ULTRASOUND

IN
THYROID LESIONS

DR RAJ BUMIYA
First Year Resident
Dept. of Radiodiagnosis
S.S.G. Hospital, Baroda.
24/03/2011
1

Clinical applications of high resolution usg.

1. Detection of thyroid and other cervical masses

before
and after thyroidectomy.
2. Differentiation of benign from malignant
masses.
. Ultrasound detects the presence, size,

site, number, characteristics of thyroid nodules

3.

FNA Guidance

With high frequency transducer(7.5 to 15Mhz)

Examination-supine position with neck

extended.
A small pad may be placed under the shoulders

to provide better exposures of neck.

Lower pole imaging is enhanced by asking the

pt. to swallow, so the gland moves upward.

Examined thoroughly in transverse and

longitudinal planes.
3

Multiple oblique and angled projections may be

taken if necessary.

Examined:
SUPERIORLY: to identify Submandibular
adenopathy
INFERIORLY : to identify Supraclavicular
adenopathy

Normal ultrasound anatomy of thyroid

It is located anterior

and lateral to trachea

below the level of
thyroid cartilage and
above the sternal
notch. (infrahyoid
compartment)
DIVISION :
RIGHT AND LEFT LOBES,
ISTHMUS
PYRAMIDAL LOBE (10-40

%)

Normal thyroid
parenchyma has
homogenous medium to
high level echogenicity &
bounded by a thin
hyperechoic line(the
thyroid capsule).
Landmarks to be
identified:
Midline -Trachea and
oesophagus.
Laterally- Common
Carotid artery, IJV
Anterolaterally:Strap
muscles of the neck

 The superior thyroid

Vessels are found at

upper pole of each lobe
and inferior thyroid vein
is found at lower pole
whereas the inferior
thyroid artery is located
posterior to lower third of
each lobe.

Anteriorly-Sternohyoid & omohyoid muscles,

As hypoechoic bands.
Lateral- Sternocleidomastoid
As large oval band
Posterior- Longus colli muscle

Recurrent laryngeal nerve & inferior thyroid

artery pass in the angle between trachea,

oesophagus & thyroid lobe.

On longitudinal scans, recurrent laryngeal nerve

& inferior thyroid artery may be seen as

hypoechoic bands between the thyroid lobe &
oesophagus on left , thyroid lobe & longus colli
on right.
8

Oesophagus
laterally & towards the left
Target appearance on transverse plane
Peristaltic movements On swallowing.
Trachea
Posteriorly
Identified by lack of sound transmission and ring
down artifacts.

10

11

Inferior thyroid
artery along the
posterior surface

Inferior thyroid
vein branches
seen at the
lower pole
12

NORMAL DIMENSIONS OF THYROID LOBES

A-P
NEWBORN
INFANT
ADULT

8-9mm
12-15mm
13-18mm

LENGTH
18-20mm
25mm
40-60mm

Normal Mean Thyroid Volume (LxWxTHICKNESSx0.52) :

18.64.5
MALE-UPTO 23gm IS NORMAL
FEMALE- UPTO 22gm IS NORMAL.
Mean thickness of isthmus 4 to 6mm
A-P diameter is most precise because relatively

independent of possible dimensional asymemetry

between two lobes.
13

CONGENITAL ABNORMALITIES
AGENESIS/HYPOPLASIA
ECTOPIC

14

EMBRYOLOGY
Thyroid gland is originated from epithelial

cells of floor of pharynx.

It descends from pharynx & remains

connected to pharynx through a

tract,known as thyroglossal duct.

The gland reaches to its normal location by

7 weeks of gestational age.

Then after duct involutes.

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THYROID
USG : AGENESIS
Abnormal echogenic tissue in
the expected location of the thyroid,
without any normal flow on color
Doppler imaging. There is no evidence
of ectopic thyroid tissue.
Pertechnetate scintigraphy
demonstrates no functioning thyroid
tissue.
17

Sonography of the thyroid in this 1 yr. old female child revealed

congenital absence of the entire thyroid. Note the empty fossae
where the right and left lobes would normally lie. The carotid artery
and jugular vein of both sides are seen in the color doppler images.
These ultrasound and color doppler images suggest congenital
agenesis of the thyroid.
18

ECTOPIC THYROID
The thyroid gland develops as a median angle from a
diverticulum of the foramen cecum.
Normally, it descends to its typical location anterior to the
cervical trachea via the thyroglossal duct. Anomalies of descent
can lead to a lingual or sublingual position of the gland.
Nuclear medicine scintigraphy with sodium iodine-123 or
pertechnetate-99m is used to evaluate the neck for the
presence of thyroid tissue.
Diagnosis of lingual thyroid is made when uptake is seen at the
tongue base but not in the thyroid bed.
Further evaluation can be done using CT & MRI imaging.
19

CT image- round mass at tongue base which enhances after contrast

administration. A pertechnetate-99m scan shows uptake corresponding to
mass at tongue base without uptake in the thyroid bed.

20

Thyroid disorders
Thyroid disorders can be divided into
Nodular thyroid disease
Diffuse thyroid disease.

21

Nodular thyroid disease

Hyperplasia and goiter
Adenoma
Carcinoma
Lymphoma
Metastases
22

Hyperplasia and Goitre:

Etiology:
Iodine deficiency, dishormonogenesis(familial),poor
utilization of Iodine.
F:M-3:1 ,more between 35-50 years.
Hyperplasia leads to an overall increase in size or

volume of the gland.

Hyperplastic nodules often undergo liquefactive

degeneration with the accumulation of blood, serous

fluid and colloid substance, reffered to as
hyperplastic,adenomatous, or colloid nodules.
Coarse and perinodular calcification occur.

23

Sonography
Most hyper plastic or adenomatous nodules are isoechoic
compared to normal thyroid tissue.
As Size of the massincreases, it may become hyperechoic.
Less frequently hypo echoic SPONGElike OR HONEY COOMB
CYSTIC pattern is seen.
When nodule is hyperechoic or isoechoic, a thin peripheral
hypoechoic halo is commonly seen-due to perinodular blood
vessels and edema or compression of adjacent normal
parenchyma.
Perinodular, intranodular vascularity on colour Doppler.
DEGENERATIVE CHANGES:
Purely anechoic -due to serous/colloid fluid.
Echogenic fluid/moving fluid-fluid levels due to hemorrhage.
Bright echogenic foci with comet tail artifacts due to dense
colloid material/microcrystals.
Eggshell(thin peripheral) or coarse calcification.
24

Sonogram of the left lobe of the thyroid gland in the transverse plane
showing a rounded lobe of a goiter. L=enlarged lobe, I= widened
isthmus,T=trachea,C=carotid artery,J=jugular vein,
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S=Sternocleidomastoid muscle, m=strap muscles, E=esophagus.

Hyperplastic nodules
Oval homogenous

isooechoic nodule
with well defined
peripheral halo.

Multiple hyperechoic

nodules

26

Cystic degenerative changes in adenomatous

nodules

27

Adenoma
F:M 7:1
Solitary or as a part of multinodular goiter.

Sonography
Hyperechoic, iso or hypoechoic solid masses .
Have Peripheral hypoechoic halo which is thick

& smooth- due to fibrous capsule and blood

vessels.
Typical spoke and wheel type of appearance on
color doppler.
D/D : FOLLICULAR CARCINOMA where

28

Isoechoic solid mass with thick irregular complete halo.

Power doppler spoke and wheel like appearance
FOLLICULAR ADENOMA

29

multiple nodular densities in cervical region that are palpable on physical examination.CT scan
obtained 9 months before sonogram shows absent left thryoid lobe and enlarged right thryoid
lobe with small low-attenuation lesion.
30

Carcinoma:

Most primary thyroid cancers are of epithelial

origin and are derived from either the follicular

or the parafollicular cells.Most are well
differentiated.
Papillary carcinoma- 75-90% .
Medullary/Follicular/anaplastic car. -10-25%
Papillary cancer
3rd and 7th decade.F>M

The major route of spread is through lymphatics

to nearby cervical lymph nodes.

Distant metastasis is rare (2-3%) and occurs to
mediastinum and lungs.
31

Sonography
Hypoechoic nodules with microcalcifications

(tiny punctuate hyperechoic foci with or without

acoustic shadowing).
Disorganized hypervascularity on color

doppler,Mostly in well encapsulated form.

Cervical lymphnode metatasis which may

contain tiny punctate echogenic foci due to

microcalcifications.
Cystic lymph node metatasis in neck occur32

Hypoechoic solid nodule with Isoechoic nodule & punctate

echogenic foci within it
punctate calcification

33

Hetrogenous oval nodes

Two rounded hypoechoic
nodes typical of metastasis containing microcalcifications
to cervical nodes

34

 Longitudinal and transverse sonographic images of the thyroid gland reveal a normal left lobe and

thyroid isthmus. Multiple small punctate calcifications are seen scattered through the mass in right
lobe.
35

Punctate echogenicities in thyroid nodules. (a) Sagittal US image of nodule

containing multiple fine echogenicities with no comet-tail artifact. These are highly
suggestive of malignancy.FNA and surgery confirmed papillary carcinoma. (b)
Transverse US image of nodule containing cystic areas with punctate echogenicities
and comet-tail artifact consistent with colloid crystals in a benign nodule.
36

Role of color Doppler US. (a) Transverse gray-scale image of

Predominantly solid thyroid nodule (b) Addition of color Doppler modeshows
marked internal vascularity,indicating increased likelihood
that nodule is malignant. This was a papillary carcinoma.
37

Woman with history of papillary thyroid cancer - underwent thyroidectomy &

radioiodine ablation. Two years later, patient presented with thyroglobulin
level of 6.1 ng/mL (TSH suppressed) and negative findings on 131I WBS. 18FFDG PET (A) demonstrates small foci of increased 18F-FDG uptake
corresponding to small lymph nodes in right lower neck on CT (B). These are
clearly visualized on fused 18F-FDG PET/CT (C) and were subsequently proven
to be thyroid cancer metastases.

38

Follicular Carcinoma

5 -15% (2 variants-widely invasive and minimally

invasive)
WIDELY
Hematogenous
spread to
bone/lung/brain/liver
INVASIVE FORM
MINIMALLY
INVASIVE FORM
-Not well encapsulated
-Invasion of vessels and adjacent
thyroid is more easily
demonstrated.
-Metastasis is in 20-40% cases

-Well encapsulated
-No gross invasion seen. Only focal
histologic invasion noted.
-5-10% cases.

Sonography:Cant be differentiated from follicular

adenoma
So treatment for both is surgical excision.
Hypoechoic nodule with irregular tumor margins
Thick, irregular halo.
Tortuous or chaotic arrangement of internal
39
blood vessels on color doppler.

Heterogenous solid mass with peripheral and internal

flow follicular carcinoma

40

Medullary Carcinoma
only 5 % thyroid cancer.
Derived from parafollicular or C cells
secretes calcitonin.- useful serum marker.
Frequently familial and Associated with MEN II

syndrome.
Bilateral in 90% of familial cases.
High incidence of metastatic to lymphnodes.

Sonography
- Similar to papillary carcinoma-hypoechoic solid mass
with calcifications(often, but coarse than papillary
carcinoma).
-Local invasion and cervical lymphadenopathy are 41
also

Heterogenous nodule with

multiple punctate foci of
calcification within it
medullary carcinoma

Isoechoic nodule & punctate

echogenic foci within it
42

Longitudnal color and power doppler

intranodular hypervascularity

43

Anaplastic thyroid carcinoma

Occurs in elderly
< 5% tumors
worst prognosis
Presents as a rapidly enlarging mass extending beyond

gland and invading adjacent structures.

Show aggressive local invasion of muscle and vessels.

Sonography
Hypoechoic masses often seen to encase or invade
blood vessel and neck muscles(CT or MRI demonstrates
the tumor more accurately owing to their large size) .
44

Longitudnal scan solid hypoechoic mass extending into

the upper mediastinum anaplastic carcinoma

45

Aggressive thyroid cancer in left neck with spread to lungs

46

Lymphoma
4% of all thyroid malignancies.
Mostly non-Hodgkins type
Elder females
In 70-80% cases arises from pre-existing chronic

lymphocytic thyroiditis(HASHIMOTOS thyroiditis) with

subclinical or overt hypothyroidism.
Sonography
Markedly Hypoechoic lobulated mass .
Hypovascular or show blood vessels with chaotic
distribution and arteriovenous shunts.
Large areas of cystic necrosis may occur as well as
encasement of adjacent neck vessels.
Adjacent thyroid parenchyma heterogenous due to
associated chronic thyroiditis.
47

Nodule within a cystic lesion. No flow within the

nodule

48

Isotope scan of thyroid demonstrating a photopenic area within the left lobe.
Axial contrast enhanced CT of the same patient shows a solid mass within
left lobe of thyroid . Lymphoma was proven by biopsy.
49

Differentiation

Feature

Benign

malignant

Internal contents
Purely cystic
Cystic with thin septae
Mixed solid and cystic
Comet tail artifact

++++
++++
+++
+++

+
+
++
+

Echogenicity
Hyperechoic
Isoechoic
hypoechoic

++++
+++
+++

+
++
+++
50

Feature

Benign

malignant

Halo
Thin
Thick incomplete

++++
+

++
+++

Margin
Well defined
Poorly defined

+++
++

++
+++

Calcification
Eggshell
Coarse calcification
Microcalcification

++++
+++
++

+
+
++++
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Feature

Benign

malignant

Doppler
Peripheral flow
Internal flow

+++
++

++
+++

+ rare (<1%)
++ low probability (<15%)
+++ intermediate probability(16 to 84%)
++++ high probability (>85%)
52

Sagittal image of predominantly cystic Sagittal image of predominantly

nodule (calipers), which proved to be solid nodule , which proved to be
benign at cytologic examination.
benign at cytologic examination.
53

Transverse US images of mostly cystic thyroid nodule with a mural component containing
flow. (a) Gray-scale image shows predominantly cystic nodule with small solid-appearing
mural component (b) Addition of color Doppler mode demonstrates flow within mural
component , confirming that it is tissue and not debris. US-guided FNA can be directed
into this area. The lesion was benign at cytologic examination.

54

Peripheral coarse calcification

with acoustic shadowing
favours benign nature

Peripheral egg shell calcification

55

HYPERPLASTIC
NODULAR
Iso/hyperechoic
hypoechoic-honey
coomb
Thin peripheral halo
Peri & intranodular
vascula.

ADENOMA
Hyper/iso/hypoechoic
Thick peripheral halo
Spoke wheel
Appearance

LYMPHOMA

METS

Elder
NHL
Dyspnoea,Dysphagia
Hashimotos
thyroditis
Hypovascular/chaotic
vasc.

Homogenous
Hypoechoic
No calcification
Primary-Rcc/breast/
Melanoma

CARCINOMA
PAPILARY

FOLLICULAR

MEDULARY

ANAPLASTIC

3RD,7TH Decade
Psammoma bodies
Cervical LN
HYPERECHOIC
PUNCTATE
CALCIFICATION
Disorganised
hypervascularity
Cystic LN Mets

Hyperechoic
Thick irregular
halo
Tortous vessels
Hematogenous
spread
To
Bone/lung/
brain/liver

Famillial
MEN type-2
Calcitonnin
LN METS-HIGH
HYPOECHOIC
COARSE
CALCIFICA

Elder
Aggressive
Invasion=
muscles,vessels
Worst prognosis

56

Evaluation of nodules
incidentally detected by
sonography
Nodules<1.5cm : followed by palpation at

time of next physical examinaton

Nodules > 1.5cm : evaluation usually by FNA
Any nodule with malignant features like

microcalcifications, irregular margin , thick

halo , or internal flow: FNA

57

Biopsy guidance
INDICATIONS

Nonpalpable suspected nodule with inconclusive

physical examination.

Patients at high risk of developing thyroid cancer,

normal gland by physical examination but
sonography demonstrates a nodule.

Previous non diagnostic / inconclusive biopsy.

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DIFFUSE THYROID DISEASE

1.THYROIDITIS

CHRONIC AUTOIMMUNE
INVASIVE
ACUTE SUPPURATIVE
LYMPHOCYTIC THYROIDITS
FIBROUS
THYROIDITIS
HASHIMOTOS THYROIDITIS)
THYROIDITIS
SUBACUTE GRANULOMATOUS
SILENT/
THYROIDITIS
PAINLESS
(DE QUERVAINS DISEASE)
THYROIDITIS

2.ADENOMATOUS OR COLLOID GOIT

3. GRAVES DISEASE

Diffuse Thyroid disease

Characterised by Generalized enlargement of

gland and no palpable nodules.

Diagnosis is usually based on clinical and

laboratory finding and occasion by FNA.

Sonography helpful when underlying disease

causes asymmetric thyroid enlargement.

Sonographic diagnosis of diffuse thyroid disease

is made when isthmus may be up to 1 cm or

62
more thickness.

Diffuse enlargement of the

isthmus and both lobes

Diffuse enlargement heterogenous

gland with multiple nodules

63

ACUTE SUPPURATIVE THYRODITIS

Rare inflammatory disease caused by bacteria

affecting children.
Sonography useful in selected cases to detect
thyroid abscess-ill defined hypoechoic mass
with debris and/or septa and gas.

SUBACUTE GRANULOMATOUS THYROIDITIS(DE

QUERVAINS)
Spontaneously remitting inflammatory disease

probably caused by viral infection.

C/F :fever, enlargement of gland ,Tenderness

Sonography enlarged hypoechoic gland with
64

Ill defined hypoechoic area focal area of subacute thyroiditis

resolved after 4 wks of medical therapy

65

Sagittal sonogram of left lobe of thyroid shows solid,

predominately hyperechoic, poorly marginated nodule in lower pole
corresponding to palpable abnormality.Fine-needle aspiration of this lesion
was consistent with thyroiditis.Background of thyroid was
heterogeneous,with geographic regions of hypoechogenicity.
66

Chronic autoimmune lymphocytic

(Hashimotos) thyroiditis
As a painless diffuse enlargement of thyroid
often associated with hypothyroidism.
genetic tendency .
F:M 8 : 1 .Young woman are affected.
Lymphocytic infiltration of thyroid gland.
Sonography
Diffuse coarsened hypoechoic glandular

enlargement

67

Multiple discrete hypoechoic micronodules

of 1-6 mm size is strongly suggestive of chronic

thyroiditis.
Surrounded by multiple linear echogenic fibrous
septations- giving pseudo lobulated
appearance.
Normal or hypovascular.Occasionally

hypervascular .

Often Cervical lymphadenopathy may be

present.

68

Various appearances of Hashimotos disease

69

Nodule was predominantly hyperechoic, with both solid and cystic-appearing

Fine-needle aspiration of this 28 mm palpable nodule was consistent with
lymphocytic thyroiditis.
70

Sagittal sonogram of right lobe obtained at time of diagnosis of left-sided thyroid

carcinoma shows 11-mm hypoechoic solid nodule with ill-defined margins
(delineated by electronic calipers) in upper pole of right lobe. Sonographically
guided fine-needle aspiration of this nodule and surgical pathology findings were
consistent with lymphocytic thyroiditis.

71

Painless thyroiditis
Thyroid enlargement in early phase followed by

hypothyroidism.
Clinical findings are similar to subacute thyroiditis
Histologic and sonographic pattern of chronic
autoimmune thyroiditis.

72

Graves disease
Diffuse abnormality of thyroid gland with

associated thyrotoxicosis

Sonography
Diffusely hypoechoic or inhomogenous texture
Color Doppler shows hypervascular pattern

known as thyroid inferno.

Spectral Doppler shows peak velocities

exceeding 70cm/sec.

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74

Graves disease diffuse hypervascularity and

peak systolic velocity of 80cm\sec

75

Pinhole images from a Tc-99m pertechnetate thyroid exam

demonstrate diffuse thyroid enlargement with decreased background
activity.
76

Invasive fibrous thyroiditis

(Riedels struma)
Female
Tends to progress to complete destruction
USG
Diffusely enlarged thyroid gland
Inhomogenous parenchymal echo texture
May have associated mediastinal or retroperitoneal
fibrosis or sclerosing cholangitis.
D/D : From Anaplastic thyroid carcinoma.by biopsy.
77

Role of CT and MRI in thyroid disorders

To demonstrate- Extent of local invasion

- regional LN metastasis
To determine recurrence following Surgery.
Detection of retrosternal & retrotracheal

extension of the thyroid enlargement.

Confirm the location of mass within the gland,

evaluating nodal disease and assessing the

airway.
78

CT signs suggesting the thyroid origin of mediastinal

mass include
Intimate association of the superior pole of mass

with thyroid gland & close proximity to the trachea.

Hyperdensity of lesion compared to surrounding

tissue.

Presence of calcification.
Persistent enhancement of the mass.
79

Differentiation of benign and malignant

primary thyroid masses is impossible on

imaging, although the associated
lymphadenopathy, vocal cord paralysis and
bone or cartilage invasion obviously suggests
malignancy.
MRI helps to differentiate scar from residual

or recurrent tumor.
Tumor - hypointense to isointense on T1WI

iso to hyperintense on T2WI

scar - hypointense on both T1 and T2WI.
80

81

GOITER -Enhancing
heterogenous soft tissue
mass orignated in thyroid and
causing deviation of the
trachea

Large heterogenous soft tissue

mass replacing the thyroid with
speck of calcification,causing
deviation of the trachea
medullary carci.

82

Cystic metastasis from thyroid

carcinoma

83

Role of radionuclide thyroid scintigraphy

To determine functional status of the nodules.
Nodules may be cold, warm or hot depending

on the uptake of tracer as compared to the

normal thyroid tissue.
Thyroid nodules concentrate less radioiodine

(only 1%) than normal thyroid tissue hence

appear cold.
Most cold nodules are adenomas, colloid
nodules or foci of thyroiditis or rarely
intrathyroid lymphnodes, lymphoma or
metastases.
84

Approximately 10 to 20 % of cold solitary

thyroid nodules are malignant.

Cold nodules further require FNAC or biopsy.
The demonstration of hot nodule on

scintigraphy is not synonymous with autonomy,

as it often represents spared focus of normal
thyroid tissue in gland otherwise involved in
destructive process.
The more important role is of 131 I whole body

scintigraphy to identify most functioning

metastases, usually in the neck, lungs or bone,
following total thyroidectomy.
85

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 TYPES

HASHIMOTOS
THYROIDITIS

USG

HYPOECHOIC
COARSENED
MICRONODULATION

RADIOACTIVE IODINE
UPTAKE

VARIABLE

SUBACUTE
GRANULOMATOUS

HYPOECHOIC
N/HYPOVASCULAR

GRAVES DISEASE

INHOMOGENOUS
HYPERVASCULAR

INCREASED

INHOMOGENOUS
EXTRATHYROID INFLAMMATION
VESSEL ENCASEMENT

VARIABLE

INVASIVE FIBROUS

DECREASED

87

MCQs

88

1. GIVE THE DIAGNOSIS

89

2. Egg cell calcifications

are more common in
which type of tumor?

90

3.Which type of carcinoma has such appearance ?

91

4. GIVE THE DIAGNOSIS

92

5.GIVE THE DIAGNOSIS

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THANK YOU
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