Mediastinal lymph node metastases in thyroid cancer: surgery without limits

Metastases to lymph nodes of the superior mediastinum have been found in up to 10% of patients with thyroid carcinoma. The treatment of mediastinal lymph node metastases in thyroid cancer is still far from being standardized. However, in selected cases, especially in case of radioiodine ablation and radiation therapy failure, a surgical resection may improve the patients’ survival in addition to the symptomatic benefits. We report our experience in four consecutive patients who underwent extended mediastinal surgery for large lymph node metastases from thyroid cancer during the last year. All patients were pre-operatory evaluated by a multidisciplinary team involving endocrinologist, anaesthesiologist and surgeons. Surgery was carried out in all cases in two steps, firstly through a cervicotomy in order to remove the eventual local recurrence and ensure a radical neck dissection bilaterally and then by sternotomy, in order to dissect all the lymphadenopathies from the mediastinal structures. Two patients (50%) had an extended vascular infiltration and the extracorporeal circulation (ECC) and, at least, one vascular graft, were needed. No intraoperative or perioperative mortality occurred in this series. Two patients (50%) presented a sternal dehiscence that required a second surgery and a prolonged postoperative hospital stay. In all cases the surgery was radical, and the histological report revealed a macroscopic complete resection and, up to date, no recurrences were found. When feasible, surgery is more effective than systemic therapy in the treatment of thyroid cancer recurrences, especially for medullary thyroid cancer in which radioiodine therapy is ineffective and should always be evaluated in case of vascular infiltration or symptomatic patients. Moreover, due to diversity and complexity of the cervical and mediastinal structures that may be involved, a multidisciplinary medical team should always be guaranteed during the surgery.