Management of occult metastatic cervical disease from well-differentiated thyroid carcinoma

It can be agreed that up to 90% of patients with well-differentiated thyroid carcinomas have occult cervical disease; however, the biologic and prognostic implications of that prevalence remain debatable. Thyroid suppression therapy is supported, but I131 treatment is recommended only for manifest distant metastases or extracapsular invasion by the primary tumor--not for occult cervical disease alone. A cervical central compartment block resection, consisting of an extended glandular-primary tumor excision that includes adjacent node-bearing soft tissue between the jugular veins, below the hyoid, and into the superior mediastinum, appears to be the best treatment for the primary tumor and occult regional metastases. This resection can be done through a single low, transverse incision, leaving the sternocleidomastoid muscle, the accessory nerve, and submandibular triangle intact, yet better clearing the primary source and the high-risk nodes in the parathyroid area. The rationale for this degree of resection is based on (1) the high risk of central neck recurrences and (2) the fact that the superior mediastinal nodal metastases may become extensive or inoperable before they are detectable and are the most likely nodes in which metastases may result in death. Delayed manifestations of other laterally placed occult cervical nodes can be treated by conservative neck dissection at the time of their appearance, without a worsening of the prognosis.