EP60 – The impact of occult lymph node metastasis for regional recurrence in papillary thyroid cancer after bilateral prophylactic central neck dissection

      Lee, Young Chan1 1 Department of Otolaryngology-Head & Neck Surgery, School of Medicine, Kyung Hee University, Seoul, Korea   Background/ Purpose: The risk factor for regional recurrence after prophylactic central neck dissection (pCND) for preoperative nodal-negative papillary thyroid cancer (PTC) is controversial. We evaluated risk factors including clinicopathological characteristics and occult lymph node (LN) metastasis patterns for regional LN recurrence in PTC patients who underwent total thyroidectomy and bilateral pCND. Methods: This study enrolled 211 consecutive patients who underwent total thyroidectomy with bilateral pCND for PTC without evidence of central LN metastasis on preoperative imaging. Clinicopathological features and central LN metastasis patterns were analyzed for predicting regional recurrence. Multivariate Cox regression analysis was used to identify independent factors for recurrence. Results: Median follow-up time was 43 months (24-95 months). Ten patients (4.7%) showed regional LN recurrence. Among 10 patients, 2 recurred at the central LN compartment (20.0%) and 8 at the lateral LN compartment (80.0%). The estimated 5-year regional recurrence-free survival rate (RFS) was 95.2%. Tumor size ?1cm, central LN metastasis, LN ratio (LNR) and prelaryngeal LN metastasis were associated with regional recurrence in univariate analysis (p < 0.05). In multivariate analysis, LNR ? 0.26 was a significant risk factor for regional LN recurrence (odds ratio = 11.63, p=0.003). LNR ? 0.26 was an independent predictor of worse RFS on Cox -regression analysis. (hazard ratio = 11.49, p=0.002) Discussion & Conclusion: LN ratio ? 0.26 was an independent predictor of regional LN recurrence in PTC patients who underwent total thyroidectomy and bilateral pCND. A more careful surveillance of lateral neck is warranted in patients with LN ratio ? 0.26.   References:
    1. Pearce EN, Braverman LE. Papillary thyroid microcarcinoma outcomes and implications for treatment. J Clin Endocrinol Metab. 2004;89:3710-2.
    2. Lundgren CI, Hall P, Dickman PW, Zedenius J. Clinically significant prognostic factors for differentiated thyroid carcinoma: a population-based, nested case-control study. Cancer. 2006;106:524-31.
    3. Ito Y, Higashiyama T, Takamura Y, Miya A, Kobayashi K, Matsuzuka F, et al. Risk factors for recurrence to the lymph node in papillary thyroid carcinoma patients without preoperatively detectable lateral node metastasis: validity of prophylactic modified radical neck dissection. World J Surg. 2007;31:2085-91.
    4. Kim MK, Mandel SH, Baloch Z, Livolsi VA, Langer JE, Didonato L, et al. Morbidity following central compartment reoperation for recurrent or persistent thyroid cancer. Arch Otolaryngol Head Neck Surg. 2004;130:1214-6.
    5. Moley JF, Lairmore TC, Doherty GM, Brunt LM, DeBenedetti MK. Preservation of the recurrent laryngeal nerves in thyroid and parathyroid reoperations. Surgery. 1999;126:673-7; discussion 7-9.
    6. Zaydfudim V, Feurer ID, Griffin MR, Phay JE. The impact of lymph node involvement on survival in patients with papillary and follicular thyroid carcinoma. Surgery. 2008;144:1070-7; discussion 7-8.
    7. Nixon IJ, Wang LY, Palmer FL, Tuttle RM, Shaha AR, Shah JP, et al. The impact of nodal status on outcome in older patients with papillary thyroid cancer. Surgery. 2014;156:137-46.
    8. Adam MA, Pura J, Goffredo P, Dinan MA, Reed SD, Scheri RP, et al. Presence and Number of Lymph Node Metastases Are Associated With Compromised Survival for Patients Younger Than Age 45 Years With Papillary Thyroid Cancer. J Clin Oncol. 2015;33:2370-5.
    9. Popadich A, Levin O, Lee JC, Smooke-Praw S, Ro K, Fazel M, et al. A multicenter cohort study of total thyroidectomy and routine central lymph node dissection for cN0 papillary thyroid cancer. Surgery. 2011;150:1048-57.
    10. Hadad S, Balasubramanian S. Prophylactic central neck dissection for papillary thyroid cancer (Br J Surg 2013; 100: 410-418). Br J Surg. 2013;100:1115.
    11. Hartl DM, Mamelle E, Borget I, Leboulleux S, Mirghani H, Schlumberger M. Influence of prophylactic neck dissection on rate of retreatment for papillary thyroid carcinoma. World J Surg. 2013;37:1951-8.
    12. Randolph GW, Duh QY, Heller KS, LiVolsi VA, Mandel SJ, Steward DL, et al. The prognostic significance of nodal metastases from papillary thyroid carcinoma can be stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. Thyroid. 2012;22:1144-52.
    13. Shan CX, Zhang W, Jiang DZ, Zheng XM, Liu S, Qiu M. Routine central neck dissection in differentiated thyroid carcinoma: a systematic review and meta-analysis. Laryngoscope. 2012;122:797-804.
    14. Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. 2010;17:1471-4.
    15. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1-133.
    16. Ryu IS, Song CI, Choi SH, Roh JL, Nam SY, Kim SY. Lymph node ratio of the central compartment is a significant predictor for locoregional recurrence after prophylactic central neck dissection in patients with thyroid papillary carcinoma. Ann Surg Oncol. 2014;21:277-83.
    17. Vas Nunes JH, Clark JR, Gao K, Chua E, Campbell P, Niles N, et al. Prognostic implications of lymph node yield and lymph node ratio in papillary thyroid carcinoma. Thyroid. 2013;23:811-6.
    18. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19:1167-214.
    19. Teixeira G, Teixeira T, Gubert F, Chikota H, Tufano R. The incidence of central neck micrometastatic disease in patients with papillary thyroid cancer staged preoperatively and intraoperatively as N0. Surgery. 2011;150:1161-7.
    20. Lang BH, Wong KP, Wan KY, Lo CY. Impact of routine unilateral central neck dissection on preablative and postablative stimulated thyroglobulin levels after total thyroidectomy in papillary thyroid carcinoma. Ann Surg Oncol. 2012;19:60-7.
    21. 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;138:1095-100, discussion 100-1.
    22. Shindo M, Wu JC, Park EE, Tanzella F. The importance of central compartment elective lymph node excision in the staging and treatment of papillary thyroid cancer. Arch Otolaryngol Head Neck Surg. 2006;132:650-4.
    23. White ML, Gauger PG, Doherty GM. Central lymph node dissection in differentiated thyroid cancer. World J Surg. 2007;31:895-904.
    24. Leboulleux S, Rubino C, Baudin E, Caillou B, Hartl DM, Bidart JM, et al. Prognostic factors for persistent or recurrent disease of papillary thyroid carcinoma with neck lymph node metastases and/or tumor extension beyond the thyroid capsule at initial diagnosis. J Clin Endocrinol Metab. 2005;90:5723-9.
    25. Lee YC, Shin SY, Kwon KH, Eun YG. Incidence and clinical characteristics of prelaryngeal lymph node metastasis in papillary thyroid cancer. Eur Arch Otorhinolaryngol. 2013;270:2547-50.
    26. Eun YG, Lee YC, Kwon KH. Predictive factors of contralateral paratracheal lymph node metastasis in papillary thyroid cancer: prospective multicenter study. Otolaryngol Head Neck Surg. 2014;150:210-5.
    27. Shaha AR, Shah JP, Loree TR. Risk group stratification and prognostic factors in papillary carcinoma of thyroid. Ann Surg Oncol. 1996;3:534-8.
    28. Baek SK, Jung KY, Kang SM, Kwon SY, Woo JS, Cho SH, et al. Clinical risk factors associated with cervical lymph node recurrence in papillary thyroid carcinoma. Thyroid. 2010;20:147-52.
    29. Iyer NG, Kumar A, Nixon IJ, Patel SG, Ganly I, Tuttle RM, et al. Incidence and significance of Delphian node metastasis in papillary thyroid cancer. Ann Surg. 2011;253:988-91.


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