Post on 15-Apr-2016
Thyroid Ultrasound for Thyroidologists
Durr-e-Sabih
...Ultrasound allows surgeons and endocrinologists to better follow nodules, identify tumors, make decisions about surgery on the contralateral lobe, map metastatic disease and recurrence and better follow patients with treated malignancy. Ultrasound improves our selectivity of patients eligible for surgery because of improvements in sensitivity and specificity of ultrasound guided fine needle aspiration biopsy…
Summary of proceedings of the second world congress on Thyroid Cancer. July 2013. Canada
Whyo Accurate depiction of neck anatomyo Clarifies doubtful findingso Differentiates thyroid from non-thyroidal
masseso Detection of non-palpable disease o Follow-up of focal diseaseo Guides FNA/therapy o Suggests probable benign/malignant for
stratification of further workup
The section
The section
Surroundings
ThyroidTrachea
Oesophagus
Cervical VertebraC-6
CCA
Int Jug vein
Sternocleidomastoid
Sternohyoid
Sternothyroid
Longus coli
Scalenus anterior
Surroundings
Surroundings
Thyroid
Trachea
Oesophagus
Cervical VertebraC-6
CCA Int Jug vein
Sternocleidomastoid
SternohyoidSternothyroid
Longus coliScalenus anterior
Size
o Each lobe 4-6 cm in cranio-caudal extento <1.8 cm in maximum depth, isthmus <6mm
in thickness o Volume 7-14ml, calculated for each lobe
and add
4-6 cm
<1.8cm
<1.8cm
<1.8cm
<0.6cm
Size4-6 cm
Volume; 7-14 ml. Calculate for each lobe and add
Textureo Medium to high density
echoes, homogenous o Thin capsule occasionally
seen… might become calcified in uraemia
o Muscles are hypoechoic o Texture can appear different
with different equipment… use same equipment for follow-up
o Parathyroids not visible unless enlarged
My thyroid
Xario
Aplio
Nemio
Blood supply
o Superior thyroid artery and vein at the upper pole of each lobe
o Inferior thyroid vein at the lower poleo Inferior thyroid artery is posterior to the
lower third of each lobe
Superior thyroid artery
Inferior thyroid artery
Inferior thyroid vein
Sup th. vein
Mid th. vein
Inf th. vein
Int jug vein
Thyroida ima
Parenchymal vascularity
What do we look for in a thyroid nodule?Echogenicity Isoechoic, Hyperechoic
HypoechoicMarkedly hypoechoic
Same , more or less than normal areas of thyroidLess than strap muscles
Content Predominantly CysticMixed Cystic and SolidPredominantly Solid
75-100% of volume cystic26-74%0-25%
Calcification Microcalcifications (Psammoma bodies) <1mm, no shadowing
Macrocalcificaions, rim calcifications >1mm, may cause shadowing
Colloid crystals Reverberating echogenicities
Margin Smooth/irregular
Orientation Taller- than- wide/wider-than- than tall
Vascularity None, marginal, central
Nodes Shape (eliptical or round), hilum (present or absent), microcalcification or colloid
Extension beyond thyroid
1) Society of Radiologists in Ultrasound consensus conference Statement. Radiology Vol 237 (3). 2005.2) Huang JK; Lee WK; Lee M et al. US Features of Thyroid Malignancy: Pearls and Pitfalls. RadioGraphics 2007; 27:847–865
Features Feature Benign Malignant
Tall/Wide Wider than tall +++ ++
Taller than wide + ++++
Contents Purely cystic ++++ +
Cystic with thin septa +++ +
Mixed Solid/cystic +++ ++
Purely solid +++ ++
Comet tail reverberations +++ +
Echogenicity Hyperechoic ++++ +
Isoechoic +++ ++
Hypoechoic +++ +++
Markedly hypoechoic + ++++
Halo Thin ++++ ++
Thick + +++
Absent + +++
Margins Well defined +++ ++
Poorly defined ++ +++
Spiculated + ++++
Calcification Eggshell +++ ++
Coarse +++ +
Micro ++ ++++
Doppler Peripheral +++ ++
Internal flow ++ +++
Thyroid nodules
Thyroid Nodules
o Is it in the thyroid or outside it?
Hyperplastic, Adenomatous or Colloid Nodule
o Cellular hyperplasia, microndule nodule, macronodule formation
o Liquefactive degeneration with accumulation of serous fluid, blood and colloid material
o Calcification, often coarse and peripheralo Can be hypo functioning, normally
functioning or hyperfunctioning
Colloid cyst and Nodule, Haemorrhagic cyst
© Dr. Ravi Kadasne. UAE
Colloid Nodules
Follicular Neoplasm
o Follicular adenoma is a true neoplasm with compression of adjacent tissue and fibrous capsulation
o Capsular/vascular invasion is the hallmark of follicular carcinoma, that can be seen on histology and not cytology
Follicular Neoplasm
o FNA does not differentiate between benign follicular adenoma and carcinoma (capsular and vascular invasion)
o Usually solidoHypo, iso or hyperechoico Thin or thick haloo Peripheral rim of vessels, sometimes extending
inwards in spoke-wheel pattern
Follicular Neoplasm Colloid Nodule
Papillary Thyroid Cancer
o Hypoechoico Microcalcificationo Hypervascular o Cervical nodes with possible
microcalcification or cystic degeneration
Papillary Carcinoma with Nodes
Metastatic Papillary Thyroid Cancer
Papillary Carcinoma
Follicular Thyroid Carcinoma
o Similar to follicular neoplasm on ultrasound o Difficult to differentiate from follicular
neoplasm on cytology… so many advocate surgical removal of all follicular neoplasms
o Some may have very irregular margins, thick irregular halos and chaotic internal vascularity
Follicular Thyroid Carcinoma
o Hypoechoico Vascularo Minimally
irregular o Reverberating
echogenicities
Image courtesy Dr. Ravi Kadasne, Al Ain. UAEVia www.ultrasound-images.com
Other Carcinomaso Medullary
o Part of the MEN-II syndrome, tends to be multicentric or bilateral
o Similar to papillary carcinoma on ultrasoundo Calcifications tend to be coarse
o Anaplastic o Large, hypoechoic, encase or invade blood vessels and muscles
o Lymphomao In most there is pre-existing Hashimoto’s and hypothyroidism,
rapidly growing masso Extremely hypoechoic, lobulated, areas of cystic necrosis
How specific is ultrasound?
o Ji-Zhen Zhang, Bing Hu. Sonographic features of thyroid follicular carcinoma in comparison with thyroid follicular adenoma. J Ultrasound Med 2014; 33:221-227
o Ji Hyun Lee, Jung Hee Shin et al. Sonographic and cytopathologic correlation of papillary carcinoma variants. J Ultrasound Med 2015; 34:1-15
How specific is ultrasound?
o Ji-Zhen Zhang, Bing Hu. Sonographic features of thyroid follicular carcinoma in comparison with Thyroid follicular adenoma. J Ultrasound Med 2014; 33:221-227
o Ji Hyun Lee, Jung Hee Shin et al. Sonographic and cytopathologic correlation of papillary carcinoma variants. J Ultrasound Med 2015; 34:1-15 Retr
ospect
ive
Features, Scores and Patterns…Organizing the Data
ScoreStudy Score Interpretation
Adamczewski and Lewiński. Proposed algorithm for management of patients with thyroid nodules/focal lesions, based on ultrasound (US) and fine-needle aspiration biopsy (FNAB); our own experience. Thyroid Research 2013, 6:6
Retrospective. Major features: Central vascularity, microcalcificaions, taller than wide, solid, hypoechoic, irregular margins, halo (1 point). Minor features: size >3cm, irregular margin, absence of halo, solid (0.5 points). Rapid growth and abnormal nodes (3 points)
0 <4, low risk of malignancy4 <7, Intermediate risk> 7 High risk
Afshin Mohammad, Tohid Hajizadeh. Evaluation of diagnostic efficacy of ultrasound scoring system to select thyroid nodules requiring fine needle aspiration biopsy. Int J Clin Exp Med 2013;6(8):641-648
Retrospective. Hypoechogenicity, irregular margin, calcification and vascularity … if present awarded 2 points each
1 feature: 81% sensitivity.>2 features FNAB
Pu Cheng, En-Dong Chen, Hua-Min Zheng et a. Ultrasound Score to Select Subcentimeter-sized Thyroid Nodules Requiring Ultrasound-guided Fine Needle Aspiration Biopsy in Eastern China. Asian Pac J Cancer Prev, 14 (8), 4689-4692
Retrospective. Irregular shape, hypoechioc, absent capsule, calcifications, taller than wide… all with score of 1 except microcalcification with a score of 2
> 2 biopsy threshold, sensitivity of 80.3% specificity of 72.3%
PatternPattern Significance
Spongiform without hypervascularity
Benign Cyst with avascular colloid plug
Giraffe pattern (skin, not the neck)
White knight (uniform hyperechogenicity)
Red light (intense hypervascularity)
Unpredictable
Intense hypoechogenicity
Isoechogenic without halo
Isoechogenic with halo
Ring-of-fire (isoechogenic with peripheral vascularity)
Other
1. Reading CC, Charboneau JW, Hay ID, Sebo TJ. Sonography of thyroid nodules: a “classic pattern” diagnostic approach. Ultrasound Q 2005; 21:157– 165
2. John A. Bonavita, Jason Mayo, James Babb et al. Joseph Yee. Pattern Recognition of Benign Nodules at Ultrasound of the Thyroid: Which Nodules Can Be Left Alone? AJR 2009; 193:207–213.
PatternSpongiform without hypervascularityCyst with avascular colloid plug
Giraffe pattern (skin, not the neck)
White knight (uniform hyperechogenicity)
John A. Bonavita, Jason Mayo, James Babb et al. Joseph Yee. Pattern Recognition of Benign Nodules at Ultrasound of the Thyroid: Which Nodules Can Be Left Alone? AJR 2009; 193:207–213.
PatternRed light (intense hypervascularity)
Intense hypoechogenicity
Isoechogenic without halo
Isoechogenic with halo
isoechogenic with peripheral vascularity (Ring-of-fire )Other
John A. Bonavita, Jason Mayo, James Babb et al. Joseph Yee. Pattern Recognition of Benign Nodules at Ultrasound of the Thyroid: Which Nodules Can Be Left Alone? AJR 2009; 193:207–213.
What then for nodules?
Thyroid vs. extra-thyroidal YesRecurrent disease YesGuiding procedures YesBiopsy vs. observe ?YesBenign ?YesMalignant ?
Diffuse Thyroid Disease
o Hyperplasiao Thyroiditiso Graves diseaseo Colloid goitre
Thyroid Hyperplasia
o Hyperplasia of cells or acini, followed by micro and then macronodule formation
o Hyperplastic nodules can undergo liquefaction with accumulation of serous fluid, blood and colloid
Suppurative and Subacute Thryoiditis
o Suppurative thyroiditis is very rare and a typical abscess is seen.
o Subacute granulomatous thyroiditis (De Quervain’s disease)oHypoechoic, diffusely or focallyoDecreased flow in involved area, normal flow
in uninvolved areas
http://www.thyroidmanager.org/chapter/ultrasonography-of-the-thyroid/#toc-sonography-in-the-patient-with-an-enlarged-thyroid-gland-goiter
Ultrasound Surprises
Short history, painless, cold on scan, irregular, hypoechoic, vascular… underwent STT…… HP- Subacute thyroiditis
Thyroiditis on two FNAs
Hashimoto’s Thyroiditis
o Enlarged, hypoechoic, hypervascular, coarse
o Micronodular, nodules are hypoechoic, intervening bands can be echogenic.
o Very high flow to very low flow
Thyroiditis
Thyrotoxicosis
Thank you