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Endocrine Care: Sophie Leboulleux, Elizabeth Girard, Mathieu Rose, Jean Paul Travagli, Nadia Sabbah, Bernard Caillou, Dana M. Hartl, Nathalie Lassau, Eric Baudin, and Martin Schlumberger Ultrasound Criteria of Malignancy for Cervical Lymph Nodes in Patients Followed Up for Differentiated Thyroid Cancer J Clin Endocrinol Metab 2007; 92: 3590-3594 [Abstract] [Full text] [PDF]

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Ultrasonographic differentiation of cervical lymph nodes in patients with thyroid cancer

Pedro Weslley Rosario, Wilson C. Tavares   (26 July 2007)

Ultrasonographic differentiation of cervical lymph nodes in patients with thyroid cancer 26 July 2007
Pedro Weslley Rosario Santa Casa de Belo Horizonte, Brazil, Wilson C. Tavares Send letter to journal: Re: Ultrasonographic differentiation of cervical lymph nodes in patients with thyroid cancer pedrorosario{at}globo.com Pedro Weslley Rosario, et al.	Leboulleux et al. (1) correlated ultrasound features with the histological diagnosis of 56 lymph nodes from 19 patients with differentiated thyroid carcinoma. In their discussion, the authors point out the limitations of their study: 1. only patients with known residual disease were selected; inclusion of patients previously submitted to treatment (i.e., thyroidectomy, neck dissection and radioiodine) that might change LN features; 2. diagnosis of recurrence based on US scans in only 3/19 patients; 3, histology obtained for only half the LN; and 4) small sample size (n = 56 LN). The potential influences of these factors may be answered, in larger part, by viewing the results of Leboulleux et al. (1) in light of our previously published experience (2). In our latter study, 112 consecutive patients were included without pre-selection and evaluated before thyroidectomy. The patients were systematically examined by US and not because of a suspicion of metastases determined by other methods. All LN detected on US scans were removed during surgery and a histological diagnosis was obtained. In addition, a larger number of LNs were examined (n = 350 LN, 198 malignant and 152 benign). Microcalcifications and/or cystic degeneration were observed in 135/198 malignant LN (data not previously shown) and in 0/152 benign LN (100% specificity). Visualization of a hyperechogenic hilum was highly suggestive of benign disease and when combined with a long-to-short axis (L/S) ratio > 2 presented a negative predictive value of 100% (100/100 LN were benign) (data not previously shown). In the absence of microcalcifications and/or cystic degeneration, the lack of a echogenic hilum associated with an L/S ratio < 2 was highly suggestive of malignancy (47/53 LN were metastatic) (data not previously shown). The absence of a hyperechogenic hilum alone was less discriminative, whereas an L/S ratio < 2 as the single finding was associated high probability of benign disease. Based on these findings, we proposed the following approach in clinical practice (3): LN with visible hyperechogenic hilum and L/S > 2 (benign): No additional procedure. LN with visible hyperechogenic hilum and L/S < 2 (probably benign): Repetition of US after 3 months. LN with absent hyperechogenic hilum and L/S > 2 (indeterminate): FNAB if peripheral vascularization is present and repetition of US after 3 months if absent (FNAB might be performed in patients with high suspicion of recurrence). LN with absent hyperechogenic hilum and L/S < 2 (probably malignant): FNAB. LN with microcalcification and/or cystic degeneration (malignant): Surgery. We hope that further studies on this subject will validate our proposal or reveal its limitations so that the suggested management can be improved. References 1. Leboulleux S, Girard E, Rose M, Travagli JP, Sabbah N, Caillou B, Hartl DM, Lassau N, Baudin E, Schlumberger M. 2007. Ultrasound criteria of malignancy for cervical lymph nodes in patients followed for differentiated thyroid cancer. J Clin Endocrinol Metab doi:10.1210/jc.2007-0444, published online July 3, 2007 2. Rosario PW, de Faria S, Bicalho L, Alves MF, Borges MA, Purisch S, Padrao EL, Rezende LL, Barroso AL. 2005. Ultrasonographic differentiation between metastatic and benign lymph nodes in patients with papillary thyroid carcinoma. J Ultrasound Med 24:1385-1389 3. Rosario PW, Tavares WC, Biscolla RP, Purisch S, Maciel RM. 2007. Usefulness of neck ultrasonography in the follow-up of patients with differentiated thyroid cancer. Braz Arch Endocrinol Metab 51:593-600