Surgical morbidity of cervical lymphadenectomy for thyroid cancer: A retrospective cohort study over 25 years

International Journal of Surgery 21 (2015) 128e134

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Original research

Surgical morbidity of cervical lymphadenectomy for thyroid cancer: A retrospective cohort study over 25 years Andrea Polistena*, Massimo Monacelli, Roberta Lucchini, Roberta Triola, Claudia Conti, Stefano Avenia, Ivan Barillaro, Alessandro Sanguinetti, Nicola Avenia University of Perugia, Medical School, Endocrine Surgery Unit, S. Maria University Hospital, Terni, Italy

h i g h l i g h t s
Cervical lymphadenectomy has a key role in the treatment of advanced thyroid cancer.
Central and lateral neck dissection is characterized by potential severe complications.
Central lymphadenectomy has increased complications compared to total thyroidectomy.
Radical modified dissection is the elective technique for lateral neck metastases.
Complications can be reduced by correct indications and expertise in specialized centre.

a r t i c l e i n f o

a b s t r a c t

Article history: Received 3 January 2015 Received in revised form 18 July 2015 Accepted 27 July 2015 Available online 5 August 2015

Introduction: Prognosis of thyroid cancer is strictly related to loco-regional metastases. Cervical lymphadenectomy has a specific oncologic role but may lead to significant increase of morbidity. Aim of the study is the analysis of surgical morbidity in cervical lymphadenectomy for thyroid cancer. Methods: We retrospectively analyzed 1.765 thyroid cancers operated over a period of 25 years at S. Maria University Hospital, Terni, University of Perugia, Italy. Type of lymphadenectomy, histology and complications were analysed. Results: A prevalence of differentiated and medullary cancers was observed (respectively 88% and 7.2%). Central lymphadenectomy was carried out in 425 patients, lateral modified and radical lymphadenectomy respectively in 651 and 17 cases. Following central neck dissection we observed: bilateral and unilateral temporary recurrent nerves palsy respectively of 0.7% and 3.5%, unilateral permanent palsy in 1.6% of cases, temporary and permanent hypoparathyroidism respectively in 17.6% and 4.4%. After lateral neck dissection we observed: intra and post-operative haemorrhage respectively in 2% and 0.29%, respiratory distress in 0.29%, lesions of facial nerve in 0.44%, of vagus in 0.14%, of phrenic nerve in 0.14%, of hypoglossal nerve in 0.29%, of the accessory nerve, transient in 1.34% and permanent in 0.29%, permanent lesion of cervical plexus in 0.29%, salivary fistula in 0.14% and chylous fistula in 1.04% of patients. Student's t test was used to compare groups when appliable. Conclusion: Central and lateral cervical lymph node dissection are associated to severe morbidity. Correct indication, surgical expertise, high volume of patients and early multidisciplinary management of complications is the key of an acceptable balance between oncologic benefits and surgical morbidity. © 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

Keywords: Thyroid cancer Surgery Lymphadenectomy Complication

1. Introduction  Chirurgiche, S. * Corresponding author. UOC Chirurgia Generale e Specialita Maria University Hospital, via Tristano di Joannuccio 1, Terni 05100, Italy. E-mail addresses: [email protected] (A. Polistena), massimo.monacelli@mail. com (M. Monacelli), [email protected] (R. Lucchini), triolaroberta@gmail. com (R. Triola), [email protected] (C. Conti), [email protected] (S. Avenia), [email protected] (I. Barillaro), alessandrosanguinetti@gmail. com (A. Sanguinetti), [email protected] (N. Avenia).

Cervical lymph nodes dissection is commonly adopted to treat cervical lymphatic metastases of thyroid cancer [1]. Prognosis of differentiated thyroid cancer (DTC) is strictly related to the metastatic spreading to loco-regional lymph nodes which represents a crucial point in the multimodal management of this disease.

http://dx.doi.org/10.1016/j.ijsu.2015.07.698 1743-9191/© 2015 IJS Publishing Group Limited. Published by Elsevier Ltd. All rights reserved.

A. Polistena et al. / International Journal of Surgery 21 (2015) 128e134

Although DTCs present a very good prognosis, with a 10-year survival rate greater than 90%, however they frequently show lymph node metastases (20e50%) [2] and in about 15% of patients, evidence of regional recurrence after total thyroidectomy (TT) with consequent increased mortality [3e6]. Medullary (MTC) and anaplastic (ATC) thyroid carcinomas are as well potentially characterized by metastases to cervical lymph nodes and are both associated to worse prognosis compared to DTC [7e9]. In patients presenting a DTC with in the central compartment pathologic like lymph nodes at the preoperative evaluation or at surgical exploration, central neck dissection (CND) is considered the standard of treatment, being level VI lymph nodes involved in up to 29% of cases [10e17]. Prophylactic CND is still debated as standard procedure in cN0 thyroid cancer [5,6,18]. Lymph nodes of supraomohyoid, upper-, middle-, lower-jugular and supraclavicular chains (respectively levels I, II, III, IV, V) are frequent site of metastatic disease for all cervico-facials tumours. There are specific criteria to indicate lateral neck dissection (LND) of levels from II to V which are those more frequently involved in thyroid cancer [18,19]. According to the most used classification [19], LND can be divided into radical standard and extended (RND and ERND), radical modified (MRND) and selective (SND) based on the structures removed and preserved during surgery. RND corresponds to removal of all the lymph nodes laterally to the carotid artery, including three important anatomic structures: the sternocleidomastoideus muscle, the internal jugular vein, and the spinal accessory nerve. Compared to RND additional lymph node groups or not lymphatic structures are removed in ERND. MRND corresponds to a functional neck dissection acting the radical removal of lymph nodes preserving totally or in part the above loco-regional structures otherwise resected. The prognostic value of nodal metastases is nevertheless controversial: some authors consider their presence predictive of local disease recurrence, but overall disease survival does not seem to be adversely affected [20e24]. Specifically in thyroid cancer some authors support the conviction that undetected metastases lead to morbidity due to local recurrence and to inadequate postsurgical dosage of radio active iodine (RAI) [18,20]. As a matter of fact performing routine prophylactic bilateral CND or indiscriminate LND is not appropriate either. Cervical lymphadenectomy in fact, as an advanced demolitive procedure, may lead to significant morbidity for potential damage to critical loco-regional structures [25e29]. Since extreme variability of the experience reported in literature with few reports dedicated to morbidity of neck dissection for thyroid cancer in large series, in the present study we aimed to analyze of the experience of an high volume endocrine surgical unit, focussing on the surgical morbidity of the different procedures. The principal objective was to evaluate if adopting the current indication to cervical lymphadenectomy for thyroid cancer, the related morbidity might be considered acceptable. 2. Patients and methods We retrospectively analyzed 1.765 thyroid cancers in a population of 11.824 patients operated for thyroid disease by the same surgical team, with standard surgical technique, over a period of 25 years, since 1986e2011, in the Unit of Endocrine Surgery, S. Maria University Hospital, Terni, University of Perugia, Italy, referral centre (AFOI, Area Funzionale Omogenea Interaziendale) of Umbria region (middle Italy). This retrospective cohort study is fully compliant with the STROBE criteria [30]. Data available in the

129

observational period were collected from our database and analysed. Preoperative work-out included blood text, ECG, chest X-ray and neck ultrasound with preoperative fine needle aspiration cytology (FNAC) when indicated and neck computed tomography (CT) in selected cases. In DTC indication to CND and LND was the evidence of central or lateral compartment pathologic like lymph nodes at the preoperative ultrasound with or without cytological confirmation or for CND their observation at surgical exploration. In MTC, CND was routinely performed whereas LND carried out only if there was evidence of lateral compartment pathologic like lymph nodes at ultrasounds. In ATC lymphadenectomy was suited to each patient in consideration of the local invasiveness. We considered the different complications observed in relation to the procedures (TT þ CND, RND and MRND) carried out for the treatment of thyroid cancer and cervical lymph nodes metastases. In the present series the type of MRND (preservation of the spinal accessory nerve, type I, of the spinal accessory nerve and internal jugular vein, type II and of the spinal accessory nerve, internal jugular vein, and sternocleidomastoideus muscle, type III) was chosen considering the intraoperative findings. ERND, as removal of additional lymph node groups, was not carried out in the present series, but additional procedures such as tracheal resection (TR), laryngo-tracheal resection (LTR), laryngeal resection (LR) tracheostomy (TCT) or just stent placing were in selected cases associated to thyroidectomy and/or lymphadenectomy in those patients presenting laryngo-tracheal infiltration. As standard of treatment when approaching the central compartment, although parathyroids are identified and preserved in the standard technique, if vascular damage or accidental excision of the glands was observed, their direct autoimplatation in the sternocleidomastoideus muscle was carried out. In all patients plasmatic Calcium level was tested twice in 1st post-operative day and once in 2nd post-operative day, while in hypocalcemic patients daily, until normalization. Hypoparathyroidism was defined as a concentration of parathormone (PTH) under 10 ng/L (normal range 10e65 ng/L) strictly correlated to hypocalcemia defined as an ionized calcium level (iCa) under 1.0 mmol/L (normal range 1.12e1.32 mmol/L). Treatment included, at first severe hypocalcemia (iCa under 0.94 or muscular spasm and tetany) promptly intravenous calcium gluconate and oral calcitriol (Rocaltrol; Roche SpS, Milan Italy) 1.5 mcg per day (0.5 mcg every 8 h) and for asymptomatic patients, oral calcium (Calcium-Sandoz Forte; ans, France) 3 gr per day (1 gr every 8 h) Novartis Pharma SA, Orle plus calcitriol. Permanent hypocalcemia was defined as iCa under 1.12 mmol/L 6 months after surgery 25. Indirect laryngoscopy was operated preoperatively and postoperatively in all patient, eventually supported by direct examination with flexible device, for evaluation of cordal motility, to asses laryngeal nerve function, although inferior laryngeal nerves are identified and preserved in the standard procedure of TT. We considered transient palsy if recovered up to 12 months after surgery, permanent if unmodified 12 months after surgery. In all patients Jackson Pratt drainages were used, one in the thyroid space in TT with or without CND and one along the carotid artery in LND, with three drainages in case of bilateral lymphadenectomy. The medial one is usually removed in 1st post-operative day, the lateral one according to the volume of drainage collected. On the left side caution with precocious removal was always considered to identify late chylous fistula from an unrecognised lesion of the thoracic duct. When a chyle fistula is suspected postoperatively after macroscopic changes of drained fluids, diagnosis was confirmed by laboratory assessment with triglycerides dosage over 100 mg/dL. Nervous lesions were considered with their specific clinical

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signs and when applicable by electromyography or for the phrenic nerve by chest X-ray. They were considered permanent if persistent 12 months after surgery. In the 98% of cases, patients were discharged in 2nd postoperative day when receiving only TT with or without CND, later on in case of RMND or additional demolitive procedures. When indicated after surgery patients were referred to RAI according the guidelines of the Oncological Multidisciplinary Team of Umbria region and either follow-up was scheduled considering stage and prognostic risk as previously described [18]. Patients were regularly followed up in the outpatient clinic every three months for at least one year to asses L-thyroxin dosage and to evaluate eventual complications observed.

Procedure RND 1%

other 4% TT 33%

MRND 37%

TT+CND 24%

HT 1%

3. Statistical analysis We used Student's t test for analysis of variance between groups when applicable. A p-value <0.05 was considered statistically significant. All of the data were analyzed using XLSTAT (Addinsoft, New York, NY, USA). No statistical correlation could be made in the incidence of complications, considering separately patients underwent respectively MRND and RND, being the two groups not comparable for number of patients and due to low number of cases for each complication registered. 4. Results The 1.775 thyroid cancers included 1563 DTC, 127 MTC, 39 ATC and 46 rarer tumors, which were all excluded from the analysis, including 35 insular thyroid carcinoma, 7 lymphomas, 2 plasmocytomas and 2 angiosarcomas (Fig. 1). The cases included 1.232 female (70.9%) and 543 males (30.5%), with a mean age of 42.3 ± 11.3 years (range 16e88 years). Surgical procedures carried out were classified in: 13 emithyroidectomy (HT), 569 TT, 425 TT þ CND, 651 MRND, 17 RND (Fig. 2) and in 76 cases with laryngo-tracheal infiltration were carried out 16 TT þ TR, 3 TT þ LTR, 3 TT þ L, 14 TT þ TCT, 28 stents, 12 TCT. We only considered complications following TT þ CND, MRND, RND and analysed separately CND and LND (MRND and RND together). An average volume of 40 cc was collected in the drainages which were removed, according to the different procedure necessity, between the 1st and the 4th post operative day. In the 98% of cases, patients were discharged in 2nd post-operative day when receiving only TT and CND, later on in case of LND. We registered the following complications after TT þ CND (Table 1):

MTC 7%

ATC 2%

Histology

other 1%

Fig. 2. Procedures carried out. Surgical procedures carried out were classified as total thyroidectomuy (TT), emithyroidectomy (HT), central neck lymphadenectomy (CND), modified radical neck dissection (MRND), radical neck dissection (RND), isolated procedures including laringectomy, laringotracheal resection, tracheostomy and stent placing (other).

We observed 3 cases of bilateral temporary laryngeal recurrent nerve palsy (0.7%), 15 cases of unilateral temporary laryngeal recurrent nerve palsy (3.5%), 7 cases of unilateral permanent laryngeal recurrent nerve palsy (1.6%), 75 cases of temporary hypoparathyroidism (17.6%), 19 cases of permanent hypoparathyroidism (4.4%). We registered the following complications after both MRND and RND (Table 1): 4.1. Intra-operative haemorrhage It was observed in 14 patients (2% out of 668), in 3 patients (0.44%) it was referred to a carotid artery lesion which was repaired by direct suture, in 11 (1.64%) it was referred to a jugular vein lesion, which was directly sutured in 8 cases while in the remnant 3 patients the vein ligature was required. 4.2. Post-operative haemorrhage It was observed in 2 cases (0.29%), in both bleeding originated from the jugular vein which was directly sutured. 4.3. Respiratory distress It was observed in 2 cases (0.29%) following bilateral MRND, in both a unilateral ligature of the jugular vein determined a venous hypertension with oedema of the larynx and airways obstruction. A temporary TCT was required in both patients. 4.4. Nervous lesions

DTC 90%

We observed 3 cases (0.44%) of facial nerve lesion (1 permanent and 2 transient), 1 case (0.14%) of permanent lesion of vagus, 1 case (0.14%) of phrenic nerve lesion (it was present in a patients with extended infiltration of the nerve by metastatic lymph nodes), 2 permanent lesions (0.29%) of hypoglossal nerve, 9 permanent (1.34%) and 2 transient (0.29%) lesions of the accessory nerve (all following MRND), 2 cases (0.29%) of permanent lesion of the cervical plexus (both following RND). 4.5. Salivary fistula

Fig. 1. Histologic distribution of cases: differentiated thyroid tumor (DTC), medullary thyroid carcinoma (MTC), anaplastic thyroid carcinoma (ATC), rarer tumors including lymphomas, plasmocytoma and angiosarcomas (other).

It was observed in 1 case (0.14%) and was approached with conservative treatment and dressing.

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Table 1 Incidence of complications in the different type of lymphadenectomy. Not statistical correlation could be made between MRND and RND (not statistically comparable, n.c.). Complication

Incidence

Surgery carried out

p

Treatment

Intraoperative haemorrhage

14 (3 carotid artery, 11 jugular vein)

6 RND, 8 MRND type III

n.c.

Postoperative haemorrage Respiratory distress Salivary fistula Chylous fistula

2 (jugular vein) 2 1 7

2 2 1 1

/ / / n.c.

3 Arterial suture 8 Vein suture 3 Vein ligature 2 Vein suture Temporary TCT Conservative treatment 2 Intraoperative repair 1 Postoperative duct ligation 4 Conservative treatment

Hypoparathyroidism Recurrent laryngeal nerve unilateral palsy Recurrent laryngeal nerve bilateral palsy Facial nerve lesion Vagus nerve lesion Phrenic nerve lesion Hypoglossal nerve lesion Accessory nerve lesion Cervical plexus lesion

Permanent 19 (4.4%) 7 (1.6%) / 1 1 1 (right) 2 9 2

Transient 75 (17.6%) 15 (3.5%) 3 (0.7%) 2 / / 1 2 /

MRND type III bilateral MRND type I MRND type I RND, 6 MRND type III

CND CND CND 1 RND, 2 MRND type II 1 RND 1 MRND type III 1 RND, 2 MRND type III 11 MRND type III 2 RND

4.6. Chylous fistula It was observed in 7 patients (1.04%). One was related to bilateral MRND while left unilateral lymph nodes dissection was performed before the onset of the other 6 cases. The finding of an active lymphatic leak allowed a prompt surgical repair in 2 cases out of 7. Other 4 cases, appearing as of “low-flow” fistula, healed after conservative therapy. Right supra-diaphragmatic lymphatic duct ligation was performed by videothoracoscopic approach in the last patient. We registered not significant (p ¼ 0.89) difference in the mean number of lymph nodes removed by RND and MRND with respectively 30.2 and 27.8 nodes. Although no statistical correlation could be made considering separately patients underwent respectively MRND and RND, in the direct analysis we observed 12 complications in 8 patients out of 17 (47%) following RND, with four cases with double complications. We observed instead 35 complications in 35 patients (5.37%) out of 651 following MRND. 5. Discussion Neck dissection has been recognized as an integral part of the surgical treatment of head and neck cancer since the 19th century and many technical changes were standardized in order to preserve loco-regional structures, to conserve function and to prevent dysmorphism without reducing the oncologic efficacy of the procedure [31]. In the present study we analysed the incidence and the characteristics of the complications following CND and LND with the aim of demonstrating that although they are both demolitive procedures if correctly indicated and managed in experienced hand, their surgical morbidity can be limited to an acceptable rate. Limitation of the present study is the lack of homogeneous groups receiving MRND and RND, which makes impossible to refer an increased risk of certain complication to one or to the other procedure. This bias was impossible to correct in a retrospective analysis in which indication to RND was extremely limited. RND in fact was progressively abandoned in favour of MRND which is nowadays the most adopted technique worldwide to treat lateral neck metastases. Intraoperative evaluation guides the type of MRND in each patient, according to local invasiveness of metastatic disease [19]. Furthermore the limited number of the different

n.c. / / n.c. / /

20 Parathyroid autoimplatation, substitutive therapy Corticosteroids therapy, rehabilitation Temporary TCT Corticosteroids therapy / / Corticosteroids therapy Corticosteroids therapy, rehabilitation Corticosteroids therapy, rehabilitation

complications observed, sometimes associated only to RND or to MRND, didn't permit either any correlation with the technique adopted. The therapeutic value of removing nodal metastases is still debated: some authors consider their presence predictive of local disease recurrence, but not adversely affecting overall diseasespecific survival [20]. In patients with MTC, the extent of the primary surgical resection and the evidence of local or distant metastases significantly influence the outcome. An extensive lymphadenectomy performed early in the treatment and re-operative cervical lymphadenectomy, in patients with persistently high calcitonin levels after thyroidectomy, significantly improve the prognosis [7e9]. ATC is as well potentially characterized by metastases to cervical lymph nodes and presents aggressive behaviour with indication to lymphadenectomy only in selected resectable cases [7e9]. As in our series, CND is considered the standard of treatment for patients with macroscopic central neck nodal disease, recognized preoperatively or intraoperatively during surgical exploration [32]. Although general consent is registered regarding the extension of TT, different authors report controversial experiences regarding lymphadenectomy of levels VIeVII of the neck. The American Thyroid association (ATA) guidelines recommend central lymphadenectomy in high risk patients but it is not considered mandatory in patients with T1 tumors [33]. Conzo et al. define CND therapeutic rather than prophylactic in case of clinical pathological lymph nodes considering the high rate of transient and definitive complications of lymphadenectomy [34]. Other authors propose routine CND [6] which is supported by the rationale that surgical morbidity is justified by potential avoidance of morbidity associated with not necessary RAI, although a potential overtreatment [18,35]. In clinical practice, due to the lack of evidence, some authors recommend lymphadenectomy only for high risk patients [36,37] or suggest to limit it to ipsilateral lymph nodes thus avoiding unnecessary surgical related morbidity [38]. Among complications following CND, transient hypoparathyroidism is the more common. To prevent permanent hypoparathyroidism, parathyroid autotransplantation, if an accidental removal or damage with devascularisation is observed at surgery, as we performed in our series, is strongly recommended [25]. Recurrent laryngeal nerve injury is extremely rare in high volume centres and patients tolerate quite well unilateral palsy, while although very rare, bilateral true palsy requires urgent

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tracheostomy to secure the airway [39,40]. The rates of temporary and permanent hypoparathyroidism and of inferior laryngeal nerve palsy we observed are similar to those presented in the main experiences reported in literature, especially when considering the higher risk of complications if reoperation is required (up to 9% of laryngeal nerves injury and 14% of permanent hypoparathyroidism) [16,41e46]. We agree that further studies concerning CND in DTC are required to better define the risk class and properly indicate the nodal dissection. This must balance the impact of surgical morbidity of CND with eventual real benefit in the survival rate. The oncologic role of LND in papillary cancer is nowadays recognised either in synchronous and metachronous metastases. MRND is the most commonly performed lymph node dissection for thyroid cancer and it is usually carried out with clearance of compartments IIa, III and IV [14,41]. LND is also well-established for radical surgical treatment together with CND of selected cases of MTC [47]. In comparison with the central compartment, the lateral lymph nodes are site of occult metastasis with a lower incidence (23%) but LND is characterized by high post operative complication rate. Despite this severe morbidity some authors advocate prophylactic LND, considering the high rate of occult metastasis and the increase of complications due to the scar tissue resulting from previous surgery if reoperation is required [48]. The American Thyroid Association guidelines although recognized the importance of lateral neck metastases in DTC, supported only therapeutic, but not prophylactic node dissection [49], since no benefit in terms of improved survival [50]. Neck ultrasound (US) is the principle preoperative method which guides the indication to a correct LND, based on the evidence of enlarged lymph nodes (>1.5 cm in levels I and IIa or >1.0 cm in levels IIbeVb) and/or suspicious sonographic features which require eventual FNAC with dosage of thyroglobulin, for all the other cases only US control is recommended [51,52]. Recurrences after MRND range from 10% to 50% [53] and they are usually linked to an incomplete initial surgical procedure [54]. The complications of LND are significant and therefore risks and benefits must be balanced. Strict indications to LND for DTC are mandatory to gain oncologic benefit limiting the comorbidity related to the procedure [49]. Thoracic duct injury, with consequent chyle leak, can follow LND on the left side. The lesion usually occurs at the junction of the left jugular and subclavian vein at the level of the confluence with the thoracic duct. In most cases, the injury occurs to small lymphatic routes and a minimal chylous leak occurs [55]. Chyle leak lesion evident at surgery must be treated, at the same time, by suture ligation with non-absorbable material [56] as we experienced in 2 patients. When a chyle fistula is demonstrated postoperatively a conservative treatment with starving and artificial nutrition or a fat free diet and pressure dressing is suggested [55,57]. This approach is successful in almost all patients. If conservative treatment is not effective a reoperation must be tempted with biological sealant or sclerosing agents application or with attempt to direct suture and ligation as we did in 1 case by a videothoracoscopic approach. Some other conditions can support the decision for an operative approach including chyloma not reducible with compressive dressing, cutaneous inflammation and necrosis, chylothorax. Other alternative methods are reported such as muscle flap with pectoralis major or lymphography with duct catheterization and selective embolization [58e60]. Severe lesion to the spinal accessory nerve following LND, determines a clinical condition characterized by decreased neck and shoulder mobility, anesthesia, numbness, neuropathic pain and dysmorphy for hypotrophy of the upper trapezius and

sternocleidomastoideus muscles [57]. Spinal accessory nerve should be preserved with careful dissection during LND and even traction, potential thermal injury, extensive dissection and skeletonization, devascularisation and ischemia must be limited [61,62] but, although anatomical integrity of the nerve is obtained, this is not sufficient to avoid that a relevant number of patients complains of chronic shoulder's pain. Electromyography can help in detecting different degrees of nerve dysfunction and an intensive program of rehabilitation with specific physiotherapy can improve shoulder function [63] as we experienced in our series. Injury to the cervical sympathetic nerves can result in permanent Horner's syndrome, characterized by ipsilateral ptosis, miosis, and anhidrosis [56]. Cervical and brachial plexus lesion may result in severe functional limitation of the upper limb with limited recovery after corticosteroids therapy and rehabilitation as we observed in 2 cases following RND. Phrenic nerve damage, almost asymptomatic on the right side, on the left results in a unilateral paralysis of the diaphragm with some amount of reduction in lung capacity, shortness of breath, headaches, blue lips and fingers, fatigue, insomnia and overall breathing difficulty. Affected patients usually recover without any medical intervention and corrective surgery is limited to selected cases [64]. 6. Conclusion CND and LND are associated to potential severe complications. Correct indication to lymphadenectomy in thyroid cancer, expertise in the surgical procedure, high volume of treated patients in referral centres and early multidisciplinary management of the surgical morbidity is the key of an acceptable balance between oncologic benefits and surgical morbidity. Ethical approval Not relevant. Funding All Authors have no source of funding. Author contribution Andrea Polistena: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also the drafted and editing of the manuscript. Massimo Monacelli: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Roberta Lucchini: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Roberta Triola: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Claudia Conti: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Stefano Avenia: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Ivan Barillaro: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data. Alessandro Sanguinetti: Participated substantially in conception, design, and execution of the study and in the analysis and

A. Polistena et al. / International Journal of Surgery 21 (2015) 128e134

interpretation of data. Nicola Avenia: Participated substantially in conception, design, and execution of the study and in the analysis and interpretation of data; also partecipated substantially in the drafting and editing of the manuscript.

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List of abbreviations DTC: differentiated thyroid carcinoma TT: total thyroidectomy MTC: medullary thyroid carcinoma ATC: anaplastic thyroid carcinoma CND: central neck dissection LND: lateral neck dissection RND: radical neck dissection ERND: extended radical neck dissection MRND: modified radical neck dissection SND: selective neck dissection RAI: radio active iodine FNAC: fine needle aspiration cytology CT: computed tomography TR: tracheal resection LTR: laryngo-tracheal resection LR: laryngeal resection TCT: tracheostomy PTH: parathormone iCa: ionized calcium HT: emithyroidectomy US: ultrasound