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Rationale for Central and Bilateral Lymph Node Dissection in Sporadic and Hereditary Medullary Thyroid Cancer

Nuclear Medicine (C.S., E.B., S.L., M.S.), Surgery (J.-P.T.), Biostatistics and Epidemiology (N.B.), and Pathology (B.C.), Institut Gustave-Roussy, 94805 Villejuif cedex, France

Address all correspondence and requests for reprints to: Dr. Martin Schlumberger, Service de Médecine Nucléaire et de Cancérologie Endocrinienne, Institut Gustave-Roussy, 39 rue Camille Desmoulins, 94805 Villejuif Cedex, France. E-mail: schlumbg{at}igr.fr.

A retrospective study was performed on 101 consecutive medullary thyroid cancer (MTC) patients who underwent at Institut Gustave-Roussy (IGR) total thyroidectomy with central and bilateral lymph node dissection. At histology, lymph node metastases were found in 55% of patients. In sporadic MTC, lymph node metastases were observed in the central compartment in 50% of patients, in the ipsilateral jugulocarotid chain in 57%, and in the contralateral jugulocarotid chain in 28%. In hereditary MTC, lymph node metastases were identified in the central compartment in 45% of patients, in the ipsilateral jugulocarotid chain in 36%, and in the contralateral jugulocarotid chain in 19%. Contralateral lymph nodes were found in 37% of metastatic patients with an unilateral tumoral involvement of the thyroid gland. A strong association was observed between tumor size and lymph node involvement for both hereditary and sporadic MTC (P < 0.02). Permanent hypoparathyroidism occurred in 4% of patients and laryngeal nerve palsy in 5%. An undetectable calcitonin level was obtained after surgery in 61% of patients, in 95% of patients without lymph node metastases, and in 32% of patients with lymph node metastases. Among patients with lymph node involvement, undetectable calcitonin level was obtained in 57% of patients with less than or with 10 lymph node metastases and in 4% of patients with more than 10 (P < 0.01).

In conclusion: 1) lymph node metastases occur early in the course of MTC; 2) the pattern of lymph node metastatic distribution in neck areas varied between patients and was not related to the thyroid tumor size; 3) contralateral lymph node metastases were observed even in patients with small thyroid tumor; 4) total thyroidectomy with central and complete bilateral neck dissection should be performed routinely in all patients with sporadic and hereditary MTC, even in those with small thyroid tumors—a contralateral neck dissection may be avoided only in sporadic MTC patients with unilateral involvement of the thyroid gland in the absence of central and ipsilateral neck involvement; and 5) the number of lymph node metastases was predictive of biological cure after surgery.

C.S. is recipient of an Associazione Italiana Ricerca sul Cancro fellowship.

Abbreviations: CT, Calcitonin; FMTC, familial MTC; IGR, Institut Gustave-Roussy; MEN, multiple endocrine neoplasia; MTC, medullary thyroid cancer; RET, rearranged during transfection.

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