Controversies about the central compartment in thyroid cancer

Alexandre Bozec et al. [1]. discuss their experience with 368 patients undergoing central compartment neck dissection in this contemporary article. The issue of central compartment neck dissection continues to be controversial in the modern era. The management of thyroid cancer has always been a controversial subject;however, the major thrust of debate has switched from total versus less than total thyroidectomy to the indications for routine prophylactic central compartment neck dissection[2] and the use of postoperative radioactive iodine ablation. These issues have seen a major paradigm shift over the past 10–15 years, primarily due to our ability to detect the early recurrent disease with thyroglobulin assay and routine follow-up ultrasound of the neck. The subject of management of the neck has been extensively debated since the prognostic implications of the presence of positive nodes, either in the central compartment or in the lateral neck, was found to be minimal. Patients do remarkably well with positive neck nodes. In patients below the age of 45, the stage of the tumor does not change from stage I whether the nodes are positive or not. In view of this, prophylactic neck dissection raises a major issue about the long-term effect on prognosis, recurrence, and complications from the surgical procedure itself. It is very important to balance the risk of complications against the long term benefit of any surgical procedure. The authors have reviewed their large experience in a retrospective fashion. This article raises some difficulties in the interpretation and conclusion, primarily since the data are retrospective and the decision regarding prophylactic central compartment dissection was the surgeon’s choice. The extent of central compartment dissection also remains unclear, and it would be appropriate to assume that, again, it is of the operating surgeon’s choice and experience. However, the authors conclude three important features of positive central compartment nodes: the age of the patient, size of the tumor, and the extrathyroidal extension. These are important prognostic features for the possibility of future recurrence with or without central compartment dissection. The major issues concerning any operating surgeon are the risks of elective central compartment dissection, mainly related to transient and permanent recurrent laryngeal nerve injury, and the transient or permanent hypoparathyroidism. In the majority of the series, the incidence of permanent hypoparathyroidism is much higher in this group of patients, even with the dedicated parathyroid autotransplantation. The authors in this article have frankly reported a higher incidence of temporary and permanent hypoparathyroidism with prophylactic central compartment dissection. Prior to the era of thyroglobulin and ultrasound studies, there was hardly any discussion about the central compartment dissection. This subject appears to be a contemporary physicianand technology-driven problem. In the past, patients were evaluated clinically in follow-up, and unless recurrent disease was clinically palpable, no treatment intervention was undertaken. Patients continued to do well and required surgical intervention only on a therapeutic basis. In 2006, ATA guidelines recommended that the elective central compartment dissection may be considered in patients with papillary carcinoma of the thyroid. This recommendation was used by the proponents of elective central compartment dissection to support their viewpoint. However, it was apparent to the ATA committee that there was no fundamental strong basis for this recommendation, and the A. R. Shaha (&) Head and Neck Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA e-mail: shahaa@mskcc.org