title: SPECT/CT sentinel lymph node identification in papillary thyroid cancer: lymphatic staging and surgical management improvement.
abstract: OBJECTIVE
  Lymphadenectomy in papillary thyroid carcinoma (PTC) continues to be controversial. A better staging method is needed to provide adequate individual surgical treatment. SPECT/CT lymphoscintigraphy and sentinel lymph node (SLN) biopsy may improve lymphatic staging and surgical treatment. Our main objectives were to describe the lymphatic drainage of PTC using lymphoscintigraphy, to evaluate the lymphatic spread (comparing SLN and lymphadenectomy results) and to analyse the impact of SLN identification in surgery.
  
  
  METHODS
  We prospectively studied 24 consecutive patients with PTC (19 women; mean age 52.7 years, range 22-81 years). The day before surgery, lymphoscintigraphy with ultrasound-guided intratumoral injection ((99m)Tc-nanocolloid, 148 MBq) was performed, obtaining planar and SPECT/CT images. All patients underwent total thyroidectomy, SLN biopsy (hand-held gamma probe) with perioperative analysis, central compartment node dissection, or laterocervical lymphadenectomy if perioperative stage N1b or positive SLNs in this lymphatic basin.
  
  
  RESULTS
  Lymphoscintigraphy revealed at least one SLN in 19 of 24 patients (79 %) on planar and SPECT/CT images, and in 23 of 24 patients (96 %) during surgery using a hand-held gamma probe. Lymph node metastases were detected with classical perioperative techniques (ultrasound guidance and surgical inspection) in 3 of 24 patients, by perioperative SLN analysis in 10 of 23, and by definitive histology in 13 of 24. The false-negative (FN) ratio for SLN was 7.7 % (one patient with bulky lymph nodes). The FN ratio for perioperative frozen sections was 15.4 % (two patients, one with micrometastases, the other with bilateral SLN). Lymphatic drainage was only to the central compartment in 6 of 24 patients (3 of the 6 with positive SLNs for metastases), only to the laterocervical basin in 5 of 24 patients (all unilateral, 2 of 5 positive SLNs) and to the central and laterocervical compartments in 12 of 24 patients (6 of 12 and 3 of 12 positive SLNs, respectively).
  
  
  CONCLUSIONS
  Lymphoscintigraphy reveals the lymph node drainage in a high proportion of patients. It detects laterocervical drainage in a significant percentage of patients, allowing the detection of occult lymph node metastases and improving the surgical management in PTC.
authors.affiliation: Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain, ampagarcia@vhebron.net.
authors.forename: Amparo
authors.initials: A
authors.lastname: Garcia-Burillo
authors.forename: Isabel
authors.initials: I
authors.lastname: Roca Bielsa
authors.forename: Oscar
authors.initials: O
authors.lastname: Gonzalez
authors.forename: Carles
authors.initials: C
authors.lastname: Zafon
authors.forename: Monica
authors.initials: M
authors.lastname: Sabate
authors.forename: Josep
authors.initials: J
authors.lastname: Castellvi
authors.forename: Xavier
authors.initials: X
authors.lastname: Serres
authors.forename: Carmela
authors.initials: C
authors.lastname: Iglesias
authors.forename: Ramon
authors.initials: R
authors.lastname: Vilallonga
authors.forename: Enric
authors.initials: E
authors.lastname: Caubet
authors.forename: Jose Manuel
authors.initials: JM
authors.lastname: Fort
authors.forename: Jordi
authors.initials: J
authors.lastname: Mesa
authors.forename: Manuel
authors.initials: M
authors.lastname: Armengol
authors.forename: Joan
authors.initials: J
authors.lastname: Castell-Conesa
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002277:Carcinoma / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D002291:Carcinoma, Papillary; D005260:Female; D006801:Humans; D008197:Lymph Node Excision; D008207:Lymphatic Metastasis / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000473:pathology; D008297:Male; D008875:Middle Aged; D064847:Multimodal Imaging; D009367:Neoplasm Staging; D021701:Sentinel Lymph Node Biopsy; D000077273:Thyroid Cancer, Papillary; D013964:Thyroid Neoplasms / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed
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