The Decision-Making Process for Prophylactic Central Neck Dissection in a Patient Presenting with an Indeterminate Thyroid Nodule on Cytology Assessment: Role of Preoperative Ultrasound and Molecular Marker Testing

Abstract

Nodular thyroid disease is a common clinical entity in the United States, with an estimated annual incidence of approximately 0.1 % per year. The clinical importance of nodular thyroid disease rests with the need to exclude nodules that are malignant. Although this goal can be achieved in most patients with conventional diagnostic techniques, including ultrasound (US) and fine-needle aspiration biopsy, conventional diagnostic methods cannot provide definitive diagnoses in many situations, and such cases are reported as “indeterminate”. Due to a lack of definitive diagnosis for indeterminate or suspicious thyroid nodules, the majority of these patients usually undergo diagnostic thyroidectomy to establish a histopathologic diagnosis. To detect nonpalpable lymph node metastases in patients undergoing surgical resection, a dedicated cervical US should be performed to evaluate the central and lateral neck compartments. The detection of lymph node metastases in this setting affords the opportunity to move forward with complete initial resection of all tumor tissue, that is, thyroidectomy and comprehensive compartment-oriented neck dissection. However, the role of prophylactic central neck dissection (CND) remains a contentious issue, because high-level evidence is lacking for such an approach. The clinical utilization of molecular markers as diagnostic preoperative adjuncts appears promising in differentiating benign from malignant thyroid nodules. This may enable the tailoring of more effective initial surgical management strategies in this patient population. However, the true impact of these adjuncts on determining the most optimal surgical extent from an oncologic standpoint has yet to be proven, as none of the currently commercially available molecular markers have been demonstrated to be clear, independent prognostic indicators and therefore should not impact the decision for prophylactic CND.