Papillary thyroid cancer is one of the cancers with favorable prognosis, although the long-term recurrence rate in the paratracheal region is reported to be as high as 30%. The use of
I is considered ...to be a reliable treatment option for lymph node metastases in the paratracheal region. According to the majority of internationally accepted guidelines, it is not recommended to perform central node dissection (CND) routinely. Total thyroidectomy (TT) remains an adequate treatment for these patients. According to many studies, CND is associated with higher rates of hypoparathyroidism. However, CND improves staging.
We performed a retrospective study. We included 248 patients treated for papillary thyroid cancer during a 20-year period. Data were collected on patient (age, sex) and tumor (size, focality) characteristics, presence of metastases in the central neck compartment, incidence of postoperative hypoparathyroidism, and locoregional failure. We divided patients into two groups based on pathological analysis: those without positive lymph nodes (N0) and those with positive paratracheal lymph nodes (N1). We compared patient and tumor characteristics and risk of recurrence between the two groups.
There were 39.5% patients with central neck metastases in our series. In the central neck dissection specimen, 5.5 nodes were found on average. Hypoparathyroidism was found in 23.4% of patients and remained permanent in 3.2% of patients. Female and older patients had a lower chance of central compartment metastases, as did patients with smaller and unifocal tumors. Recurrence risk was doubled for the N1 group. All tested differences between the groups reached statistical significance.
In our hands, CND was a safe and effective surgical procedure. It improved staging and postsurgical management. Efforts should be made to improve the preoperative work-up in order to more accurately identify high-risk patients.
Uvod: Primarni hiperparatireoidizam liječi se kirurški. Opseg i uspješnost operacije ovise o točnosti prepoznavanja lokalizacije patološki promijenjene žlijezde dijagnostičkim pretragama prije ...operacije te o intraoperativnoj potvrdi uklanjanja izvora povišene koncentracije PTH. Materijali i metode: Učinjena je retrospektivna analiza bolesnika s dijagnozom primarnog hiperparatireoidizma liječenih u Klinici za tumore u periodu od 2012. do 2019. Godine. Uključena su 54 bolesnika s dijagnozom primarnog hiperparatireoidizma, jedna bolesnica operirana je dva puta. Raspon normalnih koncentracija intaktnog PTH je 15 – 65 pg/mL, a ukupnog kalcija 2,14 – 2,53 mmol/L. Preoperativna koncentracija PTH mjerena je nakon uvoda u opću anesteziju. Intraoperativna koncentracija PTH mjerena je 15 minuta nakon vađenja žlijezde koju smo smatrali zahvaćenom. Kriterij uspješno učinjene operacije bio je pad koncentracije PTH veći od 50% u odnosu na početnu vrijednost. U slučaju izostanka pada koncentracije PTH, prema odluci kirurga, a ovisno o intraoperativnoj situaciji, operacija je produljena traženjem zahvaćene žlijezde, te ponavljanim mjerenjem. Rezultati: Prosječna koncentracija PTH prije operacije bila je 117,4 (39,6 – 305,4) pg/mL, a ukupnog kalcija 2,75 (2,45 – 3,15) mmol/L. Prosječna koncentracija intraoperativnog PTH bila je 35,6 (8,1 – 198,6) pg/mL. Intraoperativne vrijednosti bile su 67,6% manje u odnosu na preoperativne. Kod 44
bolesnika bilo je dovoljno jedno intraoperativno mjerenje koncentracije PTH, dok je kod 11 bolesnika bilo potrebno više mjerenja. Prosječna koncentracija ukupnog kalcija šest mjeseci nakon operacije bila je 2,39 (1,96 – 2,7) mmol/L. Primjenom intraoperativnog određivanja PTH postignuta je uspješnost operacije kod 53 bolesnika (98,14%). Određivanje intraoperativnog pada koncentracije PTH ima visoku osjetljivost 88,7% i pozitivnu prediktivnu vrijednost 97,9%. Zaključak: Intraoperativna potvrda pada koncentracije PTH povećava uspjeh kirurškog
liječenja primarnog hiperparatireoidizma, posebno u skupini bolesnika s multiglandularnom bolesti. Zaključak je temeljen na skupini bolesnika kod kojih je bilo potrebno više od jednog određivanja intraoperativnog PTH.
The aim of this study was to compare the incidence of postoperative hypoparathyroidism in two groups of patients who were treated for differentiated thyroid cancer.
A retrospective analysis of 179 ...patients who were treated for differentiated thyroid cancer in our institution from January 2011 until December 2018 was performed. Only patients initially treated with total thyroidectomy and those who did not have preoperatively confirmed central compartment and lateral neck lymph node metastases were included in this study. Two main groups of patients were analysed. The patients who were treated with total thyroidectomy and elective central compartment lymph node dissection simultaneously were included in the first group. The patients who were treated only with total thyroidectomy were included in the second group. The rate of transitory and persistent postoperative hypoparathyroidism was compared between the two groups.
A total of 117 patients (65.4%) underwent total thyroidectomy and elective central compartment lymph node dissection simultaneously (TT + CCLNd group). The remaining 62 patients (34.6%) underwent total thyroidectomy only (TT group). A total of 22.6% patients in the TT group developed postoperative hypoparathyroidism compared with 25.6% in the TT + CCLNd group. The rate of persistent hypoparathyroidism in the TT and TT + CCLNd groups was 3.2% and 6.0%, respectively. The difference in the rate of transient and persistent postoperative hypoparathyroidism was not statistically significant between the two groups. Within the TT + CCLNd group, 82.9% of patients underwent ipsilateral paratracheal lymph node dissection and 17.1% underwent bilateral paratracheal lymph node dissection. The rate of postoperative hypoparathyroidism was analysed in those two subgroups of patients and did not prove to be statistically significant.
While its impact on the local recurrence rate is still controversial, elective central compartment lymph node dissection could be a great tool for selection of patients who could profit from adjuvant radioiodine treatment. On the other hand, central compartment lymph node dissection could potentially increase the risk of hypoparathyroidism due to involuntary injury to parathyroid glands and/or their blood supply. Our study did not find a statistically significant difference regarding postoperative hypoparathyroidism between patients who underwent central compartment lymph node dissection compared with patients who underwent total thyroidectomy only. Our data are not in accordance with some of the previously published studies.
Our results demonstrated that elective central compartment lymph node dissection is a safe procedure and does not significantly increase the risk of postoperative hypoparathyroidism when it is performed simultaneously with total thyroidectomy.
Introduction: Papillary thyroid cancer is one of the cancers with favorable prognosis, although the long-term recurrence rate in the paratracheal region is reported to be as high as 30%. The use of ...(131 )I is considered to be a reliable treatment option for lymph node metastases in the paratracheal region. According to the majority of internationally accepted guidelines, it is not recommended to perform central node dissection (CND) routinely. Total thyroidectomy (TT) remains an adequate treatment for these patients. According to many studies, CND is associated with higher rates of hypoparathyroidism. However, CND improves staging. Methods: We performed a retrospective study. We included 248 patients treated for papillary thyroid cancer during a 20-year period. Data were collected on patient (age, sex) and tumor (size, focality) characteristics, presence of metastases in the central neck compartment, incidence of postoperative hypoparathyroidism, and locoregional failure. We divided patients into two groups based on pathological analysis: those without positive lymph nodes (N0) and those with positive paratracheal lymph nodes (N1). We compared patient and tumor characteristics and risk of recurrence between the two groups. Results: There were 39.5% patients with central neck metastases in our series. In the central neck dissection specimen, 5.5 nodes were found on average. Hypoparathyroidism was found in 23.4% of patients and remained permanent in 3.2% of patients. Female and older patients had a lower chance of central compartment metastases, as did patients with smaller and unifocal tumors. Recurrence risk was doubled for the N1 group. All tested differences between the groups reached statistical significance. Discussion and conclusion: In our hands, CND was a safe and effective surgical procedure. It improved staging and postsurgical management. Efforts should be made to improve the preoperative work-up in order to more accurately identify high-risk patients. Key Words: differentiated thyroid cancer, total thyroidectomy, central compartment lymph node dissection Papilarni karcinom stitnjace spada u tumore s povoljnom prognozom unatoc opisivanoj stopi recidiva u paratrahealnoj regiji i do 30% slucajeva. Radiojodna ablacija se smatra pouzdanom metodom lijecenja metastaza u paratrahealnim cvorovima. Vecina mectunarodno prihvacenih smjernica ne preporuca rutinsko izvoctenje disekcije regije VI (CND) vec se samo totalna tireidektomija (TT) smatra adekvatnim lijecenjem u ovoj skupini bolesnika. Prema mnogim studijama CND je povezana s visom pojavnoscu hipoparatireoidizma. S druge strane, CND pomaze u utvrctivanju tocnog staginga bolesti. Metode: Proveli smo retrospektivnu studiju u koju smo ukljucili 248 bolesnika koji su lijeceni zbog papilarnog karcinoma stitnjace tijekom 20 godina. Podaci su analizirani temeljem karakteristika bolesnika (dob, spol), tumora (velicina, uni--i mutifokalnost), prisustva metastaza u centralnoj regiji vrata, incidencije postoperativnog hipoparatireoidizma i stope lokoregionalnog povrata bolesti. Na osnovu patohistoloskog nalaza podijelili smo bolesnike u dvije skupine: bolesnike bez pozitivnih limfnih cvorova u regiji VI (N0 skupina) kao i one s pozitivnim limfnim cvorovima u regiji VI (N1 skupina). Usporectivali smo osobine bolesnika i karakteristike tumora kao i rizik lokalnog recidiva bolesti izmectu ove dvije skupine. Rezultati: U nasoj seriji bilo je 39.5% bolesnika s metastazama u regiji VI vrata ciji su disektati u prosjeku sadrzavali 5.5 limfnih cvorova. Postoperativni hipoparatireoidizam je verificiran kod 23.4% bolesnika, a ostao trajan u 3.2% bolesnika. Zene i bolesnici starije zivotne dobi imali su manji rizik od metastaza u regiju VI, isto kao i bolesnici s manjim i unifokalnim tumorima. Rizik povrata bolesti bio je udvostrucen za N1 skupinu bolesnika. Sve analizirane razlike izmedu skupina pokazale su statisticku znacajnost. Rasprava i zakljucak: U nasoj ustanovi CND smatramo sigurnom i ucinkovitom operacijom koja poboljsava staging bolesti i time unapreduje daljnje lijecenje bolesnika. Nuzno je poboljsati preoperativnu obradu kako bismo prepoznali bolesnike visokog rizika. Kljucne rijeci:papilarni karcinom, disekcija regije VI
Aim: The aim of this study was to compare the incidence of postoperative hypoparathyroidism in two groups of patients who were treated for differentiated thyroid cancer. Methods: A retrospective ...analysis of 179 patients who were treated for differentiated thyroid cancer in our institution from January 2011 until December 2018 was performed. Only patients initially treated with total thyroidectomy and those who did not have preoperatively confirmed central compartment and lateral neck lymph node metastases were included in this study. Two main groups of patients were analysed. The patients who were treated with total thyroidectomy and elective central compartment lymph node dissection simultaneously were included in the first group. The patients who were treated only with total thyroidectomy were included in the second group. The rate of transitory and persistent postoperative hypoparathyroidism was compared between the two groups. Results: A total of 117 patients (65.4%) underwent total thyroidectomy and elective central compartment lymph node dissection simultaneously (TT + CCLNd group). The remaining 62 patients (34.6%) underwent total thyroidectomy only (TT group). A total of 22.6% patients in the TT group developed postoperative hypoparathyroidism compared with 25.6% in the TT + CCLNd group. The rate of persistent hypoparathyroidism in the TT and TT + CCLNd groups was 3.2% and 6.0%, respectively. The difference in the rate of transient and persistent postoperative hypoparathyroidism was not statistically significant between the two groups. Within the TT + CCLNd group, 82.9% of patients underwent ipsilateral paratracheal lymph node dissection and 17.1% underwent bilateral paratracheal lymph node dissection. The rate of postoperative hypoparathyroidism was analysed in those two subgroups of patients and did not prove to be statistically significant. Discussion: While its impact on the local recurrence rate is still controversial, elective central compartment lymph node dissection could be a great tool for selection of patients who could profit from adjuvant radioiodine treatment. On the other hand, central compartment lymph node dissection could potentially increase the risk of hypoparathyroidism due to involuntary injury to parathyroid glands and/or their blood supply. Our study did not find a statistically significant difference regarding postoperative hypoparathyroidism between patients who underwent central compartment lymph node dissection compared with patients who underwent total thyroidectomy only. Our data are not in accordance with some of the previously published studies. Conclusion: Our results demonstrated that elective central compartment lymph node dissection is a safe procedure and does not significantly increase the risk of postoperative hypoparathyroidism when it is performed simultaneously with total thyroidectomy. Key Words: differentiated thyroid cancer, total thyroidectomy, central compartment lymph node dissection, paratracheal dissection, postoperative hypoparathyroidism Cilj rada je usporediti incidenciju postoperativnog hipoparatireoidizma izmectu dvije skupine bolesnika lijecenih zbog dobro diferenciranog karcinoma stitnjace. Metode: Retrospektivno smo analizirali 179 bolesnika koji su u nasoj ustanovi lijeceni zbog dobro diferenciranog karicnoma stitnjace u periodu od sijecnja 2011 do prosinca 2018. U studiju su bili ukljuceni samo bolesnici kod kojih je inicijalno ucinjena totalna tiroidektomija te oni koji na osnovu preoperativne obrade nisu imali potvrcene metastaze na lateralnom vratu i u regiji VI. Analizirane su dvije skupine bolesnika. U prvu skupinu su ukljuceni bolesnici kod kojih je u istom aktu ucinjena totalna tireoidektomija i disekcija regije VI. Svi ostali bolesnici kod kojih je ucinjena samo totalna tireoidektomija ukljuceni su u drugu skupinu. Stopa tranzitornog i trajnog hipoparatireoidizma je usporectivana izmectu dvije skupine. Rezultati: Kod ukupno 117 bolesnika (65,4%) ucinjena je disekcija regije VI istodobno s totalnom tireoidektomijom. (TT + CCLNd skupina). Kod preostalih 62 bolesnika (34,6%) ucinjena je samo totalna tireoidektomija. (TT skupina). Ukupno 22,6% bolesnika iz TT skupine je razvilo postoperativni hipoparatireoidizam usporedno s 25,6% bolesnika iz TT + CCLNd skupine. Stope trajnog hipoparatireoidizma u TT i TT + CCLNd skupinama su iznosile 3,2 i 6 %. Stopa tranzitornog kao i trajnog postoperativnog hipoparatireoidizma nije bila statisticki znacajna izmecu dvije skupine. Unutar TT + CCLNd skupine, kod 82,9% bolesnika je ucinjena disekcija ipsilateralnih paratrahealnih limfnih cvorova, za razliku od 17,1% bolesnika kod kojih je ucinjena disekcija bilateralnih paratrahealnih cvorova. Stopa postoperativnog hipoparatireoidizma je analizirana u dvjema podskupinama i nije se pokazala statisticki znacajnom. Rasprava: Iako je utjecaj elektivne disekcije regije VI na lokoregionalno recidiviranje i dalje kontroverzan, ona moze biti odlican alat za probir bolesnika koji mogu imati korist od adjuvantne radiojodne ablacije. S druge strane, disekcija regije VI potencijalno moze povecati rizik hipoparatireoidizma zbog nenamjerne ozljede dostitnih zlijezda ili/i njihove krvne opskrbe. Nasa studija nije pokazala statisticki znacajnu razliku u stopi postoperativnog hipoparatireoidizma izmectu skupine bolesnika kod kojih je ucinjena disekcija regije VI u usporedbi sa skupinom bolesnika kod kojih je ucinjena samo totalna tireoidektomija. Nasi podaci su u proturijecju s nekim ranije publiciranim studijama. Zakljucak: Nasi rezultati su pokazali da je elektivna disekcija regije VI sigurni postupak i znacajno ne povecava rizik postoperativnog hipoparatireoidizma kada se izvodi istodobno s totalnom tireoidektmijom. Kljucne rijeci: dobro diferencirani karcinom stitnjace, totalna tiroidektomija, disekcija regije VI, paratrahealna disekcija, postoperativni hipoparatireoidizam
Papilarni karcinom štitnjače spada u tumore s povoljnom prognozom unatoč opisivanoj stopi recidiva u paratrahealnoj
regiji i do 30% slučajeva. Radiojodna ablacija se smatra pouzdanom metodom ...liječenja metastaza u paratrahealnim
čvorovima. Većina međunarodno prihvaćenih smjernica ne preporuča rutinsko izvođenje disekcije regije VI (CND) već se
samo totalna tireidektomija (TT) smatra adekvatnim liječenjem u ovoj skupini bolesnika. Prema mnogim studijama CND
je povezana s višom pojavnošću hipoparatireoidizma. S druge strane, CND pomaže u utvrđivanju točnog staginga bolesti.
Metode: Proveli smo retrospektivnu studiju u koju smo uključili 248 bolesnika koji su liječeni zbog papilarnog karcinoma
štitnjače tijekom 20 godina. Podaci su analizirani temeljem karakteristika bolesnika (dob, spol), tumora (veličina, uni – i
mutifokalnost), prisustva metastaza u centralnoj regiji vrata, incidencije postoperativnog hipoparatireoidizma i stope lokoregionalnog
povrata bolesti. Na osnovu patohistološkog nalaza podijelili smo bolesnike u dvije skupine: bolesnike bez pozitivnih
limfnih čvorova u regiji VI (N0 skupina) kao i one s pozitivnim limfnim čvorovima u regiji VI (N1 skupina). Uspoređivali
smo osobine bolesnika i karakteristike tumora kao i rizik lokalnog recidiva bolesti između ove dvije skupine. Rezultati:
U našoj seriji bilo je 39.5% bolesnika s metastazama u regiji VI vrata čiji su disektati u prosjeku sadržavali 5.5 limfnih čvorova.
Postoperativni hipoparatireoidizam je verificiran kod 23.4% bolesnika, a ostao trajan u 3.2% bolesnika. Žene i bolesnici
starije životne dobi imali su manji rizik od metastaza u regiju VI, isto kao i bolesnici s manjim i unifokalnim tumorima. Rizik
povrata bolesti bio je udvostručen za N1 skupinu bolesnika. Sve analizirane razlike između skupina pokazale su statističku
značajnost. Rasprava i zaključak: U našoj ustanovi CND smatramo sigurnom i učinkovitom operacijom koja poboljšava staging
bolesti i time unapređuje daljnje liječenje bolesnika. Nužno je poboljšati preoperativnu obradu kako bismo prepoznali
bolesnike visokog rizika.
Cilj rada je usporediti incidenciju postoperativnog hipoparatireoidizma između dvije skupine bolesnika liječenih
zbog dobro diferenciranog karcinoma štitnjače. Metode: Retrospektivno smo analizirali ...179 bolesnika koji su u našoj ustanovi
liječeni zbog dobro diferenciranog karicnoma štitnjače u periodu od siječnja 2011 do prosinca 2018. U studiju su bili
uključeni samo bolesnici kod kojih je inicijalno učinjena totalna tiroidektomija te oni koji na osnovu preoperativne obrade
nisu imali potvrđene metastaze na lateralnom vratu i u regiji VI. Analizirane su dvije skupine bolesnika. U prvu skupinu su
uključeni bolesnici kod kojih je u istom aktu učinjena totalna tireoidektomija i disekcija regije VI. Svi ostali bolesnici kod
kojih je učinjena samo totalna tireoidektomija uključeni su u drugu skupinu. Stopa tranzitornog i trajnog hipoparatireoidizma
je uspoređivana između dvije skupine. Rezultati: Kod ukupno 117 bolesnika (65,4%) učinjena je disekcija regije VI
istodobno s totalnom tireoidektomijom. (TT + CCLN d skupina). Kod preostalih 62 bolesnika (34,6%) učinjena je samo
totalna tireoidektomija. (TT skupina). Ukupno 22,6% bolesnika iz TT skupine je razvilo postoperativni hipoparatireoidizam
usporedno s 25,6% bolesnika iz TT + CCLN d skupine. Stope trajnog hipoparatireoidizma u TT i TT + CCLN d skupinama
su iznosile 3,2 i 6 %. Stopa tranzitornog kao i trajnog postoperativnog hipoparatireoidizma nije bila statistički značajna između
dvije skupine. Unutar TT + CCLN d skupine, kod 82,9% bolesnika je učinjena disekcija ipsilateralnih paratrahealnih
limfnih čvorova, za razliku od 17,1% bolesnika kod kojih je učinjena disekcija bilateralnih paratrahealnih čvorova. Stopa
postoperativnog hipoparatireoidizma je analizirana u dvjema podskupinama i nije se pokazala statistički značajnom. Rasprava:
Iako je utjecaj elektivne disekcije regije VI na lokoregionalno recidiviranje i dalje kontroverzan, ona može biti odličan alat
za probir bolesnika koji mogu imati korist od adjuvantne radiojodne ablacije. S druge strane, disekcija regije VI potencijalno
može povećati rizik hipoparatireoidizma zbog nenamjerne ozljede doštitnih žlijezda ili/i njihove krvne opskrbe. Naša studija
nije pokazala statistički značajnu razliku u stopi postoperativnog hipoparatireoidizma između skupine bolesnika kod kojih
je učinjena disekcija regije VI u usporedbi sa skupinom bolesnika kod kojih je učinjena samo totalna tireoidektomija. Naši
podaci su u proturiječju s nekim ranije publiciranim studijama. Naši rezultati su pokazali da je elektivna disekcija
regije VI sigurni postupak i značajno ne povećava rizik postoperativnog hipoparatireoidizma kada se izvodi istodobno s totalnom
tireoidektomijom.
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