Rethinking prophylactic central neck dissection in clinically node-negative papillary thyroid cancer

Papillary thyroid cancer is associated with a high rate of lymph node metastases, mainly in the form of small metastases in the central compartment. Even when present, these metastases are most often undetected by preoperative ultrasound (clinically node-negative or cN0) and only identified by systematically performing a prophylactic central neck dissection. However, even in the absence of prophylactic central neck dissection to remove these metastases, clinically detected recurrence in lymph nodes occurs in fewer than 10% of patients, which explains the controversy surrounding the procedure. Clinical data have not shown an advantage in survival, although some studies point to an incremental reduction in regional recurrence rates with a concomitant increase in morbidity in temporary hypoparathyroidism. Thus, over the past decade, guidelines have kept the option of prophylactic central neck dissection open for discussion, leaving clinicians to make these decisions. Resolving this issue remains a challenge due to the difficulties inherent in implementing randomised trials in a surgical setting. This Personal View aims to summarise the current controversy and evidence surrounding prophylactic central neck dissection and to suggest new directions for research.