Therapeutic central neck dissection (CND) is an accepted part of the management of papillary thyroid carcinoma (PTC), while prophylactic CND remains controversial. Regardless of the indication for CND, the lower anatomic border of the central compartment, specifically the inclusion or otherwise of level VII, is not always clearly defined in the literature. This study aimed to determine if the routine inclusion of level VII lymph node dissection as part of CND confers increased utility in the detection of macrometastatic lymph nodes compared with level VI dissection alone.
This was a prospective cohort study of patients undergoing CND for PTC at a tertiary referral center. All patients received either a prophylactic or therapeutic CND. The CND specimens were divided by the surgeon into level VI and level VII at the level of the suprasternal notch and submitted separately for histopathology. Criteria for macroscopic lymph node disease were taken from the American Joint Committee on Cancer (AJCC) recommendations for breast cancer.
A total of 45 patients with PTC underwent total thyroidectomy and routine CND, at a tertiary referral center; 77 % of the therapeutic CND group had positive level VI lymph nodes, and 38 % had positive level VII lymph nodes. Of the prophylactic CND group, 50 % of patients had positive level VI nodes and 16 % has positive level VII nodes detected. All patients with positive level VII lymph nodes in the prophylactic CND group had macrometastatic disease. Temporary hypocalcemia rate was 31 % in the therapeutic group and 6 % in the prophylactic CND group. One patient experienced permanent hypoparathyroidism. There was no vascular injury or recurrent laryngeal nerve palsy in either group.
CND incorporating both level VI and level VII can be undertaken safely through a cervical incision with no increased risk of permanent complications of hypoparathyroidism or recurrent laryngeal nerve injury. Failure to include level VII as part of CND will leave significant macrometastatic nodal disease behind in both therapeutic and prophylactic dissections. As level VII is in direct anatomic continuity with the pretracheal level VI nodes, it should be routinely included as part of every CND.
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Rosenbaum MA, McHenry CR. Contemporary management of papillary carcinoma of the thyroid gland. Expert Rev Anticancer Ther. 2009;9:317–29.
Mazzaferri EL Jhiang SM. Long-term impact of initial surgical and medical therapy on papillary and follicular thyroid cancer. Am J Med. 1994;97:418–28.
Lundgren CI, Hall P, Ekbom A, Frisell J, Zedenius J, Dickman PW. Incidence and survival of Swedish patients with differentiated thyroid cancer. Int J Cancer. 2003;106:569–73.
Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19:1167–214.
Scheumann GF, Gimm O, Wegener G, Hundeshagen H, Dralle H. Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer. World J Surg. 1994;18:559–67; discussion 567–8.
Hughes CJ, Shaha AR, Shah JP, Loree TR. Impact of lymph node metastasis in differentiated carcinoma of the thyroid: a matched-pair analysis. Head Neck. 1996;18:127–32.
American Thyroid Association Surgery Working, Carty SE, Cooper DS, Doherty GM, Duh QY, Kloos RT, Mandel SJ, et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid. 2009;19:1153–8.
Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A, eds. AJCC cancer staging manual. 7th ed., New York: Springer, 2010.
Crile GJ. The pattern of metastasis of carcinoma of the thyroid. Ann Surg. 1956; 143:580–7.
Grebe SK, Hay ID. Thyroid cancer nodal metastases: biologic significance and therapeutic considerations. Surg Oncol Clin N Am. 1996;5:43–63.
Mulla M. Central cervical lymph node metastases in papillary thyroid cancer: a systematic review of imaging-guided and prophylactic removal of the central compartment. Clin Endocrinol (Oxf). 2012;76:131–6.
Block MA, Miller JM, Horn RC Jr. Significance of mediastinal lymph node metastases in carcinoma of the thyroid. Am J Surg. 1972;123:702–5.
Cheema Y, Repplinger D, Elson D, Chen H. Is tumor size the best predictor of outcome for papillary thyroid cancer? Ann Surg Oncol. 2006;13:1524–8.
Hay ID, Bergstralh EJ, Grant CS, McIver B, Thompson GB, van Heerden JA, et al. Impact of primary surgery on outcome in 300 patients with pathologic tumor-node-metastasis stage III papillary thyroid carcinoma treated at one institution from 1940 through 1989. Surgery. 1999;126:1173–81; discussion 1181–2.
Ito Y, Miyauchi A. Lateral and mediastinal lymph node dissection in differentiated thyroid carcinoma: indications, benefits, and risks. World J Surg. 2007;31:905–15.
Noguchi M, Kumaki T, Taniya T, Segawa M, Nakano T, Ohta N, et al. Impact of neck dissection on survival in well-differentiated thyroid cancer: a multivariate analysis of 218 cases. Int Surg. 1990;75:220–4.
Leboulleux S, Rubino C, Baudin E, Caillou B, Hartl DM, Bidart JM, et al. Prognostic factors for persistent or recurrent disease of papillary thyroid carcinoma with neck lymph node metastases and/or tumor extension beyond the thyroid capsule at initial diagnosis. J Clin Endocrinol Metab. 2005;90:5723–9.
DeGroot LJ, Kaplan EL, McCormick M, Straus FH, et al. Natural history, treatment, and course of papillary thyroid carcinoma. J Clin Endocrinol Metab. 1990;71:414–24.
Shaha AR, Shah JP, Loree TR. Risk group stratification and prognostic factors in papillary carcinoma of thyroid. Ann Surg Oncol. 1996;3:534–8.
Steinmuller T, Klupp J, Rayes N, Ulrich F, Jonas S, Gräf KJ, et al. Prognostic factors in patients with differentiated thyroid carcinoma. Eur J Surg. 2000;166:29–33.
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Wang, L.Y., Versnick, M.A., Gill, A.J. et al. Level VII is an Important Component of Central Neck Dissection for Papillary Thyroid Cancer. Ann Surg Oncol 20, 2261–2265 (2013). https://doi.org/10.1245/s10434-012-2833-1
- Papillary Thyroid Carcinoma
- Recurrent Laryngeal Nerve
- Papillary Thyroid Cancer
- Innominate Vein
- Central Neck Dissection