Background: The treatment of patients with regionally recurrent papillary carcinoma of the thyroid is a matter of controversy. Radioactive nodal picking was proposed as an alternative to neck dissection in these patients. Methods: We analyzed neck dissection specimens in 20 patients with PTC and compared the results to preoperative total-body scan (TBS) following a therapeutic dose of I131and ultrasonographic findings. Results: Eighteen patients underwent paratracheal neck dissection and 10 patients had a lateral neck dissection. Preoperative TBS detected the correct number of positive nodes in only 1 patient (5%) and the correct number of patients with positive nodes in 6/20 (30%) of the patients. US detected 32/98 positive nodes (36%) and 20/20 (100%) of the patients. Prediction of the number of positive nodes for both TBS and US was low (5% and 10%, respectively). Conclusions: Preoperative TBS and/or US cannot satisfactorily predict metastatic lymph node involvement and cannot safely delineate limited surgery to replace formal neck dissection in patients with regionally recurrent PTC.