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Objective: The aim of the present study was to determine the incidence of level I cervical lymph node (LN) involvement in patients
with metastatic papillary thyroid carcinoma (PTC) and the possible indications of its dissection.
Study Design: A prospective clinical study (case series) of 30 consecutive patients with N1b stage PTC, admitted to Alexandria Main
University Hospital, and subjected to total thyroidectomy (TT) and neck dissection of all cervical LN levels..
Methods: In addition to demographics and clinical assessment, pre-operative thyroid function tests, cervical ultrasonography and
computed tomography scan, and fine needle aspiration cytology were performed for all patients, and the final histopathological
examination was reviewed.
Results: A total of 24 unilateral and 6 bilateral neck dissections were performed making a total of 36 neck dissections. Level I LNs
was excised in all patients and proved positive for malignancy in five (13.9%). Levels II, III, IV, V, VI and VII were positive in 52.8%,
58.3%, 58.3%, 33.3%, 63.9% and 22.2%, respectively. Level I involvement correlated significantly with the number of LN levels affected
(3 or more) (p=0.003) and extensive neck dissection (p=0.04). It was not related to any other single LN level involvement, gender,
age, duration of symptoms, family of thyroid cancer, size of largest thyroid nodule, size of largest LN involved, or histopathological
variant of the tumor.
Conclusions: Though not uncommon in patient with PTC, level I cervical LN metastases are associated with multiple level involvement
(3 or more) and invasion of the internal jugular vein, spinal accessory nerve or sternocleidomastoid muscle. A careful selection of
patients requiring level I dissection is recommended to avoid an unjustified added morbidity of the procedure.
Key Words: Thyroid, papillary carcinoma, level I, lymph node, metastases, neck dissection
Mahmoud Sakr, MD, PhD, FACS, graduated in 1981 and completed his Master and Doctorate Degree (PhD) in Surgery at the Faculty of Medicine, Alexandria University, Egypt. He had his fellowship in Surgery and Organ Transplantation at the University of Pittsburgh School of Medicine, Pennsylvania, USA. He is a fellow of the International college of Surgeons (ICS) and American college of Surgeons (ACS) and is currently the chief, Department of Head & Neck and Endocrine Surgery, Faculty of Medicine, Alexandria University. He published 19 books and 93 articles in esteemed journals, and has been serving as an editorial board member of repute.