Noduli Tiroidei caratteristiche ecografiche di rischio

1. &
INTERVENTIONAL
TECHNIQUES
Indispensable tool for risk stratification and
interventional procedure of thyroid lesions
Massimiliano Andrioli
EndocrinologiaOggi, Rome, Italy

2. THYROID US
Detect US features suggestive of malignancy and
select the lesions for biopsy
AACE/ACE/AME Guidelines 2016
Guide in interventional techniques (FNC, PEI,
thermal ablation)

3. Thyroid ultrasonography is an useful tool
for:
 - risk stratification
 - interventional procedures
of thyroid lesions
THYROID US

4. THYROID NODULES

5.  Due to an increased use of ultrasonography we assist to
an increasing number of incidentally discovered thyroid
lesions
THYROID NODULES

6. 70
0
10
20
30
40
50
60
0 10 20 30 40 50 60 70 80 90
Age (years)
Autopsy or
Neck ultrasound
Palpation(Mazzaferri et al. 1993)
Thyroid nodule prevalence
 This figure shows the increased prevalence of thyroid
lesions discovered by neck ultrasound (compared to neck
palpation)

7. Douglas S. Ross
 So that, some authors wonder how to handle this
epidemic of thyroid nodules

8. First of all, we should reduce the number of ultrasound
examinations, and select patients to undergo
ultrasonography.
Ultrasound evaluation is recommended for patients who:
 are at risk for thyroid malignancy (<5%)
 have palpable thyroid nodules or goiter
 have neck lymphadenopathy suggestive of a malignant
lesion
INDICATIONS
AACE/ACE/AME Guidelines 2016

9. Once understood who should undergo US, we need
to clarify how to write a good US thyroid report
HOW TO WRITE A US
REPORT ?

10.  should use an universal standardized terminology for
description of thyroid lesions
 should reduce the variability in ultrasound reports
among operators
 should help endocrinologists to take reproducible
decisions on thyroid lesions
 represents the best tool to select the nodule(s) at risk
of malignancy to undergo FNC
US REPORT..

12. THYROID NODULE: US REPORT
Andrioli et al. ETJ, 2013
BTA Guidelines, Clinical Endocrinology, 2014
 Total number (not describe all lesions)
 Position (capsule relationship)
 Shape
 Composition
 Echogenicity
 Echotexiture
 Margins
 Vascularity
 Size
 (Hardness)

13.  In multinodular goiters, US should detail the nodule(s)
bearing the US features associated with malignancy
rather than describe all the lesions or the largest one(s)
TOTAL NUMBER

14. Right lobe
Left lobe
Isthmus
Rarely pyramidal lobe.
More rarely median ectopic
POSITION
 The position of thyroid lesion has no relevance in the
differential diagnosis of thyroid cancer. Useful in identifying and
following-up the nodule.
 Attention in suspicious sub-capsular lesions
Upper third
Middle third
Lower third
POSITION

15.  Deformation: thyroid capsule is only dislocated with no
interruption of its hyperechogenicity
 Capsule infiltration: clear interruption of capsular
hyperechogenicity at the nodule level (suspicious for
malignancy, but not necessarily invasion of surrounding
structures)
 Invasion of adjacent tissues: more frequent in invasive tumors
(anaplastic carcinoma, thyroid lymphomas or advanced
differentiated thyroid carcinoma).
CAPSULE RELATIONSHIP

16. CAPSULE DEFORMATION

17. EXTRACAPSULAR INVASION

18. OVAL
anteroposterior diameter less
than the transverse one
ROUND
anteroposterior diameter equal
to transverse one
TALLER THAN WIDE
anteroposterior diameter greater
than the transverse one (highly
suspicious)
IRREGULAR
morphology different from the previous
ones
SHAPE

19. Taller than wide

20. TALLER THAN WIDE

21. SOLID
liquid content less than
10% of the nodule volume
MIXED – MAINLY LIQUID
Liquid portion> 50% of the
nodular volume
MIXED – MAINLY SOLID
Liquid portion> 10% but ≤ 50%
of the nodular volume
CYSTIC
Liquid portion >90%
SPONGIFORM
aggregations of multiple microcystic
areas (<5 mm) separated by thin septa
INTERNAL CONTENT

22. Solid pattern

23. INTERNAL CONTENT

24.  Anechoic: fully transonic (fluid cysts)
 Isoechoic: same echogenicity of thyroid
 Hyperechoic: more echogenic than thyroid parenchyma
 Hypoechoic: hypoechoic compared to thyroid parenchyma
(55% of benign lesions are hypoechoic)
 Markedly hypoechoic: hypoechoic to adjacent muscles
(highly suspicous)
ECHOGENICITY

25. Hypoechoic appearance

26. Hypoechoic
Hyperechoic
Modified by Andrioli et al., ETJ 2013
Markedly hypoechoic
ECHOGENICITY

27. isoechoic
ECHOGENICITY

28.  Homogeneous
 Finely inhomogeneous
 Markedly inhomogeneous
ECHOSTRUCTURE
Ecostructure is not decisive in the differential diagnosis of thyroid
cancer.

29.  Microcalcifications: small point-like hyperechoic spots (diameter
<1 mm) without posterior acoustic shadow (more frequent in large
papillary tumors, less in small PTCs, but also described in benign
nodules). It is a suspicious feature (high specificity, low sensibility)
 Macrocalcifications: large (diameter>1 mm), coarse and often
associated with posterior acoustic shadow (we can find them in
both in old-benign lesions and in cancer)
 Peripheral ring calcifications: surround the nodule (ring or egg
shell) and can be complete or incomplete (suspicious).
 Artifacts: Hyperechoic spots of uncertain significance
CALCIFICATIONS

30. Microcalcifications

31. Microcalcifications

32. Macrocalcifications
Egg shell calcification

33. Iperechoic spots (uncertain significance)

34.  Well defined: clear demarcation from the surrounding tissue
 Poor defined/blurred: absence of clear demarcation from the adjacent
thyroid parenchyma
 Regular: uniform contours
 Irregular: heterogeneous contours.
Irregular spiculated: presence of one or more points/edges on margin
surface)
Irregular lobulated: presence of one or more convexity on its surface
Peripheral halo sign: complete, incomplete, thin regular, thick irregular.
Margins definition is the US parameter with greater inter-operator
disagreement !
MARGINS

35. Irregular/Blurred margins

36. Blurred margins

37. Irregular margins

38. Flow is assessable with colorDoppler and with powerDoppler (greater
ability to evaluate the flow in small vessels).
 Absent: no or little blood flow
 Perinodular: in the periphery of the nodule, complete or partial
 Intranodular: vascularization within the nodule
 Peri-intranodular: flow in the periphery and within the nodule. It can be
moderate or increased (blood flow)
The vascularity has no role in the differential diagnosis of thyroid cancer. It
is not reported as suspicious feature in the main risk classifications
VASCULARITY

39. Color Doppler Imaging

40. Perinodular blood flow
Modified by Andrioli et al., ETJ 2013
Mild intranodular
blood flow
Increased intranodular
blood flow
Peri-intranodular
blood flow

41. Modified by Andrioli et al., ETJ 2013
Increased intranodular blood flow

42.  Each nodule should be measured in its three diameters: antero-
posterior, transverse and longitudinal
 The risk of malignancy does not change with the size of the nodule
(useless in the distinction between malignant and benign lesions)
 Useful to evaluate volume increase: a 20% increase in its diameter (with
a minimum increase of 2 mm in two diameters) or a 50% increase of its
volume.
Common opinion: cancers grow more than benign lesions. But most of the
benign thyroid nodules can increase volume over time and a PTC can
show unchanged volume for years.
In case of fast size increase: aggressive neoplasm (MTC, anaplastic or
thyroid lymphoma).
SIZE

43. Elastosonography = electronic palpation.
It is a recent ultrasound technique able to provide information on the
hardness of a nodule.
Elastography does not replace ultrasound but provides complementary
information (regarding the hardness of a nodule)
Hardness is not considered in risk classifications
ELASTOSONOGRAPHY

44. Hardness

45. Now we have many US parameters to
evaluate, but how to use/combine all these
US features?
Some classification systems have been
created to stratify the risk of malignancy
and to identify nodules that require fine-
needle aspiration cytology
US CLASSIFICATION SYSTEMS

46. In 2002 Kim first reported a combination of 4
suspect ultrasound features
US CLASSIFICATION SYSTEMS

47. 10 echographic patterns combined in different
categories. Malignancy increases with increasing
suspicious features

51. It has shown a good correlation with cytological reports

52. < 2% < 2% 5% 5-20% >20%
TI- RADS ACR
It is based on a
point scale and
not on patterns
that must be
recognized
+ clear
- ambiguous
VPN 97,8%
http://tiradscalculator.com/tirads-calculator/tirads-calculator/

55. Low-Risk Ultrasound Features
Thyroid cyst
Mostly cystic nodule
with reverberating
artifacts
Isoechoic
spongiform nodule
AACE/ACE/AME Guidelines 2016
The expected risk of malignancy is about 1%

56. Intermediate-Risk Ultrasound Features
Isoechoic nodule
with central
vascularity
Isoechoic nodule
with
macrocalcifications
Isoechoic nodule
with indeterminate
hyperechoic spots
The expected risk of malignancy is 5% to 15%
AACE/ACE/AME Guidelines 2016

57. High-Risk Ultrasound Features
Marked
hypoechogenicity
Irregular margins
Taller than wide
Microcalcifications
Suspicious
regional
lymph node
The expected risk of malignancy is 50% to 90%
AACE/ACE/AME Guidelines 2016

59. Which Classification
System should be used?
At least one!

60. descriptive report
no description of the US features of thyroid nodules
description following scoring system
USE OF SCORING SYSTEM IN ITALY

61. Which is the best one?

62. US Classification Systems
Many papers comparing different
classification systems have been published

63. US Classification Systems
Comparing Scoring System is not the focus
of this talk.
Anyway, regardless which is the best one,
in my opinion, the presence of too many
classification systems may cause even
greater confusion between operators

64. A unique classification system will be proposed with
the agreement of many international societies.

65. Thyroid ultrasonography is an useful tool
for:
 - risk stratification
 - interventional procedures
of thyroid lesions
THYROID US
I just want to give a general overview on the various interventional
techniques that will be described in detail during the second part of
this meeting

66. The main interventional procedures are:
 FNC
 PEI
 Thermal Ablation (Laser, Radiofrequency)
THYROID US

67.  Thyroid FNA should always be performed under US
guidance because it makes the procedure safer, more
reliable, and more accurate.
 The use of US guidance for FNA is recommended,
whenever possible, for all thyroid nodules or cervical
lesions.
FINE NEEDLE ASPIRATION

68.  The thin needle can be attached to a syringe (ASPIRATION) or
not attached to a syringe (CAPILLARITY).
FNA: Method
COAXIAL
TECHNIQUE
LATERAL
TECHNIQUE

69.  FNA has both a diagnostic and an evacuative purpose
FNA: Cystic nodule

70.  Sample the solid component of the lesion;
 Possibly sample the vascularized areas of complex lesions;
 Submit both the FNA specimen and the drained fluid for
cytologic examination.
FNA: Complex thyroid nodule

71.  Sample peripheral and, possibly, solid areas to avoid
fluid or necrotic zones.
FNA: Large-size nodule

72. THYROID
ULTRASONOGRAPHY
Ultrasonography is an indispensable support
for the administration of ablative therapies

73. THYROID
INTERVENTIONAL
TECHNIQUES 2000-2018

74. PEI

76. PEI: Method
 During the PEI procedure, the patient undergoes
aspiration and emptying of the cystic nodule by thin
needle;
 Still under ultrasound monitoring, a volume of 95%
sterile ethanol is injected into the cystic cavity, equal to
about half the volume of liquid removed with
aspiration (usually 1-6 ml).
 After a few minutes, the alcohol is partially aspirated.
 The procedure takes about 20 minutes.
 Once the procedure is complete, the patient is required to
observe for 1-2 hours.

78.  The procedure is rapid, safe, and well-tolerated and
does not require medical support.
 Thyroid function is unaltered, and there is no induction
of thyroid autoimmunity.
PEI

79.  Thermal ablation are non-surgical procedures for
volume reduction of large thyroid nodules and
improvement of local pressure and/or cosmetic
symptoms in patients not candidates for surgery due to
high surgical and/or anesthetic risk
THERMAL ABLATION
This is a general overview, because the various interventional techniques will
be described in detail during second part of this meeting

81. THERMAL ABLATION

82.  The procedures are well-tolerated and effective for the
persistent reduction of large benign nodules.
 No long-term influence on thyroid function or
autoimmunity has been reported.
THERMAL ABLATION

83. Thanks for your attention..