Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• The visor flap approach is a surgical technique used for extensive access to the mandible and oral cavity:
  • By elevating the facial skin from the chin and cheeks, often extending from mastoid to mastoid
• The visor flap approach:
  • Provides sufficient exposure for anteriorly located lesions:
    • But is not satisfactory for tumors
      located in the posterior oral cavity
  • The benefit of this approach:
    • Is that it avoids a lower lip–splitting incision:
      • But produces permanent numbness of the chin:
        • Because the mental nerves
          need to be transected for adequate mobilization of the flap
      • It also may cause sagging of the lower lip and drooling:
        • Because of a loss of support and sensation
    • Thus its utility is limited
• Key Aspects of the Visor Flap Approach:
  • Incision and Elevation: 
    • A horizontal incision is made in a natural neck crease:
      • Often from mastoid tip to mastoid tip
    • The flap is raised in a subplatysmal plane up to the inferior border of the mandible:
      • Then superiorly to expose the cheek and chin:
        • Avoiding injury to the marginal mandibular nerve
  • Indications: 
    • Primarily used for large, advanced anterior oral cavity or oropharyngeal tumors, mandibulectomies, and mandibular reconstructions
  • Advantages: 
    • Excellent vascular supply
    • No lip-splitting scar
    • Good access to the neck for dissection
  • Disadvantages: 
    • Potential for anesthesia of the chin skin due to sacrifice of mental nerves
  • Application:
    • It is often paired with a tracheotomy for airway management and can be combined with lingual release or mandibular osteotomies if necessary
      

• AJCC 9th Edition TNM Staging — Nasopharyngeal Carcinoma:
  • Applies to carcinomas of the nasopharynx:
    • Excludes mucosal melanoma, lymphoma, and sarcoma
  • Nasopharyngeal carcinoma is staged separately from all other head and neck mucosal sites
• PRIMARY TUMOR (T):
  • TX — Primary tumor cannot be assessed
  • T0 — No tumor identified, but EBV-positive cervical node involvement
  • Tis — Carcinoma in situ
  • T1 — Confined to nasopharynx, or extension to oropharynx and / or nasal cavity WITHOUT parapharyngeal involvement
  • T2 — Extension to parapharyngeal space, and / or adjacent soft tissue (medial pterygoid, lateral pterygoid, prevertebral muscles)
  • T3 — Unequivocal infiltration of bony structures at skull base, cervical vertebra, pterygoid structures, and / or paranasal sinuses
  • T4 — Intracranial extension, cranial nerve involvement, hypopharynx, orbit, parotid gland, and / or extensive soft tissue infiltration beyond the anterolateral surface of the lateral pterygoid muscle
• REGIONAL LYMPH NODES (N)
  • Key landmarks:
    • 6 cm size cutoff; caudal border of the cricoid cartilage
    • N0 — No regional lymph node metastasis
    • N1 — Unilateral cervical node(s) and / or unilateral or bilateral retropharyngeal node(s), ≤ 6 cm, above the caudal border of the cricoid cartilage, without advanced extranodal extension (ENE)
    • N2 — Bilateral cervical node(s), ≤ 6 cm, above the caudal border of the cricoid cartilage, without advanced ENE
    • N3 — Node(s) > 6 cm, and / or extension below the caudal border of the cricoid cartilage, and / or advanced radiologic ENE with involvement of adjacent muscles, skin, and / or neurovascular bundle
• DISTANT METASTASIS (M)
  • M0 — No distant metastasis
  • M1a — ≤ 3 metastatic lesions
  • M1b — > 3 metastatic lesions
• HISTOLOGIC GRADE
  • No grading system is applied to nasopharyngeal carcinoma
• STAGE GROUPS
  • Stage 0 — Tis, N0, M0
  • Stage IA — T1 to T2, N0, M0
  • Stage IB — T0 to T2, N1, M0
  • Stage II — T0 to T2, N2, M0
  • Stage II — T3, N0 to N2, M0
  • Stage III — T4, Any N, M0
  • Stage III — Any T, N3, M0
  • Stage IVA — Any T, Any N, M1a
  • Stage IVB — Any T, Any N, M1b
• STAGING WORKUP:
  • Nasopharyngeal fiberoptic examination
  • Biopsy of primary site or FNA of neck node
  • MRI with and without contrast from skull base to clavicle (± CT of skull base / neck for bony erosion)
  • FDG-PET/CT and / or contrast-enhanced chest CT for distant disease (bone scan if PET/CT not performed)
  • Plasma EBV DNA testing:
    • HPV testing may be considered to inform etiology
• KEY CHANGES FROM 8TH EDITION:
  • Advanced radiologic ENE added as an N3 criterion
  • Stage I expanded to T1 to 2 N0 to 1 and subdivided into IA (N0) and IB (N1)
  • Former stage III and IVA down-classified to II and III; all M0 disease now falls within stages I to III
  • Stage IV reserved exclusively for metastatic disease, subdivided by ≤ 3 cm vs > 3 cm lesions
  • T3 now requires unequivocal bone involvement
• The stage groups, T/N/M definitions, and workup elements above are taken directly from the NCCN-endorsed AJCC 9th edition tables and the nasopharynx workup algorithm
• The summarized changes from the 8th edition reflect the published TNM-9 derivation cohort of 4,914 patients:
  • Note that treatment stratification in the NCCN algorithm keys off TNM categories rather than stage groups, so the stage group alone does not determine whether concurrent chemoradiation or induction chemotherapy is indicated
  • Plasma EBV DNA, while part of workup, remains outside the anatomic staging system
• NCCN Treatment by TNM Category – Nasopharyngeal Carcinoma (v2.2026):
  • All recommendations are category 2A unless otherwise indicated
  • Recommendations are based on clinical trial data in EBV-associated nasopharyngeal cancer
• NON-METASTATIC DISEASE (M0)
  • T1, N0, M0:
    • Definitive RT alone
  • T2, N0, M0:
    • Definitive RT ± concurrent systemic therapy if high-risk features
  • T0 (EBV+) to T2, N1, M0 OR T3, N0, M0:
    • Concurrent systemic therapy / RT
    • Consider induction or adjuvant chemotherapy if high-risk features
  • T3, N1 to 3, M0 OR T4, N0 to 3, M0 OR T0 (EBV+)–T2, N2 to 3, M0:
    • Clinical trial (preferred)
    • OR induction chemotherapy followed by concurrent systemic therapy / RT (preferred; category 1)
    • OR concurrent systemic therapy / RT followed by adjuvant chemotherapy
    • OR concurrent systemic therapy / RT alone (category 2B)
  • High-risk features:
    • Bulky tumor volume
    • High serum EBV DNA copy number
• METASTATIC DISEASE (T1 to 4, N0 to 3, M1):
  • Oligometastatic disease:
    • Induction chemotherapy (if PS 0 to 1), followed by one of:
      • RT to primary and regional nodes, and to oligometastases as indicated
      • Cisplatin / RT
      • Maintenance capecitabine
    • OR concurrent cisplatin + RT (if PS 0–1)
    • OR systemic therapy (if PS 0–2)
  • Widely metastatic, good performance status (PS 0 to 2):
    • Systemic therapy:
      • If complete or near-complete response:
        • Consider definitive RT to primary and regional nodes (preferred) and to oligometastases as indicated, or continued systemic therapy
  • Widely metastatic, poor performance status (PS 3 to 4):
    • Best supportive care
• FOLLOW-UP:
  • All M0 pathways proceed to post systemic therapy / RT or post-RT neck evaluation, then routine follow-up
  • Recurrent or persistent disease is managed per the recurrent / advanced disease algorithm
• KEY POINT:
  • Treatment assignment keys off TNM category, not AJCC 9th edition stage group:
    • For example, stage II under TNM-9 encompasses both T3N0M0 (chemoradiation) and T3N2M0 (induction chemotherapy followed by chemoradiation):
      • So the stage group alone is insufficient to select therapy
• The M0 treatment branches, including the category 1 designation for induction chemotherapy followed by chemoradiation in T3N1 to 3 / T4/N2 to 3 disease and the category 2B designation for concurrent chemoradiation alone in that same group, come directly from the NCCN nasopharynx treatment algorithm
• The metastatic branch separates oligometastatic disease — where locoregional RT to the primary and to metastatic sites is incorporated — from widely metastatic disease managed with systemic therapy, with definitive RT considered only after complete or near-complete response
• Workup precedes this split, with M0 versus M1 determined by:
  • FDG-PET/CT and / or contrast chest CT
• References:
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers, Version 2.2026. AJCC TNM Staging System for the Nasopharynx (9th ed., 2021), page ST-3.
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers, Version 2.2026. Staging (nasopharynx excluded from general mucosal head and neck staging systems).
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers, Version 2.2026. Cancer of the Nasopharynx: Workup (NASO-1).
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers, Version 2.2026. Cancer of the Nasopharynx: Treatment of Primary and Neck by Clinical Staging (NASO-2).
  • Pan JJ, Mai HQ, Ng WT, et al. Ninth Version of the AJCC and UICC Nasopharyngeal Cancer TNM Staging Classification. JAMA Oncol. 2024.
  • Pan JJ, Mai HQ, Ng WT, et al. Ninth Version of the AJCC and UICC Nasopharyngeal Cancer TNM Staging Classification. JAMA Oncol. 2024.
  • Pan JJ, Mai HQ, Ng WT, et al. Ninth Version of the AJCC and UICC Nasopharyngeal Cancer TNM Staging Classification. JAMA Oncol. 2024.
  • Rai P, Lakhani DA, Agarwal A, Bhatt AA. The 9th Version of the AJCC Staging System for Nasopharyngeal Carcinoma: A Guide for Radiologists. AJR Am J Roentgenol. 2025.
  • Du XJ, Wang GY, Zhu XD, et al. Refining the 8th Edition TNM Classification for EBV Related Nasopharyngeal Carcinoma. Cancer Cell. 2024.
  • Cao C, Treechairusame T, Wu Y, et al. Staging of Non-Metastatic Nasopharyngeal Carcinoma With PET/CT. Eur Radiol. 2026.
  • Lee VH, Kwong DL, Leung TW, et al. The Addition of Pretreatment Plasma Epstein-Barr Virus DNA Into the Eighth Edition of Nasopharyngeal Cancer TNM Stage Classification. Int J Cancer. 2019.
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers, Version 2.2026. Cancer of the Nasopharynx: Treatment of Primary and Neck for T1–4, N0–3, M1 (NASO-3).
    

• The decision to extend a supraomohyoid neck dissection (levels I to III) to include level IV (extended supraomohyoid neck dissection):
  • Hinges on whether pN+ disease is discovered in levels I to III, the number of positive nodes, and the pN classification:
    • Below is a comprehensive review of the specific scenarios and supporting data
• Scenario 1 – cN0 Neck → Intraoperative Discovery of pN+ Disease in Levels I to III:
  • This is the most clinically relevant scenario
  • When a patient undergoes END for a cN0 neck and positive nodes are found on frozen section or final pathology:
    • The risk of concurrent level IV to V disease rises substantially compared to the overall cN0 population
  • The Haas et al. (2025) study directly addressed this question in 61 cN0 patients who were found to be pN+ in levels I to III [1]:
    • 9.8% (6/61) had metastases in levels IV to V:
      • Well above the 5% threshold generally used to justify elective dissection
      • > 1 positive node in levels I to III was the strongest predictor of level IV to V involvement (p = 0.027)
      • pN classification > pN2b significantly increased the prevalence of level IV to V metastases (p = 0.002)
      • Extracapsular spread (ECS) showed a trend toward increased IV to V involvement (p = 0.078), though not statistically significant in this cohort
      • This 9.8% rate stands in stark contrast to the 0.50% true skip metastasis rate in the overall cN0 population:
        • Underscoring that the discovery of pN+ disease in levels I to III fundamentally changes the risk calculus
• Scenario 2 – cN+ Neck (Preoperatively Known Nodal Disease):
  • For the clinically node-positive neck, both ASCO and NCCN guidelines explicitly recommend including level IV in the dissection [2][3]
  • The ASCO guideline states:
    • An ipsilateral therapeutic selective neck dissection for a cN+ neck should include:
      • Nodal levels Ia, Ib, IIa, IIb, III, and IV with ≥ 18 lymph nodes (evidence-based, intermediate quality, moderate strength) [2]
    • The NCCN guidelines specify:
      • cN1 to cN2a–c disease warrants selective or comprehensive neck dissection [3]
  • The American Head and Neck Society review provides the supporting data:
    • Occult level IV nodal metastatic disease is reported in 11.1% to 23.7% of cN+ oral tongue cancers, and 15% of all patients undergoing therapeutic neck dissection had level IV metastases [4]:
      • This rate is high enough that level IV dissection should be considered even in the absence of overt metastatic lymph node involvement at that level [4]
• Scenario 3 – When to Add Level V:
  • Level V dissection carries significant risk to the spinal accessory nerve and is not routinely recommended
  • However, the data support its inclusion in specific circumstances [4]:
    • Clinical involvement of levels I to IV:
      • Was associated with occult metastases in level V in 27% of oral cavity SCCs in one study
    • Level V should be considered in patients with bulky, multilevel nodal disease
  • The overall rate of level V metastasis:
    • In therapeutic neck dissections is only ~4%
• Practical Decision Framework – When to Extend to Level IV:
  • Prognostic Implications of Level IV Disease:
    • Importantly, the discovery of level IV or V disease is not merely an anatomic finding:
      • It carries significant prognostic weight
    • The NCCN guidelines list nodal disease in levels IV or V as an adverse pathologic feature:
      • Which triggers consideration of adjuvant systemic therapy / RT [3]
    • A SEER-based study of 8,281 patients:
      • Found that 5-year disease-specific survival dropped from 42.0% for level I to III disease to 30.6% for level IV [5]
    • Furthermore, level IV to V metastasis:
      • Is an independent risk factor for distant metastasis on multivariate analysis [6]
• Morbidity Considerations:
  • Extension to level IV is not without cost
  • The American Head and Neck Society review notes that dissection of level IV:
    • Is associated with a low but possible risk of injury to the phrenic nerve or brachial plexus and increases the risk of chylous fistula [4]:
      • These risks must be weighed against the oncologic benefit, particularly in the cN0 setting where the absolute risk of level IV disease is low
• Summary:
  • For the cN0 neck with no intraoperative evidence of nodal disease:
    • Levels I to III remain the standard
  • However, when intraoperative frozen section or final pathology reveals pN+ disease:
    • Particularly > 1 positive node or pN > pN2b:
      • The risk of level IV to V involvement rises to ~10%:
        • Justifying extension to level IV [1]
  • For any preoperatively cN+ neck:
    • Level IV should be included as standard practice per ASCO and NCCN guidelines [2][3]
  • Level V should be reserved for:
    • Multilevel, bulky nodal disease
• References:
  • 1. In Vivo Probability of Metastases in Levels IV-V in Oral Squamous Cell Carcinoma With a cN0/pN+ Situation in Levels I-Iii. Haas L, Mischkowski RA, Knape U, Król KM, Sakkas A. In Vivo (Athens, Greece). 2025 Nov-Dec;39(6):3437-3444. doi:10.21873/invivo.14141.
  • 2. Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline. Koyfman SA, Ismaila N, Crook D, et al. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 2019;37(20):1753-1774. doi:10.1200/JCO.18.01921.
  • 3. Head and Neck Cancers. National Comprehensive Cancer Network. Updated 2025-12-08.
  • 4. Oral Cavity Cancer Surgical and Nodal Management: A Review From the American Head and Neck Society. Eskander A, Dziegielewski PT, Patel MR, et al. JAMA Otolaryngology– Head & Neck Surgery. 2024;150(2):172-178. doi:10.1001/jamaoto.2023.4049.
  • 5. Impact of Nodal Level Distribution on Survival in Oral Cavity Squamous Cell Carcinoma: A Population-Based Study. Marchiano E, Patel TD, Eloy JA, Baredes S, Park RC. Otolaryngology–Head and Neck Surgery : Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 2016;155(1):99-105. doi:10.1177/0194599816636356.
  • 6. Risk Factors for Distant Metastasis in Locoregionally Controlled Oral Squamous Cell Carcinoma: A Retrospective Study. Tomioka H, Yamagata Y, Oikawa Y, et al. Scientific Reports. 2021;11(1):5213. doi:10.1038/s41598-021-84704-w.

• Indications for elective neck dissection (END):
  • Depth of Invasion (DOI) Thresholds:
    • DOI is the single most important predictor:
      • Guiding the decision to perform END in cN0 oral cavity SCC
    • The NCCN Guidelines stratify the decision as follows [1]:
      • DOI > 3 mm:
        • END should be strongly considered if RT is not already planned (supported by level 1 evidence from the D’Cruz / Tata Memorial trial)
      • The landmark D’Cruz et al. (2015) randomized trial of 500 patients with cT1 to T2 cN0 oral cavity SCC:
        • Demonstrated that upfront END significantly improved 3-year overall survival (80.0% vs. 67.5%) and disease-free survival (69.5% vs. 45.9%) compared to therapeutic neck dissection [2]
        • Absolute benefits: 12.5% points for OS and 23.6% point for DFS, corresponding to NNT of 8 to prevent one death and 4 to prevent one relapse
        • Adverse event rates were 6.6% with END vs. 3.6% with therapeutic dissection
        • Post hoc analysis showed no benefit for tumors with DOI ≤ 3 mm, while 28% of cN0 necks with DOI > 3 mm harbored occult metastases [3]
      • A 2025 meta-analysis of 17 studies (2,263 patients):
        • Confirmed END reduces regional recurrence (RR 0.47) and improves OS (RR 0.75) and DSS (RR 1.32) [4]
    • A validation study of 300 patients [5]:
      • Confirmed that DOI ≥ 4 mm is the optimal ROC-derived threshold (95.1% sensitivity, 52.9% specificity) for predicting occult nodal metastasis:
        • With regional recurrence-free survival significantly higher in the END group for DOI ≥ 4 mm (p = 0.002) [5]
    • A recent systematic review found:
      • Diagnostic thresholds converging around 4 mm for mixed oral cavity sites and 3 mm for high-risk subsites (floor of the mouth) [6]
• The ASCO Clinical Practice Guideline (2019) recommends [2]:
  • cT2 to cT4, cN0:
    • Ipsilateral END should be performed (strong recommendation, high-quality evidence)
  • cT1, cN0:
    • Ipsilateral END should be performed:
      • Alternatively, close surveillance with specialized ultrasound may be offered for selected highly reliable patients
• Tumor Size Considerations:
  • Under AJCC 8th edition staging, both surface size and DOI determine T classification [1]:
    • T1:
      • ≤ 2 cm with DOI ≤ 5 mm
    • T2:
      • ≤ 2 cm with DOI > 5 mm
      • > 2 cm and ≤ 4 cm with DOI ≤ 10 mm
    • T3 to T4:
      • T3:
        • > 4 cm
        • DOI > 10 mm
      • Locally advanced tumors carry ~ 40% to 50% risk of occult nodal metastases, making END essentially mandatory [2]
  • DOI cutoffs are more predictive of overall survival than T category based on tumor surface size alone [3]:
    • For T1 tumors, those with DOI ≤ 2 mm rarely demonstrate occult neck disease:
      • While DOI ≥ 2 mm confers at least a 20% risk of pN+ disease [3]
• Subsite-Specific Considerations:
  • Oral Tongue:
    • The most extensively studied subsite
    • DOI ≥ 3 mm to 4 mm:
      • Is the standard threshold for END [3]
    • Higher propensity for skip metastases:
      • To level III (17.5% of specimens) compared to other subsites
    • Anterior tongue tumors at / near midline:
      • Warrant consideration for bilateral neck dissection [1]
  • Floor of Mouth (FOM):
    • FOM tumors cross the critical 20% threshold for nodal metastasis at a lower DOI (≥ 2 mm) compared to oral tongue (≥ 4 mm):
      • Based on a study of 343 patients:
        • 41.7% nodal metastasis rate for FOM tumors 2.1 mm to 4 mm thick vs. 11.2% for tongue tumors of similar thickness [7]
    • FOM primaries have a predisposition for contralateral metastases even at earlier T stages:
      • With a 50% higher risk of contralateral metastasis and 2.6-times higher risk when FOM invasion / extension is present [3][2]
    • However, a more recent study of 825 patients:
      • Found no significant difference in the incidence of or correlation between DOI and nodal metastases when FOM was compared to other subsites [8]
    • SLN biopsy accuracy:
      • Is lower for FOM than for tongue primaries [1]
  • Buccal Mucosa:
    • Behaves more aggressively:
      • With occult metastasis rates as high as 32% and up to 43% presenting with clinical / radiographic nodal disease [3]
    • END is recommended for all buccal cases:
      • Irrespective of DOI given higher rates of nodal metastases even in early T-category disease [3]
    • A multicenter study of 101 patients confirmed END:
      • Improved survival in pT2, cN0 buccal SCC:
        • 123 months vs. 26 months, p = 0.009) [9]
    • END demonstrated improved:
      • Locoregional recurrence-free rates (61% vs. 38%, p = 0.042)
      • 5-year DFS (75% vs. 63%, p = 0.019) [10]
  • Other Subsites (Alveolar Ridge, Retromolar Trigone, Hard Palate):
    • Generally follow the same DOI-based principles
    • Hard palate and upper gingiva:
      • May not lend themselves well to SLN biopsy [1]
• Levels of Dissection – I to III vs. I to IV:
  • This is the NCCN treatment algorithm for cT1 to cT2, N0 oral cavity SCC:
    • For the cN0 neck:
      • The standard END is a supraomohyoid neck dissection (SOHND) encompassing levels I to III
    • Both the NCCN and ASCO guidelines recommend at minimum:
      • Levels Ia, Ib, II, and III, with an adequate yield of ≥ 18 lymph nodes [1][2]
    • Two randomized trials comparing SOHND (levels I to III) versus modified radical neck dissection (levels I to V):
      • Showed the adequacy of SOHND, with more extensive dissection increasing morbidity (particularly shoulder dysfunction) without survival or recurrence benefit:
        • Only 3.7% of occult metastases were detected in levels IV and V [2]
    • The American Head and Neck Society review consolidates the recommendation:
      • Level I to III dissection in the cN0 setting, with consideration of level IV inclusion in higher-risk tumors [3]
• Skip Metastasis to Level IV:
  • The Key Data:
    • The Warshavsky et al. (2019) systematic review and meta-analysis in JAMA Otolaryngology (13 studies, 1,359 patients) provides the most comprehensive data [11]:
      • Overall rate of level IV involvement in cN0 patients:
        • 2.53% (95% CI, 1.64%–3.55%)
      • True skip metastasis rate:
        • Level IV positive without levels I to III involvement): 0.50% (95% CI, 0.09%–1.11%)
  • Subgroup by T stage:
    • Level IV involvement was 0% for stages I to II and 0% for stages III to IV in the skip metastasis analysis
  • Oral tongue subsite:
    • Level IV involvement was notably higher at 3.60% (95% CI, 2.09%–5.42%):
      • The only subsite with significant findings
    • A large audit of 1,004 cases:
      • Confirmed skip metastases to level IV were 2.2% for tongue and 1.2% for gingivobuccal primaries [12]
    • A 2024 study of 544 early-stage oral tongue SCC patients:
      • Found only 1.3% had nodal involvement of level IV or V, concluding that END of levels I to III is sufficient [13]
    • A recent 2026 study directly comparing outcomes of END levels I to III vs. I to IV in 120 oral tongue SCC patients found [14]:
      • Only 1 of 33 patients (3%) undergoing level I to IV dissection had level IV metastasis
      • No significant difference in regional recurrence (21.8% vs. 18.2%, p = 0.66), level IV recurrence (3.5% vs. 3%, p = 0.91), or 5-year OS (69.3% vs. 61.1%, p = 0.7)
    • However, one study of 111 T1 / T2 N0 oral tongue SCC patients:
      • Found a 6.3% occult metastasis rate to level IV:
        • Arguing that extended SOHND covers this risk [15]
    • Additionally, when levels I to III are already pN+:
      • The risk of level IV to V metastases rises to 9.8%:
        • Particularly with > 1 positive node or pN classification > pN2b [16]
• Summary of Frequency of Nodal Metastasis by Level:
  • A meta-analysis of 17 studies found the following frequencies of lymph node metastasis across all OSCC [17] – Figure
• Clinical Synthesis:
  • For the cN0 neck, levels I to III dissection is the standard of care across all oral cavity subsites
  • The evidence does not support routine inclusion of level IV given the extremely low rate of true skip metastasis (0.50% overall)
  • For oral tongue SCC specifically:
    • The slightly higher rate of level IV involvement (3.60%) has prompted some authors to advocate for level IV inclusion:
      • But direct comparative studies show no survival or recurrence benefit from extending to level IV [14]
  • Level IV should be considered in higher-risk scenarios:
    • pN+ disease in levels I to III (especially multistation), greater DOI, or adverse pathologic features
  • For the cN+ neck:
    • Therapeutic dissection should include levels I to IV:
      • With level V considered in multistation disease [2]
• References:
  • 1. Head and Neck Cancers. National Comprehensive Cancer Network. Updated 2025-12-08.
  • 2. Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline. Koyfman SA, Ismaila N, Crook D, et al. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 2019;37(20):1753-1774. doi:10.1200/JCO.18.01921.
    
  • 3. Oral Cavity Cancer Surgical and Nodal Management: A Review From the American Head and Neck Society. Eskander A, Dziegielewski PT, Patel MR, et al. JAMA Otolaryngology– Head & Neck Surgery. 2024;150(2):172-178. doi:10.1001/jamaoto.2023.4049.
  • 4. Impact of Elective Cervical Dissection on the Prognosis of Patients With Oral Squamous Cell Carcinoma cT1/T2N0: A Systematic Review and Meta-Analysis. Binda NC, Lavareze L, de Souza Vieira G, et al. Critical Reviews in Oncology/Hematology. 2025;:104982. doi:10.1016/j.critrevonc.2025.104982.
  • 5. Depth of Invasion in Early Stage Oral Cavity Squamous Cell Carcinoma: The Optimal Cut-Off Value for Elective Neck Dissection. van Lanschot CGF, Klazen YP, de Ridder MAJ, et al. Oral Oncology. 2020;111:104940. doi:10.1016/j.oraloncology.2020.104940.
  • 6. Elective Neck Dissection Strategies Guided by AJCC-8 Depth-of-Invasion (DOI) in cT1-T2N0 Oral Cavity Cancer-a Systematic Review. Abdul NS, Shivakumar S, Alreshaid L, et al. Cancers. 2026;18(4):697. doi:10.3390/cancers18040697.
  • 7. Tumour Thickness as a Predictor of Nodal Metastases in Oral Cancer: Comparison Between Tongue and Floor of Mouth Subsites. Balasubramanian D, Ebrahimi A, Gupta R, et al. Oral Oncology. 2014;50(12):1165-8. doi:10.1016/j.oraloncology.2014.09.012.
  • 8. The Relative Propensity for Regional Metastasis in Floor of Mouth Squamous Cell Carcinoma Versus Other Oral Cavity Subsites. Wicks C, Zubair F, Ogunbowale A, McMahon J. The British Journal of Oral & Maxillofacial Surgery. 2022;60(9):1276-1278. doi:10.1016/j.bjoms.2022.07.012.
  • 9. Management of the Neck in T1 and T2 Buccal Squamous Cell Carcinoma. Nicholson OA, Van Lanschot CGF, van den Besselaar BN, et al. International Journal of Oral and Maxillofacial Surgery. 2024;53(4):259-267. doi:10.1016/j.ijom.2023.07.004.
  • 10. What Is the Role of Elective Neck Dissection in the Management of Patients With Buccal Squamous Cell Carcinoma and Clinically Negative Neck?. Dillon JK, Villing AS, Jones RS, et al. Journal of Oral and Maxillofacial Surgery : Official Journal of the American Association of Oral and Maxillofacial Surgeons. 2019;77(3):641-647. doi:10.1016/j.joms.2018.10.021.
  • 11. Assessment of the Rate of Skip Metastasis to Neck Level IV in Patients With Clinically Node-Negative Neck Oral Cavity Squamous Cell Carcinoma: A Systematic Review and Meta-analysis. Warshavsky A, Rosen R, Nard-Carmel N, et al. JAMA Otolaryngology– Head & Neck Surgery. 2019;145(6):542-548. doi:10.1001/jamaoto.2019.0784.
  • 12. Nodal Yield and Topography of Nodal Metastases From Oral Cavity Squamous Cell Carcinoma – An Audit of 1004 Cases Undergoing Primary Surgical Resection. Roy P, Mallick I, Arun I, et al. Oral Oncology. 2021;113:105115. doi:10.1016/j.oraloncology.2020.105115.
  • 13. Risk Factors and Impact of Occult and Skip Metastasis in Early-Stage Oral Tongue Squamous Cell Carcinoma. Yang X, Xiang W, Sun Y, et al. Clinical Oral Investigations. 2024;28(9):510. doi:10.1007/s00784-024-05897-8.
  • 14. The Prognostic Significance of Elective Level 4 Neck Dissection in Oral Tongue Cancer. Yosefof E, Edri N, Ritter A, et al. Journal of Surgical Oncology. 2026;133(4):459-464. doi:10.1002/jso.70191.
  • 15. How Adequate Is Supraomohyoid Neck Dissection for Node-Negative Oral Tongue Squamous Cell Carcinoma?. Sharma R, Singh N, Joshi KD, Sr A, Patrikar S. Journal of Cranio-Maxillo-Facial Surgery : Official Publication of the European Association for Cranio-Maxillo-Facial Surgery. 2025;:S1010-5182(25)00102-7. doi:10.1016/j.jcms.2025.03.006.
  • 16. In Vivo Probability of Metastases in Levels IV-V in Oral Squamous Cell Carcinoma With a cN0/pN+ Situation in Levels I-Iii. Haas L, Mischkowski RA, Knape U, Król KM, Sakkas A. In Vivo (Athens, Greece). 2025 Nov-Dec;39(6):3437-3444. doi:10.21873/invivo.14141.
  • 17. Frequency of Lymph Node Metastases at Different Neck Levels in Patients With Oral Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis. Yu YF, Cao LM, Li ZZ, et al. International Journal of Surgery (London, England). 2025;111(1):1285-1300. doi:10.1097/JS9.0000000000001953.

• The 15.8% skip metastasis rate reported by Byers et al. (1997):
  • Is widely considered an overestimate due to several important methodological issues that have been carefully dissected in subsequent literature:
    • Most notably by Warshavsky et al. in their 2019 JAMA Otolaryngology meta-analysis [1][2]
• What Byers Reported:
  • Byers et al. reviewed 277 previously untreated patients with oral tongue SCC (1970 to 1990):
    • Who underwent glossectomy and neck dissection
  • They reported that 15.8% of all patients had either:
    • Level IV metastasis as the only manifestation of neck disease
    • Level III as the only positive node without disease in levels I to II
    • Subsequent level IV recurrence after initial dissection that did not include level IV
  • Based on this, they recommended routine dissection of levels I to IV for all oral tongue SCC [2]
• Why the 15.8% Figure Is Misleading:
  • Warshavsky et al. performed a careful reanalysis of the Byers data and identified several critical flaws that inflated the rate [1]:
    • Conflation of skip metastasis definitions:
      • Byers combined true level IV skip metastasis with level III skip metastasis (level III positive without levels I to II involvement):
        • These are fundamentally different clinical scenarios — level III disease is already captured by a standard supraomohyoid neck dissection (levels I to III)
        • By lumping both together, the rate was artificially elevated
    • Inclusion of neck recurrences as “skip metastases”:
      • Nine patients (9.9%) who developed level IV recurrences after an initial dissection that did not include level IV were counted toward the 15.8% figure:
        • As Warshavsky et al. noted, counting neck recurrence as a missed pathological lymph node is problematic because the neck has lost its normal anatomical lymphatic drainage and, in many cases, has been irradiated
        • This makes it impossible to determine whether these were true skip metastases or recurrences from altered lymphatic flow [1]
    • True level IV skip metastasis rate was only 5.5%:
      • When the data are restricted to patients with cN0 disease who had level IV metastasis found in the initial neck dissection specimen (i.e., true pathologic skip metastasis):
        • The rate drops to 5.5% — roughly one-third of the reported figure [1]
      • Even the most generous calculation yields only 4.8%:
        • When accounting for all cases mentioned in the study (both initial pathologic findings and subsequent recurrences), the combined incidence of skip metastasis or subsequent recurrence in level IV was only 4.8% (13 of 270), not 15.8% [1]
  • Mixed cN0 and cN+ populations:
    • The study included patients across all clinical N stages, and the data were not clearly stratified by preoperative nodal status, making it difficult to isolate the true elective (cN0) skip metastasis rate
  • Era of the study (1970 to 1990):
    • Preoperative imaging was far less sophisticated, meaning some patients classified as cN0 may have had undetected nodal disease, further confounding the results
• What Modern Data Shows:
  • The Warshavsky et al. meta-analysis of 13 studies (1,359 cN0 patients):
    • Found the true skip metastasis rate to level IV is only 0.50% (95% CI, 0.09%–1.11%):
      • With an overall level IV involvement rate of 2.53% [1]
    • Even for oral tongue specifically — the highest-risk subsite:
      • The level IV involvement rate was 3.60% [1]
  • A large Tata Memorial audit of 761 early-stage cN0 patients:
    • Found skip metastasis to level IV in only 0.3% [3]
• In summary, the Byers 15.8% figure resulted from a broad definition of “skip” that included level III skips (already addressed by SOHND), conflation of initial pathologic findings with subsequent recurrences, and lack of stratification by preoperative nodal status:
  • Modern evidence overwhelmingly supports that true skip metastasis to level IV in cN0 oral tongue SCC is a rare event (~0.5%), and supraomohyoid neck dissection (levels I to III) remains adequate for the elective setting
• References:
  • 1. Assessment of the Rate of Skip Metastasis to Neck Level IV in Patients With Clinically Node-Negative Neck Oral Cavity Squamous Cell Carcinoma: A Systematic Review and Meta-analysis. Warshavsky A, Rosen R, Nard-Carmel N, et al. JAMA Otolaryngology– Head & Neck Surgery. 2019;145(6):542-548. doi:10.1001/jamaoto.2019.0784.
  • 2. Frequency and Therapeutic Implications of “Skip Metastases” in the Neck From Squamous Carcinoma of the Oral Tongue. Byers RM, Weber RS, Andrews T, et al. Head & Neck. 1997;19(1):14-9. doi:10.1002/(sici)1097-0347(199701)19:13.0.co;2-y.
  • 3. Incidence and Impact of Skip Metastasis in the Neck in Early Oral Cancer: Reality or a Myth?. Gurmeet Singh A, Sathe P, Roy S, et al. Oral Oncology. 2022;135:106201. doi:10.1016/j.oraloncology.2022.106201.

• Epidemiology:
  • The tall cell subtype of papillary thyroid carcinoma (PTC-TC):
    • Accounts for approximately 3% to 5% of all PTCs
      • Its incidence has been rising:
        • Partly due to evolving diagnostic criteria
  • The WHO 5th edition (2022) defines PTC-TC as:
    • PTC with ≥ 30% tall cells:
      • Height-to-width ratio ≥ 3:1
  • Patients tend to be older:
    • Mean ~ 50 years vs. 42 for classic PTC
  • PTC-TC have higher rates of:
    • Extrathyroidal extension (~ 60%)
    • Vascular invasion (~ 15%)
    • Lymph node metastasis
    • Advanced stage at presentation
  • Recurrence rates range from:
    • 27% to 42% compared to 16% to 31% for classic PTC
  • 5-year disease-specific survival of:
    • Approximately 82% vs. 98% for all PTC
  • An important recent distinction is:
    • Between PTC-TC (without high-grade features) and high-grade differentiated thyroid carcinoma with tall cell phenotype (HGDTC-TC):
      • Defined by ≥ 5 mitoses / 2 mm² and / or tumor necrosis
        • When HGDTC-TC is excluded PTC-TC has a more indolent course (10-year disease-specific survival ~99%)
• Genetics and Molecular Features:
  • BRAF V600E mutation:
    • Present in ~ 80% to 90% of cases:
      • Drives MAPK pathway activation and suppresses sodium-iodide symporter expression:
        • Contributing to RAI refractoriness
  • TERT promoter mutations:
    • Independent predictor of recurrence:
      • More frequent in PTC-TC
  • BRAF V600E + TERT co-mutation:
    • Identifies a subset with particularly poor outcomes
• Surgical Management:
  • Type of Thyroidectomy:
    • Standard indications for total thyroidectomy apply:
      • Distant metastases
      • Extrathyroidal extension
      • Lateral or gross central neck node metastases
      • Tumor > 4 cm
      • Bilateral disease
    • For tumors 1 cm to 4 cm without these features:
      • Either total thyroidectomy or lobectomy may be considered
  • Key evidence:
    • A 2026 SEER analysis of 1,463 PTC-TC patients showed total thyroidectomy had superior cancer-specific survival vs. lobectomy:
      • 5-year CSS 97.8% vs. 90.7%, p = 0.019, independent of RAI
    • A Memorial Sloan Kettering study of T1 / T2 N0 PTC-TC:
      • Found no difference in outcomes with lobectomy alone, with 100% disease-specific survival in both groups
  • Summary:
    • For small (T1 / T2), node-negative PTC-TC without high-grade features:
      • Lobectomy may be adequate
    • Larger or higher-stage tumors:
      • Should undergo total thyroidectomy
• Central Compartment Neck Dissection:
  • Therapeutic central neck dissection:
    • Recommended for clinically involved nodes (cN1a)
  • Prophylactic central neck dissection:
    • Not routinely indicated per NCCN
  • Thorough preoperative ultrasound of central and lateral compartments is essential:
    • With FNA of suspicious lateral nodes
• Radioactive Iodine (RAI):
  • NCCN classifies tall cell histology as a “high-risk subtype”:
    • For which RAI is selectively recommended based on the combination of clinical factors
  • PTC-TC is classified in the ATA intermediate risk category
  • Key considerations:
    • BRAF V600E-driven PTC-TC downregulates the sodium-iodide symporter:
      • Making these tumors frequently RAI-refractory
    • For tumors > 2 cm:
      • RAI after total thyroidectomy improved overall survival:
        • 83.4% vs. 70.0%
    • For tumors ≤ 2 cm:
      • No survival benefit from RAI was demonstrated
    • A SEER-based propensity-matched study:
      • Found no significant CSS benefit from RAI in PTC-TC overall:
        • HR 0.54, 95% CI 0.25–1.17
    • Repeated RAI should be limited to patients demonstrating continued therapeutic response
• Follow-Up:
  • After total thyroidectomy with RAI, recommended surveillance includes:
    • Physical examination, TSH, thyroglobulin (Tg), and anti-thyroglobulin antibodies (TgAb)
    • Neck ultrasound at 6 to 12 months, then every 1 to 3 years for 5 to 8 years, then discontinue
  • Rising Tg or new TgAb:
    • Should prompt additional imaging:
      • Neck CT / MRI, chest / abdomen CT, FDG-PET, or RAI imaging
  • TSH suppression with levothyroxine:
    • Per risk stratification
  • For patients with no evidence of disease (NED) at low risk after 10 to 15 years:
    • No further thyroid cancer monitoring is indicated
• RAI-Refractory Disease:
  • For RAI-refractory progressive disease:
    • Molecular analysis for actionable alterations should be pursued:
      • BRAF V600E → dabrafenib / trametinib or vemurafenib / cobimetinib
      • RET fusions → selpercatinib or pralsetinib
      • NTRK fusions → larotrectinib or entrectinib
      • ALK fusions → targeted therapy
• References:
  • Shi X, Liu R, Basolo F, et al. Differential Clinicopathological Risk and Prognosis of Major Papillary Thyroid Cancer Variants. J Clin Endocrinol Metab. 2016.
  • Wu SS, Joshi N, Sharrett J, et al. Risk Factors Associated With Recurrence and Death in Patients With Tall Cell Papillary Thyroid Cancer. JAMA Otolaryngol Head Neck Surg. 2023.
  • Holoubek SA, MacKinney EC, Khokar AM, et al. Radioactive Iodine Does Not Improve Overall Survival for Patients With Aggressive Variants of Papillary Thyroid Carcinoma Less Than 2 Cm. Surgery. 2022.
  • Jin X, Koga S, Zhou X, Khan NZ, Baloch ZW. Clinicopathologic Characteristics of Papillary Thyroid Carcinoma, Tall Cell Subtype and Subtype With Tall Cell Features, an Institutional Experience. Hum Pathol. 2025.
  • Parvathareddy SK, Siraj AK, Qadri Z, et al. Tall Cell Variant Histology Predicts Poorer Disease-Free Survival in Papillary Thyroid Carcinoma: A Propensity-Matched Cohort Study. World J Surg. 2025.
  • Ghossein R, Katabi N, Dogan S, et al. Papillary Thyroid Carcinoma Tall Cell Subtype (PTC-TC)
    
    
    

• For patients diagnosed with asymptomatic primary hyperparathyroidism (PHPT – 5% of the cases):
  • Additional evaluation is necessary to make subsequent management decisions
• In order to make management recommendations for patients with asymptomatic PHPT, I usually send the following studies:
  • Urinary calcium excretion
  • Serum 25-hydroxyvitamin D
  • Serum creatinine and estimated glomerular filtration rate (eGFR):
    • To assess for renal compromise
  • Bone density to determine if it is low
  • I some situations I will also get the following imaging studies:
    • Ultrasound of the kidneys to assess for occult kidney stones
    • Spine to assess for asymptomatic vertebral compression fracture
• The Fourth International Workshop guidelines recommended further assessment to help in the decision regarding surgery for PHPT:
  • This includes renal imaging (plain radiographs or ultrasound) to determine if the patient has a clinically silent kidney stone and vertebral imaging (spine radiograph or vertebral fracture assessment [VFA] of dual-energy x-ray absorptiometry [DXA] image) for subclinical vertebral fracture
  • Urinary stone risk profile is also recommended:
    • But only if urinary calcium excretion is extremely elevated (> 400 mg/day) and a patient is unsure about parathyroid surgery
      • However, these tests are more expensive, may not be readily available to all clinicians, and there are few data to support their role in managing patients with PHPT
• Urinary calcium excretion:
  • In asymptomatic patients:
    • The urinary calcium excretion is helpful to assess the risk of renal complications (when urine calcium is high) and thus determine subsequent management
  • The Fourth International Workshop on Asymptomatic Primary Hyperparathyroidism guidelines recommended surgical intervention as opposed to observation in asymptomatic patients who have:
    • A 24-hour urinary calcium excretion greater than 400 mg/day (> 10 mmol/day)
      • It should be noted that urinary calcium levels are considered to be elevated at a significantly lower level of excretion (250 mg/24 hours in women and 300 mg/24 hours in men):
        • There are no specific data assessing the cut-point of 400 mg calcium excretion daily
          • This particular recommendation reflected expert opinion regarding a level above which there is consensus that patients should be sent for surgery even in the absence of other criteria
• Serum vitamin D:
  • I measure serum 25(OH)D in all patients with suspected or diagnosed PHPT
  • Measurement of 25(OH)D is important:
    • To identify patients with PHPT and vitamin D deficiency (which is a significant proportion of patients)
  • Due to the significant prevalence of vitamin D insufficiency in individuals with PHPT:
    • The Fourth International Workshop on Asymptomatic Primary Hyperparathyroidism recommended measuring 25(OH)D in all patients with the disease and repleting those with low levels (defined as ≤ 20 ng/mL [50 nmol/L]) prior to making any management decisions:
      • Specially if calcium levels are within the normal range
      • In some cases, the decision regarding surgery will be clear despite the low vitamin D level:
        • In such patients, it is still advisable to replete vitamin D if this can be done safely:
          • In order to mitigate postoperative hypocalcemia
• Serum creatinine:
  • The serum creatinine concentration provides information about renal function:
    • Which can be diminished by hypercalcemia
  • Rather than using serum creatinine alone, the eGFR can be estimated in patients with a stable serum creatinine concentration:
    • An eGFR of 60 mL/min is the threshold of chronic kidney disease for deciding:
      • Which asymptomatic individuals with PHPT may benefit from early surgical treatment
• Renal imaging:
  • In several studies, clinically silent kidney stones were reported in 7%to 21% of patients with PHPT:
    • Patients with undiagnosed (subclinical) nephrocalcinosis or calcium kidney stones:
      • Are regarded as having symptomatic disease:
        • Regardless of the absence of symptoms
      • Thus, these patients meet criteria for surgical intervention
  • For the few patients who do not have other overt indications for surgery:
    • Obtaining renal imaging (ultrasound, computed tomography [CT], or abdominal radiograph):
      • To look for nephrocalcinosis or asymptomatic nephrolithiasis at the time of the original evaluation for PHPT
        • Ultrasound is typically the imaging modality used
• Bone mineral density:
  • Patients with PHPT may have decreased bone mineral density (BMD):
    • In particular at more cortical sites (forearm and hip) as compared with more trabecular (cancellous) sites (spine)
  • Although measurement of BMD is not required for the diagnosis of PHPT:
    • It is an essential part of the management of the disease:
      • BMD must be measured at the:
        • Spine, hip, and distal one-third forearm sites
  • The degree of bone loss:
    • Is reflective of the severity of hyperparathyroidism and is useful for making recommendations for parathyroid surgery or observation with monitoring in asymptomatic patients (minority of the cases)
• Assessment for vertebral fracture:
  • Patients with subclinical, idiopathic vertebral compression fractures are regarded as having osteoporosis:
    • Independent of BMD findings
  • Vertebral compression fractures are underdiagnosed in all populations:
    • Many studies have demonstrated an increased risk of asymptomatic vertebral fractures in patients with PHPT
  • In order to diagnose asymptomatic vertebral compression fractures:
    • The Fourth International Workshop guidelines recommended imaging to assess for vertebral fracture in asymptomatic patients who do not have osteoporosis on BMD testing (patients with clinical osteoporotic fractures or with BMD in the osteoporosis range already meet criteria for surgery):
      • If a vertebral fracture is present by VFA or radiograph:
        • Parathyroidectomy is recommended
      • Vertebral assessment can be performed with plain radiographs or with VFA by DXA:
        • The latter can be done at the time of BMD testing, at greater patient convenience, less cost, and lower radiation exposure than conventional radiography of the spine
• Other tests:
  • Biochemical renal stone prediction:
    • For asymptomatic patients with hypercalciuria (> 400 mg/day [10 mmol/day]):
      • The Fourth International Workshop Guidelines on the Management of Asymptomatic Primary Hyperparathyroidism recommended:
        • Assessment of the urine composition to identify patients at highest risk for nephrolithiasis [32]:
          • There are no specific data to suggest that urine stone risk profiling can predict risk of nephrolithiasis in patients with PHPT
          • Some experts believe that urinary calcium excretion > 400 mg/day alone raises sufficient enough concern about long-term renal complications to warrant a recommendation for parathyroidectomy
    • If an asymptomatic patient with a urinary calcium >400 mg/day is unsure about proceeding to surgery, a stone risk profile might provide useful information for making a decision about surgery. (See “The first kidney stone and asymptomatic nephrolithiasis in adults”.)

For asymptomatic patients at high risk for nephrolithiasis (24-hour urinary calcium >400 mg and high-risk urinary biochemical profile), the Fourth International Workshop guidelines recommended parathyroidectomy [32]. (See “Primary hyperparathyroidism: Management”, section on ‘Candidates for surgery’.)

Serum phosphorus — The serum phosphorus concentration may be decreased but typically is in the lower range of normal. Some patients have mild hyperchloremic acidosis. (See “Primary hyperparathyroidism: Clinical manifestations”.)

Markers of bone turnover — Biochemical markers of bone turnover (collagen crosslinks, osteocalcin, bone-specific alkaline phosphatase) are often at the upper end of normal or mildly elevated in asymptomatic PHPT (see “Bone physiology and biochemical markers of bone turnover”). In those with more severe disease, they are typically high. They are only occasionally helpful in the management of hyperparathyroidism and should not be routinely measured [8].

Localization studies — The diagnosis of PHPT is established by appropriate biochemical testing. Localization studies with ultrasonography, technetium-99m sestamibi, CT, or magnetic resonance imaging (MRI) scanning should not be used to establish the diagnosis of PHPT or to determine management. Localization studies should be performed only after a decision for surgery has been made. Their utility is questionable when bilateral neck exploration is planned. However, they are commonly used now, along with intraoperative parathyroid hormone (PTH) monitoring, to facilitate unilateral exploration and minimally invasive surgery in those with probable single gland disease. (See “Preoperative localization for parathyroid surgery in patients with primary hyperparathyroidism”.)

• The 10 signs of malignancy include:
  • Shadowing
  • Hypoechoic echotexture
  • Spiculation
  • Angular margins
  • Thick echogenic halo
  • Microlobulation
  • Taller than wide dimensions
  • Duct extension
  • Branching pattern
  • Calcifications
• Well-defined smooth border and posterior acoustic enhancement:
  • Are found in both malignant and nonmalignant lesions
• Layering / teacup mammographic microcalcifications:
  • Are usually associated with benign disease
• Sonographic mass with a benign mammographic imaging:
  • Is managed based on ultrasound features

• References
  • Evaluation and imaging features of malignant breast masses. In: Cardenosa G. Clinical Breast Imaging: The Essentials. Philadelphia, PA: Wolters Kluwer; 2015:234-282.
  • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.

• While all patients with symptomatic primary hyperparathyroidism (PHPT) should consider surgery (95% of patients are usually symptomatic when appropriate history is taken):
  • It is also indicated in some asymptomatic patients (5% of the cases of PHPT):
    • Indications:
      • Age less than 50
      • Kidney disease:
        • GFR less than 60
      • Osteoporosis
      • Serum calcium greater than 1 mg/dl above normal
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393490/

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #PrimaryHyperparathyroidism #CancerSurgeon #EndocrineSurgery #Teacher #Surgeon #HeadandNeckSurgeon #SurgicalOncologist #ParathyroidAdenoma #Hypercalcemia #ElevatedCalciumLevels #Miami #MountSinaiMedicalCenter #MSMC #Mexico #Hialeah

👉The overproduction of parathyroid hormone (PTH), termed hyperparathyroidism (HPT), can be categorized as primary, secondary, or tertiary.

👉Primary hyperparathyroidism (PHPT) arises from an unregulated overproduction of PTH from an abnormal parathyroid gland.

👉Increased PTH levels may also occur as a compensatory response to hypocalcemic states resulting from chronic renal failure or gastrointestinal (GI) malabsorption of calcium. This secondary HPT can be reversed by correction of the underlying problem (e.g., kidney transplantation for chronic renal failure).

👉However, chronically stimulated parathyroid glands may occasionally become autonomous, resulting in persistence or recurrence of the hypercalcemia after successful renal transplantation, resulting in tertiary HPT. This review paper will focus on PHTP

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #EndocrineSurgery #Hypercalcemia #MountSinaiMedicalCenter #MSMC #Miami #Mexico