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Evaluasi Stase USG 4

THYROID ULTRASOUND

Mellissa

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INSTRUMENTATION & TECHNIQUE
• High frequency transducers (7.5 – 15MHz)
• Provide deep US penetration (up to 5 cm) &
high-definition images
• Supine position, neck extended
• Small pad may be placed under the shoulders
 provide better exposure of the neck

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• Scan in transverse & longitudinal planes,
isthmus
• Extended laterally to include the region of the
carotid artery & jugular vein to identify jugular
chain LN, superiorly to visualize
submandibular adenopathy & inferiorly to
define pathologic supraclavicular LN

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ANATOMY
• Anteroinferior part of the neck, in space
outlined by muscle, trachea, esophagus,
carotid arteries, and jugular veins
• 2 lobes, at either side of trachea, connected
across the midline by isthmus
• 10-40% patient : pyramidal lobe arising
superiorly from the isthmus

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ANATOMY
• Size & shape varies widely in normal patient
• Newborn : 18-20 mm x 8-9 mm
• 1 year : 25 mm x 12-15 mm
• Adults : 40-60 mm x 13-18 mm
• Mean isthmus thickness : 4-6 mm
•  AP > 2 cm  may be considered enlarged
• Mean thyroid volume males : 19.6 + 4.7 ml,
female 17.5 + 4.2 ml

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Normal dimensions:
length 40–70 mm, width 10–30 mm, depth 10–20mm
(per lobe).
The isthmus is < 5mm in width.
• Total volume: < 25mL in men, < 20mL in women
• Volumetry: length x width x depth x 0.5 for each
thyroid lobe

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ANATOMY
• Normal thyroid parenchyma : homogenous,
medium-high level echogenicity
• Capsule  thin hyperechoic line that bounds
the thyroid lobes
• Vascularity : superior & inferior thyroid artery
& vein
• Esophagus : midline structure may be found
laterally on the left side, “bulls-eye”

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ULTRASOUND FEATURES OF THYROID NODULES
• MULTINODULARITY : Multiple nodules does
not indicate benignity
• SOLID / CYSTIC
• COMET TAIL SIGN : specific sign of benignity
• ECHOGENICITY
• MARGINS
• CALCIFICATION
• COLOUR FLOW IMAGING

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3 general patterns of vascular
distribution :
• Type I : complete absence of flow signal within
the nodule
• Type II : exclusive perinodular arterial flow signals
• Type III : intranodular flow with multiple vascular
poles chaotically arranged, with or without
significant perinodular flow

Type III pattern is generally associated with


malignant nodules, whereas type I & II are seen in
benign hyperplastic nodules
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Examination of Adjacent Structures
• CCA & IJV : thrombus  malignant
• SPREAD to ADJACENT STRUCTURE :
extrathyroid spread (strap muscle, trachea,
oesophagus, recurrent laryengal nerve) 
malignant nature
• CERVICAL LYMPHADENOPATHY

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CONGENITAL THYROID ABNORMALITIES
• Agenesis : 1 lobe or whole gland
• Hypoplasia
• ectopia

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Sonography of the thyroid in this 1 yr.
old female child revealed congenital
absence of the entire thyroid. Note the
empty fossae where the right and left
lobes would normally lie. The carotid
artery and jugular vein of both sides
are seen in the color doppler images.
These ultrasound and color doppler
images suggest congenital agenesis of
the thyroid.

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This 18 yr. old female patient presented with symptoms of
hypothyroidism. On sonography of the thyroid, we observed: 1) absence
of the right lobe of thyroid 2) normal or slightly enlarged left lobe and
isthmus of thyroid c) mild to moderate augmentation of vascularity of the
left lobe on color doppler imaging. These ultrasound images favor a
diagnosis of congenital absence of the right lobe or hemiagenesis of the
right lobe with Hashimoto's thyroiditis. This condition is found typically in
females with left lobe usually absent.

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This young, adult female patient complained of a midline swelling of the neck. Clinically, the nodule
was palpated in the midline, at the level of the thyroid cartilage and moved with swallowing
(deglutition). Ultrasound images of the nodule showed it to be solid, with no cystic areas or
calcification. Power Doppler imaging showed moderate vascularity of the nodule. The echogenicity
and echotexture of the lesion was same as that of normal thyroid tissue. The thyroid fossa was
empty with none of the normally located (orthotopic) thyroid seen. The nodule was long along the
sagittal axis (4 x 2 x 1 cms.). These ultrasound images suggest dysgenesis of the thyroid with
ectopic thyroid tissue in the midline of the neck. This tissue appears to show goitrous enlargement
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and appears to be the only available thyroid tissue in this patient.
NODULAR THYROID DISEASE
• Relatively common
• Thyroid cancer : rare, < 1%
• Majority of thyroid nodule are benign
• Clinical challenge : distinguish malignant –
benign nodule
• Much of nodular disease is clinically occult (<
10-15 mm)

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Hyperplasia & Goiter
• 80% thyroid nodular disease due to
hyperplasia, 5% of population
• Et : iodine deficiency (endemic), disorders of
hormonogenesis, poor utilization of idoine
• When hyperplasia leads to increase in gland
size / volume  GOITER
• Peak goiter : 35-50 years
• Women 3x more likely than men

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Hyperplasia & Goiter
Sonographically
• Most isoechoic compared to normal thyroid
tissue
• May become hyperechoic
• Hypoechoic spongelike or honeycomb pattern
• Thin peripheral hypoechoic halo 
perinodular blood vessels & mild edema or
compression of the adjacent normal
parenchyma
• Intracystic solid projections / papilla
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Hyperplasia & Goiter
Sonographically : degenerative changes
• Anechoic areas  serous / colloid fluid
• Echogenic fluid pr moving fluid-fluid level 
hemorrhage
• Bright echogenic foci with comet tail artifcats
 microcrystals
• Intracystic, thin spetations
• Calcification : eggshell or coarse

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Adenoma
• 5-10% of all nodular disease
• Females 7x more common than males
• BENIGN FOLLICULAR ADENOMA : true thyroid
neoplasm, compression of adjacent tissues &
fibrous encapsulation
• Solid mass (hyper, iso, or hypoechoic), thick
smooth peripheral hypoechoic halo (fibrous
capsule & blood vessels)
• Vessels pass from periphery to central 
“spoke-and-wheel-like” appearance
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Image in a patient with a palpable,
asymptomatic thyroid nodule shows a
solid mass in the left lobe, with a
complete surrounding halo (thyroid
adenoma).

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Transverse US image of follicular adenoma
in a 34-year-old woman shows a well-
defined smooth, ovoid-shaped, and
hypoechoic nodule. There are no micro- or
macrocalcifica-tions.

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Carcinoma
• Most epithelial origin, well differentiated, 75-
90% papillary carcinoma
• Papillary Ca : 2 peak prevalence 3rd & 7th
decade, women more than men
• Major spread route : lymphatics to nearby
cervical LN

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Papillary Carcinoma
Sonographic characteristic of typical papillary
carcinoma :
• Hypoechoic
• microcalcification (tiny punctate hyperechoic
foci, with or without acoustic shadows)
• Hypervascularity (most cases disorganized,
mostly in well-encapsulated forms)
• Cervical LN metastases, may contain
microcalcification
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Transverse US image of
papillary carcinoma in a 46-year- Longitudinal US image of
old woman shows an ill-defined, papillary carcinoma in a 59-
taller-than-wide shaped, and year-old woman shows a
hypoechoic nodule (arrow). spiculated, ovoid-shaped,
There are no micro- and and markedly hypoechoic
macrocalcifications. The taller- nodule (arrow) with a
than-wide shape suggests a microcalcification.
malignant nodule. 28
illustrate the punctate microcalcifications. These generally will not
cast an acoustic shadow because of their size.

Longitudinal US image of papillary


carcinoma in a 45-year-old man shows
a spiculated, taller-than-wide shaped,
and hypoechoic nodule with
macrocalcifications.
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Follicular Carcinoma
• 2nd subtype of well-differentiated thyroid Ca
• 5-15%, females more than males
• 2 variant : minimally invasive, widely invasive
• No unique sonographic feature that allow
differentiation of follicular carcinoma from
adenoma
• Suggest follicular carcinoma are rarely seen,
include irregular tumor margins, thick
irregular halo, tortuous or chaotic
arrangement of internal blood vessels on CDS
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Medullary Carcinoma
• Frequently familial (20%), multicentric and /or
bilateral in 90% of the familial cases
• US appearance similar to papillary carcinoma,
often hypoechoic solid mass, calcification
(more coarse than typical papillary ca)
• Calcification also in LN metastases

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Anaplastic Thyroid Carcinoma
• Typically disease of the elderly
• Less than 2% of all solid tumor
• Rapidly enlarging mass, invading adjacent
structures
• Prone to aggressive local invasion of muscles
& vessels
• Not tend to spread via lymphatics
• US : hypoechoic, encase / invade bloos vessels
& neck muscles
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Undifferentiated anaplastic carcinoma:
heterogeneous tumor with a
hypoechoic basic structure, internal
vascularity, anechoic areas of central
liquefaction, and echogenic
microcalcifications

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Lymphoma
• 4% of thyroid malignancies
• Mostly Non-Hodgkin, affect older women
• US : markedly hypoechoic & lobulated mass,
may occur cystic necrosis, encasement of
adjacent neck vessels
• CDS : nodular & diffuse thyroid lymphoma
mostly hypovascular
• Thyroid parenchyma may be heterogeneous –
chronic lymphocytic thyroiditis
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Metastases
• Infrequent
• Commonly from melanoma, breast, renal cell ca
• US : solitary well-circumscribed nodules, diffuse
involvement of the gland. Solid homogenously
hypoechoic mass, without calcification

Metastasis from a malignant


melanoma.
CDS shows pronounced internal
vascularity
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Fundamental anatomic features of a
thyroid nodule :
• Internal consistency (solid, mixed solid &
cystic, purely cystic)
• Echogenicity relative to adjacent thyroid
parenchyma
• Margin
• Presence & pattern of calcification
• Peripheral sonolucent halo
• Presence & distribution of blood flow signal
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Reliability of Sonographic Features in the
Differentiation of Benign from Malignant
Thyroid Nodules
Feature Benign Malignant
Internal Contents
Purely Cystic content ++++ +
Cystic with thin septa ++++ +
Mixed solid and cystic +++ ++
Comet-tail artifcat ++++ +

Echogenicity
Hyperechoic ++++ +
Isoechoic +++ ++
Hypoechoic +++ +++
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Halo
Thin halo ++++ ++
Thick incomplete halo + +++

Margin
Well-defined +++ ++
Poorly defined ++ +++

Calcification
Eggshell calcification ++++ +
Coarse calcification +++ +
Microcalcification ++ ++++

Doppler
Periperal flow pattern +++ ++
Internal flow pattern ++ +++
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The above sonographic images of the right lobe of thyroid show a large
cyst measuring 1.8 x 1.5 cms. The walls appear irregular with fine
debris within the lumen of the thyroid cyst. Color doppler image (on
right) shows normal vascularity with no vessels within the cyst. These
ultrasound images suggest Hemorrhagic colloid cyst of the thyroid.

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Sonography of the thyroid was done in this young girl. There is a
large, solid, echogenic, homogenous oval nodule with a hypoechoic
halo around the lesion, in the right lobe of thyroid. The lesion is
solitary, shows no cystic areas and has a rim of vessels entering it's
central area. These ultrasound images are diagnostic of a benign
follicular adenoma of the thyroid.
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Evaluation of nodules Incidentally
Detected by Sonography

• Nodules < 1.5 cm : followed by palpation at


next physical examination
• Nodules > 1.5 cm : evaluation (usually by FNA)
• Nodules that have malignant features :
evaluation

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DIFFUSE THYROID DISEASE
• Generalized enlargement of the gland (goiter),
no palpable nodules
• Specific condition that commonly produce
such diffuse enlargement include : chronic
autoimmune lymphocytic (Hashimoto’s)
thyroiditis, colloid or adenomatous goiter, and
Graves’ disease

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DIFFUSE THYROID DISEASE
• Acute supurative thyroiditis
• Subacute granulomatous thyroiditis
• Hashimoto’s (chronic lymphocytic) thyroiditis
• Adenomatous or colloid goiter
• Painless (silent) thyroiditis
• Graves’ disease
• Invasive fibrous thyroiditis

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Acute suppurative thyroiditis

• Rare, cause by bacterial infection


• Usually affects children
• US useful to detect abscess
• US abscess : ill-defined, hypoechoic,
heterogenous mass with internal debris with
or without septa and gas

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Subacute granulalomatous thyroiditis
(de Quervain’s disease)
• Spontaneously remitting inflammatory
disease
• Probably caused by viral infection
• US : enlarged gland & hypoechoic with normal
or decreased vascularity owing to diffuse
edema of the gland, or the process may
appear as focal hypoechoic regions

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Chronic autoimmune lymphocytic
thyroiditis (Hashimoto’s thyroiditis)
• Painless diffuse gland enlargement
• Young or middle aged woman
• US : diffuse coarsened parenchymal echo texture,
more hypoechoic, enlarged gland
• Multiple discrete hypoechoic micronodule 1-6 mm
(micronodulation)
• CDS : normal or decreased vascularity. Occasionally
hypervascularity similar to the “thyroid inferno” of
Graves’ disease
• Cervical lymphadenopathy
• End stage : atrophy (small thyroid gland), blood signal
(-), ill-defined margins, heterogenous texture (ec
fibrosis) 48
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Sonography of the thyroid gland in this middle aged female patient
reveal: 1) hypoechoic thyroid gland 2) coarse echotexture of the gland
3) fine linear echoes within the thyroid parenchyma s/o fibrosis 4)
Color doppler imaging reveals augmentation of the vascularity of the
thyroid gland. These ultrasound images are diagnostic of Hashimoto's
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thyroiditis.
Painless (silent) thyroiditis

• US pattern similar to chronic autoimmune


thyroiditis
• Clinical findings resemble subacute thyroiditis

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Multinodular or adenomatous goiter

• Multiple discrete nodules separated by


normal thyroid parenchyma
• Enlargement with rounding of the gland
• Diffuse parenchymal inhomogenity
• No recognizable normal tissue
• Women 3x more than men

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b Diffuse colloid goiter.
Panoramic SieScape image
shows an enlarged,
hyperechoic gland.

Predominantly hyperechoic
thyroid
gland with a nodular goiter
and regressive fibrotic
changes

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The above ultrasound images show- 1) a huge complex mass (8 x
6 cms.) containing both cystic and solid areas, in the right lobe of
the enlarged thyroid. 2) relatively spared left lobe which shows
normal size, but has fine nodularity. These ultrasound images are
highly suggestive of a multinodular goitre. 56
The above ultrasound and color doppler images reveal multiple cystic
lesions in both lobes of the thyroid. There is also evidence of few
nodular, solid masses within the lobes. Color doppler imaging reveals
multiple vessels around the lesions. These images suggest
multinodular goiter, more of a cystic variety. 57
Graves’ disease

• Common diffuse abnormality


• Caused by hyperfunction (thyrotoxicosis)
• Inhomogenous echotexture  numerous
large intraparenchymal vessels
• CDS : hypervascular pattern  “thyroid
inferno”
• CDS to monitor therapeutic response

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On ultrasound the gland will be
enlarged, usually heterogenous and
markedly hyperaemic

Graves' disease. Longitudinal


ultrasound with colour Doppler
shows diffusely increased
vascularity of the thyroid gland.
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These ultrasound/ color doppler images (taken with a Nemio-XG color
doppler scanner), reveal markedly increased vascualrity throughout the
thyroid gland. Some degree of inhomogeneity is also present. The
patient was a middle aged female with typical features of thyrotoxicosis.
Ultrasound images are diagnostic of hyperthyroidism.

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Invasive fibrous thyroiditis
(Riedel’s struma)
• Rarest type of inflammatory thyroid disease
• Primarily affects women
• Tends to progress to complete destruction of
the gland
• US : diffusely enlarged, inhomogenous
parenchymal echo texture
• US to check extrathyroid extension of the
inflammatory process with encasement of the
adjacent vessels
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References
• Diagnostic Ultrasound Vol 1
• Practical Head & Heck Ultrasound
• www.ultrasound-images.com
• www.ultrasoundpaedia.com
• Benign and Malignant Thyroid Nodules: US
Differentiation—Multicenter Retrospective
Study. Radiology, July 2008.
• Ultrasound Clinical Companion
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