Lymph node surgery in papillary thyroid carcinoma

BACKGROUND: The impact of nodal disease remains controversial in papillary thyroid carcinoma (PTC). STUDY DESIGN: One surgeon treated 159 unselected patients, who were followed up for 1 to 27 years. We present a retrospective analysis with respect to nodal disease. Occult nodal disease was investigated, including metachronous nodal disease (mpN(1)) in primarily node negative patients (pN(0), clinical [c]N(0)). RESULTS: Therapeutic lymphadenectomies, prophylactic lymphadenectomies, or no lymphadenectomy were carried out in 42 (cN(1)), 29 (cN(0)), and 88 (cN(0)) patients, respectively, with stage pN(1) in 41 (98%), in 5 (17%), and in 2 (2.3%) patients, respectively (17% versus 2.3% p < 0.005). Sensitivity and specificity of clinical staging were 85% and 99%, respectively. More frequent prophylactic lymphadenectomy during the study period (p = 0.002) led to a nonsignificant increase in stage pN(1) (26% versus 30%). Immunohistochemistry led to upstaging of only 3% of histologically negative nodes and one (4%) pN(0) patient. Nodal recurrence occurred in 8 of 156 patients (5%) treated for cure, in 12% of pN(1) versus 3% of pN(0) cN(0) tumors (p = 0.009), in 15% of TNM high-versus 3% of low-risk patients (p = 0.006), and in 5% each of patients, younger than 45 and 45 years or more. In TNM high-risk patients, tumor-related survival was 50% for stage pN(1) versus 86% for stage pN(0), cN(0) (p = 0.03) (100% and 100% in low-risk patients). CONCLUSIONS: The rate of occult nodal disease might be relatively low, and it does not frequently progress to clinical recurrent disease. Clinical nodal status might be valid for deciding the extent and radicality of node dissection. Prophylactic (central) lymphadenectomy should be carried out without radicality-associated morbidity. Macroscopic nodal disease warrants more rigorous, compartment-oriented lymphadenectomy. There is no rationale for detection of occult disease and micrometastasis by frozen section or immunohistochemistry.