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Ultrasound of thyroid nodules

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Ultrasound of thyroid nodules

  1. 1. Ultrasound of thyroid nodules Samir Haffar MD Internal medicine – Ultrasound
  2. 2. Ultrasound of thyroid nodules ① Epidemiology & etiologies of thyroid nodules ② Ultrasound features of thyroid nodules ③ Ultrasound of cervical lymph nodes ④ Ultrasound systems for thyroid nodule risk stratification ⑤ Pseudo-nodules of thyroid ⑥ Fine needle aspiration of thyroid nodules
  3. 3. ① Epidemiology & etiology of thyroid nodules
  4. 4. Epidemiology of thyroid nodules • Very common: Palpation 4 – 8%, US 10 – 40%, autopsy 50% Increases with age • Malignancy risk: Patients younger than 20 or older than 60 years History of neck irradiation History of familial thyroid cancer • Cancer prevalence: 10-13% no matter how many nodules at US No decrease of cancer risk in multiple nodules Cancer found in dominant nodules in 2/3 of cases Frates MC et al. Ultrasound Quarterly 2006;22(4):231–238. Most thyroid nodules are benign hyperplastic nodules Thyroid cancer not common compared to very frequent benign nodules
  5. 5. Indications of thyroid ultrasound • Patient with palpable thyroid nodule or with multinodular goiter • High-risk patient for thyroid malignancy: History of familial thyroid cancer Multiple endocrine neoplasia (MEN) type II Irradiated neck in childhood • Patient with palpable cervical adenopathy suspicious for malignancy • Follow-up and monitoring of thyroid nodules Haugen BR et al. Thyroid 2016;26:1–133. American thyroid association guidelines
  6. 6. Etiologies of thyroid nodules Discrete lesion in thyroid distinct from surrounding thyroid parenchyma • Benign thyroid nodules: Cyst and pseudocyst Hyperplastic adenomatous nodule (adenoma) • Malignant thyroid nodules: Papillary carcinoma: 75 – 80% Follicular carcinoma: 10 – 20% Medullary carcinoma: 3 – 5% Anaplastic carcinoma: 1 – 2% Lymphomas: < 5% Metastasis: rare Dighe M et al. Med Ultrason 2017;19:195–210.
  7. 7. ② Ultrasound features of thyroid nodules
  8. 8. Different modes of medical ultrasonography Mode What is measured What is displayed B-mode Acoustic impedance Anatomy Doppler Motion Vascular flow Elastography Mechanical properties Tissue stiffness Elastography: A Practical Approach. Barr RG Edit, Thieme Medical Publishers, New York, 2017. The three modes are applied during ultrasound examination for a more accurate diagnosis
  9. 9. Ultrasound features of thyroid nodules Nodules Ultrasound features Composition: Cystic: fluid-filled without solid component Predominantly cystic: ≥ 50% cystic Predominantly solid: ≥ 50% solid Solid: entirely solid or almost completely solid Echogenicity: Anechoic, hyperechoic, isoechoic, hypoechoic, very hypoechoic Shape: Wider-than-tall, taller-than-wide Margins: Regular, lobulated, irregular, extra-thyroidal extension Peripheral halo: No halo, thin regular vascular, thick irregular avascular Echogenic foci: Comet-tail artifact (colloid cyst) Peripheral rim calcification (eggshell) Macro-calcifications: > 1 mm Micro-calcifications: ≤ 1 mm without acoustic shadowing Vascular pattern: Peripheral, intranodular, peripheral & intranodular Tessler FN et al. J Am Coll Radiol 2017;14:587–595.
  10. 10. Some ultrasound features are considered as benign Other ultrasound features are suspicious for malignancy
  11. 11. Ultrasound features of thyroid nodules Category Benign features Suspicious features Composition Cystic predominantly cystic Spongiform Mixed cystic and solid Solid or almost completely solid Echogenicity Anechoic Hyperechoic Isoechoic Hypoechoic Very hypoechoic Shape Wider-than-tall Taller-than-wide Margins Smooth or regular Lobulated or irregular Extra-thyroidal extension Halo Thin hypoechoic vascular halo Lack of hypoechoic halo Thick irregular avascular halo Echogenic foci No calcifications Comet-tail artifacts (colloid cyst) Macro-calcifications Eggshell calcifications (rim) Micro-calcifications Vascularity Peripheral vascularity Intranodular vascularity Peripheral & intranodular Tessler FN et al. J Am Coll Radiol 2017;14:587–595.
  12. 12. Suspicious US features don’t have the same risk of malignancy Some have lower risk of malignancy: hyperechoic, isoechoic, … Other have higher risk of malignancy: hypoechoic, irregular margin, .. Suspicious US features of thyroid nodules
  13. 13. US report of thyroid nodules should include • Nodule location • Nodule size in three dimensions • Nodule sonographic features: composition, echogenicity, shape, margin, halo, calcifications, and vascularity Cosgrove D et al. Ultrasound in Med & Biol 2016;
  14. 14. Drawing to locate and number thyroid nodules Russ G et al. Eur Thyroid J 2017;6:225–237. right lobe, longitudinal left lobe, longitudinal anterioranterior posterior posterior caudalcaudalcranial cranial
  15. 15. Ultrasound features of thyroid nodules Composition, echogenicity, shape, margin, peripheral halo, calcifications and vascularity
  16. 16. Ultrasound features of thyroid nodules Composition
  17. 17. Large anechoic cyst (arrow) without calcifications or ring down artifact Most thyroid cysts are pseudocysts are hyperplastic nodules that have undergone extensive degeneration, necrosis and hemorrhage Dighe M et al. Med Ultrason 2017;19(2):195–210. 29 year old female with multiple known thyroid nodules Difficult swallows due to mass like feeling in neck Thyroid nodule Composition / Completely cystic
  18. 18. Ahuja AT. Diagnostic Ultrasound: Head and Neck. 2104, Amirsys Publishing. Large cystic thyroid nodule with internal debris mobile on Doppler Posterior acoustic enhancement esophagus debris cyst Thyroid nodule Composition / Hemorrhagic thyroid cyst
  19. 19. Ahuja AT. Diagnostic Ultrasound: Head and Neck. 2104, Amirsys Publishing. Large predominantly cystic nodule with internal debris and septa Perinodular vascularity with no vascularity within septa Power Doppler ultrasound of thyroid septa cyst perinodular vascularity Thyroid nodule Composition / Hemorrhagic thyroid cyst
  20. 20. Ahuja AT. Diagnostic Ultrasound: Head and Neck. 2104, Amirsys Publishing. Hemorrhagic thyroid cyst Sharply defined fluid level: layering of debris in its dependent portion Marked posterior enhancement Absence of any intranodular vascularity Longitudinal power Doppler US of thyroid lobe posterior enhancement fluid level Thyroid nodule Composition / Hemorrhagic thyroid cyst
  21. 21. Ahuja AT. Diagnostic Ultrasound: Head and Neck. 2104, Amirsys Publishing. Hemorrhagic thyroid nodule with multiple mural nodules within Mural nodules avascular on Doppler Representing intra-nodular blood clots Longitudinal ultrasound of thyroid lobe mural nodule Thyroid nodule Composition / Hemorrhagic thyroid cyst
  22. 22. 53-year-old male with incidental mass in right lobe seen on CT Cystic mass with large ring down artifact (arrowheads) consistent with benign colloid cyst Transverse ultrasound of right lobe Dighe M et al. Med Ultrason 2017;19(2):195–210. Thyroid nodule Composition / Colloid cyst
  23. 23. Multiple benign colloid cysts with ring-down artifact in several cysts Henrichsen TL et al. Radiol Clin N Am 2011;49:417–424. Thyroid nodule Composition /Colloid cyst
  24. 24. Thyroid nodule Composition /Colloid cyst Comet tail artifact also referred to as a ring-down artifact, a stepladder artifact, or when a single comet tail is seen within a small colloid cyst, a cat’s eye In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland. cat’s eye
  25. 25. Thyroid nodule Composition / Spongiform nodule Spongiform benign nodule with internal microcystic appearance involving more than 50% of the lesion Classic spongiform or honeycomb pattern Head and neck ultrasonography: essential and extended applications. Second edition, 2017. Editor: LA Orloff – Plural Publishing Incorporation, San Diego, CA, USA.
  26. 26. Thyroid nodule Composition / Predominantly cystic nodule Transverse US of left lobe Predominantly cystic nodule with small solid mural component Flow within mural component (arrowheads): tissue and not debris US-guided FNA directed into this area: benign lesion Corresponding color Doppler US Frates MC et al. Ultrasound Quarterly 2006;22(4):231–238.
  27. 27. Thyroid nodule Composition / Predominantly solid nodule Iso- to hyperechoic thyroid nodule containing multiple cystic components Gaitini D et al. Thyroid Ultrasound. In: EFSUMB – European Course Book – Editor: Dietrich CF – 2011
  28. 28. Thyroid nodule Composition / Completely solid nodule Transverse US of left lobe Completely solid thyroid nodule (calipers) Marked internal vascularity on color Doppler mode indicating increased likelihood that nodule is malignant This was a papillary thyroid carcinoma Corresponding color Doppler US Frates MC et al. Ultrasound Quarterly 2006;22(4):231–238.
  29. 29. Ultrasound features of thyroid nodules Echogenicity
  30. 30. Thyroid nodule Echogenicity / Hyperechoic nodule Russ G et al. Eur Thyroid J 2017;6:225–237. Hyperechoic homogenous thyroid nodule Oval shape and smooth margins – No any high-risk features Risk of malignancy decreases as the echogenicity increases Longitudinal ultrasound Transverse ultrasound
  31. 31. Die C et al. Insights Imaging 2016;7:77–86. Markedly hyper-echogenic & heterogenous nodule This is considered a suspicious nodule Thyroid nodule Echogenicity / Hyperechoic nodule
  32. 32. Thyroid nodule Echogenicity / Hyperechoic nodule Head and neck ultrasonography: essential and extended applications. Second edition, 2017. Editor: LA Orloff – Plural Publishing Incorporation, San Diego, CA, USA. Almost completely solid and hyperechoic nodule Some small cystic components Smooth margin – No calcifications
  33. 33. Thyroid nodule Echogenicity / Isoechoic nodule Isoechoic and completely solid nodule Hypoechoic thin halo with peripheral vascularity on Doppler Benign nodule at fine needle aspiration Transverse US of right lobe Correspondent color Doppler Dighe M et al. Med Ultrason 2017;19(2):195–210.
  34. 34. Thyroid nodule Echogenicity / Hypoechoic nodule Hypoechoeic nodule compared to thyroid gland (arrowheads) Asterisk: strap muscle Kwak JY et al. Radiology 2011;260(3):892–899. Transverse US of left thyroid lobe
  35. 35. Suspicious hypoechoic nodule with signal lower than surrounding thyroid tissue but higher than strap muscle above Die C et al. Insights Imaging 2016;7:77–86. Thyroid nodule Echogenicity / Hypoechoic nodule nodule strap muscle normal thyroid
  36. 36. Hypoechoic nodule with significant posterior acoustic enhancement Presence of intra-nodular vascularity identifies this as a solid nodule and not a cyst Thyroid nodule Echogenicity / Hypoechoic nodule or thyroid cyst Correspondent color DopplerTransverse US of right lobe In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  37. 37. Thyroid nodule Echogenicity / Very hypoechoic nodule Echogenicity of nodule less than that of strap muscle Proved to be papillary thyroid carcinoma on histology In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  38. 38. Thyroid nodule Echogenicity / Very hypoechoic nodule Grant EG et al. J Am Coll Radiol 2015;12:1272–1279. Very hypoechoic 10-mm nodule (N) with smooth margin Nodule less echogenic than adjacent strap muscles (S) and isoechoic to common carotid artery (C) Diagnosis: papillary thyroid carcinoma Transverse ultrasound of left thyroid lobe
  39. 39. Ultrasound features of thyroid nodules Shape
  40. 40. Thyroid nodule Shape / Taller-than-wide nodule Langer JE. Radiol Clin North Am. 2019;57(3):469–483. Hypoechoic solid nodule of 1.3 cm Larger in anteroposterior diameter than in width Highly predictive of malignancy & noted in smaller cancers < 1 cm Papillary thyroid carcinoma on surgery Transverse image of left lobe
  41. 41. Ultrasound features of thyroid nodules Margins
  42. 42. Thyroid nodule Margin / Lobular margin of nodule Die C et al. Insights Imaging 2016;7:77–86. Suspicious hypoechoic nodule with lobular margin
  43. 43. Hypoechoic solid nodule with a lobulated margin (arrow) Papillary thyroid carcinoma on FNA Thyroid nodule Margin / Lobular margin of nodule In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  44. 44. Grant EG et al. J Am Coll Radiol 2015;12:1272–1279. Thyroid nodule Margin / Irregular margin of nodule Heterogeneous 16-mm nodule with irregular margins Angulated borders anteriorly Diagnosis: papillary thyroid carcinoma Longitudinal image of thyroid lobe
  45. 45. Markedly hypoechoic nodule which is taller than wide (arrow) Presence of speculated margin (arrowheads ) Presence of microcalcifications (open arrow ) It demonstrates most of US features associated with malignancy Thyroid nodule Margin / Irregular spiculated margin of nodule In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York.
  46. 46. Thyroid nodule Margin / Extra-thyroidal extension of nodule Longitudinal US of left thyroid lobe Hypoechoic nodule with extrathyroidal extension into strap muscle Loss of thin hyperechoic capsule (red arrow) Highly reliable sign of malignancy and unfavorable prognostic sign Papillary carcinoma on surgery Head and neck ultrasonography: essential and extended applications. Second edition, 2017. Editor: LA Orloff – Plural Publishing Incorporation, San Diego, CA, USA.
  47. 47. Thyroid nodule Margin / Extra-thyroidal extension of nodule Transverse ultrasound of thyroid Extrathyroidal extension through anterior capsule (arrows) Lack of clear margin with adjacent trachea posteriorly (dashed arrow) Anaplastic carcinoma on surgery with tracheal invasion In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  48. 48. Langer JE. Radiol Clin North Am 2019;57(3):469–483. Thyroid nodule Margin / Extra-thyroidal extension of nodule Sagittal ultrasound of left thyroid lobe 3.5 cm solid hypoechoic nodule with microcalcifications Along inferior aspect of lesion: normal thyroid capsule (dashed arrow) Along superior aspect lesion: extra-thyroidal extension (arrows)
  49. 49. Ultrasound features of thyroid nodules Peripheral halo
  50. 50. • Thin, regular and vascular halo Generally forms margin for iso- and hyperechoic nodules Found in about half of benign nodule • Thick, irregular and avascular halo Presence of fibrous capsule surrounding a neoplastic growth: Follicular carcinoma or Hürthle cell carcinoma Peripheral halo of thyroid nodules Sonolucent ring that surrounds a nodule In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  51. 51. Longitudinal US of thyroid lobe Thyroid nodule Halo / Thin regular and vascular halo Halo corresponds with peripheral vascularity Coresponding color Doppler Isoechoic nodule with thin regular halo Cytology is benign In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  52. 52. Thick, irregular, and incomplete halo Surrounding solid iso- to hyperechoic nodule Hürthle cell cancer on histology Thyroid nodule Halo / Thick irregular and incomplete halo Transverse ultrasound of right thyroid lobe In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  53. 53. Thyroid nodule Halo / Thick avascular halo In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York. Heterogeneous nodule with thick halo which without vascularity Avascular halo is suspicious for a malignant nodule and represents true capsule of the lesion Longitudinal power Doppler ultrasound of thyroid lobe
  54. 54. Ultrasound features of thyroid nodules Echogenic foci (calcifications)
  55. 55. Thyroid nodule Echogenic foci / Ring down artifact Dighe M et al. Med Ultrason 2017;19(2):195–210. Transverse ultrasound of right lobe Cystic mass with large ring down artifact (arrowheads) consistent with benign colloid cyst
  56. 56. Thyroid nodule Echogenic foci / Macro-calcifications Langer JE. Radiol Clin North Am. 2019;57(3):469–483. Mixed solid & cystic nodule (calipers) Central macro-calcification (arrow) producing acoustic shadowing Benign hyperplastic nodule Sagittal US of thyroid lobe Transverse US of thyroid lobe Solid hypoechoic nodule Central dystrophic calcification outlined by calipers Medullary thyroid carcinoma
  57. 57. 69-year-old woman with medullary thyroid carcinoma Hypoechoic nodule with coarse central calcification This is suggestive of medullary thyroid carcinoma Henrichsen TL et al. Radiol Clin N Am 2011;49:417–424. Thyroid nodule Echogenic foci / Macro-calcifications
  58. 58. Thyroid nodule Echogenic foci / Peripheral rim calcifications (eggshell) Complete eggshell calcification Acoustic shadowing produced by calcific ring Twofold increase of cancer likelihood in case of eggshell calcification In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York. CCA trachea eggshell Transverse ultrasound of left thyroid lobe
  59. 59. Thyroid nodule Echogenic foci / Disrupted peripheral rim calcifications Die C et al. Insights Imaging 2016;7:77–86. Interrupted eggshell calcification around edges Corresponds with localized invasion into surrounding thyroid
  60. 60. Coarse and disrupted calcification Posterior acoustic shadowing partially obscures the nodule Highly suspicious for malignancy – Papillary thyroid carcinoma on FNA Transverse ultrasound of right lobe Head and neck ultrasonography: essential and extended applications. Second edition, 2017. Editor: Orloff LA – Plural Publishing Incorporation, San Diego, CA, USA. Thyroid nodule Echogenic foci / Disrupted peripheral rim calcifications
  61. 61. Sagittal US image of thyroid nodule Thyroid nodule (arrowheads) with micro-calcifications (arrow) Papillary thyroid carcinoma on FNA and surgery Threefold increase of cancer likelihood in case of microcalcifications Microcalcifications almost exclusively appear in hypoechoic nodules Frates MC et al. Ultrasound Quarterly 2006;22(4):231–238. Thyroid nodule Echogenic foci / Micro-calcifications (punctate echogenic foci)
  62. 62. Ultrasound features of thyroid nodules Vascularity
  63. 63. Vascularity pattern of thyroid nodules ACR TIRADS: American college of radiology – Thyroid imaging reporting and data system ATA: American thyroid association – BTA: British thyroid association FNA: fine needle aspiration Die C et al. Insights Imaging 2016;7:77–86. Nodular vascularity U classification of BTA FNA Peripheral vascularity Benign nodule not required Peripheral & intra-nodular vascularity Equivocal nodule required Intra-nodular vascularity Malignant nodule required Nodular vascularity included in U classification of BTA and not included in K-TI-RADS, ATA & ACR TI-RADS
  64. 64. Benign nodule with peripheral vascularity on Doppler Vascular haloes in benign nodules represent compressed vessels/ thyroid tissue & such nodules do not have true capsule around them Die C et al. Insights Imaging 2016;7:77–86. Thyroid nodule Vascularity /Peripheral vascularity of nodule
  65. 65. Transverse US of thyroid nodule Solid thyroid nodule with peripheral and internal vascularity This was a papillary thyroid carcinoma Increased vascularity in thyroid nodule is suggestive of malignancy but should not be considered a pathognomonic feature Corresponding color Doppler US Frates MC et al. Ultrasound Quarterly 2006;22(4):231–238. Thyroid nodule Vascularity / Peripheral and intra-nodular vascularity
  66. 66. Thyroid nodule Vascularity / Intranodular vascularity Die C et al. Insights Imaging 2016;7:77–86. Thyroid nodule with intra-nodular vascularity Later confirmed to be papillary thyroid cancer
  67. 67. Nodules in Hashimoto thyroiditis • Pseudo- nodules • White-knight nodule • Giraffe hide • Papillary thyroid carcinoma: increased risk in Hashimoto thyroiditis • Thyroid lymphoma: increased risk in Hashimoto thyroiditis Henrichsen TL et al. Radiol Clin N Am 2011;49:417–424.
  68. 68. Hashimoto’s thyroiditis Pseudonodules Thin & thicker fibrous septa in hypoechoic thyroid Creating pseudonodules and parenchymal coarsening When it is unclear if a nodule is present, FNAC may be needed FNAC: fine needle aspiration cytology Sholosh B et al. Radiol Clin N Am 2011;49:391–416. Sagittal ultrasound of thyroid lobe
  69. 69. Hashimoto’s thyroiditis white-knight nodule Background thyroid: hypoechoic with micro-nodularity features typical of diffuse Hashimoto thyroiditis Well-defined homogenous hyperechoic nodule known as white-knight Surgical removal demonstrated nodular Hashimoto thyroiditis Henrichsen TL et al. Radiol Clin N Am 2011;49:417–424. 16-year-old boy with known Hashimoto thyroiditis
  70. 70. Hashimoto’s thyroiditis Giraffe hide Sholosh B et al. Radiol Clin N Am 2011;49:391–416. Background thyroid: hypoechoic with micro-nodularity features typical of diffuse Hashimoto thyroiditis Bright blocks separated by dark bands looking like a giraffe hide This nodule is variation of echogenic nodule known as “white- knight”
  71. 71. Presence of multiple nodules is the norm on ultrasound examination With high-resolution ultrasound, it is quite unusual to see a truly solitary nodule
  72. 72. Multiple thyroid nodules Large anechoic cyst (arrow) without calcifications or ring down artifact Two small hypoechoic nodules with multiple cystic components Dighe M et al. Med Ultrason 2017;19(2):195–210. Longitudinal ultrasound of left thyroid lobe
  73. 73. Multiple thyroid nodules In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York. Sagittal ultrasound of right thyroid lobe Multiple heterogeneous nodules in right lobe (arrows) Some nodules show cystic component with comet-tail artifacts Others are isoechoic with cystic elements None of nodules show obvious features suspicious for malignancy
  74. 74. In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York. Multiple solid isoechoic non-calcified nodules Multiple thyroid nodules Sagittal ultrasound of thyroid lobe
  75. 75. Malignancy in solitary & multiple thyroid nodules 1 Cochand-Priollet B et al. Am J Med 1994; 97(2):152–157. 2 Marqusee E et al. Ann Intern Med 2000; 133(9):696–700. 3 Papini E et al. J Clin Endocrinol Metab 2002; 87(5):1941–1946. Malignancy Solitary nodules Multiple nodules Cochand-Priollet 1 13% 14% Marqusee E 2 7% 9% Papini 3 9% 6% Malignancy is similar in solitary & multiple thyroid nodules
  76. 76. Thyroid cancers
  77. 77. Thyroid cancers 1% of all malignancies Average annual incidence 5/100.000 inhabitants • Papillary thyroid carcinoma: 75 – 80% • Follicular thyroid carcinoma: 5 – 10% • Medullary thyroid carcinoma: 3 – 5% • Anaplastic thyroid carcinoma: 1 – 2% • Primary thyroid lymphoma: < 5% • Thyroid metastasis Die C et al. Insights Imaging 2016;7:77–86.
  78. 78. • Ultrasound: Heterogeneous hypoechoic nodule Irregular shape Characteristic micro-calcifications • Color Doppler: Not useful to diagnose papillary cancer (useful in follicular cancer) 20% of malignant nodules have peripheral vascularity Papillary thyroid carcinoma most common thyroid cancer (75–80%) Dighe M et al. Med Ultrason 2017;19(2):195–210.
  79. 79. Classic pattern of hypoechoic nodule with micro-calcifications Mild internal vascularity on color Doppler Papillary thyroid carcinoma Transverse US and color Doppler of right lobe Dighe M et al. Med Ultrason 2017;19(2):195–210.
  80. 80. Papillary thyroid carcinoma Sholosh B et al. Radiol Clin N Am 2011;49:391–416. Subtle hypoechoic nodule proved to be papillary thyroid carcinoma Nodule easily blends in to adjacent hypoechoic thyroid on sagittal view Multiple tiny hypoechoic nodules consistent with Hashimoto thyroiditis Patient with long-standing Haschimoto’s thyroiditis Transverse and sagittal US of right thyroid lobe
  81. 81. Langer JE. Radiol Clin North Am. 2019;57(3):469–483. Papillary thyroid carcinoma Patient with long-standing Haschimoto’s thyroiditis Sagittal ultrasound of thyroid lobe Background thyroid: micronodules of Hashimoto’s thyroiditis Papillary thyroid cancer (PTC) occurring in Haschimoto thyroiditis Echogenicity of nodule similar to background thyroid but microcalcifications within nodule facilitate its detection
  82. 82. Thrombosis of internal jugular vein Patient with known papillary thyroid carcinoma Thrombosis of left internal jugular vein (IJV) Head and neck ultrasonography: essential and extended applications. Second edition, 2017. Editor: Orloff LA – Plural Publishing Incorporation, San Diego, CA, USA.
  83. 83. Follicular thyroid carcinoma 5–10% of thyroid cancer • More common in females than males • Higher risk of distant metastases & mortality compared with PTC • Ultrasound: follicular carcinoma similar to follicular adenoma Adenoma: oval to round isoechoic or hypoechoic nodule Carcinoma: irregular margins, thick halo & caotic vessels • Doppler: characteristic high velocity pulsatile flow penetrating tumor • FNA insufficient to distinguish benign & malignant follicular lesions Follicular carcinoma dg by capsular or vascular invasion on histology Follicular adenoma must be excised for definitive diagnosis FNA: fine needle aspiration Dighe M et al. Med Ultrason 2017;19(2):195–210.
  84. 84. Benign follicular adenoma Classic pattern of follicular benign adenoma Homogeneous hypoechoic oval nodule with thin capsule Sholosh B et al. Radiol Clin N Am 2011;49:391–416. 56-year-old woman with benign follicular adenoma
  85. 85. Ovoid solid predominantly hypoechoic thyroid nodule Hypoechoic areas (arrowhead) within nodule are suspicious features Marked intranodular vascular flow on power Doppler Follicular carcinoma on histology Follicular thyroid carcinoma Longitudinal US of thyroid nodule In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York. Correspondent color Doppler US
  86. 86. • Arise from parafollicular C-cells that secrete thyrocalcitonin 10-20% of patients have familial history of pheochromocytomas Medullary carcinoma may be associated with MEN II-syndrome • Ultrasound: Solid hypoechoic nodule with central coarse calcification in 80-90% • Doppler: Chaotic intranodular vessels seen in tumor on color Doppler Medullary thyroid carcinoma 3–5 % of thyroid cancer Dighe M et al. Med Ultrason 2017;19(2):195–210.
  87. 87. Medullary thyroid carcinoma Ahuja AT. Diagnostic Ultrasound: Head and Neck. 2104, Amirsys Publishing. Transverse ultrasound of left lobe Well-defined solid hypoechoic nodules in left lobe Central dense shadowing calcification in larger nodule These were confirmed to be medullary thyroid carcinoma
  88. 88. Medullary thyroid carcinoma Dighe M et al. Med Ultrason 2017;19(2):195–210. 37 year old male with incidentally detected nodule on CT scan Transverse US & Doppler US of right lobe Large hypoechoic predominantly solid nodule Mild internal vascularity on color Doppler FNA suspicious for medullary carcinoma confirmed on histopathology
  89. 89. • Highly aggressive form of thyroid cancer Typically in elderly women in 6th to 7th decades of life Large number of patients have history of multinodular goiter • Ultrasound: Hypoechoic nodule involving entire lobe, ill-defined margins, areas of necrosis, microcalcifications, extracapsular spread, vascular invasion, nodal or distant metastases • Doppler: multiple small intra-nodular vessels • Core biopsy may be required for diagnosis due to its fibrotic nature Anaplastic thyroid carcinoma 1–2% of thyroid cancer Dighe M et al. Med Ultrason 2017;19(2):195–210.
  90. 90. Transvers ultrasound of thyroid bed ill-defined hypoechoic nodule in thyroid isthmus Tissue plane between tumor and trachea is lost (tracheal invasion) Anaplastic carcinoma revealed by core needle biopsy Anaplastic thyroid carcinoma 1–2% of thyroid cancer Ahuja AT. Diagnostic Ultrasound: Head and Neck. 2104, Amirsys Publishing.
  91. 91. ill-defined heterogeneous hypoechoic nodule (arrows) encasing left CCA (open arrow) Anaplastic carcinoma on histology Extrathyroid extension is better evaluated with CT or MR Transverse ultrasound of left thyroid lobe Anaplastic thyroid carcinoma 1–2% of thyroid cancer Ahuja AT. Diagnostic Ultrasound: Head and Neck. 2104, Amirsys Publishing.
  92. 92. Thyroid lymphoma • Uncommon: < 5% of all thyroid malignancies • Almost always in patients with underlying Hashimoto’s thyroiditis • Classically presents with rapidly enlarging thyroid gland • Ultrasound features: Markedly hypoechoic nodule in background of chronic thyroiditis Enhanced through transmission posterior to the lesion • Treatment: Chemotherapy and external beam radiation Surgery only if trachea markedly compressed by tumor • Good prognosis when disease confined to thyroid gland Sholosh B et al. Radiol Clin N Am 2011;49:391–416.
  93. 93. CECT: contrast enhanced computed tomography – PET: positron emission tomography Sholosh B et al. Radiol Clin N Am 2011;49:391–416. Thyroid lymphoma Markedly hypoechoic large expansile masses in both lobes on US Low density masses on CT scan Intensely hypermetabolic masses on PET scan Patient with Hashimoto thyroiditis & rapidly enlarging thyroid mass Transverse US of thyroid CECT PET scan
  94. 94. Thyroid lymphoma almost always in patients with underlying Hashimoto’s thyroiditis Sholosh B et al. Radiol Clin N Am 2011;49:391–416. Markedly hypoechoic nodule in isthmus Increased through-transmission: finding suggesting lymphoma Relative hypovascularity on color Doppler Background thyroid: micronodules of Hashimoto’s thyroiditis
  95. 95. Asymmetrically enlargement of left lobe with preserved contour Homogeneous & hypoechoic parenchyma of both lobes with increased through-transmission (features suggestive of lymphoma) Haschimoto thyroiditis: heterogeneous hypoechoic regions that attenuate sound Thyroid lymphoma Patient with long-standing Haschimoto thyroiditis & new neck swelling Transverse ultrasound of thyroid Langer JE. Radiol Clin North Am. 2019;57(3):469–483.
  96. 96. Thyroid metastasis rare in daily clinical practice • Generally associated with advanced stage of malignancy • Main primary tumors spreading to thyroid gland: malignant melanoma, breast carcinoma, renal cell carcinoma • Difficult to distinguish from primary thyroid lesion • No specific features on US: Solitary/multiple hypoechoic nodules without calcifications No specific information about color Doppler of metastases Dighe M et al. Med Ultrason 2017;19(2):195–210.
  97. 97. Transverse US of right and left lobe Several small hypoechoic nodules in right lobe Large hypoechoic nodule in left lobe Adenocarcinoma most probably from gastrointestinal origin on FNA Thyroid metastasis Gaitini D et al. Thyroid Ultrasound. In: EFSUMB – European Course Book – Editor: Dietrich CF – 2011
  98. 98. In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York. Thyroid metastasis Longitudinal in a patient with a known lung cancer Solid hypoechoic noncalcified nodule (arrow) in lower thyroid pole Lower pole is common location for large thyroid metastases Presence of such a nodule in a patient with known cancer suggests thyroid metastases unless proven otherwise
  99. 99. ③ Ultrasound of cervical lymph nodes
  100. 100. Six zones of cervical lymph nodes Zone I Submental triangle Zone II Upper internal jugular chain nodes Zone III Middle internal jugular chain nodes between hyoid bone & cricoid cartilage Zone IV Lower internal jugular chain nodes from zone II to clavicle Zone V Entire posterior triangle between SCM, trapezius and clavicle Zone VI hyoid bone superiorly sternal manubrium inferiorly carotid arteries laterally Head and neck ultrasonography: essential and extended applications. Second edition, 2017. Editor: Orloff LA – Plural Publishing Incorporation, San Diego, CA, USA.
  101. 101. Zones in dark blue are most common sites of metastatic papillary carcinoma Zones in lighter blue are less frequent areas of metastatic papillary carcinoma Six zones of cervical lymph nodes In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), 2012, Springer Science+Business Media, New York.
  102. 102. Pretracheal and paratracheal lymph nodes Schematic transverse section at level of thyroid gland In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), 2012, Springer Science+Business Media, New York. Relationship of pretracheal and paratracheal lymph nodes to adjacent structures
  103. 103. • Small: short axis < 5 – 8 mm • Oval: short axis/long axis < 0.5 • Echogenic hilum • Hilar vascularity or avascular hilum on Doppler Ultrasound features of benign lymph nodes At least 5–6 normal cervical nodes identified routinely by US Ting M et al. Clinical Radiology 2003;58:351–358.
  104. 104. Normal cervical lymph node Oval shape and echogenic hilum Ahuja AT et al. AJR 2005;184:1691–1699. Hypoechoic, elliptic, and elongated lymph node (arrows) Arrowheads indicate echogenic hilus continuous with adjacent soft tissue
  105. 105. Richards PS et al. Cancer Imaging 2007;7:167–178. Normal cervical lymph node oval shape & echogenic hilum Normal elliptical node with echogenic hilum
  106. 106. Normal cervical lymph node Hilar vascularity Vessels radiate out from the hilum Richards PS et al. Cancer Imaging 2007;7:167–178.
  107. 107. Ultrasound features of malignant lymph nodes • Round shape • Loss of echogenic hilum • Cystic change in lymph node • Microcalcifications • Non-hilar vascularity • Extracapsular spread Sholosh B et al. Radiol Clin N Am 2011;49:391–416.
  108. 108. Ahuja AT et al. Cancer Imaging 2008;8:48–56. Malignant lymph node Round shape Metastatic lymph node which is enlarged, hypoechoic, well-defined and without echogenic hilum (arrows)
  109. 109. Enlarged node (calipers) with cystic component Node proved to be metastatic papillary carcinoma Frates MC et al. Ultrasound Quarterly 2006;22(4):231–238. Malignant lymph node Cystic change
  110. 110. Metastatic cervical node (arrows) with intra-nodal cystic necrosis which appears ill-defined and echolucent (arrowheads) Ahuja AT et al. Cancer Imaging 2008;8:48–56. Malignant lymph node Cystic change
  111. 111. Malignant lymph node Cystic change In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York. Cystic metastatic lymph node (arrow) from papillary carcinoma Microcalcifications (arrowhead) within solid component (open arrow) of metastatic node Transverse ultrasound of left neck CCA
  112. 112. Ahuja AT et al. Cancer Imaging 2008;8:48–56. Metastatic lymph node from papillary thyroid carcinoma (arrows) Hyperechoic component within node which may be related to intra-nodal deposition of thyroglobulin (arrowheads) Malignant lymph node Hyperechoic component
  113. 113. Malignant lymph node Micro-calcifications Ahuja AT. Diagnostic Ultrasound: Head and Neck. 2104, Amirsys Publishing. Round heterogeneous hyperechoic node – Loss of echogenic hilum Characteristic punctate calcification with fine acoustic shadowing Compressed internal jugular vein (IJV) Patient with known papillary thyroid carcinoma CCA collapsed IJV lymph node punctate calcifications
  114. 114. Ahuja AT et al. Cancer Imaging 2008;8:48–56. Metastatic lymph node with peripheral vascularity (arrowheads) Power Doppler ultrasound Malignant lymph node Peripheral vascularity
  115. 115. Malignant lymph node with both peripheral (arrowheads) and hilar vascularity (arrows) Power Doppler ultrasound Ahuja AT et al. Clinical Radiology 2003:58:359–366. Malignant lymph node Peripheral & hilar vascularity
  116. 116. Head and neck ultrasonography: essential and extended applications. Second edition, 2017. Editor: Orloff LA – Plural Publishing Incorporation, San Diego, CA, USA. Metastatic lymph node Mixed (peripheral and hilar) vascularity on power Doppler Patient with known papillary thyroid carcinoma Sagittal gray scale & power Doppler ultrasound Malignant lymph node Peripheral & hilar vascularity
  117. 117. Richards PS et al. Cancer Imaging 2007;7:167–178. Malignant lymph node Extracapsular spread
  118. 118. ④ Ultrasound systems for thyroid nodule risk stratification
  119. 119. Reliable US systems are necessary to specifically target nodules that require biopsy Several published US systems for risk stratification
  120. 120. Some US systems for thyroid nodule risk stratification 2009 First TI-RADS Horvath E et al. Clin Endocrinol Metab 2009;94(5):1748–51. 2011 Korean TI-RADS Kwak JY et al. Radiology 2011;260(3):892–899. 2016 U classification of British Thyroid Association (BTA) Die C et al. Insights Imaging 2016;7:77–86. 2016 American Thyroid Association (ATA) Haugen BR et al. Thyroid 2016;26(1):1–133. 2017 ACR TI-RADS Tessler FN et al. J Am Coll Radiol 2017;14:587–595. ACR: American college of radiology TI-RADS: Thyroid imaging reporting and data system No one system has achieved universal acceptance This leads to some confusion for practitioners of sonography
  121. 121. Korean TIRADS Analysis of 1658 nodules > 1 cm that underwent FNA Category Definition Ultrasound features FNA 1 Normal thyroid gland follow-up 2 Benign: 0% Cyst & colloid cysts Spongiform grid nodule follow-up follow-up 3 Probably benign: < 5% No suspicious feature follow-up 4 4 a 4 b 4 c Suspicious nodules: 5-80% Low suspicion: Intermediate suspicion Moderate suspicion 1 suspicious feature 2 suspicious features 3-4 suspicious features ≥ 1.0 cm ≥ 1.0 cm ≥ 1.0 cm 5 Probably malignant: >80% 5 suspicious features ≥ 1.0 cm 6 Biopsy proven malignancy Less complex TI-RADS stratifying malignancy risk Kwak JY et al. Radiology 2011;260(3):892–899.
  122. 122. Suspicious ultrasound features in Korean TI-RADS • Solid component • Hypoechogenicity • Marked hypoechogenicity • Microlobulated or irregular margins • Microcalcifications • Taller-than-wide shape Kwak JY et al. Radiology 2011;260(3):892–899. Six ultrasound features
  123. 123. U classification of British Thyroid Association Classification US features of thyroid nodule FNA U1: benign thyroid not required U2: indeterminate nodule Iso- or slightly hyperechoic nodule Hypoechoic halo around nodule Anechoic with ring-down sign (colloid) Spongiform/honeycomb nodule Complete eggshell calcification Peripheral vascularity of nodule not required U3: equivocal nodule Markedly hyperechoic nodule Nodule with cystic change Peripheral & intra-nodular vascularity required U4: suspicious nodule Hypoechoic nodule Disrupted eggshell calcification Nodule with lobular margin required U5: malignant nodule Taller than wide nodule Micro-calcifications Intra-nodular vascularity required Die C et al. Insights Imaging 2016;7:77–86.
  124. 124. American Thyroid Association (ATA) guidelines for adult patients with thyroid nodules FNAC: fine needle aspiration cytology – ETE: extra-thyroidal extension – F/U: follow-up Haugen BR et al. Thyroid 2016;26(1):1–133. Category Risk of malignancy US features FNAC High suspicion > 70 – 90% Microcalcifications, hypoechoic, irregular Hypoechoic, irregular margin Hypoechoic, taller-than-wide Hypoechoic, irregular margin, ETE Hypoechoic, interrupted rim calcifications Irregular, suspicious lateral lymph node ≥ 1 cm Intermediate suspicion 10 – 20% hypoechoic solid, regular margin ≥ 1 cm Low suspicion 5 – 10% Hyperechoic solid, regular margin Isoechoic solid, regular margin Partially cystic, eccentric solid area ≥ 1.5 cm Very low suspicion < 3% Spongiform Partially cystic, no suspicious features ≥ 2 cm or F/U Benign < 1% Cyst no FNA
  125. 125. ACR TI-RADS Tessler FN et al. J Am Coll Radiol 2017;14:587–595.
  126. 126. ACR TI-RADS • Less concerning features are awarded less or no points • More suspicious features are awarded higher points • Add points of all categories to determine ACR TI-RADS level ACR TI-RADS: American college of radiology – Thyroid imaging reporting and data system Langer JE. Radiol Clin North Am. 2019;57(3):469–483.
  127. 127. Categories of nodule features in ACR TI-RADS Category Ultrasound features Points Composition: choose only one Cystic or almost completely cystic Spongiform: > 50% of small cystic spaces Mixed cystic and solid Solid or almost completely solid 0 point 0 point 1 point 2 points Echogenicity: choose only one Anechoic Hyperechoic or isoechoic Hypoechoic Very hypoechoic 0 point 1 point 2 points 3 points Shape: choose only one Wider-than-tall Taller-than-wide 0 point 3 points Margins: choose only one Smooth or ill-defined Lobulated or irregular Extra-thyroidal extension 0 point 2 points 3 points Echogenic foci: all that apply No echogenic foci or large comet-tail artifacts Macrocalcifications Peripheral (rim) calcifications Punctate echogenic foci (microcalcifications) 0 point 1 point 2 points 3 points Tessler FN et al. J Am Coll Radiol 2017;14:587–595.
  128. 128. ACR TI-RADS ACR: American college of radiology TIRADS: Thyroid imaging reporting and data system FNA: fine needle aspiration Tessler FN et al. J Am Coll Radiol 2017;14:587–595. TI-RADS Description Points FNA TR1 benign 0 points no FNA TR2 not suspicious 2 points no FNA TR3 mildly suspicious 3 points FNA if ≥ 2.5 cm TR4 moderately suspicious 4 – 6 points FNA if ≥ 1.5 cm TR5 highly suspicious ≥ 7 points FNA if ≥ 1 cm
  129. 129. Advantages and disadvantages of ARC TI-RADS • Advantages: Standard terms (lexicon) for ultrasound reporting Able to classify almost all thyroid nodules Evidence based to the greatest extent possible • Disadvantages: High size threshold for FNA in mild & moderate suspicious lesions Doesn't take into consideration thyroid nodule vascularity Doesn't take into consideration elastography ACR TI-RADS: American college of radiology – Thyroid imaging reporting and data system FNA: fine needle aspiration
  130. 130. Head and neck ultrasonography: essential and extended applications. Second edition, 2017. Editor: LA Orloff – Plural Publishing Incorporation, San Diego, CA, USA. Almost completely solid (2 points) – Hyperechoic nodule (1 point) Smooth margin (0 point) – No calcifications (0 point) Total: 3 points – ACR TR3: mildly suspicious – FNA if ≥ 2.5 cm Classification of thyroid nodule by ACR TI-RADS
  131. 131. Completely solid (2 points) – hyperechoic (1 point) Smooth margin (0 point) – No echogenic foci (0 point) Total: 3 points – ACR TR 3: mildly suspicious – FNA if ≥ 2.5 cm Classification of thyroid nodule by ACR TI-RADS In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  132. 132. Longitudinal ultrasound of thyroid Completely solid nodule (2 points) – Hypoechoic (2 points) Lobulated margin (2 points) – Microcalcifications (arrows, 3 points) Total: 9 points – ACR TR 5: highly suspicious – FNA if ≥ 1 cm Papillary carcinoma on FNA ACR: American college of radiology – FNA: fine needle aspiration – TR: TIRADS In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York. Classification of thyroid nodule by ACR TI-RADS
  133. 133. ⑤ Pseudo-nodules of thyroid
  134. 134. Pseudo-nodules of thyroid • Pyramidal lobe • Zuckerkandl tubercle • Pseudo-nodules in Hashimoto thyroiditis • Parathyroid adenoma • Osteophytes Germano A et al. Clinical imaging 2019;58:114–128.
  135. 135. • Frequency: 10–30% of individuals • Remnant of thyroglossal tract Arises from isthmus & ascends towards hyoid bone Anterior to thyroid cartilage on midline or slightly to left • Rarely visualized on ultrasound: small anteroposterior diameter Can be seen when hypertrophied such as in case of Graves disease • More commonly detected in young: progressive atrophy in adulthood In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), 2012, Springer Science+Business Media, New York. Pyramidal lobe (Lalouette lobe)
  136. 136. Pseudo-nodules of thyroid pyramidal lobe Germano A et al. Clinical imaging 2019;58:114–128. Transverse ultrasound: pyramidal lobe simulates a nodule Longitudinal ultrasound: pyramidal shape can be assessed Transverse US of thyroid Sagital US of thyroid
  137. 137. • Lateral ingress of embryologic thyroid tissue • Located along posterior midportion of thyroid lobe • Ranges from small round fragment to 2–3 cm oval structure • Becomes prominent in the setting of diffuse thyroid disease • It may be misinterpreted as a nodule & unnecessarily biopsied • Surgically, the tubercule can be a marker of nearby trajectory of recurrent laryngeal nerve Tubercle of Zuckerkandl Embryologic remnant in posterior aspect of thyroid lobe In: Thyroid and parathyroid ultrasound and ultrasound-guided FNA. Duick DS Edit, 4th edition, 2018, Springer International Publishing, Switzerland.
  138. 138. Hyperechoic thyroid capsule separates body of thyroid from tubercle of Zuckerkandl Misinterpreted as thyroid nodule which does not have capsule Transverse US of thyroid In: Atlas of Thyroid Ultrasonography. Halenka M & Fryšák Z (Edits), Springer International Publishing AG, Switzerland, 2017. Sagittal US of left lobe Pseudo-nodules of thyroid Zuckerkandl tubercle
  139. 139. Pseudo-nodules of thyroid Zuckerkandl tubercle Germano A et al. Clinical imaging 2019;58:114–128. Zuckerkandl tubercle (arrows) Longitudinal ultrasound of right lobe
  140. 140. Thin & thicker fibrous septa in hypoechoic thyroid Creating pseudonodules and parenchymal coarsening When it is unclear if a nodule is present, FNAC may be needed FNAC: fine needle aspiration cytology Sholosh B et al. Radiol Clin N Am 2011;49:391–416. Sagittal ultrasound of thyroid lobe Pseudo-nodules of thyroid Hashimoto thyroiditis
  141. 141. Germano A et al. Clinical imaging 2019;58:114–128. Pseudo-nodules of thyroid parathyroid adenoma Histology-proven parathyroid adenoma (arrow) located posteriorly to thyroid, compressing thyroid parenchyma and mimicking a thyroid nodule Transverse ultrasound of right lobe
  142. 142. Pseudo-nodules of thyroid osteophytes Osteophytes posterior to lateral lobes of thyroid gland Mimicking calcified thyroid nodules (arrows) Can be easily ruled-out with neck X-ray Longitudinal ultrasound of thyroid Germano A et al. Clinical imaging 2019;58:114–128.
  143. 143. ⑥ Fine needle aspiration of thyroid nodules
  144. 144. Indications for FNA according to US findings FNA: fine needle aspiration – US: ultrasound Gharib H et al. Endocrine Practice 2016;22 (Suppl 1):1–60. FNA Ultrasound findings
  145. 145. Indications of FNA in ACR TI-RADS • TR3 (mildly suspicious nodules): if they are ≥ 2.5 cm • TR4 (moderately suspicious nodules): if they are ≥ 1.5 cm • TR5 (highly suspicious nodules): if they are ≥ 1 cm • No FNA of nodules < 1 cm even if they are highly suspicious This is in concordance with other guidelines FNA of 5-9 mm nodules may be done in certain conditions: Shared decision making between referring physician and patient FNA: fine needle aspiration ACR TI-RADS: American college of radiology – Thyroid imaging reporting and data system Tessler FN et al. J Am Coll Radiol 2017;14:587–595.
  146. 146. Fine needle aspiration of thyroid nodules Advantages Inexpensive, widely available, easy to perform, accurate (>90%) and cost-effective Disadvantages Depends on skill of operator & cytopathologist Complications Rare – no reported case of cutaneous implantation of malignancy following FNA False negative rate 0.5 – 11.8% (pooled rate 2.4%) False positive rate 0 – 7.1% (pooled rate of 1.2%) Non-diagnostic rate Vary among different centers 5% is the maximum acceptable limit FNA: fine needle aspiration In: Ultrasound of the thyroid and parathyroid glands. RA Sofferman & AT Ahuja (Eds), Springer Science+Business Media, 2012, New York.
  147. 147. Bethesda system for reporting thyroid cytopathology BSRTC Category Management I Nondiagnostic or unsatisfactory Repeat FNAC in 3 m II Benign Ultrasound follow-up III Atypia of undetermined significance or Follicular lesion of undetermined significance Repeat FNAC in 3 m or surgery w/o repeat FNAC IV Follicular neoplasm or Suspicious for follicular neoplasm Lobectomy or Thyroidectomy if proven malig. V Suspicious for malignancy Lobectomy or Thyroidectomy VI Malignant Thyroidectomy FNAC: fine needle aspiration cytology Haugen BR et al. Thyroid 2016;26(1):1–133.
  148. 148. Complication of thyroid fine needle aspiration 1–12% of patients In: Thyroid ultrasound – From simple to complex. Editor: Sencha AN, Springer AG, 2019. Hematoma Sub-capsular, interfacial, inter-muscular, subcutaneous Pain in puncture region Usually disappears within 2 – 5 days Injury of CCA Hematoma in CCA wall with stenosis Injury of IJV Partial or complete thrombosis of IJV Nerve puncture Cervical plexus: neck, shoulder & upper extremity pain Superior laryngeal nerve: choking specially with liquids Inferior laryngeal nerve: hoarse voice Trachea puncture Instant dry hoarse cough for 1 – 5 min Insignificant subcutaneous emphysema possible Esophageal puncture Oval lesion in posterior left lobe on transverse scan Can be misinterpreted as nodule
  149. 149. In: Thyroid ultrasound – From simple to complex. Editor: Sencha AN, Springer AG, 2019. Complications of fine needle aspiration Subcapsular hematoma of thyroid
  150. 150. In: Thyroid ultrasound – From simple to complex. Editor: Sencha AN, Springer AG, 2019. Complications of fine needle aspiration interfascial hematoma
  151. 151. Complications of fine needle aspiration hematoma within common carotid artery wall CCA: common carotid artery In: Thyroid ultrasound – From simple to complex. Editor: Sencha AN, Springer AG, 2019. Transverse US of CCA Longitudinal color Doppler of CCA
  152. 152. Complications of fine needle aspiration thrombosis of internal jugular vein In: Thyroid ultrasound – From simple to complex. Editor: Sencha AN, Springer AG, 2019. Transverse US of left thyroid lobe Partial thrombosis of left internal jugular vein (arrow)
  153. 153. Conclusion • Thyroid nodules are very common • Vast majority of nodules are benign, hyperplastic regions of thyroid or benign adenomas • Minority of nodules representing a malignancy • Sonography serves as an effective tool in determining the need for FNA to diagnose or exclude thyroid malignancy especially in low-risk patients
  154. 154. Thank You
  155. 155. Benign features of thyroid nodules in ACR TI-RADS ACR TI-RADS: American college of radiology – Thyroid imaging reporting and data system Langer JE. Radiol Clin North Am 2019;57(3):469–483. Nodule Ultrasound features Points Composition Cystic or almost completely cystic Spongiform: > 50% of small cystic spaces add 0 point add 0 point Echogenicity Anechoic: cystic or almost completely cystic add 0 point Shape Taller-than-wide: assessed by visual inspection add 0 point Margin Smooth add 0 point Echogenic foci None Large comet-tail artifacts: >1 mm in cystic parts add 0 point
  156. 156. Suspicious features of thyroid nodules in ACR TI-RADS Tessler FN et al. J Am Coll Radiol 2017;14:587–595. Nodule Ultrasound features Points Choose only one Composition: Mixed cystic and solid & predominantly solid Solid or almost completely solid add 1 point add 2 points Echogenicity: Hyperechoic or isoechoic: compared to thyroid Hypoechoic: compared to thyroid Very hypoechoic: compared to strap muscle add 1 point add 2 points add 3 points Shape: Taller-than-wide: assessed by visual inspection add 3 points Margin: Lobulated or irregular Extra-thyroidal extension: obvious malignancy add 2 points add 3 points Choose all that apply Echogenic foci: Macrocalcifications: causing acoustic shadowing Peripheral rim calcifications: eggshell Punctate echogenic foci: mirocalcifications add 1 point add 2 points add 3 points Add points from all categories to determine ACR TI-RADS level

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