Increasing Thyroid Cancer Rate and the Extent of Thyroid Surgery in Korea

Background

It is evident that the rate of thyroid cancer is increasing throughout the world. One reason is increased detection of preclinical small cancers. However, it is not clear whether the increase in thyroid cancer rate is reducing the extent of thyroid surgeries. The purpose of this study was to evaluate the thyroid cancer rate and analyze recent changes in the extent of thyroid cancer surgeries in Korea.

Methods

An observational study was conducted using data from Korea’s Health Insurance Review and Assessment Service (HIRAS) for thyroidectomy with/without neck dissection, with 228,051 registered patients between 2007 and 2011. Data were categorized by the extent of surgery: unilateral thyroidectomy without neck dissection (UT), bilateral thyroidectomy or radical thyroidectomy without neck dissection (TT), any thyroidectomy with unilateral selective neck dissection (SND), any thyroidectomy with unilateral modified radical neck dissection (MRND), any thyroidectomy with unilateral radical neck dissection (RND), and any thyroidectomy with bilateral neck dissection (BND). Annual rate difference for each surgery was analyzed with a linear by linear association.

Results

The absolute numbers of total thyroid surgeries (UT+TT+SND+MRND+RND+BND) were increased from 28539 to 61481. The proportion of patients who underwent only thyroidectomy without neck dissection (UT+TT) decreased from 67.30% to 60.50%, whereas the proportion of patients who underwent neck dissection (SND+MRND+RND+BND) increased from 32.70% to 39.50% during the 5-year study period.

Conclusion

Despite the increase in rate of thyroid cancer due to earlier detection, increased rate of neck dissection was noted.     

One-stage bilateral radical neck dissection; indications and technique

Simultaneous bilateral radical neck dissection is an operation entailing acceptable risk if used in propertly selected cases. The procedure is indicated for patients with bilateral cervical lymph node metastases so situated that a two-stage radical neck dissection could not be done without cutting through cancer tissue. Such patients are those with intraoral or cervical visceral midline primary lesions or those in whom, either by direct extension or lymph node involvement, the submental and submaxillary triangles are solidly permeated with cancer. The operation is indicated only for cure; for prophylaxis or palliation, lesser or staged procedures would be more productive of better results with less morbidity and mortality.     

ONE-STAGE BILATERAL RADICAL NECK DISSECTION — Indications and Technique

Simultaneous bilateral radical neck dissection is an operation entailing acceptable risk if used in propertly selected cases. The procedure is indicated for patients with bilateral cervical lymph node metastases so situated that a two-stage radical neck dissection could not be done without cutting through cancer tissue. Such patients are those with intraoral or cervical visceral midline primary lesions or those in whom, either by direct extension or lymph node involvement, the submental and submaxillary triangles are solidly permeated with cancer. The operation is indicated only for cure; for prophylaxis or palliation, lesser or staged procedures would be more productive of better results with less morbidity and mortality.     

Use of apron flap incision for neck dissection.

Neck dissection is one of the most commonly performed surgical procedures in the management of head and neck cancer. Different skin incisions with various modifications have been described in the literature. Three commonly used but conceptually different incisions were compared with respect to the incidence of wound dehiscence in a retrospective review. There were 166 patients with 184 neck dissections carried out using a triradiate (n = 85), modified MacFee (n = 25), or an apron flap incision (n = 74). The incidence of wound dehiscence in the three groups was 11 percent, 8 percent, and 0 percent for the triradiate, modified MacFee, and apron flap incisions, respectively. There was a statistically significant difference in the incidence of wound dehiscence between the apron flap incision and the triradiate incision groups (p = 0.004). The difference in wound dehiscence was not statistically significant between the apron flap incision and the modified MacFee incision groups (p = 0.06). Overall, there was a significant increase in the incidence of wound dehiscence in previously irradiated necks (p = 0.02), but this was significant only for the triradiate incision (p = 0.005) when analyzed individually. Comparison of triradiate, apron, and MacFee incisions did not show a statistically significant difference between the incisions with regard to other postoperative complications in terms of seroma, hematoma, wound infection, and fistula formation. The apron flap incision is the recommended approach in the presence of previous neck irradiation as it gives easier access than the MacFee incision. The robustness of the flap is because of the absence of a trifurcate point as well as a good vascular supply arising from arterial territory of the external carotid artery.     

Management of Well-Differentiated Thyroid Cancer in 2010: Perspectives of a Head and Neck Surgical Oncologist

ObjectiveTo review the terminology and controversy regarding the performance of prophylactic lymph node dissection for patients without evidence suggestive of pathologic adenopathy.MethodsTerminology of lymph node levels in the neck and chest, and the issues regarding lymph node dissection, are reviewed. In addition, differences between lymph nodes are reviewed and discussed.ResultsManagement of lymph nodes in this disease process has become the most contentious aspect of surgical decision-making due to the ambiguity of their prognostic significance and the prevalence of nodal metastases in very early primary tumors. Performance of prophylactic central compartment node dissection is not technically any more difficult than therapeutic node dissection when clinically significant nodes are encountered. It is therefore reasonable to consider this technique as an important adjunct to a total thyroidectomy for the purpose of enhanced disease staging, prevention of nodal recurrence, and avoidance of having to re-enter the previously operated central compartment. A recent study is reviewed and discussed in detail. The literature regarding the prognostic significance of extracapsular spread in lymph nodes is also presented.ConclusionsMorphologic characteristics of metastatic lymph nodes in thyroid cancer vary greatly. However, the reporting of these differences is lacking. The presence of extracapsular extension in a lymph node has prognostic significance. The clinician should be aware of these variations and the impact that they may have on recurrence risk and disease-specific survival. (Endocr Pract. 2010;16:903-912)     

Planned neck dissection following chemo-radiotherapy in advanced HNSCC

BACKGROUND: Neck dissection has traditionally played an important role in the management of patients with regionally advanced head and neck squamous cell carcinoma (HNSCC) treated with radical radiotherapy alone. However, with the incorporation of chemotherapy in the therapeutic strategy for advanced HNSCC and resultant improvement in outcome the routine use of post chemo-radiotherapy neck dissection is being questioned. METHODS: Published data for this review was identified by systematically searching MEDLINE, CANCERLIT & EMBASE databases from 1995 until date with restriction to the English language. RESULTS: There is lack of high quality evidence on the role of planned neck dissection in advanced HNSCC treated with chemo-radiotherapy. A systematic literature search could identify only one small randomized controlled trial (Level I evidence) addressing this issue, albeit with major limitations. Upfront neck dissection followed by chemo-radiotherapy resulted in better disease-specific survival as compared to chemoradiation only. Several single arm prospective and retrospective reports were also identified with significant heterogeneity and often-contradictory conclusions. CONCLUSIONS: Planned neck dissection after radical chemo-radiotherapy achieves a high level of regional control, but its ultimate benefit is limited to a small subset of patients only. Unless there are better non-invasive ways to identify residual viable disease, the role of such neck dissection shall remain debatable. A large randomized controlled trial addressing this issue is needed to clarify its role and provide evidence-based answers.     

The utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population

Intraoperative lymph node mapping and sentinel lymph node biopsy have proven beneficial techniques in staging adult patients with melanoma of the head and neck, where there is great variability in lymphatic drainage. This technique has also been applied to pediatric patients with truncal cutaneous melanomas in an effort to determine nodal status without the morbidity associated with complete lymph node dissection. Nevertheless, the utility of sentinel lymph node biopsy in head and neck melanoma in the pediatric population has not been established. The objective of the authors' study was to determine the clinical utility of intraoperative lymph node mapping and sentinel lymph node biopsy of head and neck melanoma in the pediatric population. The authors reviewed the records of seven pediatric patients with head and neck melanoma or borderline melanocytic proliferations of unknown biologic potential who underwent intraoperative lymph node mapping and sentinel lymph node biopsy between 1998 and 2001. All sentinel lymph node specimens were examined by a melanoma dermatopathologist for the presence of metastatic melanoma. The mean operative time for each case was 3 hours, 8 minutes (range, 2 hours, 15 minutes to 3 hours, 50 minutes). All seven pediatric patients who underwent extirpation of a primary head and neck melanoma and preoperative lymphoscintigraphy had unique and identifiable basins of drainage to regional nodal groups. Four of seven patients had at least one positive sentinel lymph node. Overall, five of 19 sentinel nodes (26 percent) resected had evidence of metastatic melanoma. Of the patients with positive sentinel lymph nodes, two of the primary lesions were diagnosed as melanoma while two were initially considered atypical melanocytic proliferations of uncertain biologic potential with melanoma in the differential diagnosis. Sentinel lymph nodes in pediatric patients with melanoma of the head and neck can be successfully mapped and biopsied, as in adult patients. In addition, this procedure can provide critical diagnostic information for those pediatric patients with diagnostically challenging, controversial, or borderline melanocytic lesions.     

Sentinel lymph node biopsy in the management of cutaneous head and neck melanoma

Sentinel lymph node biopsy has revolutionized the surgical management of primary malignant melanoma. Most series on sentinel lymph node mapping have concentrated on extremity and truncal melanomas. The head and neck region has a rich and unpredictable lymphatic system. The use of sentinel lymph node mapping in the management of head and neck melanoma is evaluated. The authors conducted a retrospective review of patients treated for clinical stage I and stage II malignant melanoma of the head and neck with dynamic lymphoscintigraphy and gamma probe-guided sentinel lymph node biopsy. One hundred thirty-two patients (99 male patients and 33 female patients) were identified. The primary melanoma sites were the scalp (n = 54), ear (n = 14), face (n = 37), and neck (n = 27). Primary tumor staging was as follows: T1, 11; T2, 38; T3, 39; and T4, 44. Dynamic lymphoscintigraphy visualized sentinel lymph nodes in 128 patients (97 percent). In 71 cases (55 percent), a single draining nodal basin was identified, and in 57 cases there were multiple draining nodal basins (two basins, 55; three basins, two). Sentinel lymph nodes were successfully identified in 176 of 186 nodal basins (95 percent). Positive sentinel lymph nodes were identified in 22 patients (17.6 percent). Sentinel lymph node positivity by tumor staging was as follows: T2, 10.8 percent; T3, 19.4 percent; and T4, 26.8 percent. Completion lymphadenectomy revealed residual disease in seven patients (33.3 percent). Sentinel lymph node mapping for head and neck melanoma can be performed with results comparable to those of other anatomical sites.     

Are Radical and Conservative Substitution Rates Useful Statistics in Molecular Evolution?

A DNA mutation in a protein coding gene which causes an amino acid change can be classified as conservative or radical depending on the magnitude of the physicochemical difference between the two amino acids: radical mutations involve larger changes than conservative mutations. Here, I examine two key issues in determining whether radical and conservative substitution rates are useful statistics in molecular evolution. The first issue is whether such rates can be estimated reliably, and for this purpose I demonstrate considerable improvements achieved by simple modifications to an existing method. The second issue is whether conservative and radical substitution rates can tell us something about selection on protein function. I address this problem by estimating positive and negative selection on conservative and radical mutations using polymorphism and divergence data from Drosophila. These analyses show that negative selection, but not positive selection, differs significantly between conservative and radical mutations. The power of conservative and radical substitution rates in testing the nearly neutral theory of molecular evolution is illustrated by the analysis of two mammalian datasets.     

TREATMENT OF MELANOMA—SUCCESS OR FAILURE?

The treatment of melanoma should be by radical surgical excision of the primary lesion and dissection of the regional nodes.Where possible this should be done in anatomic continuity; otherwise in physical discontinuity but at the same time.If maximum salvage is to be achieved the nodal dissection must be effected before there is clinical evidence of involvement by metastasis.Amputation of extremities should be reserved for cases in which there is evident metastasis between the original focus and the regional lymph node areas.     

Predictive Factors of Superior Mediastinal Nodal Metastasis from Papillary Thyroid Carcinoma—A Prospective Observational Study

Objectives

The purpose of this study was to demonstrate the incidence rates and predictive factors of superior mediastinal lymph node (SMLN) metastasis in PTC (papillary thyroid carcinoma) patients.

Methods

A prospective observational study was performed between January 2009 and January 2011. PTC patients who had tumors with a maximal diameter greater than 1 cm and clinically negative SMLNs were included in this study. Finally, a total of 217 patients who underwent total thyroidectomy with central compartment neck dissection (CND) and elective superior mediastinal lymph node dissection (SMLND), with or without modified radical neck dissection (MRND) and revisional CND, were included.

Results

Occult SMLN metastasis was present in 15.7% (34/217). Cytological classifications of tumor, BRAFV600E mutation, Tumor size, T-stage, perithyroidal extension, lymphovascular invasion, multifocality, and paratracheal pN(+) were not predictive of SMLN metastasis (P > .05), while revision surgery, pretracheal pN(+), and multiple lateral pN(+) were associated with SMLN metastasis. There were no major complications related to SMLND. Transient and permanent hypoparathyroidism was observed in 69 cases (31.8%) and 8 cases (3.6%), respectively.

Conclusions

Despite clinically negative SMLN in preoperative evaluation, SMLN metastasis can be predicted for patients with a PTC tumor size larger than 1 cm, pretracheal LN metastasis, multiple lateral metastasis, and revisional surgery.     

Treatment of melanoma; success or failure?

The treatment of melanoma should be by radical surgical excision of the primary lesion and dissection of the regional nodes. Where possible this should be done in anatomic continuity; otherwise in physical discontinuity but at the same time. If maximum salvage is to be achieved the nodal dissection must be effected before there is clinical evidence of involvement by metastasis. Amputation of extremities should be reserved for cases in which there is evident metastasis between the original focus and the regional lymph node areas.     

Lymphatic mapping and sentinel lymph node biopsy in patients with melanoma of the lower extremity

Lymphatic mapping and sentinel lymph node biopsy is a new technique used in the surgical treatment of patients with malignant melanoma. The purpose of this study was to evaluate the results of this approach for patients with melanoma of the lower extremity. Between May of 1994 and June of 1997 at the H. Lee Moffitt Cancer Center and Research Institute, 85 consecutive patients with clinical stage I and II melanoma of the lower extremity underwent lymphatic mapping and sentinel lymph node biopsy. These nodes were identified in all 85 patients by intraoperative lymphatic mapping with both radiolymphoscintigraphy and a vital blue dye injection. Eleven patients (12.9 percent) had histologically positive sentinel lymph nodes, and 10 patients underwent inguinal complete lymph node dissections. All 10 patients had no further histologically positive lymph nodes confirmed by subsequent complete dissection. Among 74 patients with histologically negative sentinel lymph nodes, only 2 patients (2.7 percent) developed inguinal nodal metastases during a mean follow-up period of 21.8 months (range, 13.5 to 58.3 months). The sensitivity of lymphatic mapping and sentinel lymph node biopsy in this series was 100 percent and the specificity was 97.3 percent. Therefore, we conclude that the use of lymphatic mapping and sentinel lymph node biopsy can accurately stage patients with melanoma of the lower extremity and provide a rational surgical approach for these patients.     

不同手术方式对分化型甲状腺癌患者预后的影响

目的：探讨不同手术方式对分化型甲状腺癌患者临床治疗的效果及其预后的影响。方法：回顾性分析了2005.02-2012.07入住我院的60例分化型甲状腺癌患者的临床资料,采用如下三种不同的治疗方式：甲状腺切除术联合双侧中央区颈淋巴结清扫手术;保留对侧喉返神经入喉处甲状腺组织的甲状腺次全切除术联合单侧改良颈淋巴结清扫手术;保留对侧喉返神经入喉之处甲状腺组织的甲状腺次全切除手术联合双侧改良颈淋巴结清扫手术。结果：（1）上述三组患者术后,患者的甲状旁腺的功能低下之间均存在显著的统计学差异（P〈0.01）,三组喉返神经损伤的发生率之间也存在显著的统计学差异（P〈0.01）;本组60例患者均获10-172个月（平均为93.5±10.2）的随访,上述三种手术方式下患者的癌症复发率分别为77.8%、4.5%及45.0%,三组具有显著的统计学差异（P〈0.01）;生化治愈率分别为27.8%、95.5%及50.0%;平均生存时间分别为（92.3±12.5）个月、（105.8±14.5）个月及（112.3±20.9）个月。（2）三组患者术后生存质量总得分分别为（122±9）、（118±8）及（125±9）分。结论：与甲状腺切除术联合双侧中央区颈淋巴结清扫手术进行对比,保留对侧喉返神经入喉处甲状腺组织的甲状腺次全切除术联合单侧改良颈淋巴结清扫手术与保留对侧喉返神经入喉之处甲状腺组织的甲状腺次全切除手术联合双侧改良颈淋巴结清扫手术在生存时期、术后生存质量两个方面不具显著性差异。     

Impact of middle and lower jugular neck dissection on supraclavicular lymph node metastasis from endometrial carcinoma

ABSTRACT: Supraclavicular lymph node metastasis from endometrial carcinoma is considerably rarer than metastasis from uterine cervical cancer. To date, there have been no reported cases regarding systematic neck dissection as a salvage treatment. In this report, we describe the neck dissection procedure carried out on a 74-year-old woman with supraclavicular lymph node metastasis. Our objective was to histologically determine the origin of the metastasis while simultaneously providing appropriate treatment. The patient's past medical history included two prior cases of cancer: rectal cancer 7?years earlier and endometrial adenocarcinoma 4?years earlier. We determined that middle and lower jugular neck dissection was appropriate in treating this case based on the results of our preoperative FDG-PET and tumor markers. This surgery provided histological evidence that metastasis occurred from endometrial carcinoma. Middle and lower jugular neck dissection was expected to improve the patient's prognosis without impacting the patient's active daily life. We have continued to monitor the patient closely over an extended period.     

La TEP-TDM au 18FDG a-t-elle un intérêt dans la stadification ganglionnaire des mélanomes malins cutanés cervicofaciaux bénéficiant de la technique du ganglion sentinelle ? À propos de 22 cas

Background and objectivesIn N0 cutaneous head and neck melanoma, sentinel lymph node biopsy (SLNB) is less reliable and accurate than in trunk or extremities melanoma (false negative cases and spotting failure). The aim of our study was to assess the utility of PET-CT ¹⁸FDG in a specific group of N0 patients, combined with SLNB.Patients and methodsTwenty-two patients with N0 cutaneous head and neck melanoma were retrospectively reviewed. All of them had underwent PET-CT and SLNB before surgery. Average follow-up time was 17 months (1–44).ResultsAt least one sentinel lymph node (SLN) was identified in 20 patients. Ten patients (50%) had metastatic SLN. Among these 10 N+ patients, PET-CT was positive for occult nodal metastases for only two patients. During follow-up, two patients had cervical nodal recurrence, whereas SLNB was negative. PET-CT was also negative for these two patients. SLNB and PET-CT sensitivity were respectively 83 and 18%. PET-CT specificity was 84% (regarding neck sides).ConclusionIn this specific population with N0 cutaneous head and neck melanoma, PET-CT sensitivity is too low and failed to detect occult nodal metastases in two patients with false negative SLNB. Consequently, PET-CT seems to be not useful for nodal staging N0 cutaneous head and neck melanomas, in which SLNB is the most accurate technique.     

Surgical resection for gastrointestinal stromal tumors (GIST): experience on 25 patients

Background

The benefit of pelvic lymphadenectomy in patients with cancer of the urinary bladder remains controversial. Though the inclusion of lymph node dissection in conjunction with radical cystectomy for patients with clinically negative nodes is well accepted, however, the extent of the nodal dissection remains contentious, particularly in patients with gross disease and T₁G₃ cancer. The extent of the primary bladder tumor, number of lymph nodes removed and the lymph node tumor burden are important prognostic variables in patients undergoing cystectomy. We analyzed the impact of the extent of lymphadenectomy during radical cystectomy on survival in the contemporary literature.

Methods

A Pubmed search was carried out for the literature published over the last 15 years using bladder cancer, radical cystectomy, survival, lymphadenectomy and complications as the key words. We have discussed the extent of lymphadenectomy on survival and its anatomical basis to determine the optimal number of lymph nodes to be removed and the concept of node density.

Results

Evidence from contemporary literature indicate significantly increased survival rates after cystectomy in patients with bladder cancer diagnosed with stages III or IV disease who have had relatively more lymph nodes examined, suggesting that even some patients with higher stage disease may benefit from extended pelvic lymphadenectomy at the time of cystectomy. Studies also indicate that more extensive lymphadenectomy significantly improved the prognosis of patients with bladder cancer, not only by providing prognostic information but perhaps it is also due to its inherent therapeutic value.

Conclusion

Extended lymph node dissection improves local control and survival. However, in the absence of controlled randomized trial this remains a dubitable issue.     

Unilateral, multicentric Warthin's tumor mimicking a tumor metastatic to a lymph node. A case report

BACKGROUND: Warthin's tumor may be associated with false positive diagnoses of malignancy on fine needle aspiration. The most common cause of error is markedly atypical squamous metaplasia mimicking metastatic cystic squamous carcinoma. The common location of Warthin's tumors within periparotid nodes may add to the clinical suspicion of metastasis. We report a case of unilateral, multicentric Warthin's tumor arising in periparotid and intraparotid glands, leading to a strong clinical and cytologic suspicion of malignancy. CASE: A 60-year-old female presented with a 3-month history of several enlarged lymph nodes in the right side of the neck. Fine needle aspiration, performed at the right upper neck lymph node, suggested the possibility of metastatic tumor. On computed tomography and ultrasonography there were 4 nodular lesions in the right retromandibular area and lateral aspect of the neck, 1-1.5 cm in diameter. A thyroid scan revealed diffuse enlargement of the thyroid gland and a nodular lesion in the right lobe. Right thyroid lobectomy and modified radical neck dissection, including right superficial parotidectomy, were performed for evaluation of occult malignancy. Histologically we confirmed that the tumor was a synchronous, multicentric Warthin's tumor arising in the parotid gland and intraparotid and paraparotid lymph nodes. CONCLUSION: Clinicians and pathologists should consider an extraparotid Warthin's tumor in the differential diagnosis of multiple cervical masses.     

INDICATIONS FOR OPERATION IN LARYNGEAL CANCER

Improvements in the surgical treatment of laryngeal cancer by combined laryngectomy and radical neck dissection have given new importance to selection of the mode of treatment for various stages of disease at that site. To cast light on the subject, the cases of 63 patients with cancer of the larynx were reviewed. Twenty-one of them were operated on for recurrence after radiation therapy; and 42 were treated surgically at the outset, 36 of them having combined laryngectomy and radical neck dissection. In almost 80 per cent of the patients the lesion was extrinsic.In the entire series, 51 patients had combined operations, and in 41 of them the cervical lymph nodes were positive for metastasis.Reports in the literature also make note of a very high incidence of cervical node metastasis not only in cases of extrinsic cancer, but also in those in which the lesion is intrinsic.Because of the frequency of cervical node spread, and its occult nature, choice between radiation and surgical operation must be made after candid, critical appraisal of the individual condition in each patient.     

影响口腔鳞状细胞癌患者预后的临床病理因素分析

目的:研究影响口腔鳞状细胞癌(Oral squamous cellcar cinoma,OSCC)术后患者预后的临床病理因素。方法:回顾性研究55例手术治疗的原发口腔鳞状细胞癌患者与预后相关的因素:年龄、性别、发病部位、颈部淋巴结转移情况、肿瘤细胞分化程度等。结果:平均发病年龄为57.35±12.02岁,牙龈鳞癌的复发转移率最高(45.5%),舌部第二(44%),颊部第三(37.5%),唇癌预后最好(0.0%)。术前颈部淋巴结转移情况、肿瘤细胞分化程度与预后有关。肿瘤细胞的分化程度与术前淋巴结转移无显著相关性。术前有颈部淋巴结转移合并中低分化与预后差相关。结论:口腔鳞状细胞癌的预后与发病部位无显著相关性。肿瘤中低分化及术前有淋巴结转移者易出现术后复发转移。