Song et al. BMC Surg (2021) 21:329 https://doi.org/10.1186/s12893-021-01326-9 RESEARCH Open Access Video mediastinoscopy-assisted superior mediastinal dissection in the treatment of thyroid carcinoma with mediastinal lymphadenopathy: preliminary results Yuntao Song1† , Liang Dai2†, Guohui Xu1, Tianxiao Wang1, Wenbin Yu1, Keneng Chen2 and Bin Zhang1* Abstract Background: Mediastinal lymph node metastases (MLNM) are not rare in thyroid cancer, but their treatment has not been extensively studied. This study aimed to explore the preliminary application of video mediastinoscopy- assisted superior mediastinal dissection in the diagnosis and treatment of thyroid carcinoma with mediastinal lymphadenopathy. Materials and methods: We retrospectively reviewed the clinical pathologic data and short-term outcomes of thy- roid cancer patients with suspicious MLNM treated with video mediastinoscopy-assisted mediastinal dissection at our institution from 2017 to 2020. Results: Nineteen patients were included: 14 with medullary thyroid carcinoma and fve with papillary thyroid carci- noma. Superior mediastinal nodes were positive in nine (64.3%) patients with medullary thyroid carcinoma and in four (80.0%) patients with papillary carcinoma. No fatal bleeding occurred. There were three cases of temporary recurrent laryngeal nerve (RLN) palsy postoperatively, one of which was bilateral. Four patients had temporary hypocalcemia requiring supplementation, one had a chyle fstula, and one developed wound infection after the procedure. Post- operative serum molecular markers decreased in all patients. One patient died of cancer while the other 18 patients remained disease-free, with a median follow-up of 33 months. Conclusion: Video mediastinoscopy-assisted superior mediastinal dissection can be performed relatively safely in patients with suspicious MLNM. This diagnostic and therapeutic approach may help control locoregional recurrences. Keywords: Thyroid carcinoma, Video mediastinoscopy, Mediastinal lymph node metastases, Mediastinal dissection, Mediastinal lymphadenopathy Introduction Te incidence of thyroid cancer (TC) has been continu- ously increasing worldwide during the past decades [1, *Correspondence: [email protected] 2]. Common TC categories, such as papillary thyroid car- † Yuntao Song and Liang Dai contributed equally to this article as frst cinoma (PTC) and medullary thyroid carcinoma (MTC), authors 1 Key Laboratory of Carcinogenesis and Translational Research (Ministry tend to develop regional lymphatic metastasis [3], of Education/Beijing), Department of Head and Neck Surgery, Peking which is an important factor in predicting the structural University Cancer Hospital and Institute, 52 Fucheng Road, Haidian recurrence of PTC [4] and is associated with decreased District, Beijing, China Full list of author information is available at the end of the article © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Song et al. BMC Surg (2021) 21:329 Page 2 of 7 prognosis in MTC [5]. Surgical dissection is the frst enhancement or greater enhancement than the adjacent choice of treatment [6]. muscle [13]. Six patients underwent preoperative func- Lymph nodes involved in thyroid carcinoma could tional imaging examination, including 99mTc-methoxy- be classifed into three regions: the central, lateral, and isobutylisonitrile (99mTc-MIBI) single-photon emission mediastinal compartments [7]. Te central neck is the computed tomography/computed tomography (SPECT/ most commonly involved region, which is defned inferi- CT) or fuorine-18-deoxyglucose (FDG) positron emis- orly by the superior sternal border [8]. Lymphatic tissue sion tomography (PET), all with positive results. All in this portion is in continuity with the superior medi- patients underwent preoperative laryngoscopy and astinum. Terefore, mediastinal lymph node metastases signed informed consent forms. (MLNM) from TC are not uncommon. According to A multidisciplinary discussion was conducted by the the literature, the incidence of MLNM was reported to head and neck surgeon, thoracic surgeon and radiologist. range from 0.7 to 48.1% [9, 10]. Patients with mediasti- Indications for VMSASMD included: (1) PTC or MTC nal metastases have a poorer prognosis [11], and surgical with suspected upper MLNM that are not amenable to extirpation is the preferred treatment for MLNM of thy- remove through transcervical approach. (2) No major roid cancer whenever possible. vascular involvement was found by imaging investiga- Currently, there are two surgical approaches to treat tions. We routinely informed the patient of the possible MLNM. Transcervical approach is an extension of cen- complications of surgery and the possible instance that tral compartment dissection, which is indicated for postoperative pathology may be negative. Other options, LNs located superior to innominate artery. While lower such as sternotomy, were also provided to the patient. MLNM requires a more extensive operation. Sometimes, Close cooperation between head and neck surgeon a partial-complete median sternotomy or thoracotomy is and thoracic surgeon during surgery was important. All mandatory, which could potentially increase the risk of patients underwent dissection of pretracheal and paratra- complications [12]. Ultrasound-guided fne needle aspi- cheal (level VI) lymphatic tissue through a transcervical ration cannot be easily done on mediastinal lymph nodes incision above the sternal notch. If an intact or residual due to interference of bony structures of the chest wall. thyroid gland exists, a total or complemental thyroid- Consequently, it is difcult to confrm the enlarged medi- ectomy is performed, and if the lateral neck is clinically astinal lymph node by pathology preoperatively, which involved, it is dissected concurrently. Bilateral recurrent thus leads to a diagnostic dilemma for physicians. laryngeal nerves (RLNs) were routinely exposed with the To minimize operative trauma in TC patients with sus- assistance of intraoperative neuromonitoring (IONM, pected mediastinal metastasis, we explored a transcervi- NIM-Response 3.0, Medtronic, Jacksonville, Florida, cal approach of video mediastinoscopy-assisted superior USA). mediastinal dissection (VMSASMD), which has not Standard open surgical instrumentation was used for been investigated in previous literature to the best of our cervical surgery. Part of the superior mediastinal LNs knowledge. Te goal of this study was to review a series were taken together with the central neck specimen espe- of cases as preliminary communication demonstrating cially on the left side, which was superior to the innomi- this technique. nate vein. Te suprainnominate artery lymph nodes, also known as the level VII LNs, were resected through open Materials and methods approach as well. A retrospective review was performed involving patients Mediastinal dissection was performed by senior tho- with thyroid carcinomas who underwent transcervi- racic surgeons who were familiar with mediastinoscopic cal VMSASMD in the setting of suspicious mediastinal biopsy and sternotomy using video mediastinoscopy lymph nodes. Patients were treated between March 2017 (Karl Storz, Tuttlingen, Germany). Te equipment for and October 2020 at the Peking University Cancer Hos- immediate sternotomy or thoracotomy was also prepared pital. Demographic data, histology, incidence of medias- in case of intraoperative conversion. Te surgeon stood tinal nodal metastasis, postoperative complications, and on the cranial side of the patient and the video monitor follow-up were reviewed. A Wilcoxon signed rank test was placed on the caudal side. Trough routine cervical was used to compare pre- and post-operative biomarkers. thyroid incision, the thymus is separated from the tra- Data were analyzed using SPSS 22.0. chea. Te index fnger followed the trachea and broke the All patients required demonstration of suspicious pretracheal fascia (Fig. 1). Ten, the scope is introduced MLNM on preoperative contrast-enhanced CT. CT with the blades closed. features suggestive of metastasis included the pres- Te right pulmonary artery was separated, the scope ence of calcifcations, central necrosis or cystic changes, blades were spread, the right and left tracheobronchial and lymph nodes showing heterogeneous cortical angles were identifed (Fig. 2A), and the axis of the scope Song et al. BMC Surg (2021) 21:329 Page 3 of 7 Fig. 1 By separating the pretracheal fascia using the index fnger, each compartment