The Value of Microvascular Imaging for Triaging Indeterminate Cervical Lymph Nodes in Patients with Papillary Thyroid Carcinoma

Seongyong Lee, Ji Ye Lee, Ra Gyoung Yoon, Ji-Hoon Kim, Hyun Sook Hong, Seongyong Lee, Ji Ye Lee, Ra Gyoung Yoon, Ji-Hoon Kim, Hyun Sook Hong

Abstract

Assessment of lymph node (LN) status in patients with papillary thyroid carcinoma (PTC) is often troublesome because of cervical LNs with indeterminate US (ultrasound) features. We aimed to explore whether Superb Microvascular Imaging (SMI) could be helpful for distinguishing metastasis from indeterminate LNs when combined with power Doppler US (PDUS). From 353 consecutive patients with PTC, LNs characterized as indeterminate by PDUS were evaluated by SMI to distinguish them from metastasis. Indeterminate LNs were reclassified according to the SMI, the malignancy risk of each category was assessed, and the diagnostic performance of suspicious findings on SMI was calculated. The incidence of US-indeterminate LNs was 26.9%. Eighty PDUS-indeterminate LNs (39 proven as benign, 41 proven as malignant) were reclassified into probably benign (n = 26), indeterminate (n = 20), and suspicious (n = 34) categories according to SMI, with malignancy risks of 19.2%, 20.0%, and 94.1%, respectively. After combining SMI with PDUS, 80.8% (21/26) of probably benign LNs and 94.1% (32/34) of suspicious LNs could be correctly diagnosed as benign and metastatic, respectively. The diagnostic sensitivity, specificity, and accuracy of categorizing LNs as suspicious based on SMI were 78.1%, 94.9%, and 86.3%, respectively. In conclusion, the combination of SMI with PDUS was helpful for the accurate stratification of indeterminate LNs based on US in patients with PTC.

Keywords: Doppler; biopsy; lymph node metastasis; thyroid cancer; ultrasonography.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Reclassification of PDUS indeterminate LNs after the addition of SMI. LN—Lymph node, PDUS—Power Doppler ultrasound, SMI—Superb Microvascular Imaging.
Figure 2
Figure 2
A 42-year-old female patient with left PTC. (A) Gray-scale US showed an ovoid hypoechoic indeterminate LN with displaced hilar echogenicity in the left neck level 3. (B) On PDUS, a displaced hilar vascularity was noted. (C) On SMI, an additional peripheral vascular signal was noted in the medial peripheral portion of the LN (arrows). (D) Contrast-enhanced CT (early arterial phase, 25 s) showed focal cortical contrast enhancement in the corresponding area (arrowhead). (E) Subsequent FNA and modified radical neck dissection revealed a metastatic papillary thyroid carcinoma (H&E stain, ×200). PTC-papillary thyroid carcinoma, US—ultrasound, LN—lymph node, PDUS—power Doppler ultrasound, SMI—superb microvascular imaging, FNA—fine needle aspiration.
Figure 3
Figure 3
A 30-year-old female patient with right PTC. (A) Gray-scale US showed an ovoid hypoechoic indeterminate LN with loss of hilar echogenicity at right neck level 2. (B) Hilar vascularity was also absent on PDUS (arrow). (C) On SMI, hilar vascularity was noted in the central area of the LN. (D) Subsequent FNA and surgical biopsy revealed reactive hyperplasia (FNA-thyroglobulin = 0.16 ng/mL) (H&E stain, ×200). PTC = papillary thyroid carcinoma, US = ultrasound, LN = lymph node, PDUS = power Doppler ultrasound, SMI = superb microvascular imaging, FNA = fine needle aspiration.
Figure 4
Figure 4
Reclassified LN categories of SMI. (A) SMI probably benign LN. Grey scale and PDUS images show a hypoechoic LN with loss of hilum and hilar vascularity in the left neck level 3. On SMI, central hilar vascularity is noted (arrows), and this LN is classified as ‘SMI probably benign’ (final diagnosis-benign on FNA-Tg) (B) SMI indeterminate LN. Grey scale and PDUS show a small LN in right neck level 4 with loss of hilum and hilar vascularity. On SMI, no additional vascular signals are noted; therefore, this LN is classified as ‘SMI indeterminate’ (final diagnosis-benign on FNA-Tg). (C) SMI suspicious LN. Grey scale and PDUS show a hypoechoic LN with eccentric cortical thickening and displaced hilar vascularity in left neck level 3. On SMI, abnormal peripheral vascularity is noted at the medial portion of the LN (arrows, final diagnosis-metastatic PTC on CNB). The arrowheads in figures A, B, C indicates the margin of the LN. PTC = papillary thyroid carcinoma, US = ultrasound, LN = lymph node, PDUS = power Doppler ultrasound, SMI = superb microvascular imaging, FNA = fine needle aspiration, CNB = core needle biopsy, Tg = thyroglobulin.

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