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IMAGING OF THYROID CANCER
-DrAJoseph Stalin(MCh PG)
PROF RR UNITCENTRE FOR ONCOLOGY
GOVT ROYAPETTAH HOSPITALCHENNAI
An image is not simply a trademark a design a slogan or an easily remembered picture It is a studiously crafted
personality profile of an individual institution corporation product or service
The paradox of reality is that no image is as compelling as the one
which exists only in the minds eye
CONTENT
Role of Imaging in
bull AEvaluation of Thyroid nodule
bull BPreop evaluation
bull CFollowupSurveillance
bull DTherapeutic purpose
Imaging features in common malignancy
Recent advances
IMAGING MODALITIES
bull X RAY
bull USG
bull RADIONUCLEOTIDE IMAGING
bull CT
bull MRI
bull PET
AEvaluation of Thyroid nodule
bull Clinically palpable nodule 4-7 of general population
bull USG 70 of adult population
bull CTMRI Incidentaloma- 145
bull 9-13 incidence of malignancy in thyroid nodule
Evaluation of thyroid nodule
Clinical examination
Imaging
Pathology
History
Imaging
bull USG ( High resolution)
bull I -123 SCINTIGRAPHY (Low TSH)
Diagnostic thyroid USG
bull Should be performed in all patients with thyroid nodule
bull High resolution USG ndash most sensitive test to detect thyroid lesion
bull During USG- Look for coincidental nodules
Select a nodule for FNA
Look for nodes in neck
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
An image is not simply a trademark a design a slogan or an easily remembered picture It is a studiously crafted
personality profile of an individual institution corporation product or service
The paradox of reality is that no image is as compelling as the one
which exists only in the minds eye
CONTENT
Role of Imaging in
bull AEvaluation of Thyroid nodule
bull BPreop evaluation
bull CFollowupSurveillance
bull DTherapeutic purpose
Imaging features in common malignancy
Recent advances
IMAGING MODALITIES
bull X RAY
bull USG
bull RADIONUCLEOTIDE IMAGING
bull CT
bull MRI
bull PET
AEvaluation of Thyroid nodule
bull Clinically palpable nodule 4-7 of general population
bull USG 70 of adult population
bull CTMRI Incidentaloma- 145
bull 9-13 incidence of malignancy in thyroid nodule
Evaluation of thyroid nodule
Clinical examination
Imaging
Pathology
History
Imaging
bull USG ( High resolution)
bull I -123 SCINTIGRAPHY (Low TSH)
Diagnostic thyroid USG
bull Should be performed in all patients with thyroid nodule
bull High resolution USG ndash most sensitive test to detect thyroid lesion
bull During USG- Look for coincidental nodules
Select a nodule for FNA
Look for nodes in neck
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
CONTENT
Role of Imaging in
bull AEvaluation of Thyroid nodule
bull BPreop evaluation
bull CFollowupSurveillance
bull DTherapeutic purpose
Imaging features in common malignancy
Recent advances
IMAGING MODALITIES
bull X RAY
bull USG
bull RADIONUCLEOTIDE IMAGING
bull CT
bull MRI
bull PET
AEvaluation of Thyroid nodule
bull Clinically palpable nodule 4-7 of general population
bull USG 70 of adult population
bull CTMRI Incidentaloma- 145
bull 9-13 incidence of malignancy in thyroid nodule
Evaluation of thyroid nodule
Clinical examination
Imaging
Pathology
History
Imaging
bull USG ( High resolution)
bull I -123 SCINTIGRAPHY (Low TSH)
Diagnostic thyroid USG
bull Should be performed in all patients with thyroid nodule
bull High resolution USG ndash most sensitive test to detect thyroid lesion
bull During USG- Look for coincidental nodules
Select a nodule for FNA
Look for nodes in neck
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
IMAGING MODALITIES
bull X RAY
bull USG
bull RADIONUCLEOTIDE IMAGING
bull CT
bull MRI
bull PET
AEvaluation of Thyroid nodule
bull Clinically palpable nodule 4-7 of general population
bull USG 70 of adult population
bull CTMRI Incidentaloma- 145
bull 9-13 incidence of malignancy in thyroid nodule
Evaluation of thyroid nodule
Clinical examination
Imaging
Pathology
History
Imaging
bull USG ( High resolution)
bull I -123 SCINTIGRAPHY (Low TSH)
Diagnostic thyroid USG
bull Should be performed in all patients with thyroid nodule
bull High resolution USG ndash most sensitive test to detect thyroid lesion
bull During USG- Look for coincidental nodules
Select a nodule for FNA
Look for nodes in neck
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
AEvaluation of Thyroid nodule
bull Clinically palpable nodule 4-7 of general population
bull USG 70 of adult population
bull CTMRI Incidentaloma- 145
bull 9-13 incidence of malignancy in thyroid nodule
Evaluation of thyroid nodule
Clinical examination
Imaging
Pathology
History
Imaging
bull USG ( High resolution)
bull I -123 SCINTIGRAPHY (Low TSH)
Diagnostic thyroid USG
bull Should be performed in all patients with thyroid nodule
bull High resolution USG ndash most sensitive test to detect thyroid lesion
bull During USG- Look for coincidental nodules
Select a nodule for FNA
Look for nodes in neck
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Evaluation of thyroid nodule
Clinical examination
Imaging
Pathology
History
Imaging
bull USG ( High resolution)
bull I -123 SCINTIGRAPHY (Low TSH)
Diagnostic thyroid USG
bull Should be performed in all patients with thyroid nodule
bull High resolution USG ndash most sensitive test to detect thyroid lesion
bull During USG- Look for coincidental nodules
Select a nodule for FNA
Look for nodes in neck
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Imaging
bull USG ( High resolution)
bull I -123 SCINTIGRAPHY (Low TSH)
Diagnostic thyroid USG
bull Should be performed in all patients with thyroid nodule
bull High resolution USG ndash most sensitive test to detect thyroid lesion
bull During USG- Look for coincidental nodules
Select a nodule for FNA
Look for nodes in neck
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Diagnostic thyroid USG
bull Should be performed in all patients with thyroid nodule
bull High resolution USG ndash most sensitive test to detect thyroid lesion
bull During USG- Look for coincidental nodules
Select a nodule for FNA
Look for nodes in neck
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Thyroid US answers following questions
bull Whether Nodule corresponds palpable lesion
bull Cystic or solid
bull How large
bull Benign or suspicious
bull Any other nodule in gland
bull Any suspicious cervical node
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
MNG
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
USG- Features of malignancy
bull Finding ndash Hypoechogenecity
ndash An absent halo
ndash Irregular margins
ndash Taller than wide shape
ndash Presence of micro-calcifications
ndash Increased intranodular vasculariry
ndash Extrathyroidal extension
ndash Nodal disease in neck
bull No findings are definitive
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
ADENOMA
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Thyroid USG
Normal thyroid Papillary Ca Thyroid
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Indication for USG guided FNA
1 Non-palpable nodule
2 Predominantly cystic nodule
3 Posteriorly located nodule
4 Repeating FNA for non-diagnostic nodule
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Palpation-guided versus US-guided FNA Cytology of thyroid nodules
bull Diagnostic accuracy - P-FNA 60 and US-FNA - 80
bull Inadequate specimen rate - 112 in the P-FNA group 71 in the US-FNA group
bull Sensitivity positive predictive value and negative predictive value increased significantly with ultrasound guidance
Izquiero R Endocr Pract 2006 Nov-Dec12(6)609-14
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Pitfalls of USG
bull Retrosternal extension
bull Paratracheal tissues
bull Extrathyroidal extension
bull Retropharyngealparaesophageal nodes
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
THYROID SCINTIGRAPHY
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Differential Diagnosis
COLD NODULE(8-25 chance of
malignancy)
bull Thyroiditisbull Fibrosisbull Cystbull Non-functioning
Adenomabull Multinodular Goiterbull Malignancy
HOT NODULE(malignancy rare)
bull Funcioning Adenomabull Thyroiditis
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
BPRE OP EVALUATION
bull To determine extend of primary tumour
bull To evaluate regional nodal metastasis
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Extension of primary tumour
bull Spread outside thyroid capsule- strap and sternomastoid muscle involvement
bull Spread to laryngx or trachea
bull Esophageal invasion
bull Vascular invasion
bull Spread to prevertebral muscles or bone
bull Mediastinal extension
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
TRACHEAL INVASION
bull Atleast one of follwing CT criteria fulfilled
bull Tumor in contact with 180deg or more of the tracheal circumference (grades 3 and 4)
bull Deformity of the tracheal lumen at the level of the mass
bull Focal irregularity thickening or bulging in the mucosal portion adjacent to the mass
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
ESOPHAGEAL INVOLVEMENT
At least one of the following CT criteria were fulfilled
bull Tumor in contact with 180deg or more of the esophageal circumference (grades 3 and 4)
bull Loss of the normal esophageal structures (wall and lumen)
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
CAROTID VESSEL ENCASEMENT
bull Invasion of the CCA or IJV was diagnosed if the tumor was in contact with 180deg or more of the circumference of the vessel (grades 3 and 4)
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Recurrent laryngeal nerve involvement
At least two of the following three criteria were fulfilled
bull completely effaced fatty tissue in tracheoesophagealgroove
bull More than 25 of the circumference of the tumor abutted the capsule at the posterior portions of the thyroid (posterior extracapsular invasion)
bull Ipsilateral vocal cord palsy was present on the basis of CT findings such as paramedian cord anteromedialdeviation of the arytenoid cartilage enlarged pyriformsinus or enlarged laryngeal ventricle
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Recurrant laryngeal nerve involvement
bull CT scan obtained at level of vocal cords shows
bull Anteromedial deviation of arytenoid cartilage (short arrow)
bull Enlarged pyriform sinus (long arrow)
bull Enlarged laryngeal ventricle (arrowhead) on left side
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
bull Mass replacing entire right thyroid lobe isthmus and medial portion of left lobe (arrows)
bull Tumor surrounds ge 180deg of circumference of trachea and esophagus and completely encircles right common carotid artery (arrowhead)
bull Right internal jugular vein has been obliterated
bull Posterior tumor extension and completely effaced fatty tissue in right tracheoesophageal groove indicate tumor invasion of recurrent laryngeal nerve
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
bull Contrast-enhanced CT scan shows large heterogeneous mass (short arrows) in left lobe and isthmus of thyroid
bull Tumor is in contact with ge 180deg of circumference of trachea Focal bulging in mucosal portion of trachea (long arrow) suggests direct tumor invasion into tracheal lumen
bull Tumor encroaches esophagus (arrowheads) but surrounds lt 180degof circumference of esophagus
bull Posterior tumor extension and completely effaced fatty tissue are evident in left tracheoesophagealgroove
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
LIMITATION WITH IMAGING
Limitation circumferential invasion is often underestimated
Involvement is more when assessed pathologically
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
X RAY
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
USG
bull It is the primaryonly modality of imaging needed in
bull -isolated thyroid mass
bull - no palpable lymphadenopathy
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Thyroid USG
Normal thyroid Papillary Ca Thyroid
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
INDICATION FOR CTMRI
bull Fixed immobile thyroid mass
bull Palpable lymphadenopathy
bull Hoarseness dysphagia dyspnoea
bull Retrosternal extension
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
CT
bull More sensitive specific than USGampMRI in detecting nodal mets
bull Contrast interferes with iodine uptake
bull The mean sensitivity specificity and accuracy of CT were as follows 591 914 and 832 for tracheal invasion 286 962 and 907 for esophageal invasion 750 994 and 988 for invasion of the common carotid artery 333 988 and 971 for invasion of the internal jugular vein and 782 898 and 855 for invasion to the recurrent laryngeal nerve (AJR Am J Roentgenol2010
Locally advanced thyroid cancer can CT help in prediction of extrathyroidal invasion to adjacent structures
Seo YL Yoon DY Lim KJ Cha JH Yun EJ Choi CS Bae S )
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Non thyroidal causes of decreased radioiodine uptake
Contrast media Water soluable 2- 4 wksFat soluble(lymphangiography) months- year
Thyroid hormone
Iodinated drugsfoods
Heart failure Renal failure
Prior irradiation
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Interference for radioiodine uptake
bull 1 mg of stable iodine can cause significant reduction of the 24 hr radioiodine uptake
bull 10 mg can effectively block the gland with 98 reduction uptake
bull Iohexol contains 350mg of iodine
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
CECT BETTER AVOIDED IF POSTOP IODINE ABLATION
THERAPY IS PLANNED
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
MRI
bull Mainly for detecting extrathyroidal invasion
bull Paratracheal retrosternal extension and nodes in deep spaces of neck are well defined
bull Advantage over CT
- No interference with iodine uptake
- Better tissue contrast
- Multiplane evaluation
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
MRI
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
CFOLLOWUPSURVEILLANCE
bull THYROGLOBULIN USG
bull Yearly USGNeck recommended even if thyroglobulin is normal
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Elevated Thyroglobulin
bull USG NECK
bull I 131 WHOLE BODY SCAN
bull MRI- NECK
bull If everything negative then
PETCT
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
DTherapeutic Purpose
bull USG guided cyst aspirationsclerosing
bull I 131 radionucleotide ablation
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
PAP CA
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
MEDULLARY CA
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
ANAPLASTIC CARCINOMA
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
RECENT ADVANCES
bull ELASTOGRAPHY
bull OPTICAL COHERENCE TOMOGRAPHYMICROSCOPY
bull MR SPECTROSCOPY
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
ELASTOGRAPHY
bull Elastography could be considered as an ldquoimaging palpation rdquohellip technique to measure the stiffness of tissues
bull USG elastography (SE) differentiates between benign and malignant lesions on the basis of their elasticity
bull Benign lesions have an elasticity similar to the surrounding tissue while malignant lesions are harder than adjacent tissue
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
4 -1 Agar-
Gelatin Elastic
phantom
~ 100 micros
Step 1 Volumetric force
creation using
ultrasound beam focus
1D Cross-correlation
Step 3 Image
acquisition and
processingUltrasound beam
US
images
Uz(xt)
Step 2 Ultra fast imaging
of the displacement
generated by ultrasounds
Texp=20 ms~ 03 ms
Acquisition time lt 30 ms
Courtesy of Dr Anne Tardivon - Institut Curie - Paris
SuperSonic Elastography
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Table 1
Diagnostic performance of conventional US and a combination of conventional US and elastography for diagnosing thyroid malignancy according to the type of elastography
US USE US USE US USE US USE US USE
Trimboli et al [25] 2012 198 SE 850 970 540 340 620 500 380 330 910 970
Ragazzoni et al [26] 2012 132 SE 700 850 924 837 856 841 800 694 876 928
Cappelli et al [27] 2012 159 SE 800 ND 750 708 754 736 250 263 972 100
Moon et al [19] 2012 703 SE 917 922 667 650 744 734 551 541 947 949
Unluturk et al [28] 2012 237 SE 690 410 850 930 810 810 600 670 890 830
Veyrieres et al [21] 2012 297 SWE 771 971 580 553 ND ND 197 225 950 993
Shweel et al [23] 2013 66 SE 920 954 729 948 601 952 950 823 631 988
Russ et al [24] 2013 4550 SE 957 985 610 447 620 483 ND ND 997 998
Kim et al [14] 2013 99 SWE 905 500 597 800 670 786 ND ND ND ND
Accuracy () PPV () NPV ()
US conventional ultrasonography PPV positive predictive value NPV negative predictive value USE combination of conventional ultrasonography and elastography SE strain
elastography SWE shear wave elastography ND not determined
Reference Publication year Case number TypeSensitivity () Specificity ()
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
OPTICAL COHERENCE TOMOGRAPHY
bull Optical coherence tomography (OCT) allows tissue histologic-like evaluation but without tissue fixation or staining
bull Noncontact non invasive microresolutionstudy of tissues based on principle of Michelson interferometry
bull OCM (Microscopy)is an extension of OCT and provides high magnification resulting in cellular imaging
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
bull Optical coherence tomography imaging during thyroid and parathyroid surgery a novel system of tissue identification and differentiation to obviate tissue resection and frozen section
bull Conti de Freitas LC1 Phelan E Liu L Gardecki J Namati E WargerWC Tearney GJ Randolph GW
bull This pilot study demonstrated that new-generation OCT systems are capable of recognizing and differentiating neck tissues encountered during thyroid and parathyroid surgeries
bull Further advances in OCT miniaturization and development of sterile intraoperative probe formats may allow OCT to offer an intraoperativeoptical biopsy without fixation staining or tissue resection
bull Copyright copy 2013 Wiley Periodicals Inc
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
MR SPECTROSCOPY
bull MR spectroscopy is a sensitive method in differentiating thyroid carcinoma from benign follicular lesion
bull Choline peak is identified in almost all carcinomas with raised cholinecreatine ratio ranging from 16 in well differentiated carcinoma to 94 in anaplastic carcinoma
bull The normal thyroid tissue and benign follicular lesions generally demonstrate no choline peak
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
Take Home Message
bull High resolution USG neck suffice for evaluation of thyroid nodule intrathyroidalmalignancy
bull CECT better avoided if ablation therapy planned
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
ThyroidhellipOde To the Thyroid
bull
The thyroid is such a funny thing wrapped inside your neckIrsquom strong Irsquom tough Irsquom young and bold so thyroidhellipwhat the heckIt wonrsquot stop me from doing well and living life in fullItrsquos such a tiny little thing who said it had to rule
I donrsquot see why I feel so cold my fingers hurt like madI donrsquot see why I feel fatigue why is it so so badWhy is that I fall asleep at every given chanceThe muscle cramps the tired legs the sickly looking stance
I would get help for all these things but my memory lets me downI m going mad itrsquos just not fair I forgot the way to townMy minds a fuzz my hair is thin my nails a breaking fastThe lack of hair around my eyes gives everyone a laugh
bull Please doctor can you help me now as I really feel so sadYou call me in and look away you think Irsquom going madThe test are taken all sent off now its time to waitAt last there is a reason something I can hate
bull And hate you very much I do for months of grief and strifeFor all the days you made me bad to both my kids and wifeYou will not win this battle now as I have all the factsBut hell itrsquos hard to fight this thing and get myself on track
So all of you both young and old take heed and listen goodYou canrsquot ignore your bodyrsquos voice even if you couldOh so fast things slow down you donrsquot see what it isYour thyroids got you by your throat yes you Not mine not his
bull -------Jack frost
bull THANK YOU
