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Original Investigation |

The Role of SPECT/CT Lymphoscintigraphy and Radioguided Sentinel Lymph Node Biopsy in Managing Papillary Thyroid Cancer

Raquel Novas Cabrera, MD1; Carlos T. Chone, MD, PhD2; Denise E. Zantut-Wittmann, MD, PhD3; Patrcia S. Matos, MD, PhD4; Daniel M. Ferreira, MD, PhD5; Pablo S. Pereira, MD2; Mariana P. Ribeiro, MD1; Allan O. Santos, MD, PhD1; Celso D. Ramos, MD, PhD1; Agrício N. Crespo, MD, PhD2; Elba C. Etchebehere, MD, PhD1
[+] Author Affiliations
1Division of Nuclear Medicine, Campinas State University (UNICAMP), Campinas, Brazil
2Department of Otorhinolaringology, Campinas State University (UNICAMP), Campinas, Brazil
3Division of Endocrinology of the Department of Internal Medicine, Campinas State University (UNICAMP), Campinas, Brazil
4Department of Pathology, Campinas State University (UNICAMP), Campinas, Brazil.
5Department of Radiology, Campinas State University (UNICAMP), Campinas, Brazil
JAMA Otolaryngol Head Neck Surg. 2016;142(9):834-841. doi:10.1001/jamaoto.2016.1227.
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Importance  Single-photon emission computed tomography/computed tomography (SPECT/CT) and radioguided sentinel lymph node biopsy (rSLNB) are techniques that could potentially benefit surgeons and pathologists in the identification of sentinel lymph node (SLN) metastases in patients with papillary thyroid carcinoma (PTC). Evidence suggests that these novel techniques lead to substantial changes in PTC management by reducing understaging and of occult lymph node (LN) metastases and optimizing neck surgery by increasing the necessity of lateral lymphadenectomy and decreasing central lymphadenectomy.

Objectives  To correlate the presence of LN metastases in PTC with clinical and pathological features using SPECT/CT and rSLNB.

Design, Setting, and Participants  For this prospective cohort study from June 2010 to November 2013, 42 patients with thyroid nodules suspicious for papillary carcinoma or classified as malignant on cytology examination without suspicion of lymph node metastases by clinical and ultrasound examinations were recruited from a single public medical institution.

Interventions  All 42 patients underwent preoperative lymphoscintigraphy after an ultrasound-guided peritumoral injection of Technetium Tc 99m nanocolloid. Cervical images were acquired with a SPECT/CT scanner 15 minutes after radiotracer injection. Approximately 2 hours after lymphoscintigraphy, the patients were submitted to intraoperative rSLNB using a handheld gamma probe. All SLNs identified were removed alongside with non-SLNs from the same compartment. Papillary thyroid carcinoma, SLNs and non-SLNs were submitted for histopathology and immunohistochemical analyses.

Results  Of the 42 patients initially enrolled, 37 were included in analysis, including 6 men and 31 women with a mean (range) age of 47 (22-83) years. Overall, T stage was as follows: T1, 23 patients (62.2%); T2, 8 patients (21.6%); and T3, 6 patients (16.2%). Sentinel lymph nodes were identified in 92% of the patients, and among these metastases were present in 17 patients (46%). The SLNs were false-negative in 3 patients. Metastases in the lateral compartment ocurred in 7 patients (18%). There was a significant association between LN metastases and tumor size (odds ratio, 1.06; 95% CI, 1.00-1.13; P = .02), with a Cohen d effect of 0.683 (medium to large effect). Overall, 17 patients (46%) with LN metastases had management changed because they were submitted to higher radioiodine ablation doses and closer clinical surveillance.

Conclusions And Relevance  Radioguided SLNB is able to detect occult cervical lymph node metastases in patients with papillary thyroid carcinoma, and in 7 patients (18%) rSLNB detected lymph node metastases in the lateral compartments. The rSLNB technique lead to management change in 14 patients (37.8%).

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Figure 1.
The Level, Size, and Depth of a Lymph Node in a 22-Year-Old Woman

A 22-year-old female patient with a Bethesda VI 3.2-cm nodule in the right thyroid lobe underwent SPECT/CT lymphoscintigraphy with ultrasound-guided peritumoral injection of Technetium Tc 99mphytate followed by total thyroidectomy and rSLNB. A, SPECT scintigraphy images show 2 areas of focal uptake that corresponds to the peritumoral injection site (blue arrowhead) and the SLN at level V in the right (yellow arrowhead). B, Computed tomography; and C, SPECT/CT fusion images show a 0.5 × 0.3-cm level V sentinel lymph node (yellow arrowhead). Histopathology demonstrated a differentiated papillary thyroid carcinoma, aggressive variant (tall cell) with positive surgical margins, extra-thyroid extension, angio-lymphatic invasion and multifocal lesions (3.5 cm in the right and 1.5 cm in the left lobe). Only the SLN at level V was positive for metastases and the non-SLN was negative for metastases. A indicates anterior; CT, computed tomography; F, foot; H, head; L, left; P, posterior; R, right; rSLNB, radioguided sentinel lymph node biopsy; SLN, sentinal lymph node; SPECT, single-photon emission computed tomography.

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Figure 2.
Logistic Regression of Probability of Metastases

The logistic regression model shows the likelihood of having LN metastases in relation to tumor size.

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