Clinical Outcomes of a Conservative Approach in Cervical Lymph Node Metastases of Thyroid Cancer

Joana Maciel; Sara Donato; Helder Simões; Valeriano Leite


Clin Endocrinol. 2021;94(3):460-465. 

In This Article

Abstract and Introduction


Context: Lymph node metastases (LNM) can be present in 35% of patients with differentiated thyroid cancer (DTC), and the management of persistent/recurrent nodal disease has been controversial. Watchful waiting may be a reasonable approach in selected patients, but uncertainty about clinical outcomes remains a concern.

Objective: To investigate the outcomes of patients with DTC with recurrent/persistent confirmed LNM under surveillance.

Methods: Patients with LNM from DTC were selected from databases of needle washout thyroglobulin measurements and fine-needle aspiration biopsies performed in our institution. Patients with confirmed metastases, in whom active surveillance was initially proposed, were selected. Main clinical outcomes were analysed.

Results: We found 89 patients with LNM under surveillance. Classic papillary was the most frequent variant (44%). During a median follow-up of 3 (0.5–17.2) years, different treatments were needed in 35 (39.3%) patients: radioactive iodine (RAI) in 23 (25.8%), surgery in 9 (10.1%) and radiotherapy (RT) in 3 (3.4%). From those submitted initially to RAI, progression of disease was observed in 8 patients, 4 requiring other treatment modalities: surgery (n = 2), RT (n = 1) and RAI (n = 1). The remaining 54 (60.7%) patients maintained surveillance. In this group, progression of disease was observed in 26 (48.1%), due to increase in the number and/or volume of metastases, but further treatments were not required.

Conclusion: In a group of patients with cervical LNM under active surveillance, only 16.9% (n = 15) required invasive intervention (surgery or RT).


Thyroid cancer is the most common endocrine malignancy.[1] The most frequent type is papillary thyroid carcinoma (PTC), which is associated with a prevalence of metastases to the cervical lymph nodes (LN) from 30% to 90% of patients.[2] Approximately 31%-46% of differentiated thyroid cancer (DTC) patients will have persistent disease, and 1.2%-6.8% will have structural tumour recurrences during postoperative surveillance. The cervical and mediastinal LN represent the most common location (74%). About 66% of these recurrences are usually detected within 10 years of the initial therapy.[1]

The widespread use of sensitive thyroglobulin (Tg) assays and high-resolution ultrasound (US) in the follow-up of patients with DTC has resulted in the detection of small-volume persistent/recurrent disease in many patients[3] and has increased the need for lymphadenectomy in the care of these patients.[2]

Due to the common presence of reactive LN in the neck region, and the possibility of lymph node metastases (LNM) from nonthyroid tumours, fine-needle aspiration (FNA) is usually required to confirm or exclude metastases. Tg measurements in the needle washout fluid (FNA-Tg) increase the sensitivity of FNA in identifying LNM from DTC, particularly if these are small[4] or cystic.[5]

Recently, it has been suggested that small, stable cervical LN, even when suspicious by US, can be followed under watchful surveillance.[3,6] However, lymph node recurrence can be serious and is sometimes the first sign of a potentially poor outcome.[7] Therefore, clinicians need to take into account several clinical and imaging variables in order to select the best approach to each patient. There are few prospective and randomized clinical trials that have assessed the outcome of active surveillance in FNA confirmed recurrent/persistent LNM.

The aim of this study was to investigate the outcomes of patients with DTC with recurrent/persistent confirmed cervical LNM who were initially proposed for active surveillance.