LATERAL NECK DISSECTION 4 th post-grad course in Endocrine Surgery 2012

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Patrick Bell
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1 LATERAL NECK DISSECTION 4 th post-grad course in Endocrine Surgery 2012 MAURICE STEVENS ( ENT, Head and Neck ) ROYAL BRISBANE AND WOMENS HOSPITAL Head and Neck Multidiciplinary Clinic

2 PAPILLARY THYROID CANCER FNA suspicious thyroid lumps 50-75% are malignant Metastatic disease at presentation 25-64% - not a potent adverse indicator of prog. - higher chance of locoregional recurr. - clinical incidence of recurr. is no> 10-20% when the neck is not surgically treated WHY? TSH suppress - RAI - fail to grow

3 PAPILLARY THYROID CANCER prognostic factors Tumour size Extrathyroidal spread Angiolymphatic invasion Multifocal Any positive lymph nodes BRAF mutation - more aggressive!

4 PAPILLARY THYROID CANCER Presence of LN mets. does affect prognosis The days of cherry picking are over Elective dissection in a clin./radiol. Neg. neck is highly controversial Post- op RAI is not always preferred ( Japan ) or available FDG avid disease tends to be resistant to RAI

5 PAPILLARY THYROID CANCER Lymphatic Spread High incidence if Primary > 1 cm 90 % of pts. with lateral mets. have central mets. First echelon nodes are central nodes Second echelon nodes are lateral nodes???? always

6 PAPILLARY THYROID CANCER Pattern of central spread 45% of unilateral tumours >1cm cm. 40% to paratracheal-24% to pretracheal 10% contralateral central 17% contralateral occult

7 PAPILLARY THYROID CANCER Lateral cervical spread Second echelon nodes Levels 11 to Vb Levels 11 to 1V - account for 75% mets. Levels 111 /1V most common Level 1-4% mets. ( mostly 1b ) Level Vb 16% Suboccipital and Va rare Skip lesions 8% - explanation? Occult mets %

8 WHEN TO DISSECT THE NECK Elective lateral rarely - if clin./ radiol positive nodes only Elective central - dependent on - tumour size - risk factors Of no survival advantage if micropapillary

9 REGIONAL RECURRENCE Overall 5-10% Highest in first 3 years 50% in first 12 months Very few after 5 years

10 MICROPAPILLARY THYROID CANCER If total thyroidectomy and elective neck dissection occult nodes in - central 60% - lateral 40% Rate of LN recurrence <1% - whether there is neck dissection or not -?why If total thyroidectomy and no neck dissection - most LN recurrences are ipsilateral - in levels 1V,111,11 in descending order

11 MEDULLARY THYROID CANCER Management of the neck is surgical alone Early detection > better survival Surgery is the only means of cure Distant spread common Survival related to resectability Therapeutic neck dissection only Elective neck dissection does not increase survival END ( lateral ) if tumour >1 cm or known central compartment disease

12 MICROMEDULLARY CANCER < 1 cm LN mets. at diagnosis up to 30% 1/3 multifocal Most intrathyroid >5% distant mets % have >10 positive nodes 8% paediatric Survival overall 90% at 10 years - 50% alive at 10 years with distant mets

13 MICROMEDULLARY THYROID CANCER Strongest predictor of LN mets. is- - Extrathyroidal spread - Tumour size Standard of care - - Total thyroidectomy - Central dissection - Lateral dissection if Clin./ radiol. pos. nodes

14 LYMPH NODE ANATOMY IN THE NECK 300 Lymph Nodes on each side 50 are accessible surgically Presence of surgically inaccessible nodes at presentation assoc. with poor prognosis Main risks- - Nerve injury - Chylous leaks

15 LEVELS OF THE NECK

16 SKIN INCISIONS A matter of choice Don t cross the midline if unilateral XRT likely Avoid junctions over the carotid Save the Great auricular n. and MMB of V11

17 POST OPERATION Skin closure Suction drains- removal at about 4-5 days Parenteral antibiotics General medical care? Physiotherapy

9. Discuss guidelines for follow-up post-thyroidectomy for cancer (labs/tests) HH

9. Discuss guidelines for follow-up post-thyroidectomy for cancer (labs/tests) HH Differentiated thyroid cancer expresses the TSH receptor on the cell membrane and responds to TSH stimulation by increasing