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C H A P T E R 2 | Oncologic Components of Lymphadenectomy

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widely adopted. 109,110 If microscopic examination is consistent with cervical lymph node metastases, a compartment-oriented ipsilateral or bilateral CCND should be performed. Given the poor predictive value of ultrasonography of the central com- partment and of visual inspection, surgeons should anticipate the need for CCND at the time of initial thyroidectomy for PTC and discuss this potential with the patient; if a surgeon is not experienced with CCND, consideration should be given to referring the patient to a surgeon with a high-volume CCND caseload, because complication rates are lower in high-volume centers. 111–114 2.  MANAGEMENT OF THE RECURRENT LARYNGEAL NERVE WHEN INVOLVED BY EXTRANODAL EXTENSION FROM LYMPH NODE METASTASES Recommendation:  Lymph nodes with extranodal extension that involves the recurrent laryngeal nerve should be resected to avoid leaving gross residual disease while attempting to preserve the integrity of the recurrent laryngeal nerve. Type of Data:  Retrospective case series. Grade of Recommendation:  Strong recommendation, moderate-quality evidence. Rationale Gross extranodal extension of PTC nodal metastasis is uncommon, but it is associ- ated with increased risk of recurrence. 60,64,115–117 Extranodal extension rarely involves the recurrent laryngeal nerve (RLN). Preoperatively, this may be evident in patients presenting with unilateral RLN paralysis. Intraoperative discovery of extranodal ex- tension involving a functional RLN is also a rare occurrence; however, the surgeon should attempt disease resection to preserve the nerve anatomically and functionally without leaving gross disease. Intraoperative RLN monitoring can be especially help- ful in these more difficult situations. Technical Aspects Intraoperative management of central compartment lymph node metastases with ex- tranodal extension involving the RLN should be considered in the context of the functionality of the nerve. In patients with extranodal macroscopic disease and a non- functional nerve, the nerve should be resected to achieve a complete (R0) resection. In patients with extranodal macroscopic disease with a functioning RLN, attempts at preservation of the nerve anatomically and functionally should be made with a shave resection to remove all gross disease, even if this achieves only an R1 resection (microscopically positive margin), because outcomes appear similar between R0 and R1 resections. 118 A shave resection can be performed with sharp dissection of the involved node away from the neural sheath, excising as much of the node as possible while preserving the nerve. Immediate nerve reconstruction in short segment resec- tions with direct neural anastomosis can be considered if a surgeon with experience in microanastomotic techniques is available. 119,120