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
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
PAPILLARY THYROID CANCER prognostic factors Tumour size Extrathyroidal spread Angiolymphatic invasion Multifocal Any positive lymph nodes BRAF mutation - more aggressive!
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
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
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
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. 18-60 %
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
REGIONAL RECURRENCE Overall 5-10% Highest in first 3 years 50% in first 12 months Very few after 5 years
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
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
MICROMEDULLARY CANCER < 1 cm LN mets. at diagnosis up to 30% 1/3 multifocal Most intrathyroid >5% distant mets. 10-12% have >10 positive nodes 8% paediatric Survival overall 90% at 10 years - 50% alive at 10 years with distant mets
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
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
LEVELS OF THE NECK
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
POST OPERATION Skin closure Suction drains- removal at about 4-5 days Parenteral antibiotics General medical care? Physiotherapy