Cystic appearance of cervical lymph nodes is characteristic of metastatic papillary thyroid carcinoma

Suspicious cervical lymph nodes detected after thyroidectomy for papillary thyroid cancer usually remain stable over years in properly selected patients

CONTEXT

The risk of loco-regional recurrence in papillary thyroid cancer (PTC) patients ranges from 15-30%. However, the clinical significance of small-volume loco-regional recurrence detected by highly sensitive ultrasonography is unclear.

OBJECTIVE

Our objective was to describe the natural history of abnormal cervical lymph nodes (LN) diagnosed after initial treatment.

DESIGN

We conducted a retrospective cohort study.

PATIENTS

166 PTC with patients who had at least one abnormal LN outside the thyroid be on ultrasound and selected for active surveillance were included.

MAIN OUTCOME MEASURE

LN growth during a period of active surveillance was the primary outcome.

RESULTS

Most patients had classical PTC (85%) and an intermediate risk of recurrence (77%). The median LN size at the start of the observation period was 1.3 cm (range, 0.5-2.7 cm) in largest diameter, with all nodes having at least one abnormal sonographic characteristic (70% of patients had LN with at least two abnormal features). In almost all patients, the LN were in the lateral neck, primarily in levels 3 (43%) and 4 (58%). After a median follow-up of 3.5 yr, only 20% (33 of 166) grew at least 3 mm, 9% (15 of 166) grew at least 5 mm, and 14% (23 of 166) resolved. None of the clinical or sonographic features were predictive of LN growth (positive predictive value range = 0.21-0.57). There were no local complications (nerve damage or local invasion) related to the abnormal nodes and no disease-related mortality.

CONCLUSIONS

Suspicious cervical LN in the lateral neck usually remain stable for long periods of time in properly selected PTC patients and can be safely followed with serial ultrasounds.

Differences in sonographic features of papillary thyroid carcinoma between neck lymph node metastatic and nonmetastatic groups

OBJECTIVES

The purpose of this study was to assess the differences in sonographic features of papillary thyroid carcinoma between neck lymph node metastatic and non-metastatic groups.

METHODS

A total of 155 patients with 155 papillary thyroid carcinoma nodules were included and divided into two groups: with neck lymph node metastases (52 cases) and without neck lymph node metastases (103 cases). The size, shape, border, margin, halo, internal architecture, echogenicity, echo homogeneity, calcifications, and contact extent between the nodule border and thyroid capsule were evaluated by gray scale sonography, and color Doppler sonography was applied to assess the vascularization distribution and vascularization degree in the nodules. The peak systolic velocity, pulsatility index, resistive index, peak systolic velocity difference, pulsatility index difference, and resistive index difference were measured by pulsed Doppler sonography in 80 lesions. The differences in the sonographic features of papillary thyroid carcinoma between the metastatic and nonmetastatic groups were investigated.

RESULTS

The differences in the size, percentage of the nodule border that contacted the thyroid capsule, calcifications, vascularization degree, and resistive index difference of the lesions were statistically significant between the metastatic and nonmetastatic groups (P < .05).

CONCLUSIONS

Our findings suggest that a larger size, a greater contact percentage, combined microcalcifications and macrocalcifications, a higher blood supply, and a higher resistive index difference were significantly more common in the metastatic group compared to the nonmetastatic group.

Paediatric thyroid carcinoma in disguise: papillary thyroid carcinoma presenting with thyrotoxicosis and diffuse goiter

Abstract Papillary thyroid carcinoma is rare in children. Its clinical manifestation may deviate from that observed in adult patients. We present a 14-year-old girl with papillary thyroid carcinoma. We then discuss various distinctive sonographic signs that may aid diagnosis, and we discuss differences in clinical features between children and adults [added].

Ultrasound-based diagnostic classification for solid and partially cystic thyroid nodules

BACKGROUND AND PURPOSE

The ability of US to differentiate benign thyroid nodules from malignant ones is still a matter of debate. The aim of this study was to assess the diagnostic efficacy of a US-based classification system for solid and PCTNs through a prospectively designed study.

MATERIALS AND METHODS

We studied 1289 thyroid nodules in 1036 patients who underwent thyroid US, US-FNA, and thyroid surgery. Each thyroid nodule was prospectively classified into 1 of 5 diagnostic categories following real-time US examination: benign, probably benign, borderline, possibly malignant, and malignant. Solid nodules were classified by using all 5 categories, and PCTNs were classified by all except the borderline category. We calculated the diagnostic efficacy of thyroid US by comparing US diagnoses with histopathologic results of surgically resected thyroid nodules.

RESULTS

One thousand fifty-five solid nodules and 234 PCTNs were prospectively classified as benign (n = 435 and 179), probably benign (n = 213 and 25), borderline (n = 94 and 0), possibly malignant (n = 115 and 15), and malignant (n = 198 and 15), respectively. Of these 1289 nodules, 505 were surgically resected and confirmed by pathology (191 benign and 314 malignant nodules); there were 44 resected solid nodules with a borderline category. For solid nodules and PCTNs, the sensitivity, specificity, positive and negative predictive values, and accuracy of US diagnosis were 86.1 and 66.7, 90.0 and 88.9, 94.3 and 75.0, 77.3 and 84.2, and 87.5% and 81.5%, respectively, based on 505 surgical specimens and excluding the 42 solid borderline nodules.

CONCLUSIONS

Our US-based classification system can provide helpful guidance for the management of thyroid nodules.

Differentiation between benign and malignant solid thyroid nodules using an US classification system

Objective

To evaluate the diagnostic accuracy of a new ultrasound (US) classification system for differentiating between benign and malignant solid thyroid nodules.

Materials and Methods

In this study, we enrolled 191 consecutive patients who received real-time US and subsequent US diagnoses for solid thyroid nodules, and underwent US-guided fine-needle aspiration. Each thyroid nodule was prospectively classified into 1 of 5 diagnostic categories by real-time US: "malignant," "suspicious for malignancy," "borderline," "probably benign," and "benign". We evaluated the diagnostic accuracy of thyroid US and the cut-off US criteria by comparing the US diagnoses of thyroid nodules with cytopathologic results.

Results

Of the 191 solid nodules, 103 were subjected to thyroid surgery. US categories for these 191 nodules were malignant (n = 52), suspicious for malignancy (n = 16), borderline (n = 23), probably benign (n = 18), and benign (n = 82). A receiver-operating characteristic curve analysis revealed that the US diagnosis for solid thyroid nodules using the 5-category US classification system was very good. The sensitivity, specificity, positive and negative predictive values, and accuracy of US diagnosis were 86%, 95%, 91%, 92%, and 92%, respectively, when benign, probably benign, and borderline categories were collectively classified as benign (negative).

Conclusion

The diagnostic accuracy of thyroid US for solid thyroid nodules is high when the above-mentioned US classification system is applied.

Imaging surveillance of differentiated thyroid cancer

Intensive imaging surveillance has resulted in the ability to detect small-volume, often clinically occult, residual or recurrent disease. For most patients with differentiated thyroid cancer (DTC), such findings are unlikely to have an impact on disease-specific survival but our ability to predict which patients are at greatest risk and should receive the most aggressive therapies is surpassed by our ability to detect recurrence. Thus, the optimal treatment and surveillance regimens will surely continue to evolve as our ability to predict tumor behavior and aggressiveness improves. This article explains the rationale underlying current surveillance strategies and the utility and implications of imaging findings that are critical for the appropriate care of patients with DTC.

Good practice guide for cervical ultrasound scan and echo-guided techniques in treating differentiated thyroid cancer of vesicular origin

Good practice guide for cervical ultrasound scan and echo-guided techniques in treating differentiated thyroid cancer of vesicular origin. American, European and French Recommendations for the treatment of differentiated vesicular thyroid cancer were recently published. Cervical ultrasound scanning is now considered a key examination in the follow-up of these cancers. This examination is noninvasive, easy to perform and to obtain, is not costly, but remains operator-dependent. To date, there are no recommendations published that assemble all the technical aspects, results, indications and the limits of this examination in the initial medical report and the follow-up of these cancers. In order to standardise the procedure and validate the quality of the examination, a workgroup made up of a panel of experts particularly involved in carrying out ultrasound scans was set up. The aim was to draw up a good practice guide for performing cervical ultrasound scans and echo-guided techniques in treating patients with differentiated thyroid cancer of vesicular origin. The main objectives are to: (a) standardise the procedure and reports, (b) define the criteria for establishing whether lesions identified during a cervical ultrasound scan are malignant or benign, (c) standardise the indications for carrying out cytological tests and an in situ assay of markers, (d) help doctors to select the patients who ought to receive a cervical ultrasound scan and or cytological tests, (e) discuss how frequently the examinations should be carried out depending on the risk of recurrence.

Clinical and imaging assessment of cervical lymph node metastasis in papillary thyroid carcinomas

BACKGROUND

The goals of this study were to analyze clinical factors that affect cervical lymph node metastasis (LNM) in papillary thyroid cancer (PTC), and to evaluate the diagnostic accuracy of preoperative ultrasound (US) and computed tomography (CT) of the neck.

METHODS

The study sample included 589 consecutive patients who underwent surgery for PTC. Patient age and sex, number, size, and location of tumors, lymphovascular invasion, and extrathyroidal extension were evaluated as risk factors for central and lateral LNM.

RESULTS

Increased risk of lymph node metastasis was found for male patients, <45 years old, with tumor size >1 cm, lymphovascular invasion, and extrathyroidal invasion. Cancers located in the upper neck had a higher relative risk of lateral metastasis than cancers located in the lower neck. Sensitivity of both US and CT imaging was higher for lateral (70-80%) than for central (42-47%) LNM. Specificity of US and CT was high (92-97%) for both central and lateral LNM. Using central lymph node size of greater than 5 mm as an indicator of metastasis, preoperative US had 58.3% sensitivity and 71.4% specificity.

CONCLUSIONS

Preoperative US and CT imaging are useful for identifying features that indicate a high risk of LNM and for determining appropriate management of PTC.

Thyroid ultrasonography

BACKGROUND

The recent prevalence of ultrasonography (US) has facilitated the early detection and qualitative evaluation of thyroid nodules. Furthermore, novel technical developments are extending the application range of US for other thyroid diseases.

METHODS

The use of US to differentiate between thyroid carcinoma and benign nodule, between a metastatic lymph node and a reactive node, between thyroid lymphoma and chronic thyroiditis, and between destruction-induced thyrotoxicosis and Graves' disease is introduced.

RESULTS

Classification systems for thyroid nodule have shown high diagnostic accuracy for thyroid carcinomas except follicular carcinoma. US diagnosis of lymph node metastasis showed high specificity but low sensitivity. Patients who were suspected of thyroid lymphoma based on US findings should undergo incisional biopsy or thyroidectomy for diagnosis of the histologic type if fine-needle aspiration biopsy findings suggest lymphoma. Patients should be carefully followed even if they were diagnosed as negative based on cytologic findings. Measurement of thyroid blood flow is helpful for diagnosing destruction-induced thyrotoxicosis, such as painless thyroiditis, by distinguishing the lesion from Graves' disease.

CONCLUSIONS

Ultrasonography is useful for diagnosing various thyroid diseases, including thyroid carcinoma. The remaining issue to be resolved is the diagnosis of follicular carcinoma. Trials using novel techniques to differentiate these lesions are expected.

Appearance of absorbable gelatin compressed sponge on early post-thyroidectomy neck sonography: a mimic of locally recurrent or residual thyroid carcinoma

OBJECTIVE

Absorbable gelatin compressed sponge (Gelfoam; Pfizer Inc, New York, NY), a biodegradable agent prepared from purified porcine skin gelatin, is frequently used for intraoperative hemostasis. Its appearance on sonography may mimic tumor or residual thyroid when placed in the resection bed after thyroidectomy. The purpose of this study was to describe the appearance of Gelfoam on early post-thyroidectomy sonography so that an erroneous diagnosis of locally recurrent or residual tumor can be avoided.

METHODS

We reviewed the early postoperative sonographic examinations of 6 patients after thyroidectomy in which Gelfoam was used for hemostasis. Screening cervical sonography was performed to identify possible lateral compartment adenopathy before completion of thyroidectomy or ablation. Sonographic examinations were performed up to 50 days after resection. Surgical reports confirmed the use of Gelfoam in each patient.

RESULTS

In all cases, uniform elongated echogenicity was shown within the lobectomy bed. In 1 patient, sonographically guided fine-needle aspiration of lobectomy bed echogenicity yielded scant red blood cells, multinucleated giant cells, and macrophages. Follow-up sonography performed in 1 patient 14 months after thyroidectomy confirmed complete Gelfoam absorption.

CONCLUSIONS

Gelfoam may mimic residual or recurrent thyroid carcinoma on early surveillance sonography performed after thyroidectomy. Recognition of its characteristic appearance should prompt a search for an appropriate surgical history and, when placed in the appropriate clinical context, should prevent an errant diagnosis of tumor.

Advances in ultrasound for the diagnosis and management of thyroid cancer

BACKGROUND

Ultrasonography (US) is increasingly being employed by endocrinologists and surgeons in the diagnosis and management of patients with thyroid nodules and thyroid cancer. Recent consensus guidelines from the American Thyroid Association highlight the importance of this modality by recommending that patients with thyroid nodules should undergo further evaluation with cervical US to stratify the risk of malignancy. Likewise, ultrasound is advocated for the preoperative and postoperative diagnosis of cervical lymph node metastases.

SUMMARY

This article will summarize the US characteristics that impart a suspicious appearance on thyroid nodules and cervical lymph nodes as well as those findings that are reassuring. Likewise, the indications for thyroid nodule and lymph node fine-needle aspiration will be reviewed. Finally, this article will briefly discuss adjunctive tools in US such as elastography, percutaneous ethanol ablation, and radiofrequency ablation.

CONCLUSIONS

US may be used to help stratify the risk of malignancy in thyroid nodules and cervical lymph nodes. This tool further aids in the diagnosis of malignancy when used in conjunction with fine-needle aspiration. US plays an important role as both a diagnostic and therapeutic tool in the evaluation of patients with neck masses.

Management of regional metastases in well-differentiated thyroid cancer

Thyroid cancer represents the most common endocrine cancer, and rates have been increasing over the last 3 decades. The treatment of cervical metastases in well differentiated thyroid cancer remains in evolution. Many questions require further resolution. Unlike many other malignancies, most large studies have found that overall survival is not significantly affected by regional metastases. On the other hand, several studies have noted that regional disease may decrease survival in selected patient groups. The greatest effect of lymph node metastases seems to be an increase in recurrence rates. Except for the compartment-oriented removal of clinically positive nodes, few strong recommendations may be made.

[Usefulness of ultrasound in the diagnosis and management of well-differentiated thyroid carcinoma]

Thyroid nodules are found in the vast majority of the population, but only 5 to 10% are malignant. Ultrasonography of the thyroid, by virtue of being a straightforward, non-invasive method presenting strong correlation with macroscopic aspects of the thyroid gland, is being increasingly used to identify nodules that present a higher risk of malignancy. The presence of certain ultrasonographic characteristics such as hypoechogenicity, microcalcifications, irregular contours and central vascularization on Doppler, increase the risk of the lesion being malignant. Conversely, nodules presenting benign ultrasonographic characteristics such as hyperechogenicity and a mixed sponge-like aspect, and a concordant cytology, have a negative predictive value of 96.6%. It is, thus, important to examine all nodular lesions and to identify suspicious lesions that need biopsy, especially in multinodular glands. Ultrasonography is also highly sensitive in the identification of suspicious cervical lymph nodes during the follow-up of patients with thyroid carcinoma, even when PCI is negative and serum thyroglobulin (Tg) levels are undetectable. Tg measurement in the needle wash-out content is recommended as this has proven to be more sensitive than cytology in the diagnosis of cervical metastasis, especially where there is liquid content, and it is not affected by the presence of anti-Tg antibodies.

[Cervical lymph nodes metastases in patients with differentiated thyroid cancer]

Loco-regional recurrences of the differentiated thyroid cancer have been reported to be located in cervical lymph nodes in 60-75% of cases. The widespread use of neck ultrasonography (US) during the follow-up of patients with papillary thyroid carcinoma (PTC) has led to the discovery of small cervical lymph nodes (LN). Although US has a high sensitivity for diagnosing LN, fine needle aspiration biopsy (FNA) and measurement of thyroglobulin in fine needle aspirates (FNA-Tg) have proven to be invaluable tools. The aim of this paper is to review the importance of the early diagnosis of lymph node metastases in the follow-up of patients with differentiated thyroid cancer.

Ultrasound criteria of malignancy for cervical lymph nodes in patients followed up for differentiated thyroid cancer

CONTEXT

Neck ultrasonography (US) has become a keystone in the follow-up of patients with differentiated thyroid cancer.

OBJECTIVE

The aim of this study was to determine specificity and sensitivity of ultrasound criteria of malignancy for cervical lymph nodes (LNs) in patients with differentiated thyroid cancer.

DESIGN

We prospectively studied 19 patients referred to the Institut Gustave Roussy for neck LN dissection. All patients underwent a neck US within 4 d prior to surgery. Only LNs that were unequivocally matched between US and pathology were taken into account for the analysis.

RESULTS

One hundred three LNs were detected on US, 578 LNs were surgically removed, and 56 LNs were analyzed (28 benign and 28 malignant). Sensitivity and specificity were 68 and 75% for the long axis (> or =1 cm), 61 and 96% for the short axis (>5 mm), 46 and 64% for the round shape (long to short axis ratio < 2), 100 and 29% for the loss of fatty hyperechoic hilum, 39 and 18% for hypoechogenicity, 11 and 100% for cystic appearance, 46 and 100% for hyperechoic punctuations, and 86 and 82% for peripheral vascularization.

CONCLUSION

Cystic appearance, hyperechoic punctuations, loss of hilum, and peripheral vascularization can be considered as major ultrasound criteria of LN malignancy. LNs with cystic appearance or hyperechoic punctuations are highly suspicious of malignancy. LNs with a hyperechoic hilum should be considered as benign. Peripheral vascularization has the best sensitivity-specificity compromise. Round shape, hypoechogenicity, and the loss of hilum taken as single criteria are not specific enough to suspect malignancy.

Links T. A sensitive Tg assay or rhTSH stimulated Tg: what's the best in the long-term follow-up of patients with differentiated thyroid carcinoma?

Sensitivity of thyroglobulin (Tg) measurement in the follow-up of differentiated thyroid carcinoma (DTC) can be optimized by using a sensitive Tg assay and rhTSH stimulation. We evaluated the diagnostic yield of a sensitive Tg assay and rhTSH stimulated Tg in the detection of recurrences in the follow-up of DTC. Additionally the value of imaging techniques for the localization of recurrences was evaluated. We included 121 disease free patients in long-term follow-up for DTC (median 10 years, range 1-34). Tg during thyroid hormone suppression therapy (Tg-on) and rhTSH stimulated Tg were measured with a sensitive Tg assay. Patients with rhTSH stimulated Tg > or =1.0 ng/ml underwent imaging with neck ultrasound, FDG-PET and post therapy 131I WBS. Sensitive Tg measurement resulted in 3 patients with Tg-on > or =1.0 ng/ml, recurrence could be localized in 2 of them. RhTSH stimulation resulted in Tg > or =1.0 ng/ml in another 17 of 118 patients. Recurrence could be localized in only 1 additional patient (1 out of 118 patients). Recurrence was localized by neck ultrasound in 1 of 3, by FDG-PET in 2 of 3 and by post therapy 131I WBS in 2 of 3 patients. In the detection of recurrences in DTC, rhTSH stimulation had very limited additional value in comparison to Tg-on measurement with a sensitive Tg assay. We consider this too low to justify rhTSH stimulation in all patients during long-term follow up. Neck ultrasound, FDG-PET and post therapy 131I WBS showed complementary value in localization of disease, but were only positive in a small fracture of all procedures.

US diagnosis of cervical recurrence in patients operated on thyroid cancer: Sonographic features and clinical significance

OBJECTIVE

To describe the sonographic features of cervical recurrence in patient with thyroid cancer and review clinical significance.

MATERIALS AND METHODS

Twenty-two consecutive patients with 24 surgically confirmed recurrences undergoing preoperative ultrasonography (US) and US-guided fine needle aspiration biopsy (FNAB) were enrolled. Retrospective analysis was conducted on the sonographic features of recurrence including size, location, shape, echogenicity, multiplicity, laterality relative to initial primary tumor and presence of characteristic findings; cystic change and microcalcification. In addition, review was made on their clinical data including the time interval between the thyroidectomy and the recurrence, serum thyroglobulin (Tg), anti-thyroglobulin antibody (Tg Ab) and 131 iodine whole body scan (IWBS).

RESULTS

Fifteen of 24 recurrences occurred in internal jugular lymphatic chain and 9 in the postoperative paratracheal region with mostly ipsilaterally to the initial tumor (19/24). Their mean size was 1.0 cm (range: 0.5-2.5 cm) with ovoid (n=18) or lobulated (n=6) shape. They appeared hyperechoic in nine (37.5%), hypoechoic in nine (37.5%), and mixed echoic due to cystic change in six (25.0%). Microcalcification was observed in eight (33.3%) and multiplicity in seven (29.2%). US-guided FNAB established the preoperative diagnosis of recurrence in all. The mean interval between the thyroidectomy and recurrence was 59 months (range: 15-162 months). Suspicion of recurrence was possible in 8 with Tg of 2 ng/ml or greater (8/24) during thyroxine (T4) therapy and 6 (6/8) after T4 withdrawal. All of the 8 recurrences were negative on 131 IWBS. In two patients with Tg less than 2 ng/ml after T4 withdrawal, elevated Tg Ab was observed.

CONCLUSION

US and US-guided FNAB are valuable postoperative follow up modalities of thyroid cancer due to their convenience, early detection and precise localization. Therefore, it's essential to get familiar with sonographic findings of cervical recurrence.

Emprego da ultra-sonografia cervical no seguimento de pacientes com carcinoma diferenciado de tireóide

A ultra-sonografia (US) cervical é recomendada na avaliação de todos pacientes com carcinoma de tireóide após a terapia inicial, pois mesmo indivíduos de baixo risco com tireoglobulina (Tg) estimulada indetectável podem apresentar metástases cervicais. Para estas metástases, a US é o método mais sensível, superior à pesquisa de corpo inteiro (PCI) com 131I. Linfonodos cervicais com diâmetro > 5 mm com calcificações finas e/ou degeneração cística quase sempre são de etiologia maligna. Na ausência destas características, o formato arredondado e a ausência do hilo ecogênico são achados "suspeitos", enquanto linfonodos alongados e com hilo ecogênico visível são considerados benignos. A avaliação do fluxo, através do doppler, auxilia no diagnóstico diferencial, usualmente revelando hipervascularização periférica ou mista nos casos malignos. Na presença de linfonodos "suspeitos" na US, a avaliação citológica do material obtido através da punção aspirativa por agulha fina (PAAF) e a dosagem da Tg, obtida do lavado da agulha, são testes úteis e complementares para definir a etiologia, com elevada sensibilidade quando combinados e especificidade de 100%. A US também é útil antes da tiroidectomia, auxiliando e até, em alguns casos, modificando o planejamento cirúrgico; e antes da ablação, para mensuração dos remanescentes tireoidianos e pesquisa de metástases linfonodais persistentes. Outra aplicação desse método de imagem é guiar a injeção de etanol (escleroterapia) ou a introdução de eletrodos para ablação com radiofreqüência em casos selecionados de metástases linfonodais isoladas, como alternativa às terapias convencionais.

US Features of Thyroid Malignancy: Pearls and Pitfalls

Thyroid nodules are common and occur in up to 50% of the adult population; however, less than 7% of thyroid nodules are malignant. High-resolution ultrasonography (US) is commonly used to evaluate the thyroid gland, but US is frequently misperceived as unhelpful for identifying features that distinguish benign from malignant nodules. Microcalcifications are one of the most specific US findings of a thyroid malignancy. Other useful US features include a marked hypoechogenicity, irregular margins, and the absence of a hypoechoic halo around the nodule. Lymphadenopathy and local invasion of adjacent structures are highly specific features of thyroid malignancy but are less commonly seen. The number, size, and interval growth of nodules are nonspecific characteristics. Suspicious US features may be useful for selecting patients for fine-needle aspiration biopsy when incidental nodules are discovered and when multiple nodules are present. Common interpretative pitfalls that may lead to failure to recognize a malignancy include mistaking cystic or calcified nodal metastases for nodules in a multinodular thyroid, mistaking diffusely infiltrative thyroid carcinomas and multifocal carcinomas for benign disease, and failing to recognize microcalcifications in papillary thyroid cancer.

Ultrasonography of Abnormal Neck Lymph Nodes

Ultrasonography is a useful imaging modality for assessing cervical lymphadenopathy in patients with head and neck carcinomas. Features of cervical lymph nodes using gray-scale and color and power Doppler ultrasonography can help to distinguish normal and reactive lymph nodes from potentially metastatic lymph nodes. The distinguishing features that separate abnormal from normal cervical lymph nodes include peripheral vascularity, shape, overall lymph node echogenicity, absence of hilus, presence of nodal microcalcifications, and cystic changes. Often, a combination of these features is needed to assign a cervical lymph node as being abnormal.

Ultrasonographic differentiation of benign from malignant neck lymphadenopathy in thyroid cancer

OBJECTIVE

The aim of this study was to determine whether ultrasonography itself was able to distinguish benign from malignant lymphadenopathy in patients with thyroid cancer.

METHODS

We evaluated lymph nodes in a group of patients with thyroid cancer. Nodes were detected and measured by ultrasonography, and their shape, echogenicity, size, and location were noted. Ultrasonographically guided fine-needle aspiration biopsy (FNAB) was performed, and smears were analyzed cytologically.

RESULTS

Ultrasonographically guided FNAB was performed in 578 neck nodes in a group of 631 patients with thyroid cancer. In most cases, metastases had a round shape and various echo structures, with a predomination of hypoechoic nodes without a hilum. There were statistical differences in size between metastatic and benign nodes in terms of maximum diameter, minimum diameter, and volume. Among these, minimum diameter and the shape of the nodes seemed to be the most reliable in suggesting malignancy. A round shape with a longitudinal/transverse ratio of less than 2 of hypoechoic nodes indicated the presence of metastases, and we then performed FNAB. The absence of an echogenic hilum and the presence of cystic portions and calcifications were significantly greater in malignancies than in benign lesions (P<.001). In most cases, metastatic nodules were situated in the lower third of the neck. Reactively enlarged nodes occurred more frequently in the upper part of the neck.

CONCLUSIONS

Ultrasonography itself cannot distinguish benign from malignant lesions, but an echographic appearance suggests malignancy and helps in the selection of the node to aspirate with ultrasonographically guided FNAB, which is crucial for a final diagnosis.

Exploration des nodules thyroïdiens : rôle de l'échographie préopératoire

Ultrasonography is the evidence-based diagnostic method for thyroid nodules. The account has to specify the technical used, and has to exactly describe the echogenicity of the thyroid, the feature of the nodules (number, size, echostructure, echogenicity, edges), and the presence or absence of lymph nodes. The malignancy criteria of thyroid nodules are: (1) hypoechoic solid nodule, (2) presence of internal microcalicifications, (3) ill-defined-irregular edges or absence or breaking of the peripheral halo. The nodes' criteria of malignancy are: (1) diameter of 1 cm or more, (2) clear hypoechoic pattern or non-homogeneous pattern, with alternating hypoechoic and hyperechoic areas, (3) cystic appearance (4) presence of internal calcifications (5) rounded shape with increased anteroposterior diameter, (6) long/short diameter ratio higher than 0.7, (7) absence of hilum. When these criteria are present, a histological diagnosis has to be performed. They could change the operative procedure in the patients.

Papillary thyroid cancer

In summary, PTC is common, although it rarely results in disease-specific mortality. It is being diagnosed increasingly in the subclinical phase as a result of enhanced ultrasound imaging and more aggressive surveillance of smaller thyroid nodules. US-guided FNA is the "gold-standard" for diagnosis. Although controversy continues about the appropriate surgical management of PTC, total thyroidectomy is usually indicated given the frequent multicentricity and metastases of the disease, which in turn, necessitates adjuvant RAI and careful surveillance. An enhanced prognostic classification could better guide initial surgical therapy, standardize surveillance, and reduce the risk of recurrent and persistent disease. Research efforts should focus on the genetic and molecular underpinnings of PTC, as these would facilitate the identification of additional prognostic factors and potential targets for novel therapies.

US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls

Ultrasonography (US) is useful for differential diagnosis of diseases of the salivary glands. In acute inflammation, salivary glands are enlarged and hypoechoic with increased blood flow; they may contain multiple small, oval, hypoechoic areas. In chronic inflammation, salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. Sialosis appears as enlarged hyperechoic glands without focal lesions or increased blood flow. The US features of advanced Sjögren syndrome include inhomogeneous salivary glands with scattered small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow. Pleomorphic adenomas are usually hypoechoic, well-defined, lobulated lesions with posterior acoustic enhancement that may contain calcifications; Warthin tumors are usually oval, hypoechoic, well-defined lesions that often contain anechoic areas and are often hypervascularized. Malignant neoplasms of the salivary glands may have irregular shapes, irregular borders, blurred margins, and a hypoechoic inhomogeneous structure or may have a benign appearance. Salivary gland cysts have well-defined margins, anechoic contents, posterior acoustic enhancement, and no internal blood flow. However, US appearances of some diseases may overlap, thus producing diagnostic pitfalls.

Detection and surgical treatment of cervical lymph nodes in differentiated thyroid cancer

There is considerable controversy regarding the treatment of patients with cervical metastases from differentiated thyroid cancer. Most have papillary carcinoma and the main areas of contention relate to methods of assessment and staging, surgical management and mode of follow up. there is little evidence to support elective anatomical imaging with CT or MRI in those patients with suspected or proven malignancy at the primary site as indicated by fine needle aspiration cytology (FNAC) but who have no clinical evidence of nodal disease. The role of routine ultrasound (US) in the pre-operative assessment of suspected or known malignancy is developing but is largely unproven. When it is performed, high risk areas for metastatic neck disease (levels II-V) should be assessed. Suspicious nodes on US should be further evaluated by FNAC. Suspected or proven neck disease may be further assessed pre-operatively with CT or MRI and then treated surgically. Disease in the central compartment requires a total thyroidectomy and level VI central compartment neck dissection. Suspected or proven lateral compartment cancer should be treated by selective neck dissection (at least levels III, IV, and V) below the accessory nerve. There is no role for 'Berry picking' and clinically node negative high risk patients should have an elective central compartment level VI neck dissection. Sentinel node biopsy lays no role and neither does elective lateral compartment surgery in patients with no clinical or radiological evidence of disease. For follow up, US represents the most sensitive means of detecting neck recurrences and in the presence of an elevated serum thyroglobulin, imaging may also include whole body iodine-131 scanning and anatomical imaging with CT or MRI. The role of PET remains controversial but is likely to develop further as the technique becomes more widely available. In the future, the concentration of patients with this disease in large center can only improve the way we treat differentiated thyroid cancer.

[Lymph node dissection in non-medullary differentiated thyroid carcinoma]

Papillary and follicular thyroid carcinomas are the most common form of endocrine carcinomas. Lymph node involvement seems to be a low risk factor for death, but it increases the risk for loco-regional recurrences and distant metastasis. The limits and the key points of the cervical lymph node dissection are described. The sentinel lymph node is used to rarely, so it could limit the lymph dissection. Node-picking has to be avoided. Central lymph node resection is recommended for high-risk patients, as male, patients more than 45 or less than 21 years old, papillary carcinomas greater than 1 cm or follicular carcinoma more than 2 cm in diameter. Lateral lymph node resection is performed when the lymph nodes of the central compartment are involved, more than 3 cm in diameter, and bulked. Prophylactic lymphadenectomy is useless. When thyroid carcinoma is known postoperatively, re-operation depends of the cervical mass and of the results of the radioactive iodine treatment.

Diagnostic accuracy of high-resolution neck ultrasonography in the follow-up of differentiated thyroid cancer: a prospective study

OBJECTIVE

To conduct a prospective study of the diagnostic value of features of cervical lymph nodes (large size, central location, abnormal shape, cystic changes, calcifications, and loss of echogenic hilum), assessed by neck ultrasonography (US), in patients scheduled for surgical treatment of persistent or recurrent differentiated thyroid cancer.

METHODS

We studied 152 US abnormalities in 42 patients (median age, 38.5 years) who had undergone one or more neck operations, with or without radioiodine therapy, but continued to have persistent or recurrent disease, which was confirmed by fine-needle aspiration. Another surgical procedure was planned for these patients. On the day of operation, patients underwent a detailed US neck examination by an experienced radiologist. US abnormalities were plotted on a standard diagram of the neck and given specific numbers to help track them during surgical intervention and histopathologic examinations. The US features were compared with the final histopathologic diagnosis.

RESULTS

Of 152 US abnormalities, 127 involved cervical lymph nodes and 25 involved other types of tissue. In univariate analysis, size, absent echogenic hilum, cystic changes, calcifications, and central location (medial to the sternomastoid muscle) of cervical lymph nodes were significantly associated with the presence of metastatic involvement. In multivariate analysis, only central location (odds ratio, 4.07; 95% confidence interval [CI], 1.64 to 10.10) and size (odds ratio, 5.14; 95% CI, 1.64 to 16.06) remained significant. The receiver operating characteristic curve for the size of lymph nodes showed a large area under the curve of 0.77 (95% CI, 0.68 to 0.85), and a size of 7.5 mm showed the highest sensitivity and specificity.

CONCLUSION

Size and central location of cervical lymph nodes assessed by US during follow-up of patients with differentiated thyroid cancer were the most important predictors of presence of metastatic disease.

Sonography of Thyroid Nodules

This article describes an approach to some of the commonly encountered, "classic pattern," appearances of both benign and malignant thyroid nodules that are seen in day-to-day practice. These appearances include specific nodules that commonly need fine needle aspiration (FNA)/biopsy, and other nodules that do not usually need FNA/biopsy.

Diagnostic imaging of the thyroid and adrenal glands in childhood

This article reviews the clinical utility of modern imaging techniques, particularly ultrasound (US), CT, and MRI in children with disorders of the thyroid and adrenal glands. Radionuclide scanning is the modality of choice in making the anatomic diagnosis in neonates with congenital hypothyroidism, while US is most useful in defining nodular thyroid disease. CT and MRI of the thyroid tend to be limited to defining the extent of thyroid carcinoma. Adrenal US is an essential step in the differential diagnosis of ambiguous genitalia or salt-losing crises in the newborn, while CT and MRI are more useful in defining the anatomy of the adrenals in older children with tumors or diffuse hyperplasia of the glands.

Detection of recurrent papillary thyroid carcinoma by thyroglobulin assessment in the needle washout after fine-needle aspiration of suspicious lymph nodes

To evaluate an efficient method of surveillance of low-risk patients with thyroid cancer, ultrasound was performed on 74 postoperative patients being followed for stage I and II papillary carcinoma. All patients were clinically free of cancer 1-43 years after a total thyroidectomy, and were screened with ultrasound and thyroglobulin (Tg) measurement while taking thyroid hormone suppression. Ultrasound revealed findings suspicious of recurrent disease in the lymph nodes of the neck in 21 patients. An ultrasound-guided fine-needle aspiration (FNA) to obtain material for cytology and Tg analysis was done on these 21 patients, 7 of whom tested positive for Tg in their needle washout. Only 3 of the 7 had detectable Tg in their serum, and only 5 of the 7 had positive cytology. Ultrasound (with FNA-Tg analysis of needle washout of suspicious lymph nodes) is proposed as an effective and efficient method of surveillance in these low-risk patients. Presence of Tg in the needle washout proved to be more sensitive than cytology in diagnosing cancer in the lymph nodes and was not affected by positive anti-Tg antibodies in the serum.

Increased through-transmission in abdominal tuberculous lymphadenitis

OBJECTIVE

To describe 2 cases of abdominal tuberculosis in which sonographic evaluation of mesenteric lymphadenopathy showed increased through-transmission suggestive of caseating necrosis.

METHODS

Two patients with abdominal pain and other symptoms (including fever, diarrhea, and weight loss) underwent abdominal sonography with a 6-MHz curved array transducer. One patient also underwent sonographically guided fine-needle aspiration of multiple lymph nodes, and the other underwent computed tomography, colonoscopy, and colon biopsy.

RESULTS

In both patients, sonography showed multiple rounded hypoechoic lesions with increased ultrasound through-transmission suggestive of necrotic lymphadenopathy. No color flow was shown. In 1 case, the posterior acoustic enhancement was accentuated in the harmonic imaging mode. In the other case, the lesions shown on sonography corresponded to computed tomographic findings of low-density lymph nodes. Results of fine-needle aspiration and colon biopsy were positive for tuberculosis.

CONCLUSIONS

Posterior acoustic enhancement in abdominal lymphadenopathy can suggest the diagnosis of tuberculous lymphadenitis. Detection of this finding is facilitated by scanning in the harmonic mode. Necrotic nodes will lack color flow and can be distinguished from lymphadenopathy of other causes. Sonography can also be used for fine-needle aspiration of necrotic nodes to yield a definitive diagnosis.

Parapharyngeal lymph node metastasis: An unusual presentation of papillary thyroid carcinoma

BACKGROUND

Parapharyngeal space nodal metastases are usually secondary to malignancies of the pharynx and sinonasal tract, although localization of lymphomas is also possible. Parapharyngeal metastases arising from thyroid papillary carcinoma are instead an exceedingly rare event, with only 10 cases reported up to now in the literature.

METHODS

We describe two cases of parapharyngeal metastasis from thyroid papillary carcinoma in a man and a woman, aged 40 and 52 years, respectively.

RESULTS

Both patients had a lesion that clinically appeared to be located in the parapharyngeal space; they underwent CT and MRI, which detected a cystic mass in the poststyloid compartment. In the first patient, fine-needle aspiration cytology failed in identifying the histologic nature of the lesion, which was excised through a transcervical approach. A diagnosis of metastatic thyroid papillary carcinoma was rendered and therefore the patient underwent total thyroidectomy. In the second patient, a total thyroidectomy, previously scheduled for multinodular goiter, was performed along with the removal of the parapharyngeal mass. Definitive histologic findings revealed that the two parapharyngeal masses were cystic metastases from a thyroid papillary carcinoma. Both patients received postoperative 131I treatment. Twenty-four months after surgery, the first patient is free of disease, whereas the second one has clear signs of abnormal 131I uptake in the lungs.

CONCLUSIONS

The differential diagnosis of a parapharyngeal poststyloid mass should also include metastasis from thyroid papillary carcinoma. When the lesion displays a cystic appearance on imaging, it is advisable to rule out a thyroid primary by ultrasonographic examination. The occurrence of a metastasis in such unusual site, even though rarely reported, does not seem to significantly affect the prognosis of the disease.

Diagnostic utility of thyroglobulin detection in fine-needle aspiration of cervical cystic metastatic lymph nodes from papillary thyroid cancer with negative cytology

Cystic changes in metastatic cervical lymph nodes (CLN) from papillary thyroid cancer (PTC) may be a diagnostic pitfall in fine-needle aspiration biopsy (FNAB) cytology. We investigated in a series of CLN metastases from thyroid cancers (TC), including cystic PTC, and from a wide spectrum of extrathyroidal malignancies, the diagnostic role for metastatic TC of the rapid detection of thyroglobulin in eluates from FNAB (FNAB-Tg) of CLN. The study was carried out in a group of 79 subjects (22/57 M/F; median age, 56 years; range, 20-86 years) with enlarged CLN and thyroid nodules (TN), examined for potential metastatic TC, and harboring a large spectrum of incidentally diagnosed extrathyroidal malignancies (n = 24, mostly represented by lymphomas, lung, and breast cancers), CLN metastases from thyroid cancers (n = 28, including 6 cystic metastatic PTC), 6 specific lymphadenitis and 21 reactive lymphadenitis mostly detected (n = 16) during follow-up of patients with previously ablated TC. Markedly high FNAB thyroglobulin (Tg) values were found in all metastatic CLN TC. Two of the six cases with cystic metastatic CLN PTC were diagnosed by FNAB-Tg but not by cytology. In conclusion, FNAB-Tg has been confirmed as an easy modality and fast procedure to diagnose CLN metastasis from TC and high FNAB-Tg values with nondiagnostic cystic cytology strongly suggest cystic metastatic PTC.