Guidelines from the Brazilian society of surgical oncology regarding indications and technical aspects of neck dissection in papillary, follicular, and medullary thyroid cancers

Farias, Terence; Kowalski, Luiz Paulo; Dias, Fernando; Barreira, Carlos S. Ritta; Vartanian, José Guilherme; Tavares, Marcos Roberto; Vaisman, Fernanda; Momesso, Denise; Oliveira, Alexandre Ferreira; Pinheiro, Rodrigo Nascimento; Ribeiro, Heber Salvador de Castro

doi:10.20945/2359-3997000000607

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Consensus • Arch. Endocrinol. Metab. 67 (4) • 2023 • https://doi.org/10.20945/2359-3997000000607 linkcopy

Guidelines from the Brazilian society of surgical oncology regarding indications and technical aspects of neck dissection in papillary, follicular, and medullary thyroid cancers

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective: The purpose of these guidelines is to provide specific recommendations for the surgical treatment of neck metastases in patients with papillary, follicular, and medullary thyroid carcinomas.

Materials and methods: Recommendations were developed based on research of scientific articles (preferentially meta-analyses) and guidelines issued by international medical specialty societies. The American College of Physicians’ Guideline Grading System was used to determine the levels of evidence and grades of recommendations. The following questions were answered: A) Is elective neck dissection indicated in the treatment of papillary, follicular, and medullary thyroid carcinoma? B) When should central, lateral, and modified radical neck dissection be performed? C) Could molecular tests guide the extent of the neck dissection?

Results/conclusion: Recommendation 1: Elective central neck dissection is not indicated in patients with cN0 well-differentiated thyroid carcinoma or in those with noninvasive T1 and T2 tumors but may be considered in T3-T4 tumors or in the presence of metastases in the lateral neck compartments. Recommendation 2: Elective central neck dissection is recommended in medullary thyroid carcinoma. Recommendation 3: Selective neck dissection of levels II–V should be indicated to treat neck metastases in papillary thyroid cancer, an approach that decreases the risk of recurrence and mortality. Recommendation 4: Compartmental neck dissection is indicated in the treatment of lymph node recurrence after elective or therapeutic neck dissection; “berry node picking” is not recommended. Recommendation 5: There are currently no recommendations regarding the use of molecular tests in guiding the extent of neck dissection in thyroid cancer.

Keywords
Thyroid carcinoma; surgical treatment; papillary thyroid cancer; medullary thyroid cancer; follicular thyroid cancer; lymph node metastasis; elective neck dissection; therapeutic neck dissection; molecular tests; indications; guidelines

Grade of recommendation	Benefits versus risks and burdens	Implications
Strong recommendation	Benefits clearly outweigh risks and burden or vice versa	For patients, most would want the recommended course of action and only a small proportion would not; a person should request discussion if the intervention was not offered. For clinicians, most patients should receive the recommended course of action. For policymakers, the recommendation can be adopted as a policy in most situations.
Weak recommendation	Benefits closely balanced with risks and burden	For patients, most would want the recommended course of action but some would not – a decision may depend on an individual's circumstances. For clinicians, different choices will be appropriate for different patients, and a management decision consistent with a patient's values, preferences, and circumstances should be reached. For policymakers, policymaking will require substantial debate and involvement of many stakeholders.
Insufficient	Balance of benefits and risks cannot be determined	Decisions based on evidence from scientific studies cannot be made.

Grade of recommendation/Quality of evidence	Methodological quality of supporting evidence	Interpretation
Strong recommendation
High-quality evidence	Without important limitations or overwhelming evidence from observational studies	Can apply to most patients in most circumstances without reservation
Moderate-quality evidence	Important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies	Can apply to most patients in most circumstances without reservation
Low-quality evidence	Observational studies or case series	May change when higher quality evidence becomes available
Weak recommendation
High-quality evidence	Without important limitations or overwhelming evidence from observational studies	Best action may differ depending on circumstances
Moderate-quality evidence	Important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies	Best action may differ depending on circumstances
Low-quality evidence	Observational studies or case series	Alternatives may be equally reasonable
Insufficient	Evidence is conflicting, poor quality, or lacking	Insufficient evidence to recommend for or against routinely providing the service

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Sociedade Brasileira de Endocrinologia e Metabologia Rua Botucatu, 572 - Conjuntos 81/83, CEP: 04023-061 , Tel: +55 (11) 5575-0311 / +55 (11) 9 9768-6933 - São Paulo - SP - Brazil
E-mail: aem.editorial.office@endocrino.org.br

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