Feasibility of half the recommended dose of IV contrast in DECT: image quality evaluation and diagnostic acceptability in cancer patients.

PURPOSE: To assess the quality of dual-energy computed tomography (DECT) images in patients receiving 50% of the recommended weight-based volume of iodinated intravenous contrast medium. METHODS: The study included cancer patients who previously underwent abdominal CT on a DECT scanner using a single source with the full recommended weight-based dose of Iohexol 350. Using the same scanner, the patients underwent a portovenous phase DECT scan following intravenous injection of half of the recommended weight-based dose. Monochromatic energy images were processed at 60 and 70kEv and compared to polychromatic 140kVp images. Three radiologists independently scored the images for overall diagnostic acceptability and image quality of solid organs and vasculature. Regions of interest were drawn on the portal vein, aorta, liver, and fat to calculate contrast to noise ratio (CNR) and signal to noise ratio (SNR). A multivariate ordinal generalized estimating equations model was used to assess image quality score. Pairwise comparisons were performed of the readers' scores, CNR, and SNR. Agreement with respect to quality score was calculated by using Fleiss's kappa value. RESULTS: Diagnostic acceptability was better for the SECT (120kVp) scans than for the 70 and 60kEv scans, and better for the 70 and 60kEv scans than for the 140kVp scans. Noise was subjectively rated as best on the 70kEv images. SNR of the liver was highest on 70kEv images. SNR of the liver on 70kEv images was significantly better than SECT images (p < 0.0001). Liver CNR was highest on SECT (120kVp) images. CONCLUSION: DECT with 50% reduction in the volume of intravenous contrast produces image quality comparable to that of SECT in cancer patients.

Middle Fossa Encephaloceles Treated via the Transmastoid Approach: A Case Series and Review of the Literature.

BACKGROUND: Middle fossa (MF) encephaloceles are rare lesions resulting from herniation through defects in the tegmen tympani or mastoideum. Underlying etiologies and clinical presentations are variable. Surgical goals include fistula obliteration, resection of nonfunctioning parenchyma, and dehiscence repair. The middle cranial fossa approach (MCFA), transmastoid approach (TMA), and combined (MCFA + TMA) approaches have been described. The minimally invasive TMA provides excellent exposure of the pathology and allows for ample working room to repair the defect. OBJECTIVE: To present short-term follow-up results in patients treated via the TM repair at our institution. METHODS: A retrospective review of patients with symptomatic encephaloceles treated via the TMA by our multidisciplinary team. Patient demographics, clinical presentations, intraoperative findings, repair technique, and outcomes were highlighted. RESULTS: A total of 16 encephaloceles in 13 patients were treated. Defect etiologies included spontaneous (50.0%), secondary to chronic infection (25.0%), or cholesteatoma (18.8%). Defects were most often within the tegmen mastoideum (68.8%). Average length of surgery was 3.3 h (95% CI: 2.86-3.67) and length of stay 3.9 d (95% CI: 3.09-4.79). On short-term follow-up (average 11.5 mo), no patients experienced postoperative cerebrospinal fluid leak or recurrence. The majority of patients (83.3%) experienced confirmed improvement or stabilization of hearing. CONCLUSION: MF encephaloceles present with various clinical manifestations and result from multiple underlying etiologies. The TMA is an alternative to craniotomy and our short-term results suggest that this approach may be utilized effectively in appropriately selected cases.

Socioeconomic Status and Survival in Nasopharyngeal Carcinoma: A Population-Based Study.

OBJECTIVES/HYPOTHESIS: To evaluate survival for nasopharyngeal carcinoma in relation to socioeconomic status. STUDY DESIGN: Retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) Census Tract-level Socioeconomic Status Database (2000-2016). METHODS: Patients with nasopharyngeal carcinoma diagnosed between 2000 and 2016 were identified. Data were stratified based on socioeconomic status, divided into three groups: group 1 being the poorest and group 3 the wealthiest. Univariate analysis as well as multivariate Cox regression analysis adjusted for individual variables was performed. RESULTS: A total of 5,527 patients were included in the study, with 33% in group 1, 34% in group 2, and 33% in group 3. There was a significant difference between groups in regard to age at diagnosis, race, histologic subtype, overall stage, tumor stage, nodal stage, and whether or not they received radiation. Patients in group 1, the poorest socioeconomic status, were more likely to be young (P = .003), black (P < .0001), present with higher overall stage (P = .009), tumor stage (P = .01), and nodal stage (P = .02), and less likely to receive radiation (P = .005). In multivariate analysis, there was a significant difference in survival between the groups, with group 1 patients less likely to survive compared to group 3 (hazard ratio = 1.28; 95% CI 1.07-1.57). CONCLUSIONS: Patients in the poorest socioeconomic status presented with more advanced nasopharyngeal cancer and were less likely to receive radiation when compared with individuals of higher socioeconomic status. The poorest socioeconomic status groups were less likely to survive from their disease when controlling for other variables. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2719-2723, 2021.

Effect of sarcopenia on systemic targeted therapy response in patients with advanced hepatocellular carcinoma.

PURPOSE: Sarcopenia is an independent prognostic indicator for hepatocellular carcinoma (HCC). Our objective was to determine the effect of sarcopenia on response to systemic targeted therapy in patients with advanced HCC. MATERIALS AND METHODS: This was a retrospective, Institutional Review Board approved study of 36 patients on systemic targeted therapy with immune checkpoint blockade (n = 25) or tyrosine kinase inhibitor (n = 11) for biopsy-proven advanced HCC. Skeletal muscle index (SMI) was calculated from erector spinae muscle area (SMA) at the level of T12 on pretreatment CT: [SMI = SMA (cm2)/height (m2)]. SMI was compared to treatment response defined as overall survival ≥ 1 year (nonsurgical patients) or > 50% HCC necrosis (surgical patients). Receiver operating characteristic curve and area under the curve was used for analysis with p < 0.05 for statistical significance. RESULTS: Median age of men and women was 66.5 years (range 32-83) and 70 years (range 54-78), respectively. Liver disease etiology was nonalcoholic steatohepatitis (n = 9), hepatitis C (n = 10), hepatitis B (n = 5), alcohol (n = 3) and unknown (n = 9). Mean (± SD) height and SMI for men were 1.7 m (± 0.1) and 11.4 (± 3.6); values for women were 1.7 m (± 0.1) and 8.2 (± 1.9). Treatment was withdrawn in five patients due to treatment intolerance. Response occurred in 10/31 (32.3%) patients (23 men, 8 women). T12SMI correlated with treatment response using a threshold of 7.21-8.23 for women (AUC = 1; p = 0.037), and 11.47 for men (AUC = 0.83; p = 0.015); correlation was increased for men ≥ 60 years, (AUC = 0.87; p = 0.023). CONCLUSION: Sarcopenia was associated with reduced survival and HCC necrosis in patients treated with systemic targeted therapy. CLINICAL RELEVANCE: Sarcopenia may help in predicting outcomes to targeted therapy in advanced HCC.

Myxoid Liposarcoma With Skeletal Metastases: Pathophysiology and Imaging Characteristics.

Liposarcoma is a commonly occurring soft tissue sarcoma that can be divided into 4 subtypes. Myxoid and round cell liposarcoma (MRCL) represent one of these subtypes and are classified together due to their shared chromosomal translocation. Histologic analysis of MRCL reveals a myxoid matrix with a delicate capillary network and dispersed lipoblasts. Varying degrees of round cell component are also observed, with greater amounts of round cells indicating a higher histologic grade and poorer prognosis. MRCL has a unique pattern of spread due to its initial tendency to spread to extrapulmonary sites. Additionally, skeletal metastases are frequently found in cases of MRCL. While various imaging techniques are used to visualize MRCL and metastases, magnetic resonance imaging is generally the preferred method. This article reviews the pathophysiology and imaging features of MRCL as well as the imaging characteristics, advantages, and drawbacks of multiple imaging modalities for visualizing bone metastases.

Dermatofibrosarcoma Protuberans: Pathological and Imaging Review.

Dermatofibrosarcoma protuberans (DFSP) is a rare, low-to-intermediate grade sarcoma that typically arises in the dermis and infiltrates subcutaneous tissue. Due to superficial appearance of DFSP, imaging techniques are not always utilized. However, they may be useful in large or atypical cases. The standard treatment for DFSP is excision of the lesion. In this article, we review the role of different imaging modalities in the assessment and management of DFSP.

Complications Associated with Medical Tourism for Facial Rejuvenation: A Systematic Review.

BACKGROUND: Medical tourism for cosmetic surgery has become increasingly popular in recent years. The existing literature has identified poor outcomes associated with general cosmetic tourism; however, the complications associated with cosmetic tourism for facial rejuvenation remain poorly understood. The aims of this study are to delineate the risk profile associated with medical tourism for facial rejuvenation. METHODS: A systematic review of PubMed, MEDLINE, and Embase was performed through January 2019 using the PRISMA guidelines. Search terms included combinations of keywords including medical tourism and plastic surgery and other related nomenclature. Articles published in English relevant to medical tourism for facial rejuvenation and its associated complications were examined. RESULTS: We identified six retrospective studies including 31 patients who had obtained facial rejuvenation procedures abroad and experienced treatment-associated complications. Twenty-five of 26 listed patients (96%) were female (age range 33-62 years). Departure nations included the USA, Switzerland, England, Ireland, Australia, and Thailand. Destination nations included the Dominican Republic, Cyprus, the USA, Colombia, Thailand, India, and China. Procedures included blepharoplasty, facelift, rhinoplasty, chin lift, and injections with botulinum toxin and dermal fillers. Complications included abscess, poor cosmesis, facial nerve palsy, and death. CONCLUSIONS: We present the first study to systematically review the complications associated with medical tourism for facial rejuvenation. No definitive conclusions can be made given the paucity of relevant data, its clinical and statistical heterogeneity, and small sample size. Additional research is warranted to help inform patients who seek facial rejuvenation procedures abroad and to better understand the health system implications associated with cosmetic tourism for facial rejuvenation. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Primary Osteosarcoma of the Breast: Pathophysiology and Imaging Review.

Extraskeletal osteosarcoma are rare malignant mesenchymal neoplasms of soft tissues representing around 1% of all soft tissue. The exact mechanism of tumorigenesis of primary breast osteosarcoma is still unclear. However, most of the cases develop without a recognized etiologic factor. Primary osteosarcoma of the breast is often initially misdiagnosed as breast fibroadenoma. Different imaging modalities and pathology play important role in differentiating breast osteosarcoma from other benign and malignant lesions of the breast resulting in dramatic change in the management.

Locally advanced prostate cancer imaging findings and implications for treatment from the surgical perspective.

The anatomy of the prostate is reviewed in the context of discussing the staging of prostate cancer and patterns of tumor spread. The utility of prostate magnetic resonance imaging along with new advancements in tumor staging are discussed specifically in locally advanced disease. What should be included in the radiology report carries a substantial weight to formulate the urologist's decision in regards to the selection of surgical candidates, preoperative planning and avoiding postoperative complications.

Tumor necrosis factor-α triggers opposing signals in head and neck squamous cell carcinoma and induces apoptosis via mitochondrial- and non-mitochondrial-dependent pathways.

Head and neck squamous cell carcinoma (HNSCC) remains one of the most common malignancies worldwide. Although the treatment outcomes of HNSCC have improved in recent years, the prognosis of patients with advanced-stage disease remains poor. Current treatment strategies for HNSCC include surgery as a primary therapy, while radio-, chemo-, and biotherapeutics can be applied as second-line therapy. Although tumor necrosis factor-α (TNF-α) is a potent tumor suppressor cytokine, the stimulation of opposing signals impairs its clinical utility as an anticancer agent. The aim of this study was to elucidate the mechanisms regulating TNF-α­induced opposing signals and their biological consequences in HNSCC cell lines. We determined the molecular mechanisms of TNF-α-induced opposing signals in HNSCC cells. Our in vitro analysis indicated that one of these signals triggers apoptosis, while the other induces both apoptosis and cell survival. The TNF-α-induced survival of HNSCC cells is mediated by the TNF receptor-associated factor 2 (TRAF2)/nuclear factor (NF)-κB-dependent pathway, while TNF-α-induced apoptosis is mediated by mitochondrial and non-mitochondrial-dependent mechanisms through FADD-caspase-8-caspase-3 and ASK-JNK-p53-Noxa pathways. The localization of Noxa protein to both the mitochondria and endoplasmic reticulum (ER) was found to cause mitochondrial dysregulation and ER stress, respectively. Using inhibitory experiments, we demonstrated that the FADD­caspase-8­caspase-3 pathway, together with mitochondrial dysregulation and ER stress-dependent pathways, are essential for the modulation of apoptosis, and the NF-κB pathway is essential for the modulation of anti-apoptotic effects/cell survival during the exposure of HNSCC cells to TNF-α. Our data provide insight into the mechanisms of TNF-α-induced opposing signals in HNSCC cells and may further help in the development of novel therapeutic approaches with which to minimize the systemic toxicity of TNF-α.

Heterotopic ossification: radiological and pathological review.

Background Heterotopic Ossification (HO) is a common condition referring to ectopic bone formation in soft tissues. It has two major etiologies, acquired (more common) and genetic. The acquired form is closely related to tissue trauma. The exact pathogenesis of this disease remains unclear; however, there is ongoing research in prophylactic and therapeutic treatments that is promising. Conclusions Due to HO potential to cause disability, it is so important to differentiate it from other causes in order to establish the best possible management.

Surgical Approaches in the Treatment of Intracranial Complications of Paranasal Sinus Disease: A Review of the Literature.

BACKGROUND: Intracranial extension of frontal or ethmoid sinusitis carries a high morbidity and mortality if not treated aggressively. With the emergence of endoscopic sinus surgery (ESS), we questioned whether these approaches have supplanted traditional transcranial procedures for intracranial extension of sinus disease, and whether ESS approaches had a difference in patient outcomes. METHODS: Studies reporting surgical management and outcomes of frontal sinus disease with intracranial extension were queried using the United States National Library of Medicine at the National Institutes of Health PubMed database. We also queried common internet search engines. We included studies regarding sinogenic intracranial suppurative infections treated surgically with ESS and neurosurgical approaches. Studies with insufficient data regarding specific treatment methods and studies that included populations of medically treated infections were excluded. RESULTS: A total of 108 cases were identified in which patients with intracranial sinogenic disease were treated via ESS alone (morbidity: 43.5%, mortality: 0.9%), 47 cases via transcranial intervention alone (morbidity: 33.2%, mortality: 7.8%), and 43 cases via simultaneous neurosurgical and ESS approaches (morbidity: 16.3%, mortality: 6.4%). Complex sinus disease with posterior table compromise in the absence of intracranial extension treated via ESS alone was reported in 164 cases with a morbidity and mortality of 3.8% and 0%, respectively. CONCLUSIONS: Combined ESS and transcranial approaches achieve definitive control of sinogenic and intracranial disease, whereas either modality alone carries a potential risk for higher morbidity and mortality. The use of ESS alone may have use in the treatment of sinusitis with posterior table erosion prior to intracranial extension.

Single Versus Simultaneous Double Free Flaps for Head and Neck Reconstruction: Comparison of Flap Outcomes and Donor-Site Morbidity.

INTRODUCTION: Ablative procedures of the head and neck often result in substantial defects that require large-volume tissue transfer for restoration of form and function. Multiple simultaneous free flaps may be required for complex defects, but these procedures are often avoided because of the perception of an increase in associated surgical complications and morbidity. We present our experience with the use of simultaneous multiple free flaps as compared with single free flaps (SFFs) for head and neck reconstruction. METHODS: Thirty-seven patients with a history of head and neck malignancy underwent SFF reconstruction, and 21 patients underwent double free flap (DFF) reconstruction. Statistical analysis was conducted comparing demographics, comorbidities, etiology of disease, and surgical outcomes between the 2 patient groups. RESULTS: Operative time and length of hospital stay were both significantly longer in the DFF group versus the SFF group. Despite significantly higher rates of preoperative radiation, osteoradionecrosis, and operation for secondary malignancy in DFF group, no significant differences in flap survival, partial flap loss, recipient site complications, or donor site complications were found. Overall flap-related reoperation rates were low, as were total flap losses. There were 10 complications (24%) that required reoperation in the DFF group, and 1 total flap loss (2.4%), on per-flap basis. There were 10 complications (27%) that required reoperation in the SFF group and 3 total flap losses (8.1%). Per-flap incidence of donor site morbidity in the DFF group was significantly lower than that in the SFF group (23.8% vs 56.8%, respectively, P = 0.011). CONCLUSIONS: The use of multiple free flaps for reconstruction of major head and neck tissue defects is sometimes necessary to achieve adequate reconstructive results. These procedures have no significant associated increase in overall flap-related complications. Our findings suggest that donor site morbidity can be minimized in double-flap reconstructions by thoughtful flap selection.

The effects of granulocyte colony-stimulating factor on MR images of bone marrow.

Granulocyte colony-stimulating factor (G-CSF) analogs such as filgrastim/pegfilgrastim are increasingly used to enhance neutrophilic recovery after chemotherapy. It is widely known that, physiologically, pegfilgrastim stimulates marrow mitotic activity and induces marrow reconversion from fatty to cellular. However, there is limited literature discussing the effects of pegfilgrastim on musculoskeletal magnetic resonance imaging, with the consensus that marrow reconversion secondary to pegfilgrastim therapy is easily confounded with a malignant process, especially in patients with a history of cancer. We attempt to discuss the expected changes and MRI findings after pegfilgrastim therapy through a summary of current literature. Additionally, we provide images from our own practice to support the previously established findings. G-CSF-stimulated reconversion can appear as patchy expansions of baseline hematopoietic marrow, but can also appear to be diffusely homogeneous, adding to its ambiguity. We conclude that using a baseline MRI, clinical information, and assessing sequential MRI changes in conjunction with pegfilgrastim therapy may aid the differentiation between benign and pathological change. We expand our discussion to include the effects of novel technologies, such as whole-body MRI, chemical shift imaging, and contrast agents in helping the distinction.

Electrophysiological identification of nonrecurrent laryngeal nerves.

OBJECTIVES/HYPOTHESIS: The nonrecurrent laryngeal nerve (NRLN) is a common anatomic variation of the right recurrent laryngeal nerve (RLN), which has been associated with an increased risk of injury during thyroid and parathyroid surgery. We suggest that early successful identification using intraoperative nerve monitoring (IONM) and preservation of this variant will help the surgeon to avoid injury to this nerve. Our objective was to examine the electrophysiological parameters of the NRLN and the efficacy of IONM for successful identification of the NRLN. STUDY DESIGN: Retrospective database analysis. METHODS: This is a retrospective study of a prospectively collected database of all patients who underwent thyroid and parathyroid surgeries by a single surgeon at a tertiary care center over 3 years (n = 481). Patients' demographic data and operative reports, including the IONM reports, were reviewed. Average stimulation thresholds with resulting amplitudes and latencies were compared. Preoperative and postoperative laryngoscopy were performed in all cases. RESULTS: We identified 15 NRLNs (2.2%) in a total 682 laryngeal nerves. No left-sided NRLNs were observed. The average right vagus latency in the NRLN group was shorter than that of the RLN group (2.40 ms ± 0.49 ms vs. 3.43 ms ± 1.03 ms; P < .001). No statistically significant difference was observed between the initial amplitudes of the right vagus nerves in the two groups (713.67 µV ± 208.71 µV vs. 816.22 µV ± 470.45 µV; P = .14). All NRLN cases exhibited normal functioning of vocal cords on postoperative laryngoscopy. CONCLUSIONS: IONM is highly effective in the identification of the NRLN. Right vagus nerve latency in the NRLN group was found to be significantly shorter than in the RLN group. Early identification of the NRLN allowed cautious preservation of the NRLN, resulting in excellent postoperative outcomes. The rate of NRLN identification may be improved by routine use of IONM. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:2189-2193, 2017.

Change in Liver Imaging Reporting and Data System Characterization of Focal Liver Lesions Using Gadoxetate Disodium Magnetic Resonance Imaging Compared With Contrast-Enhanced Computed Tomography.

PURPOSE: The aim of this study was to determine whether gadoxetate-enhanced magnetic resonance imaging (MRI) improves lesion characterization in patients at risk for hepatocellular carcinoma compared with computed tomography (CT). MATERIALS AND METHODS: Forty-nine patients with indeterminate lesions found at contrast-enhanced CT were prospectively enrolled and imaged using gadoxetate-enhanced hepatobiliary phase (HBP) MRI within 30 days of their initial CT. Three readers graded each lesion at CT and MRI using the Liver Imaging Reporting and Data System (LI-RADS) v2014 major criteria and HBP characterization as an ancillary feature. Patients were followed for an average of 1.8 years to document growth or stability of each lesion. RESULTS: The Liver Imaging Reporting and Data System categorization changed for 71% (52/73) of lesions based on HBP MRI compared with CT, with 30% (22/73) of lesions upgraded and 41% (30/73) of lesions downgraded. There was almost perfect agreement between readers for arterial phase hyperintensity and HBP hypointensity, with lower interreader agreement for washout and capsule appearance. On the basis of composite clinical follow-up, lesions that were subsequently classified as hepatocellular carcinoma were assigned a higher LI-RADS category on HBP MRI when compared with CT. CONCLUSIONS: For patients with indeterminate lesions seen on contrast-enhanced CT, HBP MRI using gadoxetate improves lesion characterization when using LI-RADS v2014 criteria.

Locally advanced asymptomatic papillary thyroid cancer presenting with retropharyngeal lymph node metastasis symptoms.

Papillary thyroid cancer (PTC) rarely metastasizes to the retropharyngeal lymph nodes. Managing patients with locally advanced primary PTC and metastasis located in distant anatomical areas is challenging. Herein, we report a 56-year-old patient with locally advanced asymptomatic PTC, who presented with obstructive airway symptoms due to the metastatic retropharyngeal lymph node. The patient underwent simultaneous total thyroidectomy, central lymph node dissection, en bloc resection of strap muscle and left laryngeal nerve via cervical approach and transoral resection of the metastatic retropharyngeal lymph node. Metastatic PTC should be included in the differential diagnosis of a retropharyngeal masses. Simultaneous total thyroidectomy of the primary thyroid cancer via a cervical approach and transoral resection of an isolated retropharyngeal metastasis is safe and feasible.

Optimal timing for a repeat fine-needle aspiration biopsy of thyroid nodule following an initial nondiagnostic fine-needle aspiration.

BACKGROUND: In the case of a nondiagnostic thyroid fine-needle aspiration (FNA) biopsy result, recent guidelines from the Bethesda system recommend repeat thyroid FNA after 3 months to prevent false-positive results. We aimed to examine our institutional data to determine whether the 3-month period affects the diagnostic yield of repeat biopsies. METHODS: A retrospective review of patient records over a 5-year period at our institution was performed. Patients who required repeat FNA due to nondiagnostic results were included. The time between the FNA biopsies, adequacy of the FNA specimens, as well as the surgical pathology diagnosis were analyzed. RESULTS: We identified 317 patients who required a repeat FNA. Of these, 96 (30.3%) patients had repeat FNAs less than 3 months after initial biopsy, while 221 (69.7%) patients had repeat FNAs in greater than 3 months. One hundred five patients were referred to our clinic with an initial nondiagnostic biopsy from an outside institution. Repeat FNA was nondiagnostic in 35 patients (11.04%) in the total study population. There was no difference in satisfactory diagnostic yield between repeat FNAs performed greater than 3 months (201 patients, 90.95%) or less than 3 months (81 patients, 84.38%) after the initial biopsy (P = .117). Of the 35 patients with repeat nondiagnostic biopsy, 17 patients underwent diagnostic lobectomy and 3 (17.6%) patients were found to have malignant disease. CONCLUSIONS: Early (<3 months) repeat FNA does not affect diagnostic yield of the subsequent sample. Patients with suspicious thyroid nodules could therefore receive a repeat FNA as soon as needed, rather than waiting 3 months. The shortened biopsy interval would alleviate stress on patients with benign nodules and expedite surgical intervention in patients with malignancy.

The significance of enlarged cervical lymph nodes in diagnosing thyroid cancer.

INTRODUCTION: We aim to investigate the significance of enlarged cervical lymph nodes (ECLN) identified by initial surgeon-performed ultrasound (US) as a tool for determining the risk of malignancy in the patients presenting with suspicious thyroid nodules. METHODS: Radiological and surgical reports were retrospectively reviewed for the patients with suspicious thyroid nodules who underwent thyroidectomy and preoperative comprehensive neck US. Ultrasonographic features of the identified cervical lymph nodes were correlated with the final pathology report. Patients with malignancy other than papillary thyroid cancer (PTC) were excluded. RESULTS: The study consisted of 440 patients. On final pathology, PTC was found in 142 patients (32.3%), the remaining 298 (67.7%) exhibited benign findings. ECLN (>1 cm) were found in 66 (46.5%) patient with PTC compared to only 53 (17.8%) patients with benign nodules (P < 0.001). Of the 119 patients with ECLN, 54.6% had benign appearing ECLN with no suspicious features, 26.1% had one suspicious feature, and 19.3% had more than one suspicious features. Benign appearing ECLN had a positive predictive value (PPV) of 41.54%, negative predictive value (NPV) of 59.02%, sensitivity of 51.92%, and specificity of 48.65% in predicting malignancy as opposed to the absence of ECLN. While as opposed to benign looking ECLN, ECLN with only one suspicious feature had a PPV of 70.97%, NPV of 50.00%, sensitivity of 33.33%, and specificity of 83.02%, and ECLN with two or more suspicious feature had a PPV of 73.91%, NPV of 48.96%, sensitivity of 25.76%, and specificity of 88.68%. CONCLUSION: ECLN are associated with an increased likelihood of thyroid malignancy in the patients undergoing evaluation of a suspicious nodule. The risk of malignancy in thyroid nodules increases with the presence of suspicious ultrasonographic features on cervical lymph nodes.