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The purpose of this systematic review and meta-analysis was to determine the optimal extent of lateral neck dissection in patients with well-differentiated thyroid carcinoma with clinically confirmed lateral neck lymph node metastases. All studies reporting the distribution of metastatic lymph nodes in level IIb or level V, complication rate, recurrence rate, or clinical outcomes according to the extent of lateral neck dissection were collected from MEDLINE and Embase databases. Two reviewers independently retrieved articles, extracted data, and assessed the quality of the studies. A total of 40 criteria-meeting studies were included in the systematic review and meta-analysis, representing a total of 6 027 patients. The distribution of metastatic lymph nodes was 13.7% (95% confidence interval [CI]: 8.2-21.9%) in level IIb and 22.1% (95% CI: 18.6-26.1%) in level V. Shoulder syndrome complication showed a tendency to increase when comprehensive neck dissection was performed. The recurrence rate was 11.2% (95% CI: 8.4-14.9%) in the comprehensive neck dissection group and 11.0% (95% CI: 4.2-26.1%) in the selective neck dissection group. Clinical outcomes showed no difference between groups. In conclusion, selective neck dissection may be considered in patients with well-differentiated thyroid carcinoma with lateral neck lymph node metastases without any other risk factors., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: This study analyzed the incidence, pattern, and predictive factors for lateral lymph node (LN) recurrence in patients with papillary thyroid cancer (PTC) without clinical evidence of lateral LN metastasis., Methods: A retrospective analysis was performed on 246 patients with PTC who underwent total thyroidectomy and central neck dissection from 2004 to 2010. None of the patients had clinical evidence of lateral LN metastasis at the time of diagnosis. Predictive factors for lateral LN recurrence were evaluated using the chi-square test. Binary logistic regression was used for the multivariate analysis. Recurrence-free survival rates were estimated by the Kaplan-Meier and Cox regression methods., Results: Of the 246 patients, 11 (4.5%) developed lateral LN recurrence with a median follow-up of 49months. In the multivariate analysis, tumor size >1cm (odds ratio [OR], 8.14; 95% confidence interval [CI], 1.01-65.68; p=0.049) and central LN metastasis (OR, 10.59; 95% CI, 1.32-85.17; p=0.026) were independent predictive factors of lateral LN recurrence. Especially, extranodal extension of a metastatic central LN (OR, 38.82; 95% CI, 5.71-264.10; p<0.001) was an independent predictor of lateral LN recurrence., Conclusions: Tumor size and central LN metastasis were independent predictors of lateral LN recurrence in patients with PTC without initial clinical lateral neck metastasis who underwent total thyroidectomy and central neck dissection. Close surveillance may be necessary for early detection of lateral LN recurrence in PTC patients with tumor size ⩾1cm, and central LN metastasis with extranodal extension., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Despite an excellent prognosis, cervical lymph node (LN) metastases are common in patients with papillary thyroid cancer (PTC). The presence of metastasis is associated with an increased risk of locoregional recurrence, which significantly impairs quality of life and may decrease survival. Therefore, it has been an important determinant of the extent of lateral LN dissection in the initial treatment of PTC patients with lateral cervical metastasis. However, the optimal extent of therapeutic lateral neck dissection (ND) remains controversial. Optimizing the surgical extent of LN dissection is fundamental for balancing the surgical morbidity and oncological benefits of ND in PTC patients with lateral neck metastasis. We reviewed the currently available literature regarding the optimal extent of lateral LN dissection in PTC patients with lateral neck metastasis. Even in cases with suspicion of metastatic LN at the single lateral level or isolated metastatic lateral LN, the application of ND including all sublevels from IIa and IIb to Va and Vb may be overtreatment, due to the surgical morbidity. When there is no suspicion of LN metastasis at levels II and V, or when multilevel aggressive neck metastasis is not found, sublevel IIb and Va dissection may not be necessary in PTC patients with lateral neck metastasis. Thus consideration of the individualized optimal surgical extent of lateral ND is important when treating PTC patients with lateral cervical metastasis.

Skip metastasis, referred to as leaping metastasis to the lateral neck without associated lymphadenopathy in the central compartment (level VI), can occur in patients with papillary thyroid carcinoma (PTC). However, there have been few studies on its predictive value in PTC patients. We reviewed the medical records of 90 patients who underwent simultaneous central and lateral neck lymph node dissection for the primary treatment of lymph node metastasis in the lateral neck of PTC patients. No patient was suspected of having metastasis in the central compartment by preoperative imaging study. The frequency of skip metastasis to the lateral neck compartment without central neck metastasis was 19% (17/90). The number of metastatic lymph nodes dissected in the lateral neck of patients with and without skip metastasis was 5.1±2.7 and 9.5±2.6, respectively (P<0.001). Skip metastasis was closely associated with significantly fewer lymphovascular invasion (P=0.009) and extracapsular spread (P=0.035). Skip metastasis can occur significantly frequently in PTC patients. The presence of lymphovascular invasion, extracapsular spread, and number of positive lymph nodes dissected were inversely correlated with skip metastasis., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: The purpose of this study was to examine the frequency, pattern, and predictive factors associated with occult level II lymph node (LN) metastases in papillary thyroid carcinoma (PTC) patients with clinically metastatic lymph nodes in the lateral neck (level III, IV, and/or V) by preoperative ultrasonography., Methods: We retrospectively reviewed the medical records of 52 PTC patients with clinically positive neck lymph nodes in level III, IV, and/or V based on preoperative ultrasonography, who underwent therapeutic lateral neck dissection (ND) (level II-V) between March 2004 and October 2009. All patients had no suspicion of clinically positive neck nodes in level II. Histopathological analysis of neck specimens according to each node level of the neck was performed, with special attention given to level II., Results: Forty-two (81%), 41 (79%), and 6 (12%) patients had histologically positive lymph nodes in level III, IV, and V, respectively. Occult metastases in level II were observed in ten (19%) patients. Patients without suspicious positive LNs in both neck level III and IV by preoperative ultrasonography, and patients without pathologic LN metastases in level III, had no occult LN metastases occurrence to level II. Based on multivariate analysis, presence of more than four metastatic LNs was an independent predictive factor for occult level II metastases [P = 0.022, odds ratio (OR) = 7.738]., Conclusions: Prophylactic level II LN dissection may be omitted in PTC patients with clinically positive neck nodes if suspicious positive lymph nodes in level III are absent during preoperative ultrasonography.

Background: The extent of lateral neck dissection for clinically evident nodal metastases in the lateral neck in a patient with papillary thyroid cancer (PTC) continues to remain controversial., Methods: We reviewed retrospectively the medical records between March 2005 and March 2008 of 70 patients with PTC who underwent therapeutic lateral neck dissections (level II-V) to establish indications for omission of a level V lymphadenectomy. No patient in the study had a clinically positive level V lymph node. Neck dissection specimens were obtained for histologic analysis for node metastasis with respect to the individual neck levels., Results: Thirty-four (49%), 52 (74%), and 48 (69%) patients had histologically positive lymph nodes in levels II, III, and IV, respectively. Occult metastases in level V were observed in 11 (16%) patients. Isolated positive level V lymph nodes were never found, while all patients with positive level V lymph nodes had simultaneous positive level IV lymph nodes. In addition, there was no instance of a pathologically positive lymph node in level V without a suspicious metastatic lymph node in level IV by preoperative ultrasonography. In multivariate analysis, simultaneous multilevel involvement (level II, III, and IV) of lymphatic metastases was associated with level V metastasis., Conclusion: Level V lymphadenectomy may be omitted in the treatment of PTC patients if positive nodes are not found on histologic exam (frozen section analysis) or by ultrasonography in level IV., (Copyright 2010 Mosby, Inc. All rights reserved.)

Background: The extent of neck dissection (ND) appropriate for necks yielding clinical evidence of metastases of papillary thyroid carcinoma (PTC) is controversial. The need for level IIb lymph node (LN) dissection is particularly uncertain in view of its association with postoperative shoulder dysfunction. In the present study, we examined the frequency, pattern, and predictive factors of level IIb LN metastases in PTC patients with clinically positive lateral neck nodes., Methods: We reviewed the medical records of 76 PTC patients who underwent therapeutic lateral ND for the treatment of clinically positive lateral neck nodes between March 2005 and July 2008. ND specimens were separately obtained for analyzing LN involvement with respect to neck level., Results: Metastatic disease at levels II, III, IV, and V, was seen in 40 (52.6%), 55 (72.4%), 52 (68.4%), and 12 (15.8%) of the patients, respectively. The metastasis rate in level IIb was 11.8% (9 of 76). By univariate analysis, the rate of level IIb LN metastasis was significantly higher in patients with positive level IIa LNs and positive LNs in all lateral neck levels (levels IIa + III + IV) (P < .05). Multivariate analysis showed that positive LN involvement in all lateral neck levels (IIa + III + IV) was an independent predictive factor of level IIb LN metastasis (P = .044, odds ratio = 9.692)., Conclusions: Level IIb LN dissection may be omitted in the treatment of positive neck nodes in PTC patients if multilevel involvement including level IIa involvement is absent.

Background: The indications for and appropriate extent of prophylactic central lymph node (CLN) dissection for clinically node-negative patients with unilateral papillary thyroid microcarcinoma (PTMC) are unknown., Methods: The frequency, patterns and predictive factors for CLN metastases in 86 patients with unilateral PTMC and a clinically node-negative neck were analysed with respect to age and sex; metastasis, age, completeness, invasiveness, size (MACIS) score; tumour size; number and location of tumours; presence of ipsilateral CLN metastases; and presence of lymphovascular or capsular invasion. All patients underwent total thyroidectomy and CLN dissection., Results: Twenty-seven (31 per cent) of 86 patients had metastatic CLNs: 18 ipsilateral and nine bilateral. Univariable analysis suggested male sex and tumour size greater than 0.5 cm to be significant factors in predicting ipsilateral CLN metastases. Only ipsilateral nodal positivity was a significant predictor of contralateral CLN metastases in multivariable analysis (P = 0.007)., Conclusion: CLN metastases are relatively common in PTMC.

This study investigated the oncologic safety of preserving level IIb lymph nodes in ipsilateral and/or contralateral elective neck dissection (END) in patients with oropharyngeal squamous cell carcinoma (SCC). Fifty-one oropharyngeal SCC patients who underwent surgery as an initial treatment were reviewed. Twenty-one patients had clinically node negative necks (cN0) while 30 patients had ipsilateral clinically node positive necks (cN+). Of the cN0 patients, bilateral or ipsilateral END was performed in 15 and six patients, respectively. For the cN+ cases, ipsilateral therapeutic neck dissection with contralateral END was performed in 24 of 30 patients. In the cN0 patients, nodal metastasis to level IIb lymph nodes was not observed in any ipsilateral (21) or contralateral necks (15). Of the 24 cN+ patients who underwent contralateral END, two cases (8.3%) showed contralateral occult level IIb lymph node metastasis. Our data suggest that in cN0 oropharyngeal cancer patients, level IIb lymph nodes may be preserved in ipsilateral and contralateral neck dissection. However, caution is advised when preserving contralateral level IIb nodes in ipsilateral cN+ cases.

Objectives: To evaluate the prevalence of level IIb lymph node (LN) metastasis and to identify potential clinical risk factors when level IIb metastatic diseases are present in patients with clinically node-negative (N0) and node-positive (N+) necks with hypopharyngeal squamous cell carcinoma (HPSCC). This will provide a basis for determining whether this region can be excluded in elective or therapeutic neck dissection in patients with HPSCC., Design: Prospective analysis of a case series., Setting: University hospital., Patients: Fifty patients with HPSCC who underwent surgical treatment for a primary lesion and simultaneous neck dissection from January 1998 to February 2004., Main Outcome Measures: The incidences and clinical risk factors for level IIb LN metastasis and regional recurrence according to the presence or absence of pathologic LN involvement in level IIb., Results: A total of 93 neck dissections were analyzed in this study. Of these dissections, 59 (63%) were elective and 34 (37%) were therapeutic. Three percent (2 of 59) of all N0 necks and 32% (11 of 34) of all N+ necks had level IIb LN metastases. Level IIb nodal metastases were significantly more prevalent in N+ necks (P=.007) than in N0 necks and in the presence of other positive LNs (P=.01) than in the absence of other positive LNs. Of the 35 patients with pathologic LNs, the regional recurrence rate was significantly higher in cases with positive level IIb LNs (33% [4 of 12]) than without (4% [1 of 23]; P=.04)., Conclusions: Level IIb LN pads may be preserved during elective neck dissection in the treatment of patients with clinically N0 necks with HPSCC. This area should be removed during therapeutic neck dissection in the treatment of clinically N+ necks.

Objective: The hypopharynx has a rich lymphatic network that places patients with tumors of the hypopharynx at high risk for early dissemination of the disease into the cervical lymphatics. Therefore, ipsilateral elective neck dissection of clinically N0 neck in lateralized lesions of hypopharyngeal squamous cell carcinomas (SCCs) is widely accepted as a standard treatment. However, the management of the contralateral N0 neck is still controversial. The aim of this study was to evaluate the incidence and predictive factors of contralateral occult lymph node metastasis in pyriform sinus SCC., Materials and Methods: We performed a retrospective analysis of 43 patients with N0 to 3 pyriform sinus SCC with contralateral clinically node-negative necks who had also received contralateral elective neck dissections from 1994 to 2003. Surgical treatment was followed by postoperative radiotherapy in 41 patients. The follow-up period ranged from 4 to 135 months (mean, 40 months). The Kaplan-Meier method and log-rank test were used to calculate the disease-specific survival rates and prognostic significance of contralateral occult lymph node metastasis., Results: Contralateral occult lymph node metastases occurred in 16% (seven of 43) of the subjects. Twenty-six percent of the 27 subjects with clinically node-positive ipsilateral neck developed contralateral occult lymph node metastases, whereas 0% of the 16 subjects with N0 ipsilateral necks (P=.035) developed the disease. Moreover, in cases with primary site extension across the midline, the rate of contralateral occult neck metastasis was significantly higher (P=.010). However, there were no statistically significant differences in age, sex, early versus advanced T stage, number of ipsilateral positive nodes, lymph nodes with extracapsular spread, primary subsite of medial versus lateral pyriform sinus, pyriform sinus apex involvement, and growth type. Patients with no evidence of contralateral nodal cancer had significantly improved disease-specific survival over patients with any pathologically positive nodes (5-year disease-specific survival rate, 66% vs. 33%, P<.05)., Conclusion: The patients with pyriform sinus SCC with clinically ipsilateral N+ neck and/or extension across the midline are at greater risk for contralateral occult neck metastases. Furthermore, patients who present with a contralateral metastatic neck have a worse prognosis than those staged as N0. Therefore, we advocate bilateral neck treatment in patients with pyriform sinus SCC with clinically ipsilateral node metastases and/or extension across the midline.

Objectives: Postoperative shoulder dysfunction has been significantly associated with any dissection of level V secondary to traction or with ischemic injury to the spinal accessory nerve. The aim of this study was to determine whether the dissection of level V lymph node pads is absolutely necessary in therapeutic neck dissection as a treatment for oral and oropharyngeal squamous cell carcinoma (OOSCC) patients with clinically N+ neck., Study Design: Retrospective chart review., Methods: We performed a retrospective analysis of 93 OOSCC patients who underwent surgical treatment of the primary lesion along with a simultaneous comprehensive neck dissection from January 1992 to December 2003. Of these, only one patient had a clinically positive neck node at level V. During the neck dissection, the contents of the level V lymph nodes were dissected, labeled, and processed separately from the remainder of the major neck dissection specimen. We studied the incidence of pathologic metastasis to level V lymph nodes. In addition, we also evaluated several potential risk factors for metastatic disease in the level V lymph nodes such as sex, age, T stage, N stage, histologic grade, and presence of other positive lymph nodes., Results: A total of 96 comprehensive neck dissections were performed in this series. The prevalence of metastases in the level V lymph nodes was 5% (5 of 93) in ipsilateral and 0% (0 of 3) in contralateral necks. One case with clinically positive node at level V had a pathologic positive node in level II, III, IV, and V. Occult metastasis rate of ipsilateral level V was 4% (4 of 92). There was a statistically significant association between level V metastases and a positive N stage above N2b (P=.01). The presence of metastasis in other multiple neck levels, particularly the combined neck levels II, III, and IV, also have a statistically significant association with level V metastasis (P=.023)., Conclusion: Level V lymph node pads may be preserved in modified neck dissections on OOSCC patients with clinically N+ neck below the nodal stage N2a.

Objectives/hypothesis: Prophylactic treatment of contralateral N0 neck in early squamous cell carcinoma (SCC) of the oral tongue is a controversial issue. The aim of this study was to analyze the rates of occult metastases and their prognostic effects in stage I and stage II SCC of the oral tongue, and to compare the results of elective neck dissection to observation of the contralateral N0 neck in the treatment of these patients., Study Design: Retrospective review., Methods: We reviewed the medical records of 54 patients who were treated at Severance Hospital from 1992 to 2003 and had been diagnosed with stage I or stage II SCC of the oral tongue and had not received prior treatment. All patients underwent an ipsilateral elective neck dissection simultaneously with the primary lesion. The management of the contralateral N0 necks involved "watchful waiting" in 29 patients and elective neck dissection in 25 patients. Surgical treatment was followed by radiotherapy in 20 patients. Of these, seven patients belonged to the "observation" group who did not receive contralateral elective neck dissection. The follow-up period ranged from 3 to 110 months, with a mean of 56.3 months. Data were analyzed using the Kaplan-Meier method, the log-rank test, and the chi(2) test., Results: Fifteen patients (28%, 15 of 54) had occult metastases. Of these, 14 patients (26%, 14 of 54) had ipsilateral pathologic metastases. The remaining case (4%, 1 of 25) had the only contralateral level II occult neck metastasis without ipsilateral metastasis. Disease recurred in 17 of 54 patients (31%). Of these, eight cases (47%, 8 of 17) had regional recurrences. All regional recurrences developed in the ipsilateral neck; there were no cases of contralateral neck recurrence. The 5-year actuarial disease-free survival rates were 82% for the "observation" group and 68% for the elective neck dissection group. This difference was not statistically significant (P = .182). The 5-year actuarial disease-free survival rates were 83% for the "observation" group when those patients who underwent radiotherapy were excluded (n = 22) and 68% for the elective supraomohyoid neck dissection group (n = 25), which showed no statistically significant difference (P = .127)., Conclusions: This study showed that ipsilateral elective neck management is indicated for stage I and II SCC of the oral tongue. On the other hand, our series suggests that contralateral occult lymph node metastasis was unlikely in early-stage oral tongue SCC, and that there was no survival benefit for patients who underwent elective neck dissection in place of observation. Thus, it may not harmful to observe the contralateral N0 neck in the treatment of early oral tongue cancer.

Objectives: Selective neck dissection, despite preservation of the spinal accessory nerve, can lead to some degree of postoperative shoulder dysfunction as a result of removal of level IIb lymph nodes. The aim of this study was to determine whether level IIb lymph nodes can be preserved in elective or therapeutic neck dissection as a treatment for patients with laryngeal squamous cell carcinoma (SCC)., Study Design: This was a prospective analysis of a case series., Methods: A prospective analysis of 65 patients with laryngeal SCC who underwent surgical treatment of the primary lesion with simultaneous neck dissection from January 1999 to December 2002 was performed. During the neck dissection, the contents of the level IIb lymph nodes were dissected, labeled, and processed separately from the remainder of level II nodes and the main neck dissection specimen. The incidence of pathologic metastasis to level IIb lymph nodes and the regional recurrence within this area were evaluated. In addition, several potential risk factors for metastatic disease in the level IIb lymph nodes such as sex, age, cT stage, cN stage, and the presence of other positive lymph nodes were also evaluated., Results: A total of 125 neck dissections were performed in this series. Of these dissections, 102 (82%) were elective and 23 (18%) were therapeutic. The prevalence of metastases in the level IIb lymph nodes was 1% (one of 46) and 0% (zero of 56) in clinically node-negative (N0) ipsilateral and contralateral necks, respectively, and 37% (seven of 19) and 0% (zero of four) in clinically node-positive ipsilateral and contralateral necks, respectively. There was a statistically significant association between level IIb metastases and clinically positive N stage (P<.001). The presence of other positive lymph nodes was also shown to have a statistically significant association with metastasis in the level IIb lymph nodes (P=.001). Only two of 46 patients (4%) with clinically N0 necks developed a regional recurrence. However, three of eight cases (38%) with positive pathologic level IIb lymph nodes developed regional recurrence., Conclusion: Level IIb lymph node pads may be preserved in elective neck dissection in patients with laryngeal SCC. However, this area should be removed thoroughly during therapeutic neck dissection in the treatment of clinically node-positive necks.

A prospective study of 73 previous untreated consecutive patients with clinically N0 laryngeal squamous cell carcinoma (SCC) from January 1997 to October 2002 was undertaken to determine whether level IV lymph nodes can be saved in elective lateral neck dissection (LND) performed as a treatment for the N0 neck. The incidence of pathological metastases to level IV lymph nodes was evaluated, as were the incidence of regional recurrence after elective LND, and postoperative complications such as chylous leakage and phrenic nerve paralysis. A total of 142 LNDs were enrolled in this prospective study. The mean number of harvested lymph nodes by level was as follows; 13.1 in level II, 7.1 in level III, and 9.2 in level IV. Pathologic examination revealed nodal involvement in 25 neck specimens (17.6%, 25 of 142). Five necks had lymph nodes which were positive for microscopic metastasis in level IV (3.5%, 5 of 142). These necks were all ipsilateral (6.8%, 5 of 73) and none of the 69 contralateral neck specimens had level IV lymph node metastasis (0%, 0 of 69). With regard to T stage, 3.3% (1 of 30) of ipsilateral necks of T2 tumors exhibited occult metastasis in level IV lymph nodes, 5.9% (2 of 34) for T3 tumors, and 33.3% (2 of 6) for T4 tumors. There were no cases of T1 (n = 3). Separate skip metastasis in level IV lymph nodes was observed in two necks (1.4%, 2 of 142). Four cases of regional recurrence (5.5%, 4 of 73) were observed. Postoperative chylous leakage and phrenic nerve paralysis occurred in four cases (5.5%, 4 of 73) and two cases (2.7%, 2 of 73), respectively. The results of the present study demonstrate the rare incidence of level IV occult lymph node metastasis, as well as infrequent nodal recurrence after elective LND in the treatment of clinically N0 laryngeal SCC. Therefore, dissection of level IV lymph node pads, especially in the ipsilateral neck of early T staged tumors or the contralateral neck, may be unnecessary for the treatment of laryngeal SCC patients with a clinically N0 neck.