0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Papillary Thyroid Carcinoma:  Modified Radical Neck Dissection Improves Prognosis FREE

Shiro Noguchi, MD, PhD; Nobuo Murakami, MD; Hiroto Yamashita, MD, PhD; Masakatsu Toda, MD, PhD; Hitoshi Kawamoto, PhD
[+] Author Affiliations

From the Noguchi Thyroid Clinic and Hospital Foundation (Drs Noguchi, Murakami, Toda, and Kawamoto) and the Department of Pathology, Oita Medical University (Dr Yamashita), Oita, Japan.


Arch Surg. 1998;133(3):276-280. doi:10.1001/archsurg.133.3.276.
Text Size: A A A
Published online

Objective  To ascertain whether modified radical neck dissection offers a survival advantage for some subsets of patients with papillary cancer of the thyroid.

Design  A retrospective cohort study of 2966 patients curatively treated at the Noguchi Thyroid Clinic and Hospital Foundation, Oita, Japan, between 1946 and 1991.

Setting  A center for the treatment of thyroid disease, where about 1400 thyroid operations are performed per year.

Patients  Between 1946 and 1991, patients with papillary cancer whose primary tumor was 1 cm or larger and who were curatively treated were studied. Of the 2859 patients, 72.1% underwent modified radical neck dissection, 8.5% underwent partial node excision, and 19.4% underwent no node excision.

Results  A univariate analysis revealed a subset of patients who benefited from modified radical neck dissection. A multivariate analysis revealed that sex (P<.001), age at the time of the operation (P<.001), size of the primary tumor (P<.001), extrathyroidal invasion (P<.001), and the presence of nodal metastasis (P<.01) are significant risk factors.

Conclusion  Patients with nodal metastasis, patients in whom the primary tumor invades beyond the thyroid capsule, and women older than 60 years can benefit from modified radical neck dissection.

Figures in this Article

IN THE surgical management of papillary cancer, controversy exists not only about thyroidectomy but also about the extent of lymph node excision. While there are well-accepted risk factors, such as the patient's age at the time of surgery, the size of the primary tumor, and invasion of the tumor beyond the thyroid capsule, the influence of lymph node metastasis on survival is controversial. In this study, we attempted to address these issues.

A randomized trial is believed to be the most reliable and scientific way of comparing 2 therapeutic methods. However, when a randomized trial is not feasible, another approach is to determine whether a group of patients with advanced disease has a better prognosis after undergoing one surgical procedure than another group of patients with less advanced disease who has undergone a less extensive surgical procedure. If so, the more extensive surgical procedure would be justified.

We elected to use subtotal thyroidectomy and to perform modified radical neck dissection in most of our patients. Although it is unquestionably established that modified radical neck dissection reduces the recurrence rate,1,2 its influence on the survival rate still remains unclear. In this article, we report a survival advantage of modified radical neck dissection in some subgroups of patients with papillary thyroid cancer, despite the fact that these patients had more advanced disease.

Between 1946 and 1991, 3994 patients seen at the Noguchi Thyroid Clinic and Hospital Foundation, Oita, Japan, had papillary cancer. The following 2 groups of patients were excluded from the study: 124 patients who were not surgically treated or who underwent noncurative surgery (including 17 patients who had pulmonary metastases when they were initially seen and 92 who underwent incomplete resection) and 904 patients whose primary tumor had a maximum diameter of less than 10 mm. Therefore, 2966 patients were included in this study.

Information about living patients was obtained by periodic correspondence with the patients themselves, family members, referring physicians, and municipal records. For the deceased patients, the cause of death was confirmed by death certificates or contact with family members and hospitals. The mean follow-up interval in the patients last known to be alive was 15.6 years. Twelve (0.4%) of the patients were unavailable for follow-up, 170 died of thyroid cancer, and 333 died of unrelated causes.

The cause-specific survival rates were calculated according to the Kaplan-Meier method. Risk factor analysis was performed using the Cox proportional hazards regression model. χ2 Analysis was applied for comparisons between 2 groups with a similar distribution, and the Wilcoxon rank sum test–Kruskal-Wallis test was applied for groups with an irregular distribution.

PRIMARY TUMOR

The mean (±SD) diameter of the primary tumor was 27.1±14.5 mm. The smallest tumor was 10 mm in diameter by definition, and the largest was 150 mm in diameter. The tumor was confined within the thyroid capsule in 912 patients.

METASTASIS

Gross nodal metastasis was found in 1160 (39.1%) of the patients.

In 638 (21.5%) of the patients, nodal metastasis was not examined or counted; in 323 (10.9% of the patients, metastasis was histologically confirmed not to be present; and in 2005 (67.6%) of the patients, metastasis was histologically confirmed to be present.

TYPES OF THYROIDECTOMY AND LYMPH NODE EXCISION

Total thyroidectomy was performed in 75 (2.5%) of the patients; subtotal thyroidectomy, 1233 (41.6%) of the patients; lobectomy, 1217 (41.0%) of the patients; and partial lobectomy, 441 (14.9%) of the patients. Our routine method of subtotal thyroidectomy is to leave behind 1 or 2 g of the upper pole of the unaffected lobe, with the parathyroid gland left in situ. When intraglandular dissemination is present on the contralateral upper pole, we try to leave behind 1.0 or 1.5 g of the upper pole of any side that looks normal. Lobectomy is almost always accompanied by isthmectomy. A special explanation is required regarding patients who underwent partial lobectomy. Of the 441 patients, 71 had concomitant benign disease; of these 71 patients, 66 underwent the operation for that reason. The remaining patients had a small tumor. Of the 441 patients, 78 underwent modified radical neck dissection, 69 underwent central compartment node dissection, and the remaining 294 underwent no node excision. This procedure was mostly performed between 1970 and 1975. The modified radical neck dissection encompassed dissection of the fat and lymph node tissues around the trachea (central compartment) and those around the jugular vein extending from the common carotid artery up to the bifurcation, superior to the bifurcation the internal carotid artery to the trapezius muscle, and from the subclavian vein to the hypoglosseal nerve (lateral compartment).

Patients who underwent modified radical neck dissection had macroscopic metastasis, invasion of the primary tumor to surrounding tissue, or a preoperative diagnosis of cancer. Further analysis was performed by dividing the patients into 2 groups, those treated with modified radical neck dissection and those not treated with modified radical neck dissection, because of the few patients in the central compartment excision group. Table 1 shows the number and percentage of patients treated with each type of thyroidectomy and lymph node excision.

Table Graphic Jump LocationTable 1. Lymph Node Excision in Relation to Thyroidectomy*

Patients who did not undergo this dissection had no macroscopic metastasis and minimal or no invasion to surrounding tissue. The differences between the 2 groups are summarized in Table 2.

Table Graphic Jump LocationTable 2. Characteristics of Patients Who Underwent Modified Radical Neck Dissection (MRND) Compared With Patients Who Did Not Undergo MRND*
INVASION OR ADHESION

In this type of retrospective study, adhesion and invasion of the primary tumor to the surrounding tissues were hard to differentiate strictly; therefore, they were grouped together. The incidence of invasion or adhesion of the primary tumor to surrounding tissues increased with age (P<.001). The incidence of nodal metastasis in male and female patients was 92.1% and 85.5%, respectively. The difference was significant (P<.009).

The patients in whom there was invasion or adhesion of the primary tumor to surrounding tissue and who experienced gross nodal involvement had a better survival rate after a modified radical neck dissection was performed, as shown in Figure 1 and Figure 2, respectively.

Place holder to copy figure label and caption
Figure 1.

Modified radical neck dissection (MRND) improves the cause-specific survival rate in patients whose primary tumor had extrathyroidal invasion (n=912, 30.7% of the total) (P<.02, log-rank test, and P<.01, Wilcoxon rank sum test).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Modified radical neck dissection (MRND) improves the cause-specific survival rate in patients who had gross nodal metastasis (n=1157, 39.0% of the total) (P<.009, log-rank test, and P<.005, Wilcoxon rank sum test).

Graphic Jump Location

Although the overall survival rates in the group that underwent modified radical neck dissection and in the group that did not undergo modified radical neck dissection were not statistically different, among patients with any metastases, the group that underwent modified radical neck dissection had a survival advantage (Figure 3).

Place holder to copy figure label and caption
Figure 3.

Modified radical neck dissection (MRND) improves the cause-specific survival rate in patients who had nodal metastasis of any size (n=2005, 67.6% of the total) (P<.04, log-rank test, and P<.007, Wilcoxon rank sum test).

Graphic Jump Location
AGE

Patients were classified into 4 age groups: younger than 20 years, between 20 and 50 years, between 51 and 60 years, and older than 60 years. Older age was a significant (P<.001) risk factor. In women older than 60 years, who composed 17.7% of the patients, modified radical neck dissection conferred a significant (P<.02, log-rank test, and P<.007, Wilcoxon rank sum test) survival advantage regardless of the risk factors (Figure 4). The 10- and 20-year cause-specific survival rates for the group that underwent modified radical neck dissection (n=373) were 92.4% and 73.2% compared with 80.3% and 56.7%, respectively, for the group that did not undergo modified radical neck dissection (n=130).

Place holder to copy figure label and caption
Figure 4.

Modified radical neck dissection (MRND) improves the cause-specific survival rate in female patients older than 60 years, regardless of other risk factors (n=468, 15.8% of the total) (P<.02, log-rank test, and P<.007, Wilcoxon rank sum test).

Graphic Jump Location
RECURRENCE FROM REMNANT THYROID

Recurrence in the remnant thyroid tissue was observed in 97 (3.3%) of the patients. The contralateral lobe was affected in 74 patients, the ipsilateral thyroid bed was affected in 22 patients, and the bilateral lobes were affected in 1 patient. Among these patients, 83 were successfully treated by a second operation and 1 survived with disease; of the remaining 13 (0.4%) of the patients, 11 (0.37%) died of distant metastasis and 2 (0.07%) died of local disease.

MULTIVARIATE ANALYSIS OF RISK FACTORS

The significant risk factors were sex (P<.001), age at the time of the operation (P<.001), maximum diameter of the primary tumor (P<.001), extrathyroidal invasion (P<.001), and presence of metastasis regardless of the size of the tumor (P<.04).

Since 1970, when we first noted the extremely high incidence of nodal metastases in patients with papillary cancer of the thyroid, we have advocated modified radical neck dissection for these patients.3,4 Recently, Simon and Goretzki1 noticed a high nodal recurrence rate and suggested the usefulness of a modified radical neck dissection. Scheumann et al2 reported improvement of the recurrence rate and the survival rate after a modified radical neck dissection; however, the indication criteria were not clarified. Although many had failed to find improvement of the survival rate after modified radical neck dissection,58 we were able to demonstrate the beneficial effect of modified radical neck dissection on survival in some subsets of female patients with papillary cancer of the thyroid by univariate and multivariate analyses. There are several possible reasons why previous studies have failed to demonstrate any benefit of modified radical neck dissection. This form of surgery has often been applied exclusively for advanced disease: the percentage of patients with papillary cancer of the thyroid who underwent radical or modified radical neck dissection ranged from 12.3% to 30.0% in institutions in which the procedure is reserved only for patients with gross nodal metastasis.612 Moreover, because recurrence in cervical nodes can be treated easily and successfully by a second surgery, such recurrence may not have affected the survival in many instances.5,6,1315 Because of the indolent nature of papillary cancer, the probability of differences of disease-specific survival rates among groups given different treatments is small and, therefore, an analysis of many cases is necessary before any significant difference will emerge.16 Finally, not all patients benefit from modified radical neck dissection, and there are no criteria for identifying patients who are, and who are not, likely to benefit.

Recent advances of statistical models and computer technology enabled us to analyze many patients with multiple risk factors.2,9,1720 With the use of multivariate analysis, the age of the patients at the time of the operation, the size of the primary tumor, the presence of gross nodal involvement, and the presence of remote metastasis when they were specifically mentioned have been agreed on as the risk factors in the literature we examined.13,17,2123 However, a scoring system or a classification of patients based on prognosis, inclusive of nodal metastasis, is only given in the article that we previously published.20

Aside from these rather sophisticated mathematical methods of analysis, Cady et al24 made a simple and practical rating system named AMES, which is essentially based on the age of the patient, the presence of remote metastasis, the extension of the primary tumor beyond the thyroid capsule, and the size of the primary tumor. They further developed the concept of risk group definition. With the use of multivariate analysis, as well as histological grading, Hay et al25 proposed a new scoring system inclusive of histological grading, known as AGES, which denotes age of the patient, histological grade of the tumor, extension beyond the thyroid capsule, and size of the primary tumor. They further developed and improved their scoring system by excluding histological grading and including completeness of the resection, invasion of the primary tumor to surrounding tissues, and size of the primary tumor.25 None of these scoring systems but ours singularly ignored nodal involvement, despite the fact that multivariate analysis clearly proved that gross nodal involvement is one of the risk factors.

Routine or frequent use of radioactive iodine with the objective of ablating microscopic cancer foci is recommended by those who advocate total thyroidectomy.5,6,2628 Those who do not perform total thyroidectomy routinely use radioactive iodine in selected patients.29,30 We employ radioactive iodine only when remote metastasis is evident and when the metastasis can accumulate radioactive iodine, not only because of the strict regulation of radioisotopes in Japan but because we also believe that calcitonin secretion must be preserved.

In our series, male patients had a higher incidence of nodal metastasis. This observation agreed with the observations of Tisell et al,12 Tscholl and Hedinger,31 and Ahuja et al.32

Although we are aware that total thyroidectomy is a safe procedure when it is performed by skilled and well-experienced surgeons,3335 we still try to avoid total thyroidectomy for the simple reason that it does not seem to improve the survival rate. Because of this policy, we paid particular attention to recurrence at the remnant thyroid. Of the 2966 patients who we observed on average for 15.6 years, only 13 (0.4%) died of causes related to recurrence in the remnant thyroid or thyroid bed; among these patients, only 2 (0.07%) died with neck disease. Many other researchers are also unable to find any survival advantage of total thyroidectomy.7,14,3640 Samaan et al26 indicated that total thyroidectomy was associated with a longer disease-free interval and less recurrence. However, in their more recent article,41 a higher survival rate was reported.42 We wonder whether the total thyroidectomies were performed by more experienced surgeons compared with the less extensive thyroidectomies. The bone mineral content is reduced after total thyroidectomy.42 Therefore, if there is no benefit associated with total thyroidectomy in appropriately selected patients, then the increased risk of osteoporosis should be avoided.

Most researchers agree that older patients with differentiated thyroid cancer have a relatively poorer prognosis. In the men and women in our study, age was one of the most important risk factors. Women older than 60 years accrue a survival advantage when they undergo modified radical neck dissection, regardless of other risk factors.

Univariate and multivariate analyses of modified radical neck dissection indicated a survival advantage in older women. However, women younger than 55 years, those without gross metastasis, and those without extrathyroidal invasion seemed to derive no benefit from this procedure.

The size of the primary tumor is also recognized as one of the risk factors by many researchers. In this study, the size was a significant risk factor per multivariate analysis.

Invasion of the primary tumor beyond the thyroid capsule is one of the risk factors reported by others.5,6,14,15,39,43 The incidence of invasion of the primary tumor to surrounding tissues progressively increases with age. The influence of age on prognosis is not explained by invasion alone; inversely, the invasiveness of the primary tumor might be under the influence of a factor or factors possibly related to age.

Thus, we found that modified radical neck dissection improved the outcome in some subsets of patients with papillary cancer of the thyroid: specifically, those in whom gross nodal metastasis was noticed before or during surgery, those in whom the primary tumor invaded beyond the thyroid capsule, and those who were women older than 60 years.

Presented in part at the 30th World Congress of the International College of Surgeons, Kyoto, Japan, November 26, 1996.

Reprints: Shiro Noguchi, MD, PhD, the Noguchi Thyroid Clinic and Hospital Foundation, Noguchi Naka-machi 6-33, Beppu, Oita 874, Japan.

Simon  DGoretzki  PE Incidence of regional recurrence guiding radicality in differentiated thyroid carcinoma. World J Surg. 1996;20860- 866
Link to Article
Scheumann  GSWGimm  OWegener  G  et al.  Prognostic significance and surgical management of locoregional lymph node metastasis in papillary thyroid cancer. World J Surg. 1994;18559- 568
Link to Article
Noguchi  SNoguchi  AMurakami  N Papillary carcinoma of the thyroid, I: developing pattern of metastasis. Cancer. 1970;261053- 1060
Link to Article
Noguchi  SMurakami  N The value of lymph-node dissection in patients with differentiated thyroid cancer. Surg Clin North Am. 1987;67251- 261
Mazzaferri  ELYoung  RL Papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients. Am J Med. 1981;70511- 518
Link to Article
DeGroot  LJKaplan  ELMcCormick  M  et al.  Natural history, treatment, and course of papillary thyroid carcinoma. J Clin Endocrinol Metab. 1990;71414- 424
Link to Article
McConahey  WMHay  IDWoolner  LB  et al.  Papillary thyroid cancer treated at the Mayo Clinic, 1946 through 1970: initial manifestations, pathologic findings, therapy, and outcome. Mayo Clin Proc. 1986;61978- 996
Link to Article
Cunningham  MPDuda  RBRecant  W  et al.  Survival discriminants for differentiated thyroid cancer. Am J Surg. 1990;160344- 347
Link to Article
Salvensen  HNjolstad  PRAkslen  LA  et al.  Thyroid carcinoma: results from surgical treatment in 211 consecutive patients. Eur J Surg. 1991;157521- 526
McHenry  CR Prospective management of nodal metastases in differentiated thyroid cancer. Am J Surg. 1991;162353- 356
Link to Article
Proye  CCarnaille  BVix  M  et al.  Récidives ganglionaires des cancers thyroïdiens opéré: de l'inutilité du curage ganglionaire de principe (carcinomes medullaires ecclus). Chirurgie. 1992;118448- 452
Tisell  L-ENilsson  BMölne  J  et al.  Improved survival of patients with papillary thyroid cancer after surgical microdissection. World J Surg. 1996;20854- 859
Link to Article
Simpson  WJMcKinney  SECarruthers  JS  et al.  Papillary and follicular thyroid cancer: prognostic factors in 1578 patients. Am J Med. 1987;83479- 488
Link to Article
Rossi  RDCady  BSilverman  ML  et al.  Current results of conservative surgery for differentiated thyroid carcinoma. World J Surg. 1986;10612- 622
Link to Article
Vickery  AJWang  CAWalker  AM Treatment of intrathyroidal papillary carcinoma of the thyroid. Cancer. 1987;602587- 2595
Link to Article
Udelsman  RLakatos  ELandenson  P Optimal surgery for papillary thyroid carcinoma. World J Surg. 1996;2088- 93
Link to Article
Tubiana  MSchlumberger  MRougier  P Long-term results and prognostic factors in patients with differentiated thyroid cancer. Cancer. 1985;55794- 804
Link to Article
Bacourt  FAsselain  BSavoie  JC  et al.  Multifactorial study of prognostic factors in differentiated thyroid carcinoma and a re-evaluation of importance of age. Br J Surg. 1986;73274- 277
Link to Article
Kerr  DJBurt  ADBoyle  PMacFarlane  GJStorer  AMBrewin  TB Prognostic factors in thyroid tumours. Br J Cancer. 1986;54475- 482
Link to Article
Noguchi  SMurakami  NKawamoto  H Classification of papillary cancer of the thyroid based on prognosis. World J Surg. 1994;18552- 557
Link to Article
Bacourt  FAsselain  BSvoiet  JC  et al.  Multifactorial study of prognostic factors in differentiated thyroid carcinoma and reevaluation of importance of age. Br J Surg. 1986;73274- 277
Link to Article
Carcangiu  MLZampi  GPupi  A  et al.  Papillary carcinoma of the thyroid: a clinicopathologic study of 241 cases treated at the University of Florence, Italy. Cancer. 1985;55805- 828
Link to Article
Sellers  MBeeken  SBlankenship  A  et al.  Prognostic significance of cervical lymph node metastasis in differentiated thyroid cancer. Am J Surg. 1992;164578- 581
Link to Article
Cady  BSedgwick  CEMeissner  WAWool  MSSalzman  FAWerber  J Risk factor analysis in differentiated thyroid carcinoma. Cancer. 1979;43810- 820
Link to Article
Hay  IDBergstralh  EJGoellner  JREbersold  JRGrant  CS Predicting outcome in papillary thyroid carcinoma: developing a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989. Surgery. 1993;1141050- 1057
Samaan  NAMaheshwari  YKNader  S  et al.  Impact of therapy for differentiated carcinoma of the thyroid: an analysis of 706 cases. J Clin Endocrinol Metab. 1983;561131- 1138
Link to Article
Beenken  SGuillamondegui  OShallenberger  R  et al.  Prognostic factors in patients dying of well-differentiated thyroid cancer. Arch Otolaryngol Head Neck Surg. 1989;115326- 330
Link to Article
Frankenthaler  RASellin  RVCangir  A  et al.  Lymph node metastasis from papillary-follicular thyroid carcinoma in young patients. Am J Surg. 1990;160341- 343
Link to Article
Rosen  IBMaitland  A Changing the operative strategy for thyroid cancer by node sampling. Am J Surg. 1983;146504- 508
Link to Article
Cady  BRossi  R An expanded view of risk-group definition in differentiated thyroid carcinoma. Surgery. 1988;104947- 953
Tscholl  DJHedinger  CE Papillary thyroid carcinomas: morphology and prognosis. Virchows Arch [Pathol Anat]. 1982;39619- 39
Link to Article
Ahuja  SErnst  HLenz  K Papillary thyroid carcinoma: occurrence and types of lymph node metastases. J Endocrinol Invest. 1991;14543- 549
Link to Article
Attie  NJKhafif  ARSteckler  MR Elective neck dissection in papillary carcinoma of the thyroid. Am J Surg. 1971;122464- 471
Link to Article
Clark  OH Total thyroidectomy: the treatment of choice for patients with differentiated thyroid cancer. Ann Surg. 1982;196361- 370
Link to Article
Reeve  TSDelbridge  LCrummer  P Total thyroidectomy in the management of differentiated thyroid cancer: a review of 258 cases. Aust N Z J Surg. 1986;56829- 833
Link to Article
Schroder  DMChambors  AFrance  CJ Operative strategy for thyroid cancer: is total thyroidectomy worth the price. Cancer. 1986;582320- 2328
Link to Article
Shah  JPLoree  TRDharker  D  et al.  Lobectomy versus total thyroidectomy for differentiated carcinoma of the thyroid: a matched-pair analysis. Am J Surg. 1993;166331- 335
Link to Article
Hoie  JStenwig  AEBrennhovd  IO Surgery in papillary thyroid carcinoma: a review of 730 patients. J Surg Oncol. 1988;37147- 151
Link to Article
Tourniaire  JBernard  AMAdeleine  P  et al.  Les éléments du prognostic des cancers thyrïdiens différenciés: 536 observations. Ann Endocrinol (Paris). 1989;50219- 224
Starnes  HFBrooks  DCPinkus  GS  et al.  Surgery for thyroid carcinoma. Cancer. 1985;551376- 1381
Link to Article
Samaan  NASchultz  PNHickey  RC  et al.  The results of various modalities of treatment of well differentiated thyroid carcinoma: a retrospective review of 1599 patients. J Clin Endocrinol Metab. 1992;75714- 720
McDermott  MTKidd  GSBlue  P  et al.  Reduced bone mineral content in totally thyroidectomized patients: possible effect of calcitonin deficiency. J Clin Endocrinol Metab. 1983;56936- 939
Link to Article
Coburn  MCWanebo  H Prognostic factors and management considerations in patients with cervical metastases of thyroid cancer. Am J Surg. 1992;164671- 676
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Modified radical neck dissection (MRND) improves the cause-specific survival rate in patients whose primary tumor had extrathyroidal invasion (n=912, 30.7% of the total) (P<.02, log-rank test, and P<.01, Wilcoxon rank sum test).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Modified radical neck dissection (MRND) improves the cause-specific survival rate in patients who had gross nodal metastasis (n=1157, 39.0% of the total) (P<.009, log-rank test, and P<.005, Wilcoxon rank sum test).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Modified radical neck dissection (MRND) improves the cause-specific survival rate in patients who had nodal metastasis of any size (n=2005, 67.6% of the total) (P<.04, log-rank test, and P<.007, Wilcoxon rank sum test).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Modified radical neck dissection (MRND) improves the cause-specific survival rate in female patients older than 60 years, regardless of other risk factors (n=468, 15.8% of the total) (P<.02, log-rank test, and P<.007, Wilcoxon rank sum test).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Lymph Node Excision in Relation to Thyroidectomy*
Table Graphic Jump LocationTable 2. Characteristics of Patients Who Underwent Modified Radical Neck Dissection (MRND) Compared With Patients Who Did Not Undergo MRND*

References

Simon  DGoretzki  PE Incidence of regional recurrence guiding radicality in differentiated thyroid carcinoma. World J Surg. 1996;20860- 866
Link to Article
Scheumann  GSWGimm  OWegener  G  et al.  Prognostic significance and surgical management of locoregional lymph node metastasis in papillary thyroid cancer. World J Surg. 1994;18559- 568
Link to Article
Noguchi  SNoguchi  AMurakami  N Papillary carcinoma of the thyroid, I: developing pattern of metastasis. Cancer. 1970;261053- 1060
Link to Article
Noguchi  SMurakami  N The value of lymph-node dissection in patients with differentiated thyroid cancer. Surg Clin North Am. 1987;67251- 261
Mazzaferri  ELYoung  RL Papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients. Am J Med. 1981;70511- 518
Link to Article
DeGroot  LJKaplan  ELMcCormick  M  et al.  Natural history, treatment, and course of papillary thyroid carcinoma. J Clin Endocrinol Metab. 1990;71414- 424
Link to Article
McConahey  WMHay  IDWoolner  LB  et al.  Papillary thyroid cancer treated at the Mayo Clinic, 1946 through 1970: initial manifestations, pathologic findings, therapy, and outcome. Mayo Clin Proc. 1986;61978- 996
Link to Article
Cunningham  MPDuda  RBRecant  W  et al.  Survival discriminants for differentiated thyroid cancer. Am J Surg. 1990;160344- 347
Link to Article
Salvensen  HNjolstad  PRAkslen  LA  et al.  Thyroid carcinoma: results from surgical treatment in 211 consecutive patients. Eur J Surg. 1991;157521- 526
McHenry  CR Prospective management of nodal metastases in differentiated thyroid cancer. Am J Surg. 1991;162353- 356
Link to Article
Proye  CCarnaille  BVix  M  et al.  Récidives ganglionaires des cancers thyroïdiens opéré: de l'inutilité du curage ganglionaire de principe (carcinomes medullaires ecclus). Chirurgie. 1992;118448- 452
Tisell  L-ENilsson  BMölne  J  et al.  Improved survival of patients with papillary thyroid cancer after surgical microdissection. World J Surg. 1996;20854- 859
Link to Article
Simpson  WJMcKinney  SECarruthers  JS  et al.  Papillary and follicular thyroid cancer: prognostic factors in 1578 patients. Am J Med. 1987;83479- 488
Link to Article
Rossi  RDCady  BSilverman  ML  et al.  Current results of conservative surgery for differentiated thyroid carcinoma. World J Surg. 1986;10612- 622
Link to Article
Vickery  AJWang  CAWalker  AM Treatment of intrathyroidal papillary carcinoma of the thyroid. Cancer. 1987;602587- 2595
Link to Article
Udelsman  RLakatos  ELandenson  P Optimal surgery for papillary thyroid carcinoma. World J Surg. 1996;2088- 93
Link to Article
Tubiana  MSchlumberger  MRougier  P Long-term results and prognostic factors in patients with differentiated thyroid cancer. Cancer. 1985;55794- 804
Link to Article
Bacourt  FAsselain  BSavoie  JC  et al.  Multifactorial study of prognostic factors in differentiated thyroid carcinoma and a re-evaluation of importance of age. Br J Surg. 1986;73274- 277
Link to Article
Kerr  DJBurt  ADBoyle  PMacFarlane  GJStorer  AMBrewin  TB Prognostic factors in thyroid tumours. Br J Cancer. 1986;54475- 482
Link to Article
Noguchi  SMurakami  NKawamoto  H Classification of papillary cancer of the thyroid based on prognosis. World J Surg. 1994;18552- 557
Link to Article
Bacourt  FAsselain  BSvoiet  JC  et al.  Multifactorial study of prognostic factors in differentiated thyroid carcinoma and reevaluation of importance of age. Br J Surg. 1986;73274- 277
Link to Article
Carcangiu  MLZampi  GPupi  A  et al.  Papillary carcinoma of the thyroid: a clinicopathologic study of 241 cases treated at the University of Florence, Italy. Cancer. 1985;55805- 828
Link to Article
Sellers  MBeeken  SBlankenship  A  et al.  Prognostic significance of cervical lymph node metastasis in differentiated thyroid cancer. Am J Surg. 1992;164578- 581
Link to Article
Cady  BSedgwick  CEMeissner  WAWool  MSSalzman  FAWerber  J Risk factor analysis in differentiated thyroid carcinoma. Cancer. 1979;43810- 820
Link to Article
Hay  IDBergstralh  EJGoellner  JREbersold  JRGrant  CS Predicting outcome in papillary thyroid carcinoma: developing a reliable prognostic scoring system in a cohort of 1779 patients surgically treated at one institution during 1940 through 1989. Surgery. 1993;1141050- 1057
Samaan  NAMaheshwari  YKNader  S  et al.  Impact of therapy for differentiated carcinoma of the thyroid: an analysis of 706 cases. J Clin Endocrinol Metab. 1983;561131- 1138
Link to Article
Beenken  SGuillamondegui  OShallenberger  R  et al.  Prognostic factors in patients dying of well-differentiated thyroid cancer. Arch Otolaryngol Head Neck Surg. 1989;115326- 330
Link to Article
Frankenthaler  RASellin  RVCangir  A  et al.  Lymph node metastasis from papillary-follicular thyroid carcinoma in young patients. Am J Surg. 1990;160341- 343
Link to Article
Rosen  IBMaitland  A Changing the operative strategy for thyroid cancer by node sampling. Am J Surg. 1983;146504- 508
Link to Article
Cady  BRossi  R An expanded view of risk-group definition in differentiated thyroid carcinoma. Surgery. 1988;104947- 953
Tscholl  DJHedinger  CE Papillary thyroid carcinomas: morphology and prognosis. Virchows Arch [Pathol Anat]. 1982;39619- 39
Link to Article
Ahuja  SErnst  HLenz  K Papillary thyroid carcinoma: occurrence and types of lymph node metastases. J Endocrinol Invest. 1991;14543- 549
Link to Article
Attie  NJKhafif  ARSteckler  MR Elective neck dissection in papillary carcinoma of the thyroid. Am J Surg. 1971;122464- 471
Link to Article
Clark  OH Total thyroidectomy: the treatment of choice for patients with differentiated thyroid cancer. Ann Surg. 1982;196361- 370
Link to Article
Reeve  TSDelbridge  LCrummer  P Total thyroidectomy in the management of differentiated thyroid cancer: a review of 258 cases. Aust N Z J Surg. 1986;56829- 833
Link to Article
Schroder  DMChambors  AFrance  CJ Operative strategy for thyroid cancer: is total thyroidectomy worth the price. Cancer. 1986;582320- 2328
Link to Article
Shah  JPLoree  TRDharker  D  et al.  Lobectomy versus total thyroidectomy for differentiated carcinoma of the thyroid: a matched-pair analysis. Am J Surg. 1993;166331- 335
Link to Article
Hoie  JStenwig  AEBrennhovd  IO Surgery in papillary thyroid carcinoma: a review of 730 patients. J Surg Oncol. 1988;37147- 151
Link to Article
Tourniaire  JBernard  AMAdeleine  P  et al.  Les éléments du prognostic des cancers thyrïdiens différenciés: 536 observations. Ann Endocrinol (Paris). 1989;50219- 224
Starnes  HFBrooks  DCPinkus  GS  et al.  Surgery for thyroid carcinoma. Cancer. 1985;551376- 1381
Link to Article
Samaan  NASchultz  PNHickey  RC  et al.  The results of various modalities of treatment of well differentiated thyroid carcinoma: a retrospective review of 1599 patients. J Clin Endocrinol Metab. 1992;75714- 720
McDermott  MTKidd  GSBlue  P  et al.  Reduced bone mineral content in totally thyroidectomized patients: possible effect of calcitonin deficiency. J Clin Endocrinol Metab. 1983;56936- 939
Link to Article
Coburn  MCWanebo  H Prognostic factors and management considerations in patients with cervical metastases of thyroid cancer. Am J Surg. 1992;164671- 676
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 135

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles