To determine what ultrasonographic features can identify metastatic cervical lymph nodes, both preoperatively and in recurrences after complete thyroidectomy.
Study Design
Prospective.
Setting
Outpatient clinic, Department of Head and Neck Surgery, School of Medicine, University of São Paulo, Brazil.
Subjects and Methods
A total of 1976 lymph nodes were evaluated in 118 patients submitted to total thyroidectomy with or without cervical lymph node dissection. All the patients were examined by cervical ultrasonography, preoperatively and/or postoperatively. The following factors were assessed: number, size, shape, margins, presence of fatty hilum, cortex, echotexture, echogenicity, presence of microcalcification, presence of necrosis, and type of vascularity. The specificity, sensitivity, positive predictive value, and negative predictive value of each variable were calculated. Univariate and multivariate logistic regression analyses were conducted. A receiver operator characteristic (ROC) curve was plotted to determine the best cutoff value for the number of variables to discriminate malignant lymph nodes.
Results
Significant differences were found between metastatic and benign lymph nodes with regard to all of the variables evaluated (P < .05). Logistic regression analysis revealed that size and echogenicity were the best combination of altered variables (odds ratio, 40.080 and 7.288, respectively) in discriminating malignancy. The ROC curve analysis showed that 4 was the best cutoff value for the number of altered variables to discriminate malignant lymph nodes, with a combined specificity of 85.7%, sensitivity of 96.4%, and efficiency of 91.0%.
Conclusion
Greater diagnostic accuracy was achieved by associating the ultrasonographic variables assessed rather than by considering them individually.
HaugenBRAlexanderEKBibleKC. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26:1-133.
2.
HassanaimMWexlerM.Conservative management of well-differentiated thyroid cancer. Can J Surg. 2010;53:109-118.
3.
Moulton-BarrettRCrumleyRJalilieS. Complications of thyroid surgery. Int Surg. 1997;82:63-66.
4.
FilhoJGKowalskiLP.Postoperative complications of thyroidectomy for differentiated thyroid carcinoma. Am J Otolaryngol. 2004;25:225-230.
5.
PaciniFMolinaroECastagnaMG. Recombinant human thyrotropin-stimulated serum thyroglobulin combined with neck ultrasonography has the highest sensitivity in monitoring differentiated thyroid carcinoma. J Clin Endocrinol Metab. 2003;88:3668-3673.
6.
BonnetSHartlDLeboulleuxS. Prophylactic lymph node dissection for papillary thyroid cancer less than 2 cm: implications for radioiodine treatment. J Clin Endocrinol Metab. 2008;94:1162-1167.
7.
TriponezFPoderLZarnegarR. Hook needle-guided excision of recurrent differentiated thyroid cancer in previously operated neck compartments: a safe technique for small, nonpalpable recurrent disease. J Clin Endocrionol Metab. 2006;91:4943-4947.
8.
TorlontanoMAttardMCrocettiU. Follow-up of low risk patients with papillary thyroid cancer: role of neck ultrasonography in detecting lymph node metastases. J Clin Endocrinol Metab. 2004;89:3402-3407.
9.
GuerreroMAClarkOH.Controversies in the management of papillary thyroid cancer revisited. ISRN Oncol. 2011;2011:303128.
10.
LudwigBJWangJNadgirRNSaitoNCastro-AragonISakaiO.Imaging of cervical lymphadenopathy in children and young adults. AJR Am J Roentgenol. 2012;199:1105-1113.
11.
CibasESAliSZ.The Bethesda system for thyroid cytopathology. Thyroid. 2009;19:1159-1165.
12.
SomPMCurtinHDMancusoAA.Imaging-based nodal classification for evaluation of neck metastatic adenopathy. AJR Am J Roentgenol. 2000;174:837-843.
13.
AhujaATChowLChikWKingWMetreweliC.Metastatic cervical nodes in papillary carcinoma of the thyroid: ultrasound and histological correlation. Clin Radiol. 1995;50:229-231.
14.
ChammasMCLundbergJSJulianoAGSaitoOSMarcelinoASZCerriGG.Cervical lymph nodes: a dilemma for the ultrasonographist [in Portuguese]. Radiol Bras. 2004;37:357-364.
15.
AhujaATYingM.Sonographic evaluation of cervical lymph nodes. AJR Am J Roentgenol. 2005;184:1691-1699.
16.
VassalloPWerneckeKRoosNPetersPE.Differentiation of benign from malignant superficial lymphadenopathy: the role of high-resolution US. Radiology. 1992;183:215-220.
17.
IyerNGShahaAR.Management of thyroid nodules and surgery for differentiated thyroid cancer. Clin Oncol (R Coll Radiol). 2010;22:405-412.
18.
JohnsonNATublinME.Postoperative surveillance of differentiated thyroid carcinoma: rationale, techniques, and controversies. Radiology. 2008;249:429-444.
19.
ChikuiTYonetsuKNakamuraT.Multivariate feature analysis of sonographic findings of metastatic cervical lymph nodes: contribution of blood flow features revealed by power Doppler sonography for predicting metastasis. AJNR Am J Neuroradiol. 2000;21:561-567.
20.
RandolphGWDuhQYHellerKS. The prognostic significance of nodal metastases from papillary thyroid carcinoma can be stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. Thyroid. 2012;22:1144-1152.
21.
SacksWFaminiP.Lymph node metastases can have a significant impact on recurrence of thyroid cancer. Clin Thyroidol. 2013;25:233-236.
22.
YoshidaHYusaHUenoETohnoETsunoda-ShimizuH.Ultrasonographic evaluation of small cervical lymph nodes in head and neck cancer. Ultrasound Med Biol. 1998;24:621-629.
23.
SteinkampHJCornehlMHostenNPegiosWVoglTFelixR.Cervical lymphadenopathy: ratio of long- to short-axis diameter as a predictor of malignancy. Br J Radiol. 1995;68:266-270.
24.
YingMAhujaAMetreweliC.Diagnostic accuracy of sonographic criteria for evaluation of cervical lymphadenopathy. J Ultrasound Med. 1998;17:437-445.
25.
BrysonTCGaurandVSSrinivasanAMukherjiSK.Cervical lymph node evaluation and diagnosis. Otolaryngol Clin North Am. 2012;45:1363-1383.
26.
ToriyabeYNNishimuraTKitaSSaitoYMiyokawaN.Differentiation between benign and metastatic cervical lymph nodes with ultrasound. Clin Radiol. 1997;52:927-932.
27.
DudeaSMLenghelMBotar-JidCVasileuDDumaM.Ultrasonography of superficial lymph nodes: benign vs malignant. Med Ultrason. 2012;4:294-306.
28.
YuasaKKawazuTNagataTKandaSOhishiMShirasunaK.Computed tomography and ultrasonography of metastatic cervical lymph nodes in oral squamous cell carcinoma. Dentomaxillofac Radiol. 2000;29:238-244.
29.
NapolitanoGRomeoAValloneG. How the preoperative ultrasound examination and BFI of the cervical lymph nodes modify the therapeutic treatment in patients with papillary thyroid cancer. BMC Surg. 2013;13(suppl 2):S52.
30.
KunaSKBracicITesicVKunaKHercegGHDodigD.Ultrasonographic differentiation of benign from malignant neck lymphadenopathy in thyroid cancer. J Ultrasound Med. 2006;25:1531-1537.
31.
LeeYSLimYSLeeJC. Ultrasonographic findings relating to lymph node metastasis in single micropapillary thyroid cancer. World J Surg Oncol. 2014;12:273-279.
32.
SohnYMKwakJYKimEKMoonHJKimSJKimMJ.Diagnostic approach for evaluation of lymph node metastasis from thyroid cancer using ultrasound and fine-needle aspiration biopsy. AJR Am J Roentgenol. 2010;194:38-44.
33.
GiacominiCPJeffreyRBShinLK.Ultrasonographic evaluation of malignant and normal cervical lymph nodes. Semin Ultrasound CT MR. 2013;34:236-47.
34.
SomPM.Detection of metastasis in cervical lymph nodes: CT and MR criteria and differential diagnosis. AJR Am J Roentgenol. 1992;158:961-969.
35.
Van den BrekelMWStelHVCastelijnsJA. Cervical lymph node metastasis: assessment of radiologic criteria. Radiology. 1990;177:379-384.
36.
AhujaAYingMKingAYuenHY.Lymph node hilus: gray scale and power Doppler sonography of cervical nodes. J Ultrasound Med. 2001;20:987-992.
37.
ArijiYKimuraYHavashiN. Power Doppler sonography of cervical lymph nodes in patients with head and neck cancer. AJNR Am J Neurradiol. 1998;19:303-307.
38.
TschammlerAWirknerHOttGHahnD.Vascular patterns in reactive and malignant lymphadenopathy. Eur Radiol. 1996;6:473-480.
39.
KimEParkJSSonKRKimJJeonSJNaDG.Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma: comparison of ultrasound, computed tomography, and combined ultrasound with computed tomography. Thyroid. 2008;18:411-418.
40.
StulakJMGrantCSFarleyDR. Value of preoperative ultrasonography in the surgical management of initial and reoperative papillary thyroid cancer. Arch Surg. 2006;141:489-494.
41.
ShimamotoKSatakeHSawakiAIshigakiTFunahashiHImaiT.Preoperative staging of thyroid papillary carcinoma with ultrasonography. Eur J Radiol. 1998;29:4-10.
42.
VinakayaUSShivalliSRaiSHarisAMadhurkarRHemrajS.Diagnostic accuracy of high resolution ultrasound to differentiate neoplastic and non neoplastic causes of cervical lymphadenopathy. J Clin Diagn Res. 2014;8:5-7.
43.
CavallieriSAKligermanJCavallieriFAContiCDGomesCFA. Ultrasonography-guided preoperative marking of non palpable lymph node metastases in the cervical region using coal [in Portuguese]. Rev Bras Cir Cabeça Pescoço. 2013;42:83-87.
