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Original Investigation |

The Upper Limits of Central Neck Dissection

Victoria Holostenco, MD1; Avi Khafif, MD1
[+] Author Affiliations
1The Head and Neck Surgery and Oncology Unit, A.R.M. Center for Advanced Otolaryngology Head and Neck Surgery, Assuta Medical Center, Tel Aviv, Israel
JAMA Otolaryngol Head Neck Surg. 2014;140(8):731-735. doi:10.1001/jamaoto.2014.972.
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Importance  Central neck dissection (CND) is considered an imperative part of the treatment of patients with high-risk, well-differentiated thyroid carcinoma.

Objective  To examine the presence of lymphatic tissue and/or metastatic nodes in the upper part of the paratracheal region to determine the need to dissect this region as part of a paratracheal neck dissection.

Design, Setting, and Participants  We prospectively enrolled 27 nonselective patients with surgical thyroid cancer (4 men and 23 women; median age, 43 years; range, 21-74 years) from June 1, 2010, through March 31, 2011, from a head and neck surgical oncology specialist group practice within the largest private hospital in Israel. All patients were scheduled to undergo unilateral (n = 23) or bilateral (n = 4) CND as their definitive surgical care.

Interventions  A total of 31 paratracheal neck dissections were performed among the 27 patients. The surgical specimens were divided into upper and lower paratracheal regions, separated by the nerve curve line (corresponding to the level of the cricoid). These specimens were thoroughly examined separately for normal and metastatic lymph nodes. A standard pathologic technique was used, with no dedicated personnel.

Main Outcomes and Measures  The existence of lymphatic tissue and metastatic cells in all upper paratracheal surgical specimens.

Results  The surgical procedures were uneventful. Postoperative complications included temporary vocal cord palsy, minimal chyle leak, and wound infection. A median of 8 nodes were retrieved (range, 2-21). No lymphatic tissue was identified in all upper paratracheal dissection specimens. All benign and metastatic lymph nodes (mean, 5.3 and 2.5, respectively) were located in the lower paratracheal region specimens. All upper paratracheal surgical specimens (n = 31) consisted of only fibrofatty connective tissue and were devoid of lymph nodes, metastatic cells, or other endothelial-lined lymphatic structures.

Conclusions and Relevance  In this series of paratracheal neck dissections, the upper part of the paratracheal region contained no lymphatic tissue or cancer-bearing lymph nodes. The necessity to dissect this region, as part of conventional CND, is therefore challenged.

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Figure.
The Nerve Curve Line

The arrow indicates the left recurrent laryngeal nerve; star, the left upper parathyroid gland; and dotted line, the nerve curve line corresponding in most patients to the level of the cricoid.

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