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Routine Ipsilateral Level VI Lymphadenectomy Reduces Postoperative Thyroglobulin Levels in Papillary Thyroid Cancer

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Routine Ipsilateral Level VI Lymphadenectomy Reduces Postoperative Thyroglobulin Levels in Papillary Thyroid Cancer Routine ipsilateral level VI lymphadenectomy reduces postoperative thyroglobulin levels in papillary thyroid cancer Mark Sywak, MBBS, Lachlan Cornford, BSc, Paul Roach, MBBS, Peter Stalberg, PHD, Stan Sidhu, PHD, and Leigh Delbridge, MD, Sydney, Australia Background. Lymphadenectomy in clinically node-negative papillary thyroid cancer (PTC) is controversial. The aim of this study is to determine whether routine ipsilateral level VI lymphadenectomy (LNDVI) has advantages over total thyroidectomy (TT) alone. Methods. A retrospective cohort study was performed. Patients undergoing surgery for clinically node- negative PTC Ͼ1 cm were included. Group A had TT and LNDVI. Group B had TT alone. The number of radioiodine treatments and postablative stimulated serum thyroglobulin (TG) levels were compared. Results. From 1995 to 2005, 447 patients with clinically node-negative PTC underwent surgery. Group A (n ϭ 56) had TT and LNDVI. Group B (n ϭ 391) had TT alone. Tumor size was equivalent (group A, 20 mm; group B, 23 mm; P ϭ .14) as were MACIS (metastasis, age, completeness of resection, invasion, and size) scores (group A, 4.70; confidence interval, 4.23- 5.17; group B, 4.73; confidence interval, 4.4-5.05). Serum postablative TG levels were lower in group A (0.4 ␮g/L) compared with group B (9.3 ␮g/L), P ϭ .02. More patients had undetectable TG levels in group A (72%) than in group B (43%) (P Ͻ .001). Long-term complications rates were the same. Conclusions. In PTC the addition of routine LNDVI results in lower postablation levels of TG and higher rates of athyroglobulinemia when compared with TT alone. (Surgery 2006;140:1000-7.) From the Endocrine Surgical Unit, University of Sydney Locoregional lymph node metastasis is a com- paratracheal nodes lie anterior to the trachea and mon finding in papillary thyroid cancer (PTC) oc- in the region of the tracheo-esophageal groove, curring in 20% to 50% of cases when the usual respectively. histologic techniques are employed.1,2 The central When lymph node metastases are clinically evi- compartment of the neck, also known as level VI, is dent either on physical examination or sonograph, the region most frequently involved.3,4 The level VI it is generally accepted that surgical excision or compartment incorporates the Delphian/prelaryn- lymphadenectomy (LND) is the best form of treat- geal, pretracheal, and paratracheal lymph nodes.5 ment.6 The surgical approaches most frequently The prelaryngeal nodes lie in the vicinity of the used in this scenario are modified radical lymph pyramidal lobe of the thyroid. The pretracheal and node dissection and selective node dissection.7 While the management of clinically apparent nodes is generally agreed upon in most centers, contro- Presented at the 27th Annual Meeting of the American Associ- versy exists regarding the role of prophylactic cen- ation of Endocrine Surgeons, New York, New York, May, 2006. tral LND in cases in which lymphadenopathy is not Accepted for publication August 3, 2006. evident.8,9 Reprint requests: Dr Mark Sywak, University of Sydney Endo- crine Surgical Unit, AMA House, Suite 202, 69 Christie The potential benefits of routine LND, particu- St, St Leonards NSW, Australia 2065. E-mail: marksywak@ larly of the level VI compartment, are a reduction nebsc.com.au. in recurrent or persistent disease and avoidance of 0039-6060/$ - see front matter reoperative surgery in a field that places the recur- © 2006 Mosby, Inc. All rights reserved. rent laryngeal nerve at significant risk of injury. doi:10.1016/j.surg.2006.08.001 The disadvantage of performing LND routinely is a 1000 SURGERY Surgery Sywak et al 1001 Volume 140, Number 6 potential increase in perioperative complications or vitamin D supplementation at 6 months after rates, particularly hypoparathyroidism and recur- surgery. rent laryngeal nerve dysfunction. In 2002 the protocol for management of pa- The aim of this study is to examine the benefits tients with PTC was modified to include routine and complications of routine ispilateral level VI ipsilateral LNDVI in combination with TT. Lymph- lymphadenectomy (LNDVI) in patients with PTC adenectomy was performed with the use of a and no clinical evidence of lymphadenopathy pre- standardized technique immediately after thyroid- operatively. ectomy. The recurrent laryngeal nerve was mobi- lized and skeletonized along its cervical course, PATIENTS AND METHODS avoiding the use of electrocautery in close proxim- A retrospective cohort study of all patients un- ity to it. Lymph node dissection was performed dergoing surgical intervention for PTC at the Uni- extending from the carotid artery laterally to the versity of Sydney Endocrine Unit was undertaken. midline of the trachea medially and inferiorly to Data were retrieved from prospectively maintained the brachiocephalic or subclavian veins. Autotrans- surgical and nuclear medicine databases. plantation of the ipsilateral inferior parathyroid Patient selection. Patients included in the study gland was generally undertaken. This modification had histologically proven PTC measuring over 1 cm in our surgical approach has enabled us to study 2 in maximum diameter. Only patients with no clini- distinct cohorts of patients who have been exposed cally apparent lymph node metastases were studied. to different surgical interventions. All procedures Preoperative lymph node status was determined were performed after the provision of informed by physical examination and routine neck ultrasonog- consent. raphy. Only patients undergoing total thyroidectomy After surgery, patients underwent routine radio- (TT) alone or TT in combination with LNDVI were iodine ablation with iodine131 (I131) after thyroid included. Patients undergoing lymph node surgery hormone withdrawal for at least 4 to 6 weeks. The beyond level VI were excluded from the study. ablative dose given was individualized on the basis Patients were stratified into 2 separate groups on of the risk profile of the tumor being treated. In the basis of the extent of their surgery. Group A general high-risk category patients were given a consisted of those patients undergoing TT and ip- greater dose. Follow-up I131 scintigraphy and possi- silateral LNDVI. Group B included those patients ble repeat ablation was then performed 6 months undergoing TT alone. Included in group B were later and once again after thyroid hormone with- patients who underwent initial diagnostic hemithy- drawal. Serum thyroglobulin (TG) levels were mea- roidectomy for atypical nodules and then subse- sured at this point. A TG assay was performed with quently had completion thyroidectomy for PTC. the use of the Immulite 2000 Immunoanalyser (Di- Surgical protocols. A standardized surgical ap- agnostic Products Corp., Los Angeles, Calif) (ref- proach for the management of PTC was established erence range 0.8-55 ␮g/L). within the University of Sydney Endocrine Surgical Outcome measures. Postoperative wound infec- Unit in 1995. Total thyroidectomy was incorpo- tions requiring antibiotic therapy and the number rated as the operative treatment of choice and used of patients requiring return to the operating room when possible in all patients with PTC measuring for evacuation of hematoma were recorded. Data over 1 cm. A strict protocol of preoperative and were collected to compare the rates of temporary postoperative laryngoscopy performed by otolaryn- hypocalcemia and permanent hypoparathyroidism gologists affiliated with the unit has been followed between the groups. The rates of recurrent laryn- during the study period. Laryngoscopy was per- geal nerve dysfunction both early and permanent formed at 2 to 6 weeks postsurgery and repeated if were compared. The number of ablative doses of necessary. After TT all patients were placed on radioactive iodine administered to date to each calcium supplements routinely (1200 mg twice patient were recorded. Serum TG levels after with- daily) with a gradual reduction over the following 3 drawal of thyroid hormone at 6 months after sur- weeks. Serum calcium levels were measured twice gery were recorded and compared between the 2 daily for the first 2 days and then at 2 weeks and 3 groups. Also, TG autoantibodies were measured months postoperatively, or until the patient be- routinely in all patients at the time of radioiodine came normocalcemic without the need for calcium ablation. supplementation. Postoperative hypocalcemia was Statistical analysis. Data were stored and ana- defined as a serum calcium level of less than lyzed with the use of the Stata statistical software 8 mg/dL at any point after surgery. Hypoparathyo- package (College Station, Tex). Continuous data ridism was defined as the ongoing need for calcium was tested with the use of an unpaired Student t 1002 Sywak et al Surgery December 2006 Table I. Patient selection criteria hypocalcemia compared with group B patients; 1. Histologically proven PTC Ͼ1cm however, at 6 months there was no difference in the 2. PTC variants included rate of permanent hypoparathyroidism. The over- 3. No clinically apparent lymphadenopathy all rate of permanent hypoparathyroidism for both 4. Total thyroidectomy Ϯ ipsilateral LNDVI groups combined was 3/447 (0.7%). The incidence LNDVI, Level VI lymph node dissection; PTC, papillary thyroid cancer. of temporary and permanent recurrent laryngeal nerve dysfunction, as measured by laryngoscopy, was not significantly different between the 2 groups. test. Categorical data were compared with the use The overall rate of permanent recurrent laryngeal of univariate analysis
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