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Follow-Up of Low Risk Patients with Papillary Thyroid Cancer: Role of Neck Ultrasonography in Detecting Lymph Node Metastases

Unit of Endocrinology, Scientific Institute Casa Sollievo della Sofferenza (M.T., U.C.), 71013 S. Giovanni Rotondo, Foggia, Italy; Cervello Hospital (M.A., G.D’A.), 90100 Palermo, Italy; Tinchi-Pisticci Hospital (R.B.), 75020 Matera, Italy; Bentivoglio Hospital (D.M.), 40010 Bologna, Italy; Department of Biomedical Sciences, University of Catania (S.T.), 95100 Catania, Italy; Department of Experimental and Clinical Medicine, University Magna Graecia (G.C., R.S., F.A.), 88100 Catanzaro, Italy; and Department of Experimental Medicine and Pathology (E.F.) and Clinical Sciences (S.F.), University La Sapienza, 00161 Rome, Italy

Address all correspondence and requests for reprints to: Dr. Sebastiano Filetti, 2a Clinica Medica, Dipartimento di Scienze Cliniche, Universita’ degli Studi di Roma, La Sapienza, v.le del Policlinico, 155, 00161 Rome, Italy. E-mail:sebastiano.filetti{at}uniroma1.it.

Persistent or recurrent disease is rare in low risk patients with papillary thyroid cancer, and follow-up of these patients is a matter of debate. Neck ultrasonography (US), serum thyroglobulin (Tg), and whole body scan (WBS) after T₄ withdrawal were performed in 456 patients, followed up to 5 yr. At the end of the first year, 335 patients were Tg negative, and 121 were Tg positive; 65 of 96 patients with Tg levels between 1 and 10 ng/ml became spontaneously Tg negative after 2 yr. During follow-up, WBS discovered node metastases in 13 subjects, and US discovered node metastases in 38 subjects (31 Tg positive and 7 Tg negative). WBS did not add any information, because all WBS-positive patients were also US and Tg positive. Fifty percent of metastases were less than 1 cm and not palpable. Finally, the negative predictive value of both negative Tg and US at first follow-up was 98.8%. We suggest a first follow-up based upon US assessment and stimulated (after T₄ withdrawal or recombinant human TSH) serum Tg determination; subsequently, 1) US should not be mandatory at each examination in initially Tg- and US-negative subjects, but is strongly suggested in all other cases; 2) Tg determination should be repeated 1 yr later, after exogenous or endogenous TSH stimulation only in initially Tg-positive patients without any other evidence of residual disease; and 3) Tg measurement during therapy should be sufficient in all other cases.

This work was supported by the Italian Ministry of Health and a grant from Ministero dell’Istruzione dell’Università e della Ricerca (to S.F.).

Abbreviations: FNAB, Fine needle aspiration biopsy; (–), negative; (+), positive; PPV, positive predictive value; PTC, papillary thyroid carcinoma; Tg, thyroglobulin; THW, thyroid hormone withdrawal; US, ultrasonography; WBS, whole body scan.

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