Overview. Extraglandular Thyroid Lymphatics. Management of the Lateral Neck in Well-Differentiated Thyroid Carcinoma. David W. Eisele, M.D., F.A.C.S.

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1 Management of the Lateral Neck in Well-Differentiated Thyroid Carcinoma David W. Eisele, M.D., F.A.C.S. Head and Neck Surgery and Oncology U.C.S.F. Comprehensive Cancer Center University of California, San Francisco Overview Nodal metastases common in papillary ca Distribution of lateral neck nodal metastases fairly predictable Presence of nodes predictive of recurrence Impact of nodal metastases on survival unclear Patients want nodal metastases removed Thorough conservation surgery Minimize morbidity Revision surgery increases costs and morbidity Extraglandular Thyroid Lymphatics Generally thought: Primary drainage - central neck compartment nodes Secondary drainage - lateral neck nodes Skip metastases to lateral neck possible: 7.7% Chung et al; Thyroid, % Machens et al; Arch Surg, % Mirallie et al; World J Surg, 1999

2 Extraglandular Thyroid Lymphatics Extraglandular Thyroid Lymphatics In general, follow thyroid gland blood vessels Knowledge of lymphatic drainage patterns aids in neck evaluation and treatment Superior to prelaryngeal and levels II and III Lateral to levels III, IV, VB Inferior to pretracheal and paratracheal nodes, level III, and anterior superior mediastinal nodes Posterior to retropharyngeal nodes Thyroid Lymphatics Nodal Metastases - Clinical Incidence Papillary Carcinoma 47% Scheumann et al; World J Surg, % Mazzaferri & Jhiang; Am J Med, % DeGroot et al; J Clin Endo Met, 1990 From: JT Johnson and JL Gluckman, eds. Carcinoma of the Thyroid

3 Influence of Primary Tumor Size Machens et al; Cancer, 2005 Nodal Metastases - Incidence Papillary Microcarcinoma (<1.0 cm) 32% Hay et al; Surgery, % Wada et al; Ann Surg, % (< 5mm) Chow et al; Cancer, % Chung et al; Thyroid, 2009 Cervical Nodal Metastases Increased Clinical Incidence: Children (<20 y.o.) 60% Frankenthaler et al; Am J Surg, 1990 Extrathyroidal Spread 57% Andersen et al; Am J Surg, 1995 Gland Multicentricity 73% Carcangiu et al; Cancer, 1985 Nodal Metastases - Incidence Follicular Carcinoma: Less propensity for lymphatic spread 25 % Mazzaferri & Jhiang; Am J Med, % Samaan et al; J Clin Endo Metab, % Rao et al; Head Neck, 1996 Usually associated with advanced local disease and invasion

4 Nodal Metastases - Incidence Hürthle Cell Carcinoma: Slightly higher incidence compared to Follicular Carcinoma: 17% Watson et al; Mayo Clin Proc, % Har-El et al; Cancer, 1986 Less than 10% are I 131 avid Neck Dissection - Incidence 90% Noguchi et al; Cancer, % Ozaki et al; World J Surg, % Attie; Eur J Cancer Clin Oncol, 1988 Higher incidence for therapeutic ND compared to elective ND Dependent on thoroughness of both the surgeon and the pathologist Pattern of Metastatic Nodes Pattern of Lateral Neck Metastases Kupferman et al; Arch OHNS, 2004

5 Level I Involvement Low incidence of Level I involvement even in the N+ neck: Level V Involvement Kupferman et al; Head Neck, % Sivanandan and Soo; Br J Surg, % Noguchi et al; Cancer, 1970 Sequelae of Neck Dissection Impaired shoulder function possible even with preservation of spinal accessory nerve Neuropraxia Adhesive capsulitis of glenohumeral joint Can this be avoided with more selective dissection? Cooper et al; Thyroid, 2009

6 Level IIB Involvement Pingpank et al, Arch OHNS, /34 (21%) of comprehensive ND specimens positive at Level IIB 3/34 (9%) Level IIB sole disease in Level II Level IIB and Level VB Farrag et al; World J Surg, 2009 Level IIA 56% Level IIB 8.5% involved only when gross disease noted in level IIB Level VB 40% Level VA 0% Level IIB Involvement Koo et al; Ann Surg Oncol, 2009 Level IIB positive 11.8% Multivariate analysis: LN involvement in all lateral neck levels (levels IIA + III +IV) was an independent predictor of level IIB LN metastases (p=.044) Conclude IIB dissection not needed in absence of multilevel involvement including IIA Preoperative U/S Prediction Koo et al; Ann Surg Oncol, 2010 If no suspicious nodes in level III by U/S, no occult nodes in level II Lim et al; Surgery, 2010 If no suspicious nodes in level IV by U/S, no instance of occult nodes in level V

7 Bilateral Nodal Metastases Increased incidence in certain conditions: - Bilateral primary tumors Isthmus primary Recurrent tumor Noguchi et al; J Surg Oncol, Multilevel nodal involvement Mirallie et al; World J Surg, 1999 Kupferman et al; Head Neck, 2008 Impact of Nodal Metastases - Recurrence N Stage Baek et al; Thyroid, 2010 Capsular invasion, extrathyroidal extension, N stage Mercante et al; Thyroid, 2009 Male gender, age > 55, massive ETE, tumor size > 3cm even if prophylactic ND done Ito, Miyauchi; World J Surg, 2008 Impact of Nodal Metastases - Recurrence Higher incidence of recurrence (despite postoperative I 131 ablation): Mazzaferri and Jhiang; Am J Med, 1994 Beasley et al; Arch Otolaryn HNS, 2002 Matched pair analysis: higher incidence recurrence if >50 years Hughes et al; Head Neck, 1996 Papillary Carcinoma Nodal Metastases - No Impact on Survival Hughes et al; Head Neck, 1996 Coburn and Wanebo; Am J Surg, 1992 DeGroot et al; J Clin Endo Metab, 1990 Cunningham et al; Am J Surg, 1990

8 Papillary Carcinoma Nodal Metastases - Negative Impact on Survival SEER database n=9904 with known node status 14 year OS 82% vs. 79% Podnos et al; Am Surg, 2005 Swedish Cancer Registry n=5123 Patients with lymph node mets have higher mortality (odds ratio 2.5) even after adjusting for TMN stage Lundgren et al; Cancer 2006 Papillary Carcinoma Nodal Metastases - Negative Impact on Survival If bilateral nodes - Mazzaferri and Jhiang; Am J Med, 1994 If nodes fixed - Schelfhout et al; Eur J CCO, 1988 If extrathyroidal extension of primary - Simpson et al; Am J Med, 1987 Evaluation Physical examination Ultrasound +/- FNA; Tg assay (cystic node) MRI CT Scan; contrast an issue? Sentinel node identification Intraoperative palpation and inspection Frozen section Ultrasound Now routine to assist in the detection of nonpalpable nodal disease Unsuspected nodal metastases detected: 34% Kuovaraki et al; Surgery, % Solorzano et al; Am Surg, % Stulak et al; Arch Surg, 2006 Alters scope of approx. 40% of initial and reoperative surgical cases Stulak et al; Arch Surg, 2006

9 Ultrasound MRI Criteria for suspicious nodes: - round; inhomogeneous pattern - irregular cystic appearance - internal calcifications - absence or truncation of fatty hilum Antonelli et al; Thyroid, 1995 Ahuja et al; Clin Radiol, 1995 Kuovaraki et al; Surgery, 2003 Good imaging of: Parapharyngeal Retropharyngeal Paratracheal Mediastinal CT Scan Metastatic Nodes - Surgical Resection Gross nodal disease not effectively treated medically Surgical resection preferred Postoperative adjuvant therapy - I l-thyroxine suppression therapy Benefit of surgical resection of increasingly detected clinically occult nodes is unclear

10 Cervical Metastases - Impact of Surgical Resection Difficult to demonstrate due to many factors: Indolent behavior of WDTC Relatively low impact of nodal metastases on survival Retrospective, nonrandomized nature of studies reported in the literature More extensive surgery usually done for more advanced disease Adjuvant therapy inconsistencies Elective Neck Dissection for N0 Neck No reduction in neck recurrence Yamashita et al; Cancer, 1999 Wada et al; Ann Surg, 2003 Higher complication rates Noguchi et al; J Surg Oncol, 1992 Hamming et al; Surg Gynecol Obstet, 1989 Occult nodes can be effectively managed with I 131 and l-thyroxine suppression Simpson et al; Int J Rad Onc Biol Phys, 1988 Selective Nodal Resection AKA node/berry picking/plucking Not recommended: Violation of neck with scar formation Subsequent surgery can be problematic - incision planning - risk of complications Usually leaves residual nodal disease 81% Pingpank et al; Arch OHNS, 2002 Selective Nodal Resection Higher incidence of recurrence compared to neck dissection: Musacchio et al; Am Surg, 2003 (100%) Scheumann et al; World J Surg, 1994 McGregor et al; Am J Surg, 1985 No difference in survival compared to neck dissection: Bhattacharyya; Arch OHNS, 2003 (SEER) Mazzaferri and Jhiang; Am J Surg, 1994

11 Radical Neck Dissection Not recommended No advantage over selective neck dissection sparing XI, IJ, SCM, and cervical sensory nerves Ballantyne; Sem Surg Onc, 1991 Wilson and Bock; Arch Surg, 1971 ATA Thyroid Cancer Guidelines Cooper et al; Thyroid, 2009 RECOMMENDATION 28 Therapeutic lateral neck compartmental lymph node dissection should be performed for patients with biopsy-proven metastatic lateral cervical lymphadenopathy NCCN Guidelines Selective Neck Dissection II-V If lymph node(s) palpable or biopsy positive: Lateral neck dissection Levels II-IV, consider level V Spare spinal accessory nerve, internal jugular vein, and sternocleidomastoid muscle Consider preservation of the cervical sensory nerves

12 Attie Incision McFee Incision Complications Nerve injury (X, XI, XII, cervical sympathetic chain, cervical sensory) Hemorrhage Seroma Wound infection Scar Chyle fistula

13 I 131 Postoperative Adjuvant Therapy l-thyroxine suppression External beam XRT - select patients at high risk for local recurrence after surgery Neck Recurrence Diagnose clinically, thyroglobulin elevation, imaging studies Ultrasound highly sensitive for detection do Rosario et al; J U/S Med, 2004 Frasoldati et al; Cancer, 2003 Confirm with FNA - cytology - thyroglobulin in needle washout increases sensitivity Baskin; Thyroid, 2004 Uruno et al; World J Surg, 2005

14 Neck Recurrence Assess extent of disease - Clinical - Ultrasound, MRI, CT Scan Be prepared to operate if FNA confirms disease Incision planning - use or extend prior incisions - separate parallel incision - provide adequate exposure Management of the Neck in WDTC Cervical metastases common in WDTC Increased risk of recurrence Impact on survival unclear Know distribution of nodal metastases Extent of surgery should be individualized Selective neck dissection II-V Avoid morbidity and complications Avoid need for reoperation