Research Article| Volume 49, ISSUE 3, P568-574, March 2023

Risk staging with prophylactic unilateral central neck dissection in low-risk papillary thyroid carcinoma

Published:November 07, 2022DOI:



      Current guidelines favor thyroid lobectomy for intrathyroidal cT1bT2cN0 papillary thyroid carcinoma. Prophylactic neck dissection (PND) is not recommended for these low-risk tumors due to the lack of high-level evidence on improvement in outcomes, but the information from PND may be used for staging. The aim of this study was to evaluate the rate of upstaging with ipsilateral PND.

      Materials and methods

      Retrospective study of patients with intrathyroidal unifocal cT1bT2cN0 papillary thyroid carcinoma from 2008 to 2021. All patients underwent total thyroidectomy and PND. Tumors were classified as low or intermediate risk based on the information from pathological analysis of the primary tumor and then from adding the analysis of the lymph nodes. The difference between the tumor-only and the PND-added risk staging was evaluated.


      Three hundred three patients (241 women, median age 45, median tumor size 17 mm) were included. Microscopic extrathyroidal extension was found in 23.4%, aggressive histology in 6.6%, vascular invasion in 29.3%, and lymph node metastases in 37.3%. One hundred ten patients (36.3%) were intermediate-risk based on the primary tumor. An additional 26 (8.6%) were upstaged to intermediate-risk based on the ipsilateral PND and 2% based on the contralateral PND. Kaplan-Meier 10-year event-free survival in tumors upstaged with ipsilateral PND was not statistically different from intermediate-risk tumors based on the primary tumor characteristics (92% versus 90.9%, Log Rank p = 0.943).


      Ipsilateral PND upstaged low-risk cT1bT2cN0 patients to intermediate risk in only 8.6% of cases, and contralateral PND in an additional 2%. Routinely performing PND may not be warranted.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Haugen B.R.
        • Alexander E.K.
        • Bible K.C.
        • Doherty G.M.
        • Mandel S.J.
        • Nikiforov Y.E.
        • et al.
        American thyroid association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American thyroid association guidelines task force on thyroid nodules and differentiated thyroid cancer.
        Thyroid : Off J Am Thyroid Assoc. 2015; 26 (2016 PubMed PMID: 26462967; PubMed Central PMCID: PMC4739132): 1-133
        • Vargas-Pinto S.
        • Romero Arenas M.A.
        Lobectomy compared to total thyroidectomy for low-risk papillary thyroid cancer: a systematic review.
        J Surg Res. 2019; 242 (PubMed PMID: 31103828): 244-251
        • DiMarco A.N.
        • Wong M.S.
        • Jayasekara J.
        • Cole-Clark D.
        • Aniss A.
        • Glover A.R.
        • et al.
        Risk of needing completion thyroidectomy for low-risk papillary thyroid cancers treated by lobectomy.
        BJS open. 2019; 3 (PubMed PMID: 31183445; PubMed Central PMCID: PMC6551396): 299-304
        • Cheng S.P.
        • Chien M.N.
        • Wang T.Y.
        • Lee J.J.
        • Lee C.C.
        • Liu C.L.
        Reconsideration of tumor size threshold for total thyroidectomy in differentiated thyroid cancer.
        Surgery. 2018; 164 (PubMed PMID: 29843911): 504-510
        • Kluijfhout W.P.
        • Pasternak J.D.
        • Drake F.T.
        • Beninato T.
        • Shen W.T.
        • Gosnell J.E.
        • et al.
        Application of the new American Thyroid Association guidelines leads to a substantial rate of completion total thyroidectomy to enable adjuvant radioactive iodine.
        Surgery. 2017; 161 (PubMed PMID: 27855968): 127-133
        • Murthy S.P.
        • Balasubramanian D.
        • Subramaniam N.
        • Nair G.
        • Babu M.J.C.
        • Rathod P.V.
        • et al.
        Prevalence of adverse pathological features in 1 to 4 cm low-risk differentiated thyroid carcinoma.
        Head Neck. 2018; 40 (PubMed PMID: 29417654): 1214-1218
        • Dhir M.
        • McCoy K.L.
        • Ohori N.P.
        • Adkisson C.D.
        • LeBeau S.O.
        • Carty S.E.
        • et al.
        Correct extent of thyroidectomy is poorly predicted preoperatively by the guidelines of the American Thyroid Association for low and intermediate risk thyroid cancers.
        Surgery. 2018; 163 (PubMed PMID: 29128185): 81-87
        • Craig S.J.
        • Bysice A.M.
        • Nakoneshny S.C.
        • Pasieka J.L.
        • Chandarana S.P.
        The identification of intraoperative risk factors can reduce, but not exclude, the need for completion thyroidectomy in low-risk papillary thyroid cancer patients.
        Thyroid : Off J Am Thyroid Assoc. 2020; 30 (PubMed PMID: 31813323; PubMed Central PMCID: PMC7047120): 222-228
        • Lang B.H.
        • Shek T.W.
        • Wan K.Y.
        The significance of unrecognized histological high-risk features on response to therapy in papillary thyroid carcinoma measuring 1-4 cm: implications for completion thyroidectomy following lobectomy.
        Clin Endocrinol. 2017; 86 (PubMed PMID: 27467318): 236-242
        • Bakkar S.
        • Al-Omar K.
        • Donatini G.
        • Aljarrah Q.
        • Papavramidis T.S.
        • Materazzi G.
        • et al.
        Postoperatively determined high-risk histopathologic features in papillary thyroid carcinoma initially eligible for thyroid lobectomy: a game changer.
        Endocrine. 2021; 74 (PubMed PMID: 34110601): 611-615
        • Hughes D.T.
        • White M.L.
        • Miller B.S.
        • Gauger P.G.
        • Burney R.E.
        • Doherty G.M.
        Influence of prophylactic central lymph node dissection on postoperative thyroglobulin levels and radioiodine treatment in papillary thyroid cancer.
        Surgery. 2010; 148 (; discussion 006-7 PubMed PMID: 21134539): 1100-1106
        • Dobrinja C.
        • Troian M.
        • Cipolat Mis T.
        • Rebez G.
        • Bernardi S.
        • Fabris B.
        • et al.
        Rationality in prophylactic central neck dissection in clinically node-negative (cN0) papillary thyroid carcinoma: is there anything more to say? A decade experience in a single-center.
        Int J Surg. 2017; 41 (PubMed PMID: 28506412): S40-S47
        • Chen L.
        • Wu Y.H.
        • Lee C.H.
        • Chen H.A.
        • Loh E.W.
        • Tam K.W.
        Prophylactic central neck dissection for papillary thyroid carcinoma with clinically uninvolved central neck lymph nodes: a systematic review and meta-analysis.
        World J Surg. 2018; 42 (PubMed PMID: 29488066): 2846-2857
        • Sippel R.S.
        • Robbins S.E.
        • Poehls J.L.
        • Pitt S.C.
        • Chen H.
        • Leverson G.
        • et al.
        A randomized controlled clinical trial: No clear benefit to prophylactic central neck dissection in patients with clinically node negative papillary thyroid cancer.
        Ann Surg. 2020; 272 (PubMed PMID: 33759836; PubMed Central PMCID: PMCPMC8496479): 496-503
        • Conzo G.
        • Calo P.G.
        • Sinisi A.A.
        • De Bellis A.
        • Pasquali D.
        • Iorio S.
        • et al.
        Impact of prophylactic central compartment neck dissection on locoregional recurrence of differentiated thyroid cancer in clinically node-negative patients: a retrospective study of a large clinical series.
        Surgery. 2014; 155 (PubMed PMID: 24856120): 998-1005
        • Nixon I.J.
        • Wang L.Y.
        • Ganly I.
        • Patel S.G.
        • Morris L.G.
        • Migliacci J.C.
        • et al.
        Outcomes for patients with papillary thyroid cancer who do not undergo prophylactic central neck dissection.
        Br J Surg. 2016; 103 (PubMed PMID: 26511531; PubMed Central PMCID: PMC4976488): 218-225
        • Wang T.S.
        • Cheung K.
        • Farrokhyar F.
        • Roman S.A.
        • Sosa J.A.
        A meta-analysis of the effect of prophylactic central compartment neck dissection on locoregional recurrence rates in patients with papillary thyroid cancer.
        Ann Surg Oncol. 2013; 20 (PubMed PMID: 23846784): 3477-3483
        • Lang B.H.
        • Ng S.H.
        • Lau L.L.
        • Cowling B.J.
        • Wong K.P.
        • Wan K.Y.
        A systematic review and meta-analysis of prophylactic central neck dissection on short-term locoregional recurrence in papillary thyroid carcinoma after total thyroidectomy.
        Thyroid : Off J Am Thyroid Assoc. 2013; 23 (PubMed PMID: 23402640): 1087-1098
        • Barczynski M.
        • Konturek A.
        • Stopa M.
        • Nowak W.
        Prophylactic central neck dissection for papillary thyroid cancer.
        Br J Surg. 2013; 100 (PubMed PMID: 23188784): 410-418
        • Roh J.L.
        • Park J.Y.
        • Park C.I.
        Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone.
        Ann Surg. 2007; 245 (PubMed PMID: 17414610; PubMed Central PMCID: PMCPMC1877043): 604-610
        • Hartl D.M.
        • Leboulleux S.
        • Al Ghuzlan A.
        • Baudin E.
        • Chami L.
        • Schlumberger M.
        • et al.
        Optimization of staging of the neck with prophylactic central and lateral neck dissection for papillary thyroid carcinoma.
        Ann Surg. 2012; 255 (PubMed PMID: 22418010): 777-783
        • Nylen C.
        • Eriksson F.B.
        • Yang A.
        • Aniss A.
        • Turchini J.
        • Learoyd D.
        • et al.
        Prophylactic central lymph node dissection informs the decision of radioactive iodine ablation in papillary thyroid cancer.
        Am J Surg. 2021; 221 (PubMed PMID: 32878695): 886-892
        • Viola D.
        • Materazzi G.
        • Valerio L.
        • Molinaro E.
        • Agate L.
        • Faviana P.
        • et al.
        Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma: clinical implications derived from the first prospective randomized controlled single institution study.
        J Clin Endocrinol Metab. 2015; 100 (PubMed PMID: 25590215): 1316-1324
        • Giordano D.
        • Botti C.
        • Piana S.
        • Castellucci A.
        • Frasoldati A.
        • Zini M.
        • et al.
        Hemithyroidectomy and ipsilateral central neck dissection for T1 low-risk papillary thyroid cancer: single-institution retrospective observational study.
        Eur J Endocrinol. 2022; 186 (PubMed PMID: 35230264): 535-542
        • Ahn S.H.
        • Kim W.S.
        The effect of prophylactic central neck dissection during hemithyroidectomy on locoregional recurrence in patients with papillary thyroid carcinoma: a meta-analysis.
        Clin. Exp. Otorhinolaryngol. 2020; 13 (PubMed PMID: 32434311; PubMed Central PMCID: PMC7248614): 194-202
        • Leboulleux S.
        • Schlumberger M.J.
        • Borget I.
        Thyroidectomy without radioiodine in low-risk thyroid cancer. Reply.
        The New England journal of medicine. 2022; 386 (PubMed PMID: 35648717): 2155
        • Nascimento C.
        • Borget I.
        • Troalen F.
        • Al Ghuzlan A.
        • Deandreis D.
        • Hartl D.
        • et al.
        Ultrasensitive serum thyroglobulin measurement is useful for the follow-up of patients treated with total thyroidectomy without radioactive iodine ablation.
        Eur J Endocrinol. 2013; 169 (PubMed PMID: 23939918): 689-693
        • Adam M.A.
        • Pura J.
        • Gu L.
        • Dinan M.A.
        • Tyler D.S.
        • Reed S.D.
        • et al.
        Extent of surgery for papillary thyroid cancer is not associated with survival: an analysis of 61,775 patients.
        Ann Surg. 2014; 260 (; discussion 5-7 PubMed PMID: 25203876; PubMed Central PMCID: PMC4532384): 601-605
        • Agrawal N.
        • Evasovich M.R.
        • Kandil E.
        • Noureldine S.I.
        • Felger E.A.
        • Tufano R.P.
        • et al.
        Indications and extent of central neck dissection for papillary thyroid cancer: an American Head and Neck Society Consensus Statement.
        Head Neck. 2017; 39 (PubMed PMID: 28449244): 1269-1279
        • Sancho J.J.
        • Lennard T.W.
        • Paunovic I.
        • Triponez F.
        • Sitges-Serra A.
        Prophylactic central neck disection in papillary thyroid cancer: a consensus report of the European Society of Endocrine Surgeons (ESES).
        Langenbeck's Arch Surg. 2014; 399 (PubMed PMID: 24352594): 155-163
        • Adam M.A.
        • Thomas S.
        • Youngwirth L.
        • Hyslop T.
        • Reed S.D.
        • Scheri R.P.
        • et al.
        Is there a minimum number of thyroidectomies a surgeon should perform to optimize patient outcomes?.
        Ann Surg. 2017; 265 (PubMed PMID: 28059969): 402-407
        • Smaxwil C.
        • Aleker M.
        • Altmeier J.
        • Naddaf A.
        • Busch M.
        • Wagner J.
        • et al.
        Neuromonitoring of the recurrent laryngeal nerve reduces the rate of bilateral vocal cord dysfunction in planned bilateral thyroid procedures.
        J Clin Med. 2021; 10 (PubMed PMID: 33673313; PubMed Central PMCID: PMCPMC7918228)
        • Lin B.
        • Qiang W.
        • Wenqi Z.
        • Tianyu Y.
        • Lina Z.
        • Bin J.
        Clinical response to radioactive iodine therapy for prophylactic central neck dissection is not superior to total thyroidectomy alone in cN0 patients with papillary thyroid cancer.
        Nucl Med Commun. 2017; 38 (PubMed PMID: 28953211): 1036-1040
        • Ma B.
        • Wang Y.
        • Yang S.
        • Ji Q.
        Predictive factors for central lymph node metastasis in patients with cN0 papillary thyroid carcinoma: a systematic review and meta-analysis.
        Int J Surg. 2016; 28 (PubMed PMID: 26944586): 153-161
        • Moon G.
        • Jang S.W.
        • Nam K.T.
        • Park J.H.
        • Kwon H.J.
        • Yoon J.H.
        Restratification of patients with intermediate-risk papillary thyroid carcinoma.
        Ann Surg Oncol. 2022; (PubMed PMID: 35169978)
        • Schlumberger M.
        • Catargi B.
        • Borget I.
        • Deandreis D.
        • Zerdoud S.
        • Bridji B.
        • et al.
        Strategies of radioiodine ablation in patients with low-risk thyroid cancer.
        N Engl J Med. 2012; 366 (PubMed PMID: 22551127): 1663-1673
        • Leboulleux S.
        • Bournaud C.
        • Chougnet C.N.
        • Zerdoud S.
        • Al Ghuzlan A.
        • Catargi B.
        • et al.
        Thyroidectomy without radioiodine in patients with low-risk thyroid cancer.
        N Engl J Med. 2022; 386 (PubMed PMID: 35263518): 923-932
        • Nikiforov Y.E.
        • Seethala R.R.
        • Tallini G.
        • Baloch Z.W.
        • Basolo F.
        • Thompson L.D.
        • et al.
        Nomenclature revision for encapsulated follicular variant of papillary thyroid carcinoma: a paradigm shift to reduce overtreatment of indolent tumors.
        JAMA Oncol. 2016; 2 (PubMed PMID: 27078145; PubMed Central PMCID: PMCPMC5539411): 1023-1029