Selective Modified Radical Neck Dissection for Papillary Thyroid Cancer—Is Level I, II and V Dissection Always Necessary?

Abstract

If utilized in the appropriate patient population, a selective approach to lateral cervical LND for PTC can be a successful alternative to the routine modified radical LND. Levels I and V do not require resection unless there is clinical or radiological evidence of disease. Guidelines for which patients may be considered for this less aggressive approach to level II nodal metastases are suggested.

Is Level V Dissection Necessary for Low-risk Patients with Papillary Thyroid Cancer Metastasis in Lateral Neck Levels II, III, and IV

“…Turanli domonstrated that no survival advantage was gained by modified radical neck dissection (level I-V) compared to more selective neck dissection (level II-IV) (Turanli et al, 2007). Caron stated that routine modified radical neck dissection can be successfully replaced by a selective approach (Caron et al, 2006). We agree with the opinions of Caron, in this study, for PTC low risk patients with clinically negative lymph node in level V, dissection of level V was ignored,,and low recurrence rate was achieved (4.26%, 2/47), No death and distant metastasis were recorded in follow-up period, though a long followup period was required further for survival analysis, the average duration of patient follow-up still reached 48.2 months, we could come to the preliminary conclusion that selective neck dissection (level II-IV) could at least reach the same rusults as the reported results of modified radical neck dissection (level I-V).…”

“…pN1b does not independently affect the cause specific survival of patients (Ito et al, 2007), as a results, prophylactic lateral neck dissection was not recomanded (Doherty et al, 2009), this is also applied to level V. when study population was restricted to patients without a clinically evident level V lymph node, pN1b were present in a number of level V specimens (16-20%) (Roh et al, 2008), Noguchi reported that at least 75% of patients with PTC have occult lymph node metastases, but only about 20% become clinically evident, which means pN1b occasionally developed to be evident (Noguchi et al,1987). Carton reported a recurrence rate of 3% at level V, and they thought that recurrence rarely recurred at level V regardless of whether this lymphatic region had previously been found to be positive for metastatic disease, negative for metastatic disease or simply not dissected (Caron et al, 2006). In our study, 2 patients have shown recurrence to the lymph node,and just one patient showed nodal recurrence in ipsilateral level V. hence, patients with a clinically negative level V lymph node and occult lymph node metastases would be expected to have lower recurrence rate.…”

“…As the wide use and satisfactory diagnostic efficacy, high resolution ultrasonograpy has been used to detect lateral positive lymph node (Robbins et al, 2002;Caron et al, 2005;Ito et al, 2005;Cooper et al, 2006;Doherty et al, 2009). Nowadays, clinically positive lymph node metastasis includes the nodes detected both by palpation and ultrasonograpy (Caron et al, 2006), and ultrasonograpy is more sensitive than palpation, the proportion of clinically positive lymph node detected by ultrasonograpy becomes greater, we would think that the severity of cN1b detected by ultrasonograpy is less than that by palpation, and would be expected to have lower recurrrence and better survival. In our study, all the patients underwent US and found suspicious metastatic nodes, and only 19 patients found palpable cervical lymph nodes, No death and distant metastasis were recorded in follow-up period.…”

Sentinel Lymph Node Biopsy in Well Differentiated Thyroid Cancer

“…In keeping with the theory, Nogychi in a study of 68 patients after elective neck dissection, found 78% of nodal metastases in the paratracheal region and 22% in the jugular chain (Nogychi et al, 1987, as cited in Kelemen et al, 1998). Many groups have, however, reported that the risk of lymphatic metastases was greatest for the lateral nodal groups (level II, III and IV) ( Caron et al, 2006;Gimm et al, 1998;Lee et al, 2008;Roh et al, 2007Roh et al, , 2008Shah et al, 1990) while others have shown comparable rates of involvements in both the central cervical and lateral neck compartments (Machens et al, 2002).…”

Thyroid Lymphosonography: A Novel Method for Evaluating Lymphatic Drainage

“…6 Lymphatic metastasis from well-differentiated thyroid carcinoma is of little clinical significance in low-risk cases, 7,8 despite its 30% to 90% prevalence (depending on disease stage and method of assessment). 9 Although such regional metastasis may be associated with a greater rate of locoregional recurrence, it likely only has prognostic significance in those more than 45 years of age. 10 Typically, the ipsilateral central compartment nodes are involved, but some studies indicate that nearly 10% of patients may have "skip" metastases to the lateral neck.…”