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

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

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;24:102-32. 2. Thyroid gland: US screening in a random adult population. Radiology 1991;181:683–687.

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.

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

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

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

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

2. Hypoechogenicity The Thyroid Nodule. N Eng J Med 2004;351:1764-71.

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

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

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

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

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

US features in thyroid cancer

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

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

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

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

Fine needle aspiration

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

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

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