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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

Why
o Accurate depiction of neck anatomy
o Clarifies doubtful findings
o Differentiates thyroid from non-thyroidal
masses
o Detection of non-palpable disease
o Follow-up of focal disease
o Guides FNA/therapy
o Suggests probable benign/malignant for
stratification of further workup

The section

The section

Surroundings

Sternohyoid
Sternothyroid
Sternocleidomastoid

Trachea

Thyroid

Int Jug vein


CCA

Oesophagus
Cervical Vertebra
C-6

Longus coli

Scalenus anterior

Surroundings

Surroundings

Sternohyoid
Sternothyroid

Sternocleidomastoid
Trachea
Thyroid

Oesophagus

CCA
Cervical Vertebra Longus coli
C-6

Int Jug vein


Scalenus anterior

Size
o Each lobe 4-6 cm in cranio-caudal extent
o <1.8 cm in maximum depth, isthmus <6mm
in thickness
o Volume 7-14ml, calculated for each lobe
and add

Size
4-6 cm

<0.6cm

<1.8cm
<1.8cm
4-6 cm
Volume; 7-14 ml. Calculate for
each lobe and add

<1.8cm

Texture
o 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

Nemio

Aplio

Blood supply
o Superior thyroid artery and vein at the
upper pole of each lobe
o Inferior thyroid vein at the lower pole
o Inferior thyroid artery is posterior to the
lower third of each lobe

Superior thyroid artery

Inferior thyroid artery


Thyroida
ima
Sup th.
vein
Int jug
vein

Mid
th.
vein
Inf th.
vein

Inferior thyroid vein

Parenchymal vascularity

What do we look for in a thyroid nodule?


Echogenicity

Isoechoic, Hyperechoic
Hypoechoic
Markedly hypoechoic

Same , more or less than normal


areas of thyroid
Less than strap muscles

Content

Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid

75-100% of volume cystic


26-74%
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;
27:847865

Features
Tall/Wide

Contents

Echogenicity

Halo

Margins

Calcification

Doppler

Feature

Benign

Malignant

Wider than tall

+++

++

Taller than wide

++++

Purely cystic

++++

Cystic with thin septa

+++

Mixed Solid/cystic

+++

++

Purely solid

+++

++

Comet tail reverberations

+++

Hyperechoic

++++

Isoechoic

+++

++

Hypoechoic

+++

+++

Markedly hypoechoic

++++

Thin

++++

++

Thick

+++

Absent

+++

Well defined

+++

++

Poorly defined

++

+++

Spiculated

++++

Eggshell

+++

++

Coarse

+++

Micro

++

++++

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 peripheral
o 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 solid
o Hypo, iso or hyperechoic
o Thin or thick halo
o Peripheral rim of vessels, sometimes extending
inwards in spoke-wheel pattern

Follicular Neoplasm

Colloid Nodule

Papillary Thyroid Cancer


o
o
o
o

Hypoechoic
Microcalcification
Hypervascular
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 Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr. Ravi Kadasne, Al Ain. UAE
Via www.ultrasound-images.com

Other Carcinomas
o Medullary
o Part of the MEN-II syndrome, tends to be multicentric or
bilateral
o Similar to papillary carcinoma on ultrasound
o Calcifications tend to be coarse

o Anaplastic
o Large, hypoechoic, encase or invade blood vessels and muscles

o Lymphoma
o In most there is pre-existing Hashimotos and hypothyroidism,
rapidly growing mass
o 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?

e
v
i
t
c

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; 34:115

e
R

e
p
s
o
rt

Features, Scores and Patterns


Organizing the Data

Score
Study

Score

Interpretation

Adamczewski and Lewiski. 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


malignancy
4 <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 Subcentimetersized Thyroid Nodules Requiring Ultrasoundguided 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%

Pattern
Pattern

Significance

Spongiform without hypervascularity


Cyst with avascular colloid plug
Giraffe pattern (skin, not the neck)

Benign

White knight (uniform hyperechogenicity)


Red light (intense hypervascularity)
Intense hypoechogenicity
Isoechogenic without halo
Isoechogenic with halo

Unpredictable

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; 193:207213.

Pattern
Spongiform without hypervascularity
Cyst 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; 193:207213.

Pattern
Red 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; 193:207213.

What then for nodules?


Thyroid vs. extra-thyroidal
Recurrent disease
Guiding procedures
Biopsy vs. observe
Benign
Malignant

Yes
Yes
Yes
?Yes
?Yes
?

Diffuse Thyroid Disease


o
o
o
o

Hyperplasia
Thyroiditis
Graves disease
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
Quervains disease)
o Hypoechoic, diffusely or focally
o Decreased 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

Hashimotos 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