thyriod gland imaging part 3 (benign malignant thyriod nodule) Dr Ahmed Esawy

بسم هللا الرحمن الرحيم

Dr Ahmed Esawy

Dr. Ahmed Eisawy

MBBS M.Sc MD

Dr Ahmed Esawy

BENIGN THYRIOD NODULES/ MASSE

IMAGING

Dr Ahmed Esawy

Investigations

Ultrasound – Best modality

USG guided FNAC

CT

MRI

Technetium-99m pertechnetate or 131/123I scintigraphy

Ga68 DOTA scintigraphy

PET-CT

Dr Ahmed Esawy

Nodules are not a single disease but are a manifestation of different diseases including adenomas, carcinomas,inflammations, cysts, fibrotic areas, vascular regions, and accumulations of colloid.

Dr Ahmed Esawy

USG descriptors of thyroid nodules

Echogenicity

Shape

Hyperechoic (> thyroid), Isoechoic (= thyroid),

Hypoechoic (< strap muscles)

Taller > wide

Calcification

Margin

Microcalcification = / < 1mm

Circumscribed, Microlobulated, Irregular

Vascularity Central or peripheral

Composition Solid, Cystic, Mixed

Dr Ahmed Esawy

Uniform halo around nodule Enlarged thyroid with multiple nodules

Peri-nodular or spoke-and-wheel like appearance of vessels Or avascular

Predominantly cystic Avascular

US features of benign nodules

Dr Ahmed Esawy

NODULES WHICH ARE LIKELY BENIGN entirely cystic nodule Nearly entirely cystic nodule with no flow or calcification in the solid part (under 2 cm) Inspissated colloid calcifications Honeycomb or spongiform nodule without calcification (under 2 cm) Iso /hyperechioc Uniform halo around nodule Smooth margins Avascular or peripheral vascularity Pseudo nodules in autoimmune thyroid disease (chronic lymphocytic thyrioditis) Mixed cystic and solid nodules with a functioning solid component (any size)

Dr Ahmed Esawy

Features of Benign/Malignant Nodules Feature Benign Malignant

Internal Contents

Purely Cystic

Cystic with Thin Septa

Mixed Solid and Cystic

Comet Tail Artifact

++++

++++

+++

+++

+

+

++

+

Echogenicity

Hyperechoic

Isoechoic

Hypoechoic

++++

+++

+++

+

++

+++

Halo

Thin Halo

Thick Incomplete Halo

++++

+

++

+++

Margin

Well Defined

Poorly Defined

+++

++

++

+++

Calcification

Eggshell

Course

Microcalcifications

++++

+++

++

+

+

++++

Doppler Flow Pattern

Peripheral

Internal

+++

++

++

+++ Dr Ahmed Esawy

Calcification Although calcification can be seen in both benign and malignant processes, it is the ultrasound feature most closely associated with malignancy. microcalcifications

punctate echogenic foci without posterior shadowing most specific finding associated with malignancy (~95%) 2 associated with papillary thyroid carcinoma colloid (in benign colloid nodules) shows ring-down (comet tail) artefact; if an echogenic focus is not definitely colloid, biopsy is warranted

coarse calcifications

can be seen in both benign and malignant nodules associated with both papillary thyroid carcinoma and medullary thyroid carcinoma

peripheral rim calcification

can be seen in both benign and malignant nodules

Dr Ahmed Esawy

1. Calcifications

Microcalcifications

Psammoma bodies

Common in papillary carcinoma

Specificity 86%–95%

Positive Predictive Value: 42 – 94 %

Coarse calcifications

• MC in medullary carcinomas

• May coexist with microcalcifications in papillary cancers

Inspissated colloid calcifications • May mimic

microcalcifications • Distinguished by ring

down/reverberation artefact

Peripheral calcification Most common in MNG Break in peripheral calcification – malignant change in an underlying multinodular goitre

Dr Ahmed Esawy

2. Margins, contour and shape

Hypoechoic halo highly suggestive of

benignity

pseudocapsule of fibrous

connective tissue or

compressed thyroid parenchyma

specificity 95%

Shape • taller than wide • 93% specificity for

malignancy

Ill-defined margins

• > 50% of its border is not clearly demarcated

• indicate infiltration of adjacent parenchyma

• sensitivity: 53%– 89% and specificity 7%–97%

• Hence frank invasion beyond the capsule has to be demonstrated on HPE

Contour • Smooth and

rounded • Irregular/jag

ged edges

Dr Ahmed Esawy

Echogenicity hypoechoic solid nodule

most papillary thyroid carcinomas nearly all medullary thyroid carcinomas benign nodules can be hypoechoic if no other malignant features (e.g. calcifications) then hypoechoic nodules are typically biopsied after reaching size criteria

isoechoic solid nodule: 25% (follicular and medullary) hyper echoic solid nodule: 5% chance of being malignant large cystic component favors a benign entity although a significant proportion of papillary carcinomas will have a cystic component while a halo around a well-marginated hypoechoic or isoechoic nodule is typical of a follicular adenoma , it is absent in >50% of benign nodules ; what is more, up to 24% of papillary thyroid carcinomas may have a halo, be it complete or incomplete

Dr Ahmed Esawy

3. Echogenicity of the nodule

Malignant nodules are solid and hypoechoic Sensitivity 87% but low

specificity 15-27%

Marked hypoechogenicity Darker than strap muscle

Specificity 94%

4. Vascularity

Marked intrinsic hypervascularity

• Flow in the central part of tumour > surrounding thyroid parenchyma

Benign nodules • Perinodular vascularity – 25% of

circumference

• Complete avascularity is a more useful sign

These features are more useful in selecting a nodule for FNAC in multinodular goitre

Dr Ahmed Esawy

Lymph nodes enlarged regional lymph nodes are suspicious for thyroid malignancy, esp. papillary thyroid carcinoma microcalcifications in regional lymph nodes are highly suspicious lymph nodes with cystic change are highly suspicious loss of normal fatty hilum, irregular node appearance increased colour Doppler flow is suspicious no threshold criteria for lymph node biopsy

biopsy if suspicious features consider biopsy if >8 mm

Dr Ahmed Esawy

5. Local invasion and lymph node metastasis

Features of nodal involvement • Rounded bulging shape • Increased size • Replaced fatty hilum • Irregular margins • Heterogeneous

echotexture • Calcifications / Cystic areas • Vascularity throughout the

lymph node instead of normal central hilar vessels

Dr Ahmed Esawy

Selected Benign Thyroid Lesions

Benign lesions Benign follicular nodule Toxic nodule Adenomatoid nodule Colloid nodule Follicular adenoma Hürthle cell adenoma Thyroiditis Chronic lymphocytic (Hashimoto) thyroiditis

Dr Ahmed Esawy

THYPES OF THYRIOD NODULES

Adenoma neoplastic Carcinoma Colloid nodule

Macro follicular

adenoma (simple

colloid)

Papillary (75 percent) Dominant nodule in a multinodular

goiter Follicular (10 percent)

Micro follicular

adenoma (fetal)

Medullary (5 to 10 percent) Other

Embryonal

adenoma

(trabecular)

Anaplastic (5 percent) Inflammatory thyroid disorders

Hürthle cell

adenoma

(oxyphilic,

oncocytic)

Other Subacute

thyroiditis

Thyroid

lymphoma 5

percent)

Chronic

lymphocytic

thyroiditis

Atypical adenoma Cyst Granulomatous

disease

Adenoma with

papillae

Simple cyst Developmental abnormalities

Signet-ring

adenoma

Cystic/solid tumors (hemorrhagic,

necrotic)

Dermoid

Rare unilateral lobe agenesis Dr Ahmed Esawy

TIRADS - Thyroid image reporting and data system

TIRADS 1 - normal thyroid gland

TIRADS 2 - benign lesions

TIRADS 3 - probably benign lesions

TIRADS 4 - suspicious lesions (4a, 4b, and 4c with increasing risk of malignancy)

TIRADS 5 - probably malignant lesions (> 80% risk of malignancy)

TIRADS 6 - biopsy proven malignancy

Dr Ahmed Esawy

TIRADS 2 – Colloid nodules - 0% risk of malignancy

Avascular anechoic lesion with echogenic specks (colloid type I)

Vascular heteroechoic non-expansile, non-encapsulated nodules with peripheral halo (colloid type II)

Isoechoic or heteroechoic, non-encapsulated, expansile vascular nodules (colloid

type III)

TIRADS 3 Hyperechoic, iso-echoic or hypoechoic nodules, with partially formed capsule and peripheral vascularity

<5% risk of malignancy Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Combined solid and cystic lesion 13% - 26% of thyroid cancers show cystic components

Benign : Halo – fibrous pseudocapsule however 10%-24% of papillary have incomplete halos

Dr Ahmed Esawy

Benign characteristic HALO

Dr Ahmed Esawy

Benign characteristic HALO

Dr Ahmed Esawy

Calcification

Dr Ahmed Esawy

Iso/hyperechoic, halo, smooth margins, peripheral vascularity

Dr Ahmed Esawy

“Spongiform” nodules

Dr Ahmed Esawy

Benign Masses Cysts and Cystic Nodules Sonographic Appearance

Purely anechoic areas (serous / colloid fluid), well-defined walls, & distal enhancement.

Fluid levels (hemorrhage)

FNA / Ethanol Injection

Degenerative Colloid Cysts

Dr Ahmed Esawy

Sonograms showing longitudinal (left panel) and transverse (right panel) images of the left lobe containing a degenerated thyroid nodule. Note the thick wall and irregularity. N=nodule, H=hemorrhagic degenerated region.

Benign Masses Cysts and Cystic Nodules

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Sonogram of the neck in the longitudinal plane showing a hypoechogenic nodule that was surrounded by an echo free rim, called a halo. Doppler examination demonstrated great vascularity in the halo, identified as bright spots. Small blood vessels are also seen elsewhere. N=nodule, L=heterogenous thyroid lobe, m=muscle.

Dr Ahmed Esawy

Transverse US images of mostly cystic thyroid nodule with a mural component containing flow. (a) Gray-scale image shows predominantly cystic nodule (calipers) with small solid-appearing mural component (arrowheads). (b) Addition of color Doppler mode demonstrates flow within mural component (arrowheads), confirming that it is tissue and not debris. US-guided FNA can be directed into this area. The lesion was benign at cytologic examination.

Dr Ahmed Esawy

Sagittal image of predominantly solid nodule (arrowheads), which proved to be benign at cytologic examination

Dr Ahmed Esawy

Transverse image of mixed solid and cystic nodule (calipers), which proved to be benign at cytologic examination

Dr Ahmed Esawy

Sagittal image of predominantly cystic nodule (calipers), which proved to be benign at cytologic examination. (e) Sagittal image of cystic nodule (arrowheads). FNA of this presumed benign lesion was not performed because the nodule appears entirely cystic.

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

COLLIOD NODULE Colloid nodules, also known as adenomatous nodules Colloid nodules are the most common thyroid nodules Benign overgrowth of normal thyroid tissue , noncancerous enlargement of thyroid tissue. The patient may have just one colloid nodule or many Although they may grow large they are not malignant they will not spread beyond the thyroid gland.

Dr Ahmed Esawy

Dr Ahmed Esawy

COLLIOD CYST

Dr Ahmed Esawy

Incidentally detected left-sided colloid nodule of the thyroid in a 74-year-old woman. (a) Axial T2-weighted MR image shows a well-circumscribed, hyperintense 2.2-cm nodule (arrow). Colliod nodule Dr Ahmed Esawy

Colloid nodule. Transverse US image shows a predominantly anechoic cystic lesion (*) with a thin wall, well-circumscribed margins, and mild posterior acoustic enhancement. Note the linear echogenic colloid crystals suspended within the fluid (arrow). These are all benign US features. Dr Ahmed Esawy

Benign thyroid nodule in a 51-year-old woman. Transverse sonogram of the right lobe of the thyroid shows a colloid nodule with a ring-down artifact (arrow), a finding indicative of inspissated colloid calcification

Dr Ahmed Esawy

Benign characteristic Comet tail

Dr Ahmed Esawy

Benign thyroid nodule in a 51-year-old woman. Transverse sonogram of the right lobe of the thyroid shows a colloid nodule with a ring-down artifact (arrow), a finding indicative of inspissated colloid calcification

Dr Ahmed Esawy

Adenoma

Dr Ahmed Esawy

Benign Masses Adenomas Most common solid thyroid mass

Encapsulated nodule compression of adjacent tissues fibrous encapsulation

Clinical Features

Most patients euthyroid or hyperthyroid Slow growing – must be 0.5 – 1 cm to be palpated

Sonographic Appearance Variable sonographic appearance Follicular carcinoma is indistinguishable from an

adenoma

Dr Ahmed Esawy

Toxic Nodular goiter Toxic adenoma PLUMMER DISEASE = autonomous function of one/more thyroid adenomas Follicular adenoma is benign

Dr Ahmed Esawy

Adenomas

Well circumscribed; circular shaped

Peripheral halo (edema of compressed tissue)

Increased Color Flow

Cystic Degeneration

Rim Calcification

Homogeneous with variable size; Hyperechoic

Slow growing unless hemorrhage occurs (sudden painful enlargement)

Dr Ahmed Esawy

Dr Ahmed Esawy

Follicular adenoma in a 30-year-old woman. Transverse sonogram of the left lobe of the thyroid shows a follicular adenoma with a hypoechoic halo (arrows).

Dr Ahmed Esawy

Follicular adenoma in a 36-year-old woman. Longitudinal color Doppler sonogram of the right lobe of the thyroid shows perinodular flow around a follicular adenoma

Dr Ahmed Esawy

Follicular adenoma in a 30-year-old woman. Transverse sonogram of the left lobe of the thyroid shows a follicular adenoma with a hypoechoic halo (arrows).

Dr Ahmed Esawy

Follicular adenoma in a 36-year-old woman. Longitudinal color Doppler sonogram of the right lobe of the thyroid shows perinodular flow around a follicular adenoma.

Dr Ahmed Esawy

Large toxic follicular adenoma in a 45-yearold woman. (a) Transverse sonogram of the left lobe of the thyroid shows a 4.5-cm nodule (arrows) that was benign despite its size. (b) Coronal scintigram obtained with technetium 99m pertechnetate shows a hyperfunctioning adenoma (arrow).

Dr Ahmed Esawy

Large toxic follicular adenoma in a 45-yearold woman. (a) Transverse sonogram of the left lobe of the thyroid shows a 4.5-cm nodule (arrows) that was benign despite its size. (b) Coronal scintigram obtained with technetium 99m pertechnetate shows a hyperfunctioning adenoma (arrow).

Dr Ahmed Esawy

Adenomatous nodule in a 66-year-old man with a low thyroid-stimulating hormone level of 0.1 mIU/mL. (a) Transverse US image shows a predominantly solid 2.4-cm nodule with well-circumscribed margins and a surrounding halo (benign US features). (b) Scintigraphic image obtained with 123I shows increased uptake in a hot nodule and relative photopenia of the adjacent normal thyroid tissue. The outline of the neck is not well visualized.

Dr Ahmed Esawy

Autonomous functioning thyroid adenoma

Dr Ahmed Esawy

Calcified left lobe of thyroid, with deviation of trachea to right

calcified adenoma Hyperthyriodism since ten years

Dr Ahmed Esawy

non-enhanced CT showing eggshell calcification of a thyroid adenoma in the right thyroid lobe

Dr Ahmed Esawy

Enhanced axial neck CT in a different patient shows a 1.3-cm low-density mass in the left thyroid lobe (arrows). This is nonspecific regarding benign (i.e., goiter or adenoma) versus malignant disease (cancer).

Dr Ahmed Esawy

Sub sternal Thyroid (CT)

Dr Ahmed Esawy

Sonograms of the right thyroid lobe in the longitudinal plane showing a 2.7 x 3.2 mm hypoechoic nodule that is delineated in the lower panel by the xx and ++ symbols. Note the linear hypoechoic structure below that (arrow). In the upper panel the bright structure is a Doppler signal and indicates a blood vessel below the nodule. The nodule is not vascular

Dr Ahmed Esawy

a–d. A 72-year-old man with a recently diagnosed lingual thyroid. Unenhanced CT image (a) shows a round, well-defined, and heterogeneously dense soft tissue mass at the tongue base (arrows). T2-weighted MR image (b) shows slightly increased signal intensity in the lesion (arrows). Contrast enhanced T1-weighted MR image

(c) shows strong heterogeneous enhancement of the mass (arrows). The airway passage is nearly obstructed by the lingual thyroid at the oropharynx in all images. A transverse US (d) reveals a smooth hypoechoic tumor with cystic areas.

Dr Ahmed Esawy

MNG

Dr Ahmed Esawy

MNG

Antero posterior chest radiograph of an 86-year-old woman who had been unwell for a few months and was losing weight. The radiograph shows a right superior mediastinal mass.

Dr Ahmed Esawy

MNG

Ten-millimeter computed tomography section through the thorax shows a heterogeneous mass (m) at the root of the neck, on the left, that displaces the trachea to the right. The mass appears to be growing in the caudal direction and is reaching the arch of the aorta

Dr Ahmed Esawy

Thyroid nodules. CT scan shows a mass in the posterior mediastinum (P), which displaces the air-filled esophagus to the right (arrow)

Thyroid nodules. Iodine-123 thyroid scan shows that a mass is a multinodular goiter (G). The posterior mediastinal mass is a hiatus hernia (H); the stomach (S) is shown. Further investigation revealed that thyrotoxicosis was the cause of the patient's symptoms

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

MALIGNANT THYRIOD NODULES MASSE

Dr Ahmed Esawy

Ultrasound characteristics associated with an increased thyroid cancer risk

1.Hypoechoic 2.Microcalcifications 3.Central vascularity 4.Irregular margins 5.Incomplete halo 6.Tall>wide 7.Documented enlargement of a nodule Should not be used singly

Dr Ahmed Esawy

Ultrasound characteristics associated with a low thyroid cancer risk

1.Hyperechoic 2. Large, coarse calcifications (except medullary) 3.Periperal vascularity 4.Looks like puff pastry or Naponeon, Non-hypervascular Spongiform appearance 5.Comet-tail shadowing

Dr Ahmed Esawy

1.6% of patients with thyroid nodules will have thyroid cancers Approx. 96% of thyroid cancers are papillary and follicular cancers which each have excellent prognosis

Dr Ahmed Esawy

Specific features

Microcalcifications

Markedly hypoechoic

Taller than wide in transverse plane

Extension beyond thyroid margin

Cervical lymph node metastasis

Less specific features

No halo around nodule

Ill-defined or irregular margin

Solid

Increased central vascularity

US features of malignant nodules

Dr Ahmed Esawy

Selected Malignant Thyroid Lesions

Papillary carcinoma Follicular carcinoma Hürthle cell carcinoma Poorly differentiated carcinoma Anaplastic/undifferentiated carcinoma Medullary carcinoma Lymphoma Metastasis

Dr Ahmed Esawy

Dr Ahmed Esawy

TIRADS - Thyroid image reporting and data system

TIRADS 1 - normal thyroid gland

TIRADS 2 - benign lesions

TIRADS 3 - probably benign lesions

TIRADS 4 - suspicious lesions (4a, 4b, and 4c with increasing risk of malignancy)

TIRADS 5 - probably malignant lesions (> 80% risk of malignancy)

TIRADS 6 - biopsy proven malignancy

Dr Ahmed Esawy

TIRADS 4 & 5

Based on five features: 1. solid component 2. markedly hypoechoic nodule 3. microlobulations or irregular

margins 4. microcalcifications 5. taller-than-wider shape TIRADS 4a - one suspicious

feature

TIRADS 4b - two suspicious features

TIRADS 4c - 3-4 suspicious features

TIRADS 5 - all five suspicious features

4a - 5-10% risk of malignancy 4b & 4c - 10-80% risk of malignancy 5 - >80% risk of malignancy

Dr Ahmed Esawy

Hypoechoic, irregular margins, punctate microcalcifications, intra-nodular flow

Dr Ahmed Esawy

Thyroid US-Risk Stratification

Dr Ahmed Esawy

Malignant characteristic Hypo-echoic • Poorly defined • No halo

Dr Ahmed Esawy

Micro calcifications

Dr Ahmed Esawy

OVERLAPPING FINDINGS

Benign hyperplastic nodule Papillary ca

Dr Ahmed Esawy

Malignant Masses

Carcinoma of the thyroid is rare!

Risk of malignancy decreases with multiple nodules

A solitary thyroid nodule in the presence of cervical adenopathy on the same side suggests malignancy

Clinical Findings Asymptomatic nodule

Hoarseness

History of exposure to low dose ionizing radiation

Solitary fixed, rapidly enlarging nodule in patient under 14 years or over 65 years of age Dr Ahmed Esawy

Dr Ahmed Esawy

Papillary Carcinoma

Dr Ahmed Esawy

Papillary Carcinoma

Most common thyroid malignancy

Sonographic Findings

Hypo echoic

Microcalcifications

Hypervascularity

Possible cervical

lymph node metastasis

Dr Ahmed Esawy

PAPILLARY CARCINOMA

Dr Ahmed Esawy

PAPILLARY CARCINOMA

Dr Ahmed Esawy

Dr Ahmed Esawy

39-year-old man (a false-positive). A and B, Transverse and longitudinal sonographic images of the thyroid show mild hypoechogenicity, coarse echogenicity, and the presence of a microlobulated margin, but the thyroid pathology results showed a papillary thyroid carcinoma in the left lobe and normal thyroid parenchyma after thyroid surgery

Dr Ahmed Esawy

PAPILLARY CARCINOMA Hypoechoic • Poor halo • Margins poorly defined.

Dr Ahmed Esawy

PAPILLARY CARCINOMA

Dr Ahmed Esawy

PAPILLARY CARCINOMA

Dr Ahmed Esawy

Dr Ahmed Esawy

PAPILLARY CARCINOMA

Dr Ahmed Esawy

PAPILLARY CARCINOMA

Dr Ahmed Esawy

Papillary carcinoma in a 60-year-old woman with nontoxic multinodular goiter. (a) Longitudinal US image of the left lobe of the thyroid shows a 2.4-cm solid nodule in the lower pole with ill-defined margins and microcalcifications (arrow), both of which are suspicious US features. A shadowing macrocalcification is also noted (arrowhead). (b) Longitudinal US image of the right lobe shows three additional nodules: a 1.1-cm solid nodule (left), a 1.2-cm solid nodule (middle), and a 2.3-cm mixed cystic and solid nodule (right). In the right lobe, only the 2.3-cm nodule meets the US criteria for FNAB

Dr Ahmed Esawy

Punctate echogenicities in thyroid nodules. (a) Sagittal US image of nodule (arrowheads) containing multiple fine echogenicities (arrow) with no comet-tail artifact. papillary carcinoma

US image of nodule (arrowheads) containing cystic areas with punctate echogenicities and comet-tail artifact (arrow) consistent with colloid crystals in a benign nodule

Dr Ahmed Esawy

A)predominantly solid thyroid nodule (calipers). (b) marked internal vascularity,This was a papillary carcinoma

Dr Ahmed Esawy

Papillary thyroid carcinoma in a 42-year-old man. Transverse sonogram of the right lobe of the thyroid demonstrates punctate echogenic foci without posterior acoustic shadowing, findings indicative of microcalcifications (arrows).

Dr Ahmed Esawy

Transverse post-contrast CT demonstrating small bilateral papillary carcinomas, both showing substantial cystic change centrally. Small calcific foci are also discernible (arrowheads).

Dr Ahmed Esawy

3-year-old woman with Graves’ disease and diffuse sclerosing variant of papillary carcinoma. A and B, Transverse and longitudinal sonograms of right thyroid gland reveal scattered microcalcifications (arrows) and underlying heterogeneous hypoechogenicity

Papillary Thyroid Carcinoma Manifested Solely as Microcalcifications on Sonography Dr Ahmed Esawy

47-year-old woman with thyroid papillary carcinoma and ipsilateral neck node metastasis. Lesion suspected to be thyroid carcinoma was incidentally discovered during sonography intended for evaluation of palpated cervical nodules, which were proven to be benign lymph nodes. A, Longitudinal sonogram of left thyroid gland reveals multiple microcalcifications (arrows) at low pole and underlying heterogeneous hypoechogenicity. B, Transverse sonogram reveals lymph node located at left level IV, measuring 0.7 cm in length, without identifiable structure, indicating fatty hilum (arrows).

Papillary Thyroid Carcinoma Manifested Solely as Microcalcifications on Sonography Dr Ahmed Esawy

44-year-old woman with thyroid papillary carcinoma incidentally found on thyroid sonography during health examination. A and B, Transverse and longitudinal sonograms of right thyroid gland reveal clustered linear microcalcifications (arrows) and underlying heterogeneous hypoechogenicity.

Papillary Thyroid Carcinoma Manifested Solely as Microcalcifications on Sonography Dr Ahmed Esawy

Rare cystic papillary thyroid carcinoma in a 55-year-old woman

(c) Axial contrastenhanced CT image shows the tumor (arrows) but does not clearly depict its complexity.

Dr Ahmed Esawy

Diffuse follicular variant of papillary thyroid carcinoma in a 37-year-old woman with thyrotoxicosis mistaken for Graves disease.

(a) Transverse sonogram of the left lobe of the thyroid shows a heterogeneously hypoechoic enlarged thyroid (arrows) with no residual normal thyroid tissue. (b) Color Doppler image shows diffuse increased parenchymal vascularity

Dr Ahmed Esawy

Diffuse follicular variant of papillary thyroid carcinoma in a 37-year-old woman with thyrotoxicosis mistaken for Graves disease.

(c) Transverse sonogram of the right neck shows a lymph node metastasis inferior to the right lobe of the thyroid (arrow) with coarse calcification. This finding aroused suspicion about the possible presence of a primary thyroid carcinoma. Histopathologic analysis of the surgical specimen showed replacement of the thyroid gland by a diffuse follicular variant of papillary thyroid carcinoma. CCA common carotid artery

Dr Ahmed Esawy

Sagittal image of solid nodule (arrowheads), which proved to be papillary carcinoma

Dr Ahmed Esawy

Role of color Doppler US. (a) Transverse gray-scale image of predominantly solid thyroid nodule (calipers). (b) Addition of color Doppler mode shows marked internal vascularity, indicating increased likelihood that nodule is malignant. This was a papillary carcinoma.

Dr Ahmed Esawy

Papillary carcinoma in an 87-year-old man. Transverse sonogram of the thyroid isthmus shows a poorly defined tumor with marked hypoechogenicity and irregular margins (arrows) and without a hypoechoic halo. Dr Ahmed Esawy

Thyroid microcalcifications are psammoma bodies, which are 10–100-m round aminar crystalline calcific deposits . They are one of the most specific features of thyroid malignancy, with a specificity of 85.8%–95% (2,15–17) and a positive predictive value of 41.8%–94.2%

Papillary thyroid carcinoma in a 42-year-old man. (a) Photomicrograph (original magnification, 400; hematoxylin-eosin stain) shows a psammoma body (arrow), a round laminar crystalline calcification

Dr Ahmed Esawy

Papillary carcinoma of the thyroid. CT reveals an enhancing thyroid mass extending into the left neck. A central hypodense region is noted. A tissue plane separates tumor from trachea (t). e, esophagus.

Dr Ahmed Esawy

Coronal MRI scans demonstrating papillary carcinoma lymph node metastases. In the first example there is a dominant markedly enlarged left level III lymph node (A, STIR sequence) showing loss of normal architectural pattern and considerable heterogeneity. The T1 weighted sequence (B) shows the classic high signal cystic areas within the diseased node mass; heterogeneous appearances with high signal cystic areas are also demonstrated on the T2 weighted sequence (C).The second patient shows more extensive bilateral lymph node metastases, especially on the right.They are easily visible on the STIR sequence (D) while the T1 weighted sequence (E) once again demonstrates the high signal cystic areas characteristic of this condition.

Dr Ahmed Esawy

A 24-year-old woman with metastatic papillary carcinoma including a Delphian nodal metastasis. She presented with a right neck mass. Axial enhanced CT image shows a large mass in the right lobe of the thyroid. There are heterogeneously enhancing right level IV nodal masses (arrows) and an enlarged Delphian node (arrowhead).

Dr Ahmed Esawy

Papillary carcinoma arising in thyroglossal duct cyst. A multilobated cystic mass is seen anterior to the supraglottic portion of the larynx. Focal areas of calcification (arrows) and thickened soft-tissue septa (arrowheads) are seen within the mass. C, common carotid artery; J, internal jugular vein.

Dr Ahmed Esawy

Trachea, stenosis. Papillary carcinoma in a multinodular goiter (MNG) shows the compression and deviation of trachea (green arrow); the red arrow indicates the esophagus.

Dr Ahmed Esawy

A 58-year-old man with papillary thyroid carcinoma presenting with large cystic nodal metastases and occult primary on imaging. (a) Axial enhanced CT image shows bilateral neck cystic masses, larger on the left (arrows). The thyroid had normal appearance on CT without focal lesions. The gland was also normal on sonography (not shown). (b) Coronal reformatted enhanced CT image shows multiple complex solid cystic masses in lateral nodal groups, levels II, III and IV on the left and level IV on the right (arrows). There are similar smaller cystic masses inferior to both lobes of the thyroid gland in keeping with level VI nodes (curved arrows). Dr Ahmed Esawy

A 61-year-old man with papillary thyroid carcinoma in both thyroid lobes and bilateral nodal metastases of varying morphological appearance and size. Coronal enhanced CT image shows the primary tumor as a large heterogeneous mass in the inferior left thyroid lobe with areas of coarse and eggshell calcifications (arrowheads). There is a large heterogeneous left level III nodal metastasis (asterisk). The inferior right lobe of the thyroid has a subtle low attenuation region (black arrow), which was also malignant on the total thyroidectomy specimen. There are small cystic nodal metastases in the right level VI and level II nodal groups (curved arrows) of different morphology from the large left neck mass. Dr Ahmed Esawy

A 19-year-old woman with papillary thyroid carcinoma presenting with cystic nodal metastases. Axial enhanced CT image shows a radiographically simple cyst (arrowheads) that actually represents a right level IV nodal metastasis. The right internal jugular vein is compressed anterior to the cyst indicating this lesion lies in the carotid space. There is a 1 cm solid primary tumor in the right lobe of the thyroid with fine calcifications (arrow). The differential for a cystic neck mass in a young patient and particularly in a female is a cystic nodal metastasis from thyroid carcinoma, SCCa and a congenital cyst such as a branchial cleft cyst Dr Ahmed Esawy

A 52-year-old woman with papillary carcinoma and a retropharyngeal metastasis. She had a history of fibromyalgia and presented with 1 year of right-sided neck pain. On clinical examination, she was found to have right neck adenopathy and an enlarged right thyroid lobe, subsequently proven to contain papillary thyroid carcinoma. A contrast-enhanced CT scan was performed before thyroid carcinoma was suspected. (a) Axial enhanced CT image shows subtle asymmetry of the prevertebral muscles (arrows). (b) The same axial enhanced CT image with narrowed window width shows a metastatic right retropharyngeal node (arrow) to be much more conspicuous. This case highlights the subtlety of retropharyngeal nodes on CT, which may be even more problematic when contrast is not given. Dr Ahmed Esawy

A 68-year-old woman with papillary thyroid carcinoma with nodal metastatic disease invading the trachea. (a) Axial T2-weighted image shows a T2 hyperintense mass in the right paratracheal region (arrow) with soft tissue signal in the right tracheal cartilage and an intraluminal mass (arrowhead). (b) Coronal T2-weighted image shows the mass encasing the right brachiocephalic artery (BCA) with loss of the fat plane. There is also a right level IV nodal metastasis (curved arrow). She was treated with radioactive iodine and tracheal stenting. Four months later she presented with massive hemoptysis. CT images at presentation showed progression of disease. Dr Ahmed Esawy

A 41-year-old woman with treated papillary carcinoma and a cystic nodal recurrence. She was initially treated with thyroidectomy and a central neck dissection followed by ablative 131I therapy. Serum thyroglobulin levels were not increased on follow-up, but a palpable low neck mass was evident. (a) Axial T1-weighted MRI demonstrates a rounded hyperintense lesion (arrow) with a posterior solid nodule (arrowhead) anterior to the right trapezius muscle corresponding to level Vb. The lesion has similar signal intensity to adjacent fat. (b) Axial T2-weighted MRI shows the lesion to be T2 hyperintense (arrow) except for the solid posterior nodule (arrowhead). This was resected and found to be a predominantly cystic papillary thyroid nodal recurrence. The T1 and T2 hyperintense signal likely represents high protein content in the cyst from colloid, thyroglobulin or blood products. Intrinsically hyperintense nodal metastases can be difficult to appreciate on T1 and non-fat-saturated T2 and post-contrast sequences, especially when they are small nodal metastases. Cystic metastases may also be negative on 131I and PET imaging. Dr Ahmed Esawy

A, Axial T2-weighted image shows small mass located in left thyroid lobe (arrows) slightly hyperintense to abutting sternocleidomastoid muscle.

B, Apparent diffusion coefficient (ADC) map shows low ADC value (0.89 × 10−3 mm2/s) in lesion (arrows).

66-year-old woman with papillary thyroid carcinoma.

Dr Ahmed Esawy

Medullary Carcinoma C - Cells

Dr Ahmed Esawy

Medullary Carcinoma C - Cells

Clinical Findings

Hard, bulky mass

Abnormal serum calcitonin

levels

Sonographic Findings

Solid mass

Calcifications

Lymphadenopathy

Dr Ahmed Esawy

Medullary Carcinoma

Dr Ahmed Esawy

Medullary Carcinoma

Dr Ahmed Esawy

Medullary thyroid carcinoma in a 32-year-old man. (a) Transverse sonogram of the right lobe of the thyroid shows a large nodule with coarse calcification and posterior acoustic shadowing (arrows).

(b) Axial computed tomographic (CT) image shows the nodule with an internal focus of coarse calcification (arrows).

Dr Ahmed Esawy

Medullary thyroid carcinoma and calcified nodal metastases in a 57-year-old man. (a) Transverse sonogram shows a lymph node metastasis with coarse calcifications (arrows) immediately inferior to the left lobe of the thyroid. The metastasis was mistaken for a benign calcified hyperplastic thyroid nodule. Several truly benign thyroid nodules also were found at US, and these findings led to an incorrect diagnosis of multinodular thyroid. CCA common carotid artery

(b) Sagittal sonogram obtained at follow-up US shows two other calcified lymph node metastases (arrows) on the left side, at level 2

Dr Ahmed Esawy

Medullary carcinoma of thyroid gland. A large anterior neck soft-tissue mass replaces the entire normal thyroid gland on CT. The trachea (asterisk) is displaced to the right. Small flecks of calcium (arrowhead) are deposited throughout the mass.

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Thyroid nodules. Plain radiograph of the upper abdomen shows multiple conglomerates of punctate calcification in the right hypochondrium encroaching on the left hypochondrium. The final diagnosis was a medullary carcinoma of the thyroid (calcified), lymph node metastases at the root of the neck (calcified), right superior mediastinal metastases, and gross hepatomegaly with multiple calcified hepatic metastases

Dr Ahmed Esawy

Medullary carcinoma in a 36-year-old woman with a right-sided thyroid nodule. (a) Transverse duplex US image shows a 2.6-cm solid nodule with an ill-defined lateral margin and extracapsular extension beyond the thyroid margin (arrow). The nodule has a taller-than-wide appearance and is markedly hypoechoic. All of these are suspicious US features.

Dr Ahmed Esawy

Medullary thyroid carcinoma. Well-defined partially enhancing right paratracheal mass (arrowheads) is seen on the enhanced CT scan. Trachea (asterisk) is displaced to the left. The lesion abuts the right common carotid artery (arrow).

Dr Ahmed Esawy

Medullary thyroid carcinoma in a 32-year-old man. (a) Transverse sonogram of the right lobe of the thyroid shows a large nodule with coarse calcification and posterior acoustic shadowing (arrows). (b) Axial computed tomographic (CT) image shows the nodule with an internal focus of coarse calcification (arrows).

Dr Ahmed Esawy

Thyroid nodules. A 56-year-old man underwent subtotal thyroidectomy for a familial medullary carcinoma 2 years previously On routine follow-up examination, a mass was felt in the thyroid.

Coronal short-tau inversion recovery MRI shows carcinoma recurrence (R) and lymph node (L) metastases.

Coronal T1-weighted MRI shows a carcinoma recurrence (R) and lymph node (L) metastases.

Dr Ahmed Esawy

Trachea, stenosis. MRI of a patient with medullary thyroid carcinoma shows important compression and invasion of the trachea.

Dr Ahmed Esawy

Trachea, stenosis. Axial MRI shows posterolateral invasion of the trachea.

Dr Ahmed Esawy

MRI scan 4 years after thyroidectomy for medullary thyroid carcinoma. The post-contrast transverse T1 weighted image (A) demonstrates a substantial enhancing mass of recurrent tumour (arrowheads) lying against the trachea at the thoracic inlet. This is seen as a heterogeneous but predominantly high signal mass on the STIR sequence (B), which also demonstrates recurrent disease in the lymph node drainage (arrows).

Dr Ahmed Esawy

A 57-year-old man with MTC and coarsely calcified nodal metastases. Coronal reformatted unenhanced CT image shows a large coarsely calcified left level VI nodal mass. This is immediately inferior to the left lobe of the thyroid and was mistaken for a benign calcified hyperplastic thyroid nodule on initial ultrasonography before the CT. Several truly benign thyroid nodules were also found on ultrasonography leading to an incorrect diagnosis of multinodular goiter. CT showed other left level Iia and III nodal masses with coarse calcification, also representing MTC metastases (arrowheads).

Dr Ahmed Esawy

A 65-year-old man with locally invasive and metastatic MTC with tracheal invasion. He presented with a neck mass and had increased calcitonin levels. (a) Axial enhanced CT image shows a large left thyroid lobe mass that mildly narrows the trachea (asterisk), and abuts the esophagus (black arrow) with loss of the fat plane. The mass contacts the vertebral body (arrow), which was concerning for prevertebral space invasion. There is also a large left level IV nodal metastasis that displaces and indents the internal jugular vein (IJV) anteriorly and the common carotid artery (CCA) medially. (b) Coronal reformatted enhanced CT image shows tenting on the inner margin of the left trachea (arrow) suggesting intraluminal tumor extension. At surgery, there was frank invasion of the left trachea and prevertebral space, which precluded curative resection. Dr Ahmed Esawy

Dr Ahmed Esawy

Anaplastic (Undifferentiated) Carcinoma

Dr Ahmed Esawy

T categories for anaplastic thyroid cancer All anaplastic thyroid cancers are considered T4 tumors at the time of diagnosis. T4a: The tumor is still within the thyroid. T4b: The tumor has grown outside the thyroid.

Dr Ahmed Esawy

Anaplastic (Undifferentiated) Carcinoma

Clinical signs > 50 years of age Hard, fixed Rapid growth Pain, pressure,

tenderness Locally invasive

Sonographic Findings Hypoechoic mass,

possibly irregular Diffuse glandular

involvement Invasion of

surroundings Dr Ahmed Esawy

Thyroid nodules. Postero anterior chest radiograph shows a large, lytic, expanding metastasis in the anterior aspects of the right fifth and sixth ribs secondary to an anaplastic thyroid carcinoma in an 85-year-old woman. Note displacement of the trachea to the left by a mass lesion at the root of the neck.

Dr Ahmed Esawy

Anaplastic Carcinoma

Dr Ahmed Esawy

Anaplastic Carcinoma

Dr Ahmed Esawy

Poorly differentiated carcinoma in an 81-year-old man with a right-sided thyroid mass that was discovered at neck CT. (a) Transverse US image shows a predominantly hypoechoic 5.4-cm solid nodule with ill-defined margins (a suspicious US feature) and no normal adjacent thyroid parenchyma.

Dr Ahmed Esawy

Anaplastic thyroid carcinoma in an 84-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows an advanced tumor with infiltrative posterior margins (arrows) and invasion of prevertebral muscle. (b) Axial contrast-enhanced CT image shows a large tumor that has invaded the prevertebral muscle (arrows).

Dr Ahmed Esawy

Anaplastic thyroid carcinoma in an 84-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows an advanced tumor with infiltrative posterior margins (arrows) and invasion of prevertebral muscle..

(b) Axial contrast-enhanced CT image shows a large tumor that has invaded the prevertebral muscle (arrows)

Dr Ahmed Esawy

Transverse MRI scan (T2 weighted) through the thyroid and neck. The remaining normal thyroid gland is seen as relatively low signal compared with the ill-defined mass of anaplastic carcinoma arising from the posterior aspect of the right lobe

(A).The tumor extends posteriorly, coming to lie against the prevertebral muscles and laterally to encase the carotid artery (arrow).Posteromedially the tumor extends ound the back of the trachea, which it invades posteriorly (arrowhead), and abuts the esophagus (arrowhead), which is also probably invaded. For comparison a transverse post-contrast CT scan

(B) on the same patient demonstrates the irregular tumor enhancing poorly compared with the intensely enhancing normal thyroid. Once again carotid artery encasement is seen (arrow) and also invasion of the sternocleidomastoid muscle (arrowheads). Further inferiorly at the level of the thoracic inlet

Dr Ahmed Esawy

(C) the trachea is grossly narrowed by extensive tumor, the airway (arrowheads) reduced to a narrow slit.

Transverse MRI scan (T2 weighted) through the thyroid and neck. The remaining normal thyroid gland is seen as relatively low signal compared with the ill-defined mass of anaplastic carcinoma arising from the posterior aspect of the right lobe

Dr Ahmed Esawy

non-enhanced CT demonstrating diffuse hypodensity of the thyroid gland reflecting areas of cystic necrosis of anaplastic carcinoma

Dr Ahmed Esawy

A 61-year-old man with anaplastic thyroid carcinoma with invasion of the recurrent laryngeal nerve. He presented with hoarseness. (a) Axial enhanced T1-weighted MRI shows a heterogeneous enhancing mass (arrowheads) in the right lobe of the thyroid. There is loss of the fat plane in the tracheoesophageal groove. The mass abuts the trachea but the mass is5180 around the trachea. There is posterior displacement of the esophagus (arrow), but there is no circumferential mass. (b) Axial enhanced T1-weighted MRI at the level of the true vocal cords shows a dilated right laryngeal ventricle (curved arrow) and anteromedial positioning of the right arytenoid cartilage suggesting vocal cord paralysis. At surgery there was invasion of the right recurrent laryngeal nerve, and perichondrium of the cricoid and 1st to 3rd tracheal rings without deep tracheal invasion. Biopsies of the esophagus were egative. The patient had a total thyroidectomy, followed by chemoradiotherapy. One and two years later he had resection of a right adrenal metastasis and two lung metastases, respectively. Dr Ahmed Esawy

Follicular carcinoma

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Follicular carcinoma

Dr Ahmed Esawy

Follicular carcinoma

Dr Ahmed Esawy

Follicular carcinoma

Dr Ahmed Esawy

A 51-year-old woman with follicular carcinoma with venous invasion. She presented with an enlarging neck mass. (a) Axial enhanced CT image demonstrates a heterogeneously enlarged thyroid gland (arrows), displacing the trachea to the right. This was biopsied and determined to be follicular carcinoma. There was no evidence of neck adenopathy, and what resembles a node in the left neck (arrowheads) represents intravenous extension of tumor in the left internal jugular vein (IJV). (b) Coronal reformatted enhanced CT image better delineates extension of tumor in the left IJV (arrowheads). Dr Ahmed Esawy

contrast-enhanced CT showing heterogeneous nodule of the left thyroid gland, histologically proven follicular carcinoma

Dr Ahmed Esawy

Hurthle cell (follicular) carcinoma in a 60-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a partially cystic tumor with solid internal projections (arrows) and thick walls.

(b) Color Doppler sonogram (shown in black and white) depicts increased vascularity in the solid parts of the tumor (arrow).

Dr Ahmed Esawy

LYMPHOMA

Dr Ahmed Esawy

LYMPHOMA

Dr Ahmed Esawy

LYMPHOMA

Dr Ahmed Esawy

B cell lymphoma of the thyroid in a 73-yearold woman with Hashimoto thyroiditis. Transverse sonogram of the left lobe of the thyroid shows a large heterogeneous mass (between calipers) with marked hypoechogenicity when compared with the strap muscles (SM). A normal isthmus (arrow) also is visible. IJV internal jugular vein.

Marked hypoechogenicity is very suggestive of malignancy

Dr Ahmed Esawy

Thyroid lymphoma. A, B: Proton density-weighted MR images demonstrate an extensive tumor infiltrating the left and right neck. Both common carotid arteries (large arrows) are displaced posterolaterally. The left carotid is encased by tumor. The left internal jugular vein is not visualized and is most likely occluded. The posterior wall of the trachea (T) is infiltrated with tumor. The cricoid cartilage (small arrows) is well visualized because of the high signal from medullary fat. J, right jugular vein; e, esophagus; SCM, sternocleidomastoid muscle; arrowhead, enlarged lymph node.

Dr Ahmed Esawy

Primary thyroid lymphoma in a 54-year-old woman with long-standing goiter and a 1-month history of progressive neck swelling. (a) Longitudinal US image shows a diffusely enlarged and abnormally heterogeneous thyroid without normal intervening parenchyma. Note the infiltrative appearance and evidence of extracapsular extension (arrow), a suspicious US feature. (b) Axial CT image shows diffuse replacement of the thyroid parenchyma. Note the associated narrowing of the trachea and lateral displacement of the adjacent vascular structures. Mildly enlarged abnormal left cervical lymph nodes (*) are also evident

Dr Ahmed Esawy

Thyroid lymphoma. A, B: Proton density-weighted MR images demonstrate an extensive tumor infiltrating the left and right neck. Both common carotid arteries (large arrows) are displaced posterolaterally. The left carotid is encased by tumor. The left internal jugular vein is not visualized and is most likely occluded. The posterior wall of the trachea (T) is infiltrated with tumor. The cricoid cartilage (small arrows) is well visualized because of the high signal from medullary fat. J, right jugular vein; e, esophagus; SCM, sternocleidomastoid muscle; arrowhead, enlarged lymph node.

Dr Ahmed Esawy

Transverse MRI (T2 weighted image) demonstrating a homogeneous mass of lymphoma arising from the right lobe of an atrophic thyroid (long-standing Hashimoto’s disease) and extending widely in the right supraclavicular fossa and posterior to the thyroid.

Dr Ahmed Esawy

Coronal MRI scan (STIR sequence) showing heterenormous enlargement of the thyroid gland by lymphoma (A).Tumor extends in all directions, including into the mediastinum but also superomedially into the larynx and pharynx (arrowhead). Tumor can be seen on the transverse T2 weighted image (B) extending into the posterior aspect of the right vocal cord and the hypopharynx (arrowheads).

Dr Ahmed Esawy

Hürthle cell neoplasm in a 53-year-old man with a palpable thyroid nodule at physical examination. (a) Transverse US image shows a predominantly hypoechoic 1.5-cm solid nodule (arrow) that meets the criteria for biopsy

Dr Ahmed Esawy

Infiltrative primary leiomyosarcoma of the thyroid in a 90-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a tumor (between calipers) with infiltration from the posterior tumor margin into the prevertebral space (arrows).

Dr Ahmed Esawy

Malignant Lymph Nodes

Dr Ahmed Esawy

US features that should arouse suspicion about lymph node metastases include a rounded bulging shape, increased size, replaced fatty hilum, irregular margins, heterogeneous echotexture, calcifications, cystic areas vascularity throughout the lymph node instead of normal central hilar vessels at Doppler imaging

A completely uniform halo around a nodule is highly suggestive of benignity, with a specificity of 95%

Dr Ahmed Esawy

Abnormal cervical lymph nodes. (a) Sagittal US image of enlarged node (calipers) with central punctate echogenicities, consistent with microcalcifications, shows mass effect on internal jugular vein (V). Node was proved to be metastatic papillary carcinoma. (b) Sagittal US image of enlarged node (calipers) with cystic component. Node was proved to be metastatic papillary carcinoma.

papillary Carcinoma

Dr Ahmed Esawy

(7) Papillary carcinoma and cystic lymph node metastasis in a 28-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows an irregular hypoechoic tumor with microcalcifications. (b) Longitudinal sonogram of the right neck shows a cystic level 5 nodal metastasis with internal septation and foci of calcification (arrows). (c) Axial contrast-enhanced CT image shows the metastasis (arrow). Dr Ahmed Esawy

(8) Papillary carcinoma and vascular lymph node metastasis in a 27-year-old woman. (a) Transverse sonogram shows a tumor that has infiltrated the entire right lobe of the thyroid (arrows). (b) Transverse sonogram of the right neck shows a level 3 lymph node metastasis with increased vascularity (arrow). (c) Axial contrast-enhanced CT image shows a vascular lymph node with a targetlike appearance (arrow). Dr Ahmed Esawy

Papillary carcinoma and cystic lymph node metastasis in a 44-year-old woman with a multinodular thyroid. Transverse sonogram of the right lobe of the thyroid shows a hypoechoic carcinoma in the isthmus, with microcalcifications and absence of a halo (arrowheads). The right lobe of the thyroid is displaced anteriorly by a large, partially cystic, level 6 (paratracheal) nodal metastasis (arrows), which appears to be within the thyroid and which was mistaken for a benign thyroid nodule. Because several solid benign nodules were present, the initial diagnosis was benign multinodular thyroid. The cystic nodal metastasis was confirmed at surgery. CCA common carotid artery. Dr Ahmed Esawy

Transverse MRI scan through the thyroid (T2 weighted image) showing a relatively centrally placed papillary carcinoma of the thyroid (arrows) with central cystic change. Multiple abnormal lymph nodes are seen bilaterally (arrowheads) in the internal jugular and posterior cervical chains, also showing cystic change and representing metastatic disease Dr Ahmed Esawy

Metastasis to Lymph Nodes

How does the appearance of a

normal lymph node differ

from an abnormal lymph

node?

Normal

Dr Ahmed Esawy

Abnormal cervical lymph nodes. (a) Sagittal US image of enlarged node (calipers) with central punctate echogenicities, consistent with microcalcifications, shows mass effect on internal jugular vein (V). Node was proved to be metastatic papillary carcinoma. (b) Sagittal US image of enlarged node (calipers) with cystic component. Node was proved to be metastatic papillary carcinoma.

Dr Ahmed Esawy

Thyroid carcinoma. Axial contrast-enhanced CT scan shows a solitary mass (M) within the thyroid gland, lymphadenopathy (N), and infiltration of adjacent tissues.

Dr Ahmed Esawy

Metastases to thyroid

Dr Ahmed Esawy

(a) Transverse sonogram of the left lobe of the thyroid shows a tumor (between calipers) with infiltration from the posterior tumor margin into the prevertebral space (arrows).

(b) Axial unenhanced CT image shows the large size of the tumor and the extent of invasion (arrows).

Infiltrative primary leiomyosarcoma of the thyroid in a 90-year-old woman

Dr Ahmed Esawy

Metastatic lung carcinoma in a 63-year-old man with known lung carcinoma in whom a new thyroid nodule was discovered at staging CT. Longitudinal duplex US image shows a mildly heterogeneous, hypoechoic 3-cm solid nodule with increased peripheral and central vascularity. Increased central vascularity is a suspicious US feature.

Dr Ahmed Esawy

Renal cell carcinoma metastases to the thyroid in a 69-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows a round hypoechoic nodule (arrows) and an irregular-shaped hypoechoic nodule (arrowheads). (b) Color Doppler sonogram of the round nodule shows increased internal vascularity

Dr Ahmed Esawy

Renal cell carcinoma metastases to the thyroid in a 69-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows a round hypoechoic nodule (arrows) and an irregular-shaped hypoechoic nodule (arrowheads)..

(b) Color Doppler sonogram of the round nodule shows increased internal vascularity

Dr Ahmed Esawy

B cell lymphoma of the thyroid in a 73-yearold woman with Hashimoto thyroiditis. Transverse sonogram of the left lobe of the thyroid shows a large heterogeneous mass (between calipers) with marked hypoechogenicity when compared with the strap muscles (SM). A normal isthmus (arrow) also is visible. IJV internal jugular vein.

Dr Ahmed Esawy

Coronal MRI (STIR sequence) demonstrating squamous cell carcinoma metastasis to the right lobe of thyroid showing the characteristic necrotic appearance of this process. There is a large right upper cervical nodal metastasis (arrow) showing similar necrosis and a halo of high signal edema (arrowhead) indicating extranodal extension. Dr Ahmed Esawy

Thyroid carcinoma. Postcontrast CT image shows a large, irregular, low-density mass (M) destroying the left thyroid lamina and invading the left true vocal cord (arrowheads). More caudal images showed the mass arising from the left lobe of the thyroid.

Dr Ahmed Esawy

Thyroid carcinoma. A: Enhanced CT image demonstrates a large mass (M) infiltrating the right side of the neck and involving the right recurrent laryngeal nerve, resulting in right true vocal cord paralysis (white arrowheads). B: Similar findings are seen on T1-weighted MR image. Black arrowhead, common carotid artery; arrow, internal jugular vein; SCM, sternocleidomastoid muscle.

Dr Ahmed Esawy

Thyroid carcinoma. A: Enhanced CT image demonstrates a large mass (M) infiltrating the right side of the neck and involving the right recurrent laryngeal nerve, resulting in right true vocal cord paralysis (white arrowheads). B: Similar findings are seen on T1-weighted MR image. Black arrowhead, common carotid artery; arrow, internal jugular vein; SCM, sternocleidomastoid muscle.

Dr Ahmed Esawy

Cystic metastasis from thyroid carcinoma. A multiloculated, inhomogeneous, low-density mass (arrows) is seen posterior to the left internal jugular vein (J) and sternocleidomastoid muscle (SCM). C, common carotid artery; arrowheads, clinically unsuspected thyroid carcinoma.

Dr Ahmed Esawy

Differentiation of thyroid nodules whether benign or malignant can be done using the diffusion-weighted MR technique . using ADC values depending on MRI diffusion weighted imaging

Dr Ahmed Esawy

Magnetic Resonance Imaging

Arterial spin labeling (ASL)

Differentiation of autoimmune thyroid conditions

Treatment response evaluation in Graves disease

Diffusion weighted imaging (DWI)

Apparent diffusion coefficient (ADC) can be used to differentiate benign from malignant nodules (Schueller)

Benign = low signal intensities on DWI + high ADC

Malignant = high signal intensities on DWI + low ADC

Dr Ahmed Esawy

37 year old female presented with papillary thyroid cancer: Coronal T1: shows large heterogeneous nodule mainly involving the right lobe, nodule shows multiple hyper intense foci that denote . . .hemorrhagic foci, encroached upon the air column. Axial T1 shows ill heterogeneous nodule mainly involving the right lobe. It shows restricted diffusion

Dr Ahmed Esawy

Differentiated thyroid cancer:Radioiodine Whole Body Scan pre-ablation

• Radioiodine scanning remains the mainstay of staging for differentiated thyroid cancer. • Thyroid cancer surveys are possible only after neonatal thyroidectomy and are not appropriate for patients who have only undergone hemithyroidectomy. • Star artifact due to substantial thyroid remnant • I 123 or I 131

Dr Ahmed Esawy

THYROID INCIDENTALOMA

A Radiology term for a mass found incidentally on imaging studies performed for unrelated reasons. • Common incidentalomas seen in practice include: Thyroid, lung, liver, Adrenal, Renal. • Thyroid incidentalomas are the most common form of endocrine incidentalomas. • Thyroid incidentaloma is described as a mass identified on an imaging study including the neck for reasons other than Thyroid disease. All solid - 15 – 27% chance of malignancy

Dr Ahmed Esawy

Dr Ahmed Esawy

Thyroid nodules are common

• Majority >95% are benign

• About 50% of population have thyroid nodules.

• Majority of Thyroid cancers approx. 96% are Papillary or Follicular cancers.

• Papillary and follicular cancers have near 100%

5 year survival for stage 1 and stage 2.

• Observed thyroid nodules has increased rapidly in last several decades however mortality is stable.

Dr Ahmed Esawy

Nonspecificity of hypodense thyroid lesions on CT. A: A relatively low-attenuation mass (arrows), due to nodular hyperplasia, is seen in the right lobe of the thyroid gland. C, common carotid artery; J, internal jugular vein; Th, left lobe of thyroid. B: Another patient presents with a similar-appearing low-attenuation nodule (arrow), due to metastatic adenocarcinoma, in the right lobe of the thyroid gland. C, carotid artery; J, jugular vein.

Dr Ahmed Esawy

Nonspecificity of hypodense thyroid lesions on CT. A: A relatively low-attenuation mass (arrows), due to nodular hyperplasia, is seen in the right lobe of the thyroid gland. C, common carotid artery; J, internal jugular vein; Th, left lobe of thyroid. B: Another patient presents with a similar-appearing low-attenuation nodule (arrow), due to metastatic adenocarcinoma, in the right lobe of the thyroid gland. C, carotid artery; J, jugular vein.

Dr Ahmed Esawy

Sonogram in the transverse plane after thyroidectomy for cancer from a muscular man. There was no palpable mass. The image shows a rounded lymph node that was cancer. C=carotid artery, m=muscle, ++ marks the node.

Dr Ahmed Esawy

Three patients with incidental thyroid nodules that were similar in size but were reported differently. A, A 46-year-old man with a 12-mm incidental nodule in the left thyroid lobe detected on chest CTA performed to evaluate an abdominal aortic aneurysm. The nodule was reported only in the “Findings” section of the report without a recommendation. B, A 47-year-old woman with a 10-mm incidental nodule in the right thyroid lobe detected on chest CTA performed to evaluate chest pain. The nodule was reported in the “Impression” section without a recommendation. C, A 63-year-old man with several incidental thyroid nodules detected on cervical spine CT performed to evaluate neck injury.The largest was in the left thyroid lobe and measured 10 mm. The nodule was reported in the “Impression” section with a recommendation for sonography. Dr Ahmed Esawy

Pitfalls in the Diagnosis of Malignancy

Dr Ahmed Esawy

Cystic Variant of Papillary Carcinoma

Hu¨ rthle cell (follicular) carcinoma in a 60-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a partially cystic tumor with solid internal projections (arrows) and thick walls. (b) Color Doppler sonogram (shown in black and white) depicts increased vascularity in the solid parts of the tumor (arrow)

Dr Ahmed Esawy

Cystic component occurs in 13-26%

Predominant cystic appearance is rare

Can mimic benign cystic hyperplastic nodule

Cystic variant of papillary carcinoma

Look for • Solid components with vascularity • Solid excrescences protruding into

the cyst • Angle of contact by the solid

component with the cyst wall • Acute – malignancy • Obtuse – degenerating cyst (colloid)

• Microcalcifications

Dr Ahmed Esawy

Rare cystic papillary thyroid carcinoma in a 55-year-old woman. (a) Transverse sonogram of the right lobe of the thyroid shows a complex cystic lesion with thick walls and solid components (arrows). (b) Color Doppler sonogram shows vascularity in a small part of the lesion margin (arrow). (c) Axial contrastenhanced CT image shows the tumor (arrows) but does not clearly depict its complexity. A cystic component occurs in 13%–26% of all

thyroid malignancies Dr Ahmed Esawy

Cystic or Calcified Lymph Node Metastases

Medullary thyroid carcinoma and calcified nodal metastases in a 57-year-old man. (a) Transverse sonogram shows a lymph node metastasis with coarse calcifications (arrows) immediately inferior to the left lobe of the thyroid. The metastasis was mistaken for a benign calcified hyperplastic thyroid nodule. Several truly benign thyroid nodules also were found at US, and these findings led to an incorrect diagnosis of multinodular thyroid. CCA common carotid artery. (b) Sagittal sonogram obtained at follow-up US shows two other calcified lymph node metastases (arrows) on the left side, at level 2. (c) Coronal unenhanced CT image shows the calcified nodal metastases in both locations (arrows). Dr Ahmed Esawy

Diffusely Infiltrative Hypervascular Tumor

Diffuse follicular variant of papillary thyroid carcinoma in a 37-year-old woman with thyrotoxicosis mistaken for Graves disease. (a) Transverse sonogram of the left lobe of the thyroid shows a heterogeneously hypoechoic enlarged thyroid (arrows) with no residual normal thyroid tissue. (b) Color Doppler image shows diffuse increased parenchymal vascularity. (c) Transverse sonogram of the right neck shows a lymph node metastasis inferior to the right lobe of the thyroid (arrow) with coarse calcification. This finding aroused suspicion about the possible presence of a primary thyroid carcinoma. Histopathologic analysis of the surgical specimen showed replacement of the thyroid gland by a diffuse follicular variant of papillary thyroid carcinoma. CCA common carotid artery.

Dr Ahmed Esawy

Diffusely infiltrative hypervascular tumour

This variant can be seen in papillary, follicular carcinomas and lymphoma

Mimics autoimmune conditions Ex. Graves / thyroiditis

De Quervain’s thyroiditis – hypoechoic nodule, may be taller than wide / may have microcalcification Short duration of history of pain Soft on Elastography

Case of thyroid lymphoma – markedly hypoechoic and diffusely enlarged thyroid gland in a 62 year old man

Look for Echogenicity – markedly hypoechoic History Microcalcifications

Dr Ahmed Esawy

FNAB

Dr Ahmed Esawy

INDICATIONS FOR PERFORMING

ULTRASOUND-GUIDED FNA BIOPSY OF A

THYROID NODULE MANY INVESTIGATORS HAVE SHOWN A MARKED

DECREASE IN INADEQUATE SPECIMENS WHEN FNA BIOPSY IS DONE UNDER ULTRASOUND GUIDANCE. UG FNA BIOPSY IS INDICATED IN:

NON-PALPABLE NODULES (e.g. HIGH SUBSTERNAL).

SMALL NODULES (<1.5 CM).

POSTERIOR NODULES.

CYSTIC OR COMPLEX NODULES (TO BIOPSY MURAL COMPONENT).

OBESE, MUSCULAR, OR LARGE FRAME PATIENT.

DOMINANT NODULE IN MULTINODULAR GOITER.

PREVIOUS UNSUCCESSFUL FNA BIOPSY.

Dr Ahmed Esawy

US/Clinical Features Indication/Threshold for FNAB Solitary nodule Solid nodule with suspicious US features, particularly ≥1 cm microcalcifications Solid nodule without suspicious US features ≥1.5 cm Mixed cystic-solid nodule with suspicious US features ≥1.5 cm Mixed cystic-solid nodule without suspicious US features ≥2 cm Spongiform nodule ≥2 cm Simple cyst with none of the aforementioned characteristics FNAB not necessary Substantial growth (>50%) since previous US examination FNAB indicated Suspicious cervical lymph node FNAB lymph node with or without a nodule Multiple nodules Normal intervening parenchyma FNAB of up to four suspicious nodules, with selection based on criteria for a solitary nodule; if no suspicious nodule is present, biopsy of the largest nodule may be considered No normal intervening parenchyma FNAB not necessary Diffuse rapid enlargement of thyroid FNAB indicated to exclude anaplastic carcinoma, lymphoma, or metastasis Clinically high risk of thyroid cancer Threshold for FNAB is lower due to high risk of thyroid cancer (eg, threshold >0.5 cm for a suspicious solid nodule) History of radiation exposure in childhood or adolescence FDG-avid nodule at PET Age <15 y or >45 y, particularly in males First-degree relative with thyroid cancer or type 2 MEN Personal history of thyroid cancer at lobectomy Personal history of thyroid cancer–associated conditions (familial adenomatous polyposis, Carney complex, Cowden syndrome, or type 2 MEN)

Guidelines for FNAB Indications Based on US and Clinical Features

Dr Ahmed Esawy

Drawing illustrates FNAB technique, with parallel positioning of the needle relative to the US transducer and the thyroid

Dr Ahmed Esawy

Capillary technique for FNAB. (a) Photograph shows proper positioning of the biopsy needle, which is oriented parallel to the US transducer. Note that no syringe is attached to the 27-gauge biopsy needle (Movie 1 [online]). (b) Transverse US image demonstrates the hyperechoic needle along its length. The needle tip is positioned within the superficial portion of the hypoechoic left-sided thyroid nodule

Dr Ahmed Esawy

In general, for an FNAB to be considered diagnostic (adequate), a minimum of six groups of ten follicular cells must be present upon totaling all slides

If there are multiple suspicious nodules, up to four such nodules should be considered for FNAB

We suggest that core biopsy be performed in addition to FNAB for the sampling of nodules with a prior nondiagnostic or indeterminate FNAB

follicular adenoma and follicular carcinoma cannot usually be distinguished with FNAB alone and are reported as a follicular neoplasm . The histologic distinction between follicular adenoma and follicular carcinoma can be made only upon surgical excision, by assessing for the absence (adenoma) or presence (carcinoma) of capsular-vascular invasion.

Dr Ahmed Esawy

Aspiration technique for FNAB. (a) Photograph shows proper positioning of the biopsy needle, which is oriented perpendicular to the US transducer. Aspiration is achieved by means of gentle suction with a 10-mL syringe (Movie 3 [online]). (b) Transverse US image depicts the needle tip, which is identified as a hyperechoic focus (arrow) within the center of the nodule

Dr Ahmed Esawy

Neck Masses Thyroglassal Duct Cyst Congenital anomaly Midline & anterior to

trachea Remnant of tubular dev’t

of thyroid gland persisting between the base of the tongue and the hyoid bone

Clinical Signs Palpable midline mass Pain associated with

hemorrhage or infection

Sonographic Findings Cystic mass in the midline

anterior to the trachea Internal echoes caused by

hemorrhage or infection Oval, spherical

Dr Ahmed Esawy

Brachial Cleft Cyst

Anterior to CCA

Along the border of the

sternocleidomastoid

muscle

Definite separation from

the thyroid gland

Dr Ahmed Esawy

EACH LOBE, AND ISTHMUS A. DIMENSIONS OF LOBES (CM) B. SHAPE OF LOBES, (conventional shape or indentations and where they are) C. ECHOGENICITY OF LOBES Hyperechoic Hypoechoic isoechoic D. VASCULARITY OF LOBES Physiologic Increased Decreased Avascular

Dr Ahmed Esawy

E. NODULE (S) IN EACH LOBE OR ISTHMUS Location Number of Nodules( 1 or 2, a few, multinodular) Do all nodules have uniform characteristics Does one nodule have noteworthy characteristics? * MARGINS Distinct ill-defined halo continuous discontinuous Echogenicity Hyperechoic Hypoechoic * Isoechoic * Composition Solid Cystic Complex (solid with cystic component) Shape Globular Irregular Taller than wide Vascularity Physiologic Decreased Avascular Increased Periperal Central * Calcifications Punctate * Coarse Egg-shell Other features Puff-pastry “Napolean-like” layers Bright spot with “comet tail shadowing”

Dr Ahmed Esawy

2. LYMPH NODES * LOCATION Ipsolateral to nodule Contralateral to nodule Relation to another anatomic structure SHAPE Oval Globular * HILUM Fatty Vascular Absence * MARGIN Well-defined Ill-defined * VASCULARITY increased Physiologic BLOOD-FLOW FROM PERIPHERY RATHER THAN HILUM * CALCIFICATIONS Punctate * Coarse Egg-shell COMPOSITION Solid Complex with cystic component * IMPACT ON SURROUNDING STRUCTURES Deforms * No impact

Dr Ahmed Esawy

3. EXTRA-THYROID BED MASS ANATOMIC SITE (THYROGLOSSAL? SUB-LINGUAL?) ULTRASONIC CHARACTERISTICS 4. COMPARISON WITH PRIOR EXAMINATION PRIOR DATE COMPARISON BASED ON REPORT OR IMAGES? TECHNICALLY COMPARABLE? COMPARE CHARACTERISTICS OF LOBES COMPARE CHARACTERISTICS OF NODULES COMPARE CHARACTERISTICS OF NODES

Dr Ahmed Esawy

TNM CLASSIFICATION T categories for thyroid cancer

(other than anaplastic thyroid cancer) TX: Primary tumor cannot be assessed. T0: No evidence of primary tumor. T1: The tumor is 2 cm (slightly less than an inch) across or smaller and has not grown out of the thyroid. T2: The tumor is more than 2 cm but not larger than 4 cm (slightly less than 2 inches) across and has not grown out of the thyroid. T3: The tumor is larger than 4 cm across, or it has just begun to grow into nearby tissues outside the thyroid. T4a: The tumor is any size and has grown extensively beyond the thyroid gland into nearby tissues of the neck, such as the larynx (voice box), trachea (windpipe), esophagus (tube connecting the throat to the stomach), or the nerve to the larynx. This is also called moderately advanced disease. T4b: The tumor is any size and has grown either back toward the spine or into nearby large blood vessels. This is also called very advanced disease.

Dr Ahmed Esawy

TNM CLASSIFICATION

N categories for thyroid cancer NX : Regional (nearby) lymph nodes cannot be assessed. N0 : The cancer has not spread to nearby lymph nodes. N1 : The cancer has spread to nearby lymph nodes.

Dr Ahmed Esawy

TNM CLASSIFICATION

M categories for thyroid cancer

MX: Distant metastasis cannot be assessed. M0: There is no distant metastasis. M1: The cancer has spread to other parts of the body, such as distant lymph nodes, internal organs, bones, etc

Dr Ahmed Esawy

T: Tumour Tx: primary tumour cannot be assessed T0: no evidence of primary tumour T1: tumour ≤2 cm in greatest dimension limited to the thyroid

T1a: tumour ≤1 cm, limited to the thyroid T1b: tumour >1 cm but ≤2 cm in greatest dimension, limited to the thyroid

T2: tumour >2 cm but ≤4 cm in greatest dimension, limited to the thyroid T3: tumour >4 cm in greatest dimension limited to the thyroid or any tumour with minimal extrathyroid extension (e.g. extension to sternothyroid muscle or perithyroid soft tissues) T4: advanced disease

T4a: moderately advanced disease - tumour of any size extending beyond the thyroid capsule to invade subcutaneous soft tissues, larynx, trachea, oesophagus, or recurrent laryngeal nerve T4b: very advanced disease - tumour invades prevertebral fascia or encases carotid artery or mediastinal vessels cT4a: intrathyroidal anaplastic carcinoma cT4b: anaplastic carcinoma with gross extrathyroid extension

Dr Ahmed Esawy

N: Nodes

Nx: regional lymph nodes cannot be assessed N0: no regional lymph node metastasis N1: regional lymph node metastasis

N1a: metastases to level VI (pretracheal, paratracheal, and prelaryngeal/Delphian lymph nodes) N1b: metastases to unilateral, bilateral, or contralateral cervical (levels I, II, III, IV, or V) or retropharyngeal or superior mediastinal lymph nodes (level VII)

Dr Ahmed Esawy

M: Metastases

Mx: distant metastases cannot be assessed M0: no distant metastasis M1: distant metastasis

Dr Ahmed Esawy