Central Neck Lymph Node Dissection for Papillary Thyroid Cancer: The Reliability of Surgeon Judgment in Predicting Which Patients Will Benefit

Abstract

Objectives: Endocrine surgeons continue to debate whether central-neck lymph node dissection (CLND) should be routinely performed during thyroidectomy for papillary thyroid cancer (PTC). Our practice has been to perform CLND during thyroidectomy for PTC only in patients with enlarged central-neck lymph nodes detected on preoperative palpation or ultrasound, or during intraoperative inspection of the central compartment. We do not perform routine prophylactic CLND for PTC. We evaluated our experience with patients with PTC over the last decade in order to determine the outcomes of our practice of performing CLND only in patients with enlarged nodes. Methods: We retrospectively reviewed the medical records and cancer registry data of all patients with PTC who underwent operation at our university tertiary-care center over the past decade. We identified all patients with PTC who underwent CLND during thyroidectomy; we then identified an equivalent number of demographically-matched patients with PTC who did not undergo CNLND during thyroidectomy and compared the outcomes of the two groups. Results: 191 patients (mean age 40 years; 53 men, 138 women) underwent CLND for PTC during thyroidectomy in the past decade and were compared to 191 patients (mean age 46 years; 53 men, 138 women) with PTC who underwent thyroidectomy without CLND during the same period. The mean tumor size was similar for the 2 groups (2.2 cm for those who underwent CLND vs. 1.6 cm for those who did not). 49/191 (26%) patients who underwent CLND developed locoregional nodal recurrence (12% in the central neck, 21% in the lateral neck), compared with 11/191 (6%) patients who did not undergo CLND (3% in the central neck, 3% in the lateral neck) (p<0.05). 161/191 (84%) patients who underwent CLND were disease-free at their last surveillance, compared with 180/191 (94%) of the patients who did not undergo CLND (p<0.05). The rates of temporary hypocalcemia and permanent recurrent laryngeal nerve injury were three times higher in patients who underwent CLND. There was no difference in disease-specific mortality between the two groups. Conclusions: Surgeon assessment by physical examination, ultrasound, and intraoperative inspection is an accurate predictor of which patients are most likely to benefit from CLND. CLND results in significantly higher complication rates compared to total thyroidectomy alone. Prophylactic CLND is not necessary in the majority of patients with PTC and non-enlarged central neck lymph nodes.