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Operative Technique for Modified Radical Neck Dissection in Papillary Thyroid Carcinoma—Invited Critique

Operative Technique for Modified Radical Neck Dissection in Papillary Thyroid Carcinoma—Invited... The management of lymph node involvement in PTC is a controversial topic, in part because it is well documented that PTC is a disease with an exceptionally good prognosis. While patients and clinicians can respond emotionally to hearing the word cancer, such responses in PTC can be disproportionate to objective outcomes. Surgeons can exacerbate an emotional reaction with statements such as, “cancer is a surgical disease,” that on the surface seem reasonable. But the facts are that PTC is endemic in the population, frequently involves cervical nodes, and rarely causes mortality after thyroidectomy. Thanks to recent investigations on the role of lymph node dissection we can start by agreeing on the big things, eg, it would be unjustified to recommend modified radical dissection for micro-PTC without lymphadenopathy1 or to perform it solely in response to a patient's or a clinician's insistence. There are still no data showing a survival benefit for lymphadenectomy in PTC. Nevertheless, modified radical neck dissection is sometimes necessary, and because it can have risks and adverse effects, it is important to understand how to do it well. Here, Porterfield and colleagues contribute a timely, valuable, and beautifully illustrated article that sets a modern standard for endocrine surgery. The authors write from an institution that does not always use radioiodine routinely (another area of controversy in PTC), relying on lymphadenectomy to achieve chronically undetectable thyroglobulin levels. It is invigorating to practice nowadays because we look increasingly at outcomes; indeed, we continually reexamine the data available, as is happening now with the next iteration of the American Thyroid Association management guidelines.2 Although it is unusual when patients with PTC do not do well, it is also disturbing, and keeps us focused on seeking objective methods such as molecular markers to therapeutically categorize such patients with respect to nodal clearance. Correspondence: Dr Carty, Department of Surgery, University of Pittsburgh, 3471 Fifth Ave, Kauffman 101, Pittsburgh, PA 15261 (cartyse@upmc.edu). Financial Disclosure: None reported. References 1. Wada NDuh Q-YSugino 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;237399- 407PubMedGoogle Scholar 2. Cooper DSDoherty GMHaugen BR et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2006;16 (2) 109- 142PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Operative Technique for Modified Radical Neck Dissection in Papillary Thyroid Carcinoma—Invited Critique

Archives of Surgery , Volume 144 (6) – Jun 15, 2009

Operative Technique for Modified Radical Neck Dissection in Papillary Thyroid Carcinoma—Invited Critique

Abstract

The management of lymph node involvement in PTC is a controversial topic, in part because it is well documented that PTC is a disease with an exceptionally good prognosis. While patients and clinicians can respond emotionally to hearing the word cancer, such responses in PTC can be disproportionate to objective outcomes. Surgeons can exacerbate an emotional reaction with statements such as, “cancer is a surgical disease,” that on the surface seem reasonable. But the facts are that...
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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.2009.90
Publisher site
See Article on Publisher Site

Abstract

The management of lymph node involvement in PTC is a controversial topic, in part because it is well documented that PTC is a disease with an exceptionally good prognosis. While patients and clinicians can respond emotionally to hearing the word cancer, such responses in PTC can be disproportionate to objective outcomes. Surgeons can exacerbate an emotional reaction with statements such as, “cancer is a surgical disease,” that on the surface seem reasonable. But the facts are that PTC is endemic in the population, frequently involves cervical nodes, and rarely causes mortality after thyroidectomy. Thanks to recent investigations on the role of lymph node dissection we can start by agreeing on the big things, eg, it would be unjustified to recommend modified radical dissection for micro-PTC without lymphadenopathy1 or to perform it solely in response to a patient's or a clinician's insistence. There are still no data showing a survival benefit for lymphadenectomy in PTC. Nevertheless, modified radical neck dissection is sometimes necessary, and because it can have risks and adverse effects, it is important to understand how to do it well. Here, Porterfield and colleagues contribute a timely, valuable, and beautifully illustrated article that sets a modern standard for endocrine surgery. The authors write from an institution that does not always use radioiodine routinely (another area of controversy in PTC), relying on lymphadenectomy to achieve chronically undetectable thyroglobulin levels. It is invigorating to practice nowadays because we look increasingly at outcomes; indeed, we continually reexamine the data available, as is happening now with the next iteration of the American Thyroid Association management guidelines.2 Although it is unusual when patients with PTC do not do well, it is also disturbing, and keeps us focused on seeking objective methods such as molecular markers to therapeutically categorize such patients with respect to nodal clearance. Correspondence: Dr Carty, Department of Surgery, University of Pittsburgh, 3471 Fifth Ave, Kauffman 101, Pittsburgh, PA 15261 (cartyse@upmc.edu). Financial Disclosure: None reported. References 1. Wada NDuh Q-YSugino 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;237399- 407PubMedGoogle Scholar 2. Cooper DSDoherty GMHaugen BR et al. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2006;16 (2) 109- 142PubMedGoogle ScholarCrossref

Journal

Archives of SurgeryAmerican Medical Association

Published: Jun 15, 2009

Keywords: modified radical neck dissection,thyroid carcinoma, papillary

References