Node-negative Papillary Thyroid Cancer Research Articles

Evolving variation in the extent of surgery for low-risk papillary thyroid cancer in the United States

BackgroundThe continued debate over total thyroidectomy versus lobectomy and declining favor for prophylactic central neck dissection for patients with clinically node-negative papillary thyroid cancer ≤4 cm is ongoing after the 2015 guideline updates from the American Thyroid Association. This study aimed to evaluate contemporary trends in the extent of surgery in this low-risk cohort. MethodsRetrospective data from the National Cancer Database were used to identify adult patients with clinically node-negative papillary thyroid cancer ≤4 cm who underwent resection from 2012 to 2020. The primary outcome was the extent of surgery (lobectomy or total thyroidectomy, with or without prophylactic central neck dissection). Multivariable regression was performed to identify characteristics associated with variation in the extent of surgery. ResultsOf 83,464 included patients, 79.3% were female patients with a median age of 51 years. The majority underwent total thyroidectomy either with prophylactic central neck dissection (39.1%) or without (37.5%) versus lobectomy with prophylactic central neck dissection (7.2%) or without (16.2%). Lobectomy rates increased from 18.3% in 2012 to 29.9% in 2020. Prophylactic central neck dissection rates also increased (42.9% to 52.1%). Patients who were male sex, Asian American, had smaller tumors or were treated at community cancer programs had a decreased likelihood of total thyroidectomy. Patients who were older, male sex, Black race, with smaller tumors, or were treated at community cancer programs or mid- or low-volume facilities had decreased likelihood of prophylactic central neck dissection. ConclusionProportional use rates of operative approaches for low-risk, clinically node-negative papillary thyroid cancer have changed in recent years after the American Thyroid Association guideline changes, including increasing overall rates of lobectomy as well as prophylactic central neck dissection, with differences noted based on patient- and facility-level factors.

Prophylactic Central Neck Dissection Based on Preoperative Imaging and Intraoperative Surgeon's Palpation Versus Total Thyroidectomy Alone for Papillary Thyroid Cancer

IntroductionTo compare the overall morbidity and recurrence of papillary thyroid cancer (PTC) after total thyroidectomy (TT) with or without prophylactic central compartment neck dissection (CCND) in cases of both preoperative and intraoperative nonsuspicious central lymph nodes (CLNs). MethodsA total of 570 PTC patients who harbored no preoperative and intraoperative suspicious CLNs at two institutions were enrolled. They were randomly assigned to TT alone or TT with prophylactic CCND (pCCND) after intraoperative assessment of CLNs during the surgery. Lymph nodes that were hard or large enough to be palpated were regarded as suspicious metastatic lymph nodes during the surgery. The characteristics, postoperative complications, and locoregional recurrence of the two groups were recorded and compared. ResultsWith a median follow-up of 5 y, the rates of lymph node recurrence in the TT alone and TT with pCCND groups were similar (7.3% versus 4.6%, P = 0.247), but there were significantly higher rates of overall morbidity (6.6% versus 19.1%, P < 0.001) when pCCND was performed. ConclusionspCCND is not recommended for patients with clinically node-negative PTC preoperatively and intraoperatively because of the high complication rate and lack of benefit of reducing recurrence.

Surgical management of T1/T2 node-negative papillary thyroid cancer with tall cell histology: Is lobectomy enough?

BackgroundThe tall cell variant of papillary thyroid carcinoma has traditionally been treated more aggressively than classic papillary thyroid carcinoma. However, this may not be justified in patients with T1/T2 tall cell variant node-negative tumors. MethodsWe evaluated well-differentiated thyroid cancers treated surgically between 1985 and 2015 at our institution. We compared patients undergoing lobectomy for node-negative T1/T2 tall cell variant tumors with the same cohort with classic papillary thyroid carcinoma. Patients who underwent early planned completion thyroidectomy were excluded. Tall cell variant tumors were defined as those with ≥30% tall cells. Survival and recurrence outcomes were determined by the Kaplan-Meier method and groups compared using the log-rank test. ResultsThyroid lobectomy was performed for T1/T2 N0X disease in 70 (15%) tall cell cases and 429 (23%) classic papillary thyroid carcinoma cases. There was no significant difference in 10-year overall survival (P = .56) or locoregional recurrence-free probability (P = .52). Disease-specific survival and local or central nodal recurrence-free probability were 100% in both groups. In 9 papillary thyroid carcinoma cases, subsequent contralateral lobe tumors developed, and in 5, lateral neck metastases developed. No recurrences were seen in the tall cell group. ConclusionT1 node-negative tumors with tall cell histology can be satisfactorily managed with thyroid lobectomy, with equivalent oncological outcomes to classic papillary thyroid carcinoma.

Frozen section analysis of central lymph nodes in papillary thyroid cancer: the significance in determining the extent of surgery.

The indolent feature of papillary thyroid cancer (PTC) has recently led to an increase in less aggressive treatment options instead of total thyroidectomy (TT). We aimed to investigate the clinical significance of elective central compartment neck dissection (CCND) with intraoperative frozen analyses of the central lymph nodes (LNs) to determine the surgical extent of unilateral clinically node-negative PTC. We retrospectively reviewed the medical records of 290 patients with unilateral clinically node-negative PTC who underwent surgery and performed frozen analyses of the central LNs from 2020 to 2021 using our own nodal criteria with cut-off size 5 mm. The patients were divided and investigated according to the surgical extent and the National Comprehensive Cancer Network (NCCN) guidelines; diagnostic accuracy of the frozen analyses was estimated. TT was performed in 16.2% of patients. The TT group had more metastatic nodes with a larger size, higher LN ratio (LNR), and more extranodal extension. The analyses based on the NCCN guidelines showed similar findings, but more completion TT was required compared with our criteria. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the frozen analyses were 94.6%, 100%, 100%, and 96.1%, respectively. Elective CCND with intraoperative frozen analyses is a highly reliable procedure that detects occult nodal metastasis in unilateral node-negative PTC patients. Our nodal criteria yielded significant aggressive nodal characteristics in the TT group while yielding less TTs compared with the NCCN guidelines. The concept and clinical significance of small-volume nodal metastasis in PTC should be further investigated.

Identifying risk factors of recurrence for clinically node negative papillary thyroid carcinoma with pathologic N1a

BackgroundWhether or not to perform prophylactic central lymph node dissection (CLND) in the case of clinically node-negative papillary thyroid cancer (PTC) is controversial. The purpose of this study was to investigate the risk factors for recurrence in clinically node-negative PTC patients who underwent total thyroidectomy plus bilateral central neck dissection and was verified pathologic N1a.MethodsWe retrospectively reviewed the medical records of 1082 PTC patients who underwent total thyroidectomy and prophylactic bilateral CLND between January 2004 and December 2012. We used Cox-proportional hazard regression analyses in order to explore potential predictive factors for recurrence.ResultsDuring a median follow-up (range) of 78 (12–158) months, recurrence occurred in 62 (5.7%) patients. Main tumor size more than 1 cm, gross extrathyroidal extension (ETE), positive lymph node (LN) more than 3, and LN ratio > 0.5 were all significantly associated with recurrence according to univariate analysis. In model I multivariate analysis (tumor size, gross ETE, LN ratio), LN ratio > 5 (hazards ratio [HR], 4.794; 95% confidence interval [CI], 2.674–8.595; p < 0.001) was found to be predictive of recurrence. Gross ETE (HR, 1.794; 95% CI, 1.024–3.143; p = 0.041) and positive LN more than 3 (HR, 2.505; 95% CI, 1.513–4.146; p < 0.001) were predictors for recurrence in model II multivariate analysis (tumor size, gross ETE, the number of positive LN).ConclusionsWe recommend that surgeons try to focus completely on performing prophylactic CLND for patients with suspicious gross ETE during preoperative evaluation. Close monitoring and thorough management are needed for clinically node-negative PTC patients with LN ratio of more than 0.5 and more than 3 positive LN in the central compartment.

Morbidity Outcomes of Prophylactic Central Neck Dissection with Total Thyroidectomy versus Total Thyroidectomy Alone in Patients with Node Negative Papillary Thyroid Cancer: A Meta-Analysis of Observational Studies

Objective: The primary objective of this meta-analysis is to compare locoregional recurrence, vocal cord paralysis, and permanent hypoparathyroidism in patients with thyroid papillary carcinoma without neck node metastases, after total thyroidectomy with and without prophylactic central neck dissection.&#x0D; Methods: Two independent reviewers performed a detailed literature search of MEDLINE (PubMed), HERDIN and Cochrane Library electronic databases to assess research studies until 2018 for inclusion. The primary endpoints of locoregional recurrence, permanent hypoparathyroidism, and vocal cord paralysis were included in the assessment.&#x0D; Design: Meta-Analysis of Retrospective Cohort Studies&#x0D; Setting: University Hospitals and Tertiary Referral Centers&#x0D; Participants: Patients with node-negative papillary thyroid cancer who underwent either total thyroidectomy alone or total thyroidectomy with prophylactic central neck dissection (either unilateral or bilateral).&#x0D; Results: This meta-analysis showed that there is a significantly increased risk for locoregional recurrence in the total thyroidectomy alone group (1.96% TT with pCND VS 2.60% TT, RR=0.62, 95% Cl=0.40-0.95, p=.03), permanent hypoparathyroidism in the total thyroidectomy with prophylactic central neck dissection group (5.72% TT with pCND vs 3.34% TT, RR=2.19, 95% Cl=1.62-2.98, p=.00001) and no significant difference for vocal cord paralysis between the 2 groups (RR=1.56, 95% Cl=0.86-2.84, p=.14).&#x0D; Conclusion: This meta-analysis revealed that performing pCND in patients with node-negative PTC increases the risk of morbidity for hypoparathyroidism but not for vocal cord paralysis. More importantly, the incidence of recurrence is decreased in the pCND group, which may have implications on the overall survival of patients. The benefit of performing pCND may outweigh the risk but the role of prophylactic CND in the treatment of patients with PTC with clinically negative lymph nodes is still debatable in terms of overall survival.&#x0D; &#x0D; Keywords: thyroidectomy, complications; neck dissection; papillary thyroid carcinoma; lymph node dissection; recurrence; vocal cord paralysis; hypoparathyroidism

Identifying risk factors of lateral lymph node recurrence in clinically node-negative papillary thyroid cancer.

There is still debate regarding the role of routine central lymph node (LN) dissection in treating clinically node-negative papillary thyroid cancer (PTC). The aim of this study was to investigate the risk factors for lateral recurrence after total thyroidectomy and prophylactic bilateral central LN dissection in clinically node-negative PTC patients.We retrospectively collected the medical records of 1406 PTC patients who underwent total thyroidectomy and prophylactic bilateral central LN dissection between January 2004 and December 2008. We used Cox- proportional hazards regression analyses to inspect the predictive factors for recurrence.During a median follow-up of 107 months (range, 13–164 months), 68 (4.8%) and 37 (2.6%) patients experienced recurrence in any lesion and in lateral neck LN, respectively. Male, main tumor size >1 cm, nodal factors (pathologic N1a, positive delphian LN, and LN ratio >0.15), lymphovascular invasion, and extrathyroidal extension (ETE) were significantly associated with lateral neck LN recurrence in univariate analysis. Multivariate analysis showed that male (hazard ratio [HR], 2.217; 95% confidence interval [CI], 1.057–4.647; P = .035), main tumor size >1 cm (HR, 2.257; 95% CI, 1.138–4.476; P = .020), pathologic N1a (HR, 5.957; 95% CI, 2.573–13.789; P < .002), minor ETE (vs no ETE; HR, 3.027; 95% CI, 1.315–6.966; P = .009), and gross ETE (vs no ETE; HR, 4.058; 95% CI, 1.685–9.774; P = .002) were independent predictors for lateral neck LN recurrence.Among patients with pathologic N1a, those with LN ratio of more than 0.55 had worse lateral neck LN recurrence-free survival. Lateral neck LN recurrence in clinically node-negative PTC patients is predicted by the factors of male, main tumor size >1 cm, ETE, and pathologic N1a.

Is Prophylactic Central Compartment Neck Dissection Indicated for Clinically Node-Negative Papillary Thyroid Cancer: The Answer is Dependent on How the Data are Interpreted and the Weight Given to the Risks and Benefits

Is Prophylactic Central Compartment Neck Dissection Indicated for Clinically Node-Negative Papillary Thyroid Cancer: The Answer is Dependent on How the Data are Interpreted and the Weight Given to the Risks and Benefits

Prophylactic Central Compartment Neck Dissection in Papillary Thyroid Cancer and Effect on Locoregional Recurrence.

Prophylactic central compartment neck dissection (pCCND) in addition to total thyroidectomy (TT) includes removal of central compartment lymph nodes in the absence of clinical involvement on preoperative and intraoperative evaluation. The data regarding the influence of pCCND on oncologic outcomes and surgical complication rates is mixed and, therefore, is the focus of this analysis. A systematic review of the literature on total thyroidectomy with prophylactic central compartment neck dissection (TT + pCCND) from January 1990 to October 2017 identified 221 abstracts of which 17 met inclusion criteria and were reviewed (1 randomized-control trial, 13 retrospective cohort studies, and 3 meta-analyses). TT + pCCND was found to detect occult lymph node metastasis in approximately 50% of patients who had no clinical evidence of lymph node metastasis on preoperative imaging. Permanent hypoparathyroidism occurs more frequently following TT + pCCND (TT = 1.55% vs. TT + pCCND = 3.45%), but the rates of permanent recurrent laryngeal nerve dysfunction are similar (TT = 0.89% vs. TT + pCCND = 0.96%). The locoregional recurrence rates across all 14 studies included in this analysis was 6.75% for TT alone and 4.55% for TT + pCCND. The rate of locoregional recurrence was significantly lower in patients who underwent pCCND in a few studies and one meta-analysis, but were not significantly different in the majority of studies. TT + pCCND in clinically node-negative papillary thyroid cancer will detect occult lymph node metastasis in approximately half of patients. This may change their postoperative management with regard to adjuvant radioiodine therapy. There is a higher risk of hypoparathyroidism with pCCND, and the effect on rates of locoregional recurrence remains uncertain.

The significance of central neck dissection in clinically node-negative papillary thyroid cancer（clinical T1N0M0）

The significance of central neck dissection in clinically node-negative papillary thyroid cancer（clinical T1N0M0）

Preferential Use of Total Thyroidectomy without Prophylactic Central Lymph Node Dissection for Early-Stage Papillary Thyroid Cancer: Oncologic Outcomes in an Integrated Health Plan.

The oncologic benefit of prophylactic central lymph node dissection (pCLND) in node-negative papillary thyroid cancer has been debated. To determine the use of pCLND in an integrated health care system and to evaluate recurrence in the cohort. Retrospective cohort study of patients with clinically node-negative papillary thyroid cancer who underwent total thyroidectomy with or without pCLND in Kaiser Permanente Southern California Region hospitals between January 1996 and December 2008. Chart review of all patients was performed to collect demographic data, tumor features, stage, and recurrences. Proportion undergoing pCLND and recurrence rate of papillary thyroid cancer. There were 864 patients identified (mean age, 46.1 years). Almost all patients had total thyroidectomy alone, and 34 (3.9%) underwent pCLND. The TNM (tumor, node, metastasis) stages for the 2 groups were not significantly different (p = 0.18). Overall recurrence was 24 (2.8%). There were 23 (2.8%) recurrences in the no-pCLND group and 1 (2.9%) recurrence in the pCLND group (p = 0.95). The rate of recurrence in the central neck compartment in those without pCLND was 1.1% and 0% in the pCLND group (p = 0.54). The recurrence rate in the lateral neck compartment in the no-pCLND group was 2.2%, and this rate was 2.9% in the pCLND group (p = 0.76). The no-pCLND group had a recurrence-free survival rate of 96.4% at 10 years vs 96.8% in the pCLND patients (p = 0.80). Presently, routine pCLND is difficult to advocate in our medical system.

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

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.

Correlation Between Surgical Extent and Prognosis in Node-Negative, Early-Stage Papillary Thyroid Carcinoma Originating in the Isthmus.

The association between surgical extent and prognosis in papillary thyroid carcinoma originating in the isthmus is unclear. We included 233 patients with early-stage, node-negative papillary thyroid cancer originating in the isthmus; 126 were treated by lobectomy plus isthmusectomy with ipsilateral central neck dissection and 97 were treated by total thyroidectomy with bilateral central neck dissection. Subgroup analysis was performed according to tumor size (≤ 1 vs. >1 cm) to evaluate whether tumor size had a significant impact on determining the optimal extent of surgery in our cohort. Total thyroidectomy patients had longer recurrence-free survival (RFS) than those treated by lobectomy plus isthmusectomy. Subgroup analysis showed that this was true only for tumors >1 cm. In multivariate analysis, total thyroidectomy was an independent risk factor for RFS only for tumors >1 cm. Lobectomy plus isthmusectomy may be optimal for early-stage, node-negative papillary thyroid carcinoma originating in the isthmus for tumors ≤ 1 cm; total thyroidectomy might be better for tumors >1 cm.

The significance and the predictive factors of microscopic lymph node metastasis in patients with clinically node negative papillary thyroid cancer: A retrospective cohort study

BackgroundThe management of pathological lateral node involvement (pN1b) from papillary thyroid cancer (PTC) are controvertial. MethodsA consecutive series of 246 patients, diagnosed with clinically node negative (cN0) PTC who had undergone surgery with prophyractic lateral node dissection, and without postoperative radioactive iodine administration from 2001 to 11, were reviewed to clarify the significance of pN1b. ResultsEighty-five (35%) patients had pN1b disease. One-half and 30% had pN1b in younger (age less than 45) and older patients (age 45 or over), respectively. Tumor size (≥21 mm) could predict pN1b disease in older patients. Patients with pN1b disease recurred more frequently (9 cases, 10.6%) than those without (4 cases, 2.4%), and 2 cases with pN1b died of the disease. ConclusionspN1b disease was commonly found in patients with PTC even when they were diagnosed clinically as node negative. pN1b disease with prognostic meaning was often found in the older patients with larger PTC indicating the necessity for adjuvant treatments.

Total thyroidectomy without prophylactic central neck dissection in clinically node-negative papillary thyroid cancer: is it an adequate treatment?

BackgroundCervical lymph node metastases in papillary thyroid cancer are common. Although central neck dissection is indicated in clinically nodal-positive disease, it remains controversial in patients with no clinical evidence of nodal metastasis. The aim of this retrospective study was to determine the outcomes of clinically lymph node-negative patients with papillary thyroid cancer who underwent total thyroidectomy without a central neck dissection, in order to determine the rates of recurrence and reoperation in these patients compared with a group of patients submitted to total thyroidectomy with central neck dissection.MethodsTwo-hundred and eighty-five patients undergoing total thyroidectomy with preoperative diagnosis of papillary thyroid cancer, in the absence of suspicious nodes, were divided in two groups: those who underwent a thyroidectomy only (group A; n = 220) and those who also received a central neck dissection (group B; n = 65).ResultsSix cases (2.1%) of nodal recurrence were observed: 4 in group A and 2 in group B. Tumor histology was associated with risk of recurrence: Hürthle cell-variant and tall cell-variant carcinomas were associated with a high risk of recurrence. Multifocality and extrathyroidal invasion also presented a higher risk, while smaller tumors were at lower risk.ConclusionsThe role of prophylactic central lymph node dissection in the management of papillary thyroid cancer remains controversial. Total thyroidectomy appears to be an adequate treatment for clinically node-negative papillary thyroid cancer. Prophylactic central neck dissection could be considered for the more appropriate selection of patients for radioiodine treatment and should be reserved for high-risk patients only. No clinical or pathological factors are able to predict with any certainty the presence of nodal metastasis. In our experience, tumor size, some histological types, multifocality, and locoregional infiltration are related to an increased risk of recurrence. The potential use of molecular markers will hopefully offer a further strategy to stratify the risk of recurrence in patients with papillary thyroid cancer and allow a more tailored approach to offer prophylactic central neck dissection to patients with the greatest benefit. Multi-institutional larger studies with longer follow-up periods are necessary to draw definitive conclusions.

Radioactive iodine treatment for node negative papillary thyroid cancer with capsular invasion only: Results of a large retrospective study

With thyroid carcinoma the decision to use radioactive iodine (RAI) ablation depends on the risk of poor outcomes. Although extrathyroid extension (ETE) is well known as a risk of poor outcomes for papillary thyroid carcinoma (PTC), the definition of minimal ETE is too broad, as it encompasses both microscopic invasion of the thyroid capsule (capsular invasion [CI]) and macroscopic invasion of the sternothyroid muscle. We conducted a retrospective study to analyze the prognostic benefit of RAI ablation according to the presence of CI in a consecutive series of patients with PTC between October 1997 and December 2008. We studied two groups of patients, including those who received RAI (group I, n = 121) and those who did not (group II, n = 108). During follow-up, we assessed the locoregional recurrence of all patients. There were no statistically significant difference between the groups regarding locoregional recurrence at follow-up (13.2% for group I vs 9.3% for group II, P = 0.441). The association between RAI and locoregional recurrence in PTC patients with CI remained insignificant after adjusting for potential confounders, such as age, tumor size, sex, lymphatic invasion, vascular invasion and tumor multiplicity (P = 0.409, hazard ratio = 0.698, 95% confidence interval, 0.298-1.639). This retrospective study suggests that RAI treatment is not associated with less locoregional recurrence in PTC patients who only demonstrate CI, although further prospective studies are required to confirm these findings.

Prophylactic Central Neck Dissection Increases the Cost of Thyroid Cancer Care

Over the past several decades, health care spending has risen faster than any other segment of the United States economy and continues to rise. Media attention has been focused on health care costs since the introduction of the Patient Protection and Affordable Care Act of 2010, which aims to reduce costs of health care while improving outcomes. Physicians are in the best position to determine which treatments are effective and which patients benefit most, and they are more cognizant than ever of the mandate to spend our limited health care dollars wisely. Cost minimization should be the goal of every physician, as long as quality of care does not diminish. The incidence of papillary thyroid cancer (PTC) is increasing in the United States, but thankfully survival is excellent compared with many other cancers. Patients diagnosed when the disease is limited to the thyroid gland are nearly always cured with thyroidectomy. Unfortunately, regional lymph node metastases from PTC are very common, with the majority of patients having at least micrometastatic disease in the central neck at the time of diagnosis. Nodal involvement increases the risk of recurrence, which plays an important role in the long-term management of this disease. While there is no debate about removing clinically apparent lymph node disease at the initial surgery, there is significant debate regarding the utility of performing a prophylactic central lymph node dissection (pCND) as part of the initial thyroidectomy when there is no evidence of lymph node involvement. There has not been a definitive randomized controlled trial to date, and there are strong advocates on both sides of the argument. Proponents claim pCND saves future morbidity of repeat operations without adding much operative risk to the initial operation, while opponents feel it adds operative morbidity without altering long-term outcomes for the majority of patients. Most of the available literature has struggled to address either the risk or the benefit of pCND, and there has been no consensus. Lang et al., in this current issue, aim to answer the question from a costeffectiveness perspective, adding yet another dimension to this debate at a timely moment in national discourse. They report, unsurprisingly, that the initial procedural costs are higher for pCND at the time of initial surgery for node-negative PTC versus performing a simple thyroidectomy alone. The key question is whether that initial investment (and higher costs of more initial complications) saves health care spending in the long term by reducing the rates of reoperations and future complications. Using data from their recent well-done meta-analysis of 14 studies with 3,331 patients, the authors used odds ratios for complications of both initial surgeries, recurrence rates, and the likelihood of radioactive iodine (RAI) treatment to create a mathematical model. This model projected out costs for a hypothetical cohort of 100,000 women with a 1.5-cm papillary thyroid cancer. Using it, they found that pCND is not cost saving and calculated that, over 20 years, the accumulated direct costs of a thyroidectomy with pCND is $3000 more than initially performing a thyroidectomy alone and dealing with recurrences as they arise. In this hypothetical cohort of patients, the higher costs of pCND are mostly attributable to (1) longer operative time and greater complexity of the operation, (2) more initial complications, and (3) higher percentage of postoperative RAI in patients with pCND. Reoperations actually have similar costs in this model, and while fewer This is an editorial to the article available at doi: 10.1245/s10434013-3234-9.

A Meta-analysis of the Effect of Prophylactic Central Compartment Neck Dissection on Locoregional Recurrence Rates in Patients with Papillary Thyroid Cancer

It is not known whether prophylactic central compartment neck dissection (pCCND) in conjunction with total thyroidectomy decreases rates of locoregional recurrence in patients with papillary thyroid cancer (PTC). A meta-analysis was performed of reported recurrence rates of clinically node-negative PTC in patients treated with total thyroidectomy (TT) alone, or TT and pCCND. The primary outcome was locoregional recurrence of PTC. Eleven studies capturing 2,318 patients met the inclusion criteria. Overall, the recurrence rate for patients undergoing TT/pCCND was 3.8% [95% confidence interval (CI) 2.3-5.8]. In the six comparative studies, which included 1,740 patients, 995 patients undergoing TT and 745 patients undergoing TT/pCCND, the overall recurrence rate was 7.6:7.9% in the TT group and 4.7% in the TT/pCCND group. The relative risk of recurrence was 0.59 (95% CI 0.33-1.07), favoring a lower recurrence rate in the TT/pCCND arm. The number of patients that would need to be treated (NNT) in order to prevent a single recurrence is 31. The relative risk for permanent hypocalcemia was 1.82 (95% CI 0.51-6.5) and for permanent recurrent laryngeal nerve injury was 1.14 (95% CI 0.46-2.83). There was no difference in recurrence or long-term complication rates between patients undergoing TT or TT/pCCND. There was a trend toward lower recurrence rates in TT/pCCND patients, with a NNT of 31 patients. On the basis of these data, routine pCCND might be considered in the hands of high-volume surgeons treating patients with clinically node-negative PTC.

Surgical extent of central lymph node dissection in clinically node-negative papillary thyroid cancer

The indications for elective bilateral central node dissection for patients with unilateral papillary thyroid carcinoma (PTC) who are clinically node negative are still not verified. We investigated the predictive factors of lymph node metastasis and formulated guidelines for surgical extent. From 2004 to 2009, 325 patients diagnosed with unilateral PTC who had undergone total thyroidectomy with bilateral central lymph node dissection (CLND) were enrolled retrospectively. Central node metastasis was found in 45.2%, ipsilateral and contralateral lymph node metastasis was found in 40.0% and 16.0%, respectively. Tumor size larger than 1.0 cm and extrathyroidal extension were significant factors in predicting ipsilateral node metastasis (p = .004, < .001, respectively), and extrathyroidal extension and ipsilateral lymph node metastasis predicted contralateral node metastasis in multivariable analysis (p = .039, < .001, respectively). Elective bilateral central node dissection may be considered in unilateral PTC with extrathyroidal extension or ipsilateral node metastasis.

Ipsilateral and contralateral central lymph node metastasis in papillary thyroid cancer: Patterns and predictive factors of nodal metastasis

The aims of this study were to evaluate the rate and risk factors of ipsilateral and contralateral central lymph node (CLN) metastases in patients with papillary thyroid cancer (PTC). A total of 161 patients who underwent total thyroidectomy with prophylactic CLN dissection (CLND) to treat PTC were enrolled. Of 134 total cases excluding tumors located in the isthmus and bilateral lobes, 72 cases (53.7%) involved CLN metastases. Tumor size, age, and sex were found to be predictive of ipsilateral CLN metastasis and the rate of ipsilateral CLN metastasis in tumors > 1 cm was 59.6%. Contralateral CLN metastases were more prevalent only in tumors that already had ipsilateral CLN metastases (27.3%, p = .002). It is suggested that risk factors of ipsilateral and contralateral CLN metastases should be considered while planning the extent of CLND in patients with clinically node-negative and unilateral PTC upon preoperative ultrasonography.