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March 2015Background
The American Cancer Society estimates that there will be approximately 56,460 new diagnoses of thyroid cancer in the United States during 2012, and more than 90% will be papillary thyroid cancer (PTC). Despite the large, ever-increasing number of thyroid cancer cases, the ideal initial management of well-differentiated PTC remains controversial. The role of the prophylactic central neck dissection (pCND) has emerged as the most highly debated topic, with conflicting reports regarding indications, recurrence prevention, and reduction of cause-specific mortality. Currently, there is no argument that a formal, compartmental CND should be performed if pre-operative or palpable nodal disease is encountered. However, the 2009 American Thyroid Association (ATA) guidelines state that pCND may be performed in patients with PTC with clinically uninvolved central neck lymph nodes, especially for advanced primary tumors. With the advent of personalized therapy based on molecular testing, the BRAF gene has shown the most promise in predicting lymph node metastases and may be used to direct clinicians on whether to perform a pCND.
Best Practice
Based on large, population studies, one can infer that the presence of metastatic lymph nodes in patients with PTC does predict poorer survival for patients > 45. The results of the meta-analysis mentioned above suggest that the use of pCND for all PTC patients is not warranted since the risks of transient nerve paralysis and hypoparathyroidism may outweigh the benefits. While the true advantage of prophylactic CND for PTC with regard to recurrence prevention and improved survival may be impossible to ascertain, the presence of metastatic lymph nodes should be investigated for staging and post-operative treatment planning in high-risk patients.
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