Thyroid cancer patients with no evidence of disease: the need for repeat neck ultrasound

Context: Ultrasonography (US) is considered the most sensitive tool for imaging persistent or recurrent papillary thyroid cancer (PTC) in the neck. Objective: To clarify the usefulness of routine neck US in low- and intermediate-risk patients with PTC with no evidence of disease 1 year after thyroidectomy. Design: Retrospective analysis of prospectively recorded data. Setting: Academic center. Patients: Two hundred twenty-six patients with PTC with sonographically normal neck lymph nodes and unstimulated serum thyroglobulin (Tg) levels that were either undetectable (<0.20 ng/mL) or low (0.21 to 0.99 ng/mL) at the 1-year evaluation. Interventions: Yearly assessment: unstimulated serum Tg level, anti-Tg-antibody (TgAb) titer, TSH levels, and ultrasound examination of neck lymph nodes. Main outcome measures: Rates of ultrasonographic lymph node abnormalities at the 3-year and last follow-up visits. Results: In patients with an undetectable Tg level at the 1-year evaluation, sonographically suspicious neck lymph nodes were found in 1.2% of patients at 3 years and in 1.8% at the last visit [negative predictive values (NPVs) of 1-year Tg < 0.2 ng/mL: 98.8% (95% CI 95.8% to 99.9%) and 98.2% (95% to 99.6%), respectively]. Similar NPVs emerged for low detectable 1-year Tg levels [98.2% (90.3% to 99.9%) and 94.5% (84.9% to 98.9%) at the 3-year and last visits, respectively]. Seventy-five percent of the nodal lesions were likely false positive; none required treatment. Conclusions: Low- and intermediate-risk patients with PTC with negative ultrasound findings and unstimulated Tg levels <1 ng/mL at the 1-year evaluation can be safely followed with clinical assessments and unstimulated serum Tg determinations. Neck US might be repeated if TgAb titers rise, or unstimulated Tg levels exceed 1 ng/mL.