1. Evaluation of Thyroid Nodule with US and FNA
Kyung-Hee university medical center
Department of Internal medicine
R2 Han, Jae-Joon

2. Thyroid nodule
A discrete lesion within the thyroid gland that is sonographically distinguishable from the adjacent parenchyma

3. Epidemiology Thyroid nodules are found in
palpation : 4~8%
US : 10~41%
autopsy : 50%
The prevalence increases with age
1. Management of simple nodular goiter: current status and future perspectives.
Endocr Rev 2003;24:
2. Thyroid gland: US screening in a random adult population.
Radiology 1991;181:683–687.

4. Thyroid cancer Diagnosed in the United States in 2005 Papillary 75~80%
Follicular 10~20%
Medullary 3~5%
Anaplastic 1~2%
Jemal A, Murray T, Ward E, Tiwari RC,Feuer EF, Thun MJ. Cancer statistics, 2005.
CA Cancer J Clin 2005;55:10–30.

5. What suggests malignancy ?
Younger than 20 or older than 60
Firmness of the nodule
Rapid grow
Fixation to adjacent structures
Vocal cord paralysis
Regional lymph node enlargement
History of neck irradiation
History of thyroid cancer

6. US features Size Echogenicity : hypo- or hyper-
Composition : cystic, solid, or mixed
Coarse or fine calcifications ?
Halo ?
Margins
Blood flow

7. US features Size * Nodule size is not predictive of malignancy!
Echogenicity : hypo- or hyper-
→ Hypoechogenicity
Composition : cystic, solid, or mixed
→ Predominantly solid composition
Coarse or fine calcifications ?
→ Presence of calcifications
Halo ?
→ Absence of a halo
Margins
→ Irregular margins
Blood flow
→ Intranodule vascularity

8. 1. Calcification
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.
Management of Thyroid Nodules Detected at US:Society of Radiologists in
Ultrasound Consensus Conference Statement1. Radiology 2005; 237:794–800

9. 2. Hypoechogenicity
The Thyroid Nodule N Eng J Med 2004;351:

10. 3. Irregular margins
39-year-old woman with papillary carcinoma. Sonogram of right thyroid gland shows 12-mm mass with internal calcifications that is markedly hypoechoic. Calcifications appear as bright punctate echoes but are not large enough to create acoustic shadowing. Microlobulation (arrows) can also be seen.
New Sonographic Criteria for Recommending Fine-Needle Aspiration Biopsy of Nonpalpable Solid Nodules of the Thyroid AJR 2002;178:687–691

11. 4. Absence of a halo
36-year-old woman with papillary carcinoma. Sonogram of right lobe of thyroid gland reveals 4-mm, well-defined hypoechoic nodule (calipers). Two tiny hyperechoic foci suggesting microcalcifications within nodule are only sign of malignancy.
Follucular adenoma of the thyroid demonstrates a well-defined capsule
Ultrasound in head and neck surgery: thyroid, parathyroid, and cervical
lymph nodesSurg Clin N Am 84 (2004) 973–1000

12. 5. Composition Solid Predominantly solid Mixed solid and cystic
Predominantly cystic
Cystic
Figure 2. US images of thyroid nodules of varying parenchymal composition (solid to cystic). (a) Sagittal image of solid nodule (arrowheads),
which proved to be papillary carcinoma. (b) Sagittal image of predominantly solid nodule (arrowheads), which proved to be benign at cytologic examination. (c) Transverse image of mixed solid and cystic nodule (calipers), which proved to be benign at cytologic examination. (d) 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.
Management of Thyroid Nodules Detected at US:Society of Radiologists in
Ultrasound Consensus Conference Statement1. Radiology 2005; 237:794–800

13. 6.Intranodule vascularity
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.
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.
Management of Thyroid Nodules Detected at US:Society of Radiologists in
Ultrasound Consensus Conference Statement1. Radiology 2005; 237:794–800

14. Abnormal cervical lymph nodes
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.
Management of Thyroid Nodules Detected at US:Society of Radiologists in
Ultrasound Consensus Conference Statement1. Radiology 2005; 237:794–800

15. US features in thyroid cancer

16. Follicular ca Compact atlas of Thyroid & salivary gland ultrasound
by Noboru dakanashi Published by VECTOR CORE Inc.

17. Papillary ca
Compact atlas of Thyroid & salivary gland ultrasound by Noboru dakanashi Published by VECTOR CORE Inc.

18. Medullary ca Compact atlas of Thyroid & salivary gland ultrasound
by Noboru dakanashi Published by VECTOR CORE Inc.

19. Anaplastic ca Compact atlas of Thyroid & salivary gland ultrasound
by Noboru dakanashi Published by VECTOR CORE Inc.

20. Fine needle aspiration

21. Cytopathologic evaluation
FNA with cytologic evaluation
accepted method for screening of cancer
Reading
negative( or benign)
suspicious for cancer
positive( or diagnostic for cancer)
nondiagnostic

22. Fine needle aspiration
False-positive rate
less than 1%
Suspicious for cancer
30~60% will prove to be cancer
Nondiagnostic rate
15~20%
Cancer in surgically resected nodules with nondiagnostic FNA
5~9%
Management of Thyroid Nodules Detected at US:Society of Radiologists in
Ultrasound Consensus Conference Statement1. Radiology 2005; 237:794–800

23. Management of Thyroid Nodules Detected at US:Society of Radiologists in
Ultrasound Consensus Conference Statement1. Radiology 2005; 237:794–800