Clinical significance of prophylactic central compartment neck dissection in the treatment of clinically node-negative papillary thyroid cancer patients.

Claudio Gambardella,Nicola Avenia,Graziella Izzo,Giovanni Conzo,Claudio Mauriello,Salvatore Napolitano,Alessandro Sanguinetti,Guglielmo Thomas,Gianluca Rossetti,Fabio Cavallo,Giuseppe Siciliano,Domenico Testa,Anna Nunziata,Ernesto Tartaglia

doi:10.1186/s12957-016-1003-5

Abstract

BackgroundLymph nodal involvement is very common in differentiated thyroid cancer, and in addition, cervical lymph node micrometastases are observed in up to 80 % of papillary thyroid cancers. During the last decades, the role of routine central lymph node dissection (RCLD) in the treatment of papillary thyroid cancer (PTC) has been an object of research, and it is now still controversial. Nevertheless, many scientific societies and referral authors have definitely stated that even if in expert hands, RCLD is not associated to higher morbidity; it should be indicated only in selected cases.Main bodyIn order to better analyze the current role of prophylactic neck dissection in the surgical treatment of papillary thyroid cancers, an analysis of the most recent literature data was performed. Prophylactic or therapeutic lymph node dissection, selective, lateral or central lymph node dissection, modified radical neck dissection, and papillary thyroid cancer were used by the authors as keywords performing a PubMed database research. Literature reviews, PTCs large clinical series and the most recent guidelines of different referral endocrine societies, inhering neck dissection for papillary thyroid cancers, were also specifically evaluated. A higher PTC incidence was nowadays reported in differentiated thyroid cancer (DTC) clinical series. In addition, ultrasound guided fine-needle aspiration citology allowed a more precocious diagnosis in the early phases of disease. The role of prophylactic neck dissection in papillary thyroid cancer management remains controversial especially regarding indications, approach, and surgical extension. Even if morbidity rates seem to be similar to those reported after total thyroidectomy alone, RCLD impact on local recurrence and long-term survival is still a matter of research. Nevertheless, only a selective use in high-risk cases is supported by more and more scientific data.ConclusionsIn the last years, higher papillary thyroid cancer incidence and more precocious diagnoses were worldwide reported. Among endocrine and neck surgeons, there is agreement about indications to prophylactic treatment of node-negative “high-risk” patients. A recent trend toward RCLD avoiding radioactive treatment is still debated, but nevertheless, prophylactic dissections in low-risk cases should be avoided. Prospective randomized trials are needed to evaluate the benefits of different approaches and allow to drawn definitive conclusions.

Highlights

Lymph nodal involvement is very common in differentiated thyroid cancer, and in addition, cervical lymph node micrometastases are observed in up to 80 % of papillary thyroid cancers
In the last decades, thanks to a better sensitivity of cancer detection methods, more efficacy of diagnostic imaging and molecular markers, a precocious diagnosis allowed to identify a higher number of node-negative low-risk patients, in which the mean tumor size was mostly less than 2 cm, as well as a sensible increase of microcarcinoma incidence was reported in different series
In the management of differentiated thyroid cancer (DTC), a routine lymph node dissection may be selectively suggested with similar oncologic outcomes reported after more extensive and risky dissections even if the literature review demonstrated that indications to routine central lymph node dissection (RCLD) or to radioactive iodine (RAI) ablation, in Papillary thyroid cancers (PTCs) ranging between 1 and 2 cm of diameter, are a matter of intensive research [10, 11]

Summary

Conclusions

The role of routine neck dissection remains a matter of research, and the frequent lateral postoperative involvement might be cited against its supposed benefits, avoiding risky morbidity. In the absence of data supporting the favorable effects of RCLD, we believe that, in the treatment of PTC without a suspicious enlarged lymph node, it is not indicated, and more prospective, randomized controlled studies with large sample and sufficient follow-up are needed in the attempt to better define its clinical significance and demonstrate its prognostic impact. Availability of data and materials Not applicable. Authors’ contributions GC, CG, and TE contributed to this work, collected and analyzed the data, and drafted the manuscript; MC provided analytical oversight; AN and TDM designed and supervised the study; RG, SG, IG, CF, TG, SA, NA, and NS revised the manuscript for important intellectual content; all authors have read and approved the final version to be published. Ethics approval and consent to participate Not applicable. Author details 1Department of Anaesthesiology, Surgery and Emergency Sciences, Second University of Naples, Via Pansini 5, 80131 Naples, Italy. Author details 1Department of Anaesthesiology, Surgery and Emergency Sciences, Second University of Naples, Via Pansini 5, 80131 Naples, Italy. 2Endocrine Surgical Unit, University of Perugia, Perugia, Italy

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