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

ThyroidTrachea

Oesophagus

Cervical Vertebra

C-6

CCA

Int Jug vein

Sternocleidomastoid

Sternohyoid

Sternothyroid

Longus coli

Scalenus anterior

Surroundings

Surroundings

Thyroid

Trachea

Oesophagus

Cervical Vertebra

C-6

CCA Int Jug vein

Sternocleidomastoid

Sternohyoid

Sternothyroid

Longus coliScalenus 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

4-6 cm

<1.8cm

<1.8cm

<1.8cm

<0.6cm

Size

4-6 cm

Volume; 7-14 ml. Calculate for

each lobe and add

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

Aplio

Nemio

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

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

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;

27:847–865

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 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 Hypoechoic

o Microcalcification

o 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 Hypoechoic

o Vascular

o Minimally

irregular

o Reverberating

echogenicities

Image courtesy Dr. Ravi Kadasne, Al Ain. UAE

Via 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 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 Hashimoto’s 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?

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

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

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 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%

Pattern

Pattern 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.

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; 193:207–213.

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; 193:207–213.

What then for nodules?

Thyroid vs. extra-thyroidal Yes

Recurrent disease Yes

Guiding procedures Yes

Biopsy vs. observe ?Yes

Benign ?Yes

Malignant ?

Diffuse Thyroid Disease

o Hyperplasia

o Thyroiditis

o Graves disease

o 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)

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

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