|Year : 2013 | Volume
| Issue : 4 | Page : 12-13
Central compartment in thyroid surgery: When, what and how?
Amit Agarwal, Roma Pradhan
Department of Endocrine Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India
|Date of Web Publication||2-Feb-2013|
Department of Endocrine Surgery, SGPGIMS, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Central compartment lymph node (CCLND) management in patients without clinical or radiologic evidence of CCLND metastasis is debatable. CCLND in Papillary Thyroid Cancer has the advantages of complete clearance of the disease, thereby reducing the chances of recurrence and the subsequent morbidity of reoperation. However, it is associated with increased risk of hypo-parathyroidism and recurrent laryngeal nerve palsy. Therefore experience is required from the part of the operating surgeon, to minimize surgical morbidity.
Keywords: Thyroidectomy, papillary thyroid cancer
|How to cite this article:|
Agarwal A, Pradhan R. Central compartment in thyroid surgery: When, what and how?. Thyroid Res Pract 2013;10, Suppl S1:12-3
| Introduction|| |
The central compartment lymph nodes dissection (CCLND) in Papillary Thyroid Cancer has the advantages of complete clearance of the disease, thereby reducing the chances of recurrence and the subsequent morbidity of reoperation, also it provides the nodes for exact nodal staging to plan further adjuvant therapy and prognosticate the patient. However, it is associated with increased risk of hypo-parathyroidism and recurrent laryngeal nerve palsy. Therefore for high-risk with clinically involved nodes the routine CCLND is acceptable; it is controversial for low-risk, clinically uninvolved nodes,  with some advocating for  and some against  routine bilateral clearance while a third group of surgeons adopted a midway, by dissecting the ipsilateral side only, thus sparing the contralateral parathyroid glands and recurrent laryngeal nerve.
CCLND can be prophylactic or therapeutic. By definition, prophylactic is a total compartment dissection that is performed when there is no preoperative or intraoperative evidence of cervical lymph-node metastases. Prophylactic CCLND is done in a systematic manner with removal of all nodal tissue from the larynx superiorly to the innominate artery inferiorly. The lateral borders of level VI are defined by the carotid arteries. After or during removal of the thyroid gland, an en bloc dissection is performed that includes the Delphian node, pre-tracheal nodes and nodes along both para-tracheal region.
Currently, there is no non- or minimally invasive method that is completely reliable for detecting all of the metastases that are present. While no controversies exist regarding the therapeutic CCLND, prophylactic CCLND is a matter of ongoing debate. Numerous national and international guidelines have published specific recommendations for management of prophylactic central compartment node dissection (CCLND). The American Association of Endocrine Surgeons (AACE/ AAES), the British Thyroid Association (BTA), and the National Comprehensive Cancer Network (NCCN) guidelines do not recommend prophylactic CCND, particularly in low-risk patients.  In contrast, the European Thyroid Association (ETA) has stated that prophylactic CCND might also provide useful patho-logic N staging information that may guide subsequent treatment and follow-up.  The level of evidence for recommending prophylactic CCND by the American Thyroid Association (ATA) 2009 guidelines is considered insufficient; therefore, the issue still remains unresolved.  Therefore, some have advocated prophylactic cervical lymph node dissection as part of the operative procedure. There is no unanimity, however, on the efficacy and safety of prophylactic cervical lymph node dissection .
The rationales for prophylactic central neck dissection are that lymph node metastases have a negative effect on patient outcome and can not be reliably identified at operation. Central neck dissection can be performed safely and reoperation for central neck recurrence has greater morbidity. In addition, micro-metastases are common, being present in 90% of examined nodes in one series. Others recommend prophylactic CCLND for patients having two or more of the four following clinic-pathological characteristics: male gender, age > 55 years, maximal tumor diameter >3 cm, and massive extra-thyroid extension. 
Contrary to this there is a large body of evidence documenting consistently greater morbidity rates for patients undergoing CCLND along with thyroidectomy than total thyroidectomy alone. The known complications are recurrent laryngeal nerve injury and hypoparathyroidism. Study done at our institute suggests that bilateral CCLND should be done with thyroidectomy in PTC, otherwise the risk of residual diseases and subsequent recurrence is high. The long-term morbidity is comparable in experienced hands. 
Experience is therefore required from the part of the operating surgeon, who should be able to perform safely CCLND at the time of initial surgery (thyroidectomy), to minimize surgical morbidity.
The long-term morbidity of bilateral CCLND done in primary setting is comparable with total thyroidectomy alone, and is safe in the hands of experienced endocrine surgeons.
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