Central node dissection in papillary thyroid carcinoma in the era of near-infrared fluorescence

Abstract

The most common site of lymph node metastases in papillary thyroid carcinoma is the central compartment of the neck (level VI). In many patients, nodal metastases in this area are not clinically apparent, neither on preoperative imaging nor during surgery. Prophylactic surgical clearance of the level VI in the absence of clinically suspicious lymph nodes (cN0) is still under debate. It has been suggested to reduce local recurrence and improve disease-specific survival. Moreover, it helps to accurately diagnose the lymph node involvement and provides important staging information useful for tailoring of the radioactive iodine regimen and estimating the risk of recurrence. Yet, many studies have shown no benefit to the long-term outcome. Arguments against the prophylactic central lymph node dissection (CLND) cite minimal oncologic benefit and concomitant higher operative morbidity, with hypoparathyroidism being the most common complication. Recently, near-infrared fluorescence imaging has emerged as a novel tool to identify and preserve parathyroid glands during thyroid surgery. We provide an overview of the current scientific landscape of fluorescence imaging in thyroid surgery, of the controversies around the prophylactic CLND, and of fluorescence imaging applications in CLND. To date, only three studies evaluated fluorescence imaging in patients undergoing thyroidectomy and prophylactic or therapeutic CLND for thyroid cancer. The results suggest that fluorescence imaging has the potential to minimise the risk of hypoparathyroidism associated with CLND, while allowing to exploit all its potential benefits. With further development, fluorescence imaging techniques might shift the paradigm to recommend more frequently prophylactic CLND.

Development and validation of a nomogram for preoperative prediction of ipsilateral cervical central lymph node metastasis in papillary thyroid cancer: a population-based study

“…Understanding the extent and location of LNM is crucial for developing treatment plans. Studies have confirmed that PTC patients with CLNM have a lower survival rate and a higher risk of recurrence ( 4 , 5 ). Therefore, it has been suggested that prophylactic central lymph node dissection can identify lymph node lesions and potentially reduce the risk of disease recurrence ( 6 ).…”

Significant role of 1,25-dihydroxyvitamin D on serum calcium levels after total thyroidectomy: a prospective cohort study

“…Various factors contribute to the risk of post-thyroidectomy hypocalcemia, including perioperative parathyroid hormone (PTH) levels, preoperative vitamin D (VD) deficiency, and potential parathyroid gland damage or removal during surgery ( 3 ). Recently, the introduction of new intraoperative modalities aimed at preserving intraoperative parathyroid function has been reported ( 4 , 5 ). The literature also discusses using preoperative VD or calcium (Ca) supplementation ( 1 , 3 , 6 ), as well as various postoperative Ca management strategies ( 7 , 8 ), to address this issue.…”

Significant Role of 1,25-Dihydroxyvitamin D on Serum Calcium Levels After Total Thyroidectomy: A Prospective Cohort Study

“…Various factors contribute to the risk of post-thyroidectomy hypocalcemia, including perioperative parathyroid hormone (PTH) levels, preoperative vitamin D (VD) de ciency, and potential parathyroid gland damage or removal during surgery [3]. Recently, the introduction of new intraoperative modalities aimed at preserving intraoperative parathyroid function has been reported [4,5]. The literature also discusses using preoperative VD or calcium (Ca) supplementation [1,3,6], as well as various postoperative Ca management strategies [7,8], to address this issue.…”

“…PTH is crucial in regulating Ca concentrations, both directly and indirectly by producing 1,25dihydroxyvitamin D (1,25(OH)2D). However, the difference in the half-life of PTH and 1,25(OH)2D (3)(4)(5) min for the former and 5-20 h for the latter) [17 18 19], suggests that 1,25(OH)2D is not completely subordinate to PTH in in uencing Ca metabolism. While both PTH and 1,25(OH)2D are vital for managing Ca concentration after thyroidectomy, research on the role of 1,25(OH)2D is very limited.…”