NECK DISSECTION FOR SURGICAL-TREATMENT OF LYMPH-NODE METASTASIS IN PAPILLARY THYROID-CARCINOMA

In papillary thyroid carcinoma lymphnode metastases at presentation do not seem to adversely affect survival, but do increase the risk of lo co-regional tumor recurrence. The value of systematic versus selective lymphadenectomy is far less standardized, whereas the role of postope rative radioiodine in preventing either nodal recurrence or cancer dea th remains controversial. Clinical data of 36 N+ patients with papilla ry thyroid carcinoma who had undergone from 1990 to 1996 ipsilateral o r bilateral neck dissection were retrospectively reviewed, to analyse the value of systematic lymphadenectomy. In our series of 50 extensive lymph node dissections (levels 2-6), the number of metastases in each specimen (mean value: 5) and the incidence of multiple level metastas es (36%) were high. In 37.5% of the metastases at level 6 and in 11.1% at level 4, coexisting nodal involvement at level 2 was observed, wit hout metastasization at intermediate levels. Multiple levels metastase s and skip metastases were present in at least one third of the patien ts and could be excised only performing a complete dissection of the l evels 2-6. Extra-capsular spread was found in 56% of the specimens. In 64.3% of these cases a functional neck dissection was performed. A mo dified radical or radical neck dissection was carried out in the other 35.7% of the cases. These patients received modified radical neck dis section (functional dissection with sacrifice of internal jugular vein ) in 60% of the cases and radical neck dissection in the other 40%. In papillary thyroid carcinoma extensive lymphnode dissection at present ation has been stated to offer no advantage versus selective lymphaden ectomy, causing increased morbidity. However, experienced surgeons rep ort a low incidence (less than 5%) of accessory spinal nerve and cervi cal plexus permanent sequelae after functional neck dissection, In our opinion, patients with cervical lymph node metastases require a compl ete loco-regional neck dissection. Systematic lymphadenectomy, perform ed by lateral neck plus upper anterior mediastinal dissection, can yie ld a high disease-free survival. Moreover, this can limit the overall radio-iodine therapeutic dose and the risk of de-differentiation of re current tumor to the anaplastic type in patients with a long-term and near normal life-span.