Is it possible to rule out level II and level VB dissection in patients with metastatic papillary thyroid cancer?

Tugba Matlim Ozel^1*Sezer Akbulut^1*Aykut Celik¹Gorkem Yildiz¹Hamit Yucel Barut²Fatih Mert Dogukan³Serkan Sari¹

• ¹Department of General Surgery, Basaksehir Cam and Sakura City Hospital, Istanbul, Türkiye
• ²Radiology Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Istanbul, Türkiye
• ³Department of Pathology, Laboratory Branches, Division of Clinic, Basaksehir Cam and Sakura City Hospital, Istanbul, Türkiye

Background: The completeness of surgical resection is an important determinant of outcomes in patients with papillary thyroid carcinoma (PTC) and regional lymph node metastasis. However, the optimal extent of therapeutic lateral neck dissection remains controversial. This study aimed to evaluate the diagnostic value of preoperative ultrasonography (US) for detecting lateral lymph node metastasis in patients with PTC and to identify predictive factors associated with metastases at levels II and V.Methods: A retrospective analysis was conducted of consecutive patients with PTC who underwent comprehensive lateral neck dissection at a single institution between June 2020 and July 2024.In 63 patients, a total of 78 comprehensive lateral neck dissections were performed. Of the patients, 41 (65%) were male and 22 (35%) were female, with a median age of 37 years (range, 24-49 years). Lymph node metastases were identified in 46 (58.9%), at level II, 561 (78.2%) at level III, 60 (76.9%) at level IV, and 9 (11.5%) at level Vb. Metastasis to level IIb was detected in 5 dissections. Among the 9 patients with level Vb metastases, 7 (77.8%) had involvement of four different cervical levels. The specificity of US for detecting metastatic involvement was high at level II (80%) and level Vb (87%). Independent predictors of metastatic involvement at level II and level Vb lymph nodes was associated with extrathyroidal extension [level II: odds ratio (OR) 7.88, p=0.03; level V: OR 6.91, p=0.043] and a largest metastatic lateral lymph node size greater than 2 cm [level II: OR 18.58, p=0.03; level V: OR 11.32, p=0.03]. Conclusion: Routine dissection of level IIa is recommended in N1b PTC due to high metastasis rates. However, level IIb dissection may be omitted in selected cases given its low metastasis rate and potential morbidity, with intraoperative frozen section serving as a useful guide. Similarly, level Vb dissection may be avoided when lateral lymph nodes are <2 cm, multilevel involvement is absent, and ultrasonographic findings are negative.