Thyroid tissue in cervical lymph nodes,not always malignant

Thyroid tissue in cervical lymph nodes is an interesting and rare phenomenon that cannot be directly explained by embryology. Distinguishing malignant from benign thyroid tissue in cervical lymph nodes can be challenging but is essential for treatment and might have legal implications. Patients with incidentally found thyroid tissue in cervical lymph nodes during thyroid surgery were retrospectively identified. Clinical data and findings on pathology were retrospectively collected. Two patients with thyroid tissue in cervical lymph nodes were identified. Conventional pathology complemented with immunohistochemistry and molecular diagnostics showed the thyroid tissue in cervical lymph nodes to be benign. We show that benign thyroid tissue in cervical lymph nodes can be found in the absence or presence of a primary thyroid malignancy. A conservative approach is recommended if pathology shows benign thyroid tissue in cervical lymph nodes.     

纳米炭在甲状腺癌再手术中应用价值的初步研究

【目的】探讨在甲状腺癌再手术中应用纳米炭混悬液对甲状旁腺保护的作用与价值。【方法】选取2011年2月至2012年8月湖南省人民医院乳腺甲状腺外科25例甲状腺癌再手术患者,随机分为实验组（纳米炭组）12例和对照组13例,实验组在术中先向残余甲状腺或癌灶周围注射纳米炭0．3～0．5mL不等,对照组不使用纳米炭,观察两组辨别甲状旁腺和淋巴结的差异。【结果】实验组使再手术的甲状腺癌患者的甲状旁腺负显影与第Ⅵ区淋巴结黑色显影形成鲜明对比率达91．7％,明显高于对照组的23．1％,两组比较有显著性差异,而且术后一过性的甲状旁腺功能减退的并发症在实验组亦有显著降低（P〈0．05）。实验组清扫的中央区淋巴结等于或大于10个的为75％（9／12）,显著高于对照组的30．8％（4／13）,两组比较差异有显著性（P〈0．05）。【结论】纳米炭对甲状腺癌再手术中的甲状旁腺的负显影和淋巴结的黑染,使甲状旁腺易于识别和保护并降低一过性甲状旁腺功能减退的并发症,有利于彻底清扫中央区淋巴结。     

Role of Contrast-Enhanced Ultrasound in the Pre-operative Diagnosis of Cervical Lymph Node Metastasis in Patients with Papillary Thyroid Carcinoma

The objective of this study was to prospectively evaluate the diagnostic accuracy of contrast-enhanced ultrasonography (CEUS) in differentiating between benign and metastatic cervical lymph nodes in patients with papillary thyroid cancer (PTC). Three hundred nineteen cervical lymph nodes (162 metastatic from PTC and 157 benign) were evaluated using conventional ultrasonography (US) and CEUS before biopsy or surgery. Metastatic lymph nodes more often manifested centripetal or asynchronous perfusion, hyper-enhancement, heterogeneous enhancement, perfusion defects and ring-enhancing margins than benign lymph nodes at pre-operative CEUS (all p values < 0.001). The area under the receiver operating characteristic curve (AUC) for the combination of conventional US and CEUS (0.983, 95% confidence interval [CI]: 0.971–0.994) was higher than that of conventional US alone (0.929, 95% CI: 0.899–0.958) and CEUS (0.911, 95% CI: 0.876–0.947). In conclusion, CEUS is a promising tool in conjunction with conventional US for the pre-operative prediction of metastatic cervical lymph nodes in patients with PTC.     

Ultrasound-Guided Fine-Needle Aspiration of Non-palpable and Suspicious Axillary Lymph Nodes with Subsequent Removal after Tattooing: False-Negative Results and Concordance with Sentinel Lymph Nodes

Ultrasonography-guided fine-needle aspiration (US-guided FNA) for axillary lymph nodes (ALNs) is currently used with various techniques for the initial staging of breast cancer and tagging of ALNs. With the implementation of the tattooing of biopsied ALNs, the rate of false-negative results of US-guided FNA for non-palpable and suspicious ALNs and concordance with sentinel lymph nodes were determined by node-to node analyses. A total of 61 patients with breast cancer had negative results for metastasis on US-guided FNA of their non-palpable and suspicious ALNs. The biopsied ALNs were tattooed with an injection of 1–3 mL Charcotrace (Phebra, Lane Cove West, Australia) ink and removed during sentinel lymph node biopsy or axillary dissection. We determined the rate of false-negative results and concordance with the sentinel lymph nodes by a retrospective review of surgical and pathologic findings. The association of false-negative results with clinical and imaging factors was evaluated using logistic regression. Of the 61 ALNs with negative results for US-guided FNA, 13 (21%) had metastases on final pathology. In 56 of 61 ALNs (92%), tattooed ALNs corresponded to the sentinel lymph nodes. Among the 5 patients (8%) without correspondence, 1 patient (2%) had 2 metastatic ALNs of 1 tattooed node and 1 sentinel lymph node. In multivariate analysis, atypical cells on FNA results (odds ratio = 20.7, p = 0.040) was independently associated with false-negative FNA results. False-negative ALNs after US-guided FNA occur at a rate of 21% and most of the tattooed ALNs showed concordance with sentinel lymph nodes.     

The neck -- a sonographically interesting region for many medical fields

The soft tissues of the neck can be examined at the highest resolution with ultrasound probes of high frequencies due to their superficial position. There are many clinically important diagnostic issues concerning the thyroid gland, the parathyroid, lymph nodes, vessels of the neck, salivary glands and other structures of the field of ENT and even the nerves of this region. Numerous different medical departments therefore work in this field either together or I a parallel fashion. In addition to different sub-specialties of internal medical and surgical departments, radiologists, neurologists, ENT doctors, gnathologists and radio-oncologists are all active here. Even intensive care personnel and anaesthesiologists use ultrasound for sonographically guided punctures. It is therefore obvious that the cervical region is of special importance for an interdisciplinary journal, constituting a large part of publications. In the last 2 (1/2) years, we published two articles about cervical lymph nodes , eight concerning the topic of vessels , two articles about salivary glands and three dealing with the parathyroid glands . The present issue again contains three publications concerning this area, characteristically from three different medical specialties, each of great significance for various medical fields. An important article deals with deQuervain thyroiditis . Albeit this is not a common disease, any clinician working on the cervical region should be well aware of this entity, as the patients concerned often go through a medical "odyssey" with different specialists before the right diagnosis is made. An important addition to sonographical interventional techniques is percutaneous instillation therapy for focal autonomous adenomas of the thyroid : it is fast acting and effective, representing a genuine therapeutic alternative to surgery or radioactive iodine treatment in many cases. The case report on a - fortunately non-permanent - partial laryngeal necrosis resulting from the instillation of 96 % alcohol demonstrates the potential damage an established method can cause if applied without expertise. It is therefore mandatory to be aware of potential side effects and carry out the intervention proficiently, strictly keeping in mind the indication for therapy. A further case report demonstrates in an impressive way the importance of cervical sonography for the detection and landmarking of parathyroid adenomas. The fact that the author is a surgeon might serve as valid proof, as the surgery of parathyroid glands almost solely depended on the experience and the explorative skill of the surgeon until recently.     

Thyroid and parathyroid imaging

This article reviews the current roles of imaging in the diagnosis of thyroid and parathyroid disorders, with an emphasis on ultrasound evaluation. Imaging of the thyroid and parathyroid can be performed with nuclear medicine, ultrasound, CT, and MRI. Indications for thyroid and parathyroid imaging studies have recently changed. The availability of experienced endocrine surgeons, as well as the development of accurate laboratory tests, fine-needle aspiration (FNA) biopsy, and high-resolution ultrasound, have dramatically influenced the evaluation of thyroid and parathyroid disease. In patients with thyroid nodular disease, a clinical examination by an experienced clinician with appropriate lab values and palpation-guided FNA is the current diagnostic protocol of choice. Ultrasound evaluation of high-risk patients and ultrasound-guided FNA both augment this protocol when necessary. In patients with diffuse thyroid glandular disease, radionuclide imaging and color Doppler sonography both can be used for evaluation. When preoperative imaging is clinically necessary, sonography or scintigraphy can be used for parathyroid adenoma localization in patients with primary hyperparathyroidism. The recent development of technetium-99m sestamibi as a parathyroid imaging agent has improved the sensitivity of scintigraphy for parathyroid adenoma localization. Ultrasound and radionuclide imaging have also become valuable imaging techniques for parathyroid localization in patients with recurrent or persistent hyperparathyroidism.     

Thyroid metastasis from breast cancer presenting with enlarged lateral cervical lymph nodes: A case report

BACKGROUND Secondary malignancy of the thyroid occurs infrequently and mainly originates from malignant tumors of the kidney,gastrointestinal tract,lungs,breast,and skin.The correct diagnosis is important but difficult.Importantly,there are major differences in the treatment of primary and metastatic thyroid cancer,which has a significant impact on prognosis and survival.Therefore,how to diagnose thyroid metastasis(TM)correctly before surgery is a major concern for surgeons.CASE SUMMARY We report a 38-year-old woman who presented with palpable cervical lymph nodes after breast cancer(BC)surgery 2 years ago.Ultrasonography and computed tomography revealed thyroid nodules with irregular margins and enlarged cervical lymph nodes.Biopsy was performed for the right largest cervical lymph node,and immunohistochemical analysis revealed negativity for thyroglobulin,estrogen receptor,and progestin receptor and positive for human epidermal growth factor receptor 2.The diagnosis was TM from BC with cervical lymph node metastasis.Total thyroidectomy with bilateral central and lateral neck lymph node dissection was performed.After a 5-mo follow-up,no recurrence or novel distant metastasis was identified.CONCLUSION TM from BC is a rare secondary malignancy.Broad differential diagnosis by biopsy and immunohistochemical analysis needs to be considered.     

Thoracoscopy-assisted treatment for mediastinal metastasis of thyroid cancer: a case report

Advanced thyroid cancer with upper mediastinal lymph node metastasis is not rare in the clinical setting. For patients with severe metastasis, a thoracocervical incision is usually performed for dissection of lymph nodes. However, the difficult operation of three-port thoracoscopy to support performance of a cervical incision in the treatment of upper mediastinal lymph node metastasis has rarely been reported to date. We herein describe a case involving the treatment of thyroid cancer with upper mediastinal lymph node metastasis. The lymph node metastasis was severe, closely adhered to the innominate vein, and fused into a mass. Thoracoscopy with a cervical incision was performed and proved to be a highly difficult surgical maneuver. The patient recovered quickly after the operation. Repeat computed tomography showed no swollen metastatic lymph nodes, indicating that the dissection was thorough. Thoracoscopy with a neck incision is more difficult than conventional longitudinal split sternotomy in the treatment of upper mediastinal lymph node metastasis, but its advantages are less severe trauma and faster recovery. This procedure may be performed by surgeons with proficient skill in cervical surgery and thoracoscopy techniques.     

Distant lymph node metastases in esophageal cancer: impact of endoscopic ultrasound-guided biopsy.

BACKGROUND AND STUDY AIMS: The aim of this retrospective study was to evaluate the impact of endoscopic ultrasound (EUS)-guided biopsy in patients with esophageal carcinoma where distant lymph nodes which were possibly metastatic were visualized using EUS. PATIENTS AND METHODS: Out of 198 patients (150 men, mean age 66 years) examined over a 4-year period by EUS for local staging of esophageal cancer (121 squamous cell carcinomas and 77 adenocarcinomas), there was EUS visualization of distant lymph nodes in 40 (20%). EUS-guided biopsy was carried out in the latter patients, of cervical nodes with mediastinal tumors (n = 19), of celiac nodes with cervical tumors (n = 2) or superior mediastinal tumors (n = 9), and upper mediastinal lymph nodes in the case of distal adenocarcinomas (n = 10). RESULTS: On EUS-guided biopsy, results were positive in 31 patients, eight were correctly negative (as confirmed by surgery), and in one patient there was a technical failure, with positive findings on subsequent surgery. The sensitivity and specificity of the diagnosis of malignant lymph nodes were therefore 97% and 100% respectively. The positive results of EUS-guided biopsy modified the tumor staging in 31 of these cases (77.5%), proving distant lymph node metastasis which is classified as stage M1. With regard to actual clinical management, surgery was withheld from 24 patients (60% of 40 cases) who were then treated with concomitant radiotherapy and chemotherapy. CONCLUSION: EUS-guided biopsy of distant lymph nodes was indicated in 20% of patients with esophageal cancers, and the biopsy results led to upgrading of the tumor stage in about 80% of cases and influenced the treatment decision in about 60%.     

实时组织弹性成像与常规超声诊断甲状腺癌术后颈部淋巴结转移癌的对比研究

目的探讨实时组织弹性成像(RTE)与常规超声鉴别甲状腺癌术后颈部淋巴结病变的价值。方法对69例甲状腺癌术后患者行颈部淋巴结检查,常规超声观察淋巴结大小、形状、边界、内部回声、皮髓质界限及淋巴门的血流情况;RTE观察淋巴结及其周围组织。113枚病变淋巴结均经活检手术病理证实。结果本组非转移性淋巴结常规超声评分多在5～6分(Ⅰ～Ⅱ级),甲状腺癌术后颈部淋巴结转移常规超声评分多在7～10分(Ⅲ～Ⅴ级)。RTE鉴别甲状腺癌术后颈部淋巴结病变的准确性、敏感性、特异性、阳性预测值、阴性预测值及Kappa值分别为90.6%、86.7%、89.2%、92.0%、75.9%及0.91,常规超声的准确性、敏感性、特异性、阳性预测值、阴性预测值及Kappa值分别为80.1%、90.1%、59.5%、81.0%、51.7%及0.72。RTE的诊断一致性较常规超声好。结论 RTE具有简便、准确的诊断一致性的特点,有助于甲状腺癌术后复查时颈部淋巴结转移情况的鉴别诊断。     

超声在颈部淋巴结良恶性鉴别中的研究进展

颈部淋巴结肿大涉及多种疾病,对于肿瘤患者,明确是否具有颈部淋巴结转移,对于治疗方案的选择至关重要。超声检查具有安全方便、经济快捷、可重复性好等优点,随着超声造影、弹性成像技术及超声引导下穿刺活检技术的发展与普及,超声在颈部淋巴结良恶性鉴别中的应用价值日益提高。     

The value of quantitative shear wave elastography in differentiating the cervical lymph nodes in patients with thyroid nodules

Purpose

This study aimed at evaluating the diagnostic performance of quantitative shear wave elastography (SWE) in differentiating metastatic cervical lymph nodes from benign nodes in patients with thyroid nodules.

Methods

One hundred and forty-one cervical lymph nodes from 39 patients with thyroid nodules that were diagnosed as papillary thyroid cancer had been imaged with SWE. The shear elasticity modulus, which indicates the stiffness of the lymph nodes, was measured in terms of maximum shear elasticity modulus (maxSM), minimum shear elasticity modulus (minSM), mean shear elasticity modulus (meanSM), and standard deviation (SD) of the shear elasticity modulus.

Results

All the patients underwent thyroid surgery, 50 of the suspicious lymph nodes were resected, and 91 lymph nodes were followed up for 6 months. The maxSM value, minSM value, meanSM value, and SD value of the metastatic lymph nodes were significantly higher than those of the benign nodes. The area under the curve of the maxSM value, minSM value, meanSM value, and SD value were 0.918, 0.606, 0.865, and 0.915, respectively.

Conclusions

SWE can differentiate metastasis from benign cervical lymph nodes in patients with thyroid nodules, and the maxSM, meanSM, and SD may be valuable quantitative indicators for characterizing cervical lymph nodes.

     

Value of parathyroid hormone assay for preoperative sonographically guided parathyroid aspirates for minimally invasive parathyroidectomy

PURPOSE: The key to successful parathyroid surgery is accurate preoperative tumor localization. This study investigates the use of ultrasound (US)-guided parathyroid fine needle aspiration (FNA) as a confirmatory diagnostic method in patients with hyperparathyroidism undergoing minimally invasive parathyroidectomy. METHODS: Patients were selected for minimally invasive parathyroidectomy based on the finding of a single parathyroid adenoma identified with US and/or sestamibi scans and confirmation of the suspected parathyroid lesion via FNA and parathyroid hormone (PTH) assay. The value of aspirate obtained from the thyroid gland intraoperatively served as the negative control. RESULTS: A total of 56 tissue FNAs were performed in 27 patients. US detected masses suggestive of parathyroid lesion in all 27 patients, and 31 US-guided FNAs were performed. No complications related to the procedure were noted. Intraoperatively, FNA was performed in the thyroids of 25 patients undergoing minimally invasive parathyroidectomy. Aspirates from lesions subsequently confirmed as having developed from the parathyroid gland had a mean PTH level of 4,677 +/- 123 pg/ml (range, 3,600-5,000 pg/ml), which was significantly higher than thyroid aspirates, which yielded a mean PTH level of 48 +/- 7 pg/ml (range, 5-57 pg/ml). The sensitivity of US and sestamibi scans in the detection of abnormal parathyroid glands was 88% and 77%, respectively. The sensitivity of US-guided FNA in confirming the parathyroid origin of a lesion was 100%. CONCLUSION: US-guided FNA for PTH assay can be performed safely for the confirmation of lesions identified with preoperative US for the selection of patients eligible for minimally invasive parathyroidectomy.     

How to Identify Cervical Traumatic Neuromas in the Post-operative Neck Dissection: Brief Review of the Cervical Plexus Ultrasound

Cervical traumatic neuromas (CTNs) are a non-neoplastic hyperplasia of damaged nerves and may be misinterpreted as metastatic lymph nodes during cervical ultrasound of patients with thyroid cancer after lateral neck dissection, resulting in unnecessary and painful fin-needle aspiration biopsy. The anatomy of the cervical plexus is challenging, and the correct identification and recognition of its neural roots and branches on ultrasound are key to the correct CTN diagnosis. This review outlines the US technique used to characterize CTNs in 10 standardized steps and describes the sonographic features of the cervical plexus, to assist the radiologist in the recognition of CTNs and their differentiation from lymph node metastases.     

超声在甲状腺癌颈部淋巴结转移的诊断价值探讨

目的：探讨超声在甲状腺癌颈部淋巴结转移中的诊断价值。方法：术前超声检查47例甲状腺癌患者的颈部淋巴结,超声所见与手术切除病理结果对照分析。结果：超声检查与病理结果对照,符合的淋巴结41个,符合率78.8%。淋巴结的内部回声不均、髓质变形或缺失、周边型及混合型血流预示淋巴结有转移。结论：超声检查对甲状腺癌颈部淋巴结转移具有较高的诊断价值。     

纳米碳在甲状腺手术中保护甲状旁腺的应用

目的探讨纳米碳在甲状腺手术中对甲状旁腺的保护作用。方法甲状腺手术时，游离部分甲状腺外科包膜后注射纳米碳各0.1~0.2ml于甲状腺上下极，待甲状腺和周围淋巴组织染色后完整游离甲状腺外科包膜，保护未染色组织（可能含有甲状旁腺组织），再常规行甲状腺手术。结果低血钙观察组发生4例，对照组发生10例，差异有统计学意义（P<0.05）；甲状旁腺素下降观察组发生2例，对照组发生9例，差异有统计学意义（P<0.05）；病理证实误切甲状旁腺观察组0例，对照组6例；患者自诉出现低血钙症状观察组5例，对照组11例，差异无统计学意义（P>0.05）。结论在甲状腺手术中使用纳米碳，可以避免甲状旁腺受损。     

甲状腺癌的CT诊断

目的:本次研究主要通过对甲状腺癌经过CT检查之后的结果进行探讨,以此来提升在该方面的认知。方法:选自于2016年2月-2017年2月期间在我院进行CT检查的160例甲状腺内结节患者完整的临床资料、CT影像以及精细穿刺活检的的证实结果进行回顾性的分析。结果:对160患者使用平扫与增强扫描后发现患者的病灶的密度要低于周边甲状腺组织与肌肉组织。出现边界不清晰、内壁不够光整、颈淋巴结肿大。结论:对患者进行CT扫描之后其结节病情的结果出现了相互重叠的情况,对患者病情的判定难度较大。而患者的甲状腺癌的CT结果多数表现为内壁不光整、病灶的边界不够清晰、颈淋巴结肿较大等情况,而对患者进行CT增强扫描的意义不大。     

Reintervention in C-cell carcinoma

Cervical re-exploration in persistent medullary thyroid cancer usually fails to normalize serum calcitonin levels, which is the most sensitive criterion of tumour-free status (2 out of 21 patients in our re-exploration series). Positive lymph nodes - even at an early tumour stage - seem much more important (postoperative normal serum calcitonin: 86% in the occult tumour group, 71% in patients with palpable primary tumour and negative lymph nodes, as opposed to only 18% with a palpable cervical mass and positive lymph nodes). However, local re-exploration in case of persistent medullary thyroid cancer seems to offer a possible curative chance for the control of recurrence, especially after inadequate primary surgery. In cases without visible distant metastases a marked reduction in serum calcitonin level may be expected (21% of the preoperative level for stages N1 and N2 and 16% for stage N3 on average). In patients with elevated calcitonin levels after stimulation as sole indicator of persistent tumour the indication for reoperation should be handled cautiously. Thus, in 3 out of 5 patients with occult medullary thyroid cancer diagnosed only on the basis of venous sampling who were subjected to multiple cervical re-explorations, distant metastases were subsequently found during follow-up.     

不同病理类型甲状腺癌颈部转移淋巴结的声像图分析

目的探讨不同病理类型甲状腺癌颈部转移淋巴结的声像图特征。方法分析75例甲状腺癌颈部转移淋巴结的声像图的特点,其中乳头状癌50例,滤泡癌8例,髓样癌10例,未分化癌7例。结果甲状腺乳头状癌颈部转移性淋巴结局部可见团状偏高回声,部分淋巴结内可见沙砾样的微小钙化点,局部或整体可出现囊性变;甲状腺髓样癌颈部转移性淋巴结皮髓质分界不清,部分转移性淋巴结内也可见沙砾样的微小钙化点,但未见囊性变;滤泡癌和未分化癌颈部转移性淋巴结纵横比缩小,近似球形,皮髓质分界不清,淋巴门结构消失,呈低回声,均未见微小钙化点和囊性变。结论不同病理类型的甲状腺癌颈部转移淋巴结具有不同的声像图特征,病变淋巴结的超声表现与其病理改变密切相关。     

头颈部恶性肿瘤患者颈部肿大淋巴结的超声诊断

目的探讨头颈部恶性肿瘤患者颈部肿大淋巴结的超声诊断价值。方法回顾分析经手术证实的46例头颈部恶性肿瘤患者颈部肿大淋巴结的超声检出情况。二维及彩色多普勒超声观察患者颈部肿大淋巴结的数目、纵横比、形态、边界、内部回声、有无微小钙化及内部血流状态等。结果46例患者中甲状腺癌22例、鼻咽癌15例、恶性淋巴瘤9例。超声检查共探及颈部肿大淋巴结93枚。术后经病理诊断为肿瘤淋巴结转移者75枚,非淋巴结转移18枚。肿瘤转移淋巴结纵横比〈1．5者占84．9％,内部回声不均者占75．3％,边界欠规则者占74．0％、淋巴结内可见微小钙化者占32．9％。转移性和非转移性淋巴结组间上述超声指标比较,差异均具有统计学意义（P〈0．05）。转移性淋巴结血流分布较丰富,多普勒血流速度（PSV）和阻力指数（RI）也高于非转移性淋巴结（P〈0．05）。结论超声是诊断头颈部恶性肿瘤颈部淋巴结转移的一种简便、有效的方法。