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Background Thyroglobulin measurement in fine-needle aspiration (FNA-Tg) is an additional diagnostic tool of lymph node metastasis (LNM) in papillary thyroid carcinoma (PTC). However, its performance as a preoperative indicator of lateral neck LNM in PTC is unclear. We evaluated the use of FNA cytology and FNA-Tg to detect neck LNM presurgery using a simple methodology, and established a cut-off value for diagnosing LNM in PTC. Methods We performed a retrospective cohort study based on hospital records, including 299 FNA-Tg measurements from 228 patients with PTC. The cut-off value for FNA-Tg was obtained through a receiver operating characteristic (ROC) curve analysis. The relationships between various parameters and FNA-Tg were analyzed using Spearman’s correlation. Results Of 299 lymph nodes (LNs) from 228 patients following surgery, 151 were malignant and 148 were benign. The median FNA-Tg levels were 414.40 ng/mL and 6.36 ng/mL in the metastatic and benign LNs, respectively. An FNA-Tg cut-off value of 28.3 ng/mL had the best diagnostic performance (93.38% sensitivity, 70.27% specificity, area under the ROC curve [AUC] 0.868) in the whole cohort. The diagnostic value performed better in the lateral neck group (level II–V, n = 163) than in the central neck group (level VI, n = 136); in the lateral neck group, the sensitivity and specificity of the FNA-Tg cut-off (16.8 ng/mL) were 96.25% and 96.36%, respectively. Conclusions FNA-Tg is a useful technique for the diagnosis of LNM before surgery, especially in lateral neck dissection. Clinical trial registration number ChiCTR1900028547.

Papillary thyroid cancer (PTC) is commonly associated with neck lymph node metastasis (LNM), and recurrence does occur after radioactive iodine (RAI) ablation therapy. This study aimed to analyze the effectiveness of RAI ablation with regard to disease recurrence in intermediate-risk PTC patients with neck LNM. In addition, the study identified possible predisposing risk factors that might benefit from RAI ablation and analyzed common RAI therapy complications among these patients. A retrospective analysis of 349 intermediate-risk PTC patients with neck LNM who underwent thyroidectomy with neck dissection was performed. The oncologic results and clinicopathologic characteristics of these patients together with the incidence of postoperative RAI therapy complications were evaluated. Of the 349 patients, disease recurrence after treatment occurred for 27 patients (8%) during a mean follow-up period of 58.7 months (range 7–133 months). The recurrence-free survival curve of the patients who received postoperative RAI therapy (n = 208) did not differ significantly from that of the patients who did not receive it (n = 141) (P = 0.567). Nine patients without adjuvant RAI therapy (6%, 9/141) had recurrence. The recurrence rate for the central LNM patients without RAI therapy was only 2% (2/106). Both of these patients with recurrence had pathologic extranodal spread (ENS) and a high number (> 5) of metastatic central LNs. Postoperative RAI-related complications were observed in 24 patients (12%). Postoperative RAI is not necessary for intermediate-risk papillary thyroid cancer patients with central LNM, especially for patients with negative ENS and low number (< 5) of metastatic lymph nodes.

Damage of the vascular system secondary to radical neck dissection and/or radiotherapy or other treatments has a negative impact on microsurgical reconstruction. The search for adequate recipient vessels is hindered by the complexity of previous procedures. A systematic review of microsurgical head and neck reconstruction in the vessel-depleted neck was performed. The issues analyzed were indications for surgery, more frequently performed flaps, vascular systems used as recipient vessels, outcomes, and complications. The eligibility criteria were fulfilled by 57 studies published between September 1993 and January 2020. In 8235 patients, 8694 flaps were performed, 925 of which were for a vessel-depleted neck. The most commonly used flap was the anterolateral thigh flap, used in 195 cases (30%), followed by the radial forearm free flap, used in 157 cases (24%). The potential recipient vessels were numerous for arteries (26 options) and veins (31 options). For the 712 flaps with an identifiable recipient artery, the superficial temporal artery was the most commonly used vessel (n = 142, 20%). The superficial temporal vein was the most commonly used vessel for 639 flaps with an identifiable recipient vein (n = 118, 18.5%). Complications amounted to 11%; 80 out of 716 flaps in papers that reported them. Flap losses were reported in 2% of cases. Major microsurgical head and neck reconstruction for postoncologic defects depends on appropriate recipient vessels. Vein availability is paramount. Understanding the complexity of this problem is useful for preoperative planning, precise decision-making, and an accurate surgical approach.

Objective: We aimed to analyze oncologic outcomes and identify patterns of failure and negative prognostic factors in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx. Methods: This was a retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018 for residual/recurrent/second primary SCC in the larynx or hypopharynx after initial (chemo)radiation. Prognostic factors for oncologic outcomes were identified using univariable and multivariable analysis. Results: A total of 405 patients were included in the final analysis. Five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and locoregional relapse-free survival (LRFS) estimates were 47.7% (95% confidence interval [CI] 42.0–53.2%), 68.7% (95% CI 63.7–73.7%), 42.1% (95% CI 36.7–47.4%), and 44.3% (95% CI 38.8–49.7%), respectively. In a multivariable model, increasing clinical tumor stage of the residual/recurrent/second primary tumor, increasing number of metastatic cervical lymph nodes retrieved during neck dissection, hypopharyngeal and supraglottic tumor location, positive section margin status and perineural invasion were independent negative prognostic variables for OS, DSS, DFS, and LRFS. The type of second tumor was identified as an additional independent prognosticator for DSS, with local recurrences and second primary tumors having a better prognosis than residual tumor. Conclusions and Relevance: Favorable oncologic outcomes are reported after STL. Increasing clinical tumor stage, increasing number of metastatic cervical lymph nodes, hypopharyngeal and supraglottic tumor location, positive section margins, and perineural invasion are identified as independent negative prognosticators for all oncologic outcome measures.

BACKGROUND: The 2015 American Thyroid Association guidelines state that a prophylactic central compartment neck dissection (PCND) should be considered for patients with papillary thyroid carcinoma (PTC) and clinically involved lateral neck lymph nodes (cN1b). The aim of our study was to determine the rate of central neck recurrence in select cN1b patients, with no evidence of clinically involved central compartment lymph nodes, treated without a PCND. METHODS: After institutional review board approval, adult PTC patients with cN1b disease who were treated with a total thyroidectomy and lateral neck dissection were identified from an institutional database of 6,259 patients who underwent initial surgery for well-differentiated thyroid carcinoma from 1986 to 2015. Patients with gross extrathyroidal extension, distant metastases, and no pre-operative imaging were excluded. Patients with evidence of clinically involved central compartment lymph nodes, on pre-operative imaging or intra-operative evaluation, were also excluded. One hundred fifty-two cN1b patients were included and categorized into non-PCND and PCND groups. Central neck recurrence-free probability (CNRFP) was calculated using the Kaplan-Meier method and log-rank tests. RESULTS: One hundred three patients (67.8%) did not have a PCND. With a median follow-up of 65 months, the 5- and 10-year CNRFP was 98.4% in the non-PCND group and 93.6% in the PCND group (p = 0.133). CONCLUSIONS: Select PTC patients with cN1b disease but no evidence of clinically involved central compartment lymph nodes, on pre-operative imaging and intra-operative evaluation, appear to have a low rate of central neck recurrence. These patients may not require or benefit from a PCND.

Transoral robotic thyroidectomy (TORT) for differentiated thyroid carcinoma is increasing in popularity. However, studies are limited to small tumors. This study aimed to compare the outcomes of TORT for papillary thyroid carcinomas smaller than 1 cm and 1 cm or larger. The study analyzed 269 patients with papillary thyroid carcinoma who underwent TORT at Korea University Hospital, Korea between January 2001 and December 2017. Surgical outcomes and postoperative complications were compared. Group 1 (tumor

BACKGROUND: In the current guidelines for differentiated thyroid cancer (DTC), computed tomography (CT) of the neck has a limited role. The authors hypothesized that adding CT to the workup of clinically low-risk DTC size 4 cm or smaller changes the surgical management for a portion of patients due to detection of clinically significant lymph node metastases not located by ultrasound of the neck. METHODS: A prospective cohort of DTC patients at an academic referral center between 2012 and 2016 was reviewed. All the patients with fine-needle aspiration cytopathology results suspicious for malignancy or malignant tumor (Bethesda category 5 or 6, respectively) underwent CT before surgery. Clinically low-risk DTC patients were selected if they had a tumor diameter of 4 cm or less and no evidence for local invasion or suspicious lymph nodes seen on ultrasound. Outcomes focused on alteration of the surgical plan based on CT and correlation with pathology. RESULTS: The CT findings for 25 (22.5%) of 111 patients with clinically low-risk DTC led to a change in surgical management. Of these 25 patients, 16 (14.4% of the entire cohort) benefited due to the removal of clinically significant lymph node disease not seen on ultrasound. Categorization of the group that had a change in management showed that 6 (85.7%) of 7 lateral neck dissections and 10 (55.6%) of 18 central neck dissections (CND) harbored metastatic nodes larger than 2 mm. CONCLUSIONS: In the group with clinically low-risk DTC, CT changed surgical management for a substantial number of the patients with clinically significant nodal disease not detected by ultrasound. This highlights the fact that in certain practice settings, adding CT to the preoperative staging may be favorable for the detection of nodal metastasis.

Background The optimal extent of therapeutic lateral neck dissection (ND) in papillary thyroid carcinoma (PTC) continues to be debated. We analyzed the frequency, patterns, and predictive factors of occult level Va and Vb metastasis in clinically lateral node-positive PTC patients. Methods We reviewed the data of PTC patients who underwent thyroidectomy and therapeutic lateral ND from level II to V between May 2008 and August 2020. In our study, 46 patients without clinically positive metastatic lymph nodes (LNs) at level V on the preoperative evaluation were included to analyze occult metastasis at level Va and Vb, respectively. Patient demographics, including age, sex, distribution of pathologic LNs, and characteristics of the primary tumors, were reviewed. In addition, clinicopathologic factors associated with occult level Va and Vb metastasis were analyzed. Results Of the 46 patients, 14 (30.4%) patients had occult metastases at level Vb. No occult metastases were found at level Va. Clinically positive level II metastasis (p = 0.015) and simultaneous level II, III, and IV metastases (p = 0.010) in the preoperative evaluation were significantly associated with occult level Vb metastasis. Patients without LN metastasis at level IV or with three or fewer metastatic LNs in the lateral neck never had occult LN metastases at level Vb. Conclusions Occult metastasis at level Va is rare in PTC with lateral LN metastasis. Occult metastasis at level Vb may occur in PTC patients with multilevel involvement, including level II and/or four or more lateral LN metastases.

It is important to identify prognostic factors for lateral lymph node metastasis (LLNM) in papillary thyroid microcarcinoma (PTMC) because they determine the extent of surgery. Several similarly designed studies have investigated predictors of LLNM, but with no more than 1000 cases. In addition, there are no recommendations or guidelines covering the differences in risk by tumor location. This study is the largest, using a papillary thyroid microcarcinoma population with 2967 patients. The purpose of this study is to address predictive factors of LLNM, focusing on lesion location. We retrospectively reviewed the data of 2967 PTMC patients who underwent total thyroidectomy and central neck dissection and/or lateral neck dissection (unilateral or bilateral) between January 1997 and June 2015. On multivariate analysis, superior lesion [adjusted odds ratio (OR) 3.32, p

The prognosis of advanced nodal (N3) squamous cell carcinoma of the head and neck (HNSCC) is poor. We investigated whether surgery or radiotherapy of early (T1–2) primary stage HSNCC is preferable to limit the overall morbidity after upfront neck dissection (uND) for N3 disease. This retrospective multicentric Groupe d’Etude des Tumeurs de la Tete Et du Cou study included patients undergoing uND and surgery or radiotherapy of their primary. Prognostic factors were evaluated using propensity score matching to account for biases in performing surgery depending on primary site and stage. Of 189 T1–2, N3 HNSCC patients, 70 (37.0%) underwent uND: 42 with surgery of their primary and 28 with radiotherapy only. Radiotherapy alone was more frequent in patients with hypopharyngeal primaries. All local (N = 3) and regional (N = 10) relapses (included 2 locoregional relapses) occurred within the first 2 years. There were 16 distant metastatic failures. Five-year locoregional relapse and survival incidences were 15.7% and 66.5% and were similar regardless of the treatment of the primary. The overall morbidity rate was 65.2% and was similar after weighting by the inverse propensity score (p = 0.148). The only prognostic factor for morbidity was the radicality of the uND. Prolonged parenteral feeding was not more frequent in patients only irradiated to their primary (p = 0.118). Prolonged tracheostomy was more frequent after surgery of the primary. In patients with T1–2, N3 HNSCC undergoing uND, radiotherapy and surgery of the primary yield similar oncological outcomes. Morbidity was related to the extent of neck dissection.

Background This multicenter retrospective study aimed to determine whether elective neck dissection (END) can be performed for T1-2N0M0 tongue cancer. Methods Patients with T1-2N0M0 tongue squamous cell carcinoma who received treatment between January 2000 and December 2012 were enrolled at 14 multicenter study sites. The 5-year overall survival (OS) and 5-year disease-specific survival (DSS) were compared between the propensity score-matched END and observation (OBS) groups. Results The results showed that the OS rates among the 1234 enrolled patients were 85.5% in the END group and 90.2% in the OBS group (P = 0.182). The DSS rates were 87.0% in the END group and 94.3% in the OBS group (P = 0.003). Among the matched patients, the OS rates were 87.1% in the END group and 76.2% in the OBS group (P = 0.0051), and the respective DSS rates were 89.2% and 82.2% (P = 0.0335). Conclusion This study showed that END is beneficial for T1-2N0M0 tongue cancer. However, END should be performed for patients with a tumor depth of 4–5 mm or more, which is the depth associated with a high rate of lymph node metastasis. The use of END should be carefully considered for both elderly and young patients.

Background The transoral endoscopic vestibular approach (TOETVA) for thyroidectomy is gaining popularity (Russell et al. in Thyroid 28(7):825-829, 2018; Le et al. in Surg Laparosc Endosc Percutan Tech 30(3):209-213, 2020; Liao et al. in Laryngoscope 130(6):1603-1608, 2020). TOETVA has been utilized successfully in performing thyroidectomy, parathyroidectomy, and neck dissection, via both endoscopic and robotic techniques (Razavi et al. in Head Neck 40(10):2246-2253, 2018; Otolaryngol Head Neck Surg 159(4):625-629, 2018; Ngo et al. in J ENT, 2020. https://doi.org/10.1177/0145561320943358 ; Ann Surg Oncol 28(5):2766, 2021). In this video, we show bilateral central neck dissection via transoral approach in papillary thyroid carcinoma. Patient and methods A 37-year-old female with no significant medical history was diagnosed pT3bN0M0 intraoperatively with the tumor having slightly invaded the strap muscle. Thus, we decided to perform total thyroidectomy with bilateral central neck dissection via transoral approach. Methods Prelaryngeal dissection: in the prelaryngeal compartment, soft tissue containing these lymph nodes was intimately associated with the pyramidal lobe. Right paratracheal dissection: fibrofatty tissue was dissected off the prevertebral fascia and the trachea with preservation of right parathyroid glands. Pretracheal lymph nodes were removed with paratracheal dissection. Left paratracheal dissection: the lymphatic tissue was then dissected off the prevertebral and esophageal musculature and the trachea after identifying the left parathyroid glands. Finally, bilateral central neck dissection was finished with preservation of the nerve and parathyroid glands. Results The operation was completed successfully without conversion to open surgery. The operative time for central neck dissection was 20 min. There were nine harvested lymph nodes in the central compartments, while there were two metastatic lymph nodes of papillary thyroid carcinoma with 3 × 3 mm maximal dimension. There were no major postoperative complications. Conclusion Central neck dissection via TOETVA is a safe and feasible method in selected patients.

To Identify predictors of recurrent disease following lateral neck dissection (LND) for papillary thyroid carcinoma (PTC). A retrospective review of patients who underwent first-time LND for PTC at our institution (2000–2015) was performed. Medical records were examined for biopsy or pathologically proven lateral neck recurrence. Differences between the groups with and without recurrence were compared. All LNDs were then classified in to two groups: “comprehensive” (CND), involving levels IIa-Vb at minimum, or “selective”, labelling less extensive dissection (SND). Four hundred nine patients underwent 467 LNDs. Surveillance data were available for 317 patients who underwent 362 LNDs (mean age 45 ± 16; range 18–88). The median follow-up was 64 ± 48 months (range 3–197). Recurrence was detected in 71 lateral necks (20%). The total number of lymph nodes was greater in the group without recurrence compared to those with recurrence (23 vs. 19, p = 0.02). Among patient demographics, radioactive iodine treatment, primary tumor characteristics and characteristics of nodal metastases, only an older patient age (mean 50 vs. 43 years) was associated with lateral neck recurrence (p

This study aimed to assess whether surgical case volume for lateral neck dissection has an impact on the survival of patients who have well-differentiated thyroid cancer (WDTC) with lateral cervical node metastases. The authors used a population-based cohort study design.The study cohort consisted of WDTC patients in Ontario Canada who underwent thyroidectomy and lateral neck dissection. These patients were identified using both hospital- and surgeon-level administrative data between 1993 and 2017 (n = 1832). Surgeon and hospital volumes were calculated based on the number of cases managed in the year before the procedure by the physician and at the institution managing each case, respectively, and divided into tertiles. Multilevel Cox regression models were used to estimate the effect of volume on disease-free survival (DFS).A crude model without patient or treatment characteristics demonstrated that DFS was associated with both higher surgeon volume tertiles (p0.01) and higher hospital volume tertiles (p0.01). After control for clustering, patient/treatment covariates, and hospital volume, the lowest surgeon volume tertile (range, 0-20/year; mean, 6.5/year) remained an independent statistically significant negative predictor of DFS (hazard ratio, 1.71; 95 % confidence interval, 1.22-2.4; p0.01).Surgeon lateral neck dissection case volume is a predictor of better DFS for thyroid cancer patients, with the lowest surgeon volume tertile (20 neck dissections per year) demonstrating poorer DFS.

Given the rapidly evolving nature of the field, the current state of “high-risk” head and neck cutaneous squamous cell carcinoma (HNcSCC) is poorly characterized. Narrative review of the epidemiology, diagnosis, workup, risk stratification, staging and treatment of high-risk HNcSCC. Clinical and pathologic risk factors for adverse HNcSCC outcomes are nuanced (e.g., immunosuppression and perineural invasion). Frequent changes in adverse prognosticators have outpaced population-based registries and the variables they track, restricting our understanding of the epidemiology of HNcSCC and inhibiting control of the disease. Current heterogeneous staging and risk stratification systems are largely derived from institutional data, compromising their external validity. In the absence of staging system consensus, tumor designations such as “high risk” and “advanced” are variably used and insufficiently precise to guide management. Evidence guiding treatment of high-risk HNcSCC with curative intent is also suboptimal. For patients with incurable disease, an array of trials are evaluating the impact of immunotherapy, targeted biologic therapy, and other novel agents. Population-based registries that broadly track updated, nuanced, adverse clinicopathologic risk factors, and outcomes are needed to guide development of improved staging systems. Design and development of randomized controlled trials (RCTs) in advanced-stage HNcSCC populations are needed to evaluate (1) observation, sentinel lymph node biopsy, or elective neck dissection for management of the cN0 neck, (2) indications for surgery plus adjuvant radiation versus adjuvant chemoradiation, and (3) the role of immunotherapy in treatment with curative intent. Considering these knowledge gaps, the authors explore a potential high-risk HNcSCC treatment framework.

BACKGROUND: Patients with medullary thyroid carcinoma (MTC) often receive lateral lymph node dissection with total thyroidectomy when calcitonin levels are elevated, even in the absence of structural disease, but the effect of this intervention on disease specific outcomes is not known. METHODS: We retrospectively reviewed patients from 1986 to 2017 who underwent thyroidectomy with curative intent for MTC at our institution. The association of disease specific survival (DSS) and clinicopathologic features was examined using univariate and multivariate Cox regression. RESULTS: We identified 316 patients who underwent curative resection for medullary thyroid carcinoma. Overall and disease specific survival were 76% and 86% at 10-years. To investigate the effect of prophylactic ipsilateral lateral lymph node dissection, we analyzed 89 patients without known structural disease in the neck lymph nodes at the time of resection and preoperative calcitonin > 200 pg/ml, of which 45 had an ipsilateral lateral lymph node dissection (LND) and 44 did not. There were no differences in tumor size or preoperative calcitonin levels. There was no difference at 10 years in cumulative incidence of recurrence in the neck (20.9% LND vs 30.4% no LND, p=0.46), cumulative incidence of distant recurrence (18.3% vs 18.4%, p=0.97), disease specific survival (86% vs 93%, p=0.53), or overall survival at (82% vs 90%, p=0.6). CONCLUSION: Lateral neck dissection in the absence of clinical or radiologic abnormal lymph nodes is not associated with improved survival in patients with MTC.

The risk for occult neck nodal metastasis in carcinoma of the parotid gland is inconclusive. Therefore, addressing a negative neck prophylactically and the extent to do so remain controversial. This systematic review aimed to determine the rate of occult nodal metastasis for each neck level, and consequently, to elucidate the proper extent of elective neck dissection (END). A meta-analysis of all studies that included patients with a diagnosis of parotid malignancies who underwent an END was performed. The risk for occult nodal metastasis was calculated for each neck level separately. The search strategy identified 124 papers from January 1980 to December 2019 in the various databases. Nine retrospective studies (n =548) met the inclusion criteria. The risk for occult neck nodal metastasis ranged from 0.0 to 9.43% with a random-effect model of 2.2% for level 1 (n =459), from 3.4 to 28.38% with a random-effect model of 16.51% for level 2 (n =548), from 0.0 to 21.63% with a random-effect model of 4.23% for level 3 (n =518), from 0.0 to 17.02% with a fixed-effect model of 0.39% for level 4 (n =310), and from 0.0 to 11.63% with a fixed-effect model of 1.7% for level 5 (n =417). The rate of occult neck nodal metastasis in parotid malignancies is low, with neck level 2 the most commonly involved. The results of this meta-analysis prevented the authors from substantiating the appropriate extent of an END in parotid cancer.

The prognostic value of central lymph node (CLN) status in papillary thyroid cancer (PTC) remains controversial. This study aimed to provide the first evidence on this issue for the aggressive tall-cell variant (TCV) subtype.The study identified TCV patients from the Surveillance, Epidemiology, and End Results database. The Kaplan-Meier method, log-rank test, and multivariate Cox regression models were used for analysis.Of the 744 patients included, 404 were recorded as N0, which were pathologically or only clinically confirmed. Overall survival (OS) and cancer-specific survival (CSS) did not differ significantly between the N0 and pN1a patients (p 0.05). To investigate the reason, the N0 patients were subdivided according to the number of examined lymph nodes (ELN). The patients with a N0 diagnosis confirmed by two or more ELNs (N0-e2+) showed significantly better outcomes than the pN1a patients and their N0 counterparts without ELN (N0-e0) (p 0.05), whereas the N0-e0 and pN1a groups demonstrated comparable outcomes in both the log-rank and multivariate analyses (p 0.05). Moreover, the subgroup analyses showed that even among the patients with early T-staging (T1-T2) or receipt of radioactive iodine (RAI) therapy, the N0-e0 patients still demonstrated compromised OS compared with the N0-e2+ group (p 0.05).The cN0 patients without ELN (N0-e0) had outcomes similar to those of the pN1a patients, but showed a poorer OS than the N0-e2+ group regardless of T-staging and RAI administration, suggesting that occult CLN metastases might act as a negative prognosticator in cN0 TCV. Therefore, prophylactic central neck dissection might be considered for biopsy-proven cN0 TCV patients. Prospective studies are expected to further validate our conclusions.

Prophylactic central compartment neck dissection (pCCND) in addition to total thyroidectomy (TT) includes removal of central compartment lymph nodes in the absence of clinical involvement on preoperative and intraoperative evaluation. The data regarding the influence of pCCND on oncologic outcomes and surgical complication rates is mixed and, therefore, is the focus of this analysis. A systematic review of the literature on total thyroidectomy with prophylactic central compartment neck dissection (TT + pCCND) from January 1990 to October 2017 identified 221 abstracts of which 17 met inclusion criteria and were reviewed (1 randomized-control trial, 13 retrospective cohort studies, and 3 meta-analyses). TT + pCCND was found to detect occult lymph node metastasis in approximately 50% of patients who had no clinical evidence of lymph node metastasis on preoperative imaging. Permanent hypoparathyroidism occurs more frequently following TT + pCCND (TT = 1.55% vs. TT + pCCND = 3.45%), but the rates of permanent recurrent laryngeal nerve dysfunction are similar (TT = 0.89% vs. TT + pCCND = 0.96%). The locoregional recurrence rates across all 14 studies included in this analysis was 6.75% for TT alone and 4.55% for TT + pCCND. The rate of locoregional recurrence was significantly lower in patients who underwent pCCND in a few studies and one meta-analysis, but were not significantly different in the majority of studies. TT + pCCND in clinically node-negative papillary thyroid cancer will detect occult lymph node metastasis in approximately half of patients. This may change their postoperative management with regard to adjuvant radioiodine therapy. There is a higher risk of hypoparathyroidism with pCCND, and the effect on rates of locoregional recurrence remains uncertain.

The updated version of the National Comprehensive Cancer Network (NCCN) guidelines revised pretreatment workup for nasopharyngeal carcinoma (NPC) into “biopsy of the primary site or neck.” Despite provision of important diagnostic information, concerns regarding tumor cell dissemination limit the application of lymph node biopsy. This study aimed to investigate whether biopsy of the neck is associated with impaired survival in NPC. A propensity score-matched, population-based cohort identified from the Surveillance, Epidemiology, and End Results database was used to compare overall survival (OS) and disease-specific survival (DSS) of patients who underwent pretreatment cervical lymph node biopsy without subsequent neck dissection or removal of node compared with patients who did not undergo node biopsy. Of 2910 eligible patients, 416 (14.3%) underwent pretreatment lymph node biopsy. After use of control for patient, tumor, and demographic characteristics, biopsy was not associated with impaired OS (hazard ratio [HR], 1.15; 95% confidence interval [CI] 0.89–1.47; P = 0.29) or DSS (HR, 1.07; 95% CI 0.81–1.40; P = 0.63). Interestingly, in the subgroup analysis, the unfavorable effect of biopsy was observed for patients with differentiated non-keratinizing squamous cell carcinoma (but not other histologic types). Race did not positively alter the survival outcomes. The findings provide reference for clinical practice, showing that pretreatment cervical lymph node biopsy is not associated with impaired survival in NPC, except for patients with differentiated non-keratinizing squamous cell carcinoma. The recommended NCCN guidelines would be more specific by adding details to the general recommendation that neck biopsy is safe for all patients. Future prospective studies are needed to verify the study findings.

Papillary thyroid cancer (PTC) frequently disseminates into cervical lymph nodes. Lateral node involvement is described in up to 50 % patients undergoing prophylactic lateral neck dissection. This study aimed to assess this finding and identify which factors predict for occult lateral node disease.Patients with fine needle aspiration-confirmed PTC (Bethesda V or VI), without evidence of cervical lymph node metastases, underwent a total thyroidectomy with prophylactic ipsilateral central and level 3 dissection. Level 3 nodes were removed by compartmental dissection or by sampling the sentinel nodes overlying the jugular vein, according to surgeon preference. Data were collected prospectively from January 2011 to August 2014. Statistical analysis was performed by SPSS software.A total of 137 patients underwent total thyroidectomy with prophylactic ipsilateral central and level 3 dissection for PTC. The incidence of occult level 3 disease was 30 % (41/137 patients). A total of 48 % of patients (66/137) harbored occult central neck disease. A total of 80.5 % of patients with pN1b disease had macrometastases (aeyen2 mm), and 15 % exhibited skip metastases with central compartment sparing. In patients with pN1b disease, a median of 6 level 3 nodes were retrieved, with an average involved nodal ratio of 0.29. Multivariate regression demonstrated risk factors for occult lateral neck metastasis include tumor size (odds ratio 1.1), upper pole tumors (odds ratio 6.6), and vascular invasion (odds ratio 3.2) (p PTC is associated with a significant incidence of occult central and lateral nodal metastases. In patients undergoing prophylactic central neck dissection, inclusion of level 3 dissection should be considered in patients with large upper lobe cancers.

Patients with recurrent oropharyngeal cancer often require extensive salvage surgery. For patients with clinically N0 necks, the indication for concurrent neck dissection remains unclear. This study aimed to determine predictors, prevalence, and distribution of nodal disease in patients treated with salvage oropharyngectomy. In a case series with data collection at a single tertiary academic National Cancer Institute (NCI)-designated comprehensive cancer center, this study analyzed patients treated with prior radiation or chemoradiation who had persistent, recurrent, or second primary squamous cell carcinoma of the oropharynx requiring oropharyngeal resection between 1998 and 2017 (n = 95). Clinical and oncologic characteristics and treatment outcomes were collected, and statistical analyses were performed. The overall rate of nodal positivity was 21% (24/95), and the rate of occult nodal disease was 6% (4/65). Ipsilateral and contralateral level 2 were the most common areas harboring positive nodes. Bivariate analysis showed female sex (p = 0.01), initial overall stage (p = 0.02), and N status (p = 0.03), as well as recurrent overall and T stage (p = 0.05) to be predictors of nodal disease. In the multivariate analysis, recurrent T stage continued to be significantly predictive of pathologic nodal disease. Both computed tomography (CT) and positron emission tomography–CT were moderately accurate in predicting nodal disease in the salvage setting (area under the curve, 0.79 and 0.80, respectively). Occult nodal disease is observed in few patients undergoing salvage oropharyngeal resection. This study identified factors predictive of nodal disease in patients undergoing salvage oropharyngectomy and appropriate diagnostic tests in this setting.

Long-term outcomes after curative resection in patients with germline RET mutations and medullary thyroid cancer (MTC) are highly variable and mutation-specific oncologic outcomes are not well-described. Sixty-six patients identified from 1986 to 2017 from a single-institution cancer database were assessed for recurrence and survival using Kaplan–Meier estimates, and correlated with clinicopathologic features using log-rank or Cox proportional hazards. Median follow-up was 9.3 years (range 0.3–31.5), median tumor diameter was 1.5 cm (range 0.1–7.5), and preoperative calcitonin was known in 41 patients [median 636 (range 0–9600)]. Overall survival (OS) of the cohort was 94% at 10 years, the cumulative incidence of locoregional recurrence was 38% at 10 years, and 19/24 (79%) patients underwent repeat neck operation. The cumulative incidence of distant recurrence was 27% at 10 years. Predictors of distant recurrence were tumor size, positive lymph nodes, and pre- and postoperative carcinoembryonic antigen, but not calcitonin. M918T mutation-bearing patients had 10-year distant recurrence-free survival of 0%, compared with 83% in all other patients (p

Cancers of the thyroid isthmus are less frequent compared with the lobar cancers yet have their own unique clinicopathological characteristics. Herein, we sought to examine the isthmic papillary thyroid carcinomas (PTCs) for the pattern of and risk factors for nodal metastasis and the significance of extrathyroidal extension (ETE).The medical records of 3138 patients diagnosed with solitary PTC who had undergone surgery were retrospectively reviewed. Of these, 122 isthmic PTCs were matched to common lobar PTCs at a ratio of 1:3 for age, sex, and nodule size. Patient demographics, surgical findings, and pathology reports were analyzed.Isthmic PTCs comprised 4.6% of all PTCs and had more lymphatic invasion (22.1% vs. 13.4%, p = 0.021), ETE (73.0% vs. 57.1%, p = 0.002), and perithyroidal and prelaryngeal node metastasis (18.0% vs. 9.0%, p = 0.006) compared with lobar PTCs. However, there were no significant differences in the rate of central and lateral node metastasis between the two groups. ETE was identified not to be a risk factor for isthmic PTCs for central and lateral node metastasis, in contrast to lobar PTCs in which ETE was a significant risk factor (odds ratio 3.18, 95% confidence interval [CI] 1.89-5.34; and 4.72, 95% CI 1.04-21.41).The rates of central and lateral node metastasis of isthmic PTCs are comparable with that of lobar PTCs despite a higher rate of ETE in the isthmic counterpart. Although the extent of surgery for isthmic PTCs remains to be investigated, careful dissection of perithyroidal and prelaryngeal nodes may be necessary for isthmic PTCs.

BACKGROUND Recently, transoral endoscopic thyroidectomy via the vestibular approach (TOETVA) has become popular worldwide.1-3 After controlling for the technique, the authors used the transoral endoscopic approach to modified radical neck dissection (MRND) for papillary thyroid carcinoma with clinically positive lymph nodes in the lateral compartments. To the best of their knowledge, the authors report the first case of TOETVA for MRND. PATIENT A 27-year-old woman had a diagnosis of cT1aN1bM0 right papillary thyroid carcinoma (metastatic to a small right level 4 lymph node). Therefore, total thyroidectomy, bilateral central neck dissection, and MRND of right levels 2, 3, and 4 were performed via the transoral endoscopic approach. METHODS Total thyroidectomy and bilateral central lymph node dissections were performed based on the three-trocar Anuwong technique.4 Then, the fourth incision was made near the sixth teeth in the right oral vestibular area for insertion of the fourth 5-mm trocar, which was used to expose the lateral lymph compartment and to perform right MRND easily. RESULTS The operation was completed successfully without conversion to open surgery. The total operative time was 170 min, and the operating time for MRND was 55 min. The numbers of harvested lymph nodes were 7 and 8 in the central and right lateral compartments, respectively. The numbers of metastatic lymph nodes were 2 and 1 in the central and lateral compartments, respectively. No major postoperative complications occurred. CONCLUSION Transoral endoscopic MRND of levels 2, 3, and 4 can be feasible and safe for highly selected patients.

This study aimed to investigate whether the elasticity index of shear-wave elastography (SWE) can predict cervical lymph node (LN) metastasis of papillary thyroid carcinoma (PTC). This retrospective study included 363 patients with a surgical diagnosis of PTC who underwent preoperative SWE evaluation. The elasticity indices of PTC (E mean, E max, E min, E ratio-p, and E ratio-m) and gray-scale ultrasound (US) parameters (extrathyroidal extension, multifocality, and cervical LN metastasis) were correlated with the pathologic staging parameters. The optimal cutoff values for the elasticity indices were determined for the prediction of cervical LN metastasis, and diagnostic performance was compared between gray-scale US and the combined application of gray-scale US and SWE. The findings showed E mean and E max to be associated with central LN metastasis (P = 0.037) and E min to be associated with lateral LN metastasis (P = 0.015). An E mean value higher than 124 kPa or an E max value higher than 138 kPa with suspicious gray-scale US findings improved the sensitivity and area under the curve (AUC) for predicting central LN metastasis (sensitivity, 45.4 and 44.6 % vs. 28 %, P

The reported rate of incidental parathyroidectomy (IP) during thyroid surgery is between 5.2 and 21.6 %. Current literature reports wide discrepancy in incidence, risk factors, and outcomes. Thus study was designed to address definitively the topic of IP and identify associated risk factors and clinical outcomes with this multi-institutional study. This retrospective cohort study included 1767 total thyroidectomies that occurred between 1995 and 2014 at two academic centers. Pathologic reports were reviewed for the presence of unintentionally removed parathyroid glands. Demographics, potential risk factors, and postoperative calcium levels were compared with matched control group. Logistic regression, t tests, and Chi squared tests were used when appropriate. IP occurred in 286 (16.2 %) of thyroidectomies. Risk factors for IP were: malignancy, neck dissection, and lymph node metastases (p = 0.005

Lateral lymph node dissection (LND) in the absence of macroscopic nodal metastasis remains controversial in sporadic medullary thyroid carcinoma (MTC). The aims of our study were to determine the risk of lateral lymph node (LN) metastases with a focus on lateral contralateral N1, and to define a risk-adapted surgical treatment for these patients. All patients who underwent surgery from 1980 to 2012 for previously untreated RET-negative MTC were reviewed. We focused on the lateral compartments of LN metastases and identified three groups: no lateral LN metastases, ipsilateral lateral (ILL)–LN metastases with no contralateral LN involvement, and contralateral lateral (CLL)–LN metastases. Overall, 131 patients underwent surgery for RET-negative MTC. A total thyroidectomy with LND was performed in 112 patients (85 %), including 97 patients who had an ILL–LND and 92 patients who had a CLL–LND. Lateral LN metastases (N1) occurred in 40 patients (37 %): 31 patients (32 %) had ILL–LN metastases with no contralateral LN involvement, and 9 patients (10 %) had CLL–LN metastases. The preoperative cut-offs for LN metastases in the ILL compartment were very low, with a smallest tumor size of 5 mm, and lowest serum calcitonin level of 38 pg/ml. Disease-free survival rates decreased from 92 % for patients with no lateral LN metastases to 41 % for patients with ILL–LN metastases and 0 % for patients with CLL–LN metastases. ILL–LND should be performed in every patient and only a minority of MTC patients with small micro-MTC, and low serum calcitonin levels should not have a CLL–LND.

Chyle fistula is a relatively rare complication of neck dissection, and there is a lack of consensus regarding its incidence, risk factors, and management. Between 2007 and 2014, a total of 472 cases of neck dissection involving the level IV compartment were included in the study. The incidence, risk factors, and clinical course of chyle fistula were investigated, as well as the outcomes of conventional management and the use of octreotide injection in high-output chyle fistula. The overall incidence of chyle fistula was 4.7 % (22/472), with an incidence of 3.0 % and 6.2 % after right and left neck dissection, respectively. The presence of a metastatic lesion around the junction of the internal jugular vein and subclavian vein was the only factor significantly associated with the development of chyle fistula (approximately fourfold higher risk) in univariate and multivariate analyses. In 22 cases of chyle fistula, the mean total drainage volume was 3226 mL during a mean 15.4 days of drain placement. Total parental nutrition for the management of chyle fistula was required in 16 cases. Nine (40.9 %) of 22 cases experienced additional complications related to chyle fistula. Of the six high-output cases, four were managed with conservative methods plus octreotide injection, and three did not require surgery. The incidence of chyle fistula after neck dissection was higher than expected, especially on the right side. Surgeons should pay greater attention to chyle fistula from preoperative evaluation to postoperative management.

Secondary thyroid cancer is believed to lead to a more aggressive clinical course than primary thyroid cancer. We aim to examine the difference between primary and secondary thyroid cancer in terms of patient characteristics and perioperative outcomes at the national level.A cross-sectional study utilizing the Nationwide Inpatient Sample database for 2003-2010 was merged with County Health Rankings Data. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to identify adult patients with thyroid cancer.A total of 21,581 discharge records were included. Overall, 16,625 (77.0 %) patients had primary cancer, while the rest (23.0 %) had secondary cancer. Younger (45 years) and older (65 years) patients, males, and those of White or Hispanic background were more likely to have secondary cancers (p0.05 each). The prevalence of secondary cancer was higher in communities of low health risk (24.0 % vs. 21.1 %; p0.024). Secondary cancer was more likely to be managed by total thyroidectomy (odds ratio [OR] 2.40, 95 % CI 2.12-2.73) and to require additional radical neck dissection (OR 12.51, 95 % CI 10.98-14.25). Patients with secondary thyroid cancers were at higher risk of postoperative complications (p0.01 each). The cost of secondary cancer management was significantly higher than primary cancer (US$12,449.00 ± 302.07 vs. US$7848.12 ± 149.05; p0.001). However, compared with intermediate-volume surgeons, the complication risk was lower for high-volume (OR 0.47, 95 % CI 0.24-0.92; p = 0.026).Secondary thyroid cancer is associated with a higher risk of perioperative complications and higher cost and distinct demographic profile. Patients managed by higher-volume surgeons were less likely to experience disadvantageous outcomes.

Background Extranodal extension (ENE) is a poor prognostic indicator for patients with head and neck squamous cell carcinoma (HNSCC), but pretreatment detection assists with proper treatment planning. This study evaluated whether the ENE of HNSCC is accurately detected by computed tomography (CT) versus fluorine 18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT and whether it has any impact on patient prognosis.

Background. To date, this prospective cohort study is the largest of its kind from a single European academic tertiary care center to report 2-year survival outcomes for head and neck squamous cell carcinoma treated primarily with transoral robotic-assisted resection. Patients and Methods. Fifty consecutive, appropriately staged patients were enrolled prospectively, and underwent transoral robotic surgery (TORS) between September 2011 and August 2013. Overall, 24 patients had a T1 primary tumor, 23 had a T2 primary tumor, 2 had a T3 primary tumor, and 1 had a T4a primary tumor. Eighteen patients had overall stage I–II disease, and 32 patients had stage III–IV disease. Following transoral robotic resection of their primaries and appropriate neck dissection(s) as indicated, adjuvant treatment could be spared for 20 patients; another 5 patients refused the recommended adjuvant treatment. Seventeen patients received 60 Gy adjuvant radiotherapy and 8 patients underwent 66 Gy adjuvant chemoradiotherapy. Results. At the time of the last follow-up visit (median 27 months), overall survival was 94 %, with two diseasespecific deaths and one unrelated death (heart attack). The 2-year disease-free and recurrence-free survival rates were 88 and 80 %, respectively; however, the local recurrence rate was only 10 % after 2 years. Conclusion. Using TORS as their primary modality, 40 % of patients did not need adjuvant treatment and showed similar survival rates to that of conventional surgery or primary chemoradiotherapy. In another 34 % of patients, adjuvant chemotherapy could be spared and adjuvant radiotherapy could be reduced by 10 Gy compared with primary chemoradiotherapy of 70 Gy. Further studies are warranted with respect to long-term survival.

Papillary thyroid carcinoma (PTC) does recur, despite its favorable long-term outcome. The incidence of thyroid cancer in South Korea increased during the 1990s, then increased rapidly after the turn of the century. In 2011, the rate of thyroid cancer diagnoses was 15 times that observed in 1993. The present study aimed to identify factors associated with the locoregional recurrence of recently increasing conventional PTC. The records of 3381 patients with conventional PTC were reviewed for this retrospective cohort study. Between January 2004 and January 2012, these patients underwent ultrasonography, computed tomography, and preoperative and total thyroidectomy with central neck dissection. Disease recurrence was defined as structural evidence of disease following the remission period. Median length of follow-up was 5.6 (range 2.1–10.1) years. Of 3381 patients, 75 (2.2 %) experienced recurrence. The univariate analysis suggested that locoregional recurrence was associated with tumor size, multifocality, extrathyroidal extension (ETE), lymph node metastasis, lymphatic invasion, vascular invasion, and positive surgical margin. However, multivariate analysis showed that only tumor size (p

To identify lateral lymph node (LN) characteristics predictive of outcome in papillary thyroid cancer patients with clinically evident nodal disease.A total of 438 patients with lateral neck metastases from papillary thyroid cancer were identified from an institutional database of 3,664 differentiated thyroid cancers. The number of positive LNs, size of the largest LN, number of positive LNs to total number of LNs removed (LN burden), and presence of extranodal spread (ENS) were recorded. Cutoffs for continuous variables were determined by receiver operating characteristic curves. LN variables predictive of recurrence free survival and disease-specific survival (DSS) were identified by the Kaplan-Meier method and the Cox proportional hazard model.The median age was 41 years (range 5-86 years). The median follow-up was 65 months (range 1-332 months). Fifty-nine patients developed disease recurrence; these were local in five, regional in 40, and distant in 30 patients. Fifteen patients died of disease. Receiver operating characteristic cutoffs were10 positive LNs and a LN burden17 %. No lateral LN characteristics were predictive of DSS. In patients45 years old, univariate predictors of recurrence were10 positive nodes (p = 0.049) and LN burden17 % (p0.001). In patients ≥45 years old,10 positive nodes, LN burden17 %, and presence of ENS were predictive of recurrence (p = 0.019, p = 0.019, and p = 0.029, respectively).LN burden17 % (1 positive LN in 6 LNs removed) in the lateral neck is predictive for recurrence in patients of all ages, whereas ENS is also prognostic for recurrence in older patients.

Understanding recurrence patterns is vital for guiding treatment. This study describes recurrence patterns for patients with stage IIIB/C head and neck melanoma (HNM) after therapeutic lymph node dissection (TLND) ± adjuvant radiation therapy (RT). We also report outcomes for salvage therapy for patients with isolated regional relapse.A single-institution prospective database of 173 patients with American Joint Committee on Cancer (AJCC) stage IIIB/C HNM undergoing TLND between 1997 and 2012 was retrospectively reviewed. Timing and patterns of recurrence were reviewed. Univariable and multivariable analyses were undertaken using the Kaplan-Meier and Cox regression methods to determine factors predictive of recurrence. Median follow-up was 32 months.Adjuvant RT was administered to 66/173 (38 %) patients. Patients selected for RT had a higher AJCC stage and had more extracapsular invasion. The 5-year distant, cervical nodal and in-transit recurrence rates were 38, 10, and 13 %, respectively, following surgery alone compared with 60, 17, and 31 %, respectively, for the adjuvant RT group. The head and neck regional 5-year recurrence rate (combining in-basin nodal and in-transit) was 23 % for the entire cohort. Isolated cervical recurrence occurred in 19 patients: 17/19 underwent salvage surgery (10/17 patients received RT after salvage surgery) and 2/19 had RT alone. However, distant recurrence occurred in 12/19 salvage patients, with most occurring within 12 months, while 4/19 were disease free.Using a selective approach for adjuvant RT, isolated cervical recurrence after TLND is uncommon. Isolated cervical recurrence can be salvaged effectively with further local therapy; however, distant disease frequently follows.

Traditionally, total thyroidectomy was performed through an open transcervical incision; in cases where there was evident nodal metastasis, the conventional surgical approach was to extend the incision into a large single transverse incision to complete the required neck dissection. However, recent innovation in the surgical technique of thyroidectomy has offered the opportunity to reduce the patient's burden from these prominent surgical scars in the neck. Minimally invasive surgical techniques have been developed and applied by many institutions worldwide, and more recently, various techniques of remote access surgery have been suggested and actively applied.1-6 Since the advent of robotic surgical systems, some have adopted the concept of remote access surgery into developing various robotic thyroidectomy techniques. The more former and widely acknowledged robotic thyroidectomy technique uses a transaxillary (TA) approach, which has been developed by Chung et al. in Korea.7,8 This particular technique has some limitations in the sense that accessing the lymph nodes of the central compartment is troublesome. Terris et al. realized some shortcomings of robotic TA thyroidectomy, especially in their patients in the United States, and developed and reported the feasibility of robotic facelift thyroidectomy.9-13 In cases of thyroid carcinomas with lateral neck node metastases, most abandoned the concept of minimally invasive or remote access surgery and safely adopted conventional open surgical methods to remove the tumor burden. However, Chung et al. have attempted to perform concomitant modified radical neck dissection (MRND) after robotic thyroidectomy through the same TA port.14 This type of robot-assisted neck dissection (RAND) had some inherent limitations, due to fact that lymph nodes of the upper neck were difficult to remove. Over the past few years, we have developed a RAND via modified facelift (MFL) or retroauricular (RA) approach and reported the feasibility and safety of this technique.15, 16 Since then, we have actively applied such RAND techniques in various head and neck cancers. In our country, almost all cases of robotic total thyroidectomy utilize the TA approach. According to the reports made by Terris et al., robotic facelift thyroidectomy technique has been solely applied for ipsilateral hemithyroidectomy. For total thyroidectomy, Terris et al. performed the robotic surgery with bilateral RA incisions. Here, we intend to introduce our novel surgical method after successfully attempting simultaneous robotic total thyroidectomy and RAND via a single RA approach without an axillary incision. To our knowledge, this is the first to report in the medical literature.We present four cases of our surgical experience since the beginning of 2013. All patients received robotic total thyroidectomy with MRND via single RA port without axillary incision after approval from the institutional review board at Severance Hospital, Yonsei University College of Medicine. The inclusion criteria for this operation were as follows: (1) patients with malignant carcinomas of the thyroid gland with evident cervical lymph node metastasis on preoperative imaging studies which are indicated for surgery; (2) patients with no previous history of treatment for thyroid carcinoma. The exclusion criteria were as follows: (1) patients with recurred thyroid tumors; (2) patients with thyroid carcinomas that showed gross invasion to local structures or extensive extrathyroidal capsular spread; (3) patients with clinically evident neck nodal metastasis with extracapsular spread; (4) patients with past history of neck surgery of any kind. In order to assess the extent of disease, neck ultrasonography with fine needle aspiration, neck CT or MRI and PET-CT were performed as preoperative evaluation. All patients were given full information of the possible treatment options for their thyroid cancer comprising of open transcervical approach and robotic surgery via RA approach, including the advantages and disadvantages of each treatment choice and provided written, informed consents before the surgery. General clinical information of the patients is outlined in Table 1. The skin incision for the operation was designed just like the approach for robotic facelift thyroidectomy by Terris et al. and RAND, which has been first reported by our institution.11 (,) 16 The operation was performed by the following sequence. Initially, the skin-subplatysmal flap was elevated after making the skin incision to create sufficient working space. During this process, the elevated skin flap was retracted and maintained by retractors held by the assistant. After application of the self-retaining retractor (Sangdosa Inc., Seoul), neck dissection of the upper neck levels was performed under gross vision. Next, RAND through the RA incision was conducted followed by ipsilateral thyroidectomy with central compartment neck dissection (CCND) via the same approach. Finally, contralateral thyroidectomy with CCND was performed via the single RA port. During these steps, the operator is aided by the bedside assistant with long-suction tips to manipulate and direct the dissected specimen to maintain optimal surgical view or to suck out the fume created by the thermocoagulation from the Harmonic shears. The da Vinci robotic surgical system (Intuitive Surgical, Sunnyvale, CA) was introduced via the RA port with a facedown 30° dual-channel endoscopic arm placed in the center, and two instrument arms equipped at either side with 5-mm Maryland forceps and Harmonic curved shears. During the step of robotic contralateral thyroidectomy, a ProGrasp forceps was utilized at times, instead of 5-mm Maryland forceps. The rest of the surgery was completed with the robotic system (see Video for demonstration of operation for patient 2). Table 1 Clinical characteristics of the patients Patient Sex/age (yr) BMI Side(a) Approach Pathology(b) Tumor size(c) (cm) CCND(d) MRND(d) Drain removal day Drainage amount (ml) Hospital stay (days) 1 F/38 23.8 L RA PC 0.7 2/5 8/23 8 788 11 2 F/18 18.3 L RA PC 0.8 2/8 7/35 6 398 9 3 F/44 23.1 L RA PC 0.9 5/12 5/27 6 607 9 4 F/26 32.9 L RA PC 1.4 3/14 9/48 7 476 15 BMI body mass index, RA retroauricular approach, PC papillary carcinoma, CCND central compartment neck dissection, MRND modified radical neck dissection (a)Side refers to the site of main lesion (b)Pathology refers to the primary tumor within the thyroid gland (c)Tumor size refers to the diameter of the largest tumor in the thyroid gland (d)For each type of lymph node dissection, the number of positive nodes/total number of retrieved nodes is statedFor all of the patients, robotic total thyroidectomy with MRND (levels II, III, IV, V) via unilateral RA approach was successfully completed without any significant intraoperative complications or conversion to open or other approach methods. The total operation time was defined as the time from initial skin incision to removal of the final specimen, which was an average 306.1 ± 11.1 min (Table 2). This included the time for skin flap elevation and neck dissection under gross vision (87 ± 2.8 min), setting up the robotic system for RAND (6.8 ± 2.4 min), console time using the robotic system for RAND (59.3 ± 2.2 min), flap elevation for thyroidectomy (11.3 ± 2.5 min), robotic arms docking for ipsilateral thyroidectomy (6.3 ± 2.5 min), console time for ipsilateral thyroidectomy (61.3 ± 2.1 min), robotic arms docking for contralateral thyroidectomy (6.3 ± 2.5 min), and console time for contralateral thyroidectomy (61.8 ± 2.1 min). The working space created from RA incision was sufficient, and manipulations of the robotic instruments through this approach were technically feasible and safe without any mutual collisions throughout the entire operation. It also allowed for an excellent magnified surgical view enabling visualization of important local anatomical structures. There was no postoperative vocal cord palsy due to recurrent laryngeal nerve injury. However, two patients developed transient hypoparathyroidism, which resolved in the end without the need for calcium or vitamin D supplementation after certain period of medical management (Table 3). Also, there was no incidence of postoperative hemorrhage or hematoma formation, although a single patient developed a postoperative seroma on postoperative day 9, which was managed conservatively without the need for further surgical intervention. On average, the wound catheter was removed 6.8 ± 1 days after surgery and the patient was discharged from the hospital at an average 11 ± 2.8 days from admission (Table 1). Final surgical pathology confirmed the diagnosis of papillary carcinoma for every patient. The total number of cervical nodes retrieved from CCND and MRND was 9.8 ± 4 and 33.1 ± 11 respectively, and the number of positive metastatic nodes was 3 ± 1.4 and 7.3 ± 1.7 respectively (Table 1). In three patients (patients 2, 3, and 4), the presence of one parathyroid gland was each verified in the pathology specimen. All four patients have received high-dose (150 mCi) radioiodine ablation (RAI) therapy after the operation and are being followed up (average 11.3 months, range 9-13 months) on a regular basis with no evidence of recurrence (post-RAI, most recent, nonsuppressed thyroglobulin range 0.1-0.4 ng/ml, antithyroglobulin antibody range 13.7-147.5 IU/ml). (ABSTRACT TRUNCATED)

The aim of this study was to investigate whether pretreatment imaging modalities, including [18F]fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) and CT/magnetic resonance imaging (MRI) are helpful for the selection of patient groups requiring contralateral neck dissection in patients with hypopharyngeal squamous cell carcinoma (SCC). A total of 72 consecutive patients with histologically proven hypopharyngeal SCC who underwent both PET-CT and CT/MRI preoperatively were recruited. To assess the diagnostic accuracy of each imaging modality, the neck was divided into levels based on the imaging-based nodal classification, and the histopathologic results of the surgical specimen were used as a standard reference. Fifty-one (70.8 %) of the 72 patients had neck metastasis, and 12 (26.7 %) had contralateral metastatic nodes. The sensitivities of PET-CT and CT/MRI for detecting nodal metastasis in the contralateral neck were significantly lower than those in the ipsilateral neck (60.0 and 53.3 vs. 89.1 and 84.8 %, respectively; p

Prophylactic central neck dissection (pCND) at the time of the total thyroidectomy (TT) remains controversial in clinically nodal-negative (cN0) papillary thyroid carcinoma. Our study was designed to examine the predictive factors and pattern of locoregional recurrence (LRR) after pCND in the context of the postoperative stimulated Tg (sTg) level. A total of 341 patients who underwent TT and unilateral pCND were analyzed. Patients with an identifiable lesion on ultrasonography or whole-body scan within 6 months of surgery were excluded. LRR was defined as an identifiable lesion on USG, which was later confirmed by cytology/histology. Preablation sTg level was taken 2 months after surgery, whereas postablation sTg level was taken 8 months after surgery. Cox regression was used in the univariate and multivariate analyses to identify significant independent factors for LRR. After a follow-up of 66.6 ± 38.6 months, 14 (4.1 %) suffered from LRR. The duration to first LRR was 36.4 ± 21.7 months. The estimated 5- and 10-year LRR rates were 5.1 and 6.1 %, respectively. Of these 14 LRR, 3 (21.4 %) involved the central compartment alone, 9 (64.3 %) involved the lateral compartment alone, and 2 (14.3 %) involved both central and lateral compartments. After adjusting for other clinicopathological factors, postablation sTg level ≥ 1 µg/L (hazard ratio 265.109, 95 % confidence interval 1.132–62075.644, p = 0.045) was the only independent predictor of LRR. Annualized risk of LRR after pCND was approximately 1 % in the first 5 years and 0.2 % in the subsequent 5 years. Most (78.6 %) LRRs involved the lateral compartment. Postablation sTg ≥ 1 µg/L significantly predicted risk of LRR.

To review our experience in the treatment of the neck in patients with carcinoma of the parotid gland. A total of 263 patients were stratified into 3 groups: no neck dissection (NoND), elective neck dissection (END), and therapeutic neck dissection (TND). Clinicopathological characteristics of END and TND versus NoND were compared by Chi square test. Pathological positivity of each neck level was quantified. Neck recurrence–free survival was determined by Kaplan–Meier statistics. There were 232 cN0 and 31 cN+ patients. Of the cN0 patients, 74 had END. All cN+ patients had TND. Of the END group, occult neck metastases were detected in 26 (35 %) patients. The percentage of positivity was 6.7, 28.3, 21.3, 10.8, and 6.7 % for levels I to V, respectively. Compared to the NoND group, the END group was more likely to be over 60 years old, to have cT3T4 disease, and to have disease with more aggressive histology. Of the TND group, pathological positivity was found in 87 %. The percentage of positivity was 51.6, 77, 73, 53, and 40 % for levels I to V, respectively. Patients who had disease-positive necks had a poorer neck recurrence-free survival of 84.8 %. In patients with cN0 disease, observation of the neck is safe in those who are under 60 years of age with clinical T1 or T2 tumors and who have low-grade histology. END should be carried out in patients with cT3T4 disease or high-grade histology and should involve levels II to IV at a minimum. Patients with cN+ disease commonly have all neck levels involved and therefore should be managed with comprehensive neck dissection.

Lateral lymph node metastasis is an important prognostic factor and is predictive of tumor recurrence and cause-specific survival in patients with papillary thyroid cancer (PTC). However, the factors predicting recurrence and clinical outcomes after therapeutic lateral neck dissection are not well established. The aims of this study were to evaluate the incidence, pattern, and factors predictive of PTC recurrence after therapeutic lateral neck dissection.The records of 126 consecutive patients who underwent total thyroidectomy with therapeutic lateral neck dissection for primary PTC at the National Cancer Center were retrospectively reviewed. The factors predictive of recurrence were determined using both univariate and multivariate analyses considering several clinicopathologic variables.The median follow-up period was 61.2 months, during which 22 patients (17.5 %) experienced recurrence with 1 death (0.8 %) due to disease. Locoregional recurrence and distant metastasis were found in 20 cases (15.9 %) and 2 cases (1.6 %), respectively. Male gender, aggressive histology, number of lymph node metastases, initial level of T4-off Tg per ng/mL, and ATA risk categories (high risk) were independent risk factors for recurrence. Of note, initial T4-off Tg levels greater than 4.2 ng/mL showed highest sensitivity and specificity in predicting recurrence.These results provide useful information regarding the clinical outcomes after therapeutic lateral neck dissection for primary PTC and can be used to identify at-risk patients who need aggressive treatment and intensive surveillance for postoperative recurrence.

Lymphadenectomy along the left recurrent laryngeal nerve (RLN) in esophageal cancer is important for disease controlThis procedure is performed for all resectable thoracic esophageal cancers. The essence of the method is to recognize the lateral pedicle as a two-dimensional membrane that includes the left RLN, lymph nodes, and primary esophageal arteries. By drawing the proximal portion of the divided esophagus and the lateral pedicle, identification and reliable cutting of the primary esophageal arteries, as well as distinguishing the left RLN from the lymph nodes, becomes simplified.We performed 46 TEPs using this method, with no conversion to an open procedure, at Kobe University in 2015. The body mass index of these patients was distributed between 19 and 32, and the mean number of harvested lymph nodes along the left RLN was 6.9 ± 4.2. Left RLN palsy greater than Clavien-Dindo classification grade II occurred in four patients (8% )without permanent paralysis, while the incidence of lymph node metastasis along the left RLN was 22%.Our method for lymphadenectomy along the left RLN during TEP is safe and reliable. It has a low incidence of left RLN palsy and provides sufficient lymph node dissection along the left RLN.