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Location of right para-oesophageal lymph nodes. IJV, internal jugular vein; CCA, common carotid artery.
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Purpose
Although guidelines indicate that routine dissection of the central lymph nodes in patients with thyroid carcinoma should include the right para-oesophageal lymph nodes (RPELNs), located between the right recurrent laryngeal nerve and the cervical oesophagus and posterior to the former, RPELN dissection is often omitted due to high risk of...
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Context 1
... carcinoma is the most common type of endocrine malignancy, and its incidence is rapidly increasing. 1,2 Over 90% of all thyroid carcinomas exhibit a relatively indolent clinical course, with excellent prognosis. 1,3 In contrast, cervical lymph node metastasis has been observed in 30% to 90% of patients with papillary thyroid cancer (PTC) and has been shown to be closely associated with persistent and recurrent disease. 1,4-9 Most metastatic sites in patients with PTC are located in central com- partment lymph nodes, 10,11 and central lymph node dissection has been found to reduce loco-regional recurrence and improve disease-free survival in patients with PTC. 11,12 The anatomical borders of the central compartment lymph nodes include the hyoid bone superiorly, the innominate artery inferiorly, and the common carotid arteries bilaterally. A con- sensus statement has listed the prelaryngeal (Delphian), pre- tracheal, and paratracheal nodal basins bilaterally as the central compartment lymph node group. Therapeutic and prophylac- tic central lymph node dissection requires the removal of all three lymph node groups at the minimum. 4 The lymph node located between the right recurrent laryn- geal nerve and the cervical oesophagus is called the right para- oesophageal lymph node (RPELN). Due to its location, the RPELN is considered one of the central compartment lymph nodes. Although it has been recommended that routine cen- tral lymph node dissection should include the RPELN posteri- or to the right recurrent laryngeal nerve, 13 dissection of the RPELN is often omitted due to high risk of injuries to the recur- rent laryngeal nerve and the right inferior parathyroid gland (Fig. 1). To determine the necessity of RPELN dissection, we assessed the clinical significance of RPELN metastasis and the factors affecting ...
Similar publications
Background: Controversy exists over the extent of surgical treatment of papillary thyroid cancer. Reoperations may carry a significant risk of surgical complications. The aim of this study is to investigate the complications following surgical treatment of thyroid cancer and the association between the extent of surgery and complication rates.
Meth...
Citations
... CLNM is common in DTC, with a frequency of 30-90% (11) and has been demonstrated to be closely associated with higher recurrence and poorer survival rates in patients with DTC (12). The majority of metastatic sites are located in central compartment lymph nodes, and complete central lymph node dissection has been identified to reduce the incidence of disease persistence, recurrence, and mortality (13). ...
Cervical lymph node metastasis (CLNM) is frequently observed in differentiated thyroid carcinoma (DTC). After thyroidectomy, radioiodine (131I) treatment is advised to destroy any remaining thyroid tissue. It is still unknown how 131I therapy may affect the prognosis of DTC in CLNM patients. Our objectives were to examine the correlation between the ages of diagnosis and the results of 131I administration in individuals with DTC and CLNM and to examine the variables that might have an impact on clinical results. From 2004 to 2010, a total of 290 patients with PTC who received 131I administration following a near total or total thyroidectomy were recruited from the National Institute of Nuclear Medicine and Allied Sciences (NINMAS) and analyzed retrospectively. The selected patients were divided into two groups according to age: Group A (<18 years) and Group B (>18 years) with the presence of pre- or post-surgical and post-ablative lymph node metastases. The clinical outcomes are categorized as excellent response, indeterminate response and incomplete response. In Group A, out of 31, excellent responses had 16 (51.6%), indeterminate responses had 7 (22.6%), and incomplete responses had 8 (25.6%). In group B, out of 259, excellent responses had 99 (41.4%), indeterminate responses had 101 (42.3%), and incomplete responses had 39 (16.3%). Papillary thyroid cancer lymph node metastases are a potential predictor of prognosis. They are significant for the disease’s recurrence. Compared to adult patients, younger PTC patients with lymph node metastases exhibit a better response. Bangladesh J. Nuclear Med. 26(2): 133-139, 2023
... Furthermore, it can be difficult to assess metastases before surgery, and even experienced surgeons are likely to ignore this location. However, the LN-prRLN metastasis rate in PTC patients has been reported to be as high as 2.7-30.4% (3,5,7). The first surgical treatment strategy for LN-prRLN is crucial for the patient's prognosis. ...
Objective
The lymph node posterior to the right recurrent laryngeal nerve (LN-prRLN) is a crucial component of the central lymph nodes (LNs). We aimed to evaluate multimodal predictive factors of LN-prRLN metastasis in patients with papillary thyroid carcinomas (PTCs), including the clinical data, pathologic data, and preoperative sonographic characteristics of PTCs.
Methods
A total of 403 diagnosed PTC patients who underwent unilateral, sub-total, or total thyroidectomy with central neck dissection were enrolled in this retrospective study. The clinical data, pathologic data, conventional ultrasound (US) and contrast-enhanced ultrasound (CEUS) characteristics of PTCs were collected and evaluated for predicting LN-prRLN metastasis.
Results
In this study, 96 PTC patients with LN-prRLN metastasis and 307 PTC patients without LN-prRLN metastasis were included. Univariate analysis demonstrated that PTC patients with LN-prRLN metastasis more often had younger age, larger size, multifocal cancers, A/T < 1, well-margins, microcalcification, petal-like calcification, internal vascularity, centripetal perfusion pattern and surrounding ring enhancement. Multivariate logistic regression analysis revealed that the CEUS centripetal perfusion pattern, central LN detected by ultrasound and LN-arRLN metastasis were independent characteristics for predicting LN-prRLN metastasis in PTC patients.
Conclusion
According to our research, it is essential for clinicians to thoroughly dissect central LNs, particularly LN-prRLNs.
... When the chief surgeon is inexperienced, the patient may develop hoarseness and hypoparathyroidism after surgery [11][12][13]. When metastasis of the LN-prRLN (LNM-prRLN) has occurred, the probability of lateral lymph node metastasis (LLNM) is five times higher than it is in the absence of LNM-prRLN [14]. This study is different from previous studies in that it was performed to identify the risk factors for lymph node metastasis and improve the preoperative evaluation of the probability of LNM-prRLN by creating a nomogram based on those risk factors. ...
Background:
At present, it is still controversial whether lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) in papillary thyroid carcinoma (PTC) patients should be dissected. Failure to dissect metastatic lymph nodes results in continued metastasis from the positive lymph nodes to other regions. Our study aimed to establish a predictive model and predict the probability of metastasis of the lymph nodes posterior to the right recurrent laryngeal nerve (LNM-prRLN) in patients.
Methods:
A total of 309 patients underwent surgery for thyroid cancer between May 2019 and September 2022. The risk factors were identified by univariate and multivariate analyses, and statistically significant risk factors identified in the multivariate analysis were included in the nomogram. We used the calibration curve and the receiver operating characteristic (ROC) curve to verify the accuracy of the prediction model.
Results:
Multivariate analysis showed that irregular tumor margins (OR: 3.549, 95% CI 1.294-9.733, P = 0.014), extrathyroidal extension (OR: 4.507, 95% CI 1.694-11.993, P = 0.003), maximum tumor diameter > 1 cm (OR: 5.729, 95% CI 2.617-12.542, P < 0.001), overweight status (OR: 2.296, 95% CI 1.057-4.987, P = 0.036), high total cholesterol level (OR: 5.238, 95% CI 2.304-11.909, P < 0.001), and multifocality (OR: 11.954, 95% CI 5.233-27.305, P < 0.001) were independent risk factors for LNM-prRLN. The area under the ROC curve was 0.927. The calibration curve showed good agreement between the predicted and observed rates of LNM-prRLN.
Conclusion:
The probability of LNM-prRLN could be predicted by a nomogram based on the statistically significant risk factors identified in the multivariate analysis. This nomogram can guide clinicians when preoperatively evaluating the status of the LN-prRLN with regard to LNM-prRLN in PTC patients. For patients at high risk for LNM-prRLN, the preventive dissection of LN-prRLNs can be considered.
... Multivariate analyses identified a tumor size of ≥10.0 mm, multifocality, LN-arRLN metastasis, lateral neck LN metastasis, and extrathyroidal extension as significant factors for LN-prRLN metastasis. Similar findings have also been reported by Li et al. 18 and Chang et al. 19 The results of all these studies have shown that dissection of the LN-prRLN is required for tumors ≥10.0 mm in size, when there is cN+, and when there is extrathyroidal extension. However, the need for LN-prRLN dissection in patients with right lobe T1a PTC (when clinically observed) was not analyzed. ...
... Only 6.4% of their patients showed isolated LN-prRLN metastasis. Chang et al. 19 reported that 148 patients had LN-prRLN metastases; however, only six patients were negative for LN-arRLN metastases. Lee et al. 14 found that, in their study, all 14 patients with metastatic disease in the LN-prRLN had a positive LN-arRLN, and that no patient had skip metastasis of the LN-prRLN. ...
... The complication rates of recurrent laryngeal nerve palsies, persistent hypocalcemia, chyle leakages, hematomas, and wound infections were similar between the two groups. Du et al. 6 and Chang et al. 19 described similar findings as those in our study, suggesting that the dissection of LN-prRLN was safe for patients. Prophylactic central neck dissection in PTC cases remains controversial. ...
Introduction and objectives:
This study analyzed the incidence and predictors of lymph node posterior to the right recurrent laryngeal nerve metastasis in T1a papillary thyroid carcinoma of the right lobe.
Methods:
This was a retrospective cohort study. Patients were selected from those who had received surgical treatment for primary papillary thyroid carcinoma between January 2019 and December 2020. The association between clinicopathologic variables and lymph node posterior to the right recurrent laryngeal nerve metastasis was assessed using univariate and multivariate analyses. Postoperative complications were also described.
Results:
Lymph node posterior to the right recurrent laryngeal nerve metastasis was present in 6.0% of the 402 study patients. It was the most likely to occur when there were other lymph node metastases, particularly in the lymph node anterior to the recurrent laryngeal nerve. Independent predictors for lymph node posterior to the right recurrent laryngeal nerve metastasis were a tumor size of ≥5.0 mm, a lower pole location, and lymph node anterior to the right recurrent laryngeal nerve metastasis. The rate of persistent vocal cord paralysis was .5%, and no patient developed permanent hypoparathyroidism.
Conclusions:
Although lymph node posterior to the right recurrent laryngeal nerve metastases of the right lobe T1a papillary thyroid carcinoma is uncommon, the possibility of metastasis should be investigated when there is a positive lymph node anterior to the right recurrent laryngeal nerve in a tumor >5.0 mm in size located in the lower pole. Lymph node posterior to the right recurrent laryngeal nerve dissection is recommended for such tumors.
... A metastasis rate of 6.57% of LN-prRLNs was found in our study, which was consistent with previous reports (4,(21)(22)(23)(24)(25)(26). Accordingly, the metastasis rate ranges from 5.80% to 31.60% in LN-prRLN among PTCs. ...
... Accordingly, the metastasis rate ranges from 5.80% to 31.60% in LN-prRLN among PTCs. For example, Lee et al. (25) first reported that the metastasis rate was 11.38%, and adverse consequences would occur if LN-prRLN dissections were not performed (21)(22)(23)(24)(25)(26). Furthermore, studies have shown that associated, high-risk factors include tumor diameter > 1 cm, capsular invasion, multifocality, and CLNM (25,27). ...
Aim:
To establish a nomogram combining preoperative ultrasonic and clinical features for predicting lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) metastasis in papillary thyroid carcinoma (PTC) patients.
Methods:
Preoperative ultrasonic and clinical variables of patients with PTC from 2014 to 2021 were retrospectively analyzed. The risk factors associated with LN-prRLN metastasis were identified and validated through a developed nomogram model based on univariate and multivariate logistic regression analysis.
Results:
A total of 615 patients (690 lesions) were enrolled for the training dataset and 207 patients (226 lesions) for the validation dataset with 54 (6.57%) patients developing LN-prRLN metastasis. Multivariate logistic regression analysis demonstrated that the preoperative ultrasound measurement of larger tumors (≥20 mm), higher TI-RADS category (category 5), and higher thyroglobulin level (9.86 ng/mL) in patients with PTC were predictive factors for LN-prRLN metastasis. The nomogram model was established and verified yielding a relatively good predictive performance in the training and validation dataset (AUC: 0.868 vs. 0.851).
Conclusions:
The nomogram combining preoperative ultrasonography with clinical features in this study is highly predictive of LN-prRLN metastasis in patients with PTC, which may provide more personalized recommendations for clinicians in preoperative decision-making for complete dissection of LN-prRLN.
... If the parathyroids were in their usual site, the parathyroid glands and the pedicle of the blood vessels were preserved in situ ( Figure 4). However, if the parathyroid glands could not be clearly exposed, the sternothyroid ligament was still raised because there were no lymph nodes evident in the ligament, representing vestigial tissue from embryogenesis (23). In some cases, the parathyroid glands could be detected after elevating the ligament. ...
Objective
To investigate the feasibility and advantages of Fang’s capillary fascia preservation right recurrent laryngeal nerve (RLN) dissection technique (F-R-RLN dissection) with preservation of the capillary network and fascia between the RLN and common carotid artery for greater neuroprotective efficiency compared with traditional techniques.
Methods
We retrospectively analyzed 102 patients with papillary thyroid carcinoma undergoing right level VI lymph node dissection in our department from March 2021 to January 2022. Sixty patients underwent F-R-RLN dissection (the experimental group) and 42 patients underwent standard dissection (the control group). The intraoperative electrical signal amplitude ratios of the RLN, the number of dissected lymph nodes, and the preservation rates of the parathyroid glands were recorded and compared between the two groups.
Results
The electrical signal amplitude ratio of the lower neck part point of the RLN to the upper laryngeal inlet point in the experimental group was significantly lower than the ratio in the control group ( p = 0.006, Z-score = -2.726). One patient suffered transient RLN paralysis in both groups, but this resolved within 1 month after operation. There were no significant differences between the two groups in terms of the number of level VIa or level VIb lymph nodes dissected, nor in the rate of preservation of the parathyroid glands.
Conclusions
F-R-RLN dissection is a thorough dissection technique that is effective at preventing an electrical signal amplitude decrease in the RLN, and at preventing RLN paralysis by preserving its blood supply.
... On the other hand, some scholars have pointed out that the LN-prRLN metastasis rate in PTC patients is as high as 2.74-38.27% (6,7). The initial surgical treatment plan for LN-prRLN is very important for the patient's prognosis. ...
... Furthermore, incomplete CLN dissection may result in increased risks of recurrence and complications due to multiple operations. If LN-prRLN lymph nodes are not thoroughly dissected, reoperation would be very challenging and some patients may lose the chance of radical cure (7). It is possible that the remaining lymph nodes eventually lead to recurrence. ...
Objective
The right cervical central lymph nodes include lymph nodes anterior to the right recurrent laryngeal nerve (LN-arRLN) and lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN), and are separated by the right recurrent laryngeal nerve (RLN). LN-prRLN is a common site of nodal recurrence after the resection of papillary thyroid carcinoma (PTC). However, the complexity in anatomical structure brings difficulties in determining the surgical scope, so it is necessary to assess the pattern and predictive factors of right cervical central lymph nodes, especially LN-prRLN metastasis in papillary thyroid carcinoma.
Methods
A total of 562 diagnosed PTC patients who underwent right or total thyroidectomy were enrolled in this retrospective study. The clinicopathological features were collected, univariate and multivariate analyses were performed to determine predictive factors of the right central lymph node metastasis.
Results
In this study, the metastatic rates of the right CLN, the LN-arRLN and the LN-prRLN were 59.6% (335/562), 51.8% (291/562) and 30.4% (171/562), respectively. And 22.6% (127/562) of patients had both LN-arRLN and LN-prRLN metastasis. Among patients without LN-arRLN metastasis, the rate of LN-prRLN metastasis was 16.2% (44/271), accounting for 25.7% of the LN-prRLN metastasis group. Factors associated with an increased risk of LN-arRLN metastasis include male, age below 55 years, tumor size > 1cm, extrathyroidal extension (ETE), clinical lymph nodes metastasis(cN1), lateral lymph node metastasis, and left CLN metastasis. In addition, ETE, lateral lymph node metastasis, and LN-arRLN metastasis were independent factors of LN-prRLN metastasis. The predictive factors of LN-prRLN in cN0 PTC were further explored, revealing that tumor size ≥1.5cm, ETE, and LN-arRLN metastasis were independent predictors of LN-prRLN metastasis in cN0 PTC.
Conclusion
The LN-prRLN should not be ignored in surgery because of its high rate of metastasis. Our findings indicate that thorough dissection of central lymph nodes, especially LN-prRLN is crucial in clinical work.
... THE FREQUENCY of mediastinal metastasis of papillary thyroid carcinoma (PTC) ranges from 0.7% to 27% [1][2][3][4][5]. Most reports on upper mediastinal dissection (UMD) for differentiated thyroid carcinoma have been concerned with UMD outcomes via the transcervical approach consecutive to central neck dissection [1-4, 6, 7]. ...
Papillary thyroid carcinoma (PTC) is a relatively indolent disease, despite the high incidence of lymph node metastases. Although less frequent, some upper mediastinal metastases of PTC cannot be removed without sternal resection. In this study, we investigated the prognostic impact of upper mediastinal dissection (UMD) by sternotomy on patients with mediastinal metastases of PTC. Charts of patients with PTC who underwent surgical treatment at our institution between 2006 and 2018 were retrospectively reviewed. Fifty-eight patients with upper mediastinal metastases were enrolled. Kaplan-Meier survival curves were compared, and Cox hazard regression models were used for analyses. Of the 58 patients with mediastinal metastasis, 12 (20.7%) underwent dissection of the prevascular nodes, 51 (87.9%) underwent dissection of the upper paratracheal nodes, and 14 (24.1%) underwent dissection of the lower paratracheal node. The preferred site of mediastinal metastasis was the upper paratracheal nodes. The 5 and 10-year disease-specific survival rates for patients after UMD were 74.6% and 58.7%, respectively. Among 25 patients (43.1%) with locoregional recurrence, 12 (20.7%) had mediastinal recurrence and 7 were eligible for additional UMD. Although distant metastasis was the predominant poor prognostic factor, mediastinal recurrences were more frequently unresectable than cervical recurrences, suggesting that mediastinal recurrence is a poor prognostic factor. Mediastinal metastases larger than 30 mm or metastases to the lower paratracheal nodes are considered a risk factor for mediastinal recurrence. UMD by sternotomy for patient with upper mediastinal metastases which are difficult to resect via transcervical approach is an effective treatment option to improve patient prognosis.
... On the other hand, some scholars have pointed out that the LN-prRLN metastasis rate in PTC patients is as high as 2.74-38.27% (6,7). Incomplete resection of the LN-prRLN in the first surgery can make the residual lymph nodes difficult to excise in the second surgery and even render complete excision impossible. ...
... After reading the titles and abstracts, we excluded articles that were not in accordance with the inclusion criteria, and 36 articles remained. Then, we screened the full texts, and 14 articles were ultimately included in this study (4,6,7,(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) ( Table 1). The flowchart of article screening is shown in Figure 1. ...
... Fourteen studies (4,6,7,(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19) involving 2,249 males and 8,331 females were included. In the comparison of sex, our results showed that male sex was a risk factor affecting LN-prRLN metastasis (OR=1.47, ...
Background:
Whether the lymph node posterior to the right recurrent laryngeal nerve (LN-prRLN) should be dissected is still controversial. This meta-analysis aimed to assess the risk factors for LN-prRLN metastasis in papillary thyroid carcinoma (PTC).
Methods:
We retrieved relevant studies published before May 2020 from the Wanfang Data, CNKI, PubMed, Embase, Web of Science and Cochrane Library databases. Heterogeneity was assessed with the Q-test and inconsistency index and sensitivity analysis and subgroup analysis were then used to find the source of heterogeneity. Begg test and generate a funnel chart to assess publication bias.
Results:
We retrieved 236 articles, 14 articles were selected as the subjects of our research. Fourteen studies involving 10,580 patients were analysed in this study. The LN-prRLN metastasis rate was 9.22% (975/10,580). The results of the meta-analysis showed that sex (P<0.001), age (P<0.001), tumour size (P<0.001), multifocality (P<0.001), capsular invasion (P=0.04), extrathyroidal extension (P<0.001), superficial central lymph node (VIa-LN) metastasis (P<0.001), and lateral lymph node (LLN) metastasis (P<0.001) were correlated with LN-prRLN metastasis.
Discussion:
Male sex, age ≤45 years, tumour size >1 cm, multifocality, capsular invasion or extrathyroidal extension, and VIa-LN metastasis or LLN metastasis in PTC patients were significant risk factors for predicting LN-prRLN metastasis. B ultrasound and CT scans are expected to predict LN-prRLN metastasis in the future.
Registration:
This research is registered on the PROSPERO website (registration number: CRD42020200898).
... e nodes located near the posterior side of the right nerve, upper to the esophagus and prevertebral fascia, are called the lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN), which were defined as VIb compartments, and lymph nodes anterior to the right recurrent laryngeal nerve were defined as VIa compartments [9]. e reported prevalence of LN-prRLN metastasis varies from 5.76% to 26% [8,[10][11][12][13][14]. In particular, if minor lymph node metastasis (LNM) is located posterior to the right RLN, it is often neglected, and careful dissection is required because of the high likelihood of damage to the RLN. ...
... e presence of right cLNM is significantly associated with LN-prRLN metastasis. Most studies have shown that right cLNM is an independent risk factor for LN-prRLN metastasis [10,11,13]. In our study, the proportion of LN-prRLN metastasis in the LN-prRLNM-group was substantially lower than that in the LN-prRLNM+ group (41.37% vs 82.95%, P ≤ 0.001). ...
Background:
Although the American Thyroid Association (ATA) guidelines indicate that central lymph nodes posterior to the right recurrent laryngeal nerve (LN-prRLN) should be routinely dissected, pr-RLN dissection is often neglected due to the high risk of injury to the recurrent laryngeal nerve (RLN). The purpose of this study was to investigate the risk factors associated with LN-prRLN metastasis in patients with papillary thyroid carcinoma (PTC) by preoperative examination and the indications for LN-prRLN dissection.
Methods:
A total of 1487 consecutive patients with PTC who underwent total thyroidectomy or right lobectomy plus isthmic resection with central LN dissection (CLND) were divided into two groups: patients with LN-prRLN dissection (group A) and patients without LN-prRLN dissection (group B). Clinicopathologic data were reviewed of the patients who were operated on by the same thyroid surgery team in the Department of Head Neck Surgery, Fudan University Shanghai Cancer Center (FUSCC) between August 2011 and May 2019. The relationships of LN-prRLN metastasis with clinicopathologic characteristics were analyzed by univariate and multivariate logistic regression.
Results:
The incidence of LN-prRLN metastasis was 34.1% (129/378). Univariate analysis showed that sex (P ≤ 0.001), tumor size (P ≤ 0.001), extrathyroidal extension (P=0.002), concurrent Hashimoto's thyroiditis (P=0.009), cLNMa (central lymph nodes anterior to the right recurrent laryngeal nerve) (P ≤ 0.001), cLNMa number (P ≤ 0.001), and lateral LN metastasis (LLNM) (P ≤ 0.001) were significantly associated with LN-prRLN metastasis in PTC. Multivariate logistic regression analysis revealed that tumor size (P=0.039), cLNMa (P=0.001), and LLNM (P=0.025) were independent risk factors for LN-prRLN metastasis in patients with PTC. Although there was no significant difference between the two groups in recurrence, we found that 4 cases relapsed in the LN-prRLN compartment in group B, while none relapsed in group A.
Conclusion:
LN-prRLN metastasis is often identified in patients with PTC. Patients with large tumor sizes, cLNMa and LLNM are at a high risk of LN-prRLN metastasis and should be recommended for careful LN-prRLN dissection.
