The 2015 American Thyroid Association (ATA) management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer suggest that thyroid sonography with survey of the cervical lymph nodes should be performed in all patients with known or suspected thyroid nodules. This explicit recommendation to routinely survey the cervical lymph nodes with ultrasonography is pivotal because examination beyond the thyroid has traditionally been inconsistent. Many reports of thyroid ultrasonographic examination describe dimensions and characteristics of thyroid glands and nodules only without incorporating extra thyroidal structures, including lymph nodes. The 2009 and 2015 guidelines have their greatest difference with regard to imaging beyond ultrasonography. Recommendation 22 (2009) states that routine preoperative use of other imaging studies (computed tomography [CT], magnetic resonance imaging [MRI], and positron emission tomography) is not recommended. In contrast, Recommendation 33 (2015) states that preoperative use of cross-sectional imaging studies (CT and MRI) with intravenous contrast material is recommended as an adjunct to ultrasonography for patients with clinically suspected advanced disease, including an invasive primary tumour, or clinically apparent multiple or bulky lymph node involvement. However, Recommendation 33 also states that routine preoperative scanning with 18 fluorodeoxyglucose positron emission tomography is not recommended. Cross-sectional imaging with CT or MRI is appropriate when abnormal lymph nodes are identified at the periphery or limits of the sonographically accessible field or bulky nodal disease is incompletely imaged with ultrasonography or in the presence of evidence of extension of nodal disease into the mediastinum or deep structures of the neck (parapharyngeal and/or retropharyngeal regions) or when there is clinical or sonographic evidence of a very large or invasive primary tumour. 

Preoperative imaging for thyroid cancer: beyond ultrasonography.
Orloff LA, Randolph GW.
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Shabbir Akhtar

Department of Surgery, The Aga Khan University and Hospital, Karachi, Pakistan.

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