NESS - Dissection of Levels II Through V Is Required for Optimal Outcome in Patients With Lateral Neck Lymph Node Metastasis From Differentiated Thyroid Carcinoma

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Dissection of Levels II Through V Is Required for Optimal Outcome in Patients With Lateral Neck Lymph Node Metastasis From Differentiated Thyroid Carcinoma
*Mahsa Javid, *Emma Graham, *Jennifer Malinowski, *Courtney Quinn, *Tobias Carling, Robert Udelsman, *Glenda Callender
Yale University School of Medicine, New Haven, CT

Objective: To examine the optimal extent of therapeutic lateral neck dissection in patients with differentiated thyroid carcinoma (DTC) and regional lymph node (LN) metastasis. Prior data suggest lower incidence of involved LNs in levels II and V than levels III and IV; some argue formal modified radical neck dissection (MRND) of levels II-V is too aggressive and selective neck dissection (particularly levels III-IV) suffices.
Design: Retrospective cohort
Setting: Tertiary care academic center
Patients: 196 consecutive patients with DTC underwent lateral neck dissection from 6/1/2006 to 12/31/2014 with pathology specimens labeled by LN levels determined intraoperatively [119(61%) women; median age 46(range 6-87) years; median follow-up 14.4(range 0-107) months; 192(98%) papillary]. Overall, 182 patients underwent 201 initial MRNDs (median LNs 30, range 8-90; 26 bilateral MRND) and 7 initial selective neck dissections (levels II-IV:4; levels III-IV:2; level IV:1); 37 patients underwent 39 reoperative lateral neck dissections.
Intervention: Lateral neck dissection
Main outcome measure: Lymph node recurrence; nerve injury rate
Results: Among initial dissections, 134(65.4%), 135(65.2%), 106(51.0%) and 34(16.9%) had positive LNs in levels II, III, IV and V, respectively. Ipsilateral LN recurrence occurred following 22(10.6%) dissections: level II in 9(40.9%), level III in 6(27.3%), level IV in 6(27.3%) and level V in 3(13.6%). Temporary nerve injury occurred in 7(3.4%:4 marginal mandibular; 3 sympathetic chain). In reoperative dissections, positive LNs occurred in levels II, III, IV and V in 18(46.1%), 10(27.8%), 13(33.3%) and 5(12.8%), respectively; temporary nerve injury occurred in 4(10.3%: 3 sympathetic chain; 1 vagus).
Conclusions: Omitting levels II and V during lateral neck dissection potentially misses level II disease in two-thirds of patients (a higher rate than previously reported) and level V disease in one-fifth.

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