Objective: Whether lymph-node dissection (LND) influences the lymph-node recurrence (LNR) risk in patients with papillary thyroid cancer remains controversial. The prognostic impact of macroscopic and microscopic lymph-node involvement at diagnosis is also an unresolved issue. A retrospective study was conducted to assess the influence of various LND procedures and to search for LNR risk factors. Methods: Overall 545 patients without distant metastases prior to surgery and main tumour R10 mm were included. A total thyroidectomy was performed in all patients with either no LND (Group 1, nZ161), bilateral LND of the central and lateral compartments (Group 2, nZ181) or all other dissection modalities (Group 3, nZ203). Post-operative radioiodine was given to 496 (91%) patients. The 10-year cumulative probability of LNR was assessed and a prognostic study using multivariate analysis was performed. Results: Macroscopic lymph-node metastases were present in 118 patients, 57 diagnosed before surgery and 61 only at surgery (including 81% in the central compartment). Overall, the 10-year cumulative probability of LNR was 7%. Macroscopic lymph-node metastases (PZ0.001), extra-thyroidal invasion (PZ0.017) and male gender (PZ0.05) were independent risk factors, while bilateral LND of the central and lateral compartments was protective (PZ0.028). In patients with macroscopic lymph-node metastases, the 10-year probability was lower in Group 2 than in Group 3 (10% vs 30%, P!0.01). In patients without macroscopic lymph-node metastases (nZ427), no significant differences were observed between the three LND groups. Conclusions: Patients with macroscopic, but not microscopic, lymph-node involvement have a major LNR risk and need an optimal LND at primary surgery.

This study demonstrates the complementary role of neck and thorax SPECT-CT to WBS in postablation (131)I scintigraphy. Because SPECT-CT allows one to confirm or to rule out residual disease in most cases where WBS remains indeterminate, we recommend its use when available.

Dual-phase (99m)Tc sestamibi scintigraphy with SPECT/CT enables to identify a parathyroid adenoma in about two-thirds of patients with primary hyperparathyroidism and allows the surgeon to plan appropriate surgery. The likelihood of scintigraphy to be positive is affected by calcium or PTH concentrations.

Concerns remain over the risk of cancer following differentiated thyroid carcinoma and its causes. Iodine-131 ((131)I) and external irradiation are known to have potential carcinogenic effects. Thyroid carcinoma is a polygenic disease which may be associated with other malignancies. We investigated the incidence of second cancer and its aetiology in a cohort of 875 patients (146 men, 729 women) with differentiated thyroid carcinoma originating from Basse-Normandie, France. Cancer incidence was compared with that of the general population of the Département du Calvados matched for age, gender and period. The cumulative proportion of second cancer was estimated using the life-table method. Factors that correlated with the risk of second cancer were studied using the Cox model. After a median follow-up of 8 years, 58 second cancers had been observed. Compared with general population incidence rates, there was an overall increased risk of second cancer in women [standardised incidence ratio (SIR)=1.52; P<0.01], but not in men (SIR=1.27; P>0.20). Increased risk related to cancers of the genitourinary tract (SIR=3.31; P<0.001), and particularly to cancer of the kidney (SIR=7.02; P<0.01). Multivariate analysis showed that age above 40 years (P<0.01) and a history of previous primary cancer (P<0.001) correlated with risk. In contrast, neither cervical irradiation nor cumulative activity of (131)I was related to the risk. These data confirm that women with differentiated thyroid carcinoma are at risk of developing a second cancer of the genitourinary tract and kidney. Only age and medical history of primary cancer before thyroid carcinoma are risk factors for second cancer. Common environmental or genetic factors as well as long-term carcinogenic effects of primary cancer therapy should be considered.

Objective: Neck and thorax single photon emission computed tomography with computed tomography (SPECT-CT) improves the reliability of postablation 131 I whole-body scan (WBS) for differentiated thyroid cancer (DTC). The aim of this study was to assess the prognostic value for persistent or recurrent disease of postablation 131 I scintigraphy combining WBS and neck and thorax SPECT-CT with that of the previously known predictive factors. Methods: This is a single referral center prospective study with a median follow-up of 29 months. Postablation 131 I WBS and neck and thorax SPECT-CT were performed in 170 consecutive patients treated between 2006 and 2008. Stimulated serum thyroglobulin (Tg) and anti-thyroglobulin antibodies (TgAb) levels were measured. The impact on disease-free survival of age; gender; postablation 131 I scintigraphy; stimulated serum Tg level; T, N, and M status; and macroscopic lymph node involvement was assessed by univariate and multivariate analyses. Results: Persistent or recurrent disease was observed in 32 (19%) patients. In the whole group of patients, only positive WBS with SPECT-CT was related to an increased risk of persistent or recurrent disease (hazards ratio (HR)Z65.21, 95% confidence interval (CI)Z26.03-163.39, P!0.0001). In patients without TgAb (nZ146), both positive WBS with SPECT-CT (HRZ18.86, 95% CIZ5.02-70.85, P!0.0001) and serum Tg level R58 ng/ml (HRZ4.42, 95% CIZ1.18-16.53, PZ0.0271) were associated with an increased risk. Conclusion: In patients with DTC, the cross analysis of postablation 131 I scintigraphy with neck and thorax SPECT-CT and stimulated serum Tg level enables early assessment of the risk of persistent or recurrent disease.European Journal of Endocrinology 164 961-969

Objective: In patients with differentiated thyroid cancer (DTC), the stimulated serum thyroglobulin (Tg) level at radioiodine ablation is a known predictive factor of persistent disease. This prognostic value is based on data obtained after thyroid hormone withdrawal (THW), but little is known about this prognostic value after recombinant human TSH (rhTSH) stimulation and about the relationship between the stimulated Tg level and the burden of persistent tumor. We aimed to assess the impact of both radioiodine preparation modalities and persistent tumor burden on stimulated Tg levels. Design and methods: The stimulated Tg level was measured at radioablation in 308 consecutive DTC patients without serum Tg antibodies. Of these, 123 (40%) were prepared with rhTSH and 185 with THW. Post-ablation scintigraphy included total-body scan and neck and thorax single photon emission computed tomography with computed tomography (SPECT-CT). During a mean follow-up of 43 months, persistent/recurrent disease (PRD) was found in 56 patients (18%). PRD was considered structural in the presence of lesions O1 cm and nonstructural otherwise. Results: Nonstructural PRD was more frequent in the rhTSH group than in the THW group (64 vs 26%, PZ0.01). Stimulated Tg levels were lower after rhTSH than after THW in patients with (13.5 vs 99.5 ng/ml, P!0.01) and without (1.2 vs 3.2 ng/ml, P!0.001) PRD. Also, Tg levels were lower in nonstructural disease than in structural disease in both rhTSH (3.8 vs 127.0 ng/ml, P!0.01) and THW (13.0 vs 143.5 ng/ml, P!0.0001) patients. The best Tg cutoff to predict PRD was 2.8 in rhTSH and 28 ng/ml in THW patients. Conclusion: Both radioiodine preparation modalities and the burden of persistent tumor affect the stimulated Tg level at ablation.

PATIENTS with microscopic lymph node involvement present an intermediate outcome between that observed in pN0-pNx patients and pN1 macroscopic patients. These data may justify modifications to the risk recurrence staging systems.

Over and above established criteria, the present study highlighted the importance of general health and nutritional status during treatment.