Long-term oncologic outcomes of papillary thyroid microcarcinoma according to the presence of clinically apparent lymph node metastasis: a large retrospective analysis of 5,348 patients

Jung Bum Choi, Woo Kyung Lee, Seul Gi Lee, Haengrang Ryu, Cho Rok Lee, Sang Wook Kang, Jong Ju Jeong, Kee-Hyun Nam, Eun Jig Lee, Woong Youn Chung, Young Suk Jo, Jandee Lee, Jung Bum Choi, Woo Kyung Lee, Seul Gi Lee, Haengrang Ryu, Cho Rok Lee, Sang Wook Kang, Jong Ju Jeong, Kee-Hyun Nam, Eun Jig Lee, Woong Youn Chung, Young Suk Jo, Jandee Lee

Abstract

Purpose: Active surveillance (AS) of low-risk papillary thyroid microcarcinoma (PTMC) may reduce the risk of overtreatment of clinically insignificant cancer. However, the absence of predictor for the progression of PTMC resulted in treatment delay and potentially compromising cure of aggressive disease. Therefore, to anticipate potential damage of delayed surgery, we investigated the oncologic outcomes of patients with low-risk PTMC initially eligible for AS except clinically apparent lymph node metastasis (LNM), imitating delayed surgery with neck dissection.

Materials and methods: A total of 5,348 patients, enrolled between 1987 and 2016, with low-risk PTMC initially eligible for AS were included regardless of LNM. We classified our study patients into two groups: Group I, lobectomy with prophylactic central cervical node dissection; Group II, total thyroidectomy with modified radical neck dissection for LNM. In addition, we investigated the oncological outcomes of patients with second-wave surgery due to lateral lymph node recurrence (Group III, subgroup of Group I).

Results: Group I showed more favorable clinicopathological characteristics compared with Group II. In Group I, only 29 (0.58%) of 4,927 patients underwent second-wave surgery with neck dissection for lateral lymph node recurrences, whereas in Group II, all 22 (5.23%) of 421 patients underwent second-wave selective node dissection because of nodal recurrence. Disease-free survival rates were significantly different between Groups I and II (P<0.05). Of note, the recurrence rate of Group II was still significantly higher than that of Group III (5.2% vs 0%, respectively; P=0.021). In addition, Kaplan-Mayer survival analysis indicated poor disease-free survival rates in Group II compared with Group III (P<0.05).

Conclusion: The long-term treatment outcome of PTMC without LNM was favorable even if the recurrence occurs during follow-up period compared with that of PTMC with LNM. It should be noted that AS might be able to cause poor prognosis due to clinically apparent LNM.

Keywords: active surveillance; lymphatic metastasis; neoplasm recurrence; papillary thyroid microcarcinoma.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Scheme of defining group indicating immediate surgery group of ideal or appropriate candidates for AS and delayed surgery imitating group of ideal or appropriate candidates for AS except accompanying with clinically apparent LNM. Abbreviations: AS, active surveillance; CCND, central compartment neck node dissection; ETE, extrathyroidal extension; LNM, lymph node metastasis; MRND, modified radical neck dissection; PTMC, papillary thyroid microcarcinoma; TT, total thyroidectomy.
Figure 2
Figure 2
Flow chart presenting the oncologic outcomes of immediate surgery group and delayed surgery imitating group with low-risk PTMC potentially eligible for AS. Abbreviations: AS, active surveillance; CCND, central compartment neck node dissection; MRND, modified radical neck dissection; PTMC, papillary thyroid microcarcinoma; TT, total thyroidectomy.
Figure 3
Figure 3
Comparison of disease-free survival according to patients’ Group. Notes: (A) Comparison of disease-free survival of patients with low-risk PTMC who underwent lobectomy with prophylactic central cervical node dissection (Group I) with that of patients with low-risk PTMC except clinically apparent lymph node metastasis who underwent total thyroidectomy with modified radical neck dissection (Group II). (B) Comparison of disease-free survival of patients with second-wave surgery due to lateral LN recurrence (Group III, subgroup of Group I) with that of Group II. P-value was determined by the log-rank test. Abbreviation: PTMC, papillary thyroid microcarcinoma.

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