Patterns And Predictive Factors Of Contralateral Central Nodal Metastasis In Thyroid Papillary

Carcinoma: Prospective Study Of Bilateral Central Lymph Node Dis-

section

Kee-Hwan Kwon, Eun-Jae Chung, Young-Soo Rho

Department of Otolaryngology – Head & Neck SurgeryIlsong Memorial Institute of Head and Neck Cancer

Hallym Univeristy Medical Center

Introduction

Prophylactic central lymph node dissection (CLND)

Negatively - higher rate of permanent hypoparathyroidism and

permanent nerve injury without evidence of survival benefit or better local control

- no additional morbidity as a secondary procedure after local recurrence

Positively - removal of microscopic disease in central lymph

nodes may prevent recurrence and improve overall survival without increased morbidity

- second operation on recurred central lymph nodes may increase the risk of complications

Introduction

ATA guideline prophylactic CLND (ipsilateral or bilateral)

as an option in the management of ad-vanced PTC (T3 or T4 )

not for small tumors (T1 or T2 classification), noninvasive or clinically node-negative PTC

Limitations of recent guidelines even in PTC with small tumors (T1 or T2),

there is a high possibility of CLN metastasis, rates of CLN metastasis are different in ac-

cord with various clinicopathologic parame-ters

Introduction

A few studies have suggested some risk fac-

tors for ipsilateral and contralateral CLN

metastasis in cases of PTC, but there is no

consensus about predictors

Prospective study with histopathologic in-

formation and risk factors analysis in PTC

patients with clinically only contralateral

negative neck nodes

Purpose

The objective of this study was to determine

the pattern and the predictive factors for oc-

cult contralateral central neck lymph node

metastasis, prospectively

Material & Methods

Prospective study

127 PTC patients with clinically node-nega-

tive contralateral central neck

Between 2010 and 2011

Ilsong Memorial Institute Head and Neck

Cancer, Hallym University College of

Medicine

Preoperative ultrasonography was per-

formed on every patient

Material & Methods

16 men, 121 women

mean age: 49.5 years; range 29-76 years

Total thyroidectomy & bilateral CND

Central neck compartment specimens

Dephian

Ipsilateral paratracheal

contralateral paratracheal

Pretracheal

Del-phian

pretra-cheal

Rt.paratra-cheal

Lt.paratra-cheal

Central neck compartment specimen

Results

Characteristics of patients with PTC

Variables Number (%)

Age<45≥45

43 (33.9%)84 (66.1%)

Mean tumor size (cm)<1 cm ≥1 cm

1.04 cm (range 0.1 - 10)75 (59.1%)52 (40.9%)

MultiplicityNoYes

84 (66.1%)43 (33.9%)

Extrathyroidal extensionNoYes

80 (62.9%)47 (37.1%)

Bilaterality (pathologic)NoYes

98 (77.2%)29 (22.8%)

Pattern of lymph node metastasis

Central node metasta-sis

:44/ 127 patients (34.6%) Lateral neck node

metastasis : 18/127 patients (14.2%) Ipsi para + pretracheal : 16/ 127 (12.6%) Ipsi paratracheal + del-

phian : 5/ 127 (3.9%) Ipsi para + pre + del-

phian : 4/ 127 (3.1%)

Delphian:8/ 127 (6.3%)

Pretracheal: 25 (19.7%)

IpsiParatracheal:32/ 127 (25.2%)

ContraParatracheal: 13/ 127 (10.2%)

Univariate analysis of clinicopathologic characteristics re-lated to contralateral central lymph node metastasis

Variables Contra- Contra+ p-value

Age<45≥45

3480

94

0.01*

Mean tumor size<1 cm ≥1 cm

7143

49

0.038*

MultiplicityNoYes

7836

67

0.128

Bilaterality (pathologic)NoYes

9024

85

0.171

Extrathyroidal extensionNoYes

7539

58

0.05*

Variables Contra- Contra+ p-value

Ipsilateral paratracheal nodeNoYes

9420

112

<0.001*

Pretracheal nodeNoYes

9915

310

<0.001*

Delphaian nodeNoYes

1095

103

0.035*

Ipsi para & pretracheal nodeNoYes

1077

49

<0.001*

Ipsi para & delphian nodeNoYes

1122

103

0.008*

Ipsi para & pretracheal & del-phian

NoYes

1140

94

<0.001*

Lateral neck nodeNoYes

1068

310

<0.001*

Multiple logistic regression analysis for contralateral central lymph node metastases

Variables p-valueAge (<45 yrs) 0.035*

(Odd ratio 18.652, 95% CI 1.232-282.468)

Tumor size (1cm) 0.696

Extrathyroidal extension 0.918

Ipsilateral paratracheal node 0.997

Pretracheal node 0.997

Delphian node 1.000

Lateral neck node 0.03*(Odd ratio 18.672, 95% CI 1.324-

263.298)Ipsi para & pretracheal node 0.997

Ipsi paratracheal & dephian node

1.000

Ipsi para & pre & delphian node 0.999

Postoperative complications

Temporary V.palsy 2 (1.5%)

Permanent V.palsy 0 (0%)

Temporary hypoparathyroidism 17 (13.3%)

Permanent hypoparathyroidism 1 (0.8%)

Conclusion

Contralateral central lymph node metastases were sig-

nificantly associated with age, tumor size, ECS, ipsilat-

eral para/ pretracheal/ delphain and lateral neck com-

partment node metastasis

On multivariate analysis, lateral neck lymph node

metastasis (with young age) was an independent pre-

dictive factor of contralateral central compartment

metastasis