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Shaha. J Cancer Metastasis Treat 2023;9:22 https://dx.doi.org/10.20517/2394-4722.2022.101 Page 3 of 9

Table 1. Controversial issues in the management of neck node metastasis

• Evaluation - clinical and imaging
• FNA and thyroglobulin wash
• When to operate
• Management strategies
• Observation and non-surgical approaches
• Management of recurrence
• Complications of surgery
• Follow-up strategy and prognosis

concern about iodine in contrast dye is not a major issue as generally it is washed out within a few weeks, at
which point radioactive ablation can be performed.

CONTROVERSIES RELATED TO CENTRAL COMPARTMENT
The central compartment has generated considerable debate over the last two decades [Tables 2 and 3].
There are strong supporters and opponents of the elective central compartment dissection when the
imaging studies and the ultrasound do not show any obvious metastasis . It should be recognized that
[8]
elective central compartment evaluation is extremely important from carotid to carotid area, including the
superior mediastinal and thymic region, to see if there is any obvious metastatic disease. Proponents of
routine elective central compartment dissection recommend this based on high incidence of central
compartment nodal disease (50%-60%), difficulties in the second surgical procedure when patients recur in
the central compartment, decisions regarding radioactive iodine when the central compartment nodes are
positive, and upstaging of some of these patients. Opponents hold strong contrasting views mainly related
to a higher incidence of complications and low overall recurrence rate (2%-3%), which is unlikely to have
any major implication with elective central compartment dissection. Proponents also recommend that
procedures be performed by experienced surgeons, as the risk of complication is likely to be lower.
However, the majority of thyroid surgeries in the United States are still performed by surgeons with limited
experience and low-volume surgical practice. Clearly, we are always going to find the difference in the
outcome between low- and high-volume surgeons . It also depends upon the practice of individual thyroid
[9]
surgeons and individual institutions [10-13] .

EXTENT OF NECK DISSECTION FOR LATERAL DISEASE
The old “berry-picking” operation is no longer advocated, as it removes only gross disease and patients may
recur with additional neck node metastasis. The incidence of nodal metastasis at levels Ia,b and Va is rare,
so a standard neck dissection which is generally advocated includes levels IIa, III, IV, and Vb. The dissection
above the accessory nerve (IIb) is rarely indicated unless there is bulky nodal disease at level IIa . The
[14]
reasoning for these modifications in the surgical procedures is to minimize the risk of complications such as
accessory nerve injury, phrenic injury, and Horner’s syndrome . These complications need to be kept in
[14]
mind prior to considering any aggressive surgical intervention. The classical description of lateral neck node
metastasis is modified neck dissection preserving important and vital structures such as accessory nerve,
jugular vein, and sternocleidomastoid muscle. A variety of other names are also considered, such as
functional neck dissection, selective nodal dissection, jugular node dissection, and compartment-oriented
neck dissection. The basic concept of these neck dissections is akin to the removal of lymph nodes from
level II-V. Levels VI and VII are already discussed in the central compartment. The risk of thoracic duct
injury and chyle leak is mainly much more pronounced on the left side (however, it does also occur on the
right side). Chyle leak can be a major complication of neck dissection leading to prolonged hospitalization
and continuous wound problems. No firm guidelines are available as to re-exploration for control of chyle
leak, however, it may be considered in the early or late postoperative period, especially if the chyle leak is
more than 500 cc per day [15,16] . There now appears to be considerable interest in thoracic duct embolization
or transthoracic video-assisted thoracic duct ligation under the expertise of thoracic surgeons.