Significant Number of Patients with Papillary Thyroid Carcinoma Will Have Macroscopic Nodal Disease

What are the characteristics of nodal disease in patients presenting with papillary thyroid carcinoma (PTC)?

Bottom line
Overall, 35% of patients presenting with papillary carcinoma harbor macroscopic nodal disease requiring therapeutic dissection. Results suggest that a significant proportion of patients will have nodal disease in the central compartment on initial presentation, especially younger patients, and ETE and tumor size are associated with macroscopic nodal disease.

Background: Well-differentiated PTC is the most common thyroid malignancy. It has a highly favorable prognosis, but also a high incidence of lymph node metastases. There is an important distinction between macroscopic (clinically apparent, present in 28% to 42% of PTC patients) and microscopic nodal disease that can affect clinical relevance and surgical management.

Study design: Retrospective chart review of 416 PTC patients who underwent a total of 487 surgeries for thyroidectomy and/or neck dissection (revision/primary) from January 2004 to June 2009 at a tertiary-care hospital.

Setting: Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston.

Synopsis: Overall, 206 patients were found to have nodal disease in 251 cases, either on initial presentation or revision surgery, with 26 having ETE into surrounding skeletal muscle and fat. Nodal disease was defined as being located either in the central neck, lateral neck, or in an ectopic location (Figure 1). Of all initial surgery patients, 113 had evidence of nodal disease by clinical exam or imaging at presentation.

Overall, of patients with nodal involvement on pathology, 73% had central nodal disease (CND); 65% had lateral nodal disease (LND), and 3.4% had ectopic nodal disease (END). CND was found in 88% of patients during initial surgery, and in 51% on revision surgery. There was a statistically significantly higher percentage of LND (76%) in revision surgery than initial surgery (50%). There were no initial surgery patients with END but it was present in 9% of revision surgery patients. The nodal metastases rate was 72% in tumors > 4 cm compared to 48% in tumors <4 cm.

Limitations included the fact that this was a single institution, single cohort, and retrospective study without outcome measures such as recurrence or disease-free survival, and that only compartmental location of lymph node metastases were evaluated.

Citation: Goyal N, Pakdaman M, Kamani D, et al. Mapping the distribution of nodal metastases in papillary thyroid carcinoma: where exactly are the nodes? Laryngoscope. 2017;127:1959–1964.