Gland and Hormone Related Diseases

All Conditions

Neoplasms

Thyroid Diseases

Thyroid Nodule

Endocrine System Diseases

Thyroid Neoplasms

Endocrine Gland Neoplasms

Head and Neck Neoplasms

Total thyroidectomy without central lymph node dissection.

Total thyroidectomy with central lymph node dissection.

Hemi-thyroidectomy with central lymph node dissection.

Hemi-thyroidectomy without central lymph node dissection.

Total thyroidectomy includes removing all possible thyroid tissue. Central lymph node dissection is a neck level 6 dissection. This includes removal of all central lymphatics from carotid artery to carotid artery and hyoid to sternum/clavicle.

Total Thyroidectomy + CLND

Removal of all possible thyroid tissue without dissection of neck level 6.

Total thyroidectomy - CLND

Removal of one thyroid lobe and ipsilateral central lymph nodes

Hemi-thyroidectomy + CLND

Removal of one thyroid lobe only. No lymphatic dissection.

Hemi-thyroidectomy - CLND

Peter T Dziegielewski, MD

Jeffrey R Harris, MD, FRCSC

Robert Hart, MD, FRCSC

Elaine Fung, MD

When a patient presents with a thyroid mass, part of the work-up may include a fine needle aspiration biopsy (FNAB). The results of the biopsy then help plan treatment. If the results are benign, the management will typically be to follow the nodule. If the results demonstrate or are suspicious for cancer, such as papillary thyroid carcinoma (PTC), the treatment is a total thyroidectomy (total thyroid removal). The latest American thyroid association guidelines for PTC (2009) suggest that in many instances a central lymph node dissection (CLND) should be performed in conjunction with the total thyroidectomy. This procedure consists of removing the lymphatic (glandular) tissues surrounding the thyroid itself, as this tissue may have a propensity for cancer spread. The procedure's necessity has met much controversy in the last decade, but is becoming more of a standard in thyroid cancer surgery.

When a thyroid nodule FNAB is reported as indeterminate, the treatment strategy is less clear cut. While a diagnostic hemi-thyroidectomy or therapeutic total thyroidectomy may be in order, the inclusion of CLND is not clearly defined. In many centers a CLND will be omitted with surgical management for an "indeterminate" lesion, while in others, it is standard protocol. The argument of performing CLND is largely based on the tenet that it adds little surgical time, cost or risks to the patient. Because the evidence of the prognostic role of lymph node metastases is limited many would argue that the risk of not performing CLND is greater than performing CLND. Furthermore, in the event of finding cancer on final pathology, and thus, having to re-operate in the thyroid/central compartment bed, post-operative complications may increase. Opponents of CLND argue that there is a paucity of strong evidence supporting CLND in the improvement of oncologic outcomes and can potentially increase post-operative low calcium levels or vocal nerve damage However, these recommendations are based on retrospective level III evidence. Thus the debate continues: is CLND justified as an adjunct to hemi-or total thyroidectomy in indeterminate thyroid pathology?

The hypothesis is: CLND in hem- or total thyroidectomy for "indeterminate" thyroid nodules will not increase post-operative complications.

Central Compartment Neck Dissection With Thyroidectomy

Central Compartment Neck Dissection Total Thyroidectomy: a Randomized Controlled Trial

Definition: Serum Ionized Calcium (ICa) \< 0.9 mmol/L or symptoms related to hypocalcemia (acral or peri-oral paresthesia/numbness, tetany, muscle cramps/twitching, delirium etc.) and ICa \< 1.0 mmol/L

A surrogate for recurrent laryngeal nerve function. Determined pre- and post-operatively via flexible naso-pharyngoscopy (standard of care).

- evaluated by a validated measure (Voice Handicap Index)

Presence of disease with in central lymph node dissection as per pathology report.

Time from cutting skin to putting on last steri-strip on closed incision in the operating theatre.

Days spent in the hospital post-operatively.

University of Alberta

MD, FRCSC

Symptoms and General Pathology

Carcinoma

Carcinoma, Papillary

Neoplasm Metastasis

Lymphatic Metastasis

Thyroid Cancer, Papillary

Neoplastic Processes

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

Neoplasms, Squamous Cell

Adenocarcinoma

Adenocarcinoma, Papillary

All Drugs and Chemicals

Bone Density Conservation Agents

Parathyroid Hormone

Hormones

Calcium

Calcium, Dietary

Control group-Total thyroidectomy (TT) with central lymph node dissection (CLND) procedure for patients with papillary thyroid carcinoma (PTC)

Standard TT+CLND procedure only

Experimental group- Sentinel lymph node dissection (SLND) after intratumoral indocyanine green (ICG) injection and visualization of all 4 parathyroid glands with infra-red (NIR) fluorescence after intravenous (iv) ICG injection, during total thyroidectomy and central lymph node dissection (CLND).

TT+CLND with NIR fluorescence ICG

Standard TT procedure for thyroid carcinoma, for both groups

Total thyroidectomy (TT)

Standard CLND for thyroid carcinoma, for both groups

Central lymph node dissection (CLND)

Intrathyroidal injection of ICG for SL biopsy, for only experimental group

Sentinel lymph node (SLN) bopsy

Near-infrared (NIR) fluorescence visualization of PGs, for only experimental group

Identification of parathyroid glands (PGs)

Ethem Unal, MD, PhD, USMLE&IFSO-CSS, A. Prof.

Sema Yuksekdag, MD

Ethem Unal, MD, PhD, A. Prof. of Surgery & Surgical Oncology

Indocyanine green (ICG) is a water-soluble organic dye that is cleared totally through the hepatobiliary system. It has a half-life of 3-4 mins, which allows repeated applications. Near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) imaging has been recently introduced, and has been suggested as a useful tool for the identification and preservation of the parathyroid glands (PGs) during total thyroidectomy (TT). ICG can also be used for sentinel lymph node (SLN) biopsy to predict the micrometastases in central lymph nodes (CLN) in thyroid carcinoma, and central lymph node dissection can reduce local recurrence.

Incidence of thyroid cancer has doubled between 1980 and 2020, and it is now the fifth most common malignant tumor among women. The majority are papillary thyroid cancer (PTC), and TT is the procedure of choice. Since the micrometastasis rate of the central lymph nodes (CLNs) is about 30% to 90% in PTC, CLN dissection can improve the prognosis and reduce tumor recurrence as well as provide accurate information for the evaluation of tumor staging. However, TT procedure has some important complications such as vocal cord paralysis (VCP) and hypocalcemia (due to accicental parathyroidectomy or damage to the parathyroid gland-PG- vasculature). Use of intraoperative nerve monitoring (IONM) has reduced the rate of VCP. However, the incidence of postoperative hypocalcemia is still high (15-70%), and it is now the most common complication of TT. Intraoperative identification of SLNs and PGs can help surgeon to overcome these problems.

Near-infrared Fluorescence With Indocyanine Green for Identification of Sentinels and Parathyroids During Thyroidectomy

Near-infrared (NIR) Fluorescence Imaging With Indocyanine Green (ICG) for Identification of Sentinel Lymph Nodes and Parathyroid Glands During Total Thyroidectomy: Prospective Randomized Clinical Trial

Excel data is available upon request at drethemunal@gmail.com

Intrathyroidal injection of indocyanine green (ICG) dye to identify sentinel lymph node (SLN) for biopsy

İntravenous injection of ICG dye, to identify PGs under NIR (High-contrast fluorescence seen or not)

Number of positive lymph nodes (micrometastases)

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Central Compartment Neck Dissection With Thyroidectomy	NCT01106443	Indeterminate T...	Total Thyroidec... Total thyroidec... Hemi-thyroidect... Hemi-thyroidect...	18 Years -	University of Alberta
Central Compartment Neck Dissection With Thyroidectomy	NCT01106443	Indeterminate T...	Total Thyroidec... Total thyroidec... Hemi-thyroidect... Hemi-thyroidect...	18 Years -	University of Alberta
Near-infrared Fluorescence With Indocyanine Green for Identification of Sentinels and Parathyroids During Thyroidectomy	NCT04424485	Thyroid Cancer Thyroid Carcino... Thyroid Metasta... Thyroid Neoplas... Sentinel Lymph ... Lymph Node Meta...	Total thyroidec... Central lymph n... Sentinel lymph ... Identification ...	17 Years - 80 Years	Umraniye Education and Research Hospital

Spots Global Cancer Trial Database for central lymph node dissection