What is the Appropriate Extent of Lateral Neck Dissection in the Treatment of Metastatic WDTC?

Background

The evidence presented was obtained from five evidence-based medicine level 4 studies.

Although cervical metastases occur in a significant number of cases, the extent of therapeutic neck dissection in the setting of metastatic well-differentiated thyroid carcinoma (WDTC) remains unclear. Recently published American Thyroid Association guidelines recommend dissecting both the central and lateral lymph node compartments in the presence of clinically or histologically apparent lateral cervical metastases. Even though these guidelines explicitly define the central compartment dissection as the removal of level VI, the levels to be addressed in the lateral neck are not clearly stated. Modified radical neck dissection and selective neck dissection, including levels II-A, III and IV, have been advocated, but no official management guidelines exist. At the root of this controversy is the question of whether or not to routinely dissect levels II-B and V, considering the potential morbidity due to injury to the spinal accessory nerve while dissecting these nodal basins.

In this review, we summarize the recent literature regarding the extent of lateral neck dissection in the setting of metastatic WDTC and seek to define the current best clinical practices based on the available evidence.

Best Practice

The available evidence for management of the lateral neck in metastatic WDTC is somewhat inconsistent. In the absence of a recognized consensus statement on the topic, multiple therapeutic options remain viable. Evidence exists for employing both selective neck dissection, including levels II–V, with or without the inclusion of levels II-B and V-A, and modified radical neck dissection in this setting. One should remain aware of the fact that the presence of nodal disease is associated with an increased rate of locoregional recurrence, but no direct effect on overall survival has been established. Bearing this evidence in mind, one should proceed with the general approach of removing any clinically overt nodes by performing the most concise, least morbid operation. Read the full article in The Laryngoscope.