1. Introduction to the thyroid ultrasound – the thyroid nodule. T. Solymosi www.thyrosite.com 2016

2. 2. Sylabus The thyroid as a whole The various patterns of echo abnormalities The significance of the hypoechogenic thyroid What is a nodule? Which nodules have to be described? How to describe a nodule? The retrotracheal and the substernal spread Non-thyroidal elements in the region of the thyroid

3. What is a nodule? The term nodule is a pathological entity. hyperplastic/colloid nodule adenoma carcinoma The human being is among others a sensitive entity… A patient is not aware about the fact that more than 99% of thyroid discrete lesions are benign. Take into account that performing a thyroid ultrasound only exceptionally improves the life expectancy and life quality of a patient. So we must minimize the psychological harm of our medical activity. It is to be avoided to use the term nodule for each discrete echoabnormality.

4. Lesions without any significance Discrete lesions in Hashimoto’s thyroiditis

5. An incipient nodule without any significance A deceptive pattern in an operated patient

6. 2. Description of a nodule: which nodules have to be described? Solitary nodules > 5 mm Multinodular goiters the largest nodule each lesion > 5 mm which may have oncological significance the most important property is the volume of the whole thyroid (measure ALL 3 diameters!) We prefer instead of „nodule”, the term „lesion” or „discrete echoabnormality” for lesions which are < 1 cm and have no oncological significance. Be aware that a hypoechogenic discrete area may be not a nodule in a pathological sense but a more active focus of lymphocytic thyroiditis.

7. Horizontal view Longitudinal view Horizontal view Longitudinal view

8. Right lobe - horizontal view Right lobe - longitudinal view Left lobe – horizontal view Left lobe - longitudinal view

9. 2. Description of a nodule Size (3 diameters) Location Echogenicity Special features if present halo sign irregular borders intranodular hyperechogenic figures Types of vacularization I: no vascularization II.: perinodular blood flow III: intranodular blood flow irregular, chaotic subtype

10. 2. Description of a nodule Size (3 diameters) and location

11. 2. Description of a nodule Size (3 diameters) and location Echogenicity solid mixed peripheral type central type spongiform

12. A spongifrom-type cyst A peripheral-type cyst A solid nodule presenting cystic areas Central-type cystic nodule

13. 2. Description of a nodule Size (3 diameters) Location Echogenicity mixed solid hyperechogenic echonormal hypoechogenic minimally moderately deeply

14. An echonormal-hyperechogenic nodule A hypoechogenic nodule An echonormal nodule A moderately hypoechogenic nodule

15. 2. Description of a nodule Size (3 diameters) and location Echogenicity Special features if present halo sign

16. 2. The risk of malignancy in halo-positive nodules in relation to echostructure British Journal of Medicine and Medical Research, 2015, doi: 10.9734/BJMMR/2015/13743 No. of nodules Malignant No. (%) OR (95% confidence interval) Significance Hypoechogenic1542 (1.3)0.23 (0.06-0.91)p < 0.001 Moderately hypoechogenic 15620 (12.8)2.64 (1.63-4.26)p < 0.01 Mixed cystic-solid 1962 (1.0)0.18 (0.04-0.71)p < 0.001 Hyperechogenic2259 (4.0)0.72 (0.37-1.42)Not significant Normal echogenicity 3401 (0.3)0.05 (0.01-0.35)p < 0.001 Mixed hypo- hyperechogenic 150 (0)0p < 0.001

17. An almost complete halo There is no halo sign The presence of a halo is doubtful

18. An almost complete halo The presence of a halo is doubtful There is no halo sign The presence of a halo is doubtful All four cases proved to be follicular tumor on histopathology

19. 2. Description of a nodule Size (3 diameters) Location Echogenicity Special features if present halo sign borders sharp and regular sharp irregular puzzle-like lobulated blurred infiltrative

20. Irregular, partly blurred Irregular, lobulated BORDER1

21. Lobulated, partly blurred with talled than wide sign Lobulated with taller than wide sign BORDER2

22. Lobulated Lobulated, partly blurred, partly puzzle-like BORDER3

23. Infiltrative Blurred BORDER4

24. Taller than wide sign Lobulated, puzzle-like, taller than wide sign BORDER5

25. 2. Description of a nodule Size (3 diameters) Location Echogenicity Special features if present halo sign irregular borders intranodular hyperechogenic figures non-specific microcalcification comet-tail artifact coarse calcification cotton-like fibrosis

26. Comet-tail artifact Microcalcifications INTRANOD HYPERECH 1 A moderately hypoechogenic nodule

27. Microcalcifications and fibrosis A hypoechogenic nodule INTRANOD HYPERECH 2 A moderately hypoechogenic nodule

28. Non-specific granulations and coarse calcification Coarse calcification INTRANOD HYPERECH 3 Coarse calcification Coarse calcification

29. Patchy hyperechogenic focus - amyloid Patchy and granular figures - surgical thread INTRANOD HYPERECH 4

30. 2. Description of a nodule Size (3 diameters) Location Echogenicity Special features if present halo sign irregular borders intranodular hyperechogenic figures Types of vacularization I: no vascularization II.: perinodular blood flow III: intranodular blood flow

31. Type 3 vascular pattern Type 1 vascular pattern

32. Type 2 vascular pattern Combined type 2 and type 3 vascular pattern

33. Type 2 vascular pattern There is no halo sign Halo sign is present

34. 2. Substernal spread The thyroid descends with increasing age and first of all in men elder than 60 ys the lower pole of the thyroid is not infrequently located below the level of the clavicle. The position of the thyroid has to be judged in conjunction with age and the size Degrees of substernal spread 1.The lower pole of the thyroid is below the clavicle only in normal position but comes into sight by hyperextension of the neck. 2.The lower pole cannot be visualized even when the neck is hyperextended, but comes into sight during swallowing 3.The lower pole is not visible in hyperextended neck neither during swallowing In the latter case surgery is mandatory as is a preoperative CT scan.

35. The lower pole of the thyroid cannot be visualized before swallowing The lower pole of the thyroid cannot be visualized before swallowing The lower pole of the thyroid came into sight on swallowing (case 978) The lower pole of the thyroid came into sight on swallowing (case 978) The lower pole of the thyroid cannot be visualized before swallowing The lower pole of the thyroid cannot be visualized before swallowing The lower pole of the thyroid cannot be visualized even on swallowing The lower pole of the thyroid cannot be visualized even on swallowing

36. 2. The importance of examining a patient in two perpendicular sections To decrease the failure rate in nodules located in the upper or lower pole To detect and define the degree of susternal spread To measure the longest diameter of a lesion and the lobe To increase the differenctial diagnostic potential of ultrasound To increase the sensitivity of ultrasound examination To increase the specificity of ultrasound examination