Value of preoperative ultrasonography in the surgical management of initial and reoperative papillary thyroid cancer

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 wilt 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, 55.1 (381 female and 170 male; median age, 47 years; age range, 9-89 years) who underwent initial surgical management and 2.19 (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 1.51 (68.9%) of the reoperative patients before the subsequent operation (median close, 5.6 X 10(9) 13q; range, 7.4 X 10(8)-3.7 X 10(10) 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 16.7%] of the initial and 56 [25.6%] of the reoperative patients), US assessment of the extent of LNM involvement altered the operation in 1.5 (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.