Professional Documents
Culture Documents
INDIA 24/03/2011
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Ultrasound detects the presence, size, site, number, characteristics of thyroid nodules .
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3. FNA Guidance
Technique
y With high frequency transducer(7.5 to 15Mhz) y Examination-supine position with neck extended. y A small pad may be placed under the shoulders to provide
planes.
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necessary.
Normal thyroid parenchyma has homogenous medium to high level echogenicity & bounded by a thin hyperechoic line(the thyroid capsule). Landmarks to be identified: Midline -Trachea and oesophagus. Laterally- Common Carotid artery, IJV Anterolaterally:Strap muscles of the neck
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are found at upper pole of each lobe and inferior thyroid vein is found at lower pole whereas the inferior thyroid artery is located posterior to lower third of each lobe.
As hypoechoic bands. y Lateral- Sternocleidomastoid As large oval band y Posterior- Longus colli muscle
y Recurrent laryngeal nerve & inferior thyroid artery pass in
thyroid artery may be seen as hypoechoic bands between the thyroid lobe & oesophagus on left , thyroid lobe & longus colli on right.
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Oesophagus y laterally & towards the left y Target appearance on transverse plane y Peristaltic movements On swallowing. Trachea y Posteriorly y Identified by lack of sound transmission and ring down artifacts.
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LENGTH
18-20mm 25mm 40-60mm
Normal Mean Thyroid Volume (LxWxTHICKNESSx0.52) : 18.64.5 MALE-UPTO 23gm IS NORMAL FEMALE- UPTO 22gm IS NORMAL. Mean thickness of isthmus 4 to 6mm
y A-P diameter is most precise because relatively independent of possible dimensional asymemetry between two lobes. y When AP diameter- > 2cm --- Enlarged gland.
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CONGENITAL ABNORMALITIES
y AGENESIS/HYPOPLASIA y ECTOPIC
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EMBRYOLOGY
y Thyroid gland is originated from epithelial cells of
floor of pharynx.
y It descends from pharynx & remains connected to
of gestational age.
y Then after duct involutes.
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THYROID AGENESIS USG : Abnormal echogenic tissue in the expected location of the thyroid, without any normal flow on color Doppler imaging. There is no evidence of ectopic thyroid tissue. Pertechnetate scintigraphy demonstrates no functioning thyroid tissue. 17
Sonography of the thyroid in this 1 yr. old female child revealed congenital absence of the entire thyroid. Note the empty fossae where the right and left lobes would normally lie. The carotid artery and jugular vein of both sides are seen in the color doppler images. These ultrasound and color doppler images suggest congenital agenesis of the thyroid. 18
ECTOPIC THYROID
The thyroid gland develops as a median angle from a diverticulum of the foramen cecum. Normally, it descends to its typical location anterior to the cervical trachea via the thyroglossal duct. Anomalies of descent can lead to a lingual or sublingual position of the gland. Nuclear medicine scintigraphy with sodium iodine-123 or pertechnetate99m is used to evaluate the neck for the presence of thyroid tissue. Diagnosis of lingual thyroid is made when uptake is seen at the tongue base but not in the thyroid bed. Further evaluation can be done using CT & MRI imaging.
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CT image- round mass at tongue base which enhances after contrast administration. A pertechnetate-99m scan shows uptake corresponding to mass at tongue base without uptake in the thyroid bed.
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Thyroid disorders
Thyroid disorders can be divided into
y Nodular thyroid disease y Diffuse thyroid disease.
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Sonography y Most hyper plastic or adenomatous nodules are isoechoic compared to normal thyroid tissue. y As Size of the mass increases, it may become hyperechoic. y Less frequently hypo echoic SPONGElike OR HONEY COOMB CYSTIC pattern is seen. y When nodule is hyperechoic or isoechoic, a thin peripheral hypoechoic halo is commonly seen-due to perinodular blood vessels and edema or compression of adjacent normal parenchyma. y Perinodular, intranodular vascularity on colour Doppler. DEGENERATIVE CHANGES: y Purely anechoic -due to serous/colloid fluid. y Echogenic fluid/moving fluid-fluid levels due to hemorrhage. y Bright echogenic foci with comet tail artifacts due to dense colloid material/microcrystals. y Eggshell(thin peripheral) or coarse calcification.
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Sonogram of the left lobe of the thyroid gland in the transverse plane showing a rounded lobe of a goiter. L=enlarged lobe, I= widened isthmus,T=trachea,C=carotid artery,J=jugular vein, S=Sternocleidomastoid muscle, m=strap muscles, E=esophagus.25
Hyperplastic nodules
y Oval homogenous isooechoic nodule with well defined peripheral halo.
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Adenoma
y F:M 7:1 y Solitary or as a part of multinodular goiter.
Sonography
y Hyperechoic, iso or hypoechoic solid masses . y Have Peripheral hypoechoic halo which is thick & smooth-
due to fibrous capsule and blood vessels. y Typical spoke and wheel type of appearance on color doppler.
y D/D : FOLLICULAR CARCINOMA where vascular and
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Isoechoic solid mass with thick irregular complete halo. Power doppler spoke and wheel like appearance FOLLICULAR ADENOMA
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multiple nodular densities in cervical region that are palpable on physical examination.CT scan obtained 9 months before sonogram shows absent left thryoid lobe and enlarged right thryoid lobe with small low-attenuation lesion.
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Carcinoma:
y Most primary thyroid cancers are of epithelial origin and
are derived from either the follicular or the parafollicular cells.Most are well differentiated. y Papillary carcinoma- 75-90% . y Medullary/Follicular/anaplastic car. -10-25%
Papillary cancer
y 3rd and 7th decade.F>M y The major route of spread is through lymphatics to nearby
cervical lymph nodes. y Distant metastasis is rare (2-3%) and occurs to mediastinum and lungs. y HISTOLOGY: PSAMMOMA BODIES
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Sonography
y Hypoechoic nodules with microcalcifications
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Two rounded hypoechoic nodes Hetrogenous oval nodes typical of metastasis to cervical containing microcalcifications nodes
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y Longitudinal and transverse sonographic images of the thyroid gland reveal a normal left lobe and
thyroid isthmus. Multiple small punctate calcifications are seen scattered through the mass in right lobe.
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Role of color Doppler US. (a) Transverse gray-scale image of Predominantly solid thyroid nodule (b) Addition of color Doppler modeshows marked internal vascularity,indicating increased likelihood that nodule is malignant. This was a papillary carcinoma.
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Woman with history of papillary thyroid cancer - underwent thyroidectomy & radioiodine ablation. Two years later, patient presented with thyroglobulin level of 6.1 ng/mL (TSH suppressed) and negative findings on 131I WBS. 18F-FDG PET (A) demonstrates small foci of increased 18F-FDG uptake corresponding to small lymph nodes in right lower neck on CT (B). These are clearly visualized on fused 18F-FDG PET/CT (C) and were subsequently proven to be thyroid cancer metastases.
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Follicular Carcinoma
Sonography:Cant be differentiated from follicular adenoma So treatment for both is surgical excision. y Hypoechoic nodule with irregular tumor margins y Thick, irregular halo. y Tortuous or chaotic arrangement of internal blood vessels on color doppler. PATHOLOGY: Vascular & capsular invasion. 39
Heterogenous solid mass with peripheral and internal flow follicular carcinoma
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Medullary Carcinoma
y only 5 % thyroid cancer. y Derived from parafollicular or C cells y secretes calcitonin.- useful serum marker. y Frequently familial and Associated with MEN II syndrome. y Bilateral in 90% of familial cases. y High incidence of metastatic to lymphnodes.
y Sonography
- Similar to papillary carcinoma-hypoechoic solid mass with calcifications(often, but coarse than papillary carcinoma). -Local invasion and cervical lymphadenopathy are also more common.
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Heterogenous nodule with multiple punctate foci of calcification within it medullary carcinoma
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intranodular
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Sonography Hypoechoic masses often seen to encase or invade blood vessel and neck muscles(CT or MRI demonstrates the tumor more accurately owing to their large size) .
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Longitudnal scan solid hypoechoic mass extending into the upper mediastinum anaplastic carcinoma
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Lymphoma
y 4% of all thyroid malignancies. y Mostly non-Hodgkins type y Elder females y In 70-80% cases arises from pre-existing chronic lymphocytic thyroiditis(HASHIMOTOS thyroiditis) with subclinical or overt hypothyroidism.
Sonography y Markedly Hypoechoic lobulated mass . y Hypovascular or show blood vessels with chaotic distribution and arteriovenous shunts. y Large areas of cystic necrosis may occur as well as encasement of adjacent neck vessels. y Adjacent thyroid parenchyma heterogenous due to associated 47 chronic thyroiditis.
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Isotope scan of thyroid demonstrating a photopenic area within the left lobe. Axial contrast enhanced CT of the same patient shows a solid mass within left lobe of thyroid . Lymphoma was proven by biopsy.
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Differentiation
Feature Internal contents Purely cystic Cystic with thin septae Mixed solid and cystic Comet tail artifact Benign malignant ++++ ++++ +++ +++ + + ++ +
+ ++ +++
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Feature
Benign
malignant
Halo Thin Thick incomplete Margin Well defined Poorly defined Calcification Eggshell Coarse calcification Microcalcification
++++ +
++ +++
+++ ++
++ +++
++++ +++ ++
+ + ++++
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Feature
Benign
malignant
+++ ++
++ +++
y + rare (<1%) y ++ low probability (<15%) y +++ intermediate probability(16 to 84%) y ++++ high probability (>85%)
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Sagittal image of predominantly cystic Sagittal image of predominantly nodule (calipers), which proved to be solid nodule , which proved to be benign at cytologic examination. benign at cytologic examination.
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Transverse US images of mostly cystic thyroid nodule with a mural component containing flow. (a) Gray-scale image shows predominantly cystic nodule with small solid-appearing mural component (b) Addition of color Doppler mode demonstrates flow within mural component , confirming that it is tissue and not debris. US-guided FNA can be directed into this area. The lesion was benign at cytologic examination.
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HYPERPLASTIC NODULAR
Iso/hyperechoic hypoechoic-honey coomb Thin peripheral halo Peri & intranodular vascula.
CARCINOMA
PAPILARY 3RD,7TH Decade Psammoma bodies Cervical LN HYPERECHOIC PUNCTATE CALCIFICATION Disorganised hypervascularity Cystic LN Mets FOLLICULAR Hyperechoic Thick irregular halo Tortous vessels Hematogenous spread To Bone/lung/ brain/liver MEDULARY ANAPLASTIC
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physical examinaton
y Nodules > 1.5cm : evaluation usually by FNA y Any nodule with malignant features like
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Biopsy guidance
INDICATIONS
Nonpalpable suspected nodule with inconclusive physical examination. Patients at high risk of developing thyroid cancer, normal gland by physical examination but sonography demonstrates a nodule. Previous non diagnostic / inconclusive biopsy.
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1.THYROIDITIS
CHRONIC AUTOIMMUNE LYMPHOCYTIC THYROIDITS (HASHIMOTO S THYROIDITIS) SUBACUTE GRANULOMATOUS THYROIDITIS (DE QUERVAIN S DISEASE) ACUTE SUPPURATIVE THYROIDITIS SILENT/ PAINLESS THYROIDITIS INVASIVE FIBROUS THYROIDITIS
3. GRAVE S DISEASE
no palpable nodules.
y Diagnosis is usually based on clinical and laboratory
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children. y Sonography useful in selected cases to detect thyroid abscess-ill defined hypoechoic mass with debris and/or septa and gas.
SUBACUTE GRANULOMATOUS THYROIDITIS(DE QUERVAINS) y Spontaneously remitting inflammatory disease probably
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Ill defined hypoechoic area focal area of subacute thyroiditis resolved after 4 wks of medical therapy
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Sagittal sonogram of left lobe of thyroid shows solid, predominately hyperechoic, poorly marginated nodule in lower pole corresponding to palpable abnormality.Fine-needle aspiration of this lesion was consistent with thyroiditis.Background of thyroid was heterogeneous,with geographic regions of hypoechogenicity.
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of 1-6 mm size is strongly suggestive of chronic thyroiditis. Surrounded by multiple linear echogenic fibrous septations- giving pseudo lobulated appearance.
y Normal or hypovascular.Occasionally hypervascular . y Often Cervical lymphadenopathy may be present. y In end stage, atrophy of gland occurs when thyroid gland
is small with ill defined margins and heterogenous echotexture with absent blood flow.
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Nodule was predominantly hyperechoic, with both solid and cystic-appearing Fine-needle aspiration of this 28 mm palpable nodule was consistent with lymphocytic thyroiditis.
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Sagittal sonogram of right lobe obtained at time of diagnosis of left-sided thyroid carcinoma shows 11-mm hypoechoic solid nodule with ill-defined margins (delineated by electronic calipers) in upper pole of right lobe. Sonographically guided fine-needle aspiration of this nodule and surgical pathology findings were consistent with lymphocytic thyroiditis.
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Painless thyroiditis
y Thyroid enlargement in early phase followed by hypothyroidism. y Clinical findings are similar to subacute thyroiditis y Histologic and sonographic pattern of chronic autoimmune thyroiditis.
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Graves disease
y Diffuse abnormality of thyroid gland with associated
thyrotoxicosis
Sonography
y Diffusely hypoechoic or inhomogenous texture y Color Doppler shows hypervascular pattern known as
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Pinhole images from a Tc-99m pertechnetate thyroid exam demonstrate diffuse thyroid enlargement with decreased background activity.
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USG Diffusely enlarged thyroid gland Inhomogenous parenchymal echo texture May have associated mediastinal or retroperitoneal fibrosis or sclerosing cholangitis. D/D : From Anaplastic thyroid carcinoma.by biopsy.
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- regional LN metastasis
y To determine recurrence following Surgery. y Detection of retrosternal & retrotracheal extension of the
thyroid enlargement.
y Confirm the location of mass within the gland, evaluating
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masses is impossible on imaging, although the associated lymphadenopathy, vocal cord paralysis and bone or cartilage invasion obviously suggests malignancy.
y MRI helps to differentiate scar from residual or
recurrent tumor.
y Tumor - hypointense to isointense on T1WI
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GOITER -Enhancing heterogenous soft tissue mass orignated in thyroid and causing deviation of the trachea
Large heterogenous soft tissue mass replacing the thyroid with speck of calcification,causing deviation of the trachea medullary carci.
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than normal thyroid tissue hence appear cold. y Most cold nodules are adenomas, colloid nodules or foci of thyroiditis or rarely intrathyroid lymphnodes, lymphoma or metastases.
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synonymous with autonomy, as it often represents spared focus of normal thyroid tissue in gland otherwise involved in destructive process.
y The more important role is of 131 I whole body
scintigraphy to identify most functioning metastases, usually in the neck, lungs or bone, following total thyroidectomy.
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y TYPES
USG
HASHIMOTOS THYROIDITIS
VARIABLE
DECREASED INCREASED
INVASIVE FIBROUS
VARIABLE
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MCQs
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THANK YOU
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