Sheila Sheth

American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer.

BACKGROUNDnCervical lymph node metastases from differentiated thyroid cancer (DTC) are common. Thirty to eighty percent of patients with papillary thyroid cancer harbor lymph node metastases, with the central neck being the most common compartment involved. The goals of this study were to: (1) identify appropriate methods for determining metastatic DTC in the lateral neck and (2) address the extent of lymph node dissection for the lateral neck necessary to control nodal disease balanced against known risks of surgery.nnnMETHODSnA literature review followed by formulation of a consensus statement was performed.nnnRESULTSnFour proposals regarding management of the lateral neck are made for consideration by organizations developing management guidelines for patients with thyroid nodules and DTC including the next iteration of management guidelines developed by the American Thyroid Association (ATA). Metastases to lateral neck nodes must be considered in the evaluation of the newly diagnosed thyroid cancer patient and for surveillance of the previously treated DTC patient.nnnCONCLUSIONSnLateral neck lymph nodes are a significant consideration in the surgical management of patients with DTC. When current guidelines formulated by the ATA and by other international medical societies are followed, initial evaluation of the DTC patient with ultrasound (or other modalities when indicated) will help to identify lateral neck lymph nodes of concern. These findings should be addressed using fine-needle aspiration biopsy. A comprehensive neck dissection of at least nodal levels IIa, III, IV, and Vb should be performed when indicated to optimize disease control.

Algorithm for safe and effective reoperative thyroid bed surgery for recurrent/persistent papillary thyroid carcinoma

The aim of this study was to review our experience with reoperative thyroid bed surgery (RTBS) for recurrent/persistent papillary thyroid cancer (PTC), and present an algorithm for safe and effective RTBS.

Is Routine Dissection of Level II-B and V-A Necessary in Patients with Papillary Thyroid Cancer Undergoing Lateral Neck Dissection for FNA-Confirmed Metastases in Other Levels

BackgroundThe purpose of the present study was to determine the utility of routine dissection of level II-B and level V-A in patients with papillary thyroid cancer (PTC) undergoing lateral neck dissection for ultrasound-guided fine-needle aspiration (FNA)-confirmed lateral nodal metastasis in at least one neck nodal level.MethodsIn a retrospective review, we studied the charts of 53 consecutive patients (February 2002–December 2007) with PTC who had undergone therapeutic lateral neck dissection that included at least level II-(A and B) and/or level V-(A and B). The levels were designated as such in situ prior to surgical pathology specimen processing. Reports of the preoperative FNA cytopathologic findings, the extent of lateral neck dissection by levels, and the postoperative final histopathologic examination were reviewed.ResultsA total of 53 patients underwent therapeutic lateral neck dissection for FNA-confirmed nodal metastasis of PTC at a minimum of one lateral neck level. All 53 patients had preoperative ultrasonography and FNA confirmation of lateral neck disease: 46 patients had PTC, 5 had the tall cell variant of PTC, and 2 had the follicular variant of PTC on final surgical pathology. Ten patients underwent neck dissection at the time of thyroidectomy, and 43 patients underwent neck dissection for lateral neck recurrence/persistence of PTC following a previous thyroidectomy and radioactive iodinexa0±xa0previous neck dissection. A total of 46 patients underwent unilateral neck dissection and 7 patients underwent bilateral neck dissection; thus 60 neck dissection specimens were evaluated. Level II (A and B) was excised in 59/60 neck dissections, with 33 of 59 specimens (33/59xa0=xa060%) positive for metastasis. Level II-B was positive 5 times (5/59; 8.5–95% CI: 2.4, 20.4), and each time level II-B was positive, level II-A was also grossly (and histopathologically—seen at the time of surgery) positive for metastasis. Level III was excised 58 times and was positive in 38 specimens (38/58xa0=xa066%). Level IV was excised 58 times and was positive in 29 specimens (29/58xa0=xa050%). Level V (A and B) was excised 40 times and was positive in 16 specimens (16–40xa0=xa040%). Level V-A did not account for any of the positive level V results (0%).ConclusionsCervical lateral neck metastases in PTC occur in a predictable pattern, with levels III, II-A, and IV most commonly involved. Patients with PTC who undergo lateral neck dissection for FNA-confirmed nodal metastases might harbor disease in level II-B, especially if level II-A is involved. We recommend elective dissection of level II-B only when level II-A is involved, based on FNA confirmation, or when it is grossly involved on intraoperative evaluation. Routine dissection of level V-B is recommended in this patient population, while elective dissection of level V-A is not necessary.

Imaging of uncommon tumors of the pancreas

In this article, the radiological manifestations of a variety of uncommon tumors of the pancreas are illustrated, with emphasis placed on their appearance at helical CT. Islet cell tumors, because of their vascularity, typically present as masses that are hyperattenuating to the normal pancreas at dual-phase helical CT. Lymphomas appear as hypoattenuating focal lesions or can diffusely infiltrate the gland. Absence of biliary tree dilatation, despite the presence of a bulky tumor, or associated extensive retroperitoneal adenopathy should offer clues to the diagnosis. Pancreatic metastases are usually seen in patients with advanced cancers, although isolated metastases from renal cell carcinoma can occurs years after the original tumor; such patients may benefit from surgical resection. Finally, the appearance of some rare neoplasms of mesenchymal origin is discussed.

Role of Ultrasonography in Thyroid Disease

Ultrasonography (US) is the single-most valuable imaging modality in the evaluation of the thyroid gland. This review discusses the US appearances of thyroid nodules, emphasizing sonographic features associated with potentially malignant or, at the other end of the spectrum, likely benign nodules. Diffuse thyroid abnormalities have also been reviewed. The technique of ultrasound-guided fine-needle aspiration biopsy and the emerging role of elastography in characterizing thyroid nodules have also been addressed.

Imaging of the Inferior Vena Cava with MDCT

OBJECTIVEnThe purpose of this pictorial essay is to illustrate the role of MDCT in the diagnosis of disease processes affecting the inferior vena cava (IVC).nnnCONCLUSIONnHigh-speed MDCT has the potential to replace traditional imaging techniques in the evaluation of pathologic processes involving the IVC. The ability to acquire near-isotropic data allows high-quality reconstructions in the sagittal and coronal planes and thus overcomes one of the major limitations of CT in evaluating the IVC.

Patient Variability in Intraoperative Ultrasonographic Characteristics of Colorectal Liver Metastases

OBJECTIVEnTo determine the distribution of echogenicity (hypoechoic, isoechoic, or hyperechoic) and predominant intraoperative ultrasonography (IOUS) echogenic appearance of colorectal liver metastasis. The interpatient and intrapatient variability of tumor IOUS echogenicity was assessed.nnnDESIGNnRetrospective review of prospectively collected database.nnnSETTINGnTertiary cancer center.nnnPATIENTSnBetween January 1998 and July 2001, 99 patients (194 tumors) underwent hepatic resection for colorectal metastases.nnnMAIN OUTCOME MEASURESnDuring surgery, IOUS of the liver was performed and the images were digitally recorded. Images were randomly coded, blindly reviewed, and scored for echogenicity and ultrasonographic appearance pattern.nnnRESULTSnThe ultrasonographic appearance of the colorectal liver metastasis was hypoechoic in 52.0%, isoechoic in 35.7%, and hyperechoic in 12.3% of cases. Most colorectal liver metastases appeared homogeneous (50.8%). Less commonly, identified lesions were characterized by a target or bulls-eye appearance (20%) or contained calcifications (19%). Clinicopathologic characteristics, including patient age and sex, as well as tumor size, number, and location and presence of hepatic steatosis, did not correlate with tumor echogenicity or ultrasonographic appearance pattern (all P > .05). Lesions within patients were more similar in echogenicity than lesions between patients (P < .001). Similarly, intrapatient variability in appearance pattern was significantly less than the variability between patients (P = .002).nnnCONCLUSIONSnThe ultrasonographic characteristics of hepatic metastases within patients were more similar than between patients. Such information is important because it suggests that, in patients with more than 1 metastasis, the echogenic appearance of an index lesion may predict the echogenic appearance of additional occult disease.

Transcervical Ultrasonography Is Feasible to Visualize and Evaluate Base of Tongue Cancers

Background Base of tongue (BOT) is a difficult subsite to examine clinically and radiographically. Yet, anatomic delineation of the primary tumor site, its extension to adjacent sites or across midline, and endophytic vs. exophytic extent are important characteristics for staging and treatment planning. We hypothesized that ultrasound could be used to visualize and describe BOT tumors. Methods Transcervical ultrasound was performed using a standardized protocol in cases and controls. Cases had suspected or confirmed BOT malignancy. Controls were healthy individuals without known malignancy. Results 100% of BOT tumors were visualized. On ultrasound BOT tumors were hypoechoic (90.9%) with irregular margins (95.5%). Ultrasound could be used to characterize adjacent site involvement, midline extent, and endophytic extent, and visualize the lingual artery. No tumors were suspected for controls. Conclusions Ultrasonography can be used to transcervically visualize BOT tumors and provides clinically relevant characteristics that may not otherwise be appreciable.

Can ultrasound be used as the primary screening modality for the localization of parathyroid disease prior to surgery for primary hyperparathyroidism? A review of 440 cases.

Background/Aims: Sestamibi scintigraphy and neck ultrasonography have both been proposed as screening modalities for the detection of abnormal parathyroid glands in patients with primary hyperparathyroidism. As a result, many surgeons use both techniques prior to surgery. The goal of this study was to independently evaluate both ultrasound and sestamibi as single-modality preoperative screening tools for primary hyperparathyroidism. Methods: A retrospective review of consecutive patients who underwent surgery for primary hyperparathyroidism from January 1999 to December 2009. Imaging results were compared to surgical findings. Results: 440 patients were found to meet inclusion criteria. Sensitivities for correct localization of a single parathyroid adenoma for sestamibi versus ultrasound were: 83% (95% CI 78–86) versus 72% (95% CI 67–76). Ultrasound operator had no influence on sensitivity, and ultrasound identified nodular thyroid disease in 31% of patients. Conclusion: Ultrasonography alone can be used as the primary screening modality in patients with primary hyperparathyroidism. Ultrasound sensitivity is conserved despite operator variability, and identifies concomitant thyroid pathology.

Thyroid and parathyroid ultrasound examination

These guidelines are an educational tool designed to assist practitioners in providing appropriate radiologic care for patients. They are not inflexible rules or requirements of practice and are not intended, nor should they be used, to establish a legal standard of care. For these reasons and those set forth below, the American College of Radiology cautions against the use of these guidelines in litigation in which the clinical decisions of a practitioner are called into question.