Thyroid Cancer Lymph Node Metastasis

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Thyroid Cancer: Surgery for Residual or Recurrent Lymph Node Metastases. Dr. McIntyre.

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After Surgery: Radioactive Iodine And Long

Almost all people who had surgery for papillary thyroid cancer will need to see a doctor for many years to have exams and certain blood tests to make sure the cancer has been cured, and to detect any return of the cancer as soon as possible should it return. Many people with papillary thyroid cancer will need to take radioactive iodine to help cure the cancer. We have several very important pages on these topics.

Cancer Spreading To The Lymph Nodes

Cancer appearing in the lymph nodes is an indicator of how the cancer is spreading. If cancer cells are only found in the lymph nodes near the original tumor, it may indicate the cancer is in an earlier stage and has not spread far beyond its primary area.

On the other hand, if your doctor finds the cancer cells have traveled to lymph nodes far from the initial tumor, the cancer may be spreading at a faster rate and could be in a later stage.

Additionally, its important to know how many cancer cells have traveled to the respective lymph node. If theres visible or palpable cancer in lymph nodes, or the cancer has grown outside the lymph node walls, the cancer may have progressed further and may require a different treatment plan.

If cancer cells have spread to your lymph nodes , symptoms may include:

lump or swelling in your neck, under your arm, or in your groin
shortness of breath

Recommended Reading: Iodine Treatment For Thyroid Cancer

How Does The Doctor Know I Have Thyroid Cancer

Most thyroid cancers are found when patients see a doctor because of new neck lumps . Sometimes doctors find neck lumps during a physical exam. Yet other times thyroid cancer may be found during an ultrasound test for other health problems.

If signs are pointing to thyroid cancer, more tests will be done.

Lymph Node Metastasis And Extrathyroidal Extension In Papillary Thyroid Microcarcinoma In Cyprus: Suspicious Subcentimeter Nodules Should Undergo Fna When Multifocality Is Suspected

Panayiotis A. Economides

Abstract

1. Introduction

There is a high prevalence of papillary thyroid carcinoma worldwide with an increasing incidence attributed to the increased diagnosis of papillary thyroid microcarcinoma . PTMC are tumors less than or equal to 10mm along the greatest diameter and are most often incidentally identified during routine thyroid ultrasonography with the major risk factors being a positive family history and exposure to ionising radiation . Their mortality rate is less than 1%, and they have an excellent prognosis . In a 2015 study analysing thyroid nodules of patients in the island of Cyprus, 14.3% of those were found to be malignant with thyroid cancer being the second most common type of cancer in Cypriot female patients . In a cohort of low-intermediate risk papillary thyroid carcinoma patients undergoing radioiodine ablation in a referral oncology center in Cyprus, almost one quarter had cervical LN metastasis .

Central LN metastasis can occur in up to 29.3% and lateral lymph node metastasis in 3.75.6% of PTMC patients , and this is associated with locoregional re-occurrence and adverse outcomes . ETE is another risk factor that can affect the decision for total vs. hemithyroidectomy . ETE can occur in 28.040.3% of PTMC patients and is associated with increased likelihood of central, lateral LN metastasis, and increased tumor size and should be treated more aggressively .

2. Methods

3. Statistical Analysis

4. Results

5. Discussion

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What To Expect When Having A Pet Scan

In preparing for a PET scan, a radioactive substance is injected into the blood. The amount of radioactivity used is low. Because cancer cells in the body generally utilize sugar as their energy source to grow, they absorb more of the sugar than normal cells.

This test can be very useful for physicians to make a diagnosis of papillary thyroid cancer that has:

Come back following prior surgery
Spread to other sites in the body
Diagnosed as papillary thyroid cancer but didn’t take up radioactive iodine

The PET/CT scan for a diagnosis of papillary thyroid cancer combines images of both PET and CT scans at the same time. This is because PET images alone are not very detailed. The computer shows the relative amount of radioactivity in a particular area and where the sugar is localized, appearing red or hot. The combination of these two images lets the doctor compare an abnormal area on the PET scan with its detailed appearance and location on the CT scan.

PET/CT scanning is not always positive in patients with a diagnosis of papillary thyroid cancer.

Data Extraction And Quality Evaluation

Two authors abstracted the following data from the included articles: first author, countries of study, years of publication, study design, study population , number of cases, surgical intervention, and PTC-related risk factors. Age, gender, multifocal, tumor size, location, vascular invasion, thyroiditis , bilateral, and Hashimoto’s thyroiditis were the risk factors of LNM in PTC patients. The Newcastle-Ottawa quality assessment scale was used to assess the quality of the research .

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Different Kinds Of Thyroid Cancer

There are 4 main types of thyroid cancer. They are listed below. Your doctor can tell you more about the kind you have.

Papillary thyroid cancer is the most common kind of thyroid cancer. It may also be called differentiated thyroid cancer. This kind tends to grow very slowly and is most often in only one lobe of the thyroid gland. Even though they grow slowly, papillary cancers often spread to the lymph nodes in the neck.
Follicular cancer is the next most common type. Its more common in countries where people dont get enough iodine in their diet. These cancers do not tend to spread to lymph nodes, but they can spread to other parts of the body, like the lungs or bones.
Medullary cancer is a rare type of thyroid cancer. It starts in a group of thyroid cells called C-cells. C-cells make calcitonin, a hormone that helps control the amount of calcium in the blood.
Anaplastic cancer is a rare type of thyroid cancer. It often spreads quickly into the neck and to other parts of the body, and is very hard to treat.

Papillary Cancer And Its Variants

Thyroid cancer spread to Lymph Nodes

Most cancers are treated with removal of the thyroid gland , although small tumors that have not spread outside the thyroid gland may be treated by just removing the side of the thyroid containing the tumor . If lymph nodes are enlarged or show signs of cancer spread, they will be removed as well.

In addition, recent studies have suggested that people with micro-papillary cancers may safely choose to be watched closely with routine ultrasounds rather than have immediate surgery.

Even if the lymph nodes arent enlarged, some doctors recommend central compartment neck dissection along with removal of the thyroid. Although this operation has not been shown to improve cancer survival, it might lower the risk of cancer coming back in the neck area. Because removing the lymph nodes allows them to be checked for cancer, this surgery also makes it easier to accurately stag e the cancer. If cancer has spread to other neck lymph nodes, a modified radical neck dissection is often done.

Treatment after surgery depends on the stage of the cancer:

People who have had a thyroidectomy will need to take daily thyroid hormone pills. If RAI treatment is planned, the start of thyroid hormone therapy may be delayed until the treatment is finished .

Recommended Reading: Houston Thyroid And Endocrine Specialists

Papillary Thyroid Cancer: What About Lymph Nodes

We have lymph nodes all over our body that are made up of groups of infection-fighting and cancer-fighting immune cells. We all have had “swollen glands” in our neck when we had a sore throat or tonsils. These same glands that get swollen when we have a neck infection can help fight cancer by preventing the cancer cells from spreading from the thyroid to the rest of the body. It is common for papillary thyroid cancer to spread into the lymph nodes of the neck before the cancer is discovered and diagnosed. Again, since there usually aren’t any symptoms, the cancer grows slowly for years and has time to spread into the lymph nodes, which are doing their job of capturing the cancerous cells before they can spread further. Thus, cancer that has spread into the neck lymph nodes is common with papillary thyroid cancer and may occur in as many as 40 percent of patients with small papillary cancers. In patients with larger papillary thyroid cancers, lymph node spread within the neck lymph nodes may occur in up to 75 percent of cases.

Spreading To Lymph Nodes Helps Cancer Metastasize

The researchers first asked whether cancer in the lymph nodes of mice helps tumors metastasize to the lungs, one of the most common places cancer spreads to.

They implanted groups of melanoma cells under the skin of mice and let them form tumors. In some mice, the cancer spread to the lymph nodes, and in other mice, it didnt. After several weeks, the researchers injected melanoma cells that dont spread to lymph nodes into the veins of the mice and then checked their lungs for cancer.

There were far more tumors in the lungs of mice that had cancer in their lymph nodes than in mice that didnt, they found.

So, it appears that spreading to lymph nodes helps cancer metastasize to the lungs, Dr. Engleman said.

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Patterns Of Lymph Node Metastasis In Dtc And Clinical Implications

Papillary thyroid carcinoma frequently metastasizes to cervical lymph nodes, and a significant percentage of patients already have lymphatic spread at the time of diagnosis . Current evidence suggests specific patterns of lymphatic metastasis in PTC. Lymph node metastases are commonly observed in the central compartment . About two-thirds of patients with PTC > 1 cm will have lymph node metastases in compartment VI, although in only half of these will the metastases be obvious to the naked eye . Lymphatic metastases are also commonly observed in the lateral compartment . In the study by Noda et al. more than half of the microscopic lymph node metastases were found in the lateral compartment. In about 5-10% of cases, lateral lymph node metastases may skip the central neck, usually in patients where the tumor is located in the upper poles of the thyroid . Onoda et al. demonstrated that initial lymph node metastases could occur equally in the central and lateral compartment. Therefore, the central and lateral compartments are frequently involved in PTC, especially in the presence of defined and specific risk factors . Metastases to levels IIA and VB-posterior portion occur at a later stage, while metastases to levels IIB and VA are more rarely observed . Metastases to level I are extremely rare .

Common Symptoms For These People *:

Metastases To Lung : 4 people, 23.53%

Fall: 3 people, 17.65%

Malignant Neoplasm Progression : 3 people, 17.65%

Insomnia : 3 people, 17.65%

Head Injury: 3 people, 17.65%

Pulmonary Congestion : 3 people, 17.65%

Diarrhea: 3 people, 17.65%

Loss Of Consciousness: 3 people, 17.65%

Staphylococcal Infection : 3 people, 17.65%

* Approximation only. Some reports may have incomplete information.

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Relationship Between Tumor Size And Lnm Rate And Age At Diagnosis In Young And Middle

Statistical analysis showed that the relationship between age at diagnosis and tumor size and LNM fit a quadratic curve in all age groups of PTC patients. Biologically, young and middle-aged patients usually have normal immune function which may affect tumor growth and metastasis. We further selected patients with PTC from those aged 1859years to analyze the correlation between age at diagnosis and tumor size, and between age at diagnosis and LNM. Age at diagnosis correlated linearly with tumor size and LNM tumor size and LNM rate decreased with age .

Fig. 2

To analyze the contribution of age towards LNM in PTC, multivariate analyses were performed with age, from 18 to 59years, as a categorical variable. The adjusted OR was calculated with reference to the 18-year-old PTC patients. The adjusted OR value was < 1, which implied that age was a protective factor for LNM in comparison with the 18-year-old PTC patients .

To analyze changes in protective effects of age the age cutoffs were incrementally stepped from 21 to 57years in 1-yearly increments, and the adjusted OR for older age was compared across multivariate logistic regression models. The adjusted ORs for PTC patients aged 1859years are plotted in Fig. d. The adjusted OR for advanced age cut-off in PTC increased slightly and in all models, implying that the protective effect of age on LNM gradually weakened with increasing age.

Thyroid Cancer Surgery For Central Compartment Lymph Nodes

The removal of the lymph nodes of the central neck can be performed initially when the thyroid gland is removed in the treatment of the thyroid cancer or following the initial surgery in the less common circumstances when thyroid cancer recurs or persists. The central compartment lymph node surgery spares all critical structures including the nerves to the voice box and all parathyroid glands not directly involved by cancer. Central compartment dissection extends from the carotid arteries on both sides of the neck, below to the blood vessels of the upper chest, and above to where the blood vessel of the upper portion of the thyroid gland begins off of the carotid artery .

Thyroid cancer surgery of the Central compartment

Classification Of Cervical Lymph Nodes

The neck contains a very rich lymphatic network . Modern classification of neck lymph nodes, based on findings and landmarks from cross-sectional anatomic imaging, is very useful in mapping nodal surgical intervention. The first classification system for neck dissections was published in 1991 by the American Academy of Otolaryngology-Head and Neck Surgery. This schema was later modified and has become universally accepted . This classification system is composed of 7 major nodal regions and defines a compartment-oriented neck dissection. Sublevel classification is also used when certain zones within the larger levels have independent biologic significance . The classification of cervical lymph nodes is schematically described in figure 1.

Table 1

Classification of neck lymph nodes — American Head and Neck Society Committee for Neck Dissection Classification

Fig. 1

Schematic representation of lymphatic mapping of the neck in a patient with thyroid cancer. This graphic is based on ultrasonographic findings. We routinely use this schematic lymphatic mapping in patients with thyroid cancer in the operating room . CCA = Common carotid artery IJV = internal jugular vein.

What Kind Of Treatment Will I Need

SonoWorld: Ablation of Metastatic Papillary Thyroid Cancer in Neck Lymph Nodes

There are many ways to treat thyroid cancer but surgery is the main treatment. The treatment plan thats best for you will depend on:

The stage of the cancer
The chance that a type of treatment will cure the cancer or help in some way
Other health problems you have
Your feelings about the treatment and the side effects that come with it

Depending on the type and stage of your thyroid cancer, you may need more than 1 type of treatment.

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Surgery For Papillary Thyroid Cancer

Papillary thyroid cancer is treated with surgery. It is important to understand that the best chance of cure is to have an expert thyroid cancer surgeon from the beginning. A surgeon who performs surgery for papillary thyroid cancer on a daily basis has a higher cure rate than a surgeon who performs thyroid surgery several times per week, or does other types of thyroid surgery . Surgery for thyroid cancer has become very specialized, so it is important for you to be comfortable with your choice of surgeon.

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Role Of Molecular Markers In Nodal Disease

Conservatively managed thyroglossal duct cyst carcinoma with lymph node ...

In recent years, BRAF mutations, RAS mutations and RETPTC rearrangements have been identified as the main driver events in thyroid cancer. BRAF mutations occur in approximately 60% of patients with PTC and are the most studied molecular marker in PTC. BRAF mutations, most commonly of V600E, constitutionally activate the BRAF kinase in the MAPK pathway thereby promoting cell-proliferation. Its presence is diagnostic of thyroid cancer. Some studies suggest it may be associated with adverse disease characteristics and advanced disease stages . Patients with recurrent or persistent PTC have a higher incidence of BRAF mutation . Based on these findings, some have advocated for the use of BRAF mutation status to guide extent of initial thyroidectomy and neck dissection . It is, however, important to emphasize that the identification of a molecular predictor of recurrence or mortality does not equate to improved outcomes with more aggressive therapy prospective studies are required to confirm therapeutic benefit. At present, mutational status does not routinely impact management guidelines nor risk stratification systems. Further studies are required to demonstrate if BRAF-positive patients will experience therapeutic benefit from more aggressive treatment.