Search Results (57)

Objective: Papillary thyroid microcarcinoma (PTMC) often presents with multifocality and bilaterality, but the clinical significance of these features and their association with cervical lymph node metastases (LNMs) remain debated. The aim of this study was to investigate the patterns of multifocality and bilaterality in PTMC and their association with central and lateral neck lymph node metastases. Methods: This retrospective study analyzed 254 patients with histologically confirmed PTMC treated at the Institute for Oncology and Radiology of Serbia between 2004 and 2016. All patients underwent total thyroidectomy with central and, when indicated, lateral neck dissection. Associations between multifocality, bilaterality, and cervical LNM were evaluated using appropriate statistical tests. A p-value < 0.05 was considered statistically significant. Results: Multifocal tumors were present in 40.55% of patients, with bilateral involvement in 27.17%. Cervical LNM occurred in 33.07% of patients, with 26.77% showing central and 20.08% lateral metastases. Patients with multifocal tumors were associated with significantly higher proportions of male patients (p = 0.0283), higher rates of capsular invasion (p = 0.0002), larger tumor size (p = 0.0134), and increased incidence of LNM (p = 0.0152). Bilateral tumors were associated with larger tumor size (p = 0.0004) and more frequent capsular invasion (p = 0.0248), but not with a statistically significant increase in LNM. The number of tumor foci was strongly associated with both central and lateral LNM (p < 0.001). Conclusions: Multifocality, particularly with a higher number of tumor foci, is significantly associated with more aggressive tumor features and higher rates of cervical lymph node metastases in PTMC. While bilaterality also reflects a more aggressive phenotype, it was not independently predictive of LNM. These findings underscore the importance of careful risk stratification in PTMC and suggest that multifocality should inform surgical and follow-up strategies. Full article

Background: Management of lateral pelvic lymph node (LPLN) metastasis in advanced lower rectal cancer has historically exemplified a fundamental East–West divide. In Japan, the Japanese Society for Cancer of the Colon and Rectum (JSCCR) considers LPLN metastasis a regional manifestation requiring lateral pelvic lymph node dissection (LPLND). In contrast, Western practice has long approached LPLN disease as systemic, prioritizing neoadjuvant chemoradiotherapy (nCRT) followed by total mesorectal excision (TME) without additional lateral clearance. Recent Advances: Evidence generated from the JCOG0212 trial and subsequent multicenter cohorts has firmly demonstrated that LPLND markedly reduces lateral local recurrence, particularly in patients with radiologically enlarged nodes. These findings have contributed to a paradigm shift: the 2025 European Society for Medical Oncology (ESMO) Guidelines now endorse selective LPLND for suspicious nodes following neoadjuvant therapy, indicating an emerging convergence between Eastern surgical philosophy and Western multimodal treatment strategies. Surgical Innovation: Robotic surgery has transformed the technical execution of LPLND. Its stable, high-definition three-dimensional visualization, wristed instruments, and enhanced precision enable meticulous dissection across four anatomically defined planes: the medial plane (uretero-hypogastric fascia), intermediate plane (vesico-hypogastric fascia), lateral plane (pelvic sidewall), and dorsal plane (pelvic floor and lumbosacral trunk/sacral plexus). These features facilitate consistent nerve-sparing surgery, reduce blood loss, and improve postoperative urinary and sexual function compared with conventional laparoscopy or open approaches. Robotic LPLND therefore represents a contemporary synthesis of Eastern surgical precision and Western evidence-based multimodal therapy—offering an integrated pathway toward optimized oncologic control and enhanced functional outcomes. Full article

Background and Objectives: The axillary lateral vessel thoracic junction (ALTJ) is a key lymphatic drainage pathway for the arm and a potential structure to spare during regional nodal irradiation (RNI) to reduce lymphedema risk in breast cancer patients. This study aims to demonstrate the feasibility of ALTJ-sparing radiation therapy (RT) planning using Tomotherapy. Materials and Methods: Ten breast cancer patients who had undergone axillary lymph node dissection and whose dissected axillary levels were excluded from the RNI target volume were included. A TomoDirect intensity-modulated RT plan was generated at a dose of 50 Gy in 25 fractions. The dissected axilla was not designated as an organ at risk (OAR) in the original treatment plan. For this study, the axillary lymph node level I (AXL1) and the ALTJ were delineated retrospectively, with the ALTJ considered an OAR in the newly generated study plan. A total of 20 RT plans (10 per group) were statistically compared using various dose-volume parameters. Results: Compared to the original plans, the study plans with ALTJ as an OAR significantly reduced the incidental dose to both the ALTJ (mean: 41.7 ± 3.4 Gy vs. 27.2 ± 1.3 Gy; p = 0.005) and the AXL1 (mean: 43.9 ± 2.0 Gy vs. 37.7 ± 1.9 Gy; p = 0.005). All other dosimetric parameters (V25Gy, V35Gy, V40Gy, Dmin, Dmax) for the ALTJ were also significantly lower in the study plans. This ALTJ sparing was achieved while maintaining all required dose-volume constraints for target volumes and standard OARs such as the lung and heart. Conclusions: This study demonstrates that simply excluding the dissected axilla from the target volume without designating it as an OAR still results in a substantial incidental dose to this region. Our findings also show the feasibility of using Tomotherapy to selectively spare the axilla, particularly the ALTJ subregion of AXL1, which is critical for lymphedema risk in breast cancer patients. Full article

Purpose: Cervical lymph node status is the strongest prognostic factor in oral squamous cell carcinoma (OSCC). While 18F-FDG-PET and cervical ultrasonography are widely used for preoperative staging, their diagnostic accuracy remains limited for small or equivocal nodes. This study compared both modalities against histopathology on a per-level basis and examined correlations of SUVmax and RECIST values with metastatic involvement. Methods: This retrospective single-centre study included patients with histologically confirmed OSCC who underwent preoperative 18F-FDG-PET and cervical ultrasonography, followed by resection and neck dissection (October 2018–December 2024). Imaging was interpreted independently and blinded to clinical and histopathological data. Histopathology served as the reference standard. Diagnostic accuracy was assessed on a level-by-level basis. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated and compared using McNemar’s test and logistic regression. Results: Among 100 patients (mean age 63.5 ± 10.6 years; 54% male, 46% female), the lateral tongue was the most frequent site (44%), and 31% showed nodal involvement on PET imaging. PET imaging yielded 59% sensitivity, 87% specificity, and 77% accuracy; ultrasonography achieved higher sensitivity (76%) but lower specificity (67%). Combined assessment improved sensitivity (78%) and NPV (82%) but reduced specificity. PET imaging was more specific, while ultrasonography was more sensitive. SUVmax and RECIST values were higher in metastatic nodes and independently predicted metastasis, though with substantial overlap and no reliable cut-off. Conclusions: PET imaging offers higher specificity, whereas ultrasonography provides greater sensitivity. Their complementary performance supports a multimodal approach to cervical staging in OSCC. Neither SUVmax nor RECIST values reliably distinguished benign from malignant lymph nodes. Full article

Background: Contralateral lymph node metastasis (CLNM) in oral squamous cell carcinoma (OSCC) represents a major clinical challenge, in patients with a clinically contralateral node-negative neck. Individualized risk stratification is crucial to guide decisions on elective contralateral neck dissection. This study aimed to synthesize existing evidence and apply Bayesian Monte Carlo Simulation (MCS) to estimate CLNM probability across various clinic-pathological scenarios. Methods: A systematic search of PubMed, PubMed Central, and Embase (2000–2024) identified 26 eligible studies. Effect sizes for seven key risk factors—midline-crossing tumours, extranodal extension (ENE), ≥2 ipsilateral lymph nodes, depth of invasion (DOI) >10 mm, perineural invasion and lymphovascular invasion (PNI-LVI), poor differentiation, and floor of mouth subsite—were computed and incorporated into a Bayesian logistic model. Using the No-U-Turn Sampler (NUTS) in RStan, 100,000 virtual patient profiles were simulated to generate posterior probabilities of CLNM. Results: The baseline CLNM risk for lateralized tumours without additional risk factors was 4.2%. Single risk factors increased probability substantially: midline-crossing tumours (31.7%), ENE (27.4%), and ≥2 ipsilateral nodes (24.9%). Combinations of risk factors amplified the risk non-linearly: the presence of a midline-crossing tumour, ENE, and ≥2 ipsilateral nodes yielded a 76.8% CLNM probability, and the presence of all seven risk factors increased it to 93.7%. Risk tiers were classified from minimal (<20%) to very high (>50%) to guide clinical decision-making. Conclusions: This MCS-based model reveals that CLNM risk increases multiplicatively with the presence of various high-risk features. The simulation supports bilateral neck management in high-risk patients and observation in low-risk cases. Prospective validation is needed to integrate this model into routine clinical practice and to guide patient-specific surgical planning. Full article

Background/Objectives: The optimal extent of lateral lymph node dissection in cN1b differentiated thyroid cancer remains controversial. This systematic review aimed to assess the frequency of lymph node involvement across neck levels I to V. Materials and Methods: A systematic review was conducted following PRISMA guidelines. PubMed was searched for studies on lateral neck dissection in differentiated thyroid cancer. Included studies reported level-specified metastatic rates. Data on patient numbers and metastatic events were extracted. A random-effects meta-analysis with Freeman–Tukey double arcsine transformation was performed for each neck level to calculate pooled prevalence proportions and 95% confidence intervals. Heterogeneity was assessed using the I² statistic. Results: Meta-analysis of 57 studies revealed that level III (68%, 95% CI: 63–73) and level IV (66%, 95% CI: 61–70) had the highest metastatic prevalence, followed by level IIA (46%, 95% CI: 37–56). Level V demonstrated an overall prevalence of 22% (95% CI: 18–26), with sublevel VB (19%, 95% CI: 11–28) significantly higher than VA (4%, 95% CI: 1–9). Level I (6%, 95% CI: 2–11) and sublevel IIB (14%, 95% CI: 9–20) showed the lowest risk. Significant heterogeneity (I² 71–94%) was observed across all levels. Conclusions: Our findings support sparing level I, and sublevels IIB and VA during lateral neck dissection. Current guidelines recommend systematic dissection of IIA, III, IV, and VB, although VB involvement was found to be only 19% in our study. Future personalization of the extent of neck dissection, based on individual risk factors, may be key to optimizing oncologic and functional outcomes. Full article

Background/Objectives: Papillary cancer is the most common thyroid cancer. The development of lateral cervical lymph node metastases (I–V levels) is considered a major cause of recurrence. The aim of this study is to investigate the potential predictive factors for lateral cervical lymph node metastasis and disease recurrence, in order to tailor the clinical approach to these patients. An ROC (Receiver Operating Characteristic) curve has been set to search out a cut-off value for the lymph node ratio (LNR), a ratio of involved lymph nodes-to-examined lymph nodes, that could serve as an index of tumor recurrence. Methods: This was an observational retrospective study. The clinical charts of 43 patients with histopathological diagnosis of papillary thyroid cancer who underwent thyroidectomy with lateral and central neck dissection have been reviewed. These results have also been compared with those who underwent total thyroidectomy alone that served as a control group. Results: Extrathyroidal extension (p-value < 0.001), tumor size (p-value = 0.015), number of lymph nodes involvement (p-value = 0.022), and LNR (p-value = 0.004) were identified as potential predictors of tumor recurrence. The ROC curve revealed that an LNR value exceeding 0.205 is indicative of disease recurrence, with an Area Under the Curve (AUC) of 0.818, a sensitivity of 82%, and a specificity of 81%. Furthermore, fT4 value (p-value = 0.008), tumor size (p-value = 0.019), and alcohol consumption (p-value < 0.001) may serve as potential predictors of lymph node metastasis. Conclusions: Extrathyroidal extension, vascular invasion, tumor size, number of pathological lymph nodes, and LNR are associated with recurrence of papillary thyroid carcinoma; in particular, the lymph node ratio can be considered an effective indicator of recurrence risk. Full article

Background and Objectives: Breast cancer-related lymphedema (BCRL) is a complication of axillary lymph node dissection (ALND). Immediate lymphatic reconstruction (ILR) may help to decrease lymphedema after ALND by creating lymphatic bypasses. This retrospective single-institution study aimed to compare lymphedema in patients undergoing ALND with and without ILR. Materials and Methods: Bioimpedance and limb measurements determined the presence of BCRL. The categorical data that were collected and analyzed included BMI, comorbidities, BCRL onset, and number of lymphatic bypasses. Pearson’s chi-square test and multivariable logistic regression were performed to identify factors associated with the onset of lymphedema. An odds ratio compared the incidence of BCRL with and without ILR. Results: In total, 186 patients underwent ALND, 44 (24%) with ILR and 142 (76%) without. The mean number of bypasses during ILRs created was 3.54. The odds of developing lymphedema with ILR were 64% lower than for ALND alone. ILR patients who developed BCRL had a mean onset of 543 days post-operatively versus 389 days in the control group. Age, ethnicity, BMI, and bypass amount had no significant influence on lymphedema development. Conclusions: ILR was associated with lower rates of BCRL after ALND. Patients who developed lymphedema despite undergoing ILR did so 8 months later than the controls. Full article

Objectives: Papillary thyroid carcinoma (PTC) frequently presents with cervical lymph node metastasis, even in small tumors, and lateral lymph node involvement serves as an important prognostic factor. Therapeutic lateral neck dissection is typically recommended when nodal metastasis is clinically evident, usually including levels II–V. However, the necessity of routine level II dissection in patients without clinical or radiologic evidence of level II involvement remains controversial, given its association with increased surgical morbidity, particularly injury to the spinal accessory nerve. Identifying reliable clinicopathological predictors of occult level II metastasis may enable more selective surgical approaches that minimize unnecessary dissection while preserving oncologic safety. Therefore, this study aimed to identify clinicopathological risk factors associated with occult level II lymph node metastasis in patients with PTC who have clinically positive lateral nodes but no clinical evidence of level II involvement. Methods: We retrospectively analyzed 1247 patients who underwent thyroidectomy for PTC between 2015 and 2022. Of these, 67 patients with clinically positive lateral lymph node metastasis and clinically negative Level II nodes who underwent therapeutic lateral neck dissection were included. Clinicopathological features were compared between patients with and without occult Level II metastasis. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors. Results: Among the 67 patients analyzed, 24 (35.8%) had occult Level II metastasis. Compared to those without, patients with occult Level II metastasis had significantly larger primary tumors (2.18 ± 1.31 cm vs. 1.51 ± 1.02 cm, p = 0.024), a greater number of central lymph node metastases (5.88 ± 4.41 vs. 3.37 ± 2.66, p = 0.005), larger maximum size of metastatic central lymph node (1.44 ± 1.07 cm vs. 0.87 ± 0.48 cm, p = 0.004), and a higher number of metastatic lateral lymph nodes (7.63 ± 3.75 vs. 3.19 ± 2.21, p < 0.001). Multivariate analysis identified the number of metastatic lateral lymph node as the only independent predictor of occult Level II involvement (OR = 1.57, 95% CI: 1.213–2.044, p = 0.001). The final multivariate model demonstrated a Nagelkerke R² of 0.46. ROC curve analysis confirmed good predictive performance (AUC = 0.85), and the optimal cut-off value was ≥ 5 metastatic lateral lymph nodes. Conclusions: A substantial proportion of patients with clinically negative Level II nodes harbor occult metastasis. The number of metastatic lateral lymph nodes is an independent predictor of occult Level II involvement and may assist in tailoring the extent of lateral neck dissection in patients with PTC. Full article

Background: Papillary thyroid microcarcinoma (PTMC), a subtype of papillary thyroid carcinoma ≤ 1 cm in diameter, has shown a marked increase in incidence in recent decades, largely due to the widespread use of neck ultrasonography and fine needle aspiration cytology. Despite its generally indolent course, optimal management of PTMC remains controversial, with treatment strategies ranging from active surveillance to total thyroidectomy. Methods: This retrospective study analyzes five years of experience at a single tertiary care center, including 130 patients diagnosed with PTMC following thyroid surgery between July 2018 and December 2023. Clinical, cytological, and pathological data were collected and analyzed to identify factors influencing surgical decision-making and postoperative outcomes. Patients underwent either total thyroidectomy or hemithyroidectomy, with central and lateral lymph node dissection performed as indicated. Follow-up included clinical and biochemical surveillance for a mean duration of 3 years. Results: Total thyroidectomy was performed in 89.3% of patients, while hemithyroidectomy was limited to 10.7%. Multifocality was observed in 26.1% of cases, with bilateral involvement in 17.7%. Occult lymph node metastases were found in 14.6% (central compartment) and 3.8% (lateral neck). Postoperative radioactive iodine therapy was administered in 23.8% of patients. At final follow-up, 90.7% were disease-free. No significant predictors of recurrence or adverse outcomes were identified, though multifocality and lymph node involvement influenced surgical planning. Conclusions: Our findings support a risk-adapted surgical approach to PTMC, favoring total thyroidectomy in patients with suspicious or multifocal disease to avoid reoperation. While active surveillance and minimally invasive techniques are emerging, total thyroidectomy remains a safe and effective strategy in selected cases. Prospective, multicenter studies are needed to further refine management guidelines for this increasingly common thyroid malignancy. Full article

Background and Objectives: After introducing the single-port robotic surgical system (da-Vinci SP), thyroid surgeries using da-Vinci SP are becoming more popular. Although many methods have been designed for thyroidectomy using the da-Vinci SP, there are very few reports on methods that can perform not only thyroidectomy but also lateral cervical lymph node dissection. In this study, we want to report the first clinical experience with SPRA-MRND (Single Port Robotic Areolar-Modified Radical Neck dissection), using right breast access. Materials and Methods: From April 2024 to January 2025, a total of 24 robotic MRNDs were performed, of which 11 were SPRA-MRNDs. The remaining 13 were performed using conventional BABA surgery. The two data sets were compared through retrospective medical record analysis. Results: There were no significant differences regarding patient characteristics, pathologic variables and oncologic outcomes between the two groups. However, SPRA group showed significantly shorter operation time (182.1 ± 27.5 vs. 213.1 ± 31.5 min, p = 0.017), higher immediate postoperative calcium level (calcium: 8.7 ± 0.5 vs. 8.0 ± 0.8 mg/dL, p = 0.014) and lower drainage amount (98.1 ± 33.2 vs. 146.4 ± 43.2 mL, p = 0.005). Conclusions: Our initial experience has shown that SPRA-MRND is performed safely. We propose SPRA-MRND as a good method for minimally invasive robotic surgery. Full article

Background/Objectives: Papillary thyroid carcinoma (PTC) accounts for the majority of thyroid cancers, with lymph node metastasis, including skip metastasis (SM), playing a crucial role in guiding prognosis and therapeutic planning. SM, characterized by lateral lymph node spread in the absence of central compartment involvement, has been observed in PTC with a wide range of reported frequencies. The identification of risk factors for SM is crucial for preoperative evaluation and surgical planning. This research aims to explore the clinicopathological features and potential risk factors linked to SM in patients with PTC, while also offering valuable insights for preoperative risk evaluation. Methods: A retrospective cohort study was conducted on 81 PTC patients who underwent central and lateral cervical lymph node dissection (LND) in our center. Clinical, demographic, and pathological data, including age, sex, tumor size, location, subtype, extrathyroidal extension, lymphovascular invasion, and the number of lymph node metastases were analyzed. Clinicopathological characteristics were analyzed between SM-positive and SM-negative patient groups using suitable statistical methods. Additionally, a regression analysis was performed to identify the risk factors for SM. Results: Of the 81 patients, 17.3% (n = 14) were diagnosed with skip metastasis (SM). The SM-positive group had a significantly higher age (p = 0.006), smaller tumor size (p < 0.001), and higher rates of extrathyroidal extension (p = 0.006). The proportion of female patients was elevated in the SM-positive group, but this observation did not achieve statistical significance (p = 0.128). Tumors located in the upper pole were more common in the SM-positive group (p = 0.016). Multivariate analysis revealed that female sex, older age, and tumor location in the upper pole were significant risk factors for SM (p = 0.031, p = 0.004, and p = 0.017, respectively), while a lower number of lateral lymph node metastases was significantly associated with SM (p = 0.010). Additionally, an age over 43.5 years predicted SM with a sensitivity of 78.6% and a specificity of 72.7%. Conclusions: Skip metastasis is not uncommon in PTC and may be associated with older age, female sex, upper pole tumor location, and fewer lateral lymph node metastases. Recognizing these factors during preoperative assessment may aid in anticipating atypical lymphatic spread patterns and optimizing surgical strategies. Full article

Objective: Therapeutic lateral neck dissection is recommended for papillary thyroid cancer with metastatic lymph nodes detected on palpation or on preoperative imaging. Current guidelines recommend systematic dissection of levels IIA, III, IV and VB in these patients. Despite this recommendation, management of level V remains controversial due to a varying degree of clinical and occult lymph node involvement reported in published retrospective studies, but also due to the functional risk involved in level V dissection in which the spinal accessory nerve may be temporarily or permanently injured. The aim of this review was to address the issues involved in level VB dissection and to provide our view of surgical management of level VB. Method: Narrrative review. Result: We propose a new concept of a partial or “super-superselective” level VB dissection in patients with clinical disease in levels IIA, III and IV. Full article

Background: Autoimmune thyroiditis (AIT) is a common thyroid disorder in children, linked to an increased risk of papillary thyroid carcinoma (PTC). Characteristic ultrasonographic features of AIT can obscure PTC, delaying diagnosis. Case Presentation: An 11-year-old girl with a two-year history of AIT presented with persistently elevated thyroid-stimulating hormone (TSH) levels despite levothyroxine therapy. Examination revealed a firm, slightly enlarged right thyroid lobe. Serial thyroid ultrasounds showed typical AIT features, with no apparent tumor. However, a cervical lymph node ultrasound detected a suspicious lymph node with pathological vascularization. Fine-needle aspiration suggested possible PTC metastasis. The patient underwent total thyroidectomy with central and right lateral neck dissection. Histopathology confirmed multifocal PTC with cervical lymph node metastases (pT3aN1bM0). Postoperative radioactive iodine therapy resulted in undetectable thyroglobulin levels, indicating a biochemical response. Conclusions: Children with AIT may harbor occult PTC even without thyroid gland abnormalities suggestive of malignancy. Comprehensive ultrasound evaluation, including cervical lymph nodes, is vital for early detection and timely treatment. Full article

Background/Objectives: The management of lymph node metastases of the central neck compartment (CNC) in differentiated thyroid carcinoma is debated. The intraoperative measurement of thyroglobulin (Tg) has gained attention in accurately detecting metastases, reducing unnecessary CNC dissections. Methods: A total of 37 patients underwent surgery. An intraoperative assay of thyroglobulin from fine needle aspiration (Tg-FNA) was performed on CNC lymph nodes, identified by blue dye injection in 15 patients (23 nodes, group A) and by palpation in 22 patients (35 nodes, group B). The Tg-FNA values were compared with histology to calculate the diagnostic accuracy. Results: In group A, the blue dye diffused widely, complicating lymph node identification: 2 were metastatic and 21 non-metastatic, with median Tg-FNA levels of 6236 ng/mL and 99.20 ng/mL, respectively. In group B, 8 were metastatic and 27 benign, with median Tg-FNA levels of 4063 ng/mL and 121 ng/mL (p < 0.0001), respectively. ROC analysis identified 500 ng/mL as a cutoff, achieving 100% sensitivity and 74% specificity in group B and 90% sensitivity and 70% specificity overall. Finally, among the non-metastatic lymph nodes, group A exhibited some cases of very high Tg-FNA values compared to group B, with lower accuracy for the cutoff, suggesting that colorant injection might lead to increased Tg-FNA levels. Conclusions: Blue dye injection showed low accuracy. Intraoperative Tg-FNA was reliable in detecting CNC metastases, although a higher cutoff is needed in this compartment compared to what has been reported for lateral lymph nodes. Lymphatic drainage and surgical manipulation might explain these findings. The careful interpretation of Tg-FNA in CNC should be adopted. Full article