Routine bilateral central lymph node clearance for papillary thyroid cancer

Background. Controversy exists regarding the extent of surgical treatment for paratracheal (level VI) lymph nodes in patients with papillary thyroid cancer (PTC). Local recurrence within lymph nodes in the central neck compartment after total thyroidertomy can be difficult to detect and more hazardous to treat surgically. An initial bilateral central lymph node dissection (CLND) can best minimize this risk of local recurrence, if CLND is established as reasonably safe and oncologically justified. Method. This study is based on a retrospective review of the insitutitional tumor registry of all patients treated for PTC between january 2000 and May 2008 at a 636-bed tretiary referral center and university-affiliated hospital. The following data were analyzed. the operative procedures, tumor characterstics (size, lymph mode metatasis), injury to the recurrent larynegeal nerve (RLN) tumor recurrence, and need for further operative procedures Result. Of 310 patients identified as treated surgically for PTC, 281 received total thyroidectomy and 29 received a lasser operation. Bilaternal CLND was performed in 169 patient, unilateral CLND in 11, and no CLND in 130. The central lymph nodes were postitive in 84 (46.7%) of 180 patients with CLND Excluding isthmus tumors and those with blateranl same-size PTC, 41 (25.5%) of 161 patients with bilateral CLND had postitive contralateral lymph nodes. Of the 603 RLNs at risk, 13 temporary injuryes occurred, and 8 (1.3%) permenant injuries resulted The risk of RLN injury was not greater with bilateral CLND compared to unulateral or no CLND (P = .18), and those patients with bilateral CLND had statistically larger tumors (1.60 cm vs 0.814 cm; P < .0001). Of the 10 documented cancer recurrence requirng reopection, 4 were in the central neck, and all of these occrred in patients who did not have CLND. Conclusion. Lympth node metastates are present in both the ipsilateral and contralateral central lymph node basims in a significant percentage of patients with PTC. Routine inlateral CLND in patients with PTC has the potential to clear metastatic disease without significantly increasing the risk of RLN injury (Surgery 2009;146:696-705.)