What? When? Why? (How?)

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1 Surgery of the Central Neck in Thyroid Cancer Dana M Hartl MD PhD Haïtham Mirghani MD Nothing to disclose Disclosure 2 Central Neck Dissection What? When? Why? (How?) What is it? Terminology for neck dissection Neck level VI: Comprehensive, compartmentoriented removal of the prelaryngeal and pretracheal nodes and at least one paratracheal lymph node basin (on at least one side) Carty et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid 2009;19: Ferlito et al. Proposal for a rational classification of neck dissections. Head Neck 2011:33;

2 VIA VIB What is it? Level VI Removal of all fat, lymphatic, and connective tissue in the lymph node basin Limits Hyoid bone superiorly Level of the sternal notch inferiorly Common carotid artery Esophagus/prevertebral fascia Dissection and preservation Parathyroid glands (reimplantation) Recurrent nerves Thymic remnants 5 Left inferior parathyroid gland Left thymic remnant Larynx Left RLN Esophag us 6 What is it? Right RLN Inferior thyroid artery Level VI Don t forget behind the nerve on the right 7 8 2

3 What is it? Level VII Between sternal notch and innominate artery Variations with patient morphology (may not exist) Often accessible via a cervical approach What is it? Do I need to systematically resect the thymic remnants? NO: Low rate of thymic invasion (4%) Higher rate of transient hypocalcemia if thymus resected Don t resect unless necessary Extensive metastases, reoperative surgery, or level VII 9 El Khatib et al World J Surg 2010;34: What is it? What is it not? Terminology for neck dissection: «Berry picking» or removal of only a few nodes Therapeutic neck dissection Performed to remove known metastatic nodes (cn1) Clear out all gross disease Prophylactic or elective neck dissection Performed in the absence of suspected metastatic nodes (cn0) «The finger technique» or palpation in the neck searching for suspicious nodes Not recommended Carty et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid 2009;19: Carty et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid 2009;19:

4 When to do it? Recommendation 27 (a) Therapeutic central compartment neck dissection in patients with clinically (+imaging) involved central or lateral neck lymph nodes should accompany total thyroidectomy to provide clearance of disease from the central neck. Grade B When to do it? Metastatic nodes in the lateral neck are rarely alone Skip metastases to the lateral neck (without level VI involvement) 15-20% of patients N+ Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19: Where to do it? Level VI-VII If you can safely, remove as far down as you can to the innominate artery Bilateral? 25-50% contralateral metastases Higher if large tumor or multifocal tumor Sadowski BM et al, Surgery 2009;146: Koo BS et al, Ann Surg 2009;249: Evaluation of the extent of disease Ultrasound Contrast-enhanced CT Need to wait 4 weeks before radioiodine treament Visualization of «hidden lymph nodes» Visualization of mediastinal nodes Indicated for large or multiple neck nodes Optimize surgial excision for extensive neck disease Reoperative surgery 18 FDG-PET-CT Agressive pathological subtypes Reoperative surgery, iodine-refractory cases Padovani RP et al, Thyroid 2012;22:

5 Hidden lymph nodes: - Along superior thyroid pedicle, lateral to larynx - Behind right recurrent nerve/innominate artery - Behind common carotid artery - Behind innominate vein/sternal notch - In front of jugular/subclavian veinbehind sternoclavicular joint (Level VII) Meticulous dissection of the thyroid Visualize and preserve all parathyroids Inferior parathyroid gland With its vascular pedicle Often close to the summit of the thymic remnant Mark with a clip or small non-resorbable suture Useful if recurrence Or remove and reimplant Sinks in water Send a tiny piece to pathology for proof of identity Avoid reimplanting lymph nodes

6 21 22 Reoperative surgery Precise tumor mapping Ultrasound, CT, PET-CT Back-door approach Neuromonitoring Quicker identification of nerve Map the nerve during dissection Inferior parathyroids Difficult, try to locate the thymic remnants, dissect them then search for the parathyroid at the tip of the thymus Nodes more rarely superior to the inferior thyroid artery (superior parathyroid) Sometimes you just can t find them 23 «Back door route» Moley et al, Surgery 1999;125:

7 larynx Level VI nodes Sternothyroid muscle. Common carotid artery Why do it? 131 I not effective for gross disease Up to 30% of tumors do not show 131 I uptake Nodes with 131 I uptake coexist with those with no uptake 25 Podnos YD et al, Am Surg 2005;71: Durante C et al, JECM 2006;91: Travagli JP et al, JCEM 1998;83; Why do it? Macroscopic lymph node metastases (>1 cm) Higher rate of persistent neck disease More neck recurrences Higher mortality Justifies more agressive surgery General consensus endocrinologists, surgeons, nuclear médecine, oncologists Bardet S et al, Eur J Endocrinol 2008;158:551 Zaydfudim V et al, Surgery 2008;144:

8 What is it? Compartment-oriented neck dissection Prelaryngeal and pretracheal and at least one paratracheal basin No suspicious nodes on ultrasound Unilateral or bilateral Histological examination of a selective lymph node dissection will ordinarily include 6 or more lymph nodes. If the lymph nodes are negative, but the number ordinarily examined is not met, classify as pn0. 29 Sobin L, Gospodarowicz M, Wittekind D. TNM classification of malignant tumors, 7th edition ct1 T2 T3 N0 6 or more lymph nodes: Unilateral CND = only 42% harbored 6 or more Bilateral CND = only 78% harbored 6 or more Higher number of nodes if thyroiditis (p<.0001) n=80 n=237 Hartl DM, et al. Ann Surg When to do it? Recommendation 27 (b) Prophylactic central compartment neck dissection (ipsi or bilateral) may be performed in patients with papillary thyroid carcinoma, especially for advanced primary tumors (T3T4) grade C (expert opinion) (c) Near-total or total thyroidectomy without prophylactic central neck dissection may be appropriate for small (T1T2), noninvasive papillary cancers and most follicular cancer grade C Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19:

9 When to do it? To detect and remove occult lymph node metastases Incidence of occult lymph node metastases: 30-80% Tumor size Extrathyroidal extension (T3 T4) Tumor multifocality Male gender Young age 33 Ultrasound isn t perfect! Study Hwang & Orloff 30% Morita et al 64% Ahn et al 55% Kim et al 38% Choi et al 53% Hartl et al 58% Sensitivity in the central neck, thyroid in place 34 Why do it? Why not? The battle of low-level evidence 35 Why do it? Can be performed safely without more complications than total thyroidectomy alone Chisholm EJ et al, Laryngoscope 2009;119: (meta-analysis) Avoid reoperation in the central compartment But for experienced surgeons, reoperation does not carry a higher rate of complications than primary surgery Shen WT et al, Arch Surg 2010;145:272-5 Alvarado R et al, Surgery 2009;145:

10 Prophylactic Neck Dissection Why do it? Staging pn0 versus pn1 Lower risk of recurrence for pn0 Can safely treat pn0 with lower-doses or no 131 I More 131 I and closer follow-up for pn1 Risks associated with 131 I Radiation-induced second primary cancers Salivary glands Leukemia Digestive tumors, bone, bladder Miscarriage Ageusia, dysgeusia, xerostomia Radioprotection, environmental considerations Psychological considerations, quality of life Nascimento C, et al. Endocr Relat Cancer 2011;18:R29-40 Bonnet S, et al. J Clin Endocrinol Metab 2009;94: Hughes DT, et al. Surgery 2010;148: Hartl DM, et al. Ann Surg 2012;255: Rubino C et al. Br J Cancer 2003;89: Iyer NG et al. Cancer 2011;117: Why do it? Reduce rate of reoperation in level VI 1.5% with prophylactic neck dissection versus 6.1% without, p =.004 Popadich et al, 4 year follow-up 2% versus 12%, p<.0001 IGR, 6 year follow-up Reduce rate of re-treatment (surgery or 131 I) 6.5% with prophylactic neck dissection, versus 14.7% without, p=.01 (IGR) Improved rate of retreatment-free survival Popadich A et al, Surgery 2011;150: Hartl DM et al. IGR unpublished results 39 Why not do it? No high-level evidence showing impoved disease-specific survival Meta-analysis showing no effect on disease-specific survival Roh JL et al, Ann Surg 2007;245: Bardet S et al, Eur J Endocrinol 2008;158: Zetoune T et al, Ann Surg Oncol 2010;17:

11 Why not do it? Stage I: all patients <45 M0 Why not do it? Recommendation 27 These recommendations should be interpreted in light of available surgical expertise There may be more harm than benefit in some cases Loh KC et al, J Clin Endocrinol Metab 1997;82: Staging pn0 versus pn1: Can we do it without a complete prophylactic neck dissection? Ipsilateral paratracheal neck dissection + frozen section analysis Sensitivity 78% Sentinel node biopsy: Localization rate 63-99% False negatives 0-16% But less morbidity? Conclusions Therapeutic central neck dissection General consensus of its usefulness Try to be as complete as possible Chae BJ et al, Thyroid 2011;8:1-5 Balasubramian SP et al, Br J Surg 2011;98:

12 Conclusions Special Thanks: Prophylactic cental neck dissection may have some benefits (low level evidence): Staging pn0/n1 Dose of 131 I Follow-up and prognosis Improve the rate of retreatment-free survival over the long term 45 Martin Schlumberger Chief of Radiodiagnostics, Nuclear Medicine and Endocrine Tumors Sophie Leboulleux Thyroid Tumor Board Abir Al-Ghuzlan Pathology Isabelle Borget Biostatistics and Medicoeconomics Jean-Paul Travagli, Haïtham Mirghani Thyroid Surgery Unit 46 12