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LETTER TO THE EDITOR
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 46-47

Cervical lymph node metastases from papillary thyroid cancer: Can they skip the central compartment?


1 Department of Endocrinology, Diabetes and Bariatric Medicine, Narayana Health City, Bengaluru, Karnataka, India
2 Department of Pathology, Narayana Health City, Bengaluru, Karnataka, India
3 Department of Head and Neck Surgical Oncology and Reconstructive Surgery, Narayana Health City, Bengaluru, Karnataka, India

Date of Web Publication5-Jan-2016

Correspondence Address:
Subramanian Kannan
Narayana Health City, 258/A, Bommasandra Industrial Area, Bengaluru - 560 099, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0354.168901

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How to cite this article:
Kannan S, Raju N, Chandrasekhar NH. Cervical lymph node metastases from papillary thyroid cancer: Can they skip the central compartment?. Thyroid Res Pract 2016;13:46-7

How to cite this URL:
Kannan S, Raju N, Chandrasekhar NH. Cervical lymph node metastases from papillary thyroid cancer: Can they skip the central compartment?. Thyroid Res Pract [serial online] 2016 [cited 2019 Sep 18];13:46-7. Available from: http://www.thetrp.net/text.asp?2016/13/1/46/168901

Sir,

Cervical lymph node metastasis from papillary thyroid cancer (PTC) is associated with several well-described factors, including multifocality, extrathyroidal extension, larger tumor size, younger age, aggressive variants, and the presence of BRAF V600E mutation. PTC typically spreads in a stepwise fashion from the thyroid to the central neck and then laterally to the jugular chain nodes. If there is nodal involvement identified in the lateral neck, it is presumed that there is disease in the central neck as well. Levels III and IV are the most common sites of nodal metastatic disease in the lateral neck compartment; disease is rarely identified in Level I, V.[1] Isolated involvement of the lateral compartment particularly higher levels (i.e.,) Level I to IV without involvement of central compartment is rare. “Skip” metastasis, in which lateral neck involvement seen in the absence of central neck nodal disease occurs in up to 4–8% of patients and was most commonly seen in superior pole thyroid tumors.[2],[3] We briefly present a patient who was operated for PTC with total thyroidectomy and central and left lateral compartment lymph node dissection and found to have an isolated Level IIa lymph node involvement.

A 24-year-old female presented to the clinic with neck swelling of 6-month duration. She was clinically and biochemically euthyroid (thyroid stimulating hormone 5.23 mIU/L). She had a 3.4 cm (CC) × 2.3 cm (TR) × 2.5 cm (AP) thyroid nodule occupying the superior-mid pole of the left lobe. The nodule was vascular (Grade ¾ vascular flow) with micro-calcifications on ultrasound (USG). USG and computerized tomography (CT) scan (5-mm axial cuts) of the neck revealed only a suspicious appearing left Level IIa lymph node measuring 9 mm × 5 mm with micro-calcifications and disorganized blood flow [Figure 1]a. Fine-needle aspiration cytology (FNAC) of the thyroid nodule showed fairly abundant thin colloid, follicular groups with papillary configuration, tightly grouped cells, mild to moderate anisonucleosis and occasional nuclear grooves and was interpreted as atypia of undetermined significance (Bethesda 3/6). Lymph node aspirate from the suspicious left Level IIa lymph node revealed thyroid follicular cells suggesting metastatic PTC [Figure 1]b. A total thyroidectomy was performed along with central compartment neck dissection and left sided lateral neck lymph node dissection, which confirmed a 3.5 cm (mpT2) PTC on the left lobe and a micro-papillary tumor (2.4 mm) on the right side. Out of about 50 lymph nodes removed from the lateral neck (Level VI [n = 14], Level IV [n = 2], Level III [n = 14], Level II [n = 19]), only one lymph node in Level IIa showed a metastatic PTC deposit [Figure 1]c.
Figure 1: (a) Ultrasound shows a 9 mm × 5 mm Level II a lymph node (x) with micro-calcifications (arrow). (b) Ultrasound guided fine-needle aspiration cytology from the lymph node shows a papillaroid fragment of thyroid follicular cells in a bloody background suggestive of metastatic papillary thyroid carcinoma (Pap stain, original magnification, ×100). (c) Lymph node excision shows lymphoid tissue on the right and metastatic papillary thyroid carcinoma on the left side (H and E, original magnification, ×100)

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Our case highlights the need for careful lymph node assessment in patients with thyroid cancer preoperatively including Level II where lymph nodes are commonly regarded as reactive secondary to pharyngeo-tonsillar infections. USG features of a neoplastic lymph node include absence of hilum, short: long axis ratio > 0.5, disorganized vascular flow, calcifications and cystic change (aspirate is typically dark brown in color). FNAC of the lymph node will help differentiate reactive from neoplastic involvement in cervical lymph nodes. If cytology is not conclusive, estimation of thyroglobulin in the needle aspirate can be quite useful. Metastasis to lateral compartment of neck skipping the central compartment is unusual but warrants careful attention preoperatively. The newer American Thyroid Association Guidelines will likely recommend more thorough preoperative neck imaging including CT scan or magnetic resonance imaging in addition to neck ultrasound to evaluate for macroscopic lymph nodes which may alter the surgical plan mostly in larger tumors. Macroscopic lymph node involvement is associated with a high rate of local recurrence (10–42%)[4] and in those older than 45 years, with a higher mortality rate.[5] Hence, a detailed preoperative neck imaging is mandatory prior to thyroid cancer surgery.


  Acknowledgment Top


  1. We thank Dr. Raghu M (Department of Radiology for helping with the images of the neck ultrasound)
  2. We thank Dr. Moni Abraham Kuriakose and Dr. Vikram Kekatpure for their inputs in the manuscript and management of the case.


 
  References Top

1.
Caron NR, Tan YY, Ogilvie JB, Triponez F, Reiff ES, Kebebew E, et al. Selective modified radical neck dissection for papillary thyroid cancer-is level I, II and V dissection always necessary? World J Surg 2006;30:833-40.  Back to cited text no. 1
    
2.
Chung YS, Kim JY, Bae JS, Song BJ, Kim JS, Jeon HM, et al. Lateral lymph node metastasis in papillary thyroid carcinoma: Results of therapeutic lymph node dissection. Thyroid 2009;19:241-6.  Back to cited text no. 2
    
3.
Wada N, Duh QY, Sugino K, Iwasaki H, Kameyama K, Mimura T, et al. Lymph node metastasis from 259 papillary thyroid microcarcinomas: Frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg 2003;237:399-407.  Back to cited text no. 3
    
4.
Randolph GW, Duh QY, Heller KS, LiVolsi VA, Mandel SJ, Steward DL, et al. The prognostic significance of nodal metastases from papillary thyroid carcinoma can be stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. Thyroid 2012;22:1144-52.  Back to cited text no. 4
    
5.
Smith VA, Sessions RB, Lentsch EJ. Cervical lymph node metastasis and papillary thyroid carcinoma: Does the compartment involved affect survival? Experience from the SEER database. J Surg Oncol 2012;106:357-62.  Back to cited text no. 5
    


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