NECK DISSECTION IN THYROID CANCER

W. Steven Chr.
Division of Oncology - Dept. of Surgery.
Medical School of Univ. Udayana / RSUP Sanglah Denpasar

FOREWORD AND DEFINITION

Incidence thyroid cancer is the most common endocrine cancer. A spectrum of biologic behavior
exists, ranging from indolent, well-differentiated tumors to extremely aggressive, poorly
differentiated or anaplastic cancers. (Patel KN, Shaha AR. 2006; Udelsman R, Chen H, 1999).
Differentiated thyroid cancer (DTC) is associated with the highest propensity for lymph node
metastases, given the significant morbidity associated with sacrificing the spinal accessory nerve,
surgeons increasingly looked to minimizing functional deficits while maintaining oncologic
outcome. Papillary thyroid cancer (PTC) is the most common malignancy of the thyroid gland. It
typically spreads via lymphatic extension. The rate of regional PTC metastasis to the neck is
relatively high, while metastases outside the deep cervical chain are rare. Distant metastases are
found in only 1% of patients with PTC at the time of surgery; the two most common sites are the
lung and bone.
Total thyroidectomy and lymph node neck dissection are mandatory to perform in case of the
present of lymph node metastasis of thyroid cancer. A neck dissection is a systematic approach to
removing entire groups of lymph nodes from the neck. Cervical lymphadenectomy, or neck
dissection, plays an important role in the management of patients with thyroid cancer (Haugen BR,
Alexander EK, Bible KC, et al. 2015; Stack BC Jr, Ferris RL, Goldenberg D, et al. 2012). As
known, the classic or radical neck dissection entails removal of some functional non-lymphatic
structures routinely, including the spinal accessory nerve, the sternocleidomastoid muscle (SCM),
and the internal jugular vein (IJV). (Robbins KT, Medina JE, Wolfe GT, et al. 1991).
DIAGNOSTIC
The first of all is to proving whether the thyroid lesion is malignant or benign; and if malign lesion
cervical lymph node should be determined. The workup of a thyroid nodule begins with a thorough
history and physical examination. FNA biopsy remains the gold standard for evaluating thyroid
nodules beside of using of Ultrasonography to detect the thyroid itself and cervical lymph node.
Thyroid function examinations are also play an important role in managing of thyroid cancer. If
needed further examination of thyroid lesion may use thyroid radionuclide scanning; head and
neck CT Scan, or MRI. Preoperative detection of cervical lymph node metastasis in papillary
thyroid carcinoma (PTC) is crucial for determining the surgical strategy to prevent locoregional
recurrence of the disease.
A cancer cell may shed any number of metastases that lodge in lymph nodes, grow and spread.
There are over 150 lymph nodes on each side of the neck. During an operation, a surgeon will not
be able to tell if a lymph node is clean, or if it has cancer that will later grow into a visible neck
lump. The lymph nodes must be processed and tested (Frozen Section); this takes time. For that
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reason, it is recommended that the lymph nodes in a predefined region are removed, not just lymph
nodes that are obviously enlarged with cancer. Benign thyroid inclusions involve medial inferior
neck lymph nodes, whereas any thyroid tissue found lateral to large neck vessels (carotid artery or
jugular vein) should be considered metastatic tumor rather than a developmental anomaly (Wenig.
2015). However, there are occasional cases of benign inclusions in lateral (up to level II) lymph
nodes.
ANATOMY

Through knowing the Cervical Anatomy is absolutely for the surgeon, who will perform whether
thyroidectomy or neck LN dissection related to cancer neck LN metastasis. Thyroid gland and
parathyroid as well as nerve, vessel, muscle, trachea, esophagus and other related functioning
organs should be known well.

Topography of the cervical lymph node group and lymphatic drainage

from connected adjacent organ:

 Level I, II, III: oral cavity

 Level II, III, IV: oropharynx, hypopharynx, larynx
 Level V: scalp, facial skin
 Level VI: thyroid, larynx
 Level VII: thyroid

Knowing well the neck lymph node mapping to determine what type of neck dissection will be
done conjunction with the severity of lymph node metastasis.
PLANNING OF SURGERY
Appropriate surgical management has become the mainstay treatment of differentiated thyroid
cancer. The surgeon must be aware that nodal clearance for thyroid cancer should be
comprehensive, thorough and compartment-oriented. There is no role for node picking or single
compartment dissection.
Preoperative Surgical Planning should be done carefully by surgeon who will perform
thyroidectomy and lymph node neck dissection, to prevent such later complications. Plan what
type of the neck dissection will be performed, especially when undergo for bilateral lymph node
neck dissection. For the firstly, is the tumor of thyroid totally can be removed? if yes, then neck
dissection may go on according to the planning. In performing lymph node neck dissection may
be sacrifice or may be preserve of many functioning organs adjacent of thyroid gland (of course,
totally thyroidectomy assuredly be done), as below:
1. Lymph node and it’s drainage complex
2. Soft tissue surrounding of the lymph node
3. Salivatory submandibular gland with marginal mandibular nerve VII
4. Sternocleidomastoid muscle
5. Internal Jugular vein

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 6. Spinal Accessory Nerve
7. Adjacent functional organs of thyroid have to preserve
a. Parathyroid gland
b. Inferior recurrent Laryngeal nerve
c. Superior Laryngeal nerve
d. Vagal nerve
e. Phrenic nerve
WHAT IS THE TYPE OF NECK DISSECTION?
Classification of Neck Dissection (Robbins KT, Clayman G, Levine PA, et al. 2002; Robbins KT,
Shaha AR, Medina JE, et al. 2008)

 Radical Neck Dissection: Removal of lymph node groups I to V, as well as the

sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve. Extended
Radical Neck Dissection includes all of these, plus removal of additional lymph node groups
or non-lymphatic structures not accounted for in the radical neck dissection definition.
 Modified Radical Neck Dissection: Removal of lymph node groups I to V, while sparing one
or more of the three structures taken in the radical neck dissection (sternocleidomastoid
muscle, internal jugular vein and spinal accessory nerve). In old nomenclature, depending on
what structure was removed, surgeons would call them Type I, Type II or Type III modified
radical neck dissections. These days, they should be described as a modified radical neck
dissection with sacrifice of the internal jugular vein and sternocleidomastoid muscle (this
implies that the spinal accessory nerve was preserved). A modified radical neck dissection that
preserves all three structures is also called a Comprehensive Neck Dissection, indicative of
the removal of lymph nodes from Levels 1 through 5.
 Selective Neck Dissection: Removal of a select group of lymph nodes in the neck, with or
without sacrifice of additional non-lymphatic structures. Most neck dissections in current times
are really selective neck dissections. Some common selective neck dissections are given names
such as the following:
o Supraomohyoid Neck Dissection: This is the removal of lymph node Groups I, II and
III.
o Lateral Neck Dissection: This is the removal of lymph node Groups II, III and IV.
o Posterolateral Neck Dissection: This is the removal of lymph node Groups II, III, IV
and V.

 Central Compartment Lymph Node Dissection: The central compartment (Level VI) is not
included in the typical “neck dissection.” Level VI is systematically removed in cases of
thyroid cancer and larynx cancer.
 Salvage Neck Dissection: This is a neck dissection in a previously treated neck, whether
previously treated by radiation, chemotherapy or surgery. This is performed for a persistent
tumor in the neck lymph nodes despite treatment.
 Prophylactic CND in clinically node-negative PTC remains controversial. The reason in
support of pCND are that it decreases the risk of recurrence and reoperation and allows more
precise staging by identifying occult lymph node metastases, which can affect decisions about
postoperative RAI ablation. (Robbins KT, Shaha AR, Medina JE, et al. 2008; Calò PG,

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 Lombardi CP, Podda F, Sessa L, Santini L, Conzo G. 2017; . Zheng CM, Ji YB, Song CM, Ge
MH, Tae K. 2018).

PROCEDURE OF NECK LN DISSECTION

All procedures be done according to the planning of surgery. A neck dissection is done under
general anesthetic in a hospital operating room. In head and neck cancer, you will have lymph
nodes removed on one side of the neck (ipsilateral neck dissection) or both sides of the neck
(bilateral neck dissection). This is done for tumors that are very likely to spread or have already
spread to one or both sides of the neck. Skin incision may be adjusted to the state of the tumor.
In any case need reconstruction of the skin wound defect.

Total Thyroidectomy and related lymph node dissection are the main target. Several cervical
nerves need more attention during performing neck dissection: The marginal nerve, a small
branch of the facial nerve which controls lower lip movement. The spinal accessory nerve
which aids in shoulder mobility and raising the arm. The hypoglossal nerve, which controls
movement of the tongue (uncommon). The lingual nerve, which controls sensation on the side
of the tongue (rare). The vagal nerve which controls movement of one vocal cord (rare).
Laryngeal nerve (superior and recurrent inferior) which control vocal cord. Phrenic nerve
which control diaphragm movement.

PITFALL

Several of pitfalls may arise on the neck lymph node dissection, especially if perform both side
dissection. If properly done, neck lymph node dissection will prevent unsatisfaction
complications. For a smooth postoperative course, the following advices seem pertinent to
avoid pitfalls during lymph node dissection for thyroid cancer.

 Start by appropriately elevating the SCM fascia;

 Do not miss the accessory nerve;
 Do not go deep below the deep cervical fascia;
 Preserve the deep cervical plexus;
 Preserve the transverse cervical vessels;
 Identify the brachial plexus, the phrenic nerve and the vagal nerve;
 Beware of IJV torsion when dissecting the compartment IV;
 Identify and clip all lymphatic leaks after dissecting left and/or right IV
compartments;
 Dissect selectively compartments IIb and V according to cancer extension.

COMPLICATIONS
Total thyroidectomy and cervical lymph node dissection are one of devastating surgery of the neck
surgery and giving source of many complications later on. Complications of surgery may come up
during and after operation and as well as the late complications (long term problems).

 Bleeding, including hematoma

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 Seroma
 Infection
 Damage to cranial and/or cervical nerves, including those that are responsible for:
o Raising your arm way up into the air (CN XI, spinal accessory nerve)
o Moving your tongue on one side (CN XII)
o Moving the lower part of your face (Mandibular branch of CN VII)
o Moving your diaphragm when you are breath (phrenic nerve)
o Sensation to various parts of the neck, ear and ear lobe (cervical roots and greater
auricular nerve)
o Moving your vocal cords on one side and controlling other bodily functions (CN X,
vagus nerve)
o Moving your arm (brachial plexus)

 Chyle leak – may developed chyloma : This is a leak of fat containing lymphatic fluid from
the thoracic duct, accessory thoracic duct or their branches. It will show up as a milky-
appearing fluid coming into the drain in your neck (after you start eating). This complication
occurs when the neck dissection extends down to Level IV (just above the clavicles), because
this is where the lymphatic channels that carry this fatty fluid empty into the jugular vein. The
main thoracic duct is on the left side, but an accessory duct can also be found on the right side.
Therefore, though the higher risk for a chyle leak is on the left, your surgeon will be careful of
this complication on both sides. This is treated by keeping you on a non-fat diet, with or without
a drain and pressure placed over the area. If there is a really high output of chyle leaking or if
it persists for weeks, you might need to go to the operating room for exploration and clipping
of the duct.
 Recurrent or chronic facial swelling: This can happen in two situations: when both internal
jugular veins need to be sacrificed (which limits blood drainage from the face resulting in
severe facial swelling) or in lymphedema (which is severe lymphatic obstruction from removal
of all lymphatic drainage pathways. These are extremely rare complications of neck dissection
and are seen in very advanced disease in patients who have received other forms of treatment.
 Blood clots: Patients who undergo major surgeries, especially patients who have cancer, are at
an increased risk of developing blood clots in their legs (deep venous thrombosis). Sometimes
these blood clots can travel through the veins and into the lungs, causing a pulmonary embolus.

FOLLOW UP
The first is follow up of the achievement of surgery as the main purpose treatment and the
second is follow up the effect of the removal of such functioning organ of the neck. The
absence of thyroid gland and its hormone have to give substitute thyroid hormone treatment
continuously. Is the parathyroid revive and return to its function? And the last follow up of the
probability of cancer recurrences may closely anticipate in the first year after surgery.
Physiotherapy should be done continually to recover the function achieve the normal quality
of life. If needed may consider to further treatment to prevent cancer recurrence.

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PUSTAKA

Calò PG, Lombardi CP, Podda F, Sessa L, Santini L, Conzo G. 2017. Role of prophylactic central
neck dissection in clinically node-negative differentiated thyroid cancer: assessment of the risk of
regional recurrence. Updates Surg; 69:241–8. doi: 10.1007/s13304-017-0438-8

Haugen BR, Alexander EK, Bible KC, et al. 2015 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 2016;26:1-133.
Patel KN, Shaha AR. 2006. Poorly differentiated and anaplastic thyroid cancer. Cancer
Control.;13:119–128.
Robbins KT, Medina JE, Wolfe GT, et al. 1991. Standardizing neck dissection terminology.
Official report of the Academy's Committee for Head and Neck Surgery and Oncology. Arch
Otolaryngol Head Neck Surg;117:601-5.
Robbins KT, Shaha AR, Medina JE, et al. 2008. Consensus statement on the classification and
terminology of neck dissection. Arch Otolaryngol Head Neck Surg;134:536-8.
Robbins KT, Clayman G, Levine PA, et al. 2002. Neck dissection classification update: revisions
proposed by the American Head and Neck Society and the American Academy of Otolaryngology-
Head and Neck Surgery. Arch Otolaryngol Head Neck Surg;128:751-8.
Stack BC Jr, Ferris RL, Goldenberg D, et al. 2012. American Thyroid Association consensus
review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection
in differentiated thyroid cancer. Thyroid;22:501-8.
Udelsman R, Chen H. 1999. The current management of thyroid cancer. Adv Surg.;33:1–27.
Wenig: Atlas of Head and Neck Pathology, 3rd Edition, 2015. However, there are occasional cases
of benign inclusions in lateral (up to level II) lymph nodes (Eur Arch Otorhinolaryngol
2016;273:2867)

Zheng CM, Ji YB, Song CM, Ge MH, Tae K. 2018. Number of metastatic lymph nodes and ratio
of metastatic lymph nodes to total number of retrieved lymph nodes are risk factors for recurrence
in patients with clinically node negativepapillarythyroidcarcinoma.ClinExpOtorhinolaryngol;
11:58. doi: 10.21053/ceo.2017.00472

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