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American Thyroid Association Statement on Preoperative Imaging for Thyroid Cancer Surgery

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American Thyroid Association Statement on Preoperative Imaging for Thyroid Cancer Surgery THYROID STATEMENT Volume X, Number X, 2014 ª Mary Ann Liebert, Inc., and the American Thyroid Association DOI: 10.1089/thy.2014.0096 American Thyroid Association Statement on Preoperative Imaging for Thyroid Cancer Surgery Michael W. Yeh,1 Andrew J. Bauer,2 Victor A. Bernet,3 Robert L. Ferris,4 Laurie A. Loevner,5 Susan J. Mandel,5 Lisa A. Orloff,6,* Gregory W. Randolph,7 and David L. Steward8 for the American Thyroid Association Surgical Affairs Committee Writing Task Force Background: The success of surgery for thyroid cancer hinges on thorough and accurate preoperative imaging, which enables complete clearance of the primary tumor and affected lymph node compartments. This working group was charged by the Surgical Affairs Committee of the American Thyroid Association to examine the available literature and to review the most appropriate imaging studies for the planning of initial and revision surgery for thyroid cancer. Summary: Ultrasound remains the most important imaging modality in the evaluation of thyroid cancer, and should be used routinely to assess both the primary tumor and all associated cervical lymph node basins preoperatively. Positive lymph nodes may be distinguished from normal nodes based upon size, shape, echo- genicity, hypervascularity, loss of hilar architecture, and the presence of calcifications. Ultrasound-guided fine- needle aspiration of suspicious lymph nodes may be useful in guiding the extent of surgery. Cross-sectional imaging (computed tomography with contrast or magnetic resonance imaging) may be considered in select circumstances to better characterize tumor invasion and bulky, inferiorly located, or posteriorly located lymph nodes, or when ultrasound expertise is not available. The above recommendations are applicable to both initial and revision surgery. Functional imaging with positron emission tomography (PET) or PET-CT may be helpful in cases of recurrent cancer with positive tumor markers and negative anatomic imaging. INTRODUCTION lymph node compartments, and is thus an essential compo- nent in the planning of thyroid cancer surgery. As stated in hough thyroid cancer is associated with high the Revised American Thyroid Association Management Toverall survival rates exceeding 90% for most subtypes, Guidelines for Patients with Thyroid Nodules and Differ- the risk of recurrence has been reported to be as high as entiated Thyroid Cancer, ultrasound is the first-line imaging 35% (1). Most of these recurrences are detected within modality for patients with known or suspected thyroid can- the first five years after diagnosis, and thus may actually cer (Recommendation 21) (3). In addition, cross-sectional represent persistent rather than truly recurrent disease. It imaging, including computed tomography (CT) scan with is known that the majority of reoperations for thyroid contrast, has a role in primary and nodal preoperative as- cancer are preventable, and that inadequate preoperative sessment in some patients with well-differentiated thyroid imaging frequently is the root cause of incomplete initial cancer. Herein, we summarize the available literature to de- surgery (2). scribe the role of ultrasound, cross-sectional imaging, and Thorough and accurate preoperative imaging enables functional imaging in the planning of initial and subsequent complete clearance of the primary tumor as well as affected surgery for thyroid cancer. 1Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, California. 2Division of Endocrinology and Diabetes: The Thyroid Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. 3Division of Endocrinology, Mayo School of Medicine, Jacksonville, Florida. 4University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania. 5Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. 6University of California, San Francisco, San Francisco, California. 7Department of Otolaryngology, Massachusetts Eye and Ear Infirmary/Massachusetts General Hospital, Boston, Massachusetts. 8University of Cincinnati College of Medicine, Cincinnati, Ohio. *Present Address: Department of Otolaryngology, Stanford University, Stanford, California. 1 2 YEH ET AL. ULTRASOUND HARDWARE, TECHNOLOGY, Table 1. Scanning Technique: Preoperative AND TECHNIQUE Ultrasound for Thyroid Cancer Surgery Equipment Equipment: High-frequency linear array probe. Positioning: Hyperextension of neck. Currently, a variety of high-quality ultrasound machines Primary lesion: Assess size, multiplicity, margin, invasion produced by different manufacturers are available. Several of deep structures. key components are required. First, a high frequency linear Central compartment lymph nodes (level 6): Scan from transducer (12 mHz) is preferable. This permits higher res- submental area to sternal notch. Scan three distinct areas: olution imaging of the more superficial tissues of the neck (up pretracheal, right paratracheal, and left paratracheal. to about 4 cm below the skin surface). The transducer should Turn head away from side of interest to image allow for variable frequency selection, so that the frequency tracheoesophageal groove. Angle transducer inferiorly to can be decreased to 10 mHz or even 8 mHz, for deeper fields examine mediastinum. of view. Lower frequency imaging is useful in patients with Lateral compartment lymph nodes (levels 2, 3, and 4): prominent soft tissue and larger circumference necks, espe- Scan from mandible to clavicle. Angle transducer inferiorly at clavicle to image infraclavicular nodes at cially when examining the deeper paratracheal areas, the base of level 4. tracheoesophageal groove, and level 4 lymph nodes that tend Posterior compartment lymph nodes (level 5): Sweep to be located posterior to the carotid/jugular sheath. Second, laterally along clavicle to posterior border of because vascular assessment of lymph nodes is critical for sternocleidomastoid muscle, then trace posterior border assessing malignancy risk, color flow Doppler and/or power superiorly to mastoid process. Doppler are required with variable settings. Third, sono- graphic imaging is improved if at least two focal zones are available and the focal zones can be shifted to the depth of interest. Fourth, ultrasound machines should possess tech- lighting, so that it is dark while the examination is being nology for total gain correction or time-gain compensation, performed. allowing for increasing the gain in the far field, deeper in the Scanning of the neck should begin in the transverse plane. neck to maximize imaging, while decreasing the gain in the It is preferable initially to have the patient looking straight near field, since the skin is generally not a site for metastatic ahead with the chin up rather than rotating the head. This disease. Finally, an optional small sector or convex trans- position permits imaging lymph nodes in the anatomically ducer with variable frequency of up to 8.5 mHz can be useful neutral position. Turning of the head to the left or the right, for evaluation of the upper mediastinum because the curved away from the side of interest, may facilitate imaging of footprint can be placed in the sternal notch and angled infe- tracheoesophageal or deep level 6 lymph nodes because this riorly to view the mediastinum. position causes these structures to rotate more anteriorly. However, labeling of lymph node location should be done Aims of Preoperative Ultrasound with the head in the anatomically neutral position. Given that for Thyroid Cancer Surgery the anatomic borders of the compartments are not always The objectives of preoperative sonographic imaging in straightforward to identify sonographically, additional de- patients with known or suspected thyroid cancer are (a) to scriptors for the locations of abnormal lymph nodes, such as assess the primary tumor and (b) to identify abnormal lymph their positions relative to major vessels and bony landmarks, nodes in the central (4) and lateral (5) neck that should be may be useful. targeted for compartment-oriented surgical removal. The To scan the lateral compartments, levels 2–4, the trans- procedure described below should be performed in all pa- ducer should be positioned inferior to the mandible, at the tients undergoing initial surgery, as well as after thyroid- level of the submandibular gland. In the transverse plane, the ectomy in thyroid cancer patients as part of a surveillance transducer should be moved inferiorly to the clavicle with strategy. Prior to removal of the thyroid, examination of the the field of vision centered on the carotid/jugular sheath. central neck compartment is more challenging because of Imaging should not just involve one sweep from superior to the thyroid’s presence. inferior, but the examiner should move the transducer several times up and down the vascular sheath to best identify lymph nodes. On both sides, the transducer should be angled infe- Scanning Technique riorly at the clavicle to image infraclavicular nodes at the Essential points of scanning technique are summarized in base of level 4. Imaging of the posterior triangle, level 5, Table 1. Proper positioning of the patient, the examiner, and requires scanning laterally along the clavicle and posterior to the ultrasound machine are essential for optimizing the so- the sternocleidomastoid muscle (SCM). The transducer nographic examination. Typically, for a right-handed oper- should be moved laterally from level 4 along the edge of the ator, both the ultrasound console and the operator are
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