Nomogram for predicting level V lymph node metastases in papillary thyroid carcinoma with clinically lateral lymph node metastases: A large retrospective cohort study of 1037 patients from FDUSCC

Objective: Extensive lateral neck dissection (LND), especially routine level V dissection, may potentially increase morbidity and have no significant benefit to survival in patients with papillary thyroid carcinoma (PTC). Our study aimed to determine the pattern and risk factors for level V lymph node metastasis (LNM) and to develop an assessment model based on a nomogram for predicting whether level V dissection is necessary. Methods: A total of 1037 PTC patients with clinically suspected LNM (N1b) who underwent total thyroidectomy (TT) with central LND and unilateral LND from 2011 to 2015 were retrospectively retrieved. Univariate and multivariate analyses were performed to examine risk factors associated with level V metastasis. A nomogram for predicting level V metastasis was established and internally validated. Results: The overall rate of level V metastasis was 21.3% (221/1037). Unilateral central LNM (CLNM), level II/III/IV metastasis, extra nodal extension (ENE) and lymph node (LN) size ≥2 cm were found to be independent predictive factors for level V metastasis (P<0.05). In the nomogram, ENE was confirmed as the largest contributor to scores, followed by LN size, unilateral CLNM and level IV/III/II metastasis. The discrimination of the prediction model was 0.738 (95% confidence interval (CI): 0.703-0.773, P<0.001). Conclusions: The rate of level V metastasis in N1b PTC patients was apparently lower than that of other levels. With the help of our nomogram, a modified lateral neck dissection encompassing levels II-V and a strictly postoperative evaluation may be indicated when the patient has a high score.