Endocrine Abstracts

Central neck dissection for papillary thyroid cancer (PTC) was initially proposed by Scandinavian authors in the late 70’s on the following grounds: i) the common presence of obvious metastatic nodal disease in compartment VI; ii) compartment VI is the first step in lymph node dissemination of PTC; and iii) prevents cancer recurrence in the central neck leading to difficult reoperations. These same authors were also the first to suggest that thorough surgery for PTC would eliminate or substantially reduce the need for radioidine treatment. No one would argue today that in all patients with PTC the central compartment must be explored carefully and lymphadenectomy performed in all cases of macroscopic nodal involvement. Thus, therapeutic CND is out of question despite it is a quite challenging and extensive operation, often associated with locally advanced PTC, that may result in permanent hypoparathyroidism due to inadvertent parathyroidectomy and devascularization of the parathyroid glands.

Currently the controversy persists on the need to perform a prophylactic neck dissection in cases without macroscopic nodal involvement. We favor it on the following basis: i) half of the normal looking central nodes harbor PTC metastasis; ii) prevention of central neck recurrences; iii) better staging and progressive abandon of radioidine treatment; iv) few permanent complications if not bilateral and performed by experienced surgeons.

Because the rate of central lymph node metastasis increases with tumour size, we advocate to add routine CND to total thyroidectomy in all PTC >1 cm; preferentially bilateral if performed for therapeutic purposes and unilateral when performed prophylactically. In our hands, this optimized surgical approach has resulted in a low 9% recurrence rate after a mean follow-up of seven years in over 150 patients (mean T size 27 mm) with a 7.5 and 2.5% permanent hypopara rates for therapeutic and prophylactic CND respectively. All recurrences have occurred in the lateral neck (despite prior radioiodine treatment) and none in compartment VI. 30% of our patients were not treated with radioiodine; none of them has developed a recurrence.