الفهرس 
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Abstract
Papillary thyroid cancer is the most common type of thyroid cancer. The optimal strategy for treatment of patients with PTC is complete surgical resection of clinically and radiologically evident disease within the neck. Cervical LN metastases are common in PTC and are associated with a significant probability for loco-regional recurrence of the disease, even in low-risk patients.
This study was carried out on forty patients with N1b stage of PTC. The aim of the study is to determine the incidence of level I cervical LN involvement in metastatic PTC patients with multilevel involvement.We were aiming to assess the significance of routine level I dissection in patients with multilevel cervical lymph nodes involvement.
There were 32 females (80%) and 8 males (20%), their age ranged from 8 to 76 years with mean age of 40.95 + 15.97 years.
All cases are subjected to thorough history taking, complete clinical examination and vocal cord assessment by laryngoscopy. Laboratory investigations (T3, T4, TSH and routine laboratory work up), followed by neck ultrasonography (US), and computed tomography (CT) on the neck were then performed. Ultrasound guided biopsy from suspicious thyroid lesion and suspicious cervical LNs was performed.
Lateral neck mass was the chief symptom in 24 patients (60%), goiter was present in 16 cases (40%), compression manifestations in 12 cases (30%), voice changes in 5 cases (12.5%), and eight patients (20%) of patients were asymptomatic.
By local examination, palpable LNs were palpable in 29 patients (72.5%), and goiter was palpable in 25 patients (62.5%).
All laboratory investigations were normal except for one patient (2.5%), who had high level of TSH.
Ultrasound examination of the thyroid gland revealed enlarged gland (bilateral lobes) in 13 cases (32.5%). Enlarged right lobe in 9 cases (22.5%) and enlarged left lobe in 2 patients (5%). Cervical lymphadenopathy found in 39 patients (97.5%), while CT diagnose cervical lymphadenopathy in all 40 patients.
Ultrasound guided fine needle aspiration cytology from the thyroid gland and the suspicious lymph node done in 32 patients (80%), from the lymph node only in 4 patients (10%), excisional LN biopsy was done in 3 patients (7.5%) and core biopsy was done in one patient (2.5%).
Patients with other varieties of differentiated thyroid carcinoma (follicular or medullary) and poorly differentiated thyroid carcinoma were excluded.
All patients were subjected to lateral neck dissection (LND) with or without thyroidectomy and CND (90%). Levels I was dissected in all cases. All cervical levels were removed en-bloc and each level was labeled.
On histopathological examination, level I was positive for malignancy in 7 patients (17.5%), level II in 30 patients (75%), level III in 23 patients (57.5%), level IV in 19 patients (47.5%), level V in 11 patients (27.5%), level VI in 21 of 36 patients (58.3%), and level VII in 2 patients of 14 patients (14.2%).
On comparing the histopathological results of level I and other levels, we found that level I was the only level involved in 1 patient (2.5%), associated with level II involvement in 5 patients (12.5%), with level III in 4 patients(10%), with level IV in 2 patients (5%), with level 5 in 3 patients (7.5%), with level VI in 5 patients (12.5%) and there was no association with level VII. We found that there were 8 patients with 5 levels involvement, in 5 patients from these 8, level I was involved with percentage of 62.5%. Level I involvement was always associated with multilevel disease.
Patients showed following complications. Circumoral numbness and/or numbness of the hands were noted in 14 patients (35%), deviation of the angle of the mouth was noted in 8 patients (20%), weakness of shoulder elevation was noted in 7 patients (17.5%), and 5 patients (12.5%) suffered from parasethesia of the ear. Recent hoarseness of voice was noted in 3 patients (7.5%). Two patients (5%) showed delayed extubation i.e. 24 hours postoperatively. Three patients (7.5%) suffered from postoperative hematoma