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John M. Stulak, MD; Clive S. Grant, MD; David R. Farley, MD; Geoffrey B. Thompson, MD; Jon A. van Heerden, MD; Ian D. Hay, MD; Carl C. Reading, MD; J. William Charboneau

Arch Surg. 2006;141:489-496.

Background  Cervical recurrences, predominantly in lymph nodes, occur in 14% to 30% of patients with papillary thyroid cancer (PTC). Postoperative surveillance for recurrent PTC increasingly includes thyrotropin-stimulated thyroglobulin and high-resolution ultrasonography (US). This combination commonly can detect recurrent disease as small as 5 mm.

Hypothesis  Preoperative US will increase detection and assessment of the extent of lymph node metastasis (LNM) in patients with PTC.

Design  Retrospective cohort study.

Setting  Tertiary care academic center.

Patients  From January 1, 1999, to December 31, 2004, a total of 770 patients were seen, 551 (381 female and 170 male; median age, 47 years; age range, 9-89 years) who underwent initial surgical management and 219 (154 female and 65 male; median age, 44 years; age range, 5-90 years) who underwent cervical reoperation for PTC. The US images were obtained preoperatively for 486 initial and 216 reoperative patients. Therapeutic radioactive iodine was administered to 151 (68.9%) of the reoperative patients before the subsequent operation (median dose, 5.6 x 10⁹ Bq; range, 7.4 x 10⁸-3.7 x 10¹⁰ Bq).

Results  Ultrasonography identified nonpalpable lateral jugular LNMs in 70 (14.4%) of the patients undergoing initial exploration. Similarly, in reoperative patients, nonpalpable lateral LNMs were detected via US in 106 (64.2%), and 61 (28.2%) had LNMs detected in the central neck. Even when nodes were palpable preoperatively (37 [6.7%] of the initial and 56 [25.6%] of the reoperative patients), US assessment of the extent of LNM involvement altered the operation in 15 (40.5%) of the initial and 24 (42.9%) of the reoperative patients. The sensitivity, specificity, and positive predictive value for US were 83.5%, 97.7%, and 88.8% in initial patients, and 90.4%, 78.9%, and 93.9% in reoperative patients.

Conclusions  Overall, preoperative US detected nonpalpable LNMs in 231 (32.9%) of the 702 patients with PTC who underwent US, thereby altering the operative procedure performed. In addition, even in patients with palpable LNs, US helped to guide the extent of lymphadenectomy.

Author Affiliations: Departments of Gastrointestinal and General Surgery (Drs Stulak, Grant, Farley, Thompson, and van Heerden), Endocrinology (Dr Hay), and Diagnostic Radiology (Dr Reading and Mr Charboneau), Mayo Clinic College of Medicine, Rochester, Minn.

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