What Lymph Node Levels does a Lateral [Therapeutic] Neck Dissection for Differentiated Thyroid Cancer (DTC) Include?

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • What lymph node levels does a lateral [comprehensive / therapeutic] neck dissection for differentiated thyroid cancer (DTC) include?
  • Although the rate of clinical nodal involvement in the lateral compartment was initially described by Japanese (Noguchi et al. 1970) and Germans (Gimm et al. 1998):
    • Sivanandan et al (2001) were the first to systematize it by levels
  • In 2013, the Canadian group of Jeremy L. Freeman (Eskander et al. Thyroid) conducted a systematic review that included the meta-analysis of 18 publications (including his 2012 retrospective work with 185 patients; Merdad et al. Head Neck) agglutinating 1298 lateral neck dissections for DTC:
    • Although heterogeneity was a constant in all comparisons by levels (I2: 31% to 87%), it is the best evidence to date that justifies the use of selective emptying IIa-Vb in this cohort of patients with this pathology:
      • Level III is the most frequently compromised
      • The majority (73%) of patients have more than one level involved:
        • Level III and IV:
          • 46%
        • Level II, III and IV:
          • 26%
        • Level III, IV and V:
          • 11%
        • Level II, III, IV and V:
          • 13% (Merdad et al. 2012)
  • Levels I and sublevel Va (cranial to the distal spinal nerve pathway):
  • Are rarely involved, usually in patients with high disease volume and multilevel invasion
  • Emptying of sublevel IIb (retrospinal recess):
    • Is usually indicated when clinical, radiological or macroscopic involvement is evident intraoperatively
    • The macroscopic involvement evident in the intraoperative sublevel IIa usually determines the addition of sublevel IIb to the neck dissection
  • “Skip metastases” within the lateral compartment are uncommon and occur in around 9% of patients:
    • Level II with level III and IV
    • Level V with level III and IV
      • (Merdad et al. 2012)
  • Selective lymphadenectomy IIa to Vb currently dissects levels IIa, III, IV, Vb and the “infraspinal” portion of the VA [VAi] in order to avoid the functional sequelae of cranial nerve XI dissection
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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