Download PDF
Viszeralchirurgie 2002; 37(6): 404-409
DOI: 10.1055/s-2002-36062
Originalarbeit
© Georg Thieme Verlag Stuttgart · New York

Bedeutung der Lymphknoten- und Fernmetastasen für das Ausmaß der chirurgischen Therapie von papillären und follikulären Schilddrüsenkarzinomen

Significance of Lymph Node and Distant Metastases with Respect to Surgical Treatment for Papillary and Follicular Thyroid CarcinomaJ.  Witte1 , J.  Dieken1 , D.  Papathanassiou1 , H.-D.  Röher1
  • 1Klinik für Allgemeine und Unfallchirurgie, Universität Düsseldorf
Further Information

Publication History

Publication Date:
11 December 2002 (online)

    Permissions and Reprints

Zusammenfassung

Einleitung: In Bezug auf die Rezidivhäufigkeit und die Mortalität wird die Bedeutung der Lymphknoten- und Fernmetastasen als Prognosefaktoren kontrovers diskutiert. Patienten und Methode: In einer Nachbeobachtungsstudie von 346 Patienten mit einem papillären und 105 Patienten mit einem follikulären Schilddrüsenkarzinom, die zwischen 1986 und 1998 in der Chirurgischen Universitätsklinik Düsseldorf operiert worden waren, wurden univariate (Kaplan-Meier-Log-Rank- oder Breslow-Test) und multivariate (Cox Regression-Test) Risikoanalysen durchgeführt. Ergebnisse: Multivariat zeigten sich die Lymphknotenmetastasen als bedeutende Risikofaktoren für das Rezidiv und die Fernmetastasen als bedeutende Risikofaktoren für die Mortalität bei papillären und follikulären Schilddrüsenkarzinomen. Schlussfolgerung: Aufgrund der Bedeutung der Lymphknotenmetastasen für das Rezidiv empfehlen wir bei papillären und follikulären Schilddrüsenkarzinomen im Tumorstadium T3 und T4 sowie bei makroskopisch vorhandenen Lymphknoten die Erweiterung der Thyreoidektomie mit einer ein- oder beidseitigen modifizierten, systematischen Lymphknotendissektion. Wegen der guten Prognose insbesondere der follikulären Schilddrüsenkarzinome erfolgt bei langen Krankheitsverläufen die Behandlung der Fernmetastasen operativ oder mittels Radiojodtherapie zur Verbesserung der Lebensqualität.

Abstract

Introduction: The significance of lymph node and distant metastases in papillary and follicular thyroid carcinoma is still discussed controversially. Patients and methods: A retrospective survey was carried out on 346 patients with papillary and 105 patients with follicular thyroid cancer operated in the Department of surgery at the University hospital of Düsseldorf from 1986 to 1998. Univariate analysis was done by Kaplan Meier test and multivariate analysis by Cox Regression test. Results: Multivariate analysis with Cox Regression test demonstrated a high significance of lymph node metastases for recurrence and a high significance of distant metastases for mortality. Summary: With respect to the significance of lymph node metastases for recurrence we advocate thyroidectomy plus uni - or bilateral modified neck dissection in T3 and T4 thyroid carcinoma as well as in all cases with visible lymph node enlargement. Treatment of distant metastases by operation or radioiodine is recommended with respect to increased quality of life because of the favourable long term survival especially in follicular thyroid cancer.

Schlüsselwörter

Papilläre und follikuläre Schilddrüsenkarzinome - Lymphknoten- und Fernmetastasen - chirurgische Therapie

Key words

Papillary and follicular thyroid carcinoma - lymph node and distant metastases - surgical treatment

Literatur

  • 1 Junginger T h. Leitlinien der Therapie maligner Schilddrüsentumoren.  In Grundlagen der Chirurgie, Mitteilungen der Deutschen Gesellschaft für Chirurgie.. 1996;  3 G70 1-8
    PubMedGoogle Scholar
  • 2 Tubiana M, Schlumberger M, Rougier P h, Laplanche A, Benhamou E, Gardet P, Caillou B, Travagli J-P, Parmentier C. Long-term results and prognostic factors in patients with differentiated thyroid carcinoma.  Cancer. 1985;  55 794-804
    PubMedGoogle Scholar
  • 3 Mazzaferri E L, Young R L. Papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients.  Am J Med. 1981;  70 511-518
    CrossrefPubMedGoogle Scholar
  • 4 Samaan N A, Maheshwari Y K, Nader S, Hill C S, Schultz P N, Haynie T P, Hickey R C, Clark R L, Goepfert H, Ibanez M L, Litton C E. Impact of therapy for differentiated carcinoma of the thyroid: an analysis of 706 cases.  J Clin Endocrinol Metab. 1983;  56 1131-1138
    PubMedGoogle Scholar
  • 5 DeGroot L J, Kaplan E L, McCormick M, Straus F H. Natural history, treatment, and course of papillary thyroid carcinoma.  J Clin Endocrinol Metab. 1990;  71 414-424
    CrossrefPubMedGoogle Scholar
  • 6 Attie J N. Modified neck dissection in treatment of thyroid cancer: a safe procedure.  Eur J Cancer Clin Oncol. 1988;  24 315
    CrossrefPubMedGoogle Scholar
  • 7 Seiler C A, Schäfer M, Büchler M W. Pro und Contra Lymphadenektomie beim papillären und follikulären Schilddrüsenkarzinom.  Zentralbl Chir. 2000;  125 835-841
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Lerch H, Saur H-B, Schober O. Bedeutung von Lymphknotenmetastasen beim differenzierten Schilddrüsenkarzinom.  Nucl Med. 1995;  34 203-248
    PubMedGoogle Scholar
  • 9 Rossi R L, Cady B, Siverman M L, Wool M S, Horner T A. Current results of conservative surgery for differentiated thyroid carcinoma.  World J Surg. 1986;  10 612-622
    CrossrefPubMedGoogle Scholar
  • 10 McConahey W M, Hay I D, Woolner L B, van Heerden J A, Taylor W F. Papillary thyroid cancer treated at the Mayo Clinic, 1946 through 1970: initial manifestation, pathologic findings, therapy, and outcome. Mayo Clin.  Proc.. 1986;  61 978-996
    PubMedGoogle Scholar
  • 11 Akslen L A, Myking A O, Salvesen H, Varhaug J E. Prognostic importance of various clinicopathological features in papillary thyroid carcinoma.  Eur J Cancer. 1993;  29A 44-51
    PubMedGoogle Scholar
  • 12 Simpson W J, McKinney S E, Carruthers J S, Gospodarowicz M K, Sutcliffe S B, Panzarella T. Papillary and follicular thyroid cancer. Prognostic factors in 1578 patients.  Am J Med. 1987;  83 479-488
    CrossrefPubMedGoogle Scholar
  • 13 McHenry C R, Rosen I B, Walfish P G. Prospective management of nodal metastases in differentiated thyroid cancer.  Am J Surg. 1991;  162 353-356
    CrossrefPubMedGoogle Scholar
  • 14 Harness J K, Thompson N W, McLeod M K, Pasieka J L, Fukuuchi A. Differentiated thyroid carcinoma in children and adolescents.  World J Surg. 1992;  16 547-554
    CrossrefPubMedGoogle Scholar
  • 15 Noguchi S, Noguchi A, Murakami N. Papillary carcinoma of the thyroid. I: developing pattern of metastasis.  Cancer. 1970;  26 1053-1060
    CrossrefPubMedGoogle Scholar
  • 16 Byar D P, Green S B, Dor P, Williams E D, Colon J, van Gilse H A, Mayer M, Sylvester R J, van Glabbeke M. A prognostic index for thyroid carcinoma: a study of the E.O.R.T.C. Thyroid Cancer Cooperative Group.  Eur J Cancer. 1979;  15 1033-1041
    PubMedGoogle Scholar
  • 17 Sellers M, Beenken S, Blankenship A, Soong S-j, Turbat-Herrera E, Urist M, Maddox W. Prognostic significance of cervical lymph node metastases in differentiated thyroid cancer.  Am J Surg. 1992;  164 578-581
    CrossrefPubMedGoogle Scholar
  • 18 Harwood J, Clark O, Dunphy J E. Significance of lymph node metastasis in differentiated thyroid cancer.  Am J Surg. 1978;  136 107-110
    CrossrefPubMedGoogle Scholar
  • 19 Young R L, Mazzaferri E L, Rahe A J, Dorfman S G. Pure follicular thyroid carcinoma: impact of therapy in 214 patients.  J Nucl Med. 1980;  21 733-737
    PubMedGoogle Scholar
  • 20 Carcangiu M L, Zampi G, Pupi A, Castagnoli A, Rosai J. Papillary carcinoma of the thyroid.  Cancer. 1985;  55 805-828
    CrossrefPubMedGoogle Scholar
  • 21 Woolner L. B. Thyroid carcinoma: pathologic classification with data on prognosis.  Semin Nucl Med. 1971;  1 481-502
    PubMedGoogle Scholar
  • 22 Hamming J F, van de Velde C JH, Goslings B M, Fleuren G J, Hermans J, Delemarre J F, van Slooten E A. Preoperative diagnosis and treatment of metastases to the regional lymph nodes in papillary carcinoma of the thyroid gland.  Surg Gynecol Obstet. 1989;  169 107-114
    PubMedGoogle Scholar
  • 23 Yamashita H, Noguchi S, Murakami N. et al . Extracapsular invasion of lymph node metastasis is an indicator of distant metastasis and poor prognosis in patients with thyroid papillary carcinoma.  Cancer. 1997;  80 2268-2272
    CrossrefPubMedGoogle Scholar
  • 24 Noguchi S, Murakami N, Yamashita H, Toda M, Kawamoto H. Papillary thyroid carcinoma: modified radical neck dissection improves prognosis.  Arch Surg. 1998;  133 276-280
    CrossrefPubMedGoogle Scholar
  • 25 Brennan M D, Bergstrahl E J, van Heerden J A, McConahey W M. Follicular thyroid cancer treated at the Mayo Clinic, 1946 through 1970: initial manifestation, pathologic findings, therapy and outcome.  Mayo Clin Proc. 1990;  66 11-22
    PubMedGoogle Scholar
  • 26 Dralle H, Gimm O. Lymphadenektomie beim Schilddrüsenkarzinom.  Chirurg. 1996;  67 788-806
    PubMedGoogle Scholar
  • 27 Farahati J, Mörtl M, Reiners C. Die Bedeutung des Lymphknotenstatus beim papillären und follikulären Schilddrüsenkarzinom für den Nuklearmediziner.  Zentralbl Chir. 2000;  125 830-834
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Harada T, Shimaoka K, Yakumaru K, Taniguchi T, Ito K. Prognosis of thyroid carcinoma.  Int Adv Surg Oncol. 1981;  4 83-110
    PubMedGoogle Scholar
  • 29 Woolner L B, Beahrs O H, Black B M, McConahey W M, Keating F R Jr.. Classification and prognosis of thyroid carcinoma: a study of 885 cases observed in a thirty year period.  Am J Surg. 1961;  102 354-387
    CrossrefPubMedGoogle Scholar
  • 30 Mazzaferri E L, Young R L, Oertel J E, Kemmerer W T, Page C P. Papillary thyroid carcinoma: the impact of therapy in 576 patients.  Medicine (Baltimore). 1977;  56 171-196
    PubMedGoogle Scholar
  • 31 Franssila K O. Outcome in papillary carcinoma of the thyroid.  Ann Chir Gynaecol. 1978;  67 49-57
    PubMedGoogle Scholar
  • 32 Mizukami Y, Michigishi T, Nonomura A, Hashimoto T, Terahata S, Noguchi M, Hisada Y, Matsubara F. Distant metastases in differentiated thyroid carcinomas: A clinical and pathologic study.  Hum Pathol. 1990;  21 283-290
    CrossrefPubMedGoogle Scholar
  • 33 Schelfout L JDM, Creutzberg C L, Hamming J F, Fleuren G J, Smeenk D, Hermanns J, van de Velde C JH. Multivariate analysis of survival in differentiated thyroid cancer: the prognostic significance of the age factor.  Eur J Cancer Clin Oncol. 1988;  24 331-337
    CrossrefPubMedGoogle Scholar
  • 34 Böttger T, Klupp J, Sorger K, Junginger T. Prognostisch relevante Faktoren beim follikulären Schilddrüsenkarzinom.  Langenbecks Arch Chir. 1990;  375 266-271
    PubMedGoogle Scholar
  • 35 Shaha A R, Shah J P, Loree T R. Differentiated thyroid cancer presenting initially with distant metastasis.  Am J Surg. 1997;  174 474-476
    CrossrefPubMedGoogle Scholar
  • 36 Loh K C, Greenspan F S, Gee L, Miller T R, Yeo P P. Pathological tumor-node-metastasis (pTNM) staging for papillary and follicular thyroid carcinomas: a retrospective analysis of 700 patients.  J Clin Endocrinol Metab. 1997;  82 3553-3562
    CrossrefPubMedGoogle Scholar
  • 37 Jensen M H, Davis R K, Derrick L. Thyroid cancer: a computer-assisted record of 5287 cases.  Otolaryngol Head Neck Surg. 1990;  102 51-65
    PubMedGoogle Scholar
  • 38 Staunton M D, Bourne H. Malignant thyroid tumours 1932 to 1972: the outcome in 492 patients.  Eur J Surg Oncol. 1992;  18 469-474
    PubMedGoogle Scholar
  • 39 Hoie J, Stenwig A E, Kullmann G, Lindegaard M. Distant metastases in papillary thyroid cancer. A review of 91 patients.  Cancer. 1988;  61 1-6
    PubMedGoogle Scholar
  • 40 Smith S A, Hay I D, Goellner J R, Ryan J J, McConahey W M. Mortality from papillary thyroid carcinoma. A case-control study of 56 lethal cases.  Cancer. 1988;  62 1381-1388
    PubMedGoogle Scholar
  • 41 Tenvall J, Björklund A, Möller T, Ranstam J, Akerman M. Is the EORTC prognostic index of the thyroid cancer valid in differentiated thyroid carcinoma?.  Cancer. 1986;  57 1405-1414
    PubMedGoogle Scholar
  • 42 Lerch H, Schober O, Kuwert T, Saur H B. Survival of differentiated thyroid carcinoma studied in 500 patients.  J Clin Oncol. 1997;  15 2067-2075
    PubMedGoogle Scholar
  • 43 van Heerden J A, Hay I D, Goellner J R, Salomao D, Ebersold J R, Bergstralh E J, Grant C S. Follicular thyroid carcinoma with capsular invasion alone: A nonthreatening malignancy.  Surgery. 1992;  112 1130-1138
    PubMedGoogle Scholar
  • 44 Waneo H J, Andrews W, Kaiser D L. Thyroid cancer: some basic considerations.  Ca Cancer J Clin. 1983;  33 87-97
    PubMedGoogle Scholar
  • 45 Grant C S, Hay I D, Gough I R, Bergstralh E F, Goellner J R, McConahey W M. Local recurrence in papillary thyroid carcinoma: is extent of surgical resection important?.  Surgery. 1988;  104 954-962
    PubMedGoogle Scholar
  • 46 Cady B, Sedgwick C E, Meissner W A, Bookwalter J R, Romagosa V, Werber J. Changing clinical, pathologic, therapeutic, and survival patterns in differentiated thyroid carcinoma.  Ann Surg. 1976;  184 541-553
    CrossrefPubMedGoogle Scholar
  • 47 Gagel R F, Goepfert H, Callender D L. Changing concepts in the pathogenesis and management of thyroid carcinoma.  Cancer J Clin. 1996;  46 261-283
    PubMedGoogle Scholar
  • 48 Perzik S. The place of total thyroidectomy in the management of 909 patients with thyroid disease.  Am J Surg. 1976;  132 480-483
    CrossrefPubMedGoogle Scholar
  • 49 Clark O H. Total thyroidectomy: the treatment of choice for patients with differentiated thyroid cancer.  Ann Surg. 1982;  196 361-370
    PubMedGoogle Scholar
  • 50 Mazzaferri E, Jhiang S. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer.  Am J Med. 1994;  97 418-428
    CrossrefPubMedGoogle Scholar
  • 51 Salvesen H, Njolstad P R, Akslen L A, Albrektsen G, Soreide O, Varhaug J E. Papillary thyroid carcinoma: a multivariate analysis of prognostic factors including an evaluation of the p-TNM staging system.  Eur J Surg. 1992;  158 583-589
    PubMedGoogle Scholar
  • 52 Hughes C J, Shaha A R, Shah J P, Loree T R. Impact of lymph node metastasis in differentiated carcinoma of the thyroid: a matched-pair analysis.  Head Neck. 1996;  18 127-132
    CrossrefPubMedGoogle Scholar
  • 53 Clark O H. Predictors of thyroid tumor aggressiveness.  West J Med. 1996;  165 131-138
    PubMedGoogle Scholar
  • 54 Cady B. Surgery of thyroid cancer.  World J Surg. 1981;  5 3-8
    CrossrefPubMedGoogle Scholar
  • 55 Ozaki O, Ito K, Kobayashi K, Suzuki A, Manabe Y, Hosoda Y. Modified neck dissection for patients with non advanced, differentiated carcinoma of the thyroid.  World J Surg. 1988;  12 825-829
    CrossrefPubMedGoogle Scholar
  • 56 Noguchi M, Kumaki T, Taniya T, Miyazaki I. Bilateral cervical lymph node metastases in well-differentiated thyroid cancer.  Arch Surg. 1990;  125 804-806
    PubMedGoogle Scholar
  • 57 Scheumann G FW, Gimm O, Wegener G, Hundeshagen H, Dralle H. Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer.  World J Surg. 1994;  18 559-568
    CrossrefPubMedGoogle Scholar
  • 58 Simon D, Goretzki P E, Witte J, Röher H D. Incidence of regional recurrence guiding radicality in differentiated thyroid carcinoma.  World J Surg. 1996;  20 860-866
    CrossrefPubMedGoogle Scholar
  • 59 Witte J, Goretzki P E, Dieken J, Simon D, Röher H D. Importance of lymph node metastases in follicular thyroid cancer.  World J Surg. 2002;  26 1017-1022
    CrossrefPubMedGoogle Scholar

Dr. Jürgen Witte

Klinik für Allgemeine und Unfallchirurgie, Universität Düsseldorf

Moorenstraße. 5

40225 Düsseldorf