Diagnostic Approach Lympnode Metastase With Usg and Fna

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38 AJR:194 , January 2010

larity on color Doppler images [3, 6, 8, 9, 14].

Recent studies have shown excellent diag-

nostic performance using a combination of

various ultrasound characteristics [3, 710].

However, loss of fatty hilum as a diagnostic

ultrasound criterion of metastatic lymph

nodes has been the subject of debate [1619].

The cytology results of metastatic thyroid

cancer in cervical lymph nodes displayed

a higher frequency of foamy macrophages

(38.5%) and cystic degeneration (44.7%),even though no malignant cells were found

on cytology [20]. However, to the best of

our knowledge, the frequency of metastasis

according to each cytology result of lymph

nodes has not been reported. Therefore, in

this study we investigated the most accurate

criteria to differentiate metastatic from be-

nign lymph nodes on ultrasound and evalu-

ated the frequency of metastasis according to

the cytology results.

Diagnostic Approach for Evaluation

of Lymph Node Metastasis FromThyroid Cancer Using Ultrasoundand Fine-Needle Aspiration Biopsy

Yu-Mee Sohn1,2

Jin Young Kwak1

Eun-Kyung Kim1

Hee Jung Moon1

Soo Jin Kim1

Min Jung Kim1

Sohn YM, Kwak JY, Kim EK, Moon HJ, Kim SJ,

Kim MJ

1Department of Radiology, Research Institute of

Radiological Science, Yonsei University College ofMedicine, 250 Seongsanno, Seodaemun-gu, Seoul

120-752, South Korea. Address correspondence to

J. Y. Kwak ([email protected]).

2Department of Radiology, Kyung Hee University Medical

Center, Seoul, South Korea.

Neuroradiology/Head and Neck Imaging Original Research

AJR2010; 194:384 3

0361803X/10/194138

American Roentgen Ray Society

Thyroid cancer often metastasizes

to cervical lymph nodes, and ear-

ly detection of metastasis is im-

portant for planning surgery and

management of patients [1]. Ultrasound is the

imaging method of choice for detecting and

characterizing cervical lymph nodes in thy-

roid cancer and providing guidance for fine-

needle aspiration biopsy (FNAB) [1]. Ultra-

sound and ultrasound-guided FNAB are the

main diagnostic tools for detecting cervicalmetastasis of thyroid cancer by preoperative

cytologic analysis and recurrence after thy-

roid surgery [25]. Numerous previous re-

ports have described the ultrasound character-

istics of metastatic lymph nodes of papillary

thyroid cancer, such as the presence of calcifi-

cation [1, 3, 510], cystic change [1, 3, 512],

loss of an echogenic fatty hilum [3, 510, 13

15], hyperechogenicity [3, 6, 810], round

shape [3, 510, 13, 14], and abnormal vascu-

Keywords:fine-needle aspiration biopsy, lymph node

metastasis, ultrasound

DOI:10.2214/AJR.09.3128

Received June 3, 2009; accepted after revision

July 2, 2009.

FOCUSON:

OBJECTIVE.The purpose of our study was to investigate ultrasound criteria to deter-

mine the most accurate criterion to differentiate metastatic from benign lymph nodes on ul-

trasound and to evaluate the frequency of metastasis according to the cytology results.

MATERIALS AND METHODS.One hundred eighteen consecutive patients with thy-

roid malignancy underwent fine-needle biopsy of suspicious lymph nodes. We investigated

the diagnostic performance of each ultrasound feature (loss of fatty hilum, presence of cystic

change or calcification, hyperechogenicity, and round shape) and ultrasound criteria 1 and 2.We considered criterion 1 to be if one of the aforementioned malignant ultrasound findings

was present and criterion 2 to be if one of the aforementioned malignant ultrasound findings,

excluding the loss of fatty hilum, was present. Cytology results were divided into metastasis,

macrophages without malignant cells, cell paucity, and negative for malignancy, and we eval-

uated the frequency of metastasis.

RESULTS.There were 91 metastatic and 27 benign nodes. The area under the receiver

operating characteristic curve value of criterion 2 was significantly higher than that of crite-

rion 1. The frequency of metastasis was highest with a cytologic result of metastasis (95.8%),

followed by macrophages without malignant cells (87.5%), cell paucity (71.4%), and negative

for malignancy (34.4%).

CONCLUSION.The most accurate ultrasound criterion to differentiate metastatic from

benign lymph nodes was ultrasound criterion 2 (any suspicious ultrasound features except for

loss of fatty hilum), and we should not neglect lymph nodes with suspicious ultrasound fea-

tures, even if they do not contain malignant cells on cytology.

Sohn et al.Ultrasound and FNAB of Lymph Node Metastasis

Neuroradiology/Head and Neck ImagingOriginal Research


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AJR:19 4, January 2010 39

Ultrasound and FNAB of Lymph Node Metastasis

Materials and Methods

Patients

The institutional review board approved this

retrospective observational study and required nei-

ther patient approval nor patient informed consent

for the review of images and records. Informed

consent was obtained from all patients before

FNAB. From January 2003 to December 2005,

135 consecutive patients at our institution under-

went FNAB due to suspicious metastatic cervical

lymph nodes of papillary thyroid carcinoma. Dur-

ing the study period, we considered a lymph node

to be suspicious when it had one of following fea-

tures: loss of fatty hilum, cystic change, calcifica-

tion, hyperechogenicity (higher echogenicity than

the surrounding muscles), and round shape (long

to transverse diameter ratio < 1.5). Doppler ultra-

sound was not routinely performed. Eight lymph

nodes in eight patients were excluded because

there was no subsequent surgical excision or long-

term imaging follow-up for at least 2 years. Nine

patients also were excluded because ultrasound

examinations were unavailable. Ultimately, 118lymph nodes in 118 patients were included in this

analysis. Forty-eight patients had already under-

gone surgery for thyroid papillary carcinoma, and

the remaining 70 had no pr ior surgery for cytologi-

cally confirmed papillary carcinoma (Table 1).

Imaging and Image Analyses

Ultrasound evaluation of cervical lymph nodes

was undertaken using a 7-15MHz linear-array

transducer (HDI 5000, Philips Healthcare) and

8-15MHz linear-array transducer (Acuson Se-

quoia, Siemens Healthcare). Compound imaging

was performed in all cases using the HDI 5000

machine, and lymph node sizes were measured

along the longest diameter on transverse scans.

Two radiologists with 2 and 8 years of expe-

rience with thyroid imaging retrospectively re-

viewed the thyroid ultrasound examinations in

consensus. They had no knowledge of the clini-

cal history or cytopathologic results of the patients

while performing the consensus reading. Suspi-

cious ultrasound features of lymph nodes were

the following: loss of fatty hilum, cystic change,

calcification, hyperechogenicity (higher echoge-

nicity than the surrounding muscles), and round

shape (long to transverse diameter ratio < 1.5)

(Figs. 13). The ultrasound results were grouped

as positive (suspicious) and negative (benign),

and lymph nodes were considered positive if one

of the malignant sonographic findings was pres-

ent on ultrasound (cr iterion 1) [1, 3, 510]. Lymph

nodes were also considered positive if one of the

malignant sonographic findings was present, ex-

cluding loss of fatty hilum (criterion 2), on ultra-

sound [1619].

Preoperative Evaluation of Lymph Nodes

At our institution, we performed ultrasound-

guided FNAB on lymph nodes with suspicious ul-

trasound features. However, we did not perform

ultrasound-guided FNAB on central lymph nodes

with suspicious ultrasound features in patients

who were scheduled for thyroidectomy because

routine central lymph node dissections were per-

formed at the time of thyroidectomy. Lymph nodes

were considered suspicious during the study peri-od when one of the suspicious ultrasound findings

(loss of fatty hilum, calcifications, cystic change,

hyperechogenicity, and round shape) was present.

Ultrasound-guided FNAB was performed by

one of three radiologists who had 4, 6, and 10

years of experience with thyroid imaging. They

were aware of the patients clinical histories. Ul-

trasound-guided FNAB was performed with a

23-gauge needle attached to a 20-mL disposable

plastic syringe and aspirator. Materials obtained

from FNAB were smeared on glass slides. All

smears were placed in 95% alcohol for Papanico-

lau staining, and the remaining material was rinsed

in saline to be processed as a cell block. The cyto-

pathologist was not on site during the biopsy.

Cytopathologic Evaluation

One of five cytopathologists interpreted the ul-

trasound-guided FNAB according to their sched-

ules. They were blinded with respect to the ul-

trasound diagnosis. At our institution, cytology

results were divided into one of the following four

categories: metastasis, macrophages without ma-

lignant cells, cell paucity, and negative for ma-

lignancy. Metastasis was defined as positive for

metastatic thyroid carcinoma [3], macrophages

without malignant cells were reported when cy-

tology showed foamy macrophages with no malig-

nant cells [20], cell paucity was assigned in cases

with insufficient material [3], and negative for ma-

lignancy included reactive lymph nodes or other

benign lymphadenitis [3]. We used the initial cy-

tologic report for the cytopathologic evaluations.

Surgical Protocol and Histopathologic Analyses

When cytology results revealed malignant cells

in lymph nodes, unilateral modified neck dissec-

tion was performed as the initial thyroid surgery.

However, selective frozen sectioning was per-

formed as the initial thyroid surgery in patients

with lymph nodes with suspicious ultrasound fea-tures but no definite malignant cells on cytology.

Selective dissection was performed in patients

who had already undergone thyroid surgery.

We evaluated the final results of aspirated

lymph nodes in level-by-level analyses and com-

pared them to pathology reports.

TABLE 1: Aspirated Lymph Nodes in 118 Patients

Levels of Aspirated LymphNodes

No. of Patients

Initial Surgery (n= 70) Postsurgery (n= 48)

I 1

II 4 8

III 31 14

IV 28 19

V 7 4

VI 2

Fig. 137-year-oldwoman with level IVmetastatic lymph nodein left neck. Ultrasoundimage shows loss of fattyhilum, microcalcification,and hyperechogenicityin lymph node (arrows).Cytology resultsconfirmed lymph nodemetastasis.


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Sohn et al.

Statistical AnalysesA reference standard was set by pathology re-

sults from lymph node dissections or long-term

imaging follow-up for at least 2 years with no sub-

sequent surgical excision. Categorical data were

summarized using frequencies and percentages.

The Students t test was used to determine dif-

ferences between metastatic and benign lymph

nodes according to age and lymph node size on

ultrasound. The chi-square test was performed to

evaluate the differences between benign and ma-

lignant groups by sex.

Diagnostic performance, including sensitiv-

ity, specificity, accuracy, positive predictive val-

ue (PPV), and negative predictive value (NPV),

was calculated according to the ultrasound find-

ings. We also examined diagnostic performance

by ultrasound grouping (criteria 1 and 2). The chi-

square test or Fishers exact test was used to com-

pare each ultrasound finding to standard results.

Receiver operating characteristic (ROC) curve

analysis was performed to compare the two ul-

trasound criteria to differentiate metastatic from

benign lymph nodes. We evaluated the frequency

of metastasis according to cytology results. Statis-

tical significance was assumed when the pvalue

was less than 0.05.

Results

This study included 23 men and 95 women

with a mean age of 51 13.4 years. The mean

size of lymph nodes was 13.8 8.5 mm.

Pathologic confirmations were obtained from

115 patients. There were 91 malignant and

24 benign results on pathology. Three pa-

tients who did not undergo surgery had nodes

that decreased in size during the long-term

imaging follow-up duration of at least 2

years. Therefore, this study consisted of 91

malignant and 27 benign lymph nodes. There

was no significant difference between meta-

static and benign lymph nodes according to

age (p = 0.765) and sex (p = 0.071). The

mean longest diameter of metastatic lymph

nodes (14.5 mm 9 mm) was significantly

larger than that of benign nodes (11.4 mm

5.8 mm) (p= 0.042).

The diagnostic performance of each ultra-

sound finding in this study is shown in Table 2.

Ultrasound criteria 1 and 2 as well as each

suspicious ultrasound feature had statistical

significance with metastasis. Most ultrasound

features had high specificity and PPV but low

sensitivity and NPV. However, loss of fatty hi-

lum had the highest sensitivity and NPV but

showed lower specificity than other ultrasound

features. When each ultrasound feature and

ultrasound criteria 1 and 2 were compared,

criterion 2 had the highest accuracy. The area

under the ROC curve value (0.83; 95% CI,

0.7390.920] of criterion 2 was significantly

higher than that (0.704; 95% CI, 0.6090.798)

of criterion 1 (p= 0.006) (Fig. 4).

Fig. 256-year-old woman with level IV metastatic lymph nodes in right neck.Ultrasound image shows microcalcification (arrow), loss of fatty hilum, and roundshape in lymph nodes (arrowheads). Cytology results confirmed lymph nodemetastasis.

Fig. 332-year-old woman with level II metastatic lymph nodes in left neck.Ultrasound image shows loss of fatty hilum and cystic change. Cytology resultsconfirmed macrophages without malignant cells.

TABLE 2: Diagnostic Accuracy of Each Ultrasound Feature

Ultrasound Feature TP TN FP FNSensitivity

(%)Specificity

(%) Accuracy (%) PPV (%) NPV (%)

Loss of fatty hilum 91 13 14 0 100 (91/91) 48 (13/27) 88 (104/118) 87 (91/105) 100 (13/13)

Cystic change 31 26 1 60 34 (31/91) 96 (26/27) 48 (57/118) 97 (31/32) 30 (26/86)Presence of calcification 41 25 2 50 45 (41/91) 93 (25/27) 56 (66/118) 95 (41/43) 33 (25/75)

Hyperechogenicity 54 23 4 37 59 (54/91) 85 (23/27) 65 (77/118) 93 (54/58) 38 (23/60)

Round shape 50 24 3 41 55 (50/91) 89 (24/27) 63 (74/118) 94 (50/58) 37 (24/65)

Any suspicious ultrasound feature (criterion 1) 91 11 16 0 100 (91/91) 41 (11/27) 86 (102 /118) 85 (91/107) 100 (11/11)

Any suspicious ultrasound feature, excludingloss of fatty hilum (criterion 2)

87 19 8 4 96 (87/91) 70 (19/27) 89 (106/118) 92 (87/95) 83 (19/23)

NoteData in parentheses are number of cases. TP = true-positive, TN = true-negative, FP = false-positive, FN = false-negative, PPV = positive predictive value,NPV = negative predictive value.


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The frequency of metastasis was highest

with a cytology reading of metastasis (68/71,

95.8%), followed by macrophages without

malignant cells (7/8, 87.5%), cell paucity

(5/7, 71.4%), and negative for malignancy

(11/32, 34.4%).

Discussion

Ultrasound characteristics of metastatic

lymph nodes of thyroid cancer have been re-

ported by several investigators [1, 5, 6, 11].

Major ultrasound characteristics suggest-

ing metastasis of thyroid cancer included the

presence of calcification [1, 3, 510], cystic

change [1, 3, 512], loss of echogenic fatty

hilum [3, 510, 1315], hyperechogenicity

[3, 6, 810], round shape [3, 510, 13, 14],

and abnormal vascularity [3, 6, 8, 9, 14]. The

results of previous studies [5, 711] that ex-

amined diagnostic performance of each ul-

trasound characteristic are shown in Table 3.

The frequency of metastasis was 62.0100%

in lymph nodes with absent hilum [5, 710],19.080.0% in those with round shapes [7

10], 58.086.0% in those with hyperechoge-

nicity [810], 3.049.5% in those with calci-

fication [5, 711], 13.270.0% in those with

cystic change [5, 7, 911], and 47.047.6% in

those with abnormal vascularity [8, 9].

Of these ultrasound characteristics, sever-

al studies have shown that calcification and

cystic change have 100% specificity and PPV

[10, 11] and that they are not observed in nor-

mal or reactive lymph nodes [10]. Calcifica-

tions in metastatic lymph nodes are shown in

punctate microcalcifications on ultrasound,

and these calcifications are laminated, cal-cified, spherical bodies on cytology that are

called psammoma bodies [21]. Psammoma

bodies were reported to be formed by calci-

fication of intravascular tumor thrombi or in-

farcted tips of malignant papillae, and their

presence is considered to be diagnostic of

malignancy [22]. Some investigators have

reported that cystic degeneration of lymph

nodes was highly suggestive of metastasis in

thyroid cancer [1, 11, 23] and squamous cell

carcinoma of the head and neck [23]. Thy-

roid papillary carcinoma most commonly

showed cystic formation in lymph node me-

tastasis, and the incidence of cystic change of

lymph nodes in thyroid cancer was reported

in 1025% of cases [23]. This cystic change

is the result of liquefaction necrosis [12] or

spontaneous or postradiotherapeutic central

breakdown of keratin, which gives the node a

pseudocystic appearance [24]. Cystic chang-

es are shown on ultrasound as small solitary

cystic areas, multiple peripheral cystic areas,

or almost complete replacement of the node

by cystic formation [11]. Another study [12]

reported that pure cystic change was most-

ly found in young adults. These ultrasound

findings were explained by the increased ag-

gressiveness of tumors at a young age, which

caused extensive necrosis [24]. In the current

study, cystic change also had high specificity

and PPV as diagnostic ultrasound features.

Several investigators revealed good re-sults on preoperative staging when the cri-

terion involving one suspicious finding was

present on ultrasound [9, 17, 25, 26]. In this

study, we evaluated diagnostic performance

in the diagnosis of metastasis with combined

ultrasound criteria (1 and 2) as well as sus-

picious ultrasound findings, such as loss of

fatty hilum, calcification, cystic change, hy-

perechogenicity, and round shape. Most ul-

trasound features had high specificity and

PPV but low sensitivity and NPV. However,

loss of fatty hilum had the highest sensitiv-

ity and NPV but lower specificity than oth-

er ultrasound features. This result is consis-tent with previous reports [1619] that loss

of fatty hilum is not a definite criterion for

differentiation between malignant and be-

nign lymph nodes. When each ultrasound

feature and ultrasound criteria 1 and 2 were

compared, criterion 2 had the highest accu-

racy, with a significantly higher area under

the curve value than criterion 1. The results

correspond to those of previous studies that

loss of fatty hilum is not a specific ultrasound

feature for malignancy [1619].

Until now, malignant cells on cytology

have been considered suggestive of metasta-

sis, prompting surgical management. How-

ever, the frequency of metastasis has been

reported rarely on other cytologic results of

suspicious lymph nodes on ultrasound, to thebest of our knowledge. Cytology results of

metastatic thyroid cancer in cervical lymph

nodes displayed a higher frequency of foamy

macrophages (38.5%), even if no malignant

cells were found on cytology [20, 23]. In this

study, we categorized cytologic results as

metastasis, presence of macrophages with-

out malignant cells, cell paucity, and nega-

tive for malignancy. The inclusion of mac-

rophages in this criterion was supported by

a previous report [20]. The frequency of me-

tastasis was the highest in lymph nodes with

suspicious ultrasound features having malig-

nant cells (95.8%), followed by macrophag-

es without malignant cells (87.5%), cell pau-

city (71.4%), and negative for malignancy

(34.4%).

When metastatic lymph nodes were diag-

nosed on cytology, functional compartment

en bloc dissection was preferred over selec-

tive dissection (berry picking) because of

improved mortality [2730]. However, we

cannot neglect a lymph node with a suspi-

cious ultrasound feature, even when it does

not have malignant cells on cytology. A re-

cent study [31] reported an effective meth-

od of preoperative ultrasound-guided tattoo-ing using charcoal suspension for localizing

nonpalpable cervical recurrent lymph nodes

after thyroidectomy. This method can be ap-

plied to suspicious lymph nodes on ultra-

sound as a preoperative ultrasound marking

for sampling with frozen sectioning and de-

termining further surgical treatment. There-

fore, we suggest that frozen sampling with

preoperative ultrasound marking should be

performed for pathologic confirmation of a

lymph node with a suspicious ultrasound fea-

ture to prevent undertreatment of patients.

In addition to FNAB, several studies [3,

4, 17, 3234] have reported the detection ofthyroglobulin (Tg) in FNAB washout fluid.

FNAB-Tg identified metastasis and recur-

rence of the neck with excellent sensitivity

and specificity, especially cystic metastatic

lymph nodes, which can show a higher inci-

dence of false-negative findings on cytology

than metastatic lymph nodes without cystic

change [3, 23, 32, 33]. Moreover, the FNAB-

Tg test and the combination of FNAB-Tg and

1.0

Sensitivity

1 Specificity

0.8

0.6

0.4

0.2

00 1.00.80.60.40.2

Fig. 4Graph showsreceiver operatingcharacteristic curveof two ultrasoundcriteria to differentiatemetastatic from benignlymph nodes. Areaunder ROC curve value(0.83) of criterion 2

(dashed line) wassignificantly higher than

that of criterion 1 (0.704)(solid line).


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Sohn et al.

FNAB cytology have been shown to be more

sensitive and accurate than FNAB cytology

alone [3, 32, 34]. However, the current study

was a retrospective study, and additional Tg

data could not be obtained.

The first limitation of the current study

is that it is retrospective and included only

patients who underwent ultrasound-guidedFNAB and thyroid surgery or imaging fol-

low-up for at least 2 years. Therefore, selec-

tion bias does exist. Second, the high percent-

age of included lymph nodes with metastasis

with suspicious features on initial ultrasound

resulted in incomplete examination of the

most accurate criterion to differentiate ma-

lignant from benign lymph nodes. This was

another form of selection bias. Third, abnor-

mal vascularity of lymph nodes was not in-

cluded, and inclusion was not possible be-

cause of the retrospective design. Fourth, we

used the initial cytologic results of the lymph

nodes. In the study period, five cytopatholo-

gists interpreted the FNAB slides at our in-

stitution. This was a limitation of the study

because of the possibility of interobserver

variability in cytologic interpretations. Fifth,

we could not perform a node-by-node analy-

sis of all lymph nodes and instead, a level-

by-level analysis was performed. Lastly, the

study included a relatively small number of

patients. Further prospective study will be

necessary to resolve these issues.

In conclusion, the most accurate ultra-

sound criterion to differentiate metastatic

from benign lymph nodes was ultrasoundcriterion 2 (any suspicious ultrasound fea-

tures except loss of fatty hilum), and we

should not neglect lymph nodes with suspi-

cious ultrasound features, even if they do not

contain malignant cells on cytology.

Acknowledgments

The authors are grateful to Kyung Hwa

Han, biostatistician, Department of Research

Affairs, Yonsei University College of Medi-

cine, Seoul, Korea, for her help with the sta-

tistics in this study.

References 1. Miseikyte-Kaubriene E, Trakymas M, Ulys A. Cys-

tic lymph node metastasis in papillary thyroid carci-

noma.Medicina (Kaunas)2008; 44:455459

2. Boland GW, Lee MJ, Mueller PR, Mayo-Smith W,

Dawson SL, Simeone JF. Efficacy of sonographi-

cally guided biopsy of thyroid masses and cervi-

cal lymph nodes.AJR1993; 161:10531056

3. Jeon SJ, Kim E, Park JS, et al. Diagnostic benefit

of thyroglobulin measurement in fine-needle aspi-

ration for diagnosing metastatic cervical lymph

nodes from papillary thyroid cancer: correlations

with US features. Korean J Radiol2009; 10:106

111

4. Kim MJ, Kim EK, Kim BM, et al. Thyroglobulin

measurement in fine-needle aspirate washouts:

the criteria for neck node dissection for patients

with thyroid cancer. Clin Endocrinol (Oxf)2009;

70:145151

5. Takashima S, Sone S, Nomura N, Tomiyama N,

Kobayashi T, Nakamura H. Nonpalpable lymph

nodes of the neck: assessment with US and US-

guided fine-needle aspiration biopsy. J Clin Ul-

trasound1997; 25:283292

6. Fish SA, Langer JE, Mandel SJ. Sonographic im-

aging of thyroid nodules and cervical lymph

nodes. Endocrinol Metab Clin North Am 2008;

37:401417, ix

7. Kuna SK, Bracic I, Tesic V, Kuna K, Herceg GH,

Dodig D. Ultrasonographic differentiation of be-

nign from malignant neck lymphadenopathy in

thyroid cancer.J Ultrasound Med2006; 25:1531

1537; quiz 15381540

8. Lyshchik A, Higashi T, Asato R, et al. Cervical

lymph node metastases: diagnosis at sonoelastog-

raphyinitial experience. Radiology 2007; 243:

258267

9. Park JS, Son KR, Na DG, Kim E, Kim S. Perfor-

mance of preoperative sonographic staging of

papillary thyroid carcinoma based on the sixth

edition of the AJCC/UICC TNM classification

system.AJR2009; 192:6672

10. Rosario PW, de Faria S, Bicalho L, et al. Ultra-

sonographic differentiation between metastatic

and benign lymph nodes in patients with papillarythyroid carcinoma. J Ultrasound Med2005; 24:

13851389

11. Kessler A, Rappaport Y, Blank A, Marmor S,

Weiss J, Graif M. Cystic appearance of cervical

lymph nodes is characteristic of metastatic papil-

lary thyroid carcinoma.J Clin Ultrasound2003;

31:2125

12. Wunderbaldinger P, Harisinghani MG, Ha hn PF,

et al. Cystic lymph node metastases in papillary

thyroid carcinoma.AJR2002; 178:693697

13. Ahuja A, Ying M, King A, Yuen HY. Lymph node

hilus: gray scale and power Doppler sonography

of cervical nodes. J Ultrasound Med 2001; 20:

987992; quiz 994

14. Na DG, Lim HK, Byun HS, Kim HD, Ko YH,

Baek JH. Differential diagnosis of cervical lymph-

adenopathy: usefulness of color Doppler sonogra-

phy.AJR1997; 168:13111316

15. Ying M, Ahuja A, Metreweli C. Diagnostic accu-

racy of sonographic criteria for evaluation of cer-

vical lymphadenopathy.J Ultrasound Med1998;

17:437445

16. Ahuja A, Ying M. Sonography of neck lymph

T

ABLE3:PreviousReportsofDiagnosticValuesAccordingtoUltrasoundCriteriatoDifferentiateMetastaticFromB

enignLymphNodes

Study

[ReferenceNo.]

Total

No.o

f

Lymph

Nodes

No.o

f

Metastatic

Lymph

Nodes

Short-to-LongAxis

DiameterRatio>0.5

AbnormalEchogenicity

Calcification

CysticChange

AbsentHilum

PeripheralVascularity

Sensitivity

(%)

Specificity

(%)

PPV

(%)

Sensitivity

(%)

Specific

ity

(%)

PPV

(%)

Sensitivity

(%)

Specificity

(%)

PPV

(%)

Sensitivity

(%)

Specificity

(%)

PPV

(%)

Sensitivity

(%)

Specificity

(%)

PPV

(%)

Sensitivity

(%)

Specificity

(%)

PPV

(%)

Lyshchiketal.[8]

141

60

75

81

75

58

91

83

3

100

100

NA

NA

NA

72

54

54

47

99

97

Kessleretal.[11]

63

20

NA

NA

NA

NA

NA

NA

30

NA

NA

70

NA

NA

NA

NA

NA

NA

NA

NA

Takashimaetal.[5]

91

53

NA

NA

NA

NA

NA

NA

92

63

78

92

61

77

100

21

64

NA

NA

NA

Parketal.[9]

45

21

23.8

80.2

66.7

78.9

42.9

78.9

31.6

100

100

26.3

100

100

31.6

71.4

75.0

52.6

57.1

76.9

Kunaetal.[7]

517

221

65.6

NA

NA

NA

NA

NA

5.4

NA

NA

21.3

NA

NA

99.5

NA

NA

NA

NA

NA

Rosarioetal.[10]

350

198

80

70.5

78

86

95.5

96

49.5

100

100

20

100

100

88

90

92

NA

NA

NA

Thisstudy

118

91

55

89

94

59

85

93

45

93

95

34

96

97

100

48

87

NA

NA

NA

NotePPV=positivepredictivevalue,NA=notapplicable.


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nodes. Part II. Abnormal lymph nodes. Clin Ra-

diol2003; 58:359366

17. Kim E, Park JS, Son KR, Kim JH, Jeon SJ, Na

DG. Preoperative diagnosis of cervical metastatic

lymph nodes in papillary thyroid carcinoma:

comparison of ultrasound, computed tomography,

and combined ultrasound with computed tomog-

raphy. Thyroid2008; 18:411418

18. Tsunodo-Shimizu H, Saida Y. Ultrasonographic

visibility of supraclavicular lymph nodes in normal

subjects.J Ultrasound Med1997; 16:481483

19. Vassallo P, Wernecke K, Roos N, Peters PE. Dif-

ferentiation of benign from malignant superficial

lymphadenopathy: the role of high-resolution US.

Radiology1992; 183:215220

20. Tseng FY, Hsiao YL, Chang TC. Cytologic fea-

tures of metastatic papillary thyroid carcinoma in

cervical lymph nodes.Acta Cytol2002; 46:1043

1048

21. Ahuja AT, Chow L, Chick W, King W, Metreweli

C. Metastatic cervical nodes in papillary carcino-

ma of the thyroid: ultrasound and histological cor-

relation. Clin Radiol1995; 50:229231

22. Ellison E, Lapuer ta P, Mart in SE. Psammoma

bodies in fine-needle aspirates of the thyroid: pre-

dictive value for papillary carcinoma. Cancer

1998; 84:169175

23. Ustun M, Risberg B, Davidson B, Berner A. Cys-

tic change in metastatic lymph nodes: a common

diagnostic pitfall in fine-needle aspiration cytolo-

gy.Diagn Cytopathol2002; 27:387392

24. Verge J, Guixa J, Alejo M, et al. Cervical cystic

lymph node metastasis as first manifestation of

occult papillary thyroid carcinoma: report of sev-

en cases.Head Neck1999; 21:370374

25. Gonzalez HE, Cruz F, OBrien A, et al. Impact of

preoperative ultrasonographic staging of the neck

in papillary thyroid carcinoma.Arch Otolaryngol

Head Neck Surg2007; 133:12581262

26. Shimamoto K, Satake H, Sawaki A, Ish igaki T,

Funahashi H, Imai T. Preoperative staging of thy-

roid papillary carcinoma with ultrasonography.

Eur J Radiol1998; 29:410

27. Cooper DS, Doherty GM, Haugen BR, et al. Man-

agement guidelines for patients with thyroid nod-

ules and differentiated thyroid cancer. Thyroid

2006; 16:109142

28. Goropoulos A, Karamoshos K, Christodoulou A,

et al. Value of the cervical compartments in the

surgical treatment of papillary thyroid carcinoma.

World J Surg2004; 28:12751281

29. Kupferman ME, Patterson M, Mandel SJ, LiVolsi

V, Weber RS. Patterns of lateral neck metastasis

in papillary thyroid carcinoma.Arch Otolaryngol

Head Neck Surg2004; 130:857860

30. Wang TS, Dubner S, Sznyter LA, Heller KS. Inci-

dence of metastatic well-differentiated thyroid

cancer in cervical lymph nodes.Arch Otolaryngol

Head Neck Surg2004; 130:110113

31. Kang TW, Shin JH, Han BK, et al. Preoperative

ultrasound-guided tattooing localization of recur-

rences after thyroidectomy: safety and effective-

ness.Ann Surg Oncol 2009; 16:16551659

32. Cignarelli M, Ambrosi A, Marino A, et al. Diag-

nostic utility of thyroglobulin detection in fine-

needle aspiration of cervical cystic metastatic

lymph nodes from papillary thyroid cancer with

negative cytology. Thyroid2003; 13:11631167

33. Cunha N, Rodrigues F, Curado F, et al. Thyro-

globulin detection in fine-needle aspirates of cer-

vical lymph nodes: a technique for the diagnosis

of metastatic differentiated thyroid cancer. Eur J

Endocrinol2007; 157:101107

34. Frasoldati A , Toschi E, Zini M, et al. Role of thy-

roglobulin measurement in fine-needle aspiration

biopsies of cervical lymph nodes in patients with

differentiated thyroid cancer. Thyroid 1999; 9:

105111

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