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09A66039ef10065df1358b5e10d THE MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL DOI: 10.14744/SEMB.2018.14227 Med Bull Sisli Etfal Hosp 2018;52(3):149–163 Review Standards and Definitions in Neck Dissections of Differentiated Thyroid Cancer Mehmet Uludağ,1 Mert Tanal,1 Adnan İşgör,2,3 1Department of General Surgery, Istanbul Sisli Hamidiye Etfal Training and Research Hospital, Health Sciences University, Istanbul, Turkey 2Department of General Surgery, Bahcesehir University Faculty of Medicine, Istanbul, Turkey 3Department of General Surgery, Sisli Memorial Hospital, Istanbul, Turkey Abstract Papillary and follicular thyroid carcinomas arising from the follicular epithelial cells and forming differentiated thyroid cancer (DTC) consist of >95% of thyroid cancers. Lymph node metastasis to the neck is common in DTC, especially in papillary thyroid cancer. The removal of only the metastatic lymph nodes (berry picking) does not help to achieve a potential positive contribution to the survival and recurrence of lymph node dissection in the DTC. Thus, systematic dissection of the cervical lymph nodes is needed. Today, according to the widely accepted and commonly used definitions and lymph node staging, the deep lymph nodes of the lateral side of the neck are divided into five regions. Based on the fact that some groups have biologically independent regions, Groups I, II, and V are divided into the A and B subgroups. The central region lymph nodes contain VI and VII region lymph nodes, which consist of the prelaryngeal, pretracheal, and right and left paratracheal lymph node groups. Radical neck dissection (RND) is accepted as the standard basic procedure in defining neck dissections. In this method, in addition to all the regions of the Groups I–V lymph nodes at one side, the ipsilateral spinal accessory nerve, internal jugular vein, and ster- nocleidomastoid muscle are removed. Sparing of one or more of the routinely removed non-lymphatic structures in the RND is called modified RND (MRND), whereas the preservation of one or more of the routinely removed lymph node groups in the RND is termed as selective neck dissection (SND). In difference, the procedure with an addition of a lymph node and/or non-lymphatic structures to routinely removed neck structures in RND is called extended RND. Generally, involving one or more regions of SND are applied for DTC. The removal of the paratracheal, prelaryngeal, and pretracheal lymph node groups at one side is termed as ipsilateral central dissection, whereas the removal of the bilateral paratracheal lymph node groups, in other words, the excision of four lymph node groups in the central region (Groups VI and VII), is defined as bilateral central dissection. In conclusion, bilateral central neck dissec- tion (CND) is the SND in which the regions of VI and VII are removed. In the DTC, CND is prophylactically and therapeutically applied, whereas lateral neck dissection is performed only therapeutically in the presence of clinical metastasis (N1b) in the lateral neck region. Debates on the extent of SNDs to be made in the central and lateral neck regions are still ongoing. Central dissection should be made at least unilaterally. In the lateral side of the neck, SNDs can be applied in different combinations in which at least one region from Groups I to V is removed. The main variables that determine the extent of SND in the central and lateral regions in DTC are the complication rates, the effect of the procedure, and its effect on prognosis and recurrence. Keywords: Cancer; cervical; differentiated; dissection; lymphatic; thyroid. Please cite this article as ”Uludağ M, Tanal M, İşgör A. Standards and Definitions in Neck Dissections of Differentiated Thyroid Cancer. Med Bull Sisli Etfal Hosp 2018;52(3):149–163”. Address for correspondence: Mert Tanal, MD. Department of General Surgery, Bahcesehir University Faculty of Medicine, Istanbul, Turkey Phone: +90 533 721 50 62 E-mail: [email protected] Submitted Date: September 10, 2018 Accepted Date: September 11, 2018 Available Online Date: October 01, 2018 ©Copyright 2018 by The Medical Bulletin of Sisli Etfal Hospital - Available online at www.sislietfaltip.org This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc/4.0/). 150 The Medical Bulletin of Sisli Etfal Hospital hough the classification of thyroid cancer, the most in the presence of metastatic lymph nodes and rarely re- Tcommon endocrine malignancy, is still controversial, it moved the enlarged lymph nodes with the primary tumor. is generally subgrouped into three main groups: differen- This approach was generally ineffective and confirmed the tiated thyroid cancer (DTC), medullary thyroid cancer, and expectation of poor prognosis in these patients.[4] anaplastic thyroid cancer. DTC originating from the follicu- The en bloc removal of neck lymphatics is generally de- lar epithelial cells is divided into two distinct subgroups as fined as radical neck dissection (RND). In 1888, Jawdynski, well-differentiated DTC (WDTC) and poorly or non-DTC in a Polish surgeon, published details of the RND technique in terms of pathological evaluation, clinical course, and prog- a Polish medical journal.[5] This study was not widely known nosis. The incidence of thyroid cancer, especially WDTC, has globally because it was published in Polish; in 1990, Tow- been determined to increase worldwide, especially within pik, a Polish surgeon, called attention to this work.[6] Prior the last 30 years due to improvements in diagnostic and to this study, there were studies reporting that RND was monitoring methods.[1, 2] Papillary thyroid cancer (PTC) and performed at the end of the 19th century, but the technical follicular thyroid cancer (FTC) occur in the WDTC group details of the operations were not given in these studies.[4, 6] and consist of approximately >95% of thyroid cancers. Crile from the Cleveland Clinic described the RND they per- PTC, which accounts for 80%–85% of WDTCs, has the best formed systematically since the year 1900 and published prognosis and often metastasizes to the neck lymph nodes, the first largest series in RND in 1905 and 1906.[7, 8] In this re- whereas lung metastasis is rare. In contrast, FTC and poorly spect, Crile is referred as the grandfather of neck dissection differentiated DTC tend to metastasize through hematoge- in North America and is considered to be the descriptor of nous spread, especially to the lungs and bones.[1, 2] RND.[4, 9] This technique was later developed by Martin et Microscopic lymph node metastasis can be detected in al.[10] in New York Memorial Hospital. up to 80% in PTC. The role of lymph node dissection in The first descriptive study of the human lymphatic sys- these metastases is contentious. However, in patients tem was published by Rouviere in 1932.[11] This study led with clinical lymph node metastasis, the recurrence after the way to the idea that topographic classification of the lymphatic dissection is thought to be associated with mi- neck lymph nodes should be performed. In this context, crometastases.[3] the Memorial Sloan-Kettering Cancer Center has created In order to be able to make a positive contribution to the a scheme by dividing the lateral neck lymphatic system survival and recurrence of lymph node dissection in thyroid into five groups, which are topographically separated and cancer, metastatic lymph node dissection (berry picking) is widely used because it is an easy-to-remember grouping not sufficient only, and systematic lymphatic dissection is system.[12] Nowadays, grouping of the lymph node regions needed. However, there has been confusion about the de- of the neck is based on this classification system. termination of neck lymphatic dissection areas and the ex- Owing to the high morbidity and anatomical deformity tent of dissection. In addition, the lymphatic pattern of the due to RND, this technique has been modified to develop thyroid is an important anatomical feature that affects lym- new techniques with lower morbidity that could result phatic metastases of thyroid cancers in the neck. Therefore, in equivalent oncologic outcomes. In this context, first in it is important to know the standardized topographic lym- 1963, Suarez, an Argentinean surgeon, described modified phatic anatomy for the neck dissections to be performed in RND (MRND) as functional neck dissection,[13] in which sat- the DTC and their nomenclature. This approach will allow isfactory successful results could be obtained. In contrast surgeons interested in DTC to perform the same type of to RND, in functional neck dissection, important anatom- neck dissections to establish an understandable commu- ical structures, such as sternocleidomastoid muscle (SCM), nication between surgeons, endocrinologists, and nuclear internal jugular vein, and spinal accessory nerve, are pre- medicine specialists interested in thyroid cancer. The aim served. Since his study was published in Spanish, his work of the present study was to use a common terminology was often overlooked, and this method was attributed to in the examination, and naming of lymphatic dissection other researchers and studies published in English. How- types should be done according to the state of the neck ever, the true father of MRND or functional neck dissection lymphatic pattern and disease. is Suarez.[14] In 1969, in a 2–week course in Europe, Bocca from Italy and Gavilian from Spain learned this technique History from Suarez and popularized the method by applying this In the 19th century, surgeons acknowledged that head method in their own centers and publishing the clinical re- and neck tumors metastasize to the neck lymph nodes, sults they obtained with different studies.[15–18] but they thought that curative resection was not possible In 1989, Medina divided MRND into three types.[19] In MRND Uludağ et al., Standards and Definitions in Neck Dissections of Differentiated Thyroid Cancer / doi: 10.14744/SEMB.2018.14227 151 Type I, only the spinal accessory nerve is preserved; in Type boundaries or regions of these groups that are related to II, the spinal accessory nerve and internal jugular vein are the anatomical, surgical, and radiological definitions made.
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