Repeat mediastinal lymph-node dissection for palliation in advanced medullary thyroid carcinoma

In medullary thyroid carcinoma (MTC), the effectiveness of repeat mediastinal lymph-node dissection for palliation of specific symptoms caused by discrete mediastinal lesions is unclear in non-bulky tumor disease.

Between November 1994 and August 1998, five symptomatic MTC patients with radiologic evidence of mediastinal tumor and elevated calcitonin levels were subjected to repeat mediastinal lymph-node dissection.

At reoperation, an average of 7 of 25 (28%) removed cervical and 5 of 9 (56%) dissected mediastinal lymph-nodes were positive on histopathology. A substantial fraction of these were excised from anatomical regions inaccessible through a purely cervical or partial sternotomy approach. Clinical symptoms were effectively palliated in all five patients. Basal serum calcitonin levels fell only moderately, suggesting distant micrometastases. Mortality was nil. Morbidity encompassed two cases of hypoparathyroidism and a lymphatic fistula that closed spontaneously on total parenteral nutrition. One patient later required cervical reoperation deferred at secondary surgery. All five patients have since remained free of cervical and mediastinal tumor at a mean follow-up of 15 months.

In mediastinal lymph-node metastases, repeat lymph-node dissection is warranted for palliation of discrete anatomic lesions inaccessible through a cervical approach.