Presentation1.pptx, radiological imaging of the thyroid gland diseases.

Radiological imaging of thyroid diseases.

Dr/ ABD ALLAH NAZEER. MD.

Imaging modalities:

Plain X-Ray.Thyroid US.Thyroid isotope uptake Scan.CT scan.MRI study.

U/S.

Hypothyroidism.Hyperthyroidism.Goiter.Thyroid nodules.Thyroid cancer.

Thyroid diseases.

Thyroid deficiencies.

Hypofunction: (hypothyroidism).Hashimoto,s thyroiditis.Ord,s thyroiditis.Post-operative hypothyroidism.Silent thyroiditis.Acute thyroiditis.Iatrogenic hypothyroidism.Thyroid hormone resistance.Euthyroid sick syndrome.Hyperfunction: (Hyperthyroidism).Thyroid storm.Graves, disease.Toxic thyroid nodule.Toxic thyroid struma(plummer,s disease).

Hashitoxicosis.

Nodular abnormalities: (Goiter).Endemic goiter.Diffuse goiter.Multinodular goiter.Lingual thyroid.Thyroglossal cyst.Tumours: Thyroid adenoma.Thyroid cancer:Papillary, Follicular, medullary and anaplastic carcinoma.Lymphoma and metastasis from elsewhere(rare):Deficiencies:Cretinism.

Hashimoto's thyroiditis or chronic lymphocytic thyroiditis is an autoimmune disease in which the thyroid gland is attacked by a variety of cell- and antibody-mediated immune processes. It was the first disease to be recognized as an autoimmune disease. It was first described by the Japanese specialist Hakaru Hashimoto in Germany in 1912.

Signs and symptoms:Hashimoto's thyroiditis very often results in hypothyroidism with bouts of hyperthyroidism. Symptoms of Hashimoto's thyroiditis include weight gain, depression, mania, sensitivity to heat and cold, paresthesia, chronic fatigue, panic, bradycardia, tachycardia, congestive heart failure, high cholesterol, reactive hypoglycemia, constipation, migraines, muscle weakness, joint stiffness, menorrhagia, myxedematous psychosis, cramps, memory loss, vision problems, infertility and hair loss.Enlargement of the thyroid is due to lymphocytic infiltration and fibrosis rather than tissue hypertrophy. Physiologically, antibodies against thyroid peroxidase (TPO) and/or thyroglobulin cause gradual destruction of follicles in the thyroid gland. Accordingly, the disease can be detected clinically by looking for these antibodies in the blood. It is also characterized by invasion of the thyroid tissue by leukocytes, mainly T-lymphocytes.

Hashimoto's thyroiditis. Transverse gray-scale ultrasound (a) and color Doppler (b) neck, of a 35-year-old female patient, who presented with features of hypothyroidism and had antithyroid antibodies positive for the disease, demonstrates diffuse enlargement of thyroid gland with linear echogenic fibrous bands (arrowheads) but normal vascularity. Note a small hypoechoic lymph node (arrow) in posterior aspect of inferior pole of left lobe of the thyroid gland.

Diffuse Hashimoto's thyroiditis who presented with features of hypothyroidism and had anti-thyroid antibodies positive for the disease. Transverse gray-scale ultrasound neck (a) demonstrates diffuse enlargement of thyroid gland with heterogeneous echotexture. Multiple tiny and discrete hypoechoic nodules (micronodules, arrows) and few linear echogenic septae (arrowhead) are also noted. Color Doppler sonogram (b) demonstrates mildly increased parenchymal vascularity.

Acute infectious thyroiditis (AIT) also known as suppurative thyroiditis, microbial inflammatory thyroiditis, pyogenic thyroiditis and bacterial thyroiditis.The thyroid is normally very resistant to infection. Due to a relatively high amount of iodine in the tissue, as well as high vascularity and lymphatic drainage to the region, it is difficult for pathogens to infect the thyroid tissue. Despite all this, a persistent fistula from the piriform sinus may make the left lobe of the thyroid susceptible to infection and abscess formation. AIT is most often caused by a bacterial infection but can also be caused by a fungal or parasitic infection, most commonly in an Immumocompromised host.

2 cases with acute suppurative thyroiditis. Contrast-enhanced CT shows a fluid collection (arrows) with internal gas (arrowhead) involving lobes of thyroid gland (open arrows) and adjacent soft tissue.

Axial CT image with contrast enhancement at the level of the thyroid gland shows an abscess (A) with an air-fluid level anterior to the trachea and multiple abscess of the left images.

Silent thyroiditisSilent thyroiditis is swelling (inflammation) of the thyroid gland, in which the person alternates between hyperthyroidism and hypothyroidism.

Silent thyroiditis.

Subacute granulomatous thyroiditis (De Quervain,s) is an uncommon disease that occurs most often in women in their second to fifth decades of life. This disease usually presents with thyroid tenderness, a low grade fever, and occasional dysphagia. The disease resolves spontaneously, usually without thyroid function abnormalities. We herein present the CT and MR imaging findings of two cases of subacute granulomatous thyroiditis. Subacute granulomatous thyroiditis (nonsuppurative thyroiditis, subacute thyroiditis, or de Quervain thyroiditis) is a self-limited inflammatory disease of the thyroid gland that most often occurs secondary to a viral infection.

Subacute thyroiditis with enlargement of the left thyroid lobe with no uptake with the thyroid lobe. Decreased attenuation can be seen in the posterior portion of the left thyroid lobe with increased intensity at MRI images.

The transverse right (A) and left (B), and longitudinal right (C) and left (D) thyroid sonograms show ill-defined hypoechoic lesions involving nearly the entire area of both thyroid glands. Both thyroids are diffusely enlarged, but no cervical lymphadenopathy was detected. Subacute granulomatous thyroiditis was confirmed by fine needle aspiration biopsy

The transverse (A) and longitudinal (B) sonograms of the right thyroid reveal an ill-defined elongated hypoechoic lesion, which is a typical finding of subacute thyroiditis. Color Doppler ultrasonography (C) shows no vascular flow in the hypoechoic lesion. Cytology suggests subacute granulomatous thyroiditis (D). On the day after steroid therapy, the patient felt free of neck pain. On sonogram after two months (E, F), the size of the hypoechoic area was markedly decreased.

Euthyroid sick syndrome is low serum levels of thyroid hormones in clinically euthyroid patients with nonthyroidal systemic illness. Diagnosis is based on excluding hypothyroidism. Treatment is of the underlying illness; thyroid hormone replacement is not indicated.

Thyroid nuclear scan of a patient with a euthyroid goiter showing different projections with thyroid enlargement and retro-sternal extension.

Hyperthyroidism is a condition in which the thyroid gland is overactive and makes excessive amounts of thyroid hormone. The thyroid gland is an organ located in the front of your neck and releases hormones that control your metabolism (the way your body uses energy), breathing, heart rate, nervous system, weight, body temperature, and many other functions in the body. When the thyroid gland is overactive (hyperthyroidism) the body’s processes speed up and you may experience nervousness, anxiety, rapid heartbeat, hand tremor, excessive sweating, weight loss, and sleep problems, among other symptoms.

The symptoms of hyperthyroidism include the following:Fatigue or muscle weakness, Hand tremors, Mood swings, Nervousness or anxiety, Rapid heartbeat, Heart palpitations or irregular heartbeat, Skin dryness, Trouble sleeping, Weight loss, Increased frequency of bowel movements, Light periods or skipping periods.Some people may develop a goiter, which is an enlarged thyroid gland that feels like a swelling in the front of your neck.

Causes of hyperthyroidism:The most common cause of hyperthyroidism is the autoimmune disorder Graves’ disease. In this disorder, the body makes an antibody (a protein produced by the body to protect against a virus or bacteria) called thyroid-stimulating immunoglobulin (TSI) that causes the thyroid gland to make too much thyroid hormone. Graves’ disease runs in families and is more commonly found in women.Hyperthyroidism also may be caused by a toxic nodular or multinodular goiter, which are lumps or nodules in the thyroid gland that cause the thyroid to produce excessive amounts of thyroid hormones. In addition, inflammation of the thyroid gland—called thyroiditis—resulting from a virus or a problem with the immune system may temporarily cause symptoms of hyperthyroidism. Furthermore, some people who consume too much iodine (either from foods or supplements) or who take medications containing iodine (such as amiodarone) may cause the thyroid gland to overproduce thyroid hormones.Finally, some women may develop hyperthyroidism during pregnancy or in the first year after giving birth.

Graves disease, the thyroid usually appears moderately ′enlarged with hypoechoic area inside.

Graves disease.

Comparison between scans from the normal patient and a patient with Grave's disease. Note the overall increased uptake throughout the enlarged thyroid gland in the Grave's patient.

Large thyroid gland with intense homogenous activity and visualization of the pyramidal lobe in Graves disease.

CT scans of the orbits show marked enlargement of the extra-ocular muscles with sparing of the tendons consistent with the ophthalmopathy seen with Grave's disease.

Proptosis with enlargement of the eye muscles and compression of the optic nerve in the left eye.

Voluminous thickening of all orbital muscles with oedematous changes, pathognomonic for active Graves’ orbitopathy with moderate to marked enhancement at the post-contrast study.

Diagnosis Graves’ disease, Location(s) Eye, with gamuts Ocular muscles thickening

Goiter (GOI-tur) is an abnormal enlargement of your thyroid gland. Although goiters are usually painless, a large goiter can cause a cough and make it difficult for you to swallow or breathe.The most common cause of goiter worldwide is a lack of iodine in the diet. In the United States, where the use of iodized salt is common, a goiter is more often due to the over- or underproduction of thyroid hormones or to nodules that develop in the gland itself.Symptoms:A visible swelling at the base of your neck that may be particularly obvious when you shave or put on makeupA tight feeling in your throat.Coughing.Hoarseness.Difficulty swallowing.Difficulty breathing.

Multinodular goiter. A. Transverse dual ultrasound image shows enlargement of thyroid lobes and isthmus and multiple hyperechoic solid nodules with uniform thin halo (arrows). Mixed solid and cystic thyroid nodule in the left lobe. Tr: tracheal gas shadow. B. Transverse sonogram and color-doppler mode scan show a well-defined isoechoic thyroid nodule with thin complete hypoechoic halo, intranodular cystic/colloid space and peripheral vascularity, findings indicative of a hyperplasic nodule.

Colloid Nodular Goiter

Two cases of massive multinodular Goiter.

Two cases of Goiter (massive).

Endemic goiter--iodine deficiency disorders.

Retrosternal (Substernal) endemic diffuse Goiter.

A lingual thyroid is a specific type of ectopic thyroid, and results from lack of normal caudal migration of the thyroid gland.

Radiographic featuresUltrasound: Ultrasound is only of use in demonstrating absent thyroid tissue in the normal location, which is the case in the majority of cases. Only occasionally do patients have thyroid tissue both at the tongue base and elsewhere in the neck. CT: CT demonstrates are hyperdense soft tissue mass, of the same attenuation as normal thyroid tissue. It is hyperdense on account of the accumulation of iodine within the gland. Following contrast administration, the entire gland demonstrates prominent homogenous enhancement (again just like the normal thyroid gland). There are occasional case reports of inhomogeneous contrast enhancement .MRI: Usually seen as a well defined mass with no invasive featuresSignal characteristics include : T1 - iso to hyperintense to muscle T2 - can vary from hypo to iso to hyperintense to muscle .T1 C+ (Gd) - homogeneous contrast enhancementNuclear medicine: A thyroid scan is excellent at not only confirming the diagnosis, but also identifying the presence of any thyroid tissue elsewhere in the neck.

Lingual thyroid.

Lingual thyroid

Thyroglossal duct cysts are the most common congenital neck cyst. They are typically located in the midline and are the most common midline neck massses in young patients. Radiographic featuresUltrasound: Unless infected, they are painless, fluctuant masses which spread the strap muscles. The fluid is usually anechoic and the walls are thin, without internal vascularity.However, in some cases, the internal fluid may contain debris. This is particularly the case in the adult patient where the cysts may be complex heterogeneous masses.If there is associated infection, there may be surrounding inflammatory change.CT: At CT, thyroglossal duct cysts are thin walled, smooth, well defined homogeneously attenuating lesions with an anterior midline or para-midline location. The generally accepted rule is that they should be within 2 cms of the midline. The may demonstrate slight rim (capsular) enhancement.Sternocleidomastoid is typically displaced posteriorly or posterolaterally and in some cases, they may be embedded in the infrahyoid strap muscles.MRI : T1: variable low signal: if low protein / uncomplicated

high signal (most common ) due to previous hemorrhage / infectionhigh protein (probably due to previous complication)

T2 - typically high signalT1 C+ (Gd)

no enhancement in uncomplicated cyststhin peripheral enhancement may be seen

US and CT Scan of thyroglossal duct cyst.

CT and MRI image for thyroglossal duct cyst.

Thyroid nodules are lumps which commonly arise within an otherwise normal thyroid gland. They indicate a thyroid neoplasm, but only a small percentage of these are thyroid cancers.5% of adults have thyroid nodules, with a 5:1 female :male ratio.95% of thyroid nodules are benign.There are different types of thyroid nodules.Colloid nodules. These are one or more overgrowths of normal thyroid tissue. These growths are not cancerous (benign), may grow large, but do not spread beyond the thyroid gland. Thyroid cysts. These are fluid-filled or partially solid/partially fluid-filled growths inside the thyroid gland. Inflammatory nodules. These nodules develop as a result of chronic inflammation of the thyroid gland. These growths may or may not cause pain.Multinodular goiter. Sometimes an enlarged thyroid (goiter) is composed of many, usually benign, nodules. Hyperfunctioning thyroid nodules. These nodules produce thyroid hormone, which may lead to the development of hyperthyroidism. Hyperthyroidism can affect the heart, leading to such complication as sudden cardiac arrest, hypertension, arrhythmias; as well as osteoporosis and other health problems. Thyroid cancer. Of the nodules that can form as the thyroid gland enlarges, fortunately, less than 5 percent are cancerous.

Transverse ultrasound scan shows a well-defined, homogeneous, solid iso-hypoechoic oval-shaped thyroid nodule, suggestive of a follicular lesion. B. Transverse color-Doppler scan demonstrates intranodular and peripheral vascularity.

Multinodular goitre. A. Transverse dual ultrasound image shows enlargament of thyroid lobes and isthmus and multiple hyperechoic solid nodules with uniform thin halo (arrows). Mixed solid and cystic thyroid nodule in the left lobe. Tr: tracheal gas shadow. B. Transverse sonogram and color-doppler mode scan show a well-defined isoechoic thyroid nodule with thin complete hypoechoic halo, intranodular cystic/colloid space and peripheral vascularity, findings indicative of a hyperplastic nodule.

Spongiform nodule. A. Transverse and B. longitudinal ultrasound scan shows a thyroid nodule with multiple cystic spaces and punctuated echogenic foci with comet tail artifact. C. Transverse and D. longitudinal color-doppler mode scan shows peripheral vascularity.

Radioactive nuclear medicine study showing a 'hot' thyroid nodule in a patient with hyperthyroidism.

CT scan of thyroid nodules.

CT and MRI images of thyroid nodules.

Follicular adenoma: Shows high signal and intense enhancement relative to the thyroid tissue.

Thyroid cancers can be classified according to their histopathologically .characteristics. The following variants can be distinguished (distribution over various subtypes may show regional variation):Papillary thyroid cancer .(75% to 85% of cases) – often in young females – excellent prognosis. May occur in women with familial adenomatous polyposis .and in patients with Cowden syndrome.Follicular thyroid cancer (10% to 20% of cases); occasionally seen in patients with Cowden syndrome.Medullary thyroid cancer (5% to 8% of cases)- cancer of the parafollicular cells, often part of multiple endocrine neoplasia type 2.Poorly differentiated thyroid cancerAnaplastic thyroid cancer (Less than 5%). It is not responsive to treatment and can cause pressure symptoms.Others

Thyroid lymphoma.Squamous cell thyroid carcinoma.Sarcoma of thyroid.Metastasis.

Ultrasound of a papillary carcinoma (a) small hypoechoic solid nodule with punctate calcification (arrows), (b) predominantly cystic nodule (arrow heads) with smaller solid component with punctate calcification (arrows).

Ultrasound of solid hypoechoic follicular thyroid cancer

Two cases of papillary carcinoma.

Papillary thyroid carcinoma (PTC).

Two cases of Papillary carcinoma with lymph node metastasis.

Multifocal papillary carcinoma with multi-nodular masses showing marked enhancement, Extra-thyroidal extension is present bilaterally. Bilateral LN, metastasis show marked enhancement.

Anaplastic thyroid tumor. Axial unenhanced and contrast-enhanced CT scan images through the lower neck. Unenhanced images show an heterogeneous tissue replacing and expanding the thyroid gland, with some foci of calcifications inside. After contrast injection, the lesion enhances at the periphery, and the center remains hypoattenuating, suggesting necrosis. The mass has displaced the larynx to the left, invaded it and partly destroyed its cartilage. All these imaging findings provide evidence of the aggressive nature of this anaplastic thyroid carcinoma.

Anaplastic carcinoma , Esophagram demonstrates focal extrinsic narrowing of the upper esophagus, MRI large heterogenous mass lesion, invade the trachea and displacing the esophagus to the right side.

Anaplastic carcinoma, patient with hoarseness and dysphagia, MRI large infiltrative mass lesion, extending directly to the right vocal cord, with extension to the post-cricoid space.

Primary medullary thyroid carcinoma, the tumour appears iso-intense relative to the gland with marked enhancement at the post-contrast study.

Medullary carcinoma, show round well marginated mass, iso-intense at the T1WI and bright at the T2WI and mild enhancement.

US and CT Scan show mass lesion over left thyroid gland, proved to be primary lymphoma.

Thyroid lymphoma.

Thyroid lymphoma. Axial contrast-enhanced CT image shows diffuse enlargement of the thyroid gland by a relatively homogenous mass causing tracheal and jugular vein compression. Thyroid lymphoma may presents as a focal mass, multiple thyroid nodules, or diffuse enlargement of the gland, with rapid growth. An absence of calcification and necrosis aids in distinguishing it from anaplastic carcinoma. It also shows a propensity to encircle the trachea, sometimes producing a characteristic ‘‘doughnut sign’’ on CT. Associated cervical adenopathy is also present in this patient.

Diffuse large B-cell lymphoma of the thyroid gland in a 73-year-old man with Sjögren’s syndrome. (a, b) Contrast-enhanced CT images show a huge tumor replacing the left thyroid lobe (yellow arrows). Cervical lymphadenopathy is also visualized (green arrow). Note fatty deposition in the left parotid gland (blue arrow). (c) FDG-PET/CT fused image shows intense FDG uptake in the tumor and lymph nodes. (d) T2WI demonstrates relatively homogenous signal intensity of the tumor for its size. (e) Diffusion-weighted image visualizes the tumor and enlarged lymph node (orange arrow) of hyperintensity.

Axial computed tomography (CT) scan showed a large low attenuation synovial sarcoma replacing the thyroid gland with possible invasion to the trachea. (B) Axial CT scan performed 2 weeks after the first CT scan revealed tracheal intraluminal invasion. (C) Chest CT scan showed multiple variable sized nodular lesions suggestive of lung metastasis.

Two cases of primary Synovial Sarcoma of the Thyroid Gland.

CASTLE neoplasm with a hypoechoic mass is located in the inferior lobe of the right thyroid shown in transverse (A) and sagittal (B) views. The mass has an irregular border with evidence of invasion (arrows). Abnormal, round nodes are seen in right lateral neck in level 3 (C) and level 4 (D). The nodes were both rounded with loss of central fatty hilum and increased peripheral vascular flow consistent with metastases (C,D).

CASTLE neoplasm , PET/CT scan of the neck. The hypermetabolic thyroid tumor (T) in the inferior right lobe is showed in the fused PET/CT scan (top row) and CT scan (bottom row). The axial view is shown in column A, the sagittal neck in column B and the coronal images in column C. The metastatic nodes in right level 3 (N1) and right level 4 (N2) are both hypermetabolic

47-year-old man with metastatic left thyroid lobe with CT and PET images.

PET CT Scan with right thyroid metastasis.

Cretinism is a condition of severely stunted physical and mental growth due to untreated congenital deficiency of thyroid hormones (congenital hypothyroidism) usually due to maternal hypothyroidism.

Congenital cretinism can be endemic, genetic, or sporadic. If untreated, it results in mild to severe impairment of both physical and mental growth and development.Poor length growth is apparent as early as the first year of life. Adult stature without treatment ranges from 1 to 1.6 meters (3'4 to 5'3), depending on severity, sex and other genetic factors. In adults, Cretinism results in mental deterioration, swelling of the skin, loss of water and hair. Bone maturation and puberty are severely delayed. Ovulation is impeded and infertility is common.Neurological impairment may be mild, with reduced muscle tone and coordination, or so severe that the person cannot stand or walk. Cognitive impairment may also range from mild to so severe that the person is nonverbal and dependent on others for basic care. Thought and reflexes are slower.Other signs may include thickened skin, enlarged tongue, or a protruding abdomen.

Cretinism image with hand manifestation.

Skull X ray, lateral views, in a two- year-old child and 18-months old child demonstrating persistent wide anterior fontanelle, mild degree of brachycephaly in a relatively underdeveloped skull base with increased bone density, underdeveloped paranasal sinuses and slightly hypoplastic facial bones, enlarged sella turcica (Cherry sella), few wormian bones along lambdoid suture, relatively narrowed deploic space of parietal bones and overcrowded teeth. B : AP view of knee demonstrating epiphyseal dysgenesis [irregularity and mild stippling] of the lower femoral and upper tibial epiphyses which are relatively small; and a delayed appearance of the upper fibular epiphysis for age of the patient. C, D. Plain X ray of the pelvis and both hips in a two-year-old child (C ) and five-year-old (D ) demonstrating epiphyseal dysgenesis of the upper femoral epiphyses (irregular flattened upper femoral epiphysis which are small for age of the patient with coxa vara.

Thank You.