Combining radiomics with thyroid imaging reporting and data system to predict lateral cervical lymph node metastases in medullary thyroid cancer.

BACKGROUND: Medullary Thyroid Carcinoma (MTC) is a rare type of thyroid cancer. Accurate prediction of lateral cervical lymph node metastases (LCLNM) in MTC patients can help guide surgical decisions and ensure that patients receive the most appropriate and effective surgery. To our knowledge, no studies have been published that use radiomics analysis to forecast LCLNM in MTC patients. The purpose of this study is to develop a radiomics combined with thyroid imaging reporting and data system (TI-RADS) model that can use preoperative thyroid ultrasound images to noninvasively predict the LCLNM status of MTC. METHODS: We retrospectively included 218 MTC patients who were confirmed from postoperative pathology as LCLNM negative (n=111) and positive (n=107). Ultrasound features were selected using the Student's t-test, while radiomics features are first extracted from preoperative thyroid ultrasound images, and then a two-step feature selection approach was used to select features. These features are then used to establish three regularized logistic regression models, namely the TI-RADS model (TM), the radiomics model (RM), and the radiomics-TI-RADS model (RTM), in 5-fold cross-validation to determine the likelihood of the LCLNM. The Delong's test and decision curve analysis (DCA) were used to evaluate and compare the performance of the models. RESULTS: The ultrasound features of margin and TI-RADS level, and a total of 12 selected radiomics features, were significantly different between the LCLNM negative and positive groups (p<0.05). The TM, RM, and RTM yielded an averaged AUC of 0.68±0.05, 0.78±0.06, and 0.82±0.05 in the 5-fold cross-validation dataset, respectively. RM and RTM are statistically better than TM (p<0.05 and p<0.001) according to Delong test. DCA demonstrates that RTM brings more benefit than TM and RM. CONCLUSIONS: We have developed a joint radiomics-based model for noninvasive prediction of the LCLNM in MTC patients solely using preoperative thyroid ultrasound imaging. It has the potential to be used as a complementary tool to help guide treatment decisions for this rare form of thyroid cancer.

The log odds of positive neck lymph nodes is a superior lymph node predictor for overall survival in head and neck cancer: a population-based analysis in Germany.

BACKGROUND: This population-based study investigated the influence of different lymph node (LN) classifications on overall survival (OS) in head and neck cancer (HNC). METHODS: 401 patients (median age: 57 years; 47% stage IV) of the Thuringian cancer registries with diagnosis of a primary HNC receiving a neck dissection (ND) in 2009 and 2010 were included. OS was assessed in relation to total number of LN removed, number of positive LN, LN ratio, and log odds of positive LN (LODDS). RESULTS: Mean number of LODDS was 0-0.96 ± 0.57. When limiting the multivariate analysis to TNM stage, only the UICC staging (stage IV: HR 9.218; 95% CI 2.721-31.224; p < 0.001) and LODDS > - 1.0 (HR 2.120; 95% CI 1.129-3.982; p = 0.019) were independently associated with lower OS. CONCLUSION: LODDS was an independent and superior predictor for OS in HNC in a population-based setting with representative real-life data.

Magnetic resonance imaging (MRI) radiomics of papillary thyroid cancer (PTC): a comparison of predictive performance of multiple classifiers modeling to identify cervical lymph node metastases before surgery.

PURPOSE: To compare predictive efficiency of multiple classifiers modeling and establish a combined magnetic resonance imaging (MRI) radiomics model for identifying lymph node (LN) metastases of papillary thyroid cancer (PTC) preoperatively. MATERIALS AND METHODS: A retrospective analysis based on the preoperative MRI scans of 109 PTC patients including 77 patients with LN metastases and 32 patients without metastases was conducted, and we divided enroll cases into trained group and validation group. Radiomics signatures were selected from fat-suppressed T2-weighted MRI images, and the optimal characteristics were confirmed by spearman correlation test, hypothesis testing and random forest methods, and then, eight predictive models were constructed by eight classifiers. The receiver operating characteristic (ROC) curves analysis were performed to demonstrate the effectiveness of the models. RESULTS: The area under the curve (AUC) of ROC based on MRI texture diagnosed LN status by naked eye was 0.739 (sensitivity = 0.571, specificity = 0.906). Based on the 5 optimal signatures, the best AUC of MRI radiomics model by logistics regression classifier had a considerable prediction performance with AUCs 0.805 in trained group and 0.760 in validation group, respectively, and a combination of best radiomics model with visual diagnosis of MRI texture had a high AUC as 0.969 (sensitivity = 0.938, specificity = 1.000), suggesting combined model had a preferable diagnostic efficiency in evaluating LN metastases of PTC. CONCLUSION: Our combined radiomics model with visual diagnosis could be a potentially effective strategy to preoperatively predict LN metastases in PTC patients before clinical intervention.

Cervical ultrasonography has no additional value over negative 18F-FDG PET/CT scans for diagnosing cervical lymph node metastases in patients with oesophageal cancer.

OBJECTIVES: To investigate the additional value of cervical ultrasonography over 18F-FDG PET/CT for diagnosing cervical lymph node metastases in patients with newly diagnosed oesophageal cancer. METHODS: Between January 2013 and January 2016, 163 patients with newly diagnosed oesophageal cancer underwent both cervical ultrasonography and 18F-FDG PET/CT at a tertiary referral centre in the Netherlands. Retrospective clinical data analysis was performed to assess the diagnostic value of cervical ultrasonography and 18F-FDG PET/CT for the detection of cervical lymph node metastases. Fine needle aspiration or clinical follow-up was used as reference standard. RESULTS: The overall incidence of patients with cervical lymph node metastases was 14%. The sensitivity of 18F-FDG PET/CT to detect cervical lymph node metastases was 82% (95% CI 59-94%) and specificity was 91% (95% CI 85-95%). The sensitivity and specificity of cervical ultrasonography were 73% (95% CI 50-88%) and 84% (95% CI 77-90%), respectively. In patients with a negative 18F-FDG PET/CT, 12 of 133 (9%) patients had suspicious nodes on cervical ultrasonography. In all these 12 patients the nodes were confirmed benign. CONCLUSIONS: Cervical ultrasonography has no additional diagnostic value to a negative integrated 18F-FDG PET/CT for the detection of cervical lymph node metastases in patients with newly diagnosed oesophageal cancer. KEY POINTS: • Cervical ultrasonography has no value over PET/CT in evaluating cervical node metastases. • PET/CT provides greater diagnostic confidence compared to cervical ultrasonography. • Cervical ultrasonography during standard diagnostic work-up may be considered unnecessary. • Cervical lesions on PET/CT require cytopathological confirmation by FNA.

Lymph node location is a risk factor for papillary thyroid cancer-related death.

PURPOSE: Papillary thyroid cancer (PTC) has good prognosis with a very low chance of mortality. The prognostic role of metastatic lymph node location was judged controversial and more recently (TNM VIII ed.) was considered to have no impact on the prognosis of older patients. The aim of the study was to evaluate the role of metastasized node location on PTC-related mortality. METHODS: PTC-related mortality was analysed in a consecutive retrospective series of 1653 PTC patients followed at our Thyroid Clinic (mean follow-up 5.9 years). RESULTS: Sixteen out of 1653 patients (0.96%) died because of PTC. Average age was 68 years at presentation and 74.7 at death. F/M ratio was 1:1. The death rate increased in relation to the lymph node status: 0.2% in N0, 0.3% in N1a and 3.0% in N1b. CONCLUSIONS: The presence of lymph node metastases in the N1b compartment should be considered as a risk factor for distant metastatic spread and for cancer-related death and included in post-surgery evaluation.

Latero-cervical lymph node metastases (N1b) represent an additional risk factor for papillary thyroid cancer outcome.

PURPOSE: Papillary thyroid carcinoma (PTC), the most common thyroid cancer histotype, has a good prognosis even when spread to the neck lymph node (LN). The prognostic role of LN metastases' location is still controversial. The aim of the present study was to evaluate the clinical relevance of the number and location of LN metastases at presentation in PTCs. METHODS: This retrospective study included a consecutive series of 1653 PTC patients followed for a mean period of 5.9 years in a referral thyroid cancer clinic. All patients have undergone thyroidectomy with the dissection of at least six LNs. According to the LN status, patients were subdivided into 569 N0 (34.4%), 644 N1a (39.0%, central compartment) and 440 N1b (26.6%, latero-cervical compartment). RESULTS: Age at diagnosis was significantly lower in N1b (39.8, IQR 30.7-51.6) and N1a (40.1, IQR 31.3-50.1) than in N0 (44.7, IQR 36.6-55.0 yrs). The male gender was more prevalent in N1b than in N1a and N0 (F/M = 1.9/1, 4.0/1 and 5.5/1, respectively). Persistent/recurrent disease at last control was significantly more frequent in N1b (29.8%) than in N1a (14.3%), and in N1a than in N0 (4.2%) (p < 0.01 for all). Also, distant metastases were significantly (p < 0.001) more frequent in N1b (14.1%) than in N1a (4.3%) and N0 (1.6%). LN metastases' number (>5) was a significant risk factor for persistent/recurrent disease only for N1a patients. CONCLUSIONS: These data indicate that persistent/recurrent disease and distant metastases are significantly more frequent in patients with latero-cervical LN (N1b) metastases and that the LN location should be used for a better postsurgical risk stratification.

Cervical lymph node metastases of squamous cell carcinoma of unknown origin: the diagnostic value of FDG PET/CT and clinical outcome.

FDG PET/CT is perceived as a valuable diagnostic tool in addition to the standard diagnostic workup for patients with isolated neck lymph nodes of squamous cell carcinoma of unknown primary (SCCUP). For patients with SCCUP intended for primary radiotherapy, we hypothesize that the previously reported FDG PET/CT detection rates are too high. From 2008 to 2015, 30 SCCUP patients were examined with FDG PET/CT. The objective of the FDG PET/CT examination was twofold: (1) improve the radiotherapy target definition, and (2) identify the primary cancer. Before the FDG PET/CT, the patients had been through a standard workup consisting of CT of the neck and chest, examination with flexible endoscopy with patient awake, panendoscopy and examination under general anesthesia, tonsillectomy and sometimes blind sampling biopsies, and MRI (floor of the mouth). All FDG PET/CTs were performed applying a flat table, head support and fixation mask as part of the radiotherapy treatment planning. Diagnostic CT with contrast was an integrated part of the PET/CT examination. Only 1/30 patients (cancer of the vallecula) had their primary cancer detected by FDG PET/CT. In addition, a non-biopsied patient with high uptake in the ipsilateral palatine tonsil was included, giving a detection rate of ≤7 % (95 % CI 2-21 %). In this retrospective study, we found that the FDG PET/CT detection rate of the primary for SCCUP patients is lower than previously reported. It is questionable whether FDG PET/CT is necessary for these patients when improved, advanced workup is available.

Squamous cell carcinoma of unknown primary tumor metastatic to neck nodes: role of elective irradiation.

In patients with squamous cell carcinoma (SCC) metastases to neck lymph nodes and unknown primary tumor, the role of elective irradiation of uninvolved neck and potential mucosal primary sites is yet to be determined. The aim of this study was to review the experience treating SCC of unknown primary metastatic to neck nodes with surgery and postoperative radiotherapy (PORT) in Slovenia between 1995 and 2010 and to determine the importance of the extent of irradiated volume. For this purpose, the nationwide Cancer Registry of Slovenia database was used for identifying patients. 126 patients were identified. Involved-field PORT and extended-field PORT was used in 50 and 76 patients, respectively. At 5 years, locoregional control was 86 %, disease-specific survival 77 %, and overall survival 57 %. In multivariate analysis, the extent of irradiated volume has not been predictive for any outcome under study. Grade ≥3 acute and late radiotherapy-induced toxicities were more frequent in the extended-field PORT group. In conclusion, although not superior, involved-field PORT seems to be a preferred treatment option in SCC of unknown primary metastatic to neck nodes due to significantly reduced toxicity and better prospects for successful salvage.

Cytologic evaluation of cervical lymph node metastases from cancers of unknown primary origin.

Fine-needle aspiration biopsy (FNAB) is often the first diagnostic procedure performed in patients with head and neck (HN) masses. Metastatic squamous cell carcinoma (SCC) to cervical lymph nodes is by far the most common malignancy aspirated in the HN, but in approximately 3-10% of patients, a primary tumor will not be found even after complete clinico-radiological workup. Several HN cancers are associated with oncogenic viruses, including HPV-associated SCC and EBV-associated nasopharyngeal carcinoma (NPC). While the primary tumor is sometimes small or undetectable, patients often present initially with cervical lymph node metastases. HPV-associated SCC and EBV-associated NPC are typically non-keratinizing carcinomas that can mimic several other poorly differentiated HN cancers by FNAB but have a significantly better prognosis. Therefore, the precise classification of the metastatic disease in the FNAB material is very useful since it can facilitate the subsequent location of the primary tumor, and it can provide prognostic and therapeutic information as well. In this review, we discuss the major entities that can present as a metastatic cancer of unknown primary in cervical lymph node other than supraclavicular, including their cytologic features and the role of ancillary studies.

Treatment and prognosis for retrograde cervical lymph node metastases in breast cancer.

Metastasis in axillary and supraclavicular lymph nodes has been frequently observed in patients with breast cancer. The clinical staging and therapeutic principle determined according to the situation of lymph node metastasis are clear. One patient with infiltrating ductal carcinoma of the left breast was reported to undergo modified radical mastectomy. One and a half years later, lymphadenectasis was observed in area II, III, IV, V and VI of the left neck; therefore, cervical lymphadenectomy was performed under cervical plexus anesthesia, indicating lymph node metastatic adenocarcinoma (21/26). The patient took 10 mg tamoxifen twice per day for five years after lymphadenectomy and the review showed negative results in liver, lungs, mediastinum, neck and contralateral breast. This suggested that although breast cancer complicated with retrograde cervical lymph node metastases is rare, timely surgery is required even if the patient is in a good general condition, to avoid "delayed therapy" due to misjudgment of illness simply according to disease staging.

Ultrasonographic diagnosis of cervical lymph nodes.

Many patients visit outpatient clinics suffering from cervical lymphadenopathy. For those patients, ultrasonography is useful in differentiating inflammatory diseases and malignant tumors. On ultrasonographic images, normal lymph nodes are indicated as hypoechogenic masses with a well-defined border. The medullary portion near the lymph node hilum is hyperechogenic, so-called fatty hilum (FH). Color Doppler imaging reveals that blood flows from the lymph node hilum to FH. In lymph node metastasis, a metastatic focus grows within lymph nodes, which displaces and destroys the structure of normal lymph nodes. Ultrasonography can be used to detect FH, disappearance and unevenness of blood flow within lymph nodes, cyst formation, and so on. It is important to closely observe the inside of lymph nodes and make a diagnosis via ultrasonography, based on the criteria for diagnosing lymph node metastasis from head and neck squamous cell carcinoma. Additionally, it is also necessary to distinguish among inflammatory lymphadenopathy and malignant lymphoma.

Pattern, predictors, and recurrence of cervical lymph node metastases in papillary thyroid cancer.

AIM OF THE STUDY: This study investigated the pattern, predictors, and recurrence of node metastasis in papillary thyroid cancer patients. MATERIAL AND METHODS: One hundred and 65 papillary thyroid cancer (PTC) patients who underwent total thyroidectomy and cervical lymph node (LN) dissection (LND), in which more than 12 lymph nodes were dissected, were examined. The nodes were classified from levels I to VI. Final pathologic diagnosis of positive lymph node metastases in the differential node levels was determined. RESULTS: Cervical metastases of PTC were most commonly encountered in level VI, followed by levels III and IV, and then levels II and V. Metastases in level I seldom occurred. Skip metastases occurred in nine patients. Univariate analysis suggested that multifocality and extracapsular invasion were associated with LN metastases. The metastatic ratio for micro PTC and local canceration derived from benign lesions and encapsulation was low. Multivariate analysis showed that LN metastases were closely related to invasion of the thyroid capsule and primary PTC. Standardized estimation showed that the encapsulating pattern had the greatest impact on developing cervical LN metastases. Lymph node recurrence was observed in 11 patients. CONCLUSIONS: The metastatic pattern of PTC assists in delineating the extent of selective LND. Routine bilateral central node dissection at the time of thyroidectomy is recommended. Comprehensive selective LND is recommended in multifocal PTC and with capsular invasion.

Medullary thyroid carcinoma.

INTRODUCTION: Medullary thyroid carcinoma (MTC) constitutes approximately 5-10% of all thyroid cancers. Although the tumor forms in the thyroid, it doesn't originate from thyroid cells, but from the C cells or parafollicular cells which produce and release a hormone called calcitonin (CT). Starting from the second half of the 1900s, MTC was progressively studied and defined. AREAS COVERED: This study aims to analyze the history, clinical presentation and biological behavior of MTC, bio-humoral and instrumental diagnosis, molecular profiling, genetic screening, preoperative staging and instrumental procedures, indispensable in expert and dedicated hands, such as high-resolution ultrasonography, CT-scan, MRI and PET/TC. We examine recommended and controversial surgical indications and procedures, prophylactic early surgery and multiple endocrine neoplasia surgery. Also, we discuss pathological anatomy classification and targeted therapies. The role of serum CT is valued both as undisputed and constant preoperative diagnostic marker, obscuring cytology and as early postoperative marker that predicts disease persistence. EXPERT OPINION: With a complete preoperative study, unnecessary or useless, late and extended interventions can be reduced in favor of tailored surgery that also considers quality of life. Finally, great progress has been made in targeted therapy, with favorable impact on survival.

Laterocervical lymph node metastases from suspected thyroidal primary site that turned out to be metastases of lung cancer: A case report.

Incidental sonographic discovery of thyroid nodules is an increasingly common event in clinical practice. Less frequently, patients with cytological benign thyroid nodules have suspicious cervical lymph nodes detected by ultrasound examination or by cytological exam. Here, we discuss an intriguing case of cervical lymph node metastasis with a probable thyroid origin in a 65-year-old asymptomatic male smoker. He underwent thyroidectomy and unilateral cervical lymphadenectomy. Despite a negative chest X-ray, the postoperative histological examination revealed that the lymph node metastasis was actually from a lung carcinoma. Metastatic lesions in cervical lymph nodes from non-thyroidal origins must be excluded when evaluating lesions in the region, especially when thyroid nodules subjected to fine needle aspiration biopsy yield negative results, or lymph node cytological evaluations are inconsistent with thyroid cytological findings and sonographic features. Thyroid and lung adenocarcinomas share some epithelial and mesenchymal markers. Thyroglobulin helps differentiate primary thyroid tumors from lung ones, but in cases of poor differentiation, distinguishing metastatic lesions in the thyroid gland can be challenging. Lung cancer (LC) is the leading cause of cancer mortality worldwide, and survival rates have only marginally improved over the last several decades. The ongoing clinical challenge is detecting LC at earlier stages of the disease.

Cancer of unknown primary eventually diagnosed as poorly differentiated prostate cancer: a case report.

BACKGROUND: Prostate cancer has been well known to have a high prevalence among middle-aged and older men, with high incidence of metastases to the bone-the main metastatic site. However, prostate cancer among those less than 50 years of age is extremely rare, and neck swelling is seldom the initial symptom. CASE PRESENTATION: We herein report case of a 47-year-old Japanese male with poorly differentiated prostate cancer that had been initially diagnosed as a cancer of unknown primary with multiple lymph node and bone metastases before reaching a definitive diagnosis. The patient has been started on endocrine therapy and is currently alive without progression. DISCUSSION AND CONCLUSION: When locating the primary lesion in men with cancer of unknown primary, it is important to consider the possibility of prostate cancer, confirm serum prostate-specific antigen levels, and perform local prostate evaluation.

Cut-off Value for Thyroglobulin Washout Concentration in the Detection of Cervical Lymph Node Metastases in Patients after Thyroidectomy Due to Differentiated Thyroid Cancer.

The aim of this study was to establish the cut-off value for the thyroglobulin (Tg) concentration in washout fluid from fine needle aspiration biopsy (FNA-Tg) in the detection of cervical lymph node metastases of differentiated thyroid cancer (DTC). We evaluated the validity and clinical utility of fine needle aspiration biopsy cytology (FNAB-C), FNA-Tg, and the combined method in detecting DTC recurrences. The study included 82 patients after the total thyroidectomy and elective and, in some cases, also selective cervical lymphadenectomy. The majority of patients also underwent subsequent 131I ablative therapy. The patients presented with 1-6 enlarged and/or ultrasonographically suspicious cervical lymph nodes. One to four aspirates of each lymph node were taken, with a total of 297 samples. An FNA-Tg of 4.34 ng/mL was established as the cut-off value for detecting cervical lymph node DTC metastases for the IRMA Brahms DYNO test, Tg-S. FNAB-C is highly specific (91-99%) but not sensitive enough (53-69%) to be used as a standalone method in the detection of cervical lymph node metastases. FNA-Tg is more sensitive (91%), but caution should be taken when selecting patients for surgery with an FNA-Tg higher than the established cut-off value but lower than the serum Tg concentration. To select patients for lymphadenectomy, we recommend using the combined method (FNAB-C and FNA-Tg) with a sensitivity of 96% and specificity of up to 97%. More than one sample should be taken with each fine needle aspiration biopsy (FNAB) to obtain a representative set of samples.

Related factor analysis for predicting large-volume central cervical lymph node metastasis in papillary thyroid carcinoma.

The aim of this study was to investigate the factors related to large-volume central cervical lymph node metastasis (LNM) in papillary thyroid carcinoma. A retrospective study of 340 patients with 642 papillary thyroid carcinoma nodules who underwent thyroidectomy in Peking Union Medical College Hospital between 2011 and 2015 was conducted. These nodules were divided into two groups by the number of central cervical lymph node metastases: large-volume central cervical LNM (>5 metastatic lymph nodes, n = 129) and no central cervical LNM (n = 211). We evaluated the correlations between gender, age, chronic lymphocytic thyroiditis, thyroid ultrasonographic features, and large-volume central cervical LNM. We found that younger age (≤40 years) (OR = 3.796, 95% CI = 2.842, 5.070), male gender (OR = 4.005, 95% CI = 2.858, 5.61), and ultrasonographic features such as tumor macroaxis size (OR = 2.985, 95% CI = 1.581, 5.633), tumor located in the isthmus (OR = 7.578, 95% CI = 4.863, 11.810), ill-defined margin (OR = 3.008, 95% CI = 1.986, 4.556), microcalcification (OR = 2.155, 95% CI = 1.585, 2.929), and abnormal cervical lymph nodes (OR = 13.753, 95% CI = 9.278, 20.385) were independent risk factors for large-volume central cervical LNM in papillary thyroid carcinoma, while chronic lymphocytic thyroiditis (OR = 0.248, 95% CI = 0.172, 0.358) was a protective factor. Younger age (≤40 years), male sex, and ultrasonographic features such as tumor macroaxis size, tumor located in the isthmus, ill-defined margin, microcalcification, and abnormal cervical lymph nodes were independent risk factors for large-volume central cervical LNM in papillary thyroid carcinoma, while chronic lymphocytic thyroiditis can be considered a protective factor. Our results provide a reference for adjusting clinical treatment approaches.

Prevalence of Skip Metastases to Cervical Lymph-Nodes in Oral cavity Cancer in Eastern India-an observational study.

To determine the prevalence of skip metastases in Oral-squamous-cell-carcinoma (OSCC). This prospective observational study was carried out on 100-cases of biopsy proven OSCC who underwent surgical treatment for the primary tumor along with neck dissection (ND). Data regarding depth of invasion (DOI) by primary tumor, perineural-invasion, lymphovascular-invasion, presence of metastatic-lymph-node (level, size, number and extranodal-extension) were collected from histopathology reports and were analyzed. Out of 100-cases, 73-were-male and 27-were-female. Mean age was 49.5 ± 12.3 years (range 24-4 years). Common subsites of tumor were buccal-mucosa, tongue and lower-alveolus in 40, 37 and 14% respectively. Pathological staging of tumor were stage-I, stage-II, stage-III, stage-IVa and stage-IVb in 22, 14, 25, 22 and 15% cases respectively. Preoperative neck staging was cN0 in 50 necks (47.2%) and cN+ in 56 necks (52.8%). In 100-patients 106-NDs (unilateral-94 and bilateral-6) were performed. Type of NDs were Supraomohyoid, extended-Supraomohyoid and modified radical neck-dissection in 23,07and76 cases respectively. Prevalence of cervical lymph node metastases was 36% (pN + necks). Among 36pN + patients; 25 (69.4%) cases, 20 (55.5%) cases, 9 (25%) cases, 4 (11.1%) cases, 2 (5.5%) cases had metastases to level-I, II, III, IV and V respectively. Skip-metastases was present in four-cases {level-IIb:one-case (2.78%), level-III: two-cases (5.5%) and level-V:one-case (2.78%)}. No-skip-metastasis to level-IV was noticed. All-four-cases of skip-metastases were from advance cases of squamous-cell-carcinoma of tongue with DOI > 5 mm. Skip-metastases to levels IIb, IV and V are uncommon in cases of OSCC. Most of the metastasis in our study was noted to levels I, II and III in a predictable fashion. Thus, extensive ND can be avoided in patients to prevent complications and morbidities associated with the same.

Papillary thyroid microcarcinoma with contralateral large humerus metastasis and cervical lymph node metastasis: A case report.

Introduction: Papillary thyroid microcarcinoma (PTMC) that metastasizes to bone, especially metastasizes to contralateral humerus with so large mass, is rarely reported before. Case report: We presented a 50-year-old female patient with a large painful mass in the right humerus for 5 years, presenting with swelling of the right shoulder with limited mobility. Positron emission tomography-computed tomography (PET/CT) showed a large mass in the right humerus, bilateral lung lesions, and enlarged lymph nodes in the right supraclavicular fossa. Right humerus lesion biopsy and immunohistochemical evaluations confirmed that the lesion originated from the thyroid tissue. Then, the thyroid ultrasonography showed a hypo-echoic solid nodule with an irregular taller-than-wide shape in the upper of left thyroid lobe and enlarged lymph nodes with the absence of fatty hilum in the contralateral right IV compartment. The total thyroidectomy and cervical lymph node dissection were undertaken; the histopathology confirmed the diagnosis of PTMC with contralateral cervical lymph node metastasis. Conclusion: We reported a case of PTMC with contralateral large humerus and cervical lymph node metastasis and demonstrated the PET/CT images of the metastatic large humerus and thyroid ultrasonographic appearances of the PTMC and enlarged cervical lymph node.

Case report: Large follicular thyroid carcinoma with multiple cervical lymph node metastases.

Introduction: Follicular thyroid carcinoma (FTC) rarely metastasizes to regional lymph nodes, as they mainly metastasize through hematogenous route; in particular, a large FTC with only lateral lymph node metastasis and without distant metastasis has rarely been reported. Case report: We present a 66-year-old male patient with a progressively growing thyroid for more than 20 years, causing tracheal compression and narrowing. Neck ultrasonography, computed tomography (CT), magnetic resonance (MR) imaging and positron emission tomography-computed tomography (PET/CT) were carried out to obtain images of the thyroid and surrounding tissues. Total thyroidectomy and cervical lateral and central lymph node dissection were undertaken, and histopathological, and immunohistochemical evaluations and molecular pathology confirmed the diagnosis of FTC with multiple cervical lymph node metastases. Conclusion: We have reported a rare case of large FTC with diffuse nodal involvement but no distant metastases. We present the thyroid ultrasound, neck CT, MR and whole body PET/CT.