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Central and lateral compartment lymphadenectomy (neck dissection) for differentiated thyroid cancer

Rebecca S Sippel, MD, FACS
Section Editor
Sally E Carty, MD, FACS
Deputy Editor
Wenliang Chen, MD, PhD


Differentiated thyroid cancers, including papillary and follicular, account for >90 percent of thyroid cancer patients [1]. While metastatic disease to regional nodes is frequently identified in patients with papillary thyroid cancer, it is very uncommon in patients with follicular cancer. (See 'Incidence of metastatic disease to regional nodes' below.)


The anatomic neck levels and the nodal contents include (figure 1 and figure 2):

Level I – Submental (IA) and submandibular lymph nodes (IB)

Level II – Upper third of the jugular lymph nodes from the hyoid bone to the base of the skull. This includes those lymph nodes located anterior (IIA) and posterior (IIB) to the spinal accessory nerve.

Level III – Middle third of jugular lymph nodes, located between the cricoid cartilage and the hyoid bone.


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Literature review current through: Sep 2016. | This topic last updated: Mar 9, 2015.
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  1. Davies L, Welch HG. Increasing incidence of thyroid cancer in the United States, 1973-2002. JAMA 2006; 295:2164.
  2. American Thyroid Association Surgery Working Group, American Association of Endocrine Surgeons,, American Academy of Otolaryngology-Head and Neck Surgery, et al. Consensus statement on the terminology and classification of central neck dissection for thyroid cancer. Thyroid 2009; 19:1153.
  3. Musacchio MJ, Kim AW, Vijungco JD, Prinz RA. Greater local recurrence occurs with "berry picking" than neck dissection in thyroid cancer. Am Surg 2003; 69:191.
  4. Grubbs EG, Evans DB. Role of lymph node dissection in primary surgery for thyroid cancer. J Natl Compr Canc Netw 2007; 5:623.
  5. Ito Y, Uruno T, Nakano K, et al. An observation trial without surgical treatment in patients with papillary microcarcinoma of the thyroid. Thyroid 2003; 13:381.
  6. Kim E, Park JS, Son KR, et al. Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma: comparison of ultrasound, computed tomography, and combined ultrasound with computed tomography. Thyroid 2008; 18:411.
  7. Stulak JM, Grant CS, Farley DR, et al. Value of preoperative ultrasonography in the surgical management of initial and reoperative papillary thyroid cancer. Arch Surg 2006; 141:489.
  8. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009; 19:1167.
  9. Arturi F, Russo D, Giuffrida D, et al. Early diagnosis by genetic analysis of differentiated thyroid cancer metastases in small lymph nodes. J Clin Endocrinol Metab 1997; 82:1638.
  10. Noguchi S, Noguchi A, Murakami N. Papillary carcinoma of the thyroid. I. Developing pattern of metastasis. Cancer 1970; 26:1053.
  11. Qubain SW, Nakano S, Baba M, et al. Distribution of lymph node micrometastasis in pN0 well-differentiated thyroid carcinoma. Surgery 2002; 131:249.
  12. Zaydfudim V, Feurer ID, Griffin MR, Phay JE. The impact of lymph node involvement on survival in patients with papillary and follicular thyroid carcinoma. Surgery 2008; 144:1070.
  13. Caron NR, Tan YY, Ogilvie JB, et al. Selective modified radical neck dissection for papillary thyroid cancer-is level I, II and V dissection always necessary? World J Surg 2006; 30:833.
  14. Chung YS, Kim JY, Bae JS, et al. Lateral lymph node metastasis in papillary thyroid carcinoma: results of therapeutic lymph node dissection. Thyroid 2009; 19:241.
  15. Park JH, Lee YS, Kim BW, et al. Skip lateral neck node metastases in papillary thyroid carcinoma. World J Surg 2012; 36:743.
  16. Wada N, Suganuma N, Nakayama H, et al. Microscopic regional lymph node status in papillary thyroid carcinoma with and without lymphadenopathy and its relation to outcomes. Langenbecks Arch Surg 2007; 392:417.
  17. Randolph GW, Duh QY, Heller KS, et al. The prognostic significance of nodal metastases from papillary thyroid carcinoma can be stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. Thyroid 2012; 22:1144.
  18. Moreno MA, Edeiken-Monroe BS, Siegel ER, et al. In papillary thyroid cancer, preoperative central neck ultrasound detects only macroscopic surgical disease, but negative findings predict excellent long-term regional control and survival. Thyroid 2012; 22:347.
  19. Smith VA, Sessions RB, Lentsch EJ. Cervical lymph node metastasis and papillary thyroid carcinoma: does the compartment involved affect survival? Experience from the SEER database. J Surg Oncol 2012; 106:357.
  20. Howell GM, Nikiforova MN, Carty SE, et al. BRAF V600E mutation independently predicts central compartment lymph node metastasis in patients with papillary thyroid cancer. Ann Surg Oncol 2013; 20:47.
  21. Zhang L, Wei WJ, Ji QH, et al. Risk factors for neck nodal metastasis in papillary thyroid microcarcinoma: a study of 1066 patients. J Clin Endocrinol Metab 2012; 97:1250.
  22. Koo BS, Choi EC, Yoon YH, et al. Predictive factors for ipsilateral or contralateral central lymph node metastasis in unilateral papillary thyroid carcinoma. Ann Surg 2009; 249:840.
  23. Roh JL, Kim JM, Park CI. Central lymph node metastasis of unilateral papillary thyroid carcinoma: patterns and factors predictive of nodal metastasis, morbidity, and recurrence. Ann Surg Oncol 2011; 18:2245.
  24. Wada N, Duh QY, Sugino K, et al. Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg 2003; 237:399.
  25. Ito Y, Tomoda C, Uruno T, et al. Preoperative ultrasonographic examination for lymph node metastasis: usefulness when designing lymph node dissection for papillary microcarcinoma of the thyroid. World J Surg 2004; 28:498.
  26. Wada N, Masudo K, Nakayama H, et al. Clinical outcomes in older or younger patients with papillary thyroid carcinoma: impact of lymphadenopathy and patient age. Eur J Surg Oncol 2008; 34:202.
  27. Gemsenjäger E, Perren A, Seifert B, et al. Lymph node surgery in papillary thyroid carcinoma. J Am Coll Surg 2003; 197:182.
  28. Schneider DF, Mazeh H, Chen H, Sippel RS. Lymph node ratio predicts recurrence in papillary thyroid cancer. Oncologist 2013; 18:157.
  29. Bardet S, Malville E, Rame JP, et al. Macroscopic lymph-node involvement and neck dissection predict lymph-node recurrence in papillary thyroid carcinoma. Eur J Endocrinol 2008; 158:551.
  30. Lundgren CI, Hall P, Dickman PW, Zedenius J. Clinically significant prognostic factors for differentiated thyroid carcinoma: a population-based, nested case-control study. Cancer 2006; 106:524.
  31. Scheumann GF, Gimm O, Wegener G, et al. Prognostic significance and surgical management of locoregional lymph node metastases in papillary thyroid cancer. World J Surg 1994; 18:559.
  32. Shah MD, Hall FT, Eski SJ, et al. Clinical course of thyroid carcinoma after neck dissection. Laryngoscope 2003; 113:2102.
  33. Eustatia-Rutten CF, Corssmit EP, Biermasz NR, et al. Survival and death causes in differentiated thyroid carcinoma. J Clin Endocrinol Metab 2006; 91:313.
  34. Podnos YD, Smith D, Wagman LD, Ellenhorn JD. The implication of lymph node metastasis on survival in patients with well-differentiated thyroid cancer. Am Surg 2005; 71:731.
  35. Noguchi S, Murakami N, Yamashita H, et al. Papillary thyroid carcinoma: modified radical neck dissection improves prognosis. Arch Surg 1998; 133:276.
  36. Cooper DS, Doherty GM, Haugen BR, et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2006; 16:109.
  37. Sippel RS, Chen H. Controversies in the surgical management of newly diagnosed and recurrent/residual thyroid cancer. Thyroid 2009; 19:1373.
  38. Uruno T, Miyauchi A, Shimizu K, et al. Prognosis after reoperation for local recurrence of papillary thyroid carcinoma. Surg Today 2004; 34:891.
  39. Schuff KG, Weber SM, Givi B, et al. Efficacy of nodal dissection for treatment of persistent/recurrent papillary thyroid cancer. Laryngoscope 2008; 118:768.
  40. National Comprehensive Cancer Network (NCCN). NCCN Clinical practice guidelines in oncology. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp (Accessed on February 27, 2016).
  41. Chisholm EJ, Kulinskaya E, Tolley NS. Systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone. Laryngoscope 2009; 119:1135.
  42. Ondik MP, Dezfoli S, Lipinski L, et al. Secondary central compartment surgery for thyroid cancer. Laryngoscope 2009; 119:1947.
  43. Bonnet S, Hartl D, Leboulleux S, et al. Prophylactic lymph node dissection for papillary thyroid cancer less than 2 cm: implications for radioiodine treatment. J Clin Endocrinol Metab 2009; 94:1162.
  44. Mazzaferri EL, Doherty GM, Steward DL. The pros and cons of prophylactic central compartment lymph node dissection for papillary thyroid carcinoma. Thyroid 2009; 19:683.
  45. Alvarado R, Sywak MS, Delbridge L, Sidhu SB. Central lymph node dissection as a secondary procedure for papillary thyroid cancer: Is there added morbidity? Surgery 2009; 145:514.
  46. Clayman GL, Shellenberger TD, Ginsberg LE, et al. Approach and safety of comprehensive central compartment dissection in patients with recurrent papillary thyroid carcinoma. Head Neck 2009; 31:1152.
  47. Lee YS, Kim SW, Kim SW, et al. Extent of routine central lymph node dissection with small papillary thyroid carcinoma. World J Surg 2007; 31:1954.
  48. Cavicchi O, Piccin O, Caliceti U, et al. Transient hypoparathyroidism following thyroidectomy: a prospective study and multivariate analysis of 604 consecutive patients. Otolaryngol Head Neck Surg 2007; 137:654.
  49. Tisell LE, Nilsson B, Mölne J, et al. Improved survival of patients with papillary thyroid cancer after surgical microdissection. World J Surg 1996; 20:854.
  50. Barczyński M, Konturek A, Stopa M, Nowak W. Prophylactic central neck dissection for papillary thyroid cancer. Br J Surg 2013; 100:410.
  51. Giordano D, Valcavi R, Thompson GB, et al. Complications of central neck dissection in patients with papillary thyroid carcinoma: results of a study on 1087 patients and review of the literature. Thyroid 2012; 22:911.
  52. So YK, Seo MY, Son YI. Prophylactic central lymph node dissection for clinically node-negative papillary thyroid microcarcinoma: influence on serum thyroglobulin level, recurrence rate, and postoperative complications. Surgery 2012; 151:192.
  53. Wang TS, Cheung K, Farrokhyar F, et al. 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; 20:3477.
  54. Machens A, Hinze R, Thomusch O, Dralle H. Pattern of nodal metastasis for primary and reoperative thyroid cancer. World J Surg 2002; 26:22.
  55. Yeh MW, Bauer AJ, Bernet VA, et al. American Thyroid Association statement on preoperative imaging for thyroid cancer surgery. Thyroid 2015; 25:3.
  56. Choi JS, Kim J, Kwak JY, et al. Preoperative staging of papillary thyroid carcinoma: comparison of ultrasound imaging and CT. AJR Am J Roentgenol 2009; 193:871.
  57. Kaplan SL, Mandel SJ, Muller R, et al. The role of MR imaging in detecting nodal disease in thyroidectomy patients with rising thyroglobulin levels. AJNR Am J Neuroradiol 2009; 30:608.
  58. Buerba R, Roman SA, Sosa JA. Thyroidectomy and parathyroidectomy in patients with high body mass index are safe overall: analysis of 26,864 patients. Surgery 2011; 150:950.
  59. Roy M, Rajamanickam V, Chen H, Sippel R. Is DVT prophylaxis necessary for thyroidectomy and parathyroidectomy? Surgery 2010; 148:1163.
  60. McCoy KL, Yim JH, Tublin ME, et al. Same-day ultrasound guidance in reoperation for locally recurrent papillary thyroid cancer. Surgery 2007; 142:965.
  61. Sippel RS, Elaraj DM, Poder L, et al. Localization of recurrent thyroid cancer using intraoperative ultrasound-guided dye injection. World J Surg 2009; 33:434.
  62. Hartl DM, Chami L, Al Ghuzlan A, et al. Charcoal suspension tattoo localization for differentiated thyroid cancer recurrence. Ann Surg Oncol 2009; 16:2602.
  63. Desai D, Jeffrey RB, McDougall IR, Weigel RJ. Intraoperative ultrasonography for localization of recurrent thyroid cancer. Surgery 2001; 129:498.
  64. Karwowski JK, Jeffrey RB, McDougall IR, Weigel RJ. Intraoperative ultrasonography improves identification of recurrent thyroid cancer. Surgery 2002; 132:924.
  65. Zimmerman P, DaSilva M, Izquierdo R, et al. Intraoperative needle localization during neck reexploration. Am J Surg 2004; 188:92.
  66. Triponez F, Poder L, Zarnegar R, et al. Hook needle-guided excision of recurrent differentiated thyroid cancer in previously operated neck compartments: a safe technique for small, nonpalpable recurrent disease. J Clin Endocrinol Metab 2006; 91:4943.
  67. Nobori M, Saiki S, Tanaka N, et al. Blood supply of the parathyroid gland from the superior thyroid artery. Surgery 1994; 115:417.
  68. Sakorafas GH, Sampanis D, Safioleas M. Cervical lymph node dissection in papillary thyroid cancer: current trends, persisting controversies, and unclarified uncertainties. Surg Oncol 2010; 19:e57.
  69. Khafif A, Medina JE, Robbins KT, et al. Level V in therapeutic neck dissections for papillary thyroid carcinoma. Head Neck 2013; 35:605.
  70. Stack BC Jr, Ferris RL, Goldenberg D, et al. American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer. Thyroid 2012; 22:501.
  71. Farrag T, Lin F, Brownlee N, et al. Is routine dissection of level II-B and V-A necessary in patients with papillary thyroid cancer undergoing lateral neck dissection for FNA-confirmed metastases in other levels. World J Surg 2009; 33:1680.
  72. Merdad M, Eskander A, Kroeker T, Freeman JL. Metastatic papillary thyroid cancer with lateral neck disease: pattern of spread by level. Head Neck 2013; 35:1439.
  73. Lee J, Sung TY, Nam KH, et al. Is level IIb lymph node dissection always necessary in N1b papillary thyroid carcinoma patients? World J Surg 2008; 32:716.
  74. Kang BC, Roh JL, Lee JH, et al. Candidates for limited lateral neck dissection among patients with metastatic papillary thyroid carcinoma. World J Surg 2014; 38:863.
  75. Koo BS, Seo ST, Lee GH, et al. Prophylactic lymphadenectomy of neck level II in clinically node-positive papillary thyroid carcinoma. Ann Surg Oncol 2010; 17:1637.
  76. Khanna J, Mohil RS, Bhatnagar D, et al. Is the routine drainage after surgery for thyroid necessary? A prospective randomized clinical study [ISRCTN63623153]. BMC Surg 2005; 5:11.
  77. Sanabria A, Carvalho AL, Silver CE, et al. Routine drainage after thyroid surgery--a meta-analysis. J Surg Oncol 2007; 96:273.
  78. Robenshtok E, Fish S, Bach A, et al. Suspicious cervical lymph nodes detected after thyroidectomy for papillary thyroid cancer usually remain stable over years in properly selected patients. J Clin Endocrinol Metab 2012; 97:2706.
  79. Henry JF, Gramatica L, Denizot A, et al. Morbidity of prophylactic lymph node dissection in the central neck area in patients with papillary thyroid carcinoma. Langenbecks Arch Surg 1998; 383:167.
  80. Roh JL, Park JY, Park CI. 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; 245:604.
  81. Lima LP, Amar A, Lehn CN. Spinal accessory nerve neuropathy following neck dissection. Braz J Otorhinolaryngol 2011; 77:259.
  82. Cappiello J, Piazza C, Nicolai P. The spinal accessory nerve in head and neck surgery. Curr Opin Otolaryngol Head Neck Surg 2007; 15:107.
  83. Beahrs OH. Surgical anatomy and technique of radical neck dissection. Surg Clin North Am 1977; 57:663.
  84. Weiss KL, Wax MK, Haydon RC 3rd, et al. Intracranial pressure changes during bilateral radical neck dissections. Head Neck 1993; 15:546.
  85. Chai PJ, Skaryak LA, Ungerleider RM, et al. Jugular ligation does not increase intracranial pressure but does increase bihemispheric cerebral blood flow and metabolism. Crit Care Med 1995; 23:1864.
  86. Kim MK, Mandel SH, Baloch Z, et al. Morbidity following central compartment reoperation for recurrent or persistent thyroid cancer. Arch Otolaryngol Head Neck Surg 2004; 130:1214.
  87. Youngwirth L, Benavidez J, Sippel R, Chen H. Postoperative parathyroid hormone testing decreases symptomatic hypocalcemia and associated emergency room visits after total thyroidectomy. Surgery 2010; 148:841.
  88. Shaha AR. Complications of neck dissection for thyroid cancer. Ann Surg Oncol 2008; 15:397.
  89. Gupta PK, Smith RB, Gupta H, et al. Outcomes after thyroidectomy and parathyroidectomy. Head Neck 2012; 34:477.
  90. Sosa JA, Bowman HM, Tielsch JM, et al. The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 1998; 228:320.
  91. Friedman M, Pacella BL Jr. Total versus subtotal thyroidectomy. Arguments, approaches, and recommendations. Otolaryngol Clin North Am 1990; 23:413.
  92. Toniato A, Boschin IM, Piotto A, et al. Complications in thyroid surgery for carcinoma: one institution's surgical experience. World J Surg 2008; 32:572.
  93. Cheah WK, Arici C, Ituarte PH, et al. Complications of neck dissection for thyroid cancer. World J Surg 2002; 26:1013.
  94. Rubello D, Salvatori M, Casara D, et al. 99mTc-sestamibi radio-guided surgery of loco-regional 131Iodine-negative recurrent thyroid cancer. Eur J Surg Oncol 2007; 33:902.
  95. Shen WT, Ogawa L, Ruan D, et al. Central neck lymph node dissection for papillary thyroid cancer: comparison of complication and recurrence rates in 295 initial dissections and reoperations. Arch Surg 2010; 145:272.
  96. Lee SW, Choi EC, Lee YM, et al. Is lack of placement of drains after thyroidectomy with central neck dissection safe? A prospective, randomized study. Laryngoscope 2006; 116:1632.
  97. Mekel M, Stephen AE, Gaz RD, et al. Surgical drains can be safely avoided in lateral neck dissections for papillary thyroid cancer. Am J Surg 2010; 199:485.
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