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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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Central Neck Dissection
https://t.me/med1917
JaclynGellings, MichaelJosephson, andSophieDream
1 Indications
Thyroid cancer is classied by the cell of origin. Differentiated thyroid cancer from
follicular cell origin, which includes papillary and follicular thyroid cancer, accounts
for over 90% of all thyroid cancers [1]. Medullary thyroid cancer is a rare thyroid
cancer, accounting for about 1–2% of all thyroid cancers, and is derived from calcitonin-producing parafollicular cells. Medullary thyroid cancer has different biologic activity than cancers of follicular origin and can occur both sporadically and
in a hereditary form as a component of the type 2 multiple endocrine neoplasia [2].
Papillary and medullary thyroid cancer can present with lymph node involvement, with the central lymph node compartment being the rst site of metastasis.
Lymph node metastasis of papillary and medullary thyroid cancer typically follow
a step-wise approach, rst involving the lymph nodes of the ipsilateral central neck,
followed by the contralateral central neck, and then the lateral neck lymph node
basins [3]. The most commonly involved central lymph nodes in papillary and medullary thyroid cancer are the prelaryngeal, pretracheal, and paratracheal nodal basins
located in the central neck [4]. Complete resection at the initial operation is imperative to improve disease-free survival, reduce the risk of local or regional recurrence,
and improve cancer-specic survival for papillary and medullary thyroid cancers [1–3].
A therapeutic central neck dissection is performed for papillary thyroid cancer
when there is a clinically or biopsy proven central lymph node metastasis. Clinically
positive central lymph nodes are level VI or VII lymph nodes that are grossly large
J. Gellings · M. Josephson · S. Dream (*)
Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin,
Milwaukee, WI, USA
e-mail: jgellings@mcw.edu; mjosephson@mcw.edu; sdream@mcw.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_4
25© The Author(s), under exclusive license to Springer Nature
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J. Gellings et al.
on exam, suspicious on preoperative sonographic evaluation, found to contain metastatic thyroid cancer on cytologic or pathologic analysis preoperatively, or grossly
involved on intraoperative examination. Prophylactic central neck dissection is performed when the central nodes are clinically uninvolved at the time of thyroidectomy. The role of prophylactic central neck dissection for papillary thyroid cancer
is controversial as the role in reducing local recurrence and improving diseasespecic survival is not clear with the possibility of increased risk of recurrent laryngeal nerve injury and hypoparathyroidism [1, 3]. Prophylactic central neck dissection
should be considered in patients with papillary thyroid cancer who have advanced
primary tumors or clinically involved lateral neck nodes [1, 5] (Table1).
In contrast to papillary thyroid cancer, standard treatment for medullary thyroid
cancer includes total thyroidectomy and dissection of central cervical lymph nodes
in all patients, even in those without evidence of central neck lymph nodes as medullary thyroid carcinoma is more likely to have clinically relevant lymph node
involvement at presentation [2, 5].
In general, central neck dissection is performed in conjunction with a total thyroidectomy, but occasionally is performed in the reoperative setting for recurrent
thyroid cancer, when there is clinical or biopsy proven disease in the central neck.
Reoperative central neck dissection should involve a multidisciplinary work-up and
discussion, including ultrasound examination, ne needle aspiration of suspicious
lymph nodes with thyroglobulin wash-out, and consideration of timing of reoperation and risks to the patient with both observation and reoperation.
Table 1 Indications for central neck dissection
Therapeutic central neck dissection-performed for clinically positive lymph nodes:
• Grossly enlarged on physical exam
• Suspicious features on sonographic exam
– Enlargement (>7mm smallest diameter)
– Loss of fatty hilum
– Cystic appearance
– Hyperechoic punctuations
– Peripheral vascularity
– Rounded shape (not oval)
• Contain metastatic thyroid cancer on cytologic or pathologic analysis.
• Grossly involved on intraoperative exam
Prophylactic central neck dissection-clinically uninvolved central lymph nodes with advanced
disease or high-risk features:
• Lateral node metastases (levels II, III, VI, and V)
• Large tumor size (T3 or T4)
• Multifocal disease
• Extrathyroidal extension
• High risk genetic mutations
• Pediatric patient or patients older than 55years or age
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2 Preoperative Preparation
Prior to surgical intervention, patients with suspected thyroid cancer or diagnosed
with thyroid cancer should have preoperative ultrasound of the central and lateral
compartments of the neck, followed by ne needle aspiration of any suspicious
appearing lymph nodes. If there is conrmed metastasis in the lateral compartments
of the neck, then the patient will require a lateral neck dissection in addition to a
central neck dissection and total thyroidectomy (NCCN).
2.1 Position
The patient is placed in the “Rose” position, supine on the operating table with the
head of the bed at 15° of elevation. The head and neck are extended with a shoulder
roll or thyroid pillow under the shoulders. A foam ring may be helpful to help hold
the head in place. The arms should be tucked on both sides and all pressure points
should be padded. Positioning with the head of the table slightly elevated helps
decompress the veins of the neck.
3 Procedure Overview
The central neck lymph node basins are designated as levels VI and VII.The anatomic boundaries of level VI are the hyoid bone superiorly, carotid arteries laterally,
prevertebral fascia posteriorly, and suprasternal notch or innominate artery inferiorly (Table 2); the distinct central nodal packets of level VI are the prelaryngeal
pretracheal, bilateral paratracheal lymph nodes [1, 3]. Similarly, level VII is located
in the anterior superior mediastinum adjacent to the brachiocephalic vein and
innominate artery, and some sources include the innominate artery as the inferior
border of the central neck. The level VII nodes can be resected en bloc with those in
level VI if these lymph nodes are clinically involved. A central neck dissection is
Table 2 Boundaries of the
central compartment lymph
node dissection
Border Anatomic boundary
Superior Hyoid bone
Inferior Suprasternal notch, innominate artery, or
clavicle
Medial Midportion of the trachea
Lateral Carotid artery/sheath
Anterior Anterior layer of the cervical fascia
Deep Deep layer of the cervical fascia or prevertebral
fascia
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J. Gellings et al.
dened as compartment-oriented removal of both the pretracheal and prelaryngeal
nodes along with at least one paratracheal nodal basin, a bilateral dissection is distinguished by removal of the bilateral paratracheal lymph node basins [3, 4].
Structures at risk during the dissection include the parathyroid glands, particu-
larly the inferior parathyroid glands, and the recurrent laryngeal nerve.
4 Description oftheProcedure
A Kocher incision is made in a natural neck crease approximately two ngerbreadths above the sternal notch or one ngerbreadth below the cricoid cartilage to
overlay the thyroid isthmus. The incision is carried down through the subcutaneous
tissue and platysma. Subplatysmal aps are raised superiorly to the thyroid cartilage
and inferiorly to the sternal notch. The strap muscles are separated vertically along
the midline raphe in the avascular plane. The lateral boundary of the central neck
dissection is freed, opening the paratracheal space from the level of the hyoid to the
innominate, subclavian, or clavicle (whichever structure is most cranial) along the
carotid, with care to avoid injury to the inferior thyroid artery (Fig.1). Central neck
dissection can be performed either once the thyroid has been removed or in conjunction with thyroidectomy. The authors prefer to perform central neck dissections
with thyroidectomy, removing the central neck contents and thyroid as a single
Fig. 1 Central neck dissection exposure. Demonstration of the extent of the dissection with sternal
notch inferiorly, carotid artery laterally, midline of the trachea medially, and hyoid superiorly
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specimen. The initial step dening this lateral boundary facilitates the central neck
dissection once the superior pole of the thyroid is taken down. Care must be taken
to preserve the superior parathyroid gland on its vascular pedicle as the inferior
parathyroid gland may be removed with the central neck contents and difcult to
distinguish and separate from metastatic lymph nodes for autotransplantation.
Once the superior pole of the thyroid is taken down, the recurrent laryngeal nerve
is identied at the point of intersection with the inferior thyroid artery (Fig.2). The
thin fascial layer overlaying the recurrent laryngeal nerve is dissected free from the
brofatty tissue of the central compartment inferiorly to the level of the thoracic
inlet. The brofatty tissue behind the recurrent laryngeal nerve may contain lymph
nodes harboring metastatic disease that become the source of recurrence if left in
situ, it is important to remove these nodes, freeing the recurrent laryngeal nerve
circumferentially (Fig.3).
The lateral border of the dissection is freed once it is dissected down to the prevertebral fascia. The lymph node packet is elevated off the deep layer of the cervical
fascia with care to avoid stretch to the overlaying recurrent laryngeal nerve. Once
the deep layer is freed, the central node packet is passed under the recurrent laryngeal nerve and retracted medially. The pretracheal nodes laying in the midline and
anterior to the trachea are removed with the thyroid and paratracheal nodes, extending inferiorly to the sternal notch.
The inferior parathyroid is often removed with the level VI lymph nodes or
devascularized during a central neck dissection. Once the inferior parathyroid gland
Fig. 2 Central neck dissection—identication of right recurrent laryngeal nerve after the upper
pole of the thyroid is taken down
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Fig. 3 Central neck dissection—dissection of the brofatty node-bearing tissue of the central neck
uncovering of the right recurrent laryngeal nerve
J. Gellings et al.
is conrmed to be parathyroid tissue and not a lymph node harboring metastatic
thyroid cancer, it should be autotransplanted if it was removed or the blood supply
is threatened. Hemostasis should be assured prior to closure in the standard fashion.
The prelaryngeal lymph node overlying the cricoid membrane is often encountered at the time of dissection of the thyroid isthmus and pyramidal lobe. The authors
take these lymph nodes as either the rst or the last step of the central neck dissection.
5 Postoperative Care
Patients may be discharged the day of the operation or stay overnight [6]. All
patients should be instructed to sleep with the head of the bed elevated to 30 degrees
to reduce the risk of seroma formation. They can resume a normal diet once they are
alert enough to tolerate a diet. A serum calcium and parathyroid hormone level is
checked 4–6h after surgery. Oral calcium supplementation is given based on postoperative parathyroid hormone levels using evidence-based replacement protocols
to prevent hypocalcemia [7].
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References
1. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, 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. 2015;26(1):1–133.
2. Wells SA Jr, Asa SL, Dralle H, Elisei R, Evans DB, Gagel RF, et al. Revised American
Thyroid Association guidelines for the management of medullary thyroid carcinoma. Thyroid.
2015;25(6):567–610.
3. Patel KN, Yip L, Lubitz CC, Grubbs EG, Miller BS, Shen W, etal. The American Association
of Endocrine Surgeons guidelines for the denitive surgical management of thyroid disease in
adults. Ann Surg. 2020;271(3):e21–93.
4. Carty SE, Cooper DS, Doherty GM, Duh QY, Kloos RT, Mandel SJ, etal. Consensus statement
on the terminology and classication of central neck dissection for thyroid cancer. Thyroid.
2009;19(11):1153–8.
5. Eltelety AM, Terris DJ.Neck dissection in the surgical treatment of thyroid cancer. Endocrinol
Metab Clin N Am. 2019;48(1):143–51.
6. Terris DJ, Snyder S, Carneiro-Pla D, Inabnet WB 3rd, Kandil E, Orloff L, et al. American
Thyroid Association statement on outpatient thyroidectomy. Thyroid. 2013;23(10):1193–202.
7. Mazotas IG, Yen TWF, Park J, Liu Y, Eastwood DC, Carr AA, etal. A postoperative parathy-
roid hormone-based algorithm to reduce symptomatic hypocalcemia following completion/
total thyroidectomy: a retrospective analysis of 591 patients. Surgery. 2018;164(4):746–53.
Modied Radical Neck Dissection
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CordSturgeon andDinaM.Elaraj
1 Anatomy andNomenclature
The neck is divided into seven lymph node-bearing compartments, the nomenclature of which was originally described by the Memorial Sloan Kettering Head and
Neck Service [1] and has been standardized and modied several times by the
American Head and Neck Society, the American Academy of Otolaryngology-Head
and Neck Surgery, and the American Thyroid Association [2–5] (Fig.1). The seven
nodal compartments are dened as follows:
(I). Submental (IA) and submandibular (IB) triangle nodes. These nodes are bor-
dered by the body of the mandible superiorly and the hyoid bone inferiorly.
Submental (IA) nodes are in the midline between the anterior bellies of the
digastric muscles. Submandibular (IB) nodes are laterally located, between
the anterior belly of the digastric and the stylohyoid muscle.
(II). Upper third jugular nodes. These nodes are located between the skull base
and the hyoid bone from the stylohyoid muscle to the posterior border of the
sternocleidomastoid muscle (SCM). This compartment is subdivided into
IIA (anterior) and IIB (posterior) based on the relationship to the spinal
accessory nerve (CN XI).
(III). Middle third jugular nodes. These nodes are located between the hyoid bone
and the inferior border of the cricoid cartilage and bordered anteriorly by the
lateral border of the sternohyoid muscle and posteriorly by the posterior border of the SCM.
C. Sturgeon (*) · D. M. Elaraj
Department of Surgery, Section of Endocrine Surgery, Northwestern University Feinberg
School of Medicine, Chicago, IL, USA
e-mail: csturgeo@nm.org; delaraj@nm.org
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_5
33© The Author(s), under exclusive license to Springer Nature
34
Tr
tilage
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C. Sturgeon and D. M. Elaraj
Stylohyoid m.
Posterior belly
of the digastric m.
Level IIB
Spinal accessory n.
Posterior border of
sternocleidomastoid m.
Level VA
apezius m.
Level IB
Level IIA
Level III
Level VI
Level IV
Level VB
Level VII
Anterior belly of
the digastric m.
Level IA
Hyoid bone
Notch in thyroid
cartilage
Cricothyroid
membrane
Cricoid car
Omohyoid m.
Fig. 1 The neck is divided into seven lymph node-bearing compartments. Key landmarks and
structures are shown above
(IV). Lower third jugular nodes. These nodes have the same anterior and posterior
borders as level III, but these nodes are even more inferior, located between
the inferior border of the cricoid cartilage and the clavicle.
(V). Posterior triangle nodes. These nodes are located between the anterior border
of the trapezius muscle, the posterior border of the SCM, and the clavicle.
This group is subdivided into spinal accessory (VA) and supraclavicular
(VB) nodes by a horizontal plane dened by the inferior border of the cricoid
cartilage.
(VI). Central neck nodes. These nodes are located between the carotid sheaths
extending from the hyoid bone to the suprasternal notch.
(VII). Upper mediastinal nodes. These nodes are located between the suprasternal
notch and the innominate artery.
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1.1 Procedural Terminology
The radical neck dissection, as originally described by Crile in 1906 [6], entailed
removal of all of the node-bearing tissue in Levels I–V along with the SCM, internal
jugular vein and CN XI.The radical neck dissection is not considered a standard
operation for thyroid cancer. Numerous modications of the original operation have
been described, however, that do have a signicant role in the contemporary surgical management of metastatic thyroid cancer [7].
A “modied radical neck dissection” (MRND) is dened as an operation that
involves the preservation of one or more non-lymphatic structures that were routinely removed in the radical neck dissection, but still results in the formal compartmental clearance of levels I–V [2]. Some experts have referred to an operation that
formally clears compartments I–V and preserves the SCM, CN XI, and internal
jugular vein as a “functional neck dissection”. Expert guidelines would classify a
procedure as a “selective neck dissection” (SND) when one or more of the lymph
node levels is preserved during a formal neck dissection and is usually depicted in
the medical record as SND with the levels removed following in parentheses [2, 3].
Some clinicians use the terms “lateral neck dissection”, modied radical neck dissection, and “selective neck dissection”, interchangeably. An “extended neck dissection” is dened as a neck dissection that includes the removal of additional
lymph node groups or structures beyond those included in the radical neck dissection.
The term “therapeutic neck dissection” implies that nodal metastases are clinically apparent at the time of the neck dissection. The terms “prophylactic neck dissection” or “elective neck dissection” imply that there were no clinical or
radiographic ndings to suggest the presence of nodal metastases at the time of the
dissection.
Papillary and medullary thyroid cancers frequently metastasize to the cervical
lymph nodes. Thyroid cancer nodal metastases are best treated with formal compartmental clearance. There is no role for the selective removal of individual metastatic lymph nodes (“berry picking”) during an index operation [8]. For metastatic
thyroid cancer, the authors perform a formal nodal clearance of levels IIA, III, IV,
and VB, and in the text that follows we will refer to clearance of these node-bearing
regions as an MRND.We recognize that some authors include levels I and IIB, and
may perform a more extensive clearance of level V than what is described herein
[3]. The SCM, internal jugular vein and CN XI are preserved, except in rare cases
of directly invasive thyroid cancers, where sacrice of one of these structures is
required to allow resectability.
Therapeutic MRND is indicated for clinically positive or biopsy-proven lateral
neck metastases from thyroid cancer [8, 9]. Prophylactic MRND is not indicated in
the treatment of patients with papillary thyroid cancer. The role and extent of prophylactic MRND in the treatment of medullary thyroid cancer (MTC) are controversial, with some authors advocating prophylactic MRND based on clinical
parameters and intraoperative ndings [10, 11]. The National Comprehensive
Cancer Network (NCCN) recommends considering prophylactic ipsilateral MRND
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