Salari Behzad, Hammon Rebecca J, Kamani Dipti, Randolph Gregory W
1 Division of Thyroid and Parathyroid Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary & Harvard Medical School, Boston, Massachusetts, USA.
2 Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, & Harvard Medical School Boston, Massachusetts, USA.
Otolaryngol Head Neck Surg. 2017 May;156(5):816-821. doi: 10.1177/0194599817697189. Epub 2017 Apr 4.
Objective Thyroidectomy with extensive multicompartment bilateral neck dissections for advanced-stage thyroid cancer may lead to increased risk of complications, including bilateral recurrent laryngeal nerve (RLN) paralysis and hypoparathyroidism. A planned staged approach derived from a detailed preoperative radiographic map is associated with a low complication profile. This study evaluates oncologic results and safety of neural monitored, staged thyroid cancer surgery for management of advanced thyroid cancer. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods With institutional review board approval, 35 consecutive patients with advanced thyroid malignancy and extensive nodal disease managed with staged surgery between January 2004 and May 2013 by the senior author (G.W.R.) were identified, and the oncologic and surgical outcomes were reviewed. Results In total, 37.2% of patients had stage III or IV disease, with extrathyroidal extension in 71.4%, vascular invasion in 51.4%, and RLN invasion in 17% of patients. A total of 34% patients had positive lymph nodes in more than 5 nodal compartments; the average positive lymph node yield was 17, and extranodal extension was present in 51%. Three patients had RLN sacrifice, and there were no other cases of temporary or permanent RLN paralysis; permanent hypoparathyroidism and chyle leak occurred in one patient each. Locoregional recurrence occurred in 5.7% of patients after a 147-week mean follow-up. In patients with papillary thyroid carcinoma, median postoperative nonstimulated and stimulated thyroglobulin levels were 0.2 and 0.75 ng/mL, respectively. Conclusion A neural monitored, staged surgical approach was conducted without significant adverse events in this small sample and represents and effective alternative strategy option to simultaneous bilateral surgery in the management of thyroid cancer with extensive neck metastases.
目的 对于晚期甲状腺癌，行甲状腺切除术并广泛双侧多区域颈部淋巴结清扫可能会增加并发症风险，包括双侧喉返神经（RLN）麻痹和甲状旁腺功能减退。源自详细术前影像学图谱的计划性分期手术方法并发症发生率较低。本研究评估神经监测下分期甲状腺癌手术治疗晚期甲状腺癌的肿瘤学结果及安全性。研究设计 病例系列并进行图表回顾。研究地点 三级医疗中心。研究对象与方法 经机构审查委员会批准，确定了2004年1月至2013年5月间由资深作者（G.W.R.）采用分期手术治疗的35例晚期甲状腺恶性肿瘤且伴有广泛淋巴结疾病的连续患者，并对其肿瘤学和手术结果进行回顾。结果 总体而言，37.2%的患者为III期或IV期疾病，71.4%的患者有甲状腺外侵犯，51.4%的患者有血管侵犯，17%的患者有喉返神经侵犯。共有34%的患者在超过5个淋巴结区域有阳性淋巴结；平均阳性淋巴结数为17个，51%有结外侵犯。3例患者行喉返神经牺牲术，无其他暂时性或永久性喉返神经麻痹病例；永久性甲状旁腺功能减退和乳糜漏各发生1例。平均随访147周后，5.7%的患者出现局部区域复发。在甲状腺乳头状癌患者中，术后非刺激状态和刺激状态下甲状腺球蛋白水平的中位数分别为0.2和0.75 ng/mL。结论 在这个小样本中，神经监测下分期手术方法未发生重大不良事件，是治疗伴有广泛颈部转移的甲状腺癌时同步双侧手术的一种有效替代策略选择。
