Total thyroidectomy, without prophylactic central lymph node dissection, in the treatment of differentiated thyroid cancer. Clinical retrospective study on 221 cases

Abstract

Total thyroidectomy (TT) is the standard of care for differentiated thyroid cancer (DTC), but still there is no consensus about the role of routine use of prophylactic central lymph node dissection. The aim of this study was to analyze our results of TT without prophylactic central lymphadenectomy in the treatment of DTC. Clinical records, between January 1998 and December 2005, of 221 patients undergoing TT, without prophylactic central lymph node dissection, were retrospectively evaluated. Two hundred and eleven patients (95.47 %) also underwent radioiodine (RAI) ablation followed by thyroid stimulating hormone (TSH) suppression therapy. In patients with loco-regional lymph nodal recurrence, lateral and central lymph node dissection was performed. The incidence of permanent hypoparathyroidism (iPTH <10 pg/ml) and permanent vocal fold paralysis were, respectively, 0.91 and 0.91 %. After a 9.6 ± 3.5 years mean follow-up, the rate of loco-regional recurrence, with positive cervical lymph nodes, was 3.16 % (7/221 patients). In these cases a lateral and central lymphadenectomy was carried out without significant complications. Our results showed that TT without prophylactic central lymph node dissection, followed by RAI ablation, was associated with low morbidity and low loco-regional recurrence rate, even if the lack of a control group treated with TT plus prophylactic central lymphadenectomy suggests caution against generalization of our assumption. Such last combined procedure could be indicated in high-risk patients, in whom loco-regional recurrence is more frequent. However, given the trend in the literature toward prophylactic lymphadenectomy and the avoidance of RAI treatment, prospective randomized trials should be conducted to better clarify this issue.

Nasotracheal Prolonged Safe Extubation Reduces the Need of Tracheotomy in Patients with Acute Respiratory Failure following Thyroidectomy

“…Incidence of Acute Respiratory Failure (ARF) following thyroid surgery is reported as high as 0.9% [1][2][3][4]. This life-threatening condition is often only temporary, and it may recover spontaneously.…”

Prophylactic central lymph node dissection in differentiated thyroid cancer

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Conzo et al [1] describe their experience of treating differentiated thyroid carcinoma in patients who lack clinically evident nodal disease (cN0) with total thyroidectomy, without prophylactic central lymph node dissection, followed by radioactive iodine (RAI). 93.8 % of their 221 patients had AJCC Stage I or II papillary thyroid carcinoma.

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“…They note that the current literature lacks conclusive evidence of survival or recurrence benefit, but has established an increase in complication rates (specifically, transient hypocalcemia) associated with prophylactic central nodal dissection compared with total thyroidectomy alone. Based on their results and their scrutiny of this literature, those authors have come to conclude that their treatment paradigm is acceptable and that prophylactic central neck dissection can be avoided [1].Multiple staging systems for papillary thyroid carcinoma have been developed, many of which do not include cervical nodal metastasis as a factor. However, TNM staging is utilized by the American Thyroid Association in its most recently published guidelines for differentiated thyroid carcinoma.…”

“…They note that the current literature lacks conclusive evidence of survival or recurrence benefit, but has established an increase in complication rates (specifically, transient hypocalcemia) associated with prophylactic central nodal dissection compared with total thyroidectomy alone. Based on their results and their scrutiny of this literature, those authors have come to conclude that their treatment paradigm is acceptable and that prophylactic central neck dissection can be avoided [1].…”

“…Conzo et al [1] observe that for cN0 patients in whom the decision to give RAI is made preoperatively, prophylactic central lymphadenectomy adds no benefit. While advocates for routine prophylactic nodal dissection have not yet proven definitive recurrence/survival benefit, some propose value added regarding diminished thyroglobulin (TG), suggesting it as a surrogate for recurrence, and more accurate staging which can guide adjuvant RAI usage.…”