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Ultrasound Features of Thyroid Nodules
Stephanie A. Fish, MD
Memorial Sloan Kettering Cancer CenterNew York, NY
Disclosure of Relevant Financial Relationships
The USCAP requires that anyone in a position to influence or control the content of all CME activities disclose any relevant relationship(s) which they or their spouse/partner have, or have had within the past 12 months with a commercial interest(s) [or the products or services of a commercial interest] that relate to the content of this
educational activity and create a conflict of interest. Complete disclosure information is maintained in the USCAP office and has been reviewed by the CME Advisory Committee.
Dr. Stephanie Fish declares she has no conflict(s) of interest to disclose.
Thyroid nodules are common
Thyroid nodules are common
PalpationN Engl J Med 1993 328:553Autopsy & US
Differential Diagnosis of Thyroid Nodules
• MALIGNANT (5‐10%)–Papillary (75%), follicular (15%), medullary (5%), lymphoma, anaplastic, mets to thyroid
• BENIGN (90%)–Colloid or adenomatous nodules, follicular/Hurthle cell adenomas, lymphocytic thyroiditis
Thyroid Cancer
>5.0cm
2.1-5.0cm
Thyroid Cancer
0-1.0cm
1.1-2.0cm
Davies, JAMA 2006295:2164
Ultrasound
Ultrasound: Normal thyroid
trachea
esophagus
carotidcarotid
jugularjugular
isthmus
strap muscles strap musclesSCMSCM
longus collilongus colli
Why is a diagnostic US necessary?• Confirmation of a nodule corresponding to the palpable abnormality
– 16% no corresponding nodule on US1,2,3
• Detection of additional nonpalpable nodules for which FNA may be indicated
– 15% additional nonpalpable nodule>1cm1,3
• Identification of sonographic features of the thyroid nodule(s) for FNA selection
• Location and consistency (solid/cystic) of nodule that will determine feasibility of FNA by palpation
• Determination of baseline size• Evaluate cervical lymph nodes1Marqusee, Ann Intern Med 2000; 2Brander, J Clin Ultrasound 1992; 3Tan, Arch Intern Med 1995; Mandel, Endocr Pract2004
Palpable left thyroid nodule
trachea
4mm
Nonpalpable 1.5 cm nodule
trachea
1.9cm
0
5
10
15
20
25
30
35
< 1cm 1‐2cm >2cm
# Nod
ules fo
und by
US
Nodule size by US
Nodules MISSED by palpation
Nodules FOUND by palpation
What nodules can’t we feel?Ultrasound vs. Palpation
94%
50%
42%
Brander, J Clin Ultrasound 1992
Diagnostic thyroid ultrasound
ATA Guidelines 2009; AACE/AME/ETA Guidelines 2010
Risk Stratification
US characteristics of thyroid nodules1. Echogenicity (hypo‐*, hyper‐, iso‐)2. Calcifications (micro‐*, dense)3. Margins (infiltrative*, well‐defined regular)4. Vascularity (intranodular*, peripheral, absent)5. Shape (taller than wide*, round)
*associated with thyroid cancer
Brkljacic J Clin Ultrasound 1994; Takashima J Clin Ultrasound 1994; Rago Euro J Endorinol 1998; Cerbone Horm Res 1999; Leenhardt J Clin Endocrinol Metab 1999; Kim AJR 2002; Papini J Clin Endocrinol Metab 2002; Cappelli Clin Endocrinol 2006; Frates J Clin Endocrinol Metab 2006
Transverse
Sagittal
Hypoechoic nodule
Markedly hypoechoic nodule1
[sensitivity 27%, specificity 94%]
Isoechoic nodule
1Kim et al, AJR 2002
Echogenicity
Hyperplastic nodule
Microcalcifications• multiple bright (< 1 mm) echoes without shadowing usually in a HYPOechoic nodule
• pitfall: colloid with reverberation artifact (“comet tail”) in a hyperplastic nodule1
1Ahuja J Clin Ultrasound 1996
Coarse calcifications
• Larger than 1mm• Coarse calcifications common in lymphocytic thyroiditis
secondary to dystrophic calcifications • Present in PARENCHYMA WITHOUT associated nodule
Khoo ML, Arch Oto Head Neck Surg 2002; Bonavita AJR 2009
• Concerning for malignancy if mixed with microcalcifications or present in a SOLID nodule
Peripheral calcification
Complete, regular or “eggshell”
InterruptedPapillary cancer
Follicular cancerUsually benign Nam‐Goong Thyroid 2003; Lee J Ultrasound Med 2009
Infiltrative margins
Sagittal
microcalcifications
microlobulated border
Patterns of nodular flowsagittal
intranodular vascularity
sagittal
peripheral vascularity
• Nodule is taller than wide on the transverse view—AP > transverse
Nodule Shape
Kim AJR 2002; Cappelli Clin Endocrinol 2005; Moon Radiology 2008
CA
trachea2.5cm1.6cm
INDIVIDUAL analysis of US predictors
Sensitivity SpecificityMicrocalcifications 44% 89%Hypoechoic 81% 53%Solid 86% 18%Absence of halo 66% 54%Intranodular vascularity 62% 77%Poorly defined margins 55% 79%Tall versus Wide 48% 92%
Brkljacic J Clin Ultrasound 1994; Takashima J Clin Ultrasound 1994; Rago Euro J Endorinol 1998; Cerbone Horm Res 1999; Leenhardt J Clin Endocrinol Metab 1999; Kim AJR 2002; Papini J Clin Endocrinol Metab 2002; Nam-GoongThyroid 2003; Cappelli Clin Endocrinol 2005; Frates, J Clin Endocrinol Metab 2006; Kovacevic, J Clin Ultrasound 2007; Moon Radiology 2008; Bonavita AJR 2009; Ahn AJR 2010; Cap Clin Endocrinol 1999
The “suspicious” sonographic appearance has HIGH specificity but
LOW sensitivity
But, for a diagnostic test, you want HIGH sensitivity!!
FNA sensitivity 92% specificity 84%
Diagnostic Thyroid Ultrasound
What to FNA???
Risk stratification by sonographic PATTERNS
MicrocalcificationsIrregular borderTaller>wide shape
Hypoechoic, solid
Iso/hyperechoic,solidPartially cystic, w/eccentric solid area
Mixed cystic/SolidSpongiform
Purecyst
Metastatic LNsExtrathyroidalinvasion
LOW HIGH
Updated ATA GuidelinesSonographic Pattern US features Estimated risk of
malignancyConsiderbiopsy
High suspicion Solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with one or more of the following features: irregular margins (infiltrative, microlobulated), microcalcifications, taller than wide shape, rim calcification with small extrusive soft tissue component, evidence of extrathyroidal extension.
>70‐90% >1cm
Intermediate suspicious Hypoechoic solid nodule with smooth margins without microcalcifications, extrathyroidal extension, or taller than wide shape
10‐20% >1cm
Low suspicion Isoechoic or hyperechoic solid nodule, or partially cystic nodule with eccentric solid areas, without microcalcifications, irregular margin or extrathyroidal extension, or taller than wide shape
5‐10% >1.5cm
Very low suspicion Spongiform or partially cystic nodules without any of the sonographic features described in low, intermediate or high suspicious patterns
<3% >2cm
Benign Purely cystic nodule (no solid component) <1% No biopsy
HIGH Suspicion >80‐90%
microCa2+
extrathyroidal extension
Irregular margin
Papillary carcinoma
HIGH Suspicion >80‐90%Hypoechoic, solid
HIGH Suspicion >80‐90%
CA
Sagittal Left lobe Transverse left lateral neck
HIGH Suspicion >80‐90%
Papillary carcinoma
capsular invasion, infiltrative margins, microcalcifications
INTERMEDIATE Suspicion 10‐20%: Hypoechoic nodules, regular smooth margins
• Most papillary cancers (>80%) are hypoechoic• However, since benign nodules are much more common, most hypoechoic
nodules are benign!
Benign hyperplastic nodulePapillary carcinoma
INTERMEDIATE Suspicion 10‐20%: Hypoechoic nodules, regular smooth margins
LOW Suspicion: 5‐10%Iso‐ to hyperechoic nodules with regular margins
Papillary thyroid CA Benign Hürthle cell adenoma
Follicular thyroid cancer
20‐30% of all cancers are Iso/hyperechoic: predominantly follicular/ Hürthle/PTC follicular variant
Hyperplastic noduleHyperplastic nodule
LOW Suspicion: 5‐10%Iso‐ to hyperechoic nodules with regular margins
VERY LOW Suspicion <3%: “Spongiform”
Transverse Sagittal
peripheral vascularityMoon, Radiology 2008; 247:762‐770, Bonavita AJR 2009 193:207‐13.
Only 1 of 360 cancers had this appearance specificity 99.7%
Moon
VERY LOW Suspicion <3%: “Spongiform”
Frates, J Clin Endocrinol Metab 2006
Benign cystComet tailartifact
BENIGN <1%:Pure cystic nodule
Updated ATA GuidelinesSonographic Pattern US features Estimated risk of
malignancyConsiderbiopsy
High suspicion Solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with one or more of the following features: irregular margins (infiltrative, microlobulated), microcalcifications, taller than wide shape, rim calcification with small extrusive soft tissue component, evidence of extrathyroidal extension.
>70‐90% >1cm
Intermediate suspicious Hypoechoic solid nodule with smooth margins without microcalcifications, extrathyroidal extension, or taller than wide shape
10‐20% >1cm
Low suspicion Isoechoic or hyperechoic solid nodule, or partially cystic nodule with eccentric solid areas, without microcalcifications, irregular margin or extrathyroidal extension, or taller than wide shape
5‐10% >1.5cm
Very low suspicion Spongiform or partially cystic nodules without any of the sonographic features described in low, intermediate or high suspicious patterns
<3% >2cm
Benign Purely cystic nodule (no solid component) <1% No biopsy
Ultrasound Elastography• Provides an objective measure of tissue stiffness
Strain elastographyShear wave elastography
Jin Young Kwak, et al. Ultrasonography 2014
Ultrasound ElastographyLimitations:• Can only be applied to solid
nodules• Index nodule must not overlap
with other nodules in the anterioposterior plane
– Obese patients– multinodular goiters and coalescent
nodules– patients in whom the nodule is
posterior or inferior
• Thus, while USE holds promise as a non‐invasive method to assess cancer risk, its performance is highly variable and operator dependent
Jin Young Kwak, et al. Ultrasonography 2014
Thanks to Susan Mandel, MD Jill Langer, MD
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