The Pros and Cons of Prophylactic Central Compartment Lymph Node Dissection for Papillary Thyroid Carcinoma

Abstract

A well-established feature of papillary thyroid carcinoma (PTC) is it propensity to metastasize to cervical lymph nodes in the central and lateral compartments. Currently, there is no nonor minimally invasive method that is completely reliable for detecting all of the metastases that are present. Therefore, some have advocated prophylactic cervical lymph node dissection as part of the operative procedure for PTC. There is no unanimity, however, on the efficacy and safety of prophylactic cervical lymph node dissection for this tumor. At the recent National Thyroid Cancer Workshop II,* two distinguished surgeons, Dr. Gerard M. Doherty from the University of Michigan and Dr. David L. Steward at the University of Cincinnati, were invited to debate the pros and cons of prophylactic cervical lymph node dissection. More specifically, Dr. Doherty was asked to take the positive view and Dr. Steward the contrary view concerning prophylactic central compartment (Level VI) dissection (CLND). By definition, this is a total compartment dissection that is performed when there is no preoperative or intraoperative evidence of cervical lymph-node metastases. Each participant was asked to marshal the case for one side and not necessarily reflect their personal views. To help them prepare, they were given the following hypothetical case to consider. A 22-year-old woman is referred by her endocrinologist for surgical management of an asymptomatic 2-cm PTC diagnosed 1 week before. There is no family history of thyroid cancer, and she has had no exposure to radiation. Her thyroidstimulating hormone (TSH) level is 1.7 (IU=mL. Repeat neck ultrasonography reveals a single 2-cm right lobe thyroid nodule with a hazy border and no lateral or central neck lymph-node abnormalities. The question posed to the debaters is: What are the pros and cons of prophylactic level VI lymph-node dissection for this patient? After the workshop, these surgeons, who are recognized authorities on the surgical management of thyroid cancer, were asked to prepare written commentary based on their presentations. What follows are two concise, carefully articulated, literature-based reviews that support each side of the debate.