The management of a patient with suspected thyroid cancer should include a detailed examination of the thyroid gland and the cervical lymph node compartments. Patients with PTC occasionally present with cervical lymphadenopathy, which is most often located in the central neck compartment or levels III and IV of the lateral neck, usually in conjunction with an ipsilateral thyroid nodule. Cervical ultrasound (US) is often the initial imaging modality employed in the assessment since it is readily accessible, inexpensive, and noninvasive. High-resolution ultrasonography can detect cervical nodal metastasis in up to 20 % of patients with PTC. These US findings may alter the planned surgical procedure in up to 39 % of thyroid cancer patients. Pathologic lymph nodes have sonographic features that include round shape, absent hilus, calcification, intranodal necrosis, reticulation, matting, soft tissue edema, and peripheral vascularity. However, many nodal metastases demonstrate a wide variety of nondiagnostic features. To detect nonpalpable lymph node metastases in patients undergoing surgical evaluation for any thyroid cancer, a dedicated cervical ultrasound (including levels II–VI) should be performed, ideally by a dedicated clinician such as a thyroid endocrinologist, the operating surgeon, or a radiologist. However, US can miss as many as 50 % of involved lymph nodes in the central neck as the overlying thyroid gland hinders adequate visualization. In patients with suspected mediastinal disease or with bulky cervical lymphadenopathy, cross-sectional imaging with computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) should be considered. These often identify pathologic level VI and VII lymph nodes within the superior mediastinum that are not detected on cervical US or physical examination. This consideration for additional anatomical imaging is made despite the relatively low sensitivities of CT, MRI, and PET for the screening and detection of cervical lymph node metastases (30–40 %).

A CT with iodinated contrast is considered extremely helpful to evaluate the extent of cervical lymphadenopathy when there is gross nodal disease present, as it can help define the extent of surgery necessary to clear all gross disease in the neck. CT with contrast can delay postoperative thyroid scanning and radioactive iodine (RAI) administration for 4–8 weeks. However, this delay would seem justified in cases of bulky lymphadenopathy or locally invasive disease since complete surgical resection of gross disease is of paramount importance for disease control.

Regardless of the initial treatment paradigm utilized for thyroid cancer, some patients will manifest persistent or recurrent disease. Much of persistent or recurrent disease is detected subclinically by surveillance strategies advocated by the ATA guidelines. High-resolution US and serum thyroglobulin (Tg) assays, with or without thyrotropin stimulation, have led to a new category of patients with persistent or recurrent small volume disease of uncertain clinical significance. Many authors have demonstrated that reoperative surgery for this disease, especially in the central compartment, is safe. Definitions of microscopic and macroscopic nodal recurrences should help to define which groups of patients could be observed versus those that should be offered surgery. Reasonable and realistic expectations should be set for the practitioners and patients involved. When surgery is chosen, a compartmental dissection of the neck nodal region involved should be performed to reduce the risk of locoregional recurrence and the morbidity of further reoperation. Many of these patients with persistent disease have undergone multiple surgeries in the central or lateral compartments. Further attempts at formal compartmental dissection must be conducted with a thoughtful assessment of the risks and benefits to the patient. Perhaps the realistic goal of all reoperative surgery should not be to render the serum Tg level undetectable but rather to prevent local disease progression in critical areas of the neck. Long-term follow-up of these patients is warranted to determine the optimal surveillance and treatment paradigm.