We here present two cases of differentiated thyroid carcinoma with mediastinal lymph nodes metastases below level 106 according to the classification of the Guidelines for the Clinical and Pathologic Studies for Carcinoma of the Esophagus (9 th edition) edited by the Japanese Society for Esophageal Diseases. For Case 1, we adopted a conventional anterior approach with resection of the right half of the manubrium and sternum to the level of the second intercostal space and medial half of the right clavicule. Case 2 underwent a combined cervical approach and video-assisted thoracoscopic surgery (VATS). In Case 1, the lymph nodes around the subclavian vein, 105R, 106pre and 106recR were successfully dissected under clear view. However, through this case, the difficulty in the dissection of 106tbR was recognized, because it is quite challenging to gain an adequate surgical view in this small compartment by this approach. Conversely, in Case 2, in which mediastinal lymph nodes extended to level 107, the lymph nodes were relatively easily dissected by VATS under excellent surgical views of 106tbR and 107. Although VATS is associated with difficulty in en bloc resection, requirements of a thoracotomy, changes of body position and an intubation tube during the surgery, this approach is of great use for the dissection of 106tbR and 107.
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