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DR/ Wafik Ebrahim, MD
Assistant Professor of Radiodiagnosis
Faculty of Medicine
Alazhar University
 Ultrasonography is the single-most
valuable imaging modality in the evaluation
of the thyroid gland. In many radiology
d...
Anatomy
 Thyoroid is an endocrine gland located in
anterior inferior part of the neck.
 It is butterfly-shaped and is bu...
Thyroid and
parathyroid glands
•Thyroid glands:
 Two lobes connected by the
isthmus wrapped around the
trachea.
•parathyr...
 Use linear high frequency probe (at least 7
MHz) with color Doppler.
 Patient should be laid symmetrically on the
back ...
 Length 4-6cm.
 Width and thickness 1.3-1.8cm (not > 20mm).
 Isthmus: 4-6mm (not > 10mm.
 Consider volume:
 Males: up...
 Normal gland
 Less echogenic than adjacent subcutaneous fat
and more echogenic than surrounding muscles.
 Homogeneous....
Which is Normal?
Homogeneous Heterogeneous
 In normal gland:
 Few vessels can be seen.
 In thyrotoxic or early inflammatory process:
 Vacularity increases.
Normal Hypervascular
 Location:
 Right, left or isthmus.
 Upper, middle or lower part of the lobe.
 Measurement: In three planes.
 Echogen...
 Used device:
 Size of gland: (remember retrosternal extension)
 Echogenecity:
 Vascularity:
 Focal lesion assessment...
 Artifacts are images which appear on the
display and do not represent actual physical
structures.
 These shadows or enh...
Posterior enhancement Back shadow
Microcalcifications do not produce back
shadow
The uniform character of tissues result in even
transmission of sound waves with little attenuation
giving posterior enhan...
 Chronic autoimmune-mediated lymphocytic
inflammation of thyroid gland.
 Non-specific enlargement of the gland without
c...
 Real time US:
 Early Stages: Non-specific:
○ Enlarged Heterogeneous Hypoechoic gland.
○ Hypoechoic foci may be seen (mi...
Diffusely enlarged gland with
fibrous septae and high
vascularity
(A) “micronodulation,” Diffuse, illmarginated
innumerable small hypoechoic nodules (arrow)
surrounded by echogenic stroma ...
Localized form of
Hashimoto’s
Nodule consisting of
bright blocks separated
by dark bands.
The background thyroid
is hypoec...
Chronic end stage disease:
small atrophic with fibrous
septae
 It is an autoimmune disease.
 Binding of thyroid autoantibodies to the
thyrotropin receptor on the follicular
cells. Au...
 Diagnosis is made when patient
presents with diffuse thyroid
enlargement and hyperthyroidism
(thyrotoxic goiter).
 Seco...
 There is no gray scale specific finding for the
disease.
 Suggestive signs are diffuse enlargement,
convex bowing of th...
 High vascularity with high velocity flow is
characteristic (> 60cm/sec PSV).
 DD from early Hashimoto’s thyroiditis is ...
 Is an uncommon disease that occurs most
often in women in their second to fifth
decades of life.
 This disease usually ...
 The characteristic ultrasound findings for this
disorder are ill- defined, moderately, or
markedly patchy hypoechoic are...
 The thyroid is normally very resistant to
infection. Due to a relatively high
amount of iodine in the tissue, as well as...
 It is usually autoimmune where the
antibodies block the receptors of
follicular cells with resultant gland
atrophy and l...
Atrophic thyroiditis. The thyroid gland is small to
normal in size and diffusely hypoechoic with
micronodulation.
 Diffuse enlargement of the thyroid gland.
 It may be simple diffuse (non-nodular) or
Nodular goiter .
 The simple form...
Simple diffuse goiter. A transverse ultrasound image shows a
moderately to markedly enlarged thyroid gland with normal
hom...
 The gland is enlarged yet well marginated.
 Calcification, necrosis, cystic degeneration
and hemorrhage may be seen.
 ...
Do not forget searching for
retrosternal extension.
 The most common congenital neck cyst.
They are typically located in the midline
and are the most common midline neck
mas...
 Thyroid adenoma: (true neoplasm with
complete capsule): Single well defined
intrathyroid mass within normal gland.
 Ade...
 US: hypo, iso or hyperechoic nodule:
 Thyroid adenoma: has thick smooth hypoechoic
halo.
 Adenomatous polyp: Has incom...
 Types:
 Differentiated carcinoma:
○ Papillary (70%).
○ Follicular and carcinoma (10%).
 Aggressive tumors:
○ Medullary...
 Unfortunately the appearance of thyroid
malignancy is usually non-specific.
 Nodules with irregular margin or mass
inva...
Thyroid malignancy:
 Role of imaging:
 Evaluation of thyroid capsule integrity.
 Detection of infiltration of surroundi...
Differentiated carcinoma:
 Invasive mass with
thyroid capsular
invasion and
metastatic lymph
nodes.
 Hypoechoic mostly
s...
Malignant thyroid:
Medullary carcinoma Anaplastic carcinoma
 Colloid nodules. These are one or more overgrowths of
normal thyroid tissue. These growths are not cancerous
(benign).
...
TIRADS: OVERVIEW
 TIRADS system is ultrasonographic classification for thyroid nodules.
 The terminology “Thyroid Imagin...
TIRADS by Horvath et al.
Horvath E, Majilis S, Rossi R, Franco C, Niedmann J, Castro A & Dominguez M. An ultrasonogram rep...
TIRADS by Russ et al
Authors proposed the following flowchart to assign a nodule to one of TIRADS categories
Suspect patte...
 It is well defined small mass in expected location.
 Associated hyperparathyroidism.
Diagnosis?
Signs (2) ?
Quiz 2
Diagnosis:
Quiz 3
Diagnosis?
Quiz 4
Diagnosis?
Quiz 5
cyst or solid nodule?
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Thyroid us

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Thyroid US

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Thyroid us

  1. 1. DR/ Wafik Ebrahim, MD Assistant Professor of Radiodiagnosis Faculty of Medicine Alazhar University
  2. 2.  Ultrasonography is the single-most valuable imaging modality in the evaluation of the thyroid gland. In many radiology departments it is one of the most frequently performed ultrasound examinations.  Why?  Simple, painless, no radiation, no contrast  Superficial position of gland:  Development of high resolution machines
  3. 3. Anatomy  Thyoroid is an endocrine gland located in anterior inferior part of the neck.  It is butterfly-shaped and is built by two cone-like lobes and isthmus between them.  Pyramidal lobe is seen (in 50% of patients) extending from midline of isthmus to the root of the tongue. It is remnant from thyroglossal duct.
  4. 4. Thyroid and parathyroid glands •Thyroid glands:  Two lobes connected by the isthmus wrapped around the trachea. •parathyroid gland:  Four lobes at the posterior surface of thyroid gland. .
  5. 5.  Use linear high frequency probe (at least 7 MHz) with color Doppler.  Patient should be laid symmetrically on the back on a high table with stretched out neck.  Examine in transverse plane (for width and thickness) and longitudinal plane for length.  For any lesion, consider the two planes.
  6. 6.  Length 4-6cm.  Width and thickness 1.3-1.8cm (not > 20mm).  Isthmus: 4-6mm (not > 10mm.  Consider volume:  Males: up to 25ccm.  Females: up to 20ccm. ○ Automatically generated. ○ Or use correction factor (three diameters X 0.53 ). Then summation of both lobes.  Roughly enlarged gland has bulging anterior surface.
  7. 7.  Normal gland  Less echogenic than adjacent subcutaneous fat and more echogenic than surrounding muscles.  Homogeneous.  Diffuse low echogencity or heterogenity means diffuse disease. Examine for echogenecity in Which plane?. Examine for echogenecity in Long plane!.
  8. 8. Which is Normal?
  9. 9. Homogeneous Heterogeneous
  10. 10.  In normal gland:  Few vessels can be seen.  In thyrotoxic or early inflammatory process:  Vacularity increases.
  11. 11. Normal Hypervascular
  12. 12.  Location:  Right, left or isthmus.  Upper, middle or lower part of the lobe.  Measurement: In three planes.  Echogenecity: malignant lesions mostly hypoechoic.  Echostructure: cystic changes, calcifications.  Vascularity: no flow, intranodular flow, perinodular, or both (suspecious for malignancy).  Elastography if available: malignant lesions are stiffer.
  13. 13.  Used device:  Size of gland: (remember retrosternal extension)  Echogenecity:  Vascularity:  Focal lesion assessment:  Lymph nodes assessment.  Conclusion:  TIRADS is developed (Thyroid Imaging Reporting and Data system:  Recommendatios
  14. 14.  Artifacts are images which appear on the display and do not represent actual physical structures.  These shadows or enhanced representation of tissue elements tell a story.  Posterior enhancement:  Back shadowing: Cyst calcifications
  15. 15. Posterior enhancement Back shadow
  16. 16. Microcalcifications do not produce back shadow
  17. 17. The uniform character of tissues result in even transmission of sound waves with little attenuation giving posterior enhancement (pleomorphic adenoma)
  18. 18.  Chronic autoimmune-mediated lymphocytic inflammation of thyroid gland.  Non-specific enlargement of the gland without calcification or necrosis.  Most common form of thyroiditis.  More common in female :
  19. 19.  Real time US:  Early Stages: Non-specific: ○ Enlarged Heterogeneous Hypoechoic gland. ○ Hypoechoic foci may be seen (micronodulation).  Late: small hypoechoic heterogenous fibrotic gland.  Uncommon: focal disease within normal gland.  Color Doppler:  Early: increased vascularity.  Late: absent blood flow signal.
  20. 20. Diffusely enlarged gland with fibrous septae and high vascularity
  21. 21. (A) “micronodulation,” Diffuse, illmarginated innumerable small hypoechoic nodules (arrow) surrounded by echogenic stroma termed (B) Swiss-cheese appearance. Diffuse small hypoechoic lesions (arrow) in the thyroid create pseudocystic appearance
  22. 22. Localized form of Hashimoto’s Nodule consisting of bright blocks separated by dark bands. The background thyroid is hypoechoic and coarsened with micronodularity typical of diffuse Hashimoto’s thyroiditis.
  23. 23. Chronic end stage disease: small atrophic with fibrous septae
  24. 24.  It is an autoimmune disease.  Binding of thyroid autoantibodies to the thyrotropin receptor on the follicular cells. Autoantibody binding stimulates the cells as though TSH triggered the receptor.  The result is increased hormone synthesis and secretion, and growth of the thyroid gland.
  25. 25.  Diagnosis is made when patient presents with diffuse thyroid enlargement and hyperthyroidism (thyrotoxic goiter).  Secondary finding may present (orbitopathy).
  26. 26.  There is no gray scale specific finding for the disease.  Suggestive signs are diffuse enlargement, convex bowing of the anterior gland margin, and mild textural coarsening.  Hypoechoic pattern is also noted due to high blood flow, high cellularity on expense of colloid contents and lymphocytic infiltration.
  27. 27.  High vascularity with high velocity flow is characteristic (> 60cm/sec PSV).  DD from early Hashimoto’s thyroiditis is difficult however, here the gland is less hetrogeneous and less lobular and has higher velocity vessels.  Normally velocity in inferior thyroid A is 10- 15cm/sec and in the parenchymal vessels is 3- 5cm/sec.  In Grave’s disease 10-15 fold increase in PSV.
  28. 28.  Is an uncommon disease that occurs most often in women in their second to fifth decades of life.  This disease usually presents with thyroid tenderness, a low grade fever, and occasional dysphagia.  The disease resolves spontaneously, usually without thyroid function abnormalities.
  29. 29.  The characteristic ultrasound findings for this disorder are ill- defined, moderately, or markedly patchy hypoechoic areas of thyroid parenchyma that show little to no vascular flow on color Doppler interrogation.  Hypoechoic areas tend to elongate along the long axis of the thyroid.
  30. 30.  The thyroid is normally very resistant to infection. Due to a relatively high amount of iodine in the tissue, as well as high vascularity and lymphatic drainage.  Despite all this, a persistent fistula from the piriform sinus may make the thyroid susceptible to infection and abscess formation.
  31. 31.  It is usually autoimmune where the antibodies block the receptors of follicular cells with resultant gland atrophy and loss of function (contradictory to Grave’s disease where the antibodies stimulate the receptors) .  It may be also end stage of thyroiditis.
  32. 32. Atrophic thyroiditis. The thyroid gland is small to normal in size and diffusely hypoechoic with micronodulation.
  33. 33.  Diffuse enlargement of the thyroid gland.  It may be simple diffuse (non-nodular) or Nodular goiter .  The simple form eventually develops into nodular form.  The cause of simple goiter is multifactorial and involves complex interactions between environmental (iodine intake), genetic, and endogenous (female gender) factors.
  34. 34. Simple diffuse goiter. A transverse ultrasound image shows a moderately to markedly enlarged thyroid gland with normal homogenous thyroid echogenicity.
  35. 35.  The gland is enlarged yet well marginated.  Calcification, necrosis, cystic degeneration and hemorrhage may be seen.  US  shows focal or diffuse replacement of the thyroid parenchyma by closely opposed, isoechoic solid nodules and cystic nodules without normal intervening parenchyma and background heterogeneity shows  Hemorrhage may be seen as high echogenecities within the cysts.
  36. 36. Do not forget searching for retrosternal extension.
  37. 37.  The most common congenital neck cyst. They are typically located in the midline and are the most common midline neck masses in young patients.  Ultrasound: Unless infected, they are usually anechoic and the walls are thin, without internal vascularity.  If infected, the fluid may be turbid.
  38. 38.  Thyroid adenoma: (true neoplasm with complete capsule): Single well defined intrathyroid mass within normal gland.  Adenomatous polyp: adenomatous hyperplasia with incomplete capsule: less distinct and may be multiple.
  39. 39.  US: hypo, iso or hyperechoic nodule:  Thyroid adenoma: has thick smooth hypoechoic halo.  Adenomatous polyp: Has incomplete halo.  Signs of benignity: Thin halo, regular margin and coarse calcifications.  Color Doppler:  Thyroid adenoma: peripheral vascularity extending toward center (Spoke and wheel appearance).  Adenomatous polyp: more diffuse vascularity
  40. 40.  Types:  Differentiated carcinoma: ○ Papillary (70%). ○ Follicular and carcinoma (10%).  Aggressive tumors: ○ Medullary carcinoma (5%). ○ Anaplastic carcinoma (5%).  Others including lymphoma and metastasis (10%).
  41. 41.  Unfortunately the appearance of thyroid malignancy is usually non-specific.  Nodules with irregular margin or mass invading surrounding structures should alert for malignancy.  60% of malignant nodules have irregular border and also 45% of benign nodules have irregular border.  Calcifications:  Microcalcifications  malignancy  Egg shell calcifications  benignity. Thyroid malignancy:
  42. 42. Thyroid malignancy:  Role of imaging:  Evaluation of thyroid capsule integrity.  Detection of infiltration of surrounding structures.  Identification of malignant lymph nodes.
  43. 43. Differentiated carcinoma:  Invasive mass with thyroid capsular invasion and metastatic lymph nodes.  Hypoechoic mostly solid tumor but cystic changes are seen in follicular type
  44. 44. Malignant thyroid: Medullary carcinoma Anaplastic carcinoma
  45. 45.  Colloid nodules. These are one or more overgrowths of normal thyroid tissue. These growths are not cancerous (benign).  Thyroid cysts.  Inflammatory nodules. These nodules develop as a result of chronic inflammation of the thyroid gland.  Multinodular goiter.  Hyperfunctioning thyroid nodules.  Thyroid cancer. Of the nodules that can form as the thyroid gland enlarges, fortunately, less than 5 percent are cancerous.
  46. 46. 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.
  47. 47. TIRADS by Horvath et al. Horvath E, Majilis S, Rossi R, Franco C, Niedmann J, Castro A & Dominguez M. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. Journal of Clinical Endocrinology and Metabolism 2009 90 1748–1751 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
  48. 48. TIRADS by Russ et al Authors proposed the following flowchart to assign a nodule to one of TIRADS categories 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 Russ B, Royer B, Bigorgne C, et al. Prospective evaluation of thyroidimaging reporting and data system on 4550 nodules with and without elastography. Eur J Endocrinol. 2013;168:649–655.
  49. 49.  It is well defined small mass in expected location.  Associated hyperparathyroidism.
  50. 50. Diagnosis? Signs (2) ?
  51. 51. Quiz 2 Diagnosis:
  52. 52. Quiz 3 Diagnosis?
  53. 53. Quiz 4 Diagnosis?
  54. 54. Quiz 5 cyst or solid nodule?

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