Indikation und Ausmaß der zervikalen Lymphadenektomie beim differenzierten Schilddrüsenkarzinom

Zusammenfassung

Einleitung: Indikation und Ausmaß der Lymph­adenektomie (LAD) beim differenzierten Schild­düsenkarzinom werden kontrovers diskutiert. Die Zusammenfassung der Tumorentitäten in klinischen Fallstudien, die geringen Fallzahlen sowie die allgemein gute Langzeitprognose führen dazu, dass evidenzbasierte Empfehlungen selten sind oder auf einem niedrigen Evidenzgrad basieren. Den Grundlagen der Evidence-Based-Medicine folgend sollen die unterschiedlichen therapeutisch-operativen Strategien dargestellt werden. Material und Methoden: Literaturrecherche in Medline und EMBase mit den Stichworten: Dif­ferentiated / papillary / follicular thyroid carcinoma, lymphadenectomy, lymph node dissection. Ergebnisse: PTC: Zurzeit liegen 11 klinische retrospektive Studien vor, die prophylaktische vs. nicht durchgeführte LAD bezüglich Rezidivrate und Langzeitüberleben vergleichen. Sechs davon analysieren PTC und FTC gemeinsam. Es kann eine gering evidenzbasierte Empfehlung zur prophylaktischen zervikozentralen LAD beim PTC ausgesprochen werden (Evidenzgrad 3). Eine systematische LAD im zervikolateralen Kompartiment sollte nur bei klinisch auffälligem Lymphknotenstatus durchgeführt werden (Evidenzgrad 3). Eine prophylaktische mediastinale LAD ist nicht indiziert (Evidenzgrad 4), eine therapeutische mediastinale LAD kann aufgrund der erhöhten Morbidität und Mortalität nicht generell empfohlen werden (Evidenzgrad 3). FTC: Es liegen zurzeit 3 klinische retrospektive Studien vor, die Langzeitüberleben und Rezidivrate nach prophylaktischer LAD analysieren. Aufgrund der vorliegenden Daten kann beim präoperativ bekannten invasiven follikulären Schilddrüsenkarzinom eine prophylaktische zervikozentrale systematische LAD empfohlen werden (Evidenzgrad 3). Eine Indikation zur prophylaktischen zervikolateralen oder mediastinalen Lymphadenektomie besteht nicht (Evidenzgrad 3). Schlussfolgerung: Bezüglich der Lymphadenektomie beim differenzierten Schilddrüsenkarzinom können folgenden Empfehlungen gegeben werden: Bei klinisch auffälligen zervikalen Lymphknoten des zentralen und lateralen Kompartiments besteht die Indikation zur systematischen Lymphknotendissektion (Evidenzgrad 3). Die prophylaktische zervikozentrale Lymphknotendissektion wird für PTC größer 10 mm und das invasive FTC empfohlen, eine zervikolaterale oder mediastinale prophylaktische LAD ist nicht indiziert (Evidenzgrad 3). Beim papillären Mikrokarzinom sowie dem minimal invasiven follikulären Karzinom kann empfohlen werden, keine prophylaktische Lymphknotendissektion durchzuführen (Evidenzgrad 3). 

Abstract

Introduction: Indication and extent of lymph node dissection in differentiated thyroid carcinoma are still subject to controversy. The overall favourable prognosis, low study numbers and the different biological features of papillary and follicular carcinoma lead to few evidence-based recommendations and a low level of evidence. The different therapeutic and operative strategies are illustrated on the principles of evidence-based medicine. Material and Methods: A literature search was carried out in Medline and EMBase using the keywords differentiated / papillary / follicular thyroid carcinoma, lymphadenectomy, lymph node dissection. Results: PTC: Eleven retrospective studies outline the effect of prophylactic vs. no lymph node dissection on tumour relapse rate and long-term survival. Six of these studies combine PTC and FTC. A minor evidence-based recommendation for prophylactic cervico-central lymph node dissection in PTC can be given (evidence level 3). Lymph node dissections involving the cervico-lateral compartment can be recommended in the case of clinically pathological findings at the lymph nodes (evidence level 3). A prophylactic mediastinal lymph node dissection is not indicated (evidence level 4), a therapeutic mediastinal LAD cannot be recommended because of higher morbidity and mortality (evidence level 3). FTC: 3 retrospective studies outline the effect of prophylactic lymph node dissection on tumour relapse rate and long-term survival. Based on these, a recommendation for prophylactic cervico-central systematic lymph node dissection can be given for invasive follicular carcinoma (evidence level 3). There is no indication for prophylactic cervico-lateral or mediastinal lymph node dissection (evidence level 3). Conclusion: The following recommendations can be given in differentiated thyroid carcinoma: In the case of clinically pathological findings in cervical lymph nodes, a systematic lymph node dissection of the lateral and central compartment is indicated (evidence level 3). Prophylactic cervico-central lymph node dissection is recommended for PTC larger than 10 mm in diameter and invasive FTC, a cervico-lateral or mediastinal prophylactic lymph node dissection is not indicated (evidence level 3). In papillary microcarcinoma and minimally invasive follicular carcinoma, a prophylactic lymph node dissection is not indicated (evidence level 3). 

Schlüsselwörter

differenziertes Schilddrüsenkarzinom - Lymphadenektomie - evidenzbasierte Medizin

Key words

differentiated thyroid carcinoma - lymph node dissection - evidence-based medicine

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