Surgical indications for upper mediastinal dissection by sternotomy in patients with papillary thyroid carcinoma.

Papillary thyroid carcinoma (PTC) is a relatively indolent disease, despite the high incidence of lymph node metastases. Although less frequent, some upper mediastinal metastases of PTC cannot be removed without sternal resection. In this study, we investigated the prognostic impact of upper mediastinal dissection (UMD) by sternotomy on patients with mediastinal metastases of PTC. Charts of patients with PTC who underwent surgical treatment at our institution between 2006 and 2018 were retrospectively reviewed. Fifty-eight patients with upper mediastinal metastases were enrolled. Kaplan-Meier survival curves were compared, and Cox hazard regression models were used for analyses. Of the 58 patients with mediastinal metastasis, 12 (20.7%) underwent dissection of the prevascular nodes, 51 (87.9%) underwent dissection of the upper paratracheal nodes, and 14 (24.1%) underwent dissection of the lower paratracheal node. The preferred site of mediastinal metastasis was the upper paratracheal nodes. The 5 and 10-year disease-specific survival rates for patients after UMD were 74.6% and 58.7%, respectively. Among 25 patients (43.1%) with locoregional recurrence, 12 (20.7%) had mediastinal recurrence and 7 were eligible for additional UMD. Although distant metastasis was the predominant poor prognostic factor, mediastinal recurrences were more frequently unresectable than cervical recurrences, suggesting that mediastinal recurrence is a poor prognostic factor. Mediastinal metastases larger than 30 mm or metastases to the lower paratracheal nodes are considered a risk factor for mediastinal recurrence. UMD by sternotomy for patient with upper mediastinal metastases which are difficult to resect via transcervical approach is an effective treatment option to improve patient prognosis.

Novel surgical methods for reconstruction of the recurrent laryngeal nerve: Microscope-guided partial layer resection and intralaryngeal reconstruction of the recurrent laryngeal nerve.

BACKGROUND: The optimal strategy for surgical management of papillary thyroid carcinoma invasion of the recurrent laryngeal nerve remains controversial. Our aim was to evaluate the efficacy of 2 surgical methods and provide detailed descriptions of microscope-guided partial layer resection and intralaryngeal reconstruction of the recurrent laryngeal nerve. METHODS: This retrospective study enrolled 85 patients with papillary thyroid carcinoma who underwent initial surgical excision for invasion of the recurrent laryngeal nerve. Twenty-seven patients (28 recurrent laryngeal nerve sites) underwent partial layer resection, and 11 patients (11 recurrent laryngeal nerve sites) underwent intralaryngeal reconstruction of the recurrent laryngeal nerve. The remaining patients underwent either only resection or resection with immediate reconstruction of the recurrent laryngeal nerve. Pre and postoperative phonetic function and rates of locoregional recurrence were extracted from medical charts for analysis. RESULTS: Isolated locoregional recurrence specific to the aerodigestive tract was identified in 1 patient (3.7%) in the partial layer resection group and 1 patient (9.1%) in the intralaryngeal reconstruction group. Seventy-five percent of patients in the partial layer resection group recovered or had preserved vocal cord function, and the mean maximum phonation time of the patients with postoperative complete vocal cord palsy was 15.3 seconds. The mean maximum phonation time of the patients, excluding 4 patients with permanent stoma in the intralaryngeal reconstruction group, was 22.3 seconds. The mean maximum phonation time of either group was longer than that of patients with recurrent laryngeal nerve resection only and comparable with that of patients with recurrent laryngeal nerve resection and immediate reconstruction. CONCLUSION: Patients who underwent either partial layer resection or intralaryngeal reconstruction had low rates of locoregional recurrence specific to the aerodigestive tract and good postoperative functional outcomes.

Axillary lymph node metastases from thyroid carcinoma: Report of seven cases.

Axillary lymph node metastasis (ALNM) of well- or poorly-differentiated thyroid cancer is rare. Notably, there are only 14 single case reports available; therefore, the mechanism of metastasis is unclear at this point. Because we encountered seven cases at a single institution, we were able to infer the mechanism of ALNM of thyroid cancer. The seven cases treated at our institution were analyzed retrospectively. In addition, 14 cases reported from other institutions were reviewed. All seven patients we treated and the 10 patients, among the 14, from other institutions were postoperative recurrences. All seven patients we treated had lymph node metastases near the venous angle, and invasive manipulation had been performed during the previous surgery. Therefore, we can presume that fibrosis at the venous angle caused by ablative surgery or tumor invasion could have resulted in anomalous lymphatic flow from the neck to the axilla. Hence, the subclavian region would probably need to be dissected besides axillary dissection. All 21 cases underwent surgical treatment for ALNM. Metastatic lymph nodes in the venous angle, subclavian or axilla, occasionally invade or adhere to the vessels. Hence, a surgical strategy is required in those cases rather than molecular targeted therapy or radioactive iodine irradiation.

Parathyroid carcinoma coexisting with multiple parathyroid adenomas: a case report.

Primary hyperparathyroidism is usually caused by parathyroid adenoma; however, parathyroid carcinoma is a rare cause. We report a rare case of 74-year-old female of primary hyperparathyroidism caused by parathyroid carcinoma (PC) and coexisting multiple parathyroid adenomas. She was referred to our hospital for primary hyperparathyroidism and a suspected thyroid tumor. She had no family history of malignant tumor. Computed tomography (CT) and ultrasonography of the neck revealed some masses posterior to both thyroid lobes. Those masses were believed to be parathyroid lesions. However, another mass located posterior to the right upper thyroid lobe seemed to be heterogeneous, which indicated a malignant thyroid tumor as well as parathyroid tumor. The preoperative diagnosis was multiple parathyroid adenoma and suspicious incidental thyroid carcinoma. Therefore, the patient underwent total parathyroidectomy and thyroidectomy. The histopathological diagnosis was parathyroid carcinoma coexisting with multiple parathyroid adenomas. There was no evidence of recurrence at 1 year after the surgery. It was difficult to diagnose PC preoperatively. Few rare cases of PC coexisting with parathyroid adenoma in multiple endocrine neoplasia type 1 (MEN1) have been reported. Therefore, careful follow-up was necessary considering the possibility of MEN1, though she did not wish for a genetic examination.

Impact of gross extrathyroidal extension into major neck structures on the prognosis of papillary thyroid carcinoma according to the American Joint Committee on Cancer eighth edition.

This study investigated the impact of gross extrathyroidal extension into major neck structures on the prognosis of papillary thyroid carcinoma according to changes in the American Joint Committee on Cancer (AJCC)/Tumor-Node-Metastasis staging system. Overall, 183 patients with gross extrathyroidal extension into major neck structures were enrolled. The 10-year disease-specific survival (DSS) of patients in each stage showed appropriate correlation and stratification with the AJCC eighth edition. However, the 10-year DSS rate in stage III was better than the expected 10-year DSS rate, according to the AJCC eighth edition. Patients in stage III were subcategorized into three new groups: stage IIIA, patients with only recurrent laryngeal nerve invasion; stage IIIB, patients with superficial invasion of the aerodigestive tract; and stage IIIC, patients with intraluminal invasion of the aerodigestive tract. The prognostic differences among these three groups and stage IVA were examined. Although the DSS rate of patients in stage IIIA was excellent, that of patients with T4a disease was worse due to the progression of aerodigestive tract infiltration. Of the four groups, the time to locoregional recurrence was the shortest for patients in stage IVA. The distant recurrent-free survival for patients in stages IIIC and IVA tended to be worse than those for patients in stages IIIA and IIIB. These results indicate that the progression of aerodigestive tract infiltration has an impact on the incidence of distant recurrence, and the presence of T4b disease has an impact on the incidence of distant and locoregional recurrences.

Classifying Dysphagic Swallowing Sounds with Support Vector Machines.

Swallowing sounds from cervical auscultation include information related to the swallowing function. Several studies have been conducted on the screening tests of dysphagia. The literature shows a significant difference between the characteristics of swallowing sounds obtained from different subjects (e.g., healthy and dysphagic subjects; young and old adults). These studies demonstrate the usefulness of swallowing sounds during dysphagic screening. However, the degree of classification for dysphagia based on swallowing sounds has not been thoroughly studied. In this study, we investigate the use of machine learning for classifying swallowing sounds into various types, such as normal swallowing or mild, moderate, and severe dysphagia. In particular, swallowing sounds were recorded from patients with dysphagia. Support vector machines (SVMs) were trained using some features extracted from the obtained swallowing sounds. Moreover, the accuracy of the classification of swallowing sounds using the trained SVMs was evaluated via cross-validation techniques. In the two-class scenario, wherein the swallowing sounds were divided into two categories (viz. normal and dysphagic subjects), the maximum F-measure was 78.9%. In the four-class scenario, where the swallowing sounds were divided into four categories (viz. normal subject, and mild, moderate, and severe dysphagic subjects), the F-measure values for the classes were 65.6%, 53.1%, 51.1%, and 37.1%, respectively.

Ultrasonography findings in immunoglobulin G4-related lymphadenopathy: a report of two cases.

Lymphadenopathy is frequently observed in immunoglobulin G4 (IgG4)-related disease in some cases, and such cases are known as IgG4-related lymphadenopathy. The ultrasonography findings associated with IgG4-related lymphadenopathy have not been described in previous reports. Herein, we describe ultrasonography findings in two cases of IgG4-related lymphadenopathy in conjunction with histopathological findings. Combined ultrasound scanning with Doppler examination accurately represented the specific histopathological features of IgG4-related lymphadenopathy.

Appropriateness of Subadventitial Resection for Invasion of the Carotid Artery by Papillary Thyroid Carcinoma.

BACKGROUND: Selection of surgical treatment for patients with papillary thyroid carcinoma (PTC) that includes great vessel invasion is challenging. We investigated the efficacy of tumor excision, with regard to safety of the surgical procedure and prognosis among patients with PTC invasion of the carotid or vertebral artery. METHODS: This study is a retrospective review of patients who underwent surgical excision for PTC at our institution, between 1981 and 2010, with 49 patients treated for carotid artery invasion and nine for vertebral artery invasion. RESULTS: Twenty patients with carotid artery invasion receiving initial treatment underwent subadventitial resection. Among 29 relapsing patients with carotid artery invasion, subadventitial resection was performed in 27 and en-block resection and reconstruction in the other two. In patients with carotid artery invasion, locoregional recurrence was identified in 14 patients, with the recurrence specific to the carotid artery in one case and distant recurrence in 15. The 10-year disease-specific survival rate was shorter among relapsing patients (21.7%) than among those receiving an initial treatment (69.3%). At 8 years after surgery, however, the survival rates were comparable between the two groups. Of the nine patients with vertebral artery invasion, two received initial treatment, with either preservation or reconstruction of the vertebral artery. The other six cases were tumor recurrences, treated by tumor and vertebral artery resection. Vertebral artery invasion was associated with carotid artery invasion in five patients and subclavian artery invasion in four. CONCLUSIONS: Carotid artery invasion by PTC did not extend beyond the adventitia of the artery in the majority of patients. Most patients with vertebral artery invasion required tumor excision with vertebral artery resection.

A case report of thyroid metastasis from p16-positive oropharyngeal squamous cell carcinoma.

Thyroid metastasis from head and neck squamous cell carcinoma (SCC) is a very rare form of rarely observed metastatic thyroid tumor. We herein report a case of thyroid metastasis from oropharyngeal SCC (OSCC). The patient was a 68-year-old male diagnosed with p16-positive tonsillar OSCC on the right side with multiple lymph node metastases and a thyroid mass, which was determined as metastatic p16-positive OSCC by immunohistochemistry of specimens collected by fine-needle aspiration cytology (FNAC). He received one cycle of induction chemotherapy followed by concurrent chemoradiotherapy. No visible primary lesions were observed after treatment. The disappearance of the tonsillar lesion was considered to be a complete response by the magnetic resonance imaging (MRI) and positron emission tomography-computed tomography (PET-CT). The thyroid lesion was also decreased, but a solid lesion with unclear boundaries in the right thyroid lobe remained. Therefore, the patient underwent total thyroidectomy to remove any residual tumor. Postoperative pathological evaluation revealed no residual viable carcinoma cells in the resected specimen. As illustrated in this case, immunohistochemistry of the FNAC specimen for p16 was successful in determining the thyroid tumor as a metastatic lesion from the oropharynx. Although radical radiotherapy might be sufficient to control thyroid gland metastasis of OSCC, in this case, early-stage remedial surgery was thought to be necessary for a secure radical cure.

Thyrolipomatosis: A case report with review of the literature.

Fatty tissue is not usually present within the thyroid gland. Only a few fat-containing thyroid lesions have been reported to date, and thyrolipoma is the most common fat-containing lesion of the thyroid gland. Thyrolipomatosis is a condition characterized by diffuse mature adipose cell infiltration of the normal thyroid gland. In this report, we describe what is, to the best of our knowledge, the 12th documented case of thyrolipomatosis, and review the fat-containing lesions of the thyroid gland. A 68-year-old Japanese woman presented with a neck mass that had first been noticed ~7 years earlier. A computed tomography scan revealed diffuse thyroid gland enlargement and total thyroidectomy was performed. The histopathological examination revealed that mature fatty tissue was diffusely distributed throughout the thyroid gland, as well as among the hyperplastic follicles. Capsular formation or amyloid deposition were not observed. Nuclear grooves or intranuclear cytoplasmic inclusions were not observed. Accordingly, thyrolipomatosis was diagnosed. Albeit rare, various neoplastic and non-neoplastic thyroid lesions may contain mature fatty tissue. Therefore, thyrolipomatosis must be included in the differential diagnostic consideration of fat-containing lesions of the thyroid gland.

Window Resection for Intraluminal Cricotracheal Invasion by Papillary Thyroid Carcinoma.

BACKGROUND: Invasion of the upper aerodigestive tract by papillary thyroid carcinoma (PTC) affects both prognosis and quality of life. We assessed the efficacy of window resection for patients with intraluminal cricotracheal invasion. METHODS: Clinical data were retrospectively reviewed for all patients with PTC undergoing surgery at our institution during 1981-2009. Seventy-six patients with intraluminal cricotracheal invasion were enrolled, including 34 relapsing patients. RESULTS: The 10-year disease-specific survival rate of 42 patients with intraluminal invasion who underwent initial surgery was 60.8%. The lesion was located on the laryngo-trachea in 3 (4%) of 12 patients with locoregional recurrence. No major surgical complications were associated with cricotracheal resection. Stomal closure was achieved in 30 of 76 patients (39%). Twelve patients (16%) had a permanent stoma that was directly related to cricotracheal invasion. Their stomas had been caused by large cricotracheal defects with greater than or equal to 50% circumferential resection of the trachea. Sixty-seven patients (88%) had PTC invasion into other aerodigestive structures, including the recurrent laryngeal nerve (n = 54), esophagus (n = 38), and thyroid cartilage or intraluminal invasion of the larynx (laryngeal invasion n = 23). Multivariate analysis showed that cricotracheal invasion accompanied by recurrent laryngeal nerve invasion was predictive of permanent stoma (odds ratio 0.32; 95% CI 0.107-0.945; p = 0.039). CONCLUSIONS: Window resection appears to be an effective treatment option for patients with intraluminal cricotracheal invasion. However, this surgical technique may be inappropriate for the treatment of large cricotracheal defects without a supportive hard structure.

Impact of superior mediastinal metastasis on the prognosis of papillary thyroid carcinoma.

The impact of lymph node (LN) metastasis on survival or tumor recurrence in patients with papillary thyroid carcinoma (PTC) is controversial. The objective of this study was to investigate the effect of superior mediastinal metastasis on the prognosis of patients with PTC and to identify any correlations between such metastasis and clinical indicators. Medical records of PTC patients who underwent surgery as their initial treatment between 1981 and 2008 at our institution were retrospectively reviewed. Patients with or without superior mediastinal metastasis were selected. Prognosis was determined using the Kaplan-Meier method and Cox-hazard regression model with the forward stepwise method. Correlations between multiple factors and superior mediastinal metastasis were investigated using a binary logistic regression analysis. The study cohort included 488 patients of whom 75 (15.4%) had superior mediastinal metastasis. The survival differences between patients with superior mediastinal metastasis dissected via the transcervical approach and patients without metastasis were not significant. The prognosis of patients with superior mediastinal metastasis dissected by sternotomy was significantly poorer. As for disease-free survival, significant differences were found between patients with superior mediastinal metastases dissected by either method and patients without metastases. The main variables predicting superior mediastinal metastasis were an age of 45 years or older and the total number of cervical LN metastases. Superior mediastinal metastasis was an independent predictive factor for recurrence-free survival in PTC patients. The main variables predicting superior mediastinal metastasis were being 45 years of age or older, and having a greater total number of cervical LN metastases.

Parapharyngeal Metastasis of Papillary Thyroid Carcinoma.

BACKGROUND: Nodal involvement of papillary thyroid carcinoma (PTC) commonly occurs in the paratracheal region and the internal jugular chain. Lymph node metastasis in the parapharyngeal space (PPS) is rare. In this report, we describe our experience and surgical outcomes of patients with PPS metastasis of PTC. METHODS: Clinical data of patients with PTC who underwent surgery at our institution between January 2006 and December 2013 were retrospectively reviewed, and 22 patients with PPS metastasis were enrolled. RESULTS: There were 2 primary and 20 secondary cases of PPS metastasis. Involvement of the jugular nodes was noted before or at the time of PPS metastasis detection in all cases. A transcervical surgical approach with partial resection of the mandibular angle was performed in 21 patients, while 1 patient underwent extirpation of the PPS metastasis via a transoral approach. Although curative resection was performed in 21 patients, the PPS metastasis was not removable in 1 patient owing to an invaded internal carotid artery at the skull base. Twelve and 6 patients had locoregional and distant recurrence, respectively. Of the 12 patients with locoregional recurrence, isolated locoregional recurrence in the PPS occurred in 1. Eight patients died of distant or locoregional recurrence, with a median survival time of 91.7 months. CONCLUSIONS: For patients who experience recurrence after thyroid surgery, the possibility of PPS metastasis should be considered. In this series, all patients with PPS metastasis also had previous unilateral or bilateral cervical metastasis. Despite curative attempt, most patients experienced local or distant recurrence.

Surgical Management of Cricotracheal Invasion by Papillary Thyroid Carcinoma.

BACKGROUND: In general, patients with papillary thyroid carcinoma (PTC) have an excellent postoperative prognosis. Those with cricoid and/or tracheal PTC invasion, however, are at a higher risk of postoperative morbidity and airway insufficiency. METHODS: We investigated postoperative airway outcomes, locoregional recurrence, and survival rates in patients with PTC who underwent cricotracheal resection. The records of PTC patients who underwent surgery at our institution between 1981 and 2009 were reviewed retrospectively, and 110 patients with cricotracheal invasion were enrolled. Curative resection was performed in all patients, and cricotracheal function was preserved or reconstructed when possible. RESULTS: Of the 110 patients, 57 and 53 patients had superficial and intraluminal invasion of the larynx, respectively. After the initial surgery, the 10-year disease-specific survival rates were 90.8 and 44.4 % in patients with superficial and intraluminal invasion of the cricotracheal area, respectively. Only six patients (5.5 %) had an isolated upper aerodigestive tract recurrence. Five patients were managed with an additional window resection as salvage surgery. Consequently, only one patient (0.9 %) underwent total laryngectomy. Altogether, 31 patients (28.0 %) had a permanent stoma, 9 and 15 of which were caused by cricotracheal invasion and invasion of other aerodigestive structures, respectively. CONCLUSIONS: Window resection for intraluminal cricotracheal invasion by PTC produced good surgical outcomes that resulted in a low local recurrence rate and survival rates that resembled those associated with other surgical treatments. Treatment of multiple organ invasion of the aerodigestive tract was necessary to improve postoperative functional outcomes in these patients.

Surgical management of laryngeal invasion by papillary thyroid carcinoma: a retrospective analysis.

BACKGROUND: Papillary thyroid carcinoma (PTC) has an excellent prognosis. Although rare, PTC invasion into the upper aerodigestive tract can adversely affect patient prognosis and quality of life. This study investigated the impact of tumor excision on the prognosis and postoperative status of patients with PTC invasion of the larynx. METHODS: Data on PTC patients who underwent surgery at the author's institution between April 1981 and March 2010 were retrospectively reviewed, and 55 patients with thyroid cartilage invasion were enrolled. Curative resection was performed for all patients, and laryngeal function was preserved or reconstructed when possible. RESULTS: Of the 55 patients, 40 and 15 patients had superficial and intraluminal invasion of the larynx, respectively. The 10-year disease-specific survival rates were 81.0% and 61.4% in patients who underwent surgery for superficial and intraluminal invasion of the larynx, respectively. Only two patients (3.6%) had an isolated locoregional recurrence in the larynx. Four patients (7.3%) underwent total laryngectomy during the initial surgery or surgery for laryngeal recurrence. Permanent stoma remained in 26 patients (47%): 14 with laryngeal invasion, and 12 with invasion of other aerodigestive structures. The number of invaded aerodigestive structures including the larynx was correlated with the presence of permanent stoma. CONCLUSIONS: In many patients, PTC invasion of the larynx remained at the thyroid cartilage or paraglottic space. Most patients did not require total laryngectomy. Good locoregional control was achieved with surgical tumor excision in patients with laryngeal invasion. Distant metastases were the major cause of death in patients with PTC invasion of the larynx.

Impact of lymph node metastases with recurrent laryngeal nerve invasion on patients with papillary thyroid carcinoma.

BACKGROUND: Although rare, invasion by papillary thyroid carcinoma (PTC) of the upper aerodigestive tract significantly affects patients' prognosis and quality of life. Within the central compartment, the recurrent laryngeal nerve (RLN) is most frequently invaded by lymph node metastases (LNM). However, such an invasion has not been described in the literature, although reports on RLN invasion by primary tumors have been published. The present study aimed to characterize LNM with RLN invasion in patients with PTC. METHODS: The participants of this retrospective investigation were selected from 629 PTC patients who received initial surgical treatment at our institution between January 1981 and December 2012. They included 38 (6%) patients with 40 cases of RLN invasion by LNM (LNM invasion group) and 112 (17.8%) patients with 117 cases of RLN invasion by the primary tumor (primary invasion group). RESULTS: In the LNM invasion group, 70% of the RLN invasion cases occurred on the right side, whereas those in the primary invasion group were almost equally distributed. RLN invasion caused vocal cord paralysis, affecting 13 nerves (32.5%) in the LNM invasion group and 68 nerves (58%) in the primary invasion group. Significant differences in laterality and preoperative vocal cord paralysis were observed between the two groups. In the LNM invasion group, the longest diameter of metastatic lymph nodes (mean±standard deviation) of patients with RLN paralysis was 21±8 mm, whereas it was significantly different at 14±7 mm in those without RLN paralysis. CONCLUSIONS: Our results indicate that most patients with RLN invasion by LNM did not experience preoperative vocal cord paralysis. LNM invasion of the RLN (70%) more often occurred on the right side as expected given the complexity and three-dimensional anatomy of the RLN in the right paratracheal region compared to the left. RLN invasion by LNM should be considered if preoperative paratracheal nodal disease, especially when bulky, is noted in the right paratracheal region.

Impact of invasive extranodal extension on the prognosis of patients with papillary thyroid carcinoma.

BACKGROUND: Although 20-50% of papillary thyroid carcinoma (PTC) patients initially present with lymph node metastases, prognosis is excellent. Thus, the significance of lymph node metastasis in PTC remains controversial. In this study, we examined the impact of extranodal extension to surrounding organs (invasive extranodal extension) on the prognosis for PTC patients. METHODS: Medical records of PTC patients who underwent surgery as their initial treatment at our institution between 1981 and 2008 were retrospectively reviewed. Patients with or without invasive extranodal extension were selected. Our therapeutic strategy for PTC with invasive extranodal extension included complete resection and functional reconstruction. Intergroup comparison was performed using Student's t-test or the chi-square test as appropriate. Survival curves determined by the Kaplan-Meier method were compared for statistical significance using the log-rank test. A Cox-hazard regression model with the forward stepwise method was used for multivariate analysis. RESULTS: The study cohort included 60 (12.3%) patients with and 428 (87.7%) without invasive extranodal extension. The most common site of invasive extranodal extension in the central neck compartment was the recurrent laryngeal nerve, whereas the internal jugular vein was the most frequently invaded site in the lateral neck compartment. The locoregional recurrence rate did not differ significantly between patients with and without invasive extranodal extension, but the distant recurrence rate was higher for those with invasive extranodal extension. The 10-year disease-specific survival rate was significantly lower for patients with invasive extranodal extension than for those without invasive extranodal extension. Furthermore, multivariate analysis revealed that being aged ≥45 years, poor differentiation, and extrathyroidal extension were independent predictive factors for disease-specific death in PTC. Invasive extranodal extension had no effect on the survival of PTC patients. CONCLUSIONS: Invasive extranodal extension did not affect the survival of patients with PTC. Despite a negative impact on distant recurrence, invasive extranodal extension did not affect locoregional recurrence in PTC patients.

Upper mediastinal node dissection for hypopharyngeal and cervical esophageal carcinomas.

OBJECTIVES: Hypopharyngeal cancer (HPC) and cervical esophageal cancer (Ce) are aggressive tumors with a poor prognosis. Multiple lymph node metastases often occur in the upper mediastinum, as well as in the neck, and thus upper mediastinal dissection (MD) is crucial to improving the cure rate. However, excessive MD can increase postoperative morbidity and mortality, making it important to employ the proper technique and appropriate extent of dissection. In the present retrospective study we aimed to determine the proper extent of upper MD according to tumor site and stage. The benefit and risk of upper MD are also discussed. METHODS: Chart review was completed for patients who underwent upper MD, including 64 patients with HPC, 21 patients with Ce, and 9 patients with Ce extending to involve the upper thoracic esophagus (Ce/Ut). The incidence and distribution of lymph node metastases in the upper mediastinum were assessed by postoperative histopathologic examination. Postoperative complications of upper MD, as well as the impact on survival and locoregional control, were also reviewed. RESULTS: Upper mediastinal metastases were detected in 7.8% of HPC patients, 33.3% of Ce patients, and 55.6% of Ce/Ut patients. In HPC patients, mediastinal metastases were usually associated with T4 primary tumors (80%), whereas positive nodes in the upper mediastinum were detected regardless of T stage in both Ce and Ce/Ut. Only 1 Ce/Ut patient with a T4 tumor developed late nodal metastasis in the lower mediastinum. The 5-year disease-specific survival and locoregional control rates were 58.6% and 90.2% in HPC, 45.5% and 94.1% in Ce, and 38.9% and 77.7% in Ce/Ut, respectively. Rupture of the greater vessels after MD was observed in 5 cases (5.3%). CONCLUSIONS: The present results indicate excellent locoregional control rates following upper MD, while major complications such as arterial breakdown were rare. It is suggested that upper MD may be an essential and adequate procedure for patients with Ce or Ce/Ut tumors, and may also be required for cases of HPC with a T4 primary to improve locoregional control of the disease.