Quality metrics are an increasingly important means of improving patient care. Variability in the number of lymph nodes removed during central compartment lymph node dissection (CCLND) at the time of thyroidectomy has not been studied.
Study Design
A retrospective cohort study was performed using American College of Surgeons National Quality Improvement Program (ACS-NSQIP) data.
Setting
Centers in North America and worldwide contributing data to ACS-NSQIP and performing thyroidectomy on adults in inpatient and outpatient settings were included.
Subjects and Methods
Adult patients undergoing thyroidectomy with or without CCLND were included. Outcomes of interest were number of nodes removed during CCLND and risks of postoperative hypocalcemia.
Results
In total, 6108 patients met inclusion criteria (1565 with CCLND). The median number of lymph nodes removed during CCLND was 2. There was no statistically significant association between postoperative hypocalcemia and CCNLD, regardless of number of nodes removed. However, we were underpowered to detect this association based on the overall low nodal yield of many CCLNDs performed.
Conclusion
In many cases where CCLND is documented as part of thyroidectomy, very few lymph nodes are removed. Our ability to draw conclusions regarding the effect of CCLND on postoperative hypocalcemia is restricted due to the limited nature of many CCLNDs performed.
KocotSLDang-VuCWhiteRMcClellanM.Early experiences with accountable care in Medicaid: special challenges, big opportunities. Population Health Management. 2013;16(suppl 1):S4-S11.
2.
KhuriSFDaleyJHendersonW, et al. The Department of Veterans Affairs’ NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. National VA Surgical Quality Improvement Program. Ann Surg. 1998;228:491.
3.
LewisCMAloiaTAShiW, et al. Development and feasibility of a specialty-specific National Surgical Quality Improvement Program (NSQIP): the head and neck-reconstructive surgery NSQIP. JAMA Otolaryngol Head Neck Surg. 2016;142(4):321-327.
4.
PuramSVBhattacharyyaN.Quality indicators for head and neck oncologic surgery: academic versus nonacademic outcomes. Otolaryngol Head Neck Surg. 2016:155(5):733-739.
5.
SchoppyDWRhoadsKFMaY, et al. Measuring institutional quality in head and neck surgery using hospital-level data: negative margin rates and neck dissection yield. JAMA Otolaryngol Head Neck Surg. 2017;143(11):111-116.
6.
TavaresMRCruzJAWaisbergDR, et al. Lymph node distribution in the central compartment of the neck. Head Neck. 2014;36(10):1425-1430.
7.
HaugenBRAlexanderEKBibleKC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. The American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1-133.
8.
MitraINichaniJRYapBHomerJJ.Effect of central compartment neck dissection on hypocalcaemia incidence after total thyroidectomy for carcinoma. J Laryngol Otol. 2010;125(5):497-501.
9.
HenryJFGramaticaLDenizotAKvachenyukAPucciniMDefechereuxT.Morbidity of prophylactic lymph node dissection in the central neck area in patients with papillary thyroid carcinoma. Langenbecks Arch Surg. 1998;383(2):167.
10.
AydinOUSoyluLOzbasS, et al. The risk of hypoparathyroidism after central compartment lymph node dissection in the surgical treatment of pT1, N0 thyroid papillary carcinoma. Eur Rev Med Pharmacol Sci. 2016;20(9):1781-1787.
11.
LangBH-HNgS-HLauLLCowlingBJWongKPWanKY. A systematic review and meta-analysis of prophylactic central neck dissection on short-term locoregional recurrence in papillary thyroid carcinoma after total thyroidectomy. Thyroid. 2013;23(9):1087-1098.
12.
LinY-SHsuehCWuH-YYuM-CChaoT-C.Incidental parathyroidectomy during thyroidectomy increases the risk of postoperative hypocalcemia. Laryngoscope. 2017;127:2194-2200.
13.
GiordanoDValcaviRThompsonGBPedroniCRennaLGradoniPBarbieriV.Complications of central neck dissection in patients with papillary thyroid carcinoma: results of a study in 1087 patients and review of the literature. Thyroid. 2012;22(9):911-917.
14.
Sitges-SerraARuizSGirventMManjonHDuenasJPSanchoJJ.Outcome of protracted hypoparathyroidism after total thyroidectomy. Br J Surg. 2010;97:1687-1695.
15.
CarvalhoAYDChulamTCKowalskiLP. Long-term results of observation vs prophylactic selective level VI neck dissection for papillary thyroid carcinoma at a cancer center. JAMA Otolaryngol Head Neck Surg. 2015;141(7):599.
16.
SonY-IJeongH-SBaekC-H, et al. Extent of prophylactic lymph node dissection in the central neck area of the patients with papillary thyroid carcinoma: comparison of limited versus comprehensive lymph node dissection in a 2-year safety study. Ann Surg Oncol. 2008;15(7):2020-2026.
17.
GaoL.Association between decreased serum parathyroid hormone after total thyroidectomy and persistent hypoparathyroidism. Med Sci Monit. 2015;21:1223-1231.
WangQChuBZhuJ, et al. Clinical analysis of prophylactic central neck dissection for papillary thyroid carcinoma. Clin Transl Oncol. 2013;16(1):44-48.
20.
Sitges-SerraAGallego-OtaeguiLSuárezSLorente-PochLMunnéASanchoJJ.Inadvertent parathyroidectomy during total thyroidectomy and central neck dissection for papillary thyroid carcinoma. Surgery. 2017;161(3):712-719.
21.
AlvaradoRSywakMSDelbridgeLSidhuSB.Central lymph node dissection as a secondary procedure for papillary thyroid cancer: is there added morbidity?Surgery. 2009;145(5):514-518.
22.
UnderbjergLSikjaerTMosekildeLRejnmarkL.Postsurgical hypoparathyroidism—risk of fractures, psychiatric diseases, cancer, cataract, and infections. J Bone Miner Res. 2014;29(11):2504-2510.
23.
PallottiFSeregniEFerrariLMartinettiABiancoliniDBombardieriE.Diagnostic and therapeutic aspects of iatrogenic hypoparathyroidism. Tumori. 2003;89(5):547-549.
24.
EdafeOBalasubramanianSP.Incidence, prevalence and risk factors for post-surgical hypocalcaemia and hypoparathyroidism. Gland Surg. 2017;6(suppl 1):S59-S68.
25.
RaffaelliMCreaCDSessaLFaddaGBellantoneCLombardiCP.Ipsilateral central neck dissection plus frozen section examination versus prophylactic bilateral central neck dissection in cN0 papillary thyroid carcinoma. Ann Surg Oncol. 2015;22(7):2302-2308.
26.
RaffaelliMCreaCDSessaL, et al. Prospective evaluation of total thyroidectomy versus ipsilateral versus bilateral central neck dissection in patients with clinically node-negative papillary thyroid carcinoma. Surgery. 2012;152(6):957-964.
27.
ShiloachMFrencherSKJrSteegerJE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210:6-16.
28.
KhuriSFDaleyJHendersonW, et al. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995;180:519-531.
van der VeldenJvan LindertACLammesFB, et al. Extracapsular growth of lymph node metastases in squamous cell carcinoma of the vulva: the impact on recurrence and survival. Cancer. 1995;75:2885-2890.
31.
MooreDHStehmanFB.What is the appropriate management of early stage cervical cancer (International Federation of Gynecology and Obstetrics stages I and IIA), surgical assessment of lymph nodes, and role of therapeutic resection of lymph nodes involved with cancer?J Natl Cancer Inst Monogr. 1996;21:43-46.
32.
TepperJEO’ConnellMJNiedzwieckiD, et al. Impact of number of nodes retrieved on outcome in patients with rectal cancer. J Clin Oncol. 2001;19:157-163.
33.
HerrHWBochnerBHDalbagniGDonatSMReuterVEBajorinDF.Impact of the number of lymph nodes retrieved on outcome in patients with muscle invasive bladder cancer. J Urol. 2002;167:1295-1298.
34.
GajraANewmanNGambleGPKohmanLJGrazianoSL.Effect of number of lymph nodes sampled on outcome in patients with stage I non-small-cell lung cancer. J Clin Oncol. 2003;21:1029-1034.
35.
ChangGJRodriguez-BigasMASkibberJM, et al. Lymph node evaluation and survival after curative resection of colon cancer: systematic review. J Natl Cancer Inst. 2007;99:433-441.
36.
Le VoyerTESigurdsonERHanlonAL, et al. Colon cancer survival is associated with increasing number of lymph nodes analyzed: a secondary survey of intergroup trial INT-0089. J Clin Oncol. 2003;21:2912-2919.
37.
SmithAJDrimanDKSpithoffK, et al. Guideline for optimization of colorectal cancer surgery and pathology. J Surg Oncol. 2010;101:5-12.
38.
AbdollahFSchmitgesJSunM, et al. A population-based assessment of the National Comprehensive Cancer network practice guideline indications for pelvic lymph node dissection at radical prostatectomy. BJU Int. 2012;109(8):1177-1182.
39.
WellsSAAsaSLDraleH, et al. Revised American Thyroid Association guidelines for the management of medullary thyroid carcinoma. The American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2015;25(6):567-610.
40.
AgarwalNEvasovichMRKandilE, et al. Indications and extent of central neck dissection for papillary thyroid cancer: an American Head and Neck Society consensus statement. Head Neck. 2017;39(7):1269-1279.
41.
MazzaferriELYoungRL.Papillary thyroid carcinoma: a 10 year follow-up report of the impact of therapy in 576 patients. Am J Med. 1981;70:511-518.
42.
WadaNSuganumaNNakayamaH, et al. Microscopic regional lymph node status in papillary thyroid carcinoma with and without lymphadenopathy and its relation to outcomes. Langenbecks Arch Surg. 2007;392:417-422.
43.
McHenryCRRosenIBWalfishPG.Prospective management of nodal metastases in differentiated thyroid cancer. Am J Surg. 1991;162:353-356.
44.
HughesCJShahaARShahJP, et al. Impact of lymph node metastasis in differentiated carcinoma of the thyroid: a matched-pair analysis. Head Neck. 1996;18:127-132.
45.
SuginoKKureYIwasakiH, et al. Metastases to the regional lymph nodes, lymph node recurrence, and distant metastases in nonadvanced papillary thyroid carcinoma. Surg Today. 1995;25:324-328.
46.
SchneiderDFChenHSippelRS.Impact of lymph node ratio on survival in papillary thyroid cancer. Ann Surg Oncol. 2013;20(6):1906-1911.
47.
LeeYCNaSYParkGC, et al. Occult lymph node metastasis and risk of regional recurrence in papillary thyroid cancer after bilateral prophylactic central neck dissection: a multi-institutional study. Surgery. 2017;161(2):465-471.
48.
HughesDTRosenJEEvansDB, et al. Prophylactic central compartment neck dissection in papillary thyroid cancer and effect on locoregional recurrence. Ann Surg Oncol. 2018;25:2526-2534.
49.
DiviVHarrisJHarariPM, et al. Establishing quality indicators for neck dissection: correlating the number of lymph nodes with oncologic outcomes, NRG Oncology RTOG 9501 and 0234. Cancer. 2016;122(22):3463-3471.
50.
ViolaDMaterazziGValerioL, et al. Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma: clinical implications derived from the first prospective randomized controlled single institution study. J Clin Endocrinol Metab. 2015;100(4):1316-1324.
51.
LangBHHNgSHLauLL, et al. A systematic review and meta-analysis of prophylactic central neck dissection on short-term locoregional recurrence in papillary thyroid cancer after total thyroidectomy. Thyroid. 2013;23(9):1087-1098.
52.
GiordanoDValcaviRThompsonGB, et al. Complications of central neck dissection in patients with papillary thyroid carcinoma: results of a study on 1087 patients and review of the literature. Thyroid. 2012;22:911-917.
53.
KwanWYChowTLChoiCYLamSH.Complication rates of central compartment dissection in papillary thyroid cancer. ANZ J Surg. 2015;85:274-278.
54.
ChenLWuYHLeeCH, et al. Prophylactic central neck dissection for papillary thyroid carcinoma with clinically uninvolved lymph nodes: a systematic review and meta-analysis. World J Surg. 2018;42(9):2846-2857.
55.
BarczynskiMKonturekAStopaMNowakK.Prophylactic central neck dissection for papillary thyroid cancer. Br J Surg. 2013;100:410-418.
