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

Which Ultrasound Characteristics Predict Lymphatic Spread of Papillary Thyroid Cancer?

INTRODUCTION

The 2015 American Thyroid Association guidelines recommend lymph node mapping US in patients with definitive cytological evidence of thyroid cancer. Suspicious lymph node features on imaging including enlarged size (>1 cm in any dimension), architectural distortion, loss of fatty hilum, and microcalcifications often prompt evaluation with fine needle aspiration. There is no universally agreed upon model for determining which ultrasound characteristics most strongly correlate with metastatic disease.

METHODS

A retrospective review of patients with confirmed papillary thyroid cancer (PTC) undergoing lymph node mapping ultrasound from 2013 to 2019 was performed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated for each individual ultrasound characteristic as well as for characteristic combinations.

RESULTS

Data from 119 lymph nodes were included. Malignant lymph nodes were more likely to be enlarged (71% versus 61%, P < 0.001) and to have each individual suspicious feature. Loss of fatty hilum had the highest sensitivity (89%) but was not specific (19%) for metastatic disease. Architectural distortion was found to have the highest specificity (87%). A combination of the four features was found to have higher specificity (97%) and PPV (88%) than any individual feature or combination of two/three features.

CONCLUSIONS

A combination of four sonographic features correlates with metastatic PTC to lymph nodes and has the highest specificity and PPV for malignancy. A risk stratification model based on these features may lead to better classification of ultrasound findings in PTC patients with concern for nodal metastases.

Submandibular solid-cystic mass as the first and sole manifestation of occult thyroid papillary carcinoma: A case report

BACKGROUND

Occult thyroid papillary carcinoma (OTPC) is typically characterized by initial presentation with cervical lymph node metastasis and can be detected through ultrasound. However, the initial and sole manifestation was a submandibular solid-cystic mass. High-frequency ultrasound, enhanced multislice computed tomography (CT) scan, and thyroid function tests revealed no abnormalities, which is relatively uncommon.

CASE SUMMARY

A 24-year-old Chinese female, who studied at a university in Shandong Province, presented to the clinic in June 2019 with a right submandibular mass that she had noticed 2 mo earlier. Clinical examination revealed a 2-cm, nontender, movable solid-cystic mass in the submandibular region, with no palpable thyroid mass observed. Ultrasonography revealed a 2.0 cm × 1.1 cm solid-cystic mass in the right submandibular region, and the thyroid gland showed no abnormalities. CT scan and 131I whole body follow-up scan showed that there were no abnormalities in the thyroid. However, cytology and pathology showed papillary tumor cell clusters, consistent with papillary thyroid carcinoma. Thus, we performed total thyroidectomy and right neck lymph node dissection. The pathology revealed the thyroid was detected as classical thyroid micropapillary carcinoma, and lymph nodes of levels VI central and levels II, III, IV, V on the right side showed no tumor metastasis. The patient was followed up for 2 years without significant recurrence.

CONCLUSION

The presentation of a submandibular solid-cystic mass as the primary and solitary indication of OTPC is relatively uncommon. Fine needle aspiration is advised for evaluating neck masses.

Cut-off Value for Thyroglobulin Washout Concentration in the Detection of Cervical Lymph Node Metastases in Patients after Thyroidectomy Due to Differentiated Thyroid Cancer

The aim of this study was to establish the cut-off value for the thyroglobulin (Tg) concentration in washout fluid from fine needle aspiration biopsy (FNA-Tg) in the detection of cervical lymph node metastases of differentiated thyroid cancer (DTC). We evaluated the validity and clinical utility of fine needle aspiration biopsy cytology (FNAB-C), FNA-Tg, and the combined method in detecting DTC recurrences. The study included 82 patients after the total thyroidectomy and elective and, in some cases, also selective cervical lymphadenectomy. The majority of patients also underwent subsequent 131I ablative therapy. The patients presented with 1-6 enlarged and/or ultrasonographically suspicious cervical lymph nodes. One to four aspirates of each lymph node were taken, with a total of 297 samples. An FNA-Tg of 4.34 ng/mL was established as the cut-off value for detecting cervical lymph node DTC metastases for the IRMA Brahms DYNO test, Tg-S. FNAB-C is highly specific (91-99%) but not sensitive enough (53-69%) to be used as a standalone method in the detection of cervical lymph node metastases. FNA-Tg is more sensitive (91%), but caution should be taken when selecting patients for surgery with an FNA-Tg higher than the established cut-off value but lower than the serum Tg concentration. To select patients for lymphadenectomy, we recommend using the combined method (FNAB-C and FNA-Tg) with a sensitivity of 96% and specificity of up to 97%. More than one sample should be taken with each fine needle aspiration biopsy (FNAB) to obtain a representative set of samples.

Sonographic Diagnosis of Cervical Lymph Node Metastasis in Patients with Thyroid Cancer and Comparison of European and Korean Guidelines for Stratifying the Risk of Malignant Lymph Node

OBJECTIVE

To evaluate the ultrasonography (US) features for diagnosing metastasis in cervical lymph nodes (LNs) in patients with thyroid cancer and compare the US classification of risk of LN metastasis between European and Korean guidelines.

MATERIALS AND METHODS

From January 2014 to December 2018, US-guided fine-needle aspiration was performed on 836 LNs from 714 patients for the preoperative nodal staging of thyroid cancer. The US features of LNs were retrospectively reviewed for the following features: size, presence of hilum, margin, orientation, cystic change, punctate echogenic foci (PEF), large echogenic foci, eccentric cortical thickening, abnormal vascularity, and cortical hyperechogenicity. A multiple logistic regression analysis was performed to identify the independent US features for the diagnosis of metastatic LNs. The diagnostic performance of independent US features was subsequently evaluated. LNs were categorized according to the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and European Thyroid Association (ETA) guidelines, and the correlation between the two sets of classifications was assessed.

RESULTS

Absence of the hilum, presence of cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity were independent US features of metastatic LNs. Cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity showed high specificity (86.8%-99.6%). The absence of the hilum had the highest sensitivity yet low specificity (66.4%). When LNs were classified according to the ETA guidelines and K-TIRADS, they yielded similar categorizations of malignancy risks and were strongly correlated (Spearman coefficient, 0.9766 [95% confidence interval, 0.973-0.979]). According to the ETA guidelines, 9.8% (82/836) of LNs were classified as "not specified."

CONCLUSION

Absence of hilum, cystic changes, PEF, abnormal vascularity, and cortical hyperechogenicity were independent US features suggestive of metastatic LNs in thyroid cancer. Both K-TIRADS and the ETA guidelines provided similar risk stratification for metastatic LNs with a high correlation; however, the ETA guidelines failed to classify 9.8% of LNs into a specific risk stratum. These results may provide a basis for revising LN classification in future guidelines.

Radioactive iodine therapy: multiple faces of the same polyhedron

The incidence of differentiated thyroid carcinoma (DTC) has increased in recent decades with early stage, low risk papillary thyroid cancer (PTC) being detected and diagnosed. As a result, the psychological, financial, and clinical ramifications of overdiagnosis and excessively aggressive therapy are being increasingly recognized with many authorities calling for a re-evaluation of the traditional "one size fits all" management approaches. To address these critical issues, most thyroid cancer guidelines endorse a more risk adapted management strategy where the intensity of therapy and follow up is matched to the anticipated risk of recurrence and death from DTC for each patient. This "less is more" strategy provides for a minimalistic management approach for properly selected patients with low-risk DTC. This has re-kindled the long-standing debate regarding the routine use of radioactive iodine therapy (RIT) in DTC. Although recent guidelines have moved toward a more selective use of RIT, particular in patients with low-intermediate risk DTC, the proper selection of patients, the expected benefit, and the potential risks continue to be a source of ongoing controversy and debate. In this manuscript, we will review the wide range of clinical, imaging, medical team, and patient factors that must be considered when evaluating individual patients for RIT. Through a review of the current literature evaluating the potential benefits and risks of RIT, we will present a risk adapted approach to proper patient selection for RIT which emphasizes peri-operative risk stratification as the primary tool that clinicians should use to guide initial RIT management recommendations.

Diagnostic strategy of fine needle aspiration cytology of cystic cervical lymph node metastasis from papillary thyroid carcinoma

BACKGROUND

Cystic cervical lymph node metastasis from papillary thyroid carcinoma (CLMPTC) initially presents as cervical cystic lesions, which are often underdiagnosed as other cystic cervical lesions. There is no comprehensive diagnostic strategy of fine needle aspiration (FNA) cytology for CLMPTC.

METHODS

The clinical and FNA cytomorphology data of 87 patients with CLMPTC were analyzed. Thyroglobulin (TG) immunostaining was performed in 40 cases; BRAF V600E mutation was evaluated in 42 cases; the thyroglobulin (Tg) levels of aspiration fluids were assessed in 46 cases. Correspondingly, the data of 42 cases with solid cervical lymph node metastasis from papillary thyroid carcinoma (SLMPTC) and 32 cases with other cystic cervical lesions were collected as controls.

RESULTS

Compared with SLMPTC, CLMPTC has less classical PTC cytomorphology characteristics-for example, nuclear crowding/overlapping, nuclear irregular contours, etc. (p < .05). Additionally, micropapillary architecture and histiocyte-like tumor cells were more often observed in CLMPTC than in SLMPTC (p < .01). The positive rate of TG immunocytochemistry in CLMPTC was 100% (40/40). The positive rate of BRAF V600E mutation in CLMPTC was 81.0% (34/42), which was higher than that in SLMPTC (64.3%; 27/42) (p = .087). The Tg levels in aspiration fluids were significantly higher in CLMPTC (all>500 μg/L) than in other cervical cystic lesions (range: 2.9 μg/L to 40.1 μg/L) (p < .01).

CONCLUSION

To reduce underdiagnoses of CLMPTC, a reasonable diagnostic strategy, as summarized in this study is needed: according to the number of tumor cells, choosing immunocytochemistry (TG) and/or thyroglobulin in fine needle aspirates testing as auxiliary diagnostic measures.

Fine-needle aspiration cytology of metastatic carcinomas with papillary architecture: a systemic assessment of clinical, cytologic and immunohistochemical parameters

BACKGROUND

Papillary structures are frequently encountered in metastatic carcinomas from various organs and tumors of different histotypes. This study aims to investigate the predictive value of fine-needle aspiration cytology (FNAC), immunohistochemistry (IHC) and clinical parameters in assessment of primary sites of metastatic carcinomas with papillary architecture.

METHODS

FNAC of metastatic carcinomas with papillary architecture were evaluated for overall cellularity, epithelial cohesion, background features, architecture of papillae, cytology and IHC. The corresponding clinical information were also reviewed.

RESULTS

Totally 130 cases were included. The most common primaries were thyroid (38.5%), lung (30.8%) and gynecological organs (22.3%) with the remainders being pancreaticobiliary, urothelial, colorectal, and esophageal. Age (p=.039), biopsy site (p<.001) and laterality (p=.006) correlated with primary site. Papillary structures were confirmed on biopsy/excision of most cases (n=85/87, 97.7%). Thyroid primaries demonstrated broad papillary stalks, thin lining epithelium, fewer epithelial polymorphs, and presence of background giant cells and histiocytes (p=.021-<.001). Low-grade cytologic features, nuclear grooves and inclusions (p<.001) were seen in thyroid primaries. High-grade features (p<.001-0.49), multinucleated tumor cells, apoptotic bodies and mitoses (p<.001-0.49) were more common in lung/gynecological primaries. Multivariate analysis identified nuclear/cytoplasmic ratio, chromatin character, presence of nuclear groove and mitosis as independent features (p=0.001-.024). TTF1/TGB/PAX8 panel demonstrated good agreement with cytologic assessment and primary site.

CONCLUSION

Papillary structures and cytologic features are reproducible in FNACs of metastases and corresponding primaries. Cytologic features, IHC and clinical information are invaluable in determining the primary site.

Papillary Thyroid Cancer Prognosis: An Evolving Field

Simple Summary

Over the last couple of decades, the prognostic stratification systems of differentiated thyroid cancer (DTC) patients have been revised several times in an attempt to achieve a tailored clinical management reflecting the single patients’ needs. Such revisions are likely to continue in the near future, since the prognostic value of a number of promising clinicopathological features and new molecular biomarkers are being evaluated. Here, we will review the current staging systems of thyroid cancer patients and discuss the most relevant clinicopathological parameters and new molecular markers that are potentially capable of refining the prognosis.

Abstract

Over the last few years, a great advance has been made in the comprehension of the molecular pathogenesis underlying thyroid cancer progression, particularly for the papillary thyroid cancer (PTC), which represents the most common thyroid malignancy. Putative cancer driver mutations have been identified in more than 98% of PTC, and a new PTC classification into molecular subtypes has been proposed in order to resolve clinical uncertainties still present in the clinical management of patients. Additionally, the prognostic stratification systems have been profoundly modified over the last decade, with a view to refine patients’ staging and being able to choose a clinical approach tailored on single patient’s needs. Here, we will briefly discuss the recent changes in the clinical management of thyroid nodules, and review the current staging systems of thyroid cancer patients by analyzing promising clinicopathological features (i.e., gender, thyroid auto-immunity, multifocality, PTC histological variants, and vascular invasion) as well as new molecular markers (i.e., BRAF/TERT promoter mutations, miRNAs, and components of the plasminogen activating system) potentially capable of ameliorating the prognosis of PTC patients.

Measurement of thyroglobulin level in lateral neck lymph node fine needle aspiration washout fluid in papillary thyroid cancer

Background

Thyroglobulin (Tg) level of fine needle aspiration (FNA) washout fluid (FNA-Tg) is useful to detect cervical lymph node (LN) metastasis in patients with papillary thyroid cancer (PTC). The objective of this study was to determine appropriate cutoff values of serum Tg (S-Tg) and FNA-Tg levels for diagnosis of lateral neck LN metastasis and investigate their diagnostic performance.

Methods

A total of 169 patients with PTC who underwent modified radical neck dissection (mRND) were retrospectively reviewed at Seoul St. Mary's Hospital (Seoul, Korea) from December 2011 to September 2019. Diagnostic performance of FNA-Tg, Tg ratio (FNA-Tg level/S-Tg level), and FNA-Tg combined with Tg ratio was evaluated by correlation with FNA cytology results.

Results

FNA-Tg level ≥20 ng/mL exhibited 86.6% sensitivity, 66.7% specificity, and 81.7% accuracy. Tg ratio ≥3 exhibited lower sensitivity but higher specificity (82.7% and 73.8%, respectively) than FNA-Tg level ≥20 ng/mL. FNA-Tg level ≥20 ng/mL combined with Tg ratio ≥3 had 81.9% sensitivity, 80.5% accuracy, and an integrated area under the curve (iAUC) of 0.790.

Conclusions

Measurement of FNA-Tg level increases preoperative diagnostic accuracy for the detection of metastatic LNs in patients with PTC. Diagnostic accuracy is higher using a 20 ng/mL FNA-Tg cutoff level. Tg ratio is also valuable and FNA-Tg combined with Tg ratio shows promise.

Utility of sonography for identifying metastatic cervical adenopathy in children with differentiated thyroid carcinoma at presentation

BACKGROUND

No study has evaluated the diagnostic accuracy of sonography for the depiction of metastatic cervical adenopathy in children with differentiated thyroid carcinoma at presentation or determined which sonographic features are most useful.

OBJECTIVE

To evaluate the diagnostic accuracy of sonography for identifying metastatic cervical adenopathy in children with differentiated thyroid carcinoma at presentation and to determine the most useful sonographic features.

MATERIALS AND METHODS

We evaluated cervical lymph node sonography and histology in children with proven thyroid carcinoma in a 10-year period. We excluded children in whom a preoperative sonogram was not available and those who did not have surgical resection of lymph nodes. We used histology as the gold standard. On sonography, we analyzed the size, shape, echotexture and vascularity of the lymph nodes and correlated these findings with the histology.

RESULTS

We reviewed sonograms and histology of resected lymph nodes in 52 children and adolescents with proven differentiated thyroid carcinoma (33 females; ages 5-18 years, mean 13.2 years). Metastatic cervical lymph node disease was proved on histology in 33/52 (64%) of our patients at presentation. Sonographic findings correctly predicted whether the nodes were histologically involved with metastatic disease in 42/52 (81%). Sensitivity of sonography was 79%, specificity 84%, positive predictive value (PPV) 90%, negative predictive value (NPV) 70% and accuracy 81%. A significant association was seen between round shape (P=0.0002), abnormal echotexture (P≤0.0001) and vascularity (P≤0.0001), and abnormal lymph node histology. Importantly, in 11/26 (47%) patients with sonographic and histologically proven abnormal nodes, the nodes were normal in size and shape and the presence of metastatic involvement was recognized sonographically only on the basis of abnormal echogenicity and vascularity.

CONCLUSION

Sonography has a high accuracy, specificity and PPV for identifying metastatic cervical lymph node involvement in children with differentiated thyroid carcinoma at presentation. Most of the abnormal lymph nodes were round in shape and had abnormal echogenicity and vascularity. Importantly, this paper emphasizes that in children, nodes with histologically proven metastases from differentiated thyroid carcinoma can be normal in size and shape. In these patients the presence of metastatic involvement might be recognized sonographically only on the basis of abnormal echogenicity and vascularity.

Development and validation of a nomogram for preoperative prediction of level VII nodal spread in papillary thyroid cancer: Radiologic-pathologic correlation

PURPOSE

To develop and validate a diagnostic nomogram for preoperative prediction of the level VII nodal spread in papillary thyroid cancer (PTC) by incorporating CT features.

METHODS

A dataset of 7896 patients experiencing thyroidectomy for thyroid cancer was collected retrospectively from two hospitals, and 300 patients were finally included in this study. The CT features of metastatic LN were extracted with a one by one match of radiologic-pathologic correlation. Multivariable binary logistic regression analysis was used to develop predicting model, and then a nomogram was developed utilizing a primary cohort of 152 patients from hospital #1. The nomogram was validated in external cohort of 62 patients from hospital #2 and an independent cohort of 86 patients from hospital #1. The performance of the nomogram was evaluated with respect to its calibration, discrimination.

RESULTS

531 LNs from 300 patients were analyzed. 42.6% LNs were > 5 mm in short diameter. A total of 7 selected CT features were significantly associated with LN status (P < 0.05), including nodular enhancement, cystic change, calcification and so on. These features were contained in the prediction nomogram. The model showed good discrimination and good calibration, with a C-index of 0.938 (95% CI, 0.913 to 0.963) and 0. 795 (95% CI, 0. 726 to 0.864) for the primary cohort and the validation cohort, respectively. Decision curve analysis demonstrated that the nomogram was clinically applicable.

CONCLUSIONS

This nomogram incorporating pathologically relevant CT features has demonstrated a high diagnostic value for predicting level VII nodal spread in PTC. Our work may help thyroid surgeon to decide whether upper mediastinal lymphadenectomy should be performed, which is associated with thoracotomy or other surgery.

Application of the Milan System for Reporting Salivary Gland Cytopathology to cystic salivary gland lesions

BACKGROUND

Cystic salivary gland lesions present diagnostic challenges on fine-needle aspiration (FNA) specimens that are related to sampling limitations and a broad differential diagnosis. This study evaluated the benefit of applying the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) to a series of cystic salivary gland lesions.

METHODS

The pathology archives at the Johns Hopkins Hospital were searched to identify cystic salivary gland FNA specimens over a 19-year period (2000-2018). Patient demographics, cytomorphologic features, and clinical and surgical follow-up were recorded. The MSRSGC was applied to the cases. The risk of malignancy (ROM) and the risk of neoplasia (RON) were calculated for each category.

RESULTS

One hundred seventy-eight cases were identified (96 males and 82 females) with a mean age of 53 years (range, 4-90 years). After the MSRSGC was applied, there were 52 nondiagnostic cases (29.2%), 80 nonneoplastic cases (44.9%), 35 cases of atypia of undetermined significance (AUS; 19.7%), 3 benign neoplasms (1.7%), 3 salivary gland neoplasms of uncertain malignant potential (SUMP; 1.7%), 4 cases suspicious for malignancy (SFM; 2.2%), and 1 malignant case (0.6%). One hundred fifty-six of the 178 patients (87.6%) had follow-up data available. The RON and ROM values for cases with surgical follow-up were 33.3% (3 of 9) and 22.2% (2 of 9) for the nondiagnostic category, 42.9% (9 of 21) and 19% (4 of 21) for the nonneoplastic category, 76.5% (13 of 17) and 29.4% (5 of 17) for the AUS category, 100.0% (2 of 2) and 50.0% (1 of 2) for the SUMP category, and 100% (2 of 2) and 100% (2 of 2) for the SFM category, respectively.

CONCLUSIONS

Applying the MSRSGC to cystic salivary gland lesions improves patient management by preventing unnecessary surgery for nonneoplastic conditions. The ROM was highest in the SFM category (100%), which was followed by the SUMP, AUS, nondiagnostic, and nonneoplastic categories. Less than adequate specimens may increase the diagnosis of AUS.

B-mode ultrasound, color Doppler, and sonoelastography in differentiation between benign and malignant cervical lymph nodes with special emphasis on sonoelastography

Background

Enlarged cervical lymph nodes are the most commonly encountered neck lumps. Ultrasonography is the most extensively used tool for classification of superficial lymph nodes due to its availability and low cost. Ultrasound (US) elastography refers to a non-invasive imaging technique that can describe tissue displacement (i.e., strain) or stiffness in response to a given force.

The aim of this study is to compare between B-mode sonography, color Doppler, and sonoelastography in assessment of enlarged deep cervical lymph nodes.

Results

The prevalence of benign lymph nodes was 26 out of 84 (31%). Lymphomatous lymph nodes were 22/84 (26.2%), while metastatic lymph nodes were 36/84 (42.8%). Color Doppler evaluation of nodal vascular pattern was of high sensitivity (91.7%), specificity (80.8%), and accuracy (88.6%) for differentiating metastatic and benign nodes (P value was < 0.001). There was a significant difference between elasticity scores of benign and malignant lymph nodes (P < 0.001). The most frequent score in the malignant group was 3 (21/27) (77.8%) while the most frequent score in the benign group was 2 (5/11) (45.5%). The mean strain ratio (strain index) for malignant lymph nodes (mean 3.2 ± 0.8) was significantly greater than that for benign lymph nodes (mean 1.1 ± 0.8).

Conclusion

Ultrasound elastography with its high sensitivity and specificity is a helpful improvement in US for the assessment of cervical lymph nodes, in which biopsies should be performed.

Clinical application of the ultrasound-guided fine needle aspiration for thyroglobulin measurement to diagnose lymph node metastasis from differentiated thyroid carcinoma-literature review

Papillary thyroid carcinoma (PTC) generally has a good prognosis, but disease recurs in 25% to 30% of PTC patients and significantly reduces the survival rate. Lymph node metastasis (LNM) is reported in 20% to 50% of PTC patients, mainly in the neck, and 20% originates from recurrence. LNM of papillary thyroid carcinoma are a plausible prognostic factor to determine disease recurrence. Currently, fine needle lymph node aspiration for cytology (LN-FN-cytology) is the best modality to diagnose LNM but is limited by diagnostic sensitivity and sample error. Fine needle lymph node aspiration for thyroglobulin measurement (LN-FNA-Tg) could offer a reliable and quantitative diagnostic method for LNM. The combination of LN-FNA-cytology and LN-FNA-Tg could achieve almost 100% diagnostic sensitivity and specificity for LNM. Both treatment guidelines of the American Thyroid Association and European Thyroid Association recommend LN-FNA-Tg to diagnose LNM after total thyroidectomy. Diagnostic accuracy of the LN-FNA-Tg depends on optimal equipment, scanning protocol, skill, and experience of operators. Normal saline is mainly used for aspiration needle wash-out and buffer solution. And radioimmunoassay or immunoradiometric assay are widely used for the LN-FNA-Tg measurement. So far, there is no consensus about the diagnostic threshold of LN-FNA-Tg for positive LNM, but high LN-FNA-Tg, especially higher than 10 ng/mL, strongly favors LNM.

Quantification of intranodal vascularity by computer pixel-counting method enhances the accuracy of ultrasound in distinguishing metastatic and tuberculous cervical lymph nodes

Background

Ultrasound is a common imaging method for assessment of cervical lymph nodes. However, metastatic and tuberculous lymph nodes have similar sonographic features in routine ultrasound examination. Computer-aided assessment could be a potential adjunct to enhance the accuracy of differential diagnosis.

Methods

Gray-scale and power Doppler sonograms of 100 patients with palpable cervical lymph nodes were reviewed and analyzed (60 metastatic nodes, 40 tuberculous nodes). Final diagnosis of lymph nodes was based on fine needle aspiration and cytology. Sonograms were reviewed and assessed for nodal shape, echogenic hilus, intranodal necrosis and vascular distribution (conventional assessment). Intranodal vascularity was quantified using a customized computer algorithm to determine vascularity index (VI). The diagnostic accuracy of using conventional assessment and its combination with intranodal VI method was evaluated and compared.

Results

Metastatic and tuberculous nodes tended to be round (75.0% vs. 50.0%), without echogenic hilus (86.7% vs. 72.5%) and have peripheral vascularity (73.3% vs. 85.0%). Intranodal necrosis is more common in tuberculous nodes (27.5%) than metastatic nodes (8.3%). Using conventional assessment in differentiating metastatic and tuberculous nodes, the diagnostic accuracy was 56% with a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 56.7%, 55%, 65.4% and 45.8% respectively. The VI of metastatic nodes (23.4%±2.1%) was significantly higher than that of tuberculous nodes (12.0%±1.6%) (P<0.05). The optimum cut-off of VI for the differential diagnosis was 20%. By combining conventional assessment and intranodal VI quantification, the diagnostic accuracy was increased to 69% with a sensitivity, specificity, PPV and NPV of 80%, 52.5%, 71.6%, 63.6% respectively. The increase in sensitivity was statistically significant (P=0.006).

Conclusions

Computer-aided quantification of intranodal vascularity provides added value in routine ultrasound assessment of cervical lymph nodes. It enhances the accuracy of ultrasound in distinguishing metastatic and tuberculous cervical lymph nodes.

Superior detection of metastatic cystic lymphadenopathy in patients with papillary thyroid cancer by utilization of thyroglobulin washout

BACKGROUND

Fine-needle aspiration (FNA) cytology has been the standard of care in the workup of cervical lymph nodes (LNs) in patients with recurrent papillary thyroid cancer (PTC) and suspicious cervical LNs. Recently, FNA thyroglobulin (TG) washout measurement has been proposed as an adjunct in the management of these patients. We hypothesize that using FNA-TG washout for suspicious cervical LNs would increase the accuracy of diagnosing metastatic disease especially in cystic and highly vascular cervical LN in patients with recurrent PTC.

METHODS

This is a retrospective study of a prospectively collected database for patients with thyroid cancer who underwent preoperative FNA followed by selective neck dissection by one surgeon at an academic institution. FNA-cytology and FNA-TG washout were performed simultaneously. A total of 138 patients were included in our study, of which 92 (66.7%) had undergone surgical intervention. Results of both methods were then correlated with the final surgical pathology.

RESULTS

FNA-cytology alone showed a sensitivity of 80.0%, specificity of 100.0% with a negative predictive value (NPV) of 60.0%. By contrast, FNA-TG washout had a sensitivity of 95.8%, specificity of 90.5% with a NPV of 86.4%. Combination of the FNA-cytology with FNA-TG washout of cystic/highly vascular LN increased the accuracy of diagnosis with a sensitivity of 98.2%, specificity of 100.00% with a NPV of 95.0%. All 14 malignant cervical LNs with false-negative FNA-cytology showed elevated FNA-TG washout, 10 (71.4%) of which were cystic in nature and 4 were highly vascular on ultrasonography.

CONCLUSION

FNA-TG washout increases the diagnostic accuracy in detecting metastatic disease in patients with recurrent thyroid cancer. FNA-TG washout may be of special diagnostic importance in cystic or highly vascular LNs, which might have falsely negative cytology.

LEVEL OF EVIDENCE

2B.

CT and MR imaging findings of infection-free and benign second branchial cleft cysts

PURPOSE

The present study aimed to assess CT and MR imaging findings of infection-free and benign second branchial cleft cysts (SBCCs).

METHODS

Eleven patients with histopathologically confirmed infection-free and benign SBCCs underwent preoperative contrast-enhanced CT (CECT) and/or MR imaging. We assessed qualitative (presence and extent of wall thickening, degree of contrast enhancement of the thickened wall on CECT images, and signal intensity of the thickened wall on T2-weighted images) and quantitative (maximum thickness of the thickened wall) imaging findings.

RESULTS

Eccentric and smooth wall thickening was observed in 11/11 (100%) patients. The wall thickening extent (percentage of the thickened wall to the circumference of the wall) was small (1%-25%) in 4/11 (36%), moderate (26%-50%) in 6/11 (54%), extensive (51%-75%) in 1/11 (9%), and diffuse (76%-100%) in 0/11 (0%) patients. Mild homogeneous enhancement of the thickened wall on CECT images was observed in 7/7 (100%) patients. The signal intensity of the thickened wall on T2-weighted images was isointense relative to that of normal lymph nodes in 7/8 (88%) and mildly hyperintense in 1/8 (12%) patient. The maximum thickness of the thickened walls ranged from 2 to 4 (mean 3.4) mm.

CONCLUSIONS

Infection-free and benign SBCCs are identifiable as cysts with eccentric and smooth wall thickening on CECT and MR images. The wall thickness was almost always less than half of the wall circumference, isointense relative to normal lymph nodes, and showed mild homogeneous enhancement.

Medullary Thyroid Carcinoma: Do Ultrasonography and F-DOPA-PET-CT Influence the Initial Surgical Strategy?

Background

At the time of diagnosis, one-third of medullary thyroid carcinoma (MTC) patients show lymph node (LN) or distant metastasis. A metastasized MTC requires different surgical strategies.

Objective

This study aimed to determine the value of ultrasound and [18F]fluoro-dihydroxyphenylalanine positron emission tomography with computed tomography (F-DOPA-PET-CT) in localizing MTC, as well as LN and distant metastasis.

Methods

The study included 50 patients (24 males/26 females) with preoperative ultrasound, F-DOPA-PET-CT, and histologically proven MTC. Imaging results were correlated with both preoperative basal calcitonin (bCt) levels and final histology.

Results

Tumors were classified as pT1a:17 (diameter, mean ± standard deviation: 5.8 ± 3.0 mm), pT1b:15 (15.0 ± 3.2 mm), pT2:9 (27.3 ± 7.0 mm), and pT3:9 (38.3 ± 24.2 mm). The median bCt level was 202 pg/mL (lower/upper quartile: 82/1074 pg/mL). Ultrasound was positive for tumor in 45/50 (92%) patients (20.0 ± 16.0 mm) and negative in 5 patients (3.2 ± 2.2 mm). Overall, 43/50 (86%) patients had positive F-DOPA local scans (20.0 ± 16.4 mm), while 7 (14%) patients were negative (7.7 ± 8.1 mm). Lastly, 21/50 (42%) patients had LN metastasis; 8/21 (38%) patients had positive LNs suspected with ultrasound, and 12/21 (57%) patients had positive LNs suspected with F-DOPA. Tumor and LN sensitivity of ultrasound was 92% and 43%, respectively, and 86% and 57% of F-DOPA-PET-CT, respectively. In 3/50 (6%) patients and 3/50 (6%) patients, mediastinal LN metastasis and distant metastasis, respectively, were diagnosed only by F-DOPA-PET-CT.

Conclusion

Ultrasound and F-DOPA-PET-CT are sensitive for the localization of MTC but not for the presence and location of LN metastasis (limitations: size/number). Only F-DOPA ensures the diagnosis of distant metastasis and influences the extent of LN surgery. Surgical strategy cannot be predicted based on neither ultrasound nor F-DOPA-PET-CT.

Efficacy of surgeon-performed, ultrasound-guided lymph node fine needle aspiration in patients with thyroid pathologic conditions

BACKGROUND

Although the concept of surgeon-performed fine needle aspiration of thyroid nodules is established, experience with surgeon-performed lymph node fine needle aspiration is scant. We aimed to study the efficacy of surgeon-performed lymph node fine needle aspiration in patients with thyroid pathologic conditions.

METHODS

This is an institutional review board-approved study of patients with thyroid pathologic conditions who underwent surgeon-performed lymph node fine needle aspiration between 2002 and 2017. Efficacy and utility were analyzed.

RESULTS

A total of 201 patients with benign nodular goiter (n = 30) and thyroid cancer (n = 200) underwent 230 lymph node fine needle aspirations (89 during preoperative workup, 141 at postoperative follow-up). Insufficient aspiration rate was 6% and indeterminate cytologic results 3%. In 91% of patients with suspicious lymph nodes, definite diagnosis could be obtained by fine needle aspiration; 51% (n = 118) of fine needle aspirations indicated metastasis from thyroid cancer and 40% (n = 91) benign findings. Sensitivity and specificity of lymph node fine needle aspiration in diagnosing nodal metastasis were 92% and 89%, respectively. Cytologic testing and thyroglobulin washout indicated 95% concordance. On logistic regression, spherical shape, microcalcifications, cystic appearance, and loss of hilum on ultrasound independently predicted lymph node metastasis.

CONCLUSION

Our data indicate that an adequate surgeon-performed lymph node fine needle aspiration is highly accurate in diagnosing nodal status in thyroid pathologic conditions. We recommend adoption of this technique, when feasible, to develop an efficient, comprehensive thyroid practice.

Cystic major salivary gland lesions: Utilizing fine needle aspiration to optimize the clinical management of a broad and diverse differential diagnosis

INTRODUCTION

The use of fine-needle aspiration (FNA) cytology for the preoperative evaluation of salivary gland lesions is an accepted but, currently, nonstandardized practice. More specifically, cystic major salivary gland lesions are relatively rare and can be very challenging to diagnose on FNA due to low cellularity and an incredibly broad differential diagnosis. The purpose of this study was to investigate the diagnostic utility of preoperative FNA cytology for cystic major salivary gland lesions.

METHODS AND MATERIALS

The electronic pathology archives of The Johns Hopkins Hospital were searched to identify FNA specimens of cystic major salivary gland lesions over a 15 year period (January 1, 2000 to December 21, 2015). The age, race, sex, biopsy site, use of ultrasound guidance, cytopathologic diagnosis, and presence or absence of clinical follow-up were recorded for each patient. Cases were divided into those with and without follow-up. Diagnostic performance between FNA and follow-up data were recorded.

RESULTS

A total of 145 cases met the inclusion criteria, while 123 (84.8%) patients had follow-up data available. Of these patients, 67.5% underwent FNA as the only pathologic diagnostic modality. Sensitivity, specificity, positive predictive value, and negative predictive value for the detection of cystic neoplasms were 41.6%, 99.0%, 90.9%, and 87.6%, respectively. For cases containing mucin, 100.0% sensitivity and specificity were achieved.

CONCLUSION

FNA of cystic salivary gland lesions is a useful clinical decision-making tool that can reduce the number of patients ultimately requiring surgical excision. Although specificity is high, a relatively low overall sensitivity makes clinical and radiologic correlation imperative.

Nodular thyroid disease in the elderly: novel molecular approaches for the diagnosis of malignancy

Epithelial thyroid cancers (TC) comprise two differentiated histotypes (DTC), the papillary (PTC) and the follicular (FTC) thyroid carcinomas which, following dedifferentiation, are assumed to give rise to the poorly differentiated thyroid carcinomas and the rare, but highly aggressive and invariably fatal, anaplastic thyroid carcinomas. Although thyroid cancer mortality has not been changed, its annual incidence has increased over the last two decades, mainly because of the improved ability to diagnose malignant transformation in small non-palpable thyroid nodules. Despite DTC patients have a favorable prognosis, aggressive disease is more frequently observed in the elderly showing a higher disease-specific mortality. Of relevance is the high prevalence of nodular thyroid disease in aged patients being higher than 90%, in women older than 60 year, and 60% in men older than 80 year. This implies a careful evaluation of thyroid nodules in this group of patients in order to exclude malignancy. In fact, despite the tremendous progress in the comprehension of the underlying molecular mechanisms deregulated in DTC progression, several aspects of their clinical management remain to be solved and novel diagnostic strategies are sorely needed. Here, we will attempt to review new molecular approaches, which are currently being exploited in order to ameliorate the diagnosis of thyroid nodules.

Diagnostic accuracy of ultrasonographic features for lymph node metastasis in papillary thyroid microcarcinoma: a single-center retrospective study

Background

Whether sonography is an appropriate imaging modality for cervical lymph nodes in patients with papillary thyroid microcarcinoma (PTMC) remains unclear. Hence, this study aimed to evaluate the diagnostic value of ultrasonography (US) features for lymph node metastasis in PTMC.

Methods

Seven hundred twelve patients with PTMC who underwent conventional ultrasonography examinations of the cervical lymph nodes were included. All included cases underwent total thyroidectomy plus prophylactic central lymph node dissection. The included lymph nodes were marked superficially, and the corresponding lymph nodes were completely removed and sent for pathological examination. The US features of lymph nodes with and without metastasis were compared, and the odds ratios of the suspicious US features were determined with univariate and multivariate analyses.

Results

Round shape, loss of an echogenic fatty hilum, cystic change, calcification, and abnormal vascularity were significantly more common in metastatic than nonmetastatic lymph nodes, whereas the boundary and echo did not significantly differ. Multivariate logistic regression analysis showed that round shape, loss of echogenic fatty hilum, cystic change, calcification, and abnormal vascularity were independent predictive factors for the assessment of metastatic lymph nodes. Round shape had the highest sensitivity of all variables, while loss of an echogenic fatty hilum had the highest specificity and accuracy. The area under the receiver operating characteristic curve, which was calculated to verify the relationship between the various US features and metastatic lymph nodes, was 0.793.

Conclusions

Our study found that the US features of round shape, cystic change, calcification, loss of echogenic fatty hilum, and abnormal vascularity were useful sonographic criteria for differentiating between cervical lymph nodes with and without metastasis.

Diagnostic Accuracy of Computer-Aided Assessment of Intranodal Vascularity in Distinguishing Different Causes of Cervical Lymphadenopathy

Ultrasound is useful in assessing cervical lymphadenopathy. Advancement of computer science technology allows accurate and reliable assessment of medical images. The aim of the study described here was to evaluate the diagnostic accuracy of computer-aided assessment of the intranodal vascularity index (VI) in differentiating the various common causes of cervical lymphadenopathy. Power Doppler sonograms of 347 patients (155 with metastasis, 23 with lymphoma, 44 with tuberculous lymphadenitis, 125 reactive) with palpable cervical lymph nodes were reviewed. Ultrasound images of cervical nodes were evaluated, and the intranodal VI was quantified using a customized computer program. The diagnostic accuracy of using the intranodal VI to distinguish different disease groups was evaluated and compared. Metastatic and lymphomatous lymph nodes tend to be more vascular than tuberculous and reactive lymph nodes. The intranodal VI had the highest diagnostic accuracy in distinguishing metastatic and tuberculous nodes with a sensitivity of 80%, specificity of 73%, positive predictive value of 91%, negative predictive value of 51% and overall accuracy of 68% when a cutoff VI of 22% was used. Computer-aided assessment provides an objective and quantitative way to evaluate intranodal vascularity. The intranodal VI is a useful parameter in distinguishing certain causes of cervical lymphadenopathy and is particularly useful in differentiating metastatic and tuberculous lymph nodes. However, it has limited value in distinguishing lymphomatous nodes from metastatic and reactive nodes.

Mistakes in ultrasound examination of salivary glands

Ultrasonography is the first imaging method applied in the case of diseases of the salivary glands. The article discusses basic mistakes that can be made during an ultrasound examination of these structures. The reasons for these mistakes may be examiner-dependent or may be beyond their control. The latter may include, inter alia, difficult conditions during examination (technical or patient-related), similarity of ultrasound images in different diseases, the lack of clinical and laboratory data as well as the lack of results of other examinations, their insufficient number or incorrectness. Doctor-related mistakes include: the lack of knowledge of normal anatomy, characteristics of ultrasound images in various salivary gland diseases and statistical incidence of diseases, but also attaching excessive importance to such statistical data. The complex anatomical structures of the floor of the oral cavity may be mistaken for benign or malignant tumors. Fragments of correct anatomical structures (bones, arterial wall fibrosis, air bubbles in the mouth) can be wrongly interpreted as deposits in the salivary gland or in its excretory duct. Correct lymph nodes in the parotid glands may be treated as pathologic structures. Lesions not being a simple cyst, e.g. lymphoma, benign or malignant tumors of the salivary glands or metastatic lymph nodes, can be mistaken for one. The image of disseminated focal changes, both anechoic and solid, is not pathognomonic for specific diseases in the salivary glands. However, in part, it occurs typically and requires an extended differential diagnosis. Small focal changes and infiltrative lesions pose a diagnostic problem because their etiology cannot be safely suggested on the basis of an ultrasound examination itself. The safest approach is to refer patients with abnormal focal changes for an ultrasoundguided fine-needle aspiration biopsy.

Estimation of thyroglobulin in lymph node aspirates: Pilot experience from a tertiary referral cancer center

Background:

Assessment of cervical lymph node involvement in patients with thyroid cancer either during preoperative surgical mapping or detection of recurrences during follow-up is a crucial step in the management of differentiated thyroid cancers (DTCs). In most patients, fine needle aspiration cytology (FNAC) confirms the presence of metastasis in lymph node. However, in cases of paucicellular lymph node aspirate or discordant sonogram and cytology results, thyroglobulin (Tg) measurement in the lymph node aspirate (FNA-Tg) is useful and a value >1 ng/ml is considered consistent with metastatic disease.

Context:

The addition of FNAC to the US improves the specificity, but 5–10% are nondiagnostic and 6–8% rate of false-negative results. Several studies have reported that the detection of Tg in FNA-needle washes improves the evaluation of suspicious lymph nodes in patients with DTC.Data from Indian centers on FNA-Tg are limited.

Aims:

We piloted the utility of FNA-Tg in patients with sonographically suspicious cervical lymph node enlargement in the setting of suspicious thyroid nodule or in the follow-up of thyroid cancer.

Settings and Design:

Prospective data collection.

Results:

We measured Tg in 13 lymph node aspirates (12 patients, 10 females) among whom 4 patients had a total thyroidectomy and 1 had a hemithyroidectomy. Eight of the 13 lymph node aspirates had FNA-Tg values >150 ng/ml, all of them had unequivocal malignant cytology and four among them had proven metastatic DTC on surgical pathology. The median FNA-Tg of the patients with malignant cytology was 7550 ng/ml with a range of 162–30,000 ng/ml. Among the remaining 5 lymph node aspirate, 2 lymph nodes showed cytological features suggestive of reactive lymphadenitis (FNA-Tg <0.2 ng/ml) and were not operated, 1 had a high-grade malignancy consistent with anaplastic thyroid cancer (FNA-Tg <0.2 ng/ml), and 2 had nondiagnostic cytology (one had non-caseating granuloma on surgical pathology [FNA-Tg 1.3 ng/ml] and in the other patient [FNA-Tg <0.2 ng/ml] surgical intervention was deferred).

Conclusions:

FNA-Tg was concordant with positive cytology in all patients with DTC and may serve as a useful tool in patients with negative and nondiagnostic cytology to guide surgical management.

Ultrasound-based clinical prediction rule model for detecting papillary thyroid cancer in cervical lymph nodes: A pilot study

PURPOSE

To identify sonographic features of cervical lymph nodes (LNs) that are associated with papillary thyroid cancer (PTC) and to develop a prediction model for classifying nodes as metastatic or benign.

METHODS

This retrospective study included the records of postthyroidectomy patients with PTC who had undergone cervical ultrasound and LN biopsy. LN location, size, shape, hilum, echopattern, Doppler flow, and microcalcifications were assessed. Model selection was used to identify features associated with malignant LNs and to build a predictive, binary-outcome, generalized linear mixed model. A cross-validated receiver operating characteristic analysis was conducted to assess the accuracy of the model for classifying metastatic nodes.

RESULTS

We analyzed records from 71 LNs (23 metastatic) in 44 patients (16 with PTC). The predictive model included a nonhomogeneous echopattern (odds ratio [OR], 5.73; 95% confidence interval [CI], 1.07-30.74; p = 0.04), microcalcifications (OR, 4.91; 95% CI, 0.91-26.54; p = 0.06), and volume (OR, 2.57; 95% CI, 0.66-9.99; p = 0.16) as predictors. The model had an area under the curve of 0.74 (95% CI, 0.60-0.85), sensitivity of 65% (95% CI, 50% to 78%), and specificity of 85% (95% CI, 73% to 94%) at the Youden optimal cut point of 0.38.

CONCLUSIONS

Nonhomogeneous echopattern, microcalcifications, and node volume were predictive of malignant LNs in patients with PTC. A larger sample is needed to validate this model.

A Prospective Study to Evaluate the Reliability of Thyroid Imaging Reporting and Data System in Differentiation between Benign and Malignant Thyroid Lesions

OBJECTIVES

To evaluate diagnostic reliability of the daily use of thyroid imaging reporting and data system (TIRADS) classification proposed by Kwak et al., in differentiating between a benign and a malignant thyroid lesion, to calculate inter-observer variability in the interpretation of each of the TIRADS ultrasound features and to evaluate role of TIRADS system in reducing unnecessary biopsies of benign lesions.

MATERIALS AND METHODS

Three hundred and sixty-five patients with clinically suspected thyroid lesions during the period from November 1, 2011, to August 31, 2015, were prospectively scanned on gray-scale and Doppler imaging by six radiologists separately. We used GE VOLUSON 730 PRO machine (GE healthcare, Milwaukee, USA) equipped with a 7.5-12 MHz high-frequency linear array transducer with color and power Doppler capability. We evaluated five sonological features: Internal composition, echogenicity, margins, presence and type of calcification, and shape of the lesion. Based on the TIRADS proposed by Kwak et al., we determined categories of the thyroid lesions. The diagnostic performance of TIRADS classification system was evaluated by comparison with the fine-needle aspiration cytology (FNAC) reports which were subsequently obtained after taking informed consent from the patients. All follicular neoplasms on FNAC were further followed up with excision biopsy and histology. The cytopathological report was used as the standard final diagnosis for comparison. The P value and odds ratio were determined to quantify how strongly the presence or absence of a particular ultrasound feature was associated with benignity or malignancy in the study population. The risk of malignancy was stratified for each TIRADS category-based on the total number of benign and malignant lesions in that category. Cervical lymph nodes were also evaluated for their size, loss of the central, echogenic hilum, presence of irregular and indistinct margin, microcalcification, and necrotic changes. Cohen's Kappa coefficient was determined separately for each of the five TIRADS malignant features to study the inter-observer agreement. Furthermore, the percentage of benign cases that were accurately determined by TIRADS which could have avoided unnecessary FNAC was determined.

RESULTS

The risk of malignancy in TIRADS categories 1 and 2 was found to be 0%, 0.64% in category 3, 4.76% in category 4A, 66.67% in category 4B, 83.33% in category 4C, and 100% in category 5. Out of the five suspicious sonological features, irregular margins showed the highest positive predictive value (95.45%) for malignancy followed by taller than wide shape (92.86%), microcalcifications (66.67%), marked hypoechogenicity (54.55%), and solid composition (48.15%). The specificity of three sonological features (completely cystic structure, hyperechogenicity, and macrocalcification) in classifying a nodule as benign was 100%. Loss of central echogenic hilum, presence of an irregular and indistinct margin, microcalcification and necrosis were found to have sensitivity of 100%, 63.63%, 27.27%, and 9.09%, respectively and specificity of 95.7%, 98.5%, 100%, and 100%, respectively for cervical lymph node to be malignant. The Kappa value for taller than wide shape, microcalcification, marked hypoechogenicity, solid composition, and irregular margins was 1.0 (95% confidence interval [CI]: 1-1), 1.0 (95% CI: 1-1), 0.90 (95% CI: 0.82-1), 0.88 (95% CI: 0.77-0.92), and 0.82 (95% CI: 0.64-1), respectively. The estimated decrease in unnecessary FNACs was found to be 43.83-86.30%.

CONCLUSIONS

TIRADS proposed by Kwak et al., combined with evaluation for sonological features of malignant lymph nodes is a valuable, safe, widely available, and easily reproducible imaging tool to stratify the risk of a thyroid lesion and helps in precluding unnecessary FNACs in a significant number of patients. TIRADS features convincingly show comparable results in the interpretation of TIRADS features more so, in the hands of radiologists experienced in thyroid imaging.

Improvement in the Detection of Cystic Metastatic Papillary Thyroid Carcinoma by Measurement of Thyroglobulin in Aspirated Fluid

Cystic change in metastatic lymph nodes of papillary thyroid carcinoma (PTC) is a diagnostic challenge for fine needle aspiration (FNA) because of the scant cellularity. The aim of this study was to evaluate the measurement of thyroglobulin in fine needle aspirate (Tg-FNA) for detecting metastatic PTC in patients with cystic neck lesions and to validate the optimal cutoff value of Tg-FNA. A total of 75 FNA specimens of cystic lesions were identified, including 40 of metastatic PTC. Predetermined threshold levels of 0.04 (minimum detection level), 0.9, 10.0, and 77.0 ng/mL (maximum normal serum-Tg level) were used to evaluate the diagnostic accuracy of Tg-FNA for metastatic PTC detection. The areas under the receiver operating characteristic curve for diagnosing metastatic PTC of Tg-FNA values of 0.04, 0.9, 10.0, and 77.0 ng/mL were 0.5 (95% confidence interval [CI], 0.382–0.618), 0.645 (95% CI, 0.526–0.752), 0.945 (95% CI, 0.866–0.984), and 0.973 (95% CI, 0.907–0.996), respectively. With a cutoff value of 77.0 ng/mL, the combination of Tg-FNA and FNA cytology showed superior diagnostic power (97.5% sensitivity and 100% specificity) compared to FNA cytology alone (80% sensitivity and 100% specificity). We recommend a Tg-FNA cutoff of 77.0 ng/mL, the maximum normal serum-Tg level, for cystic neck lesions.

Approach to metastatic carcinoma of unknown primary in the head and neck: squamous cell carcinoma and beyond

Metastatic carcinoma to cervical lymph nodes presenting as an unknown primary is quite common. In most cases, the primary site is ultimately identified. Carcinomas that remain of unknown primary after a thorough search are uncommon. This review will focus on those cases that initially present as unknown primaries, since this is the setting in which pathologists first encounter these cases and in which they play an important role in guiding patient management. Most are squamous cell carcinomas, the majority of which are human papillomavirus (HPV)-related and originate in the palatine tonsils and base of tongue. HPV-related oropharyngeal squamous cell carcinomas are increasing in incidence and have unique clinical and pathologic features that make them particularly likely to present as an unknown primary. Understanding these features has led to improved detection of the primary tumors. Further, even when the primary tumor is not found, prognosis is very dependent on characterization of the tumor HPV status. Papillary thyroid carcinomas may also initially present without a known or clinically detectable primary, either as a neck mass or incidentally in a neck dissection performed for another indication. The latter is a very indolent disease. Finally, primary salivary gland carcinomas may mimic an unknown primary and need to be distinguished from cutaneous metastases to the parotid gland, which may present without a recognized skin tumor. Here, we review the clinical and pathologic features of these entities and provide a systematic approach to their diagnosis.

A mathematical model using computed tomography for the diagnosis of metastatic central compartment lymph nodes in papillary thyroid carcinoma

OBJECTIVES

The purpose of this study was to establish a potential mathematical model for the diagnosis of the central compartment lymph node (LN) metastases of papillary thyroid carcinoma (PTC) using CT imaging.

METHODS

303 patients with PTC were enrolled. We determined the optimal cut-off points of LN size and nodal grouping by calculating the diagnostic value of each cut-off point. Then, calcification, cystic or necrotic change, abnormal enhancement, size, and nodal grouping were analysed by univariate and multivariate statistical methods. The mathematical model was obtained using binary logistic regression analysis, and a scoring system was developed for convenient use in clinical practice.

RESULTS

30 mm(2) for LNs area (size) and two LNs as the nodal grouping criterion had the best diagnostic value. The mathematical model was: p = e (y) /(1+ e (y) ), y = -0.670-0.087 × size + 1.010 × cystic or necrotic change + 1.371 × abnormal enhancement + 0.828 × nodal grouping + 0.909 × area. We assigned the value for cystic or necrotic change, abnormal enhancement, size and nodal grouping value as 25, 33, 20, and 22, respectively, yielding a scoring system.

CONCLUSIONS

This mathematical model has a high diagnostic value and is a convenient clinical tool.

KEY POINTS

• Papillary thyroid carcinoma has a relatively high rate of metastasis. • CT has unique advantages in evaluating the central compartment. • The mathematical model can improve the diagnosis of CT imaging. • Corresponding scoring system is a convenient clinical tool.

Differential profile of ultrasound findings associated with malignancy in mixed and solid thyroid nodules in an elderly female population

Objective. Ultrasonographic characteristics are associated with thyroid malignancy. Our aim was to compare the diagnostic value of ultrasound features in the detection of thyroid malignancy in both solid and mixed nodules. Methods. We prospectively studied female patients (≥50 years) referred to ultrasound-guided fine needle aspiration biopsy. Ultrasound features considered suspicious were hypoechogenicity, microcalcifications, irregular margins, high anteroposterior (AP)/axial-ratio, and absent halo. Associations were separately assessed in mixed and solid nodules. Results. In a group of 504 elderly female patients (age = 69 ± 8 years), the frequency of malignant cytology was 6%. Thirty-one percent of nodules were mixed and 60% were solid. The rate of malignant cytology was similar for mixed and solid nodules (7.4 versus 5.8%, P: 0.56). While in mixed nodules none of the ultrasound characteristics were associated with malignant cytology, in solid nodules irregular margins and microcalcifications were significant (all P < 0.05). The combination of irregular margins and/or microcalcifications significantly increased the association with malignant cytology only in solid nodules (OR: 2.76 (95% CI: 1.25–6.10), P: 0.012). Conclusions. Ultrasound features were of poor diagnostic value in mixed nodules, which harbored malignant lesions as often as solid nodules. Our findings challenge the recommended minimal size for ultrasound-guided fine needle aspiration biopsy in mixed nodules.

Thyroglobulin in the washout fluid of lymph-node biopsy: what is its role in the follow-up of differentiated thyroid carcinoma?

BACKGROUND

The clinical evaluation of enlarged local lymph nodes (LNs) is difficult at the beginning and throughout the follow-up of differentiated thyroid carcinoma (DTC). Although the examination of samples collected from LNs by fine-needle aspiration biopsy cytology (FNAB-C) is extremely specific for the diagnosis of metastases, its sensitivity is low, especially in paucicellular samples.

SUMMARY

The measurement of thyroglobulin (Tg) in the fine-needle aspiration biopsy (FNAB) washout fluid (FNAB-Tg) increases the diagnostic performance of cytology to up to 100% sensitivity and specificity. However, the application of FNAB-Tg is currently hindered by the absence of methodological standardization, a lack of definite cutoff points, and the ongoing debate regarding its accuracy in nonthyroidectomized patients, those with elevated serum Tg, and those with circulating anti-Tg antibodies.

CONCLUSION

FNAB-Tg improves the diagnostic performance of FNAB-C in LN metastases, even when the latter is unable to diagnose the metastases. For that reason, FNAB-Tg should be included in the monitoring of DTC.

B-mode and elastosonographic evaluation to determine the reference elastosonography values for cervical lymph nodes

Background. It is crucial to differentiate between reactive and malignant lymphadenopathies. Elastosonography measures the elasticity of the tissue. Having a reference value for benign lymph nodes (LNs) is important in interpretation. The purpose of this study is to determine the reference elastosonography values of cervical LNs. Methods. 97 LNs were evaluated by B-mode and elastosonography. Depth, length, width, length to width ratio, hilar-cortical thickness, strain ratio, and elasticity scores were measured. Results. In 18.6% of the cervical LNs cortical thickness was less than the hilar thickness (group A) and in 81.4% it was equal or more (group B). 69.1% of LNs showed strain ratio (SR) less than 3 (group 1) and 30.9% equal to or more than 3 (group 2). 33% of LNs displayed elasticity score (ES) 1; 30.9% ES 2; 22.7% ES 3, and 13.4% ES 4. There was a significant correlation between thickness ratios and elasticity scores (P: 0.011). A significant correlation was also demonstrated between SR groups and elasticity scores. Conclusion. A simple, reproducible, noninvasive imaging technique for diagnosis of malignant LNs is necessary. Elastosonography can aid in the differentiation of benign versus malignant cervical LNs, thus help reduce the number of unnecessary biopsies for benign processes.

Do black (dark) lymph-node metastases in papillary thyroid carcinoma suggest more advanced or aggressive disease?

BACKGROUND

In some patients, papillary thyroid carcinoma (PTC) lymph-node metastases are noted to be black (dark) in color at the time of surgical removal. The goal of this project was to determine histological, genetic, and clinical features that are associated with regional black PTC metastasis.

METHODS

Fifteen patients with black PTC metastases (black-PTC) were compared to a control cohort of 15 patients with nonblack PTC metastasis (nonblack PTC). Each sample was evaluated for the histological characteristics, BRAF V600E mutational status, and associated patient clinical data.

RESULTS

The degree of cystic degeneration (80% vs. 27%, p=0.004), percent hemosiderin deposition (20% vs. 6%, p=0.001), and presence of classical variant (100% vs. 67%, p=0.018) were significantly greater in black PTC than nonblack PTC (α=0.05). Other results were not significantly different.

CONCLUSION

This study demonstrates that black compared to nonblack metastases have a greater degree of cystic degeneration and hemosiderin deposition leading to discoloration, and a trend toward an increased incidence in BRAF V600E mutations. This study is the first of its kind to describe the clinical, pathological, and genetic features associated with black PTC lymph-node metastasis.

Ultrasound-based diagnosis for solid thyroid nodules with the largest diameter <5 mm

This study was aimed at assessing the efficacy of using an ultrasound (US)-based classification system to diagnose solid thyroid nodules with the largest diameter <5 mm (i.e., small solid nodules). For 406 small solid nodules in 365 patients who underwent thyroid US and US-guided fine-needle aspiration, each thyroid nodule was prospectively classified into one of five diagnostic categories: benign, probably benign, borderline, possibly malignant and malignant. Of 406 nodules, 145 were surgically removed: 95 papillary thyroid carcinomas, 1 follicular thyroid carcinoma, 1 poorly differentiated carcinoma, 3 pseudonodules related to thyroiditis and 45 nodular hyperplasias. On the basis of the histopathologic results, the diagnostic accuracies of US diagnosis and cytologic diagnosis were similar, but the sensitivity of US diagnosis was higher than that of cytologic diagnosis, and the specificity and positive predictive values of US diagnosis were lower those of cytologic diagnosis. An US-based classification system may be helpful for the diagnosis and management of small solid nodules.

Pitfalls in the staging of cancer of thyroid

Thyroid cancer includes several neoplasms originating from the thyroid gland-from indolent and curable histologies of differentiated thyroid carcinoma to aggressive anaplastic thyroid carcinoma. Differentiation of thyroid nodules is problematic on CT and MR imaging unless there is evidence of extrathyroidal extension. Evaluation of regional lymph nodes is often performed clinically or with ultrasound. The retropharyngeal and mediastinal lymph nodes are better evaluated by CT and MR imaging. Nuclear scintigraphy is useful for staging and treatment of distant metastasis in differentiated thyroid carcinoma. PET may have a role in aggressive cancers. Accurate staging affects surgical management and subsequent therapy.

Cervical lymph node metastases from thyroid cancer: does thyroglobulin and calcitonin measurement in fine needle aspirates improve the diagnostic value of cytology?

Background

Measurement of thyroglobulin (Tg) protein in the washout of the needle used for fine needle aspiration biopsy cytology (FNAB-C) has been shown to increase the sensitivity of FNAB-C in identifying cervical lymph node (CLN) metastasis from well-differentiated thyroid cancer (TC). In this study, we evaluated whether routine measurement of Tg protein (FNAB-Tgp), Tg mRNA (FNAB-Tgm) and calcitonin (CT) mRNA (FNAB-CTm) in the FNAB washout of CLN increases the accuracy of FNAB-C in the diagnosis of suspicious metastatic CLN.

Methods

In this prospective study 35 CLN from 28 patients were examined. Histology showed metastatic papillary TC (PTC) in 26 CLN, metastatic medullary TC (MTC) in 3 CLN, metastatic anaplastic TC (ATC) in 3 CLN and 3 metastatic CLN from extra-thyroidal cancers.

Results

The overall accuracy of FNAB-C was 84.4%, reaching 95.7% when the analysis was restricted to PTC. Both FNAB-Tgp and FNAB-Tgm compared favorably with FNAB-C and shown diagnostic performances not statistically different from that of FNAB-C. However, FNAB-Tgp and FNAB-Tgm/FNAB-CTm were found useful in cases in which cytology results were inadequate or provided diagnosis inconsistent with patient's clinical parameters.

Conclusions

We demonstrated that FNAB-C, Tg/CT mRNA and Tg protein determination in the fine-needle washout showed similar accuracy in the diagnosis of metastatic CLN from TC. The results of this study suggest that samples for Tg protein and Tg/CT mRNA measurements from CLN suspicious for metastatic TC should be collected, but their measurements should be restricted to cases in which FNAB-C provides uninformative or inconsistent diagnosis with respect to patient's clinical parameters.

B-flow twinkling sign in preoperative evaluation of cervical lymph nodes in patients with papillary thyroid carcinoma

Papillary thyroid cancer (PTC) is the most common histologic type of differentiated thyroid cancer. The first site of metastasis is the cervical lymph nodes (LNs). The ultrasonography (US) is the best diagnostic method for the detection of cervical metastatic LNs. We use a new technique, B-flow imaging (BFI), recently used for evaluation of thyroid nodules, to estimate the presence of BFI twinkling signs (BFI-TS), within metastatic LNs in patients with PTC. Two hundred and fifty-two patients with known PTC were examined for preoperative evaluation with conventional US and BFI. Only 83 with at least one metastatic LN were included. All patients included underwent surgery; the final diagnosis was based on the results of histology. The following LN characteristics were evaluated: shape, abnormal echogenicity, absent hilum, calcifications, cystic appearance, peripheral vascularization, and BFI-TS. A total of 604 LNs were analyzed. Of these, 298 were metastatic, according to histopathology. The BFI-TS showed high values of specificity (99.7%) and sensitivity (80.9%). The combination of each conventional US sign with the BF-TS increases the specificity. Our findings suggest that BFI can be helpful in the selection of suspicious neck LNs that should be examined at cytologic examination for accurate preoperative staging and individual therapy selection.

Terminology inaccuracies in the interpretation of imaging results in detection of cervical lymph node metastases in papillary thyroid cancer

Cervical lymph nodes (CLNs) are the most common site of metastases in papillary thyroid cancer (PTC). Ultrasound scan (US) is the most commonly used imaging modality in the evaluation of CLNs in PTC. Computerised tomography (CT) and (18)fluorodeoxyglucose positron emission tomography ((18)FDG PET-CT) are used less commonly. It is widely believed that the above imaging techniques should guide the surgical approach to the patient with PTC.

METHODS

We performed a systematic review of imaging studies from the literature assessing the usefulness for the detection of metastatic CLNs in PTC. We evaluated the author's interpretation of their numeric findings specifically with regard to 'sensitivity' and 'negative predictive value' (NPV) by comparing their use against standard definitions of these terms in probabilistic statistics.

RESULTS

A total of 16 studies used probabilistic terms to describe the value of US for the detection of LN metastases. Only 6 (37.5%) calculated sensitivity and NPV correctly. For CT, out of the eight studies, only 1 (12.5%) used correct terms to describe analytical results. One study looked at magnetic resonance imaging, while three assessed (18)FDG PET-CT, none of which provided correct calculations for sensitivity and NPV.

CONCLUSION

Imaging provides high specificity for the detection of cervical metastases of PTC. However, sensitivity and NPV are low. The majority of studies reporting on a high sensitivity have not used key terms according to standard definitions of probabilistic statistics. Against common opinion, there is no current evidence that failure to find LN metastases on ultrasound or cross-sectional imaging can be used to guide surgical decision making.