Clinically Significant Central Lymph Node Metastasis is Not Common in Patients with Clinically N0 Papillary Thyroid Carcinoma on Both Ultrasonography and CT

<b><i>Background:</i></b> The necessity of prophylactic central lymph node dissection (p-CLND) in patients with clinically node-negative papillary thyroid carcinoma (PTC) is unclear. The present study evaluated the central lymph node (LN) metastases status in patients with clinically node-negative PTC on both preoperative thyroid ultrasonography (USG) and neck computed tomography (CT) who underwent p-CLND. <b><i>Methods:</i></b> This retrospective cohort study included 3002 clinically node-negative patients diagnosed with PTC who had undergone thyroidectomy with p-CLND from January 2000 to September 2022. Clinically node-negative was defined as the absence of suspicious metastatic LNs on preoperative USG and neck CT. Low-risk central LN metastases were defined as LN metastases <2 mm in size with metastatic LNs ≤5. The median follow-up duration was 4.52 (interquartile range [IQR]: 1.6-7.5) years. <b><i>Results:</i></b> Of the 3002 patients, 1194 (39.7%) had central LN metastases, whereas 1808 (60.3%) did not. The 1194 patients with central LN metastases included 507 (16.9%) with intermediate-risk metastases and 610 (20.3%) with low-risk LN metastases, with a total of 2428 (80.5%) patients having low-risk LN metastases or no central LN metastases. High-risk metastases were observed in only 77 (2.5%) patients. Of the 584 patients with intermediate-/high-risk metastases, 577 (98.8%) had central LN metastases <1 cm in size, whereas only 7 (1.2%) had central LN metastases ≥1 cm. The disease recurrence rates for the no LN metastases, low-risk LN metastases, and intermediate-/high-risk LN metastases groups were 0.4%, 1.1%, and 1.9%, respectively (<i>p</i> = 0.012). Factors independently associated with intermediate-/high-risk central LN metastases included age <55 years (odds ratio [OR] = 2.29), male sex (OR = 2.33), tumor size >1 cm on USG (OR = 1.94), and the presence of extrathyroidal extension on CT scans (OR = 1.53), with <i>p</i> < 0.001 for all factors. <b><i>Conclusions:</i></b> Most LNs confirmed after CLND in cN0 PTC patients assessed by USG and CT were either metastasis-free or classified as low-risk metastatic LNs. Furthermore, the majority of metastatic LNs were small in size, typically measuring <1 cm. p-CLND may be unnecessary if preoperative thyroid USG and neck CT show no evidence of central neck LN metastaes.