From the Guidelines
Management of Papillary Thyroid Cancer with Lymph Node Metastasis
Patients with papillary thyroid cancer and positive lymph node status require comprehensive management, including total thyroidectomy and central lymph node dissection 1.
- The initial treatment should always be preceded by careful exploration of the neck by US to assess the status of lymph node chains 1.
- Post-operative treatment with radioactive iodine (I-131) is recommended, with a typical dose of 100-200 mCi, to ablate any residual thyroid tissue and metastatic disease 1.
- Additionally, suppressive therapy with levothyroxine (T4) is initiated, targeting a serum thyrotropin (TSH) level of <0.1 mU/L, and is typically continued for at least 5 years, with ongoing monitoring of serum thyroglobulin levels and neck ultrasound 1.
- Compartment-oriented microdissection of lymph nodes should be performed in cases of preoperatively suspected and/or intraoperatively proven lymph node metastases 1.
- The use of recombinant human TSH (rhTSH) is approved as preparation for radioiodine ablation of post-surgical thyroid remnants in patients with well-differentiated thyroid carcinoma without evidence of metastatic disease, using a fixed dose of 3700 MBq (100 mCi) of 131I, although a lower dose of 1850 MBq (50 mCi) may be equally effective in some cases 1.
From the Research
Management of Papillary Thyroid Cancer with Lymph Node Metastasis
- The management of papillary thyroid cancer with lymph node metastasis involves resection of the primary tumor, with resection of regional lymph nodes if involved with metastatic disease 2.
- Total or near-total thyroidectomy is recommended as the initial procedure of choice, given its advantages of treating potential multicentric disease, facilitating maximal uptake of adjuvant radioactive iodine, and facilitating post-treatment follow-up by monitoring serum thyroglobulin (Tg) levels 2.
- Therapeutic lymph node dissection is recommended for patients presenting with clinically evident nodal disease, while prophylactic central neck lymph node dissection is controversial and may be considered in certain cases, such as advanced primary tumors or clinical lateral neck disease 3, 4.
Surgical Options
- Total thyroidectomy with central node dissection is a valuable option in papillary thyroid cancer treatment, improving staging and postsurgical management 5.
- Prophylactic central lymph node dissection may be considered in patients with advanced primary tumors or clinical lateral neck disease, but its role in patients with small solitary papillary carcinoma is not recommended unless there are high-risk prediction factors for recurrence and diffuse nodal spread 4.
- The addition of routine central lymph node dissection to total thyroidectomy for the treatment of papillary thyroid cancer may upstage nearly one third of patients, changing the dose of radioactive iodine ablative therapy, but does not change postoperative thyroglobulin levels after completion of radioiodine treatment 6.
Adjuvant Therapy
- Postoperative adjuvant therapy consists of radioactive iodine ablation for most patients, followed by thyroid-stimulating hormone (TSH) suppression with thyroxine 2.
- Recurrent locoregional cervical lymph node disease should be treated by compartmental lymph node dissection, followed by another treatment dose of radioactive iodine 2.
- Chemotherapy is generally ineffective for the treatment of metastatic disease, while emerging therapies include redifferentiation agents, antiangiogenic agents, and multi-tyrosine kinase inhibitors for patients whose tumor has become radioactive iodine resistant 2.