From the Guidelines
Diagnosis and management of papillary thyroid carcinoma with lymph node metastasis should primarily involve total thyroidectomy with central compartment lymph node dissection (level VI) and lateral neck dissection (levels II-V) if lateral lymph node metastasis is confirmed, followed by radioactive iodine therapy and lifelong thyroid hormone replacement therapy. This approach is based on the most recent and highest quality evidence from the National Comprehensive Cancer Network (NCCN) guidelines, version 2.2018 1.
Diagnosis
Diagnosis begins with a thorough clinical examination, followed by:
- Ultrasound of the thyroid and cervical lymph nodes
- Fine needle aspiration cytology (FNAC) of the thyroid nodule and suspicious lymph nodes for cytological confirmation
- Additional imaging, such as CT scan or MRI of the neck (without iodine contrast), to assess the extent of disease
- Laboratory tests, including thyroid function tests, serum calcium, and calcitonin levels
Management
Management involves:
- Total thyroidectomy with central compartment lymph node dissection (level VI)
- Lateral neck dissection (levels II-V) if lateral lymph node metastasis is confirmed
- Postoperative radioactive iodine (RAI) therapy, typically at doses of 30-100 mCi, for ablation of residual thyroid tissue and treatment of metastatic disease
- Lifelong thyroid hormone replacement therapy with levothyroxine, starting at 1.6-1.8 mcg/kg/day, with the goal of suppressing TSH levels (usually to <0.1 mIU/L initially for high-risk patients)
Follow-up
Regular follow-up includes:
- Monitoring thyroglobulin levels
- Neck ultrasound every 6-12 months
- TSH-stimulated thyroglobulin with whole-body scan if necessary
This comprehensive approach is necessary because papillary thyroid cancer can spread to regional lymph nodes in 30-80% of cases, and proper management significantly reduces recurrence rates and improves long-term outcomes, as supported by the NCCN guidelines 1 and other studies 1.
From the Research
Diagnosis of Papillary Thyroid Carcinoma with Lymph Node Metastasis
- Cervical lymph node metastasis is frequent in patients with papillary thyroid carcinoma, with the central compartment being the most common site of metastasis, followed by the lateral compartment 2
- Preoperative imaging may not accurately detect microscopic disease, and routine prophylactic neck dissection is not recommended unless in the presence of high-risk tumors 2, 3
- The presence of macroscopic metastases in cervical lymph nodes results in a higher recurrence rate and increased death rate, especially in patients 45 years of age or older 4
Management of Papillary Thyroid Carcinoma with Lymph Node Metastasis
- Surgical removal of clinically involved nodal metastasis is mandatory to prevent recurrence and improve disease prognosis 2
- Therapeutic lateral neck dissection is performed for clinically involved nodes detected by preoperative imaging confirmed by needle biopsy, while prophylactic lateral neck dissection is contraindicated 2
- Postoperative adjuvant radioiodine is frequently administered for patients with positive nodal metastasis (intermediate-risk group) to avoid future recurrence 2
- Total thyroidectomy is the treatment of choice for clinically significant papillary thyroid carcinoma, and management of lymph node metastases is crucial to reduce recurrence and cancer death rates 5
- The extent of neck dissection has been de-escalated, and compartmental nodal dissection aiming at preservation of function is performed to achieve a complete surgical resection 2