TIRADS (thyroid nodule imaging reporting and data system) Dr Ahmed Esawy include different cases for oral radiodiagnosis examination all over the world CT /MRI Plain X ray ultrasound images INDICATIONS FOR PERFORMING ULTRASOUND-GUIDED FNA BIOPSY OF A THYROID NODULE GOITRE FOCAL/NODULAR MULTINODULAR UNINODULAR TOXIC NODULE INACTIVE COLD TOXIC NODULE TOXIC MULTINODULAR GIOTRE INACTIVE COLD DIFFUSE GIOTRE Hshimoto s thyroiditis Graves disease Subacute thyroiditis Suppurative thyroiditis Drug-induced thyroiditis Riedel s thyroiditis Iodine deficiency Organification defect Radiotion exposure pregnant ,menopause thyroiditis Silent thyrioditis/post partum thyroiditis Cold Thyroid Nodule  BENIGN TUMOR  Nonfunctioning adenoma  Cyst (11–20%)  Involutional nodule  Parathyroid tumor  INFLAMMATORY MASS  Focal thyroiditis  Granuloma  Abscess  MALIGNANT TUMOR  Carcinoma  Lymphoma  Metastasis  BENIGN NODULAR GIOTRE  NEOPLASM  Benign thyroid cysts (degenerated nodules)  Simple cyst  Haemorrhagic Cystic nodule in solid tumour  COLLIOD  Dominent colliod nodule in MNG  uninodular  Adenoma  macrofollicular (simple colliod)  microfollicular (fetal)  embryonal (trabecular)  hurthe cell adenoma  atypical adenoma  adenoma with papillae  signet ring adenoma  Inflammatory disorder  subacute thyrioditis  lymphocystic thyrioditis  granulomatous disease  (sarciodosis/TB)  abscess  developmental  dermiod  unilateral lobe agenesis  MALIGNANT NODULAR GIOTRE  MALIGNANT  Papillary carcinoma  Follicular carcinoma  Hurthle cell tumor  Medullary Thyroid Carcinoma  Anaplastic Carcinoma  Lymphoma of thyroid  HYPOTHYRIODISM  CONGENITAL  Hypoplasia & mal-descent  Agenesis ,hemiagenesis  Ectopia thyriod (sublingual thyriod)  Familial enzyme defects  Iodine deficiency (endemic cretinism)  Intake of goitrogens during pregnancy  Pituitary defects  Idiopathic  ACQUIRED  Iodine deficiency(diffuse giotre)  Hashimoto´s thyroiditis (autoimmune thyroiditis)  Subacute (De Quervein’s) thyroiditis  Thyroidectomy or RAI therapy  TSH or TRH deficiency  Medications (iodide & Cobalt,amiodarone))  Idiopathic  Post partum  amyliodosis  COMMON CAUSES OF HYPERTHYROIDISM  autoimmune diseases Graves disease (the most common cause of hyperthyroidism Lymphocytic thyroiditis With hyperthyroidism (silent thyroiditis) Postpartum thyrotoxicosis (PPT)  functioning thyroid adenomas (Hyperfunctioning thyroid nodules (toxic adenoma, toxic multinodular goiter, Plummer's disease)  Toxic multinodular goiter

1. TI-RADS (Thyroid nodule Imaging
Reporting and Data System)
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr Ahmed Esawy

2. Objectives:
Three Proposed TIRADS systems:
TIRADS by Horvath et al (2009)
TIRADS by Russ et al (2011)
TIRADS by Kwak et al (2011)
Image Reporting and Characterization System by Kwak (2013)
Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak,
Image Reporting and Characterization System by Kwak and their comparison
Dr Ahmed Esawy

3. TIRADS: OVERVIEW
 TIRADS system is ultrasonographic classification for thyroid nodules.
 The terminology “Thyroid Imaging Reporting and Data System” (TIRADS) was first used
by Horvath et al in 2009, drawing inspiration from the “Breast Imaging and Reporting
Data System” (BIRADS) of the American College of Radiology.
The goals:
 Stratify the risk of malignancy of a lesion based on the US features of the lesion.
 Standardize and simplify the reports, allowing effective communication between
radiologists, cytologists, and clinicians.
 Improve quality of care and cost-effectiveness, avoiding unnecessary biopsies.
Dr Ahmed Esawy

4. Thyroid Ultrasound Reporting Lexicon
Dr Ahmed Esawy

5. The thyroid lobes are normally 4–6 cm in craniocaudal length and 1.3–1.8 cm in their
anteroposterior and transverse dimensions; the isthmus normally has an anteroposterior
thickness of up to 3 mm
Dr Ahmed Esawy

6. Composition. (A) Solid nodule: 46-year-old man with 3.5-cm solid, hypoechoic nodule. Margins
are smooth. Macrocalcifications were identified on other sections. Diagnosis:
medullary carcinoma.
Solid:Composed entirely or nearly entirely of soft tissue, with only a few tiny cystic spaces
Category 1: Composition
Definition
■Composition describes the internal components of a nodule, that is, the presence of soft
tissue or fluid, and the proportion of each
Dr Ahmed Esawy

7. Predominately solid nodule: 63 year old female with a 1.6 cm predominately solid, hyperechoic nodule.
Margins are smooth. Note presence of punctate echogenic foci and foci with small comet tail
artifacts. Diagnosis: colloid nodule (Bethesda 2).
Predominately solid:Composed of soft tissue components occupying 50% or more of
the volume of the nodule
Dr Ahmed Esawy

8. Predominately cystic: Composed of soft tissue components occupying less than
50% of the volume of the nodule
Predominately cystic nodule: 26 year old male with a 4.5 cm predominately cystic nodule.
Note solid components along superior/posterior wall (arrow). Diagnosis:Cystic nodule,
non-diagnostic (Bethesda 1). Appearance of aspirate was consistent with old blood.
Nodule recurred but no change over two year follow up.Dr Ahmed Esawy

9. Spongiform:Composed predominately of tiny cystic spaces
Dr Ahmed Esawy

10. Category 2: Echogenicity
Definition
■Level of echogenicity of the solid, noncalcified component of a nodule, relative to
surrounding thyroid tissue
Dr Ahmed Esawy

11. Hyperechoic nodule: 63 year old female with 1.6 cm hyperechoic predominately solid,
smooth nodule. Note punctate echogenic foci. Diagnosis: colloid nodule (Bethesda 2).
Hyperechoic: Increased echogenicity relative to thyroid tissue
Dr Ahmed Esawy

12. Hypoechoic nodule: 62 year old male with 1.6 cm hypoechoic, solid nodule with smooth
margins. Note large comet tail artifact along inferior border. Diagnosis: papillary
carcinoma.
Hypoechoic: Decreased echogenicity relative to thyroid tissue
Dr Ahmed Esawy

13. Echogenicity.Very hypoechoic nodule: 55-year-old woman with 1.0-cm very hypoechoic left
lobe nodule (N).
Margins are smooth. Note that nodule is less echogenic than adjacent strap muscles (S) and
essentially isoechoic to the common carotid artery (C). Diagnosis: papillary carcinoma.
○Very hypoechoic: Decreased echogenicity relative to adjacent neck musculature
Dr Ahmed Esawy

14. Isoechoic: Similar echogenicity relative to
thyroid tissue.
Dr Ahmed Esawy

15. Shape: 56-year-old woman with taller-than-wide nodule in left lobe of thyroid .
Dimensions measured in the transverse plane are 1.4 cm transverse 1.8 cm
anteroposterior.Diagnosis : follicular variant, papillary carcinoma.
Category 3: Shape Term: taller-than-wide.
Definition
■A taller-than-wide shape is defined as a ratio of >1 in the anteroposterior diameter to the
horizontal diameter when measured in the transverse plane
Dr Ahmed Esawy

16. Category 4: Size
How the nodule should be measured:
■ Use maximal diameter on the basis of longitudinal, anteroposterior, and transverse
measurements in centimeters per millimeter.
Dr Ahmed Esawy

17. Poorly differentiated carcinoma in an 81-year-old
Ill-defined: Border of the nodule is difficult to distinguish from thyroid parenchyma;
the nodule lacks irregular or lobulated margins.
Category 5: Margins
Definition
■Refers to the border or interface between the nodule and the adjacent thyroid
parenchyma or adjacent extrathyroidal structures.
Dr Ahmed Esawy

18. 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).
Halo: Border consists of a dark rim around the periphery of the nodule.The halo can
be described as completely or partially encircling the nodule. In the literature, halos
have been further characterized as uniformly thin, uniformly thick, or irregular in
thickness
Dr Ahmed Esawy

19. Smooth margin: 49 year old female with 2.2 cm hypoechoic nodule with a smooth margin.
Diagnosis: Benign follicular nodule (Bethesda 2).
Smooth: Uninterrupted, well-defined, curvilinear edge typically forming a spherical
or elliptical shape
Dr Ahmed Esawy

20. Irregular margin: 47-year-old woman with heterogeneously hyperechoic 16-mm nodule
with irregular margins.Note angulated borders anteriorly. Diagnosis: papillary
carcinoma..
○Irregular margin:The outer border of the nodule is spiculated, jagged, or with sharp
angles with or without clear soft tissue protrusions into the parenchyma.The
protrusions may vary in size and conspicuity and may be present in only one portion
of the nodule
Dr Ahmed Esawy

21. lobulated margin: 56 year old man with 3.4 cm lobulated, hyperechoic nodule.
Macrocalcifications were present in other sections. Diagnosis: Papillary carcinoma.
Lobulated: Border has focal rounded soft tissue protrusions that extend into the
adjacent parenchyma.The lobulations may be single or multiple and may vary in
conspicuity and size (small lobulations are referred to as microlobulated)
Dr Ahmed Esawy

22. Extra-thyroidal extension: 73 year old male with a large, lobulated hypoechoic mass
involving isthmus and left lobe. Note loss of definition of tissue planes anteriorly
suggesting extra-thyroidal invasion. Diagnosis:Anaplastic carcinoma.
Extrathyroidal extension: Nodule extends through the thyroid capsule
Dr Ahmed Esawy

23. Category 6: Echogenic Foci
Definition
■Refers to focal regions of markedly increased echogenicity within a nodule relative to the
surrounding tissue. Echogenic foci vary in size and shape and may be encountered alone or
in association with several well-known posterior acoustic artifacts.
Dr Ahmed Esawy

24. Echogenic foci. Punctate echogenic foci: 44-year-old woman with 3.2-cm isoechoic smoothly
marginated nodule.Note numerous punctate echogenic foci with no posterior
acoustic artifacts. Diagnosis: colloid nodule (Bethesda 2).
Punctate echogenic foci: “Dot-like” foci having no posterior acoustic posterior artifacts.
Kwak et al defined punctate foci/microcalcifications as being <1 mm. Most authors
define this feature on the basis of appearance alone
Dr Ahmed Esawy

25. Macrocalcifications: 49 year old female with a 1.7 cm hypoechoic, ill-defined nodule at
the junction of the right lobe and isthmus. Large shadowing echogenic structure
(macrocalcification) is present in posterior portion of the nodule. Diagnosis:Colloid
nodule (Bethesda 2).
Macrocalcifications:When calcifications become large enough to result in posterior acoustic
shadowing, they should be considered macrocalcifications. Macrocalcifications may be
irregular in shape
Dr Ahmed Esawy

26. Punctate echogenicities in thyroid nodules. (a) Sagittal US image of nodule (arrowheads)
containing multiple fine echogenicities (arrow) with no comet-tail artifact.These are
highly suggestive of malignancy. FNA and surgery confirmed papillary carcinoma. (b)
Transverse 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

27. Peripheral calcifications: 43 year old female with 3.1 cm solid, hyperechoic nodule with
peripheral calcifications. Diagnosis: Follicular carcinoma.
Peripheral calcifications:These calcifications occupy the periphery of the nodule.The
calcification may not be completely continuous but generally involves the majority of the
margin. Peripheral calcifications are often dense enough to obscure the central components
of the nodule
Dr Ahmed Esawy

28. Echogenic foci with large comet tail artifacts: 41 year old male with 2.7 cm cystic nodule
containing multiple, mobile, echogenic foci with large comet tail artifacts. Note tapering
of comet tails posteriorly. Diagnosis:Colloid nodule (Bethesda 2).
Comet-tail artifacts: A comet-tail artifact is a type of reverberation artifact.The deeper
echoes become attenuated and are displayed as decreased width, resulting in a triangular
shape. If an echogenic focus does not have this feature, a comet-tail artifact should not be
described
Dr Ahmed Esawy

29. US scans show features indicative of malignancy, including (a) hypoechogenicity ( star = strap muscle,
arrows = nodule); (b) microcalcifi cations (arrows); (c) marked hypoechogenicity ( star = strap
muscle,arrows = nodule), microlobulated margin, and taller-than-wide shape; and (d) irregular margin
(arrows = nodule). Dr Ahmed Esawy

30. THYPES OFTHYRIOD NODULES
Dr Ahmed Esawy

31. Colloid nodules, also known as adenomatous nodules] or colloid nodular goiter
Colloid nodules (CN) are non-neoplastic non-inflammatory benign nodules
occurring within the thyriod gland .They form the vast majority of nodular thyriod
disease may be single or multiple
thyroid-stimulating hormone test, can help differentiate a thyrotoxic nodule from an
euthyroid nodule
PATHOLOGY
A colloid nodular goiter occurs when the thyroid gland is unable to meet the metabolic
demands of the body with sufficient hormone production.The thyroid gland compensates
by enlarging, which usually overcomes mild deficiencies of thyroid hormone.
If the thyroid gland is then re-exposed to iodine, the nodules may produce thyroid
hormone independently.Occasionally, the nodules may produce too much thyroid
hormone, causing thyrotoxicosis.This is called a toxic nodular goiter.
ULTRASOUND
iso to hypoechoic
May be cystic (cystic nodular giotre)
may have internal cystic or heterogeneous change
may have calcification
multiple echogenic foci (of inspissated colloid) with comet tail artifact
Colloid nodules
Dr Ahmed Esawy

32. TIRADS by Horvath et al.
Description Risk of
malignancy
TIRADS 1 Normal thyroid gland 0
TIRADS 2 Benign 0
TIRADS 3 Probably benign <5%
TIRADS 4A Suspicion for malignancy 5-10%
TIRADS 4B Intermediate suspicion for malignancy 10-80%
TIRADS 5 Highly suggestive of malignancy >80%
TIRADS 6 Biopsy proven malignancy
Dr Ahmed Esawy

33. C, US image of a colloid type 3 pattern: a mixed, nonencapsulated, expansile, isoechoic
nodule with hyperechoic spots and broad septa
A, US image of multiple typical colloid cysts: anechoic areas with hyperechogenic spots
(type 1 colloid pattern).
B, US image of a type 2 colloid nodule: a mixed, nonexpansile, nonencapsulated structure
with a “grid” appearance given by isoechoic solid areas and hyperechoic spots.The gland
is not enlarged.
TIRADS 2
Dr Ahmed Esawy

34. D, US aspect of Hashimoto thyroiditis with a pseudo-nodule: normal size
heterogeneous gland with lobulated borders and a hyperechoic pseudo-nodule
(arrow), partially surrounded by a halo
TIRADS 3
Dr Ahmed Esawy

35. E, US image of a simple neoplastic pattern (4A): a solid hyperechoic nodule without
calcifications, surrounded by a thin capsule. F, A hypoechoic area with ill-defined borders,
without calcifications.This pattern may be found in both subacute thyroiditis and carcinomas
G, US image of a suspicious neoplastic pattern (4B): an encapsulated heterogeneous nodule
with coarse calcifications, surrounded by a thick capsule. H, US image of malignant pattern A:
solid hypoechoic, irregular nodules with ill-defined margins, with calcifications (thin arrow) or
without calcifications (thick arrow).
TIRADS 4A
TIRADS 4B
Dr Ahmed Esawy

36. I, US image of malignant pattern B: solid, nonencapsulated, isoechoic, ill-defined nodule with a
“salt and pepper” aspect, due to peripheral microcalcifications.
J, US image of malignant pattern C: a mixed, isoechoic, vascularized, nonencapsulated nodule
with calcifications and no hyperechoic spots. -
TIRADS 5 B TIRADS 5 C
Dr Ahmed Esawy

37. Dr Ahmed Esawy

38. TIRADS by Kwak et al
Description
Number of suspicious
features
Risk of
malignancy
TIRADS 1 Negative 0 0
TIRADS 2 Benign 0 0
TIRADS 3 Probably benign 0 1.7%
TIRADS 4A Low suspicion for malignancy 1 3.3%
TIRADS 4B Intermediate suspicion for malignancy 2 9.2%
TIRADS 4C Moderate concern but not classic for malignancy 3-4 44.4-72.4%
TIRADS 5 Highly suggestive of malignancy 5 87.5%
TIRADS 6 biopsy proven malignancy
Dr Ahmed Esawy

39. MNEUMONICS:
Marry SMITH
Suspicious US feature Score
M Marked hypoechogenicity 6
S Spiculated (microlobulated) margins 5
M Microcalcifications 2
I Ill-defined borders 1
T Taller than wider (non-parallel orientation) 1
H Hypoechogenicity 2
Image Reporting and Characterization System for
Ultrasound Features ofThyroid Nodules by Kwak et al (2013)
Dr Ahmed Esawy

40. TIRADS by Russ et al
Suspect pattern Benign pattern
Thyroid Nodule
High Suspect:
Taller-than-wide
Irregular borders
Microcalcifications
Markedly hypoechoic
High stiffness on sonoelastography
Very probably
No signs of high
suspect.
Mildly hypoecoic
1-2 signs,
no metastatic lymph
nodes
3-5 signs and/or
metastatic lymph
nodes
TIRADS 4ATIRADS 4BTIRADS 5
Constantly
No sign of high
suspicion: regular
shape and borders,
no micro-
calcifications and
iso/hyperecoic
- Simple cyst
- Spongiform nodule
- “white knight”
- isolated macro-
calcifications
- Nodular hyperplasia
TIRADS 2TIRADS 3
Dr Ahmed Esawy

41. by Russ et alby Kwak et alHorvath et al.
normal thyroid glandnormal thyroid glandnormal thyroid glandTIRADS 1
CONSTATNLY
- Simple cyst
- Spongiform nodule
- “white knight”
- isolated macro-
calcifications
- Nodular hyperplasia
T2 =benign
Same as Horvath
(colloid type I)
Anechoic with
hyperechoic spots,
nonvascularized lesion.
(colloid type I)
TIRADS 2
Same as Horvath with
peripheral halo
(colloid type II)
Nonencapsulated,
mixed, nonexpansile,
with hyperechoic spots,
vascularized lesion,
″grid″ aspect
(spongiform nodule).
(colloid type II)
Same as Horvath
(colloid type III)
These conditions have
0% risk of malignancy
Nonencapsulated, mixed
with solid portion,
isoechogenic, expansile,
vascularized nodule with
hyperechoic spots.
(colloid type III)
THREE TIRADS
Dr Ahmed Esawy

42. by Russ et alby Kwak et alHorvath et al.
Very probably
No sign of high
suspicion: regular
shape and borders,
no micro-
calcifications and
iso/hyperecoic
probably benign lesions
Same as Horvath
probably benign lesions
Hyper, iso, or hypoechoic,
partially encapsulated nodule
with peripheral vascularization,
in Hashimoto’s thyroiditis.
Hashimoto pseudo- nodule
TIRADS 3
T4A=Mildly suspect
No signs of high
suspect.
Mildly hypoecoich
T4A low suspicion
one suspicious feature
suspicion 5-10%
Hyper, iso, or hypoechoic,
hypervascularized, encapsulated
nodule with a thick capsule,
containing calcifications (coarse
or microcalcifications).
Suspicious neoplastic pattern
TIRADS 4 A
T4B moderate suspicion
two suspicious features
Intermediate suspicion 10-80 %
Hypoechoic, nonencapsulated
nodule, with irregular shape and
margins, penetrating. vessels,
with or without calcifications
TIRADS 4 B
T4B=highly suspect
1-2 signs,
no metastatic lymph
nodes
THREE TIRADS
Dr Ahmed Esawy

43. by Russ et alby Kwak et alHorvath et al.
NOTIRAD CModerate concern but
not classic for
malignancy
3-4 suspicious features
NOTIRAD CTIRADS 4 C
T5=highly suspect
3-5 signs and/or
metastatic lymph
nodes
High Suspect:
Taller-than-wide
Irregular borders
Microcalcifications
Markedly hypoechoic
High stiffness on
sonoelastograph
Highly suggestive of
malignancy
all five suspicious
features
SMITHarryM
Marked
hypoechogenicity
Spiculated
(microlobulated) margins
Microcalcifications
Ill-defined borders
Taller than wider (non-
parallel orientation)
Hypoechogenicity
highly suspicion <80 %
Iso or hypoechoic,
nonencapsulated nodule with
multiple peripheral
microcalcifications and
hypervascularization.
Malignant pattern B
Nonencapsulated, isoechoic
mixed hypervascularized
nodule with or without
calcifications, without
hyperechoic spots.
Malignant pattern C
TIRADS 5
THREE TIRADS
Dr Ahmed Esawy

44. TI-RADS 1 : normal thyroid gland
Dr Ahmed Esawy

45. TI-RADS 2 : simple thyroid cyst
Dr Ahmed Esawy

46. Thyroid CystTIRADS 2Dr Ahmed Esawy

47. TI-RADS 2: solid nodule with central cyst not eccentricDr Ahmed Esawy

48. TI-RADS 2: nodule with homogeneous peripheral calcification.
Dr Ahmed Esawy

49. TI-RADS 2: spongiform nodule.Dr Ahmed Esawy

50. Spongiform noduleTIRADS 2Dr Ahmed Esawy

51. White KnightTIRADS 2Dr Ahmed Esawy

52. Isolated macro calcificationTIRADS 2Dr Ahmed Esawy

53. Regular-shaped, round, isoechoic solid nodule with regular borders and shape and no
calcifications:
TI-RADS 3.This nodule was classified as benign by cytopathological analysis
Dr Ahmed Esawy

54. TI-RADS 3: hyperechoic nodule
Dr Ahmed Esawy

55. TI-RADS 3: slightly hyperechoic nodule with small cysts and peripheral vascularity
Dr Ahmed Esawy

56. The nodule on Figure before corresponds to a toxic adenoma on thyroid scintigraphy with
99mTC-sodium pertechnetate.
Dr Ahmed Esawy

57. TI-RADS 3: several nodules in the same gland with a similar ultrasound pattern: hyper or isoechoic
nodules, with small cystic changes and small hypoechoic spots, as well as microcalcifications
(arrow) and peripheral perfusion. In the thyroid scintigraphy (lower row on the right)TNs appear as
toxic adenomas in a patient with hyperthyroidismDr Ahmed Esawy

58. Patient with nodular goiter. In a hyperechoic nodule with small cysts, consistent with TI-RADS
3, a small papillary thyroid carcinoma (pT1b) was histologically detected after surgeryDr Ahmed Esawy

59. IsoechogenicTIRADS 3Dr Ahmed Esawy

60. Moderately heterogenous nodule with isoechoic and mildly hypoechoic regions, regular shape
and borders:TI-RADS 4A. Mildly hypoechoic is defined as more hypoechoic than the
surrounding gland but less than strap muscles.This nodule was classified as a microvesicular
adenoma by histopathological analysis Dr Ahmed Esawy

61. TI-RADS4a: markedly hypoechoic nodule, of normal shape and abnormal vascularity. Score of 1.Dr Ahmed Esawy

62. Hypoechogenic noduleTIRADS 4A
Dr Ahmed Esawy

63. TI-RADS 4b: nodule with microcalcifications and poorly defined irregular margins. .
Dr Ahmed Esawy

64. TI-RADS 4b: nodule with two sonographically suspicious criteria for malignancy:
hypoechogenicity and internal vascularity.
Dr Ahmed Esawy

65. Solid isoechoic nodules with ill-defined borders and microcalcifications: several round,
sometimes linear, tiny punctuations. At the opposite of granular deposits, no US absorption
below the punctuations and no hypoechoic microcavities above them are seen, as well as no
comet-tail artifacts.TI-RADS 4B.This nodule was cytologically suspicious for malignancy
and classified as a papillary carcinoma by histopathological analysis.
Dr Ahmed Esawy

66. Taller-than-wide noduleTIRADS 4B
Dr Ahmed Esawy

67. Irregular marginsTIRADS 4BDr Ahmed Esawy

68. Marked hypoechogenicityTIRADS 4BDr Ahmed Esawy

69. MicrocalcificationsTIRADS 4BDr Ahmed Esawy

70. TI-RADS 4c: nodule with microcalcifications, irregular borders and taller than wide shape
(greater in its anteroposterior diameter than in its transverse diameter).
Dr Ahmed Esawy

71. TI-RADS 4c: hypoechoic nodule of irregular margins with a taller than wide shape.
Dr Ahmed Esawy

72. TI-RADS 5: hypoechogenic nodule with microcalcifications and poorly defined margins, with
perinodular tissue invasion (arrow).Taller than wide shape. Presence of a cervical lymph node
suspicious for malignancy Dr Ahmed Esawy

73. TI-RADS 5: suspicious hypoechoic lymph node, with round shape and abnormal
vascularity. Dr Ahmed Esawy

74. Thyroid Nodule : 1.7 cm, mixed solid and cystic, isoechoic,
circumscribed, vascular, wider than tall, no microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Mixed solid and cystic, hypervascular, ≥ 1.5-2 cm Biopsy (Recommendation B)
Society of Radiologists in
Ultrasound
Mixed solid and cystic, < 2 cm No biopsy
TIRADS Russ (2013) TIRADS 3 – Very probably benign (isoechoic, no signs
of high suspicion)
No biopsy (PPV 0.25%)
TIRADS Kwak (2011) TIRADS 4A – 1 suspicious feature (solid component) Biopsy (Risk of malignancy
3.3%)
Image Reporting and
Characterization System by
Kwak et al. (2013)
Score 0 – no malignant features N/A (Risk of malignancy 6.2%)
FNA of the nodule: Bethesda class 2 – benign: nodular hyperplasia with cystic degeneration
Dr Ahmed Esawy

75. Thyroid Nodule : 3.5 cm, spongiform, isoechoic, circumscribed,
peripheral vascularity, wider than tall, no microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Spongiform, > 2 cm Biopsy (Recommendation C)
Society of Radiologists in
Ultrasound
Mixed solid and cystic, ≥ 2 cm Biopsy
TIRADS Russ (2013) TIRADS 2 – Benign pattern (spongiform) No biopsy (PPV 0.25%)
TIRADS Kwak (2011) TIRADS 4A – 1 suspicious feature (solid component) Biopsy (Risk of malignancy
3.3%)
Image Reporting and
Characterization System by Kwak
et al. (2013)
Score 0 – no malignant features N/A (Risk of malignancy
6.2%)
FNA of the nodule: Bethesda class 2 – benign: nodular hyperplasia with cystic degeneration
Dr Ahmed Esawy

76. Thyroid Nodule 2.7 cm, predominantly solid, hypoechoic, circumscribed,
marked vascularity, wider than tall, no microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Mixed, hypoechoic, increased vascularity, >1.5
cm
Biopsy, Level B
Society of Radiologists in
Ultrasound
Predominantly solid, hypoechoic, >1.5 cm Biopsy
TIRADS Russ (2013) TIRADS 4A – mildly suspect (mildly hypoechoic,
no sign of high suspicion), >1 cm
Biopsy (PPV 6%)
TIRADS Kwak (2011) TIRADS 4B – 2 suspicious features (solid
component, hypoechoic)
Biopsy (Risk of malignancy
9.2%)
Image Reporting and
Characterization System by
Kwak et al. (2013)
Score 2 – hypoechoic N/A (Risk of malignancy
8.6%)
FNA of the nodule: Bethesda class 4 – suspicious for Hurtle cell neoplasm
Dr Ahmed Esawy

77. Thyroid Nodule : 2.5 cm, solid, hypoechoic, microlobulated
margin, vascular, wider than tall, no microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Solid, hypoechoic, > 1 cm Biopsy (Recommendation B)
Society of Radiologists in
Ultrasound
Solid, ≥ 1.5 cm Biopsy
TIRADS Russ (2013) TIRADS 4B – Highly suspect (irregular margin) Biopsy (PPV 69%)
TIRADS Kwak (2011) TIRADS 4C – 3 suspicious features (solid component,
hypoechogenicity, microlobulated margin)
Biopsy (Risk of malignancy
44.4–72.4%)
Image Reporting and
Characterization System by Kwak
et al. (2013)
Score 7 – hypoechoic, microlobulated N/A (Risk of malignancy
60.6%)
FNA of the nodule: Bethesda class 5 – suspicious for malignancy: highly suspicious for papillary carcinoma
Dr Ahmed Esawy

78. Thyroid Nodule : 2.2 cm, solid, hypoechoic, irregular margins,
vascular, taller than wide, with microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Solid, hypoechoic, > 1 cm Biopsy (Recommendation B)
Society of Radiologists in
Ultrasound
Microcalcifications, ≥ 1 cm Biopsy
TIRADS Russ (2013) TIRADS 5 – Highly suspect (taller than wide,
microcalcifications, irregular margins)
Biopsy (PPV 100%)
TIRADS Kwak (2011) TIRADS 5 – 5 suspicious features (solid, hypoechoic,
irregular margins, taller than wide, microcalcifications)
Biopsy (Risk of malignancy
87.5%)
Image Reporting and
Characterization System by Kwak
et al. (2013)
Score 10 – markedly hypoechoic, irregular margins,
taller than wide, microcalcifications
N/A (Risk of malignancy
93.8%)
FNA of the nodule: Bethesda class 6 – malignant: papillary carcinoma
Dr Ahmed Esawy

79. Thyroid Nodule : 1.7 cm solid, hypoechoic, irregular margins,
marked vascularity, wider then tall, and microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Solid, hypoechoic >1 cm Biopsy, Level B
Society of Radiologists in
Ultrasound
Solid, microcalcifications >1 cm Biopsy
TIRADS Russ (2013) TIRADS 5 (solid, hypoechoic, irregular margin,
microcalcification)
Biopsy (PPV 100%)
TIRADS Kwak (2011) TIRADS 4c (solid, markedly hypoechoic, irregular
margin, microcalcification)
Biopsy (Risk of malignancy
44-72%)
Image Reporting and
Characterization System by
Kwak et al. (2013)
Score 9 (solid, markedly hypoechoic, irregular
margin, microcalcification)
Biopsy (Risk of malignancy
79%)
FNA of this nodule: Bethesda class 6 Malignancy (papillary thyroid carcinoma)
Dr Ahmed Esawy

80. Selected Benign and Malignant Thyroid Lesions
Benign lesions
Benign follicular nodule
Adenomatoid nodule
Colloid nodule
Follicular adenoma
Hürthle cell adenoma
Thyroiditis
Chronic lymphocytic (Hashimoto) thyroiditis
Malignant lesions
Papillary carcinoma
Follicular carcinoma
Hürthle cell carcinoma
Poorly differentiated carcinoma
Anaplastic/undifferentiated carcinoma
Medullary carcinoma
Lymphoma
Metastasis
Dr Ahmed Esawy

81. US Features of benignThyroid Nodules
Features suggesting benignity
Uniform halo around nodule
Predominantly cystic
Avascular
Enlarged thyroid with multiple nodules
Dr Ahmed Esawy

82. 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

83. Sagittal image of predominantly solid nodule (arrowheads), which proved to be
benign at cytologic examination
Dr Ahmed Esawy

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

85. 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

86. 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

87. Incidentally detected left-sided colloid nodule of the thyroid in a 74-year-old woman. (a)
AxialT2-weighted MR image shows a well-circumscribed, hyperintense 2.2-cm nodule
(arrow). Colliod nodule Dr Ahmed Esawy

88. 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

89. Chronic lymphocytic (Hashimoto) thyroiditis in a 53-year-old woman with a “swollen
thyroid.” (a) Longitudinal duplex US image shows diffusely heterogeneous thyroid
parenchyma with abnormal diffusely increased vascular flow.
Dr Ahmed Esawy

90. 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

91. 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

92. 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

93. 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

94. US Features of malignant Thyroid Nodules
Features suspicious for malignancy
Specific features
Microcalcifications
Extension beyond thyroid margin
Cervical lymph node metastasis
Taller than wide in transverse plane
Markedly hypoechoic
Less specific features
No halo around nodule (Per nodular thyroid parenchyma invasion)
Ill-defined or irregular margin
Solid (Partially cystic nodule with eccentric location of the fluid portion
and lobulation of the solid component
Increased central vascularity ( Intranodular vascularity)
Dr Ahmed Esawy

95. 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

96. 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

97. 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

98. 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 suspiciousUS features.
Dr Ahmed Esawy

99. 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

100. 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

101. 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

102. 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

103. 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

104. 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

105. 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

106. 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

107. 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

108. Sagittal image of solid nodule (arrowheads),
which proved to be papillary carcinoma
Dr Ahmed Esawy

109. 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

110. 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

111. (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

112. (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

113. 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

114. Pitfalls in the Diagnosis of Malignancy
Dr Ahmed Esawy

115. 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

116. CysticVariant 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

117. 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

118. Diffusely Infiltrative HypervascularTumor
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

119. 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

120. ATA guidelines:
Initially published in 2006
(revised in 2009, new revision
expected in 2015)
ATA guidelines provide
comprehensive approach to
thyroid nodules.
Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM.
Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. American Thyroid Association (ATA)
Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer .Thyroid. 2009 Nov;19(11):1167-214.
Algorithm for the evaluation of patients with one or more
thyroid nodules:
Dr Ahmed Esawy

121. ATA nodule sonographic patterns and risk of malignancyDr Ahmed Esawy

122. Recommendations forThyroid Nodules 1 cm or Larger in Maximum Diameter US Feature
Socity of radiologists in ultrasound consensus
—FNA is likely unnecessary in diffusively enlarged gland with multiple nodules of similar US
appearance without intervening parenchyma. Presence of abnormal lymph nodes overrides US
features of thyroid nodule(s) and should prompt US-guided FNA or biopsy of lymph node
and/or ipsilateral nodule
Dr Ahmed Esawy

123. FNAB
Dr Ahmed Esawy

124. Dr Ahmed Esawy

125. 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

126. Drawing illustrates FNAB technique, with parallel positioning of the needle relative to the
US transducer and the thyroid
Dr Ahmed Esawy

127. 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

128. 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

129. 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

130. THYPES OFTHYRIOD NODULES
Adenoma neoplastic Carcinoma Colloid nodule
Macro follicular
adenoma (simple
colloid)
Papillary (75 percent) Dominant nodule in a multinodular
goiterFollicular (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 agenesisDr Ahmed Esawy