the role of lymph node dissection in the neoplasm management, are still controversial. The impact of lymph node involvement on local recurrence and long-term survival remains subject of active research. With the aim to better analyze the predictive value of lymph node involvement on recurrence and survival, we investigated the clinico-pathological patterns of local relapse following total thyroidectomy associated with lymph node dissection, for clinical nodal metastases papillary thyroid cancer, in order to identify the preferred surgical treatment.
Clinical records, between January 2000 and December 2006, of 69 patients undergoing total thyroidectomy associated with selective lymph node dissection for clinical nodal metastases papillary thyroid cancer, were retrospectively evaluated. Radioiodine ablation, followed by Thyroid Stimulating Hormone suppression therapy was recommended in every case. In patients with loco regional lymph nodal recurrence, a repeated lymph node dissection was carried out. The data were compared with those following total thyroidectomy not associated with lymph node dissection in 210 papillary thyroid cancer patients without lymph node involvement, at preoperative ultrasonography and intra operative inspection.
Incidence of permanent hypoparathyroidism (iPTH < 10 pg/ml) and permanent monolateral vocal fold paralysis were respectively 1.4 % (1/69) and 1.4% (1/69), similar to those reported after total thyroidectomy "alone". The rate of loco regional recurrence, with positive cervical lymph nodes, following 8 year follow-up, was 34.7% (24/69), higher than that reported in patients without nodal metastases (4.2%). A repeated lymph node dissection was carried out without significant complications.
Nodal metastases are a predictor of local recurrence, and a higher rate of lymph node involvement is expected after therapeutic lymph node dissection associated with total thyroidectomy. The prognostic significance of nodal metastases on long-term survival remains unclear, and more prospective randomized trials are requested to better evaluate the benefits of different therapeutic approaches.
Total thyroidectomy; Papillary thyroid cancer; Lymph node recurrence; Lymph node neck dissection; Radio active iodine ablation
The optimal extent of thyroidectomy for papillary thyroid cancers (PTCs) < 1 cm is controversial. Our aim was to identify the rate and factors predictive of contralateral PTC in these patients.
We examined 228 patients with PTC who underwent either completion or total thyroidectomy and analyzed the predictive value of tumor size, histology, margin status, capsular invasion, extrathyroid extension, multifocality, and node metastases.
We observed no differences in the rate of contralateral disease in patients with primary PTC ≥ 1 cm compared to those < 1 cm, 30% vs. 24% respectively (P=0.43). Multifocality was the only factor predictive of contralateral PTC in patients with tumors < 1 cm (P=0.02). Patients with tumors < 0.5 cm also had a comparable rate of contralateral disease (27%).
The presence of contralateral PTC appears to be unrelated to the size of the primary tumor. Furthermore, in patients with PTCs < 1 cm, multifocality is a risk factor for PTC in the contralateral lobe.
Papillary thyroid cancer; Contralateral; Size; Risk factors; Microcarcinoma
Renal metastases from thyroid carcinoma are very rare, late recurrences of papillary thyroid carcinomas (PTC) are not reported in literature and there is no universal recommendation for optimum duration of follow-up of thyroid carcinoma. We present herein a case of late renal recurrence of follicular variant PTC (FV-PTC). This study is a case report of renal metastasis revealing a late recurrence of FV-PTC. An 81-year-old woman with previously treated FV-PTC 24 years ago by total thyroidectomy, lymph nodes dissection and radioiodine therapy presented with sudden gross-hematuria. Computerized tomography scan (CT-scan) revealed a 70-mm right renal mass and histological diagnosis after nephrectomy demonstrated recurrence of FV-PTC with a positive thyroglobulin immunostaining. Despite of 131I-radioiodine therapy postoperatively, the serum thyroglobulin (Tg) increased and positron emission tomography combined to CT-scan showed 4 years later, an abdominal lymph node and distant metastases. Now the patient is alive but her general condition is too poor for systemic adjuvant therapy. This case illustrates the need of prolonged follow-up after surgery of high-risk FV-PTC.
Late recurrence; renal metastasis; thyroid carcinoma
Ectopic thyroid glands generally occur in the midline as a result of abnormal median migration, and their presence lateral to the midline is rare. We present one case of an ectopic thyroid gland masquerading as a lateral neck metastasis of a papillary thyroid carcinoma (PTC). In this case of a 54-yr-old woman with left PTC, we suspected left lateral neck metastasis on preoperative neck computed tomography. The patient underwent total thyroidectomy, central compartment neck dissection, and left modified radical neck dissection (MRND). The patient was diagnosed as having an accessory thyroid gland on the lateral neck on the final pathologic report. Surgeons should be aware of the existence of an ectopic thyroid gland in unusual locations.
Ectopic Thyroid; Carcinoma, Papillary
A clinical and pathological study was made of a series of 34 consecutive patients with thyroid carcinoma. Carcinoma occurred only in nodular goiters, and in the majority of cases was found in a gland with a solitary nodule. The degree of firmness to palpation of a thyroid nodule is unimportant in the diagnosis of carcinoma of the thyroid since hardness was an infrequent finding. In the diagnostic use of radioactive iodine, scintigram studies of a nodular goiter usually revealed an area of decreased function at the site of a thyroid carcinoma.
Twenty-three per cent of the 34 patients with thyroid carcinoma died within five years. The duration of survival for various patients was compared with the type of treatment administered.
It is believed that solitary thyroid nodules are best treated by lobectomy. Total thyroidectomy is indicated in cases of large thyroid carcinoma and also for smaller tumors if papillary adenocarcinoma. Radical neck dissection is warranted if lymph node metastasis is present and limited to the neck; and also in the absence of metastasis if the tumor is papillary in histologic pattern. Surgically inaccessible metastatic lesions are best palliated by radioactive iodine or external irradiation.
Thyroid disease is common, thyroid cancer is uncommon. Most goitres are investigated using blood tests, fine needle aspiration cytology together with ultrasound. Surgery usually entails either lobectomy or total thyroidectomy, and for malignancy, patients may need a neck dissection. Recently, significant advances have been made regarding mechanisms involved in both thyroid growth and function (goitrogenesis) and carcinogenesis at a molecular level.
PATIENTS AND METHODS
In the study cohort, 1113 patients had benign disease and 387 malignancy. For benign disease, 716 patients had lobectomy or isthmusectomy, 44 had near-total thyroidectomy and 318 a total thyroidectomy. For malignancy, patients received initial lobectomy (180) or total thyroidectomy (152). One hundred and eleven had completion surgery. Thirty patients had extensive surgery. Thyroid growth and function was investigated using 500 human thyroid cell primary cultures obtained at surgery, as well as in three animal models. The role of pituitary tumour transforming gene (PTTG), PTTG binding factor (PBF) and sodium iodide symporter (NIS) in thyroid cell function was then evaluated.
Temporary and permanent recurrent laryngeal nerve palsy rates were 2.4% and 0.4%. Other complications included temporary (21%) and permanent (3%) hypoparathyroidism, wound infection (1.2%), haematoma (1.2%) and poor scar (0.8%). Six patients have died. Regarding thyroid growth and function, TSH represents (either directly or indirectly) the main factor mediating thyroid follicular cell growth. For carcinogenesis, over-expression of the proto-oncogenes PTTG and PBF induces tumours in nude mice, and PTTG can induce proliferation of human thyroid cells and, in addition, both repress expression and function of NIS.
Thyroid disease including cancer; Growth factors; Thyroid surgery
Papillary thyroid microcarcinomas are tumors often found accidentally after thyroidectomy for other thyroid disorders.
Patients with enlarged lateral cervical masses, with unknown thyroid disease, found to have metastases from papillary thyroid carcinoma ≤10 mm in diameter, were compared to patients operated on for nodular or multinodular goiter, who were incidentally found to have papillary thyroid microcarcinomas.
Group A included 24 patients with an enlarged lateral cervical mass whereas group B included 30 patients presenting with nodular or multinodular goiter. Patients in both groups underwent surgery. After thyroidectomy and lymph node dissection, pathology revealed multifocal papillary carcinomas of 1–10 mm, with invasion of the thyroid capsule and surrounding soft tissue in most of the cases in group A. Two patients presented with distant metastases at diagnosis which were surgically removed. During follow up, 3 patients (12.5%) presented with new cervical metastases which were surgically removed or treated with additional radioactive iodine. At last follow-up, all patients were alive. In contrast, all patients in group B had unifocal papillary thyroid carcinoma 1–10 mm in maximum diameter, with no infiltration or extension into the adjacent tissue, or cervical lymph node metastases.
Two groups of papillary thyroid microcarcinomas characterized by different clinical and biological behaviours are identified. Significant differences were found between these groups concerning the age, tumor size, number of tumor foci, lymph nodes metastases and extrathyroidal extension of the tumor. Papillary thyroid carcinomas of small (≤10 mm) size may have aggressive behaviour or be metastatic, and this subgroup should be treated and followed up as are other large, differentiated thyroid cancers.
Conflicting data have been reported with regard to Hashimoto thyroiditis (HT) and risk of malignancy. The aim of this study was to evaluate coexistence of papillary thyroid cancer (PTC) with HT.
Patients and methods
This is a retrospective cohort study in which HT was diagnosed in 452 (F/M ratio = 405:47, median age 53.5 ± 12.1 years) of 7,545 patients qualified for thyroidectomy throughout the years 2002 to 2010. Pathological reports were reviewed to identify prevalence of PTC in HT vs. non-HT patients.
PTC was diagnosed in 106 of 452 (23.5 %) HT patients vs. 530 of 7,093 (7.5 %) non-HT patients (p < 0.001). Metastases to level VI lymph nodes were observed in 81 of 106 (76.4 %) patients with PTC in HT vs. 121 of 530 (22.8 %) patients with PTC in non-HT disease (p < 0.001).
HT was associated with a threefold increase of PTC prevalence as compared to other non-HT thyroid diseases, and the spread of PTC to level VI lymph nodes was four times more frequent in HT than in non-HT patients.
Hashimoto thyroiditis; Papillary thyroid carcinoma; Benign thyroid disease
This study investigated the utility of BRAF mutation testing of thyroid fine-needle aspiration biopsy (FNAB) specimens for preoperative risk stratification in papillary thyroid cancer (PTC).
Patients and Methods
We assessed the T1799A BRAF mutation status in thyroid FNAB specimens obtained from 190 patients before thyroidectomy for PTC and its association with clinicopathologic characteristics of the tumor revealed postoperatively.
We observed a significant association of BRAF mutation in preoperative FNAB specimens with poorer clinicopathologic outcomes of PTC. In comparison with the wild-type allele, BRAF mutation strongly predicted extrathyroidal extension (23% v 11%; P = .039), thyroid capsular invasion (29% v 16%; P = .045), and lymph node metastasis (38% v 18%; P = .002). During a median follow-up of 3 years (range, 0.6 to 10 years), PTC persistence/recurrence was seen in 36% of BRAF mutation–positive patients versus 12% of BRAF mutation–negative patients, with an odds ratio of 4.16 (95% CI, 1.70 to 10.17; P = .002). The positive and negative predictive values for preoperative FNAB-detected BRAF mutation to predict PTC persistence/recurrence were 36% and 88% for overall PTC and 34% and 92% for conventional PTC, respectively.
Preoperative BRAF mutation testing of FNAB specimens provides a novel tool to preoperatively identify PTC patients at higher risk for extensive disease (extrathyroidal extension and lymph node metastases) and those who are more likely to manifest disease persistence/recurrence. BRAF mutation, as a powerful risk prognostic marker, may therefore be useful in appropriately tailoring the initial surgical extent for patients with PTC.
Lymphatic metastasis in papillary thyroid cancer (PTC) is eminent; however, the extent of central compartment lymph nodes dissection (CCD) is controversial and requires the knowledge of pattern and risk factors for central compartment lymph nodes metastasis (CCM). We did a prospective study of 47 cases with PTC who underwent total thyroidectomy (TT) with CCD with/without lateral lymph nodes dissection (LND). Clinicopathological profile including CCM as ipsilateral and contralateral was documented. On histopathology, the mean tumour size was 3.57 ± 2.42 cm 59.6% had CCM, which was bilateral in the majority (60.72%). The tumour-size was the most important predictor for lymph nodes metastasis-(P=0.018)
whereas multicentricity-(P=0.002) and ipsilateral CCM-(P=0.001) were the predictors for contralateral CCM. The long-term morbidity of CCD done in primary setting is comparable with TT-alone. Bilateral CCD should be done with thyroidectomy in PTC, otherwise the risk of residual diseases and subsequent recurrence is high. The long-term morbidity is comparable in experienced hands.
Thyroid cancer is among the most common endocrine malignancies. Genetic and environmental factors play an important role in the pathogenesis of differentiated thyroid cancer. Both have good prognosis but with frequent recurrences. Cancer staging is an essential prognostic part of cancer management. There are multiple controversies in the management and followup of differentiated thyroid cancer. Debate still exists with regard to the optimal surgical approach but trends toward a more conservative approach, such as lobectomy, are being more favored, especially in papillary thyroid cancer, of tumor sizes less than 4 cm, in the absence of other high-risk suggestive features. Survival of patients with well-differentiated thyroid cancer was adversely affected by lymph node metastases. Prophylactic central LN dissection did improve accuracy in staging and decrease postop TG level, but it had no effect on small-sized tumors. Conservative approach was more applied with regard to the need and dose of radioiodine given postoperatively. There have been several advancements in the management of radioiodine resistant advanced differentiated thyroid cancers. Appropriate followup is required based on risk stratification of patients postoperatively. Many studies are still ongoing in order to reach the optimal management and followup of differentiated thyroid cancer.
Thyroid gland derives from one median anlage at the base of the tongue, and from the two fourth branchial pouches. A number of anomalies may occur during their migration. These can be in form of ectopic tissues, which are frequently found along the course of thyroglossal duct and rarely in other sites, many of these may develop same diseases as the thyroid gland.
A 36-years-old female presented with a 3 month history of left side neck mass. The mass disappeared following aspiration of brown colored fluid, which on cytological examination showed cells with nuclear irregularities that warranted the resection of the lesion. The histology demonstrated a thyroid papillary carcinoma arising within the branchial cyst. Thereafter, the patient underwent a total thyroidectomy with central lymph nodes dissection. Histology showed a multifocal papillary carcinoma with central lymph nodes metastases. Only four cases of primary thyroid carcinomas in neck branchial cyst have been described so far.
In a lateral cystic neck mass, although rare, occurrence of ectopic thyroid tissue and presence of a papillary thyroid carcinoma should be kept in mind.