Level VI lymph node dissection for papillary thyroid cancer

Papillary thyroid cancer (PTC) is the most common endocrine malignancy and commonly metastasizes to regional lymph nodes. Surgical treatment of cervical lymph nodes in PTC remains controversial. It has traditionally been accepted that regional lymph node metastases in PTC may increase local recurrence rates but do not ultimately affect survival. This conventional wisdom has been challenged by recent reports indicating that regional lymph node metastases do increase mortality. Thus, there has been renewed interest in operative control of nodal disease for PTC. A systematic review of central lymph node dissection (CLND) in the recent literature using evidence-based criteria permitted formation of the following five recommendations: 1) limited data suggest benefit with the addition of prophylactic CLND to thyroidectomy (grade C); 2) systematic compartment-oriented CLND may decrease recurrence of PTC and improve disease-specific survival (no grade); 3) the addition of CLND to total thyroidectomy can significantly reduce levels of serum thyroglobulin and increase rates of athyroglobulinemia (no grade); 4) there may be a higher rate of permanent hypoparathyroidism and unintentional permanent nerve injury when CLND is performed with total thyroidectomy than for total thyroidectomy alone (grade C); 5) reoperation in the central neck compartment for recurrent PTC may increase the risk of hypoparathyroidism and unintentional nerve injury when compared to total thyroidectomy with or without CLND, supporting a more aggressive initial operation by experienced endocrine surgeons (grade C). Taken together, these recommendations support the application of routine CLND at the initial operation for papillary thyroid cancer in expert hands.