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Imaging of thyroid
- 1. IMAGING OF THYROID DR. DEV LAKHERA
- 2. THYROID ⢠Anatomy and Embryology ⢠Imaging modalities ⢠Congenital thyroid abnormalities ⢠Nodular thyroid diseases ⢠Diffuse thyroid diseases ⢠Thyroid malignancies
- 3. Anatomy ⢠Infrahyoid compartment ⢠2-4th tracheal rings ⢠Pyramidal lobe
- 4. ⢠Size: 5 x 2 x 2 cm ⢠AP diameter > 2 cm enlarged. ⢠Isthmus 4-6 mm
- 5. Embryology ⢠Follicular thyroid tissue ⢠Parafollicular cells
- 6. IMAGING ⢠Plain Radiography ⢠USG ⢠CT /MRI ⢠Nuclear scintigraphy ⢠18 FDG-PET
- 7. Plain radiograph ⢠Paratracheal soft tissue mass ⢠Tracheal shift/narrowing ⢠Calcification ⢠Bony destruction
- 8. ULTRASONOGRAPHY Investigation of choice ⢠Diagnostic role (guided FNAC, biopsy) ⢠Therapeutic role âRFA , Alcohol ablation 7.5 to 10 Mhz ⢠Normal parenchyma â homogeneous medium to high level echoes. ⢠Capsule â Thin hypoechoic line.
- 9. Role of USG in thyroid diseases ⢠Solid vs cystic lesions. ⢠Benign vs malignant lesions ⢠Nodule detection when physical examination is unequivocal. ⢠Thyroid nodules from other cervical masses
- 10. Cross sectional imaging CT/MRI ⢠Detection lymph nodal metastasis ⢠Extension into adjacent neck and mediastinal tissues. ⢠Follow up for recurrence
- 11. Nuclear Scintigraphy ⢠Functional information about the thyroid ⢠Radiotracer :- Oralď I-123, I-131 I.v ď Tc-99m pertechnate Normal uptake 10-30 %
- 12. ⢠Hot /warm /cold nodule
- 13. PET scan ⢠Follow up of thyroid carcinoma ⢠Metastatic thyroid carcinoma ⢠Tumors that donât concentrate radioactive iodine
- 14. CONGENITAL THYROID ABNORMALITIES ďAplasia/hypoplasia of one lobe or the whole gland ďEctopic gland ⢠Radionuclide scans to detect ectopic thyroid tissue.
- 15. ⢠Ectopic (sublingual) thyroid
- 16. Nodular thyroid disease ⢠Discrete lesion/s within the substance of thyroid gland ⢠sonographically distinct from surrounding parenchyma ⢠85% benign ⢠hyperplasia of gland
- 17. Diffuse nontoxic goiter Two stages ⢠Hyperplasia ⢠Colloid involution ⢠USG: Diffusely enlarged thyroid gland . (euthyroid state)
- 18. Multinodular goiter ⢠multiple nodules with hemorrhage , calcification, scarring and cyst formation ⢠Ultrasonography: --Irregular, showing diffuse inhomogeneous echogenicity or multiple focal hypoechoic nodules.
- 19. ⢠On CT Asymmetric with multiple low density areas
- 20. Scintigraphy ⢠Enlarged gland, with heterogeneous uptake
- 21. Differentiating features Benign Malignant Internal consistency Cystic component Predominantly solid composition Echogenicity Hypoechoic /iso /hyper More marked hypoechogenicity Margins Well marginated Spiculated, illdefined, irregular
- 22. Benign Malignant Sonoluscent peripheral halo Absent Peripheral vascularity Intranodal vascularity
- 23. Benign Malignant Wider than taller Taller than wider Peripheral calcification Scattered echogenic Micro calcification Histopathology -colloid goiter
- 24. Colloid cyst
- 25. Contrast enhanced sonography ⢠Shows enhancement of septa in malignant nodules in arterial phase ⢠Benign septae do not show enhancement.
- 26. Thyroid image reporting and data system (TIRADS) ⢠TIRADS 1: normal thyroid gland â 0 % ⢠TIRADS 2: benign lesions â 0 % ďavascular anechoic lesion with echogenic specks ďvascular heteroechoic, non-encapsulated nodules with peripheral halo
- 27. TIRADS 3: probably benign lesions <5 % ďhyper, iso or hypoechoic nodules ďpartially formed capsule ďperipheral vascularity..
- 28. Suspicious lesions ⢠TIRADS 4: ďźsolid component high stiffness of nodule on elastography if available ďźmarkedly hypoechoic nodule ďźmicrocalcifications ďźtaller-than-wider shape ďźmicrolobulations or irregular margins ⢠subclassified as 4a, 4b, and later 4c
- 29. TIRADS 4a: one suspicious feature (5-10%) TIRADS 4b: two suspicious features(10-80 %) TIRADS 4c: Three/four suspicious features(10-80%) TIRADS 5: probably malignant lesions (more than 80% risk of malignancy) TIRADS 6: biopsy proven malignancy
- 30. Diffuse Thyroid diseases Acute infective Acute suppurative thyroiditis Autoimmune thyroiditis Hashimoto thyroiditis: Graves disease Postpartum thyroiditis: Riedel thyroiditis Subacute Thyroiditis De Quervain thyroiditis:
- 31. Acute suppurative thyroiditis ⢠USG: Ill defined, hypoechoic, heterogeneous mass ⢠Internal debris ⢠Septa +/- ⢠Lymph nodes
- 32. De Quervain thyroiditis (or subacute granulomatous thyroiditis) ⢠Self limiting Sonographic appearance ⢠Poorly defined regions of decreased echogenicity with decreased vascularity in the affected areas. ⢠Bilateral or unilateral.
- 33. Nuclear scintigraphy ⢠Low uptake thyroid scan in patients with hyperthyroidism is almost diagnostic
- 34. Hashimotoâs (chronic autoimmune lymphocytic) ⢠Most common type of thyroiditis ⢠Thyroglobulin antibodies ⢠Hypothyroidism
- 35. USG ⢠Diffuse coarsened echotexture ⢠Hypoechoic micronodules (1-6 mm) ⢠lobules are surrounded by multiple linear echogenic coarse fibrous septations ⢠Colour Doppler Normal or decreased flow, but occasionally there might be hypervascularity.
- 36. ⢠Lobules are surrounded by multiple linear echogenic coarse fibrous septations ⢠MRI Areas of increased signal intensity on T2W Few areas of contrast enhancement
- 37. Graves disease ⢠hyperfunctioning thyroid ⢠USG â Inhomogenous diffusely hypoechoic gland ⢠C/D- hypervascular âThyroid inferno PSV â 70 cm/sec
- 38. Nuclear scintigraphy ⢠Overall increased uptake throughout the enlarged thyroid gland in the Grave's patient.
- 39. ⢠CT enlargement of the extra-ocular muscles
- 40. Thyroid malignancies ⢠Most tumors are well differentiated Papillary carcinoma ⢠Follicular ⢠Anaplastic ⢠Medullary carcinoma ⢠Lymphoma
- 41. Papillary carcinoma ⢠Low grade ⢠Lymphatic spread USG ⢠Hypoechogenicity ⢠Microcalcification -Fine punctate ⢠Hypervascularity ⢠Lymph nodal CYSTIC /FOLLICULAR VARIENT
- 42. ⢠Heterogenous lesion with internal calcification ⢠Bony destruction ⢠CECT : Heterogeneous enhancement
- 43. Cystic variant ⢠Papillary thyroid carcinoma: atypical.
- 44. Follicular carcinoma USG ⢠Hypoechoic ill defined lesion with Thick irregular capsule ⢠Types: Minimally invasiveď Encapsulated Invasive ď Not well encapsulated with vascular invasion Central chaotic vascularity
- 45. Medullary carcinoma Multicentric Parafollicular C cells Ultrasound ⢠Hypoechoic solid nodules with coarse internal calcifications. ⢠Involved lymph nodes typically calcify.
- 46. CT ⢠Both primary and metastatic lesions usually have irregular dense calcific foci within . ⢠In the chest, bullae formation and pulmonary fibrosis Nuclear imaging ⢠do not concentrate radioactive iodine FDG-PET ⢠~75% (range 60-95%) sensitive for metastatic disease 6
- 47. Anaplastic carcinoma ⢠Fatal- elderly women, long standing goitre USG ⢠Hypoechoic lesion encasing the vessels CT Extent/ calcification / necrosis
- 48. Primary Lymphoma ⢠Old aged females Hashimotos Nodular / diffuse Nuclear: I-131 Cold nodule Gallium- Increased uptake
- 49. THANK YOU
- 50. Reidelâs thyroiditis ⢠Invasive fibrous thyroiditis ⢠Ultrasound ⢠The thyroid can appear homogeneously hypoechoic with the poor demarcation of the gland borders as the fibrotic invasion of the adjacent fat or anatomical structures progresses. ⢠CT ⢠This may demonstrate compression of local structures by an enlarged thyroid with low attenuation change within areas of the involved thyroid gland. ⢠MRI ⢠The fibrosing thyroid gland appears low on T1 and T2 and can have a variable pattern of enhancement. â˘
- 51. CT SCAN ⢠Supine position with neck in hyperextension ⢠Contiguous 3-5 mm sections from base of tongue to superior mediastinum ⢠CT-appearance 80 -100 HU because of I content ⢠CT Perfusion
- 52. MRI ⢠Can be used in conjugation with scintigraphy since gadolinium does not interfere in I uptake. ⢠MRA ⢠MRS ⢠Dynamic MRI
Editor's Notes
- Thyroid gland is an endocrine gland.anteroinferior part of neck. Twolobes connected in midline by an sthmus. Ascessory lobe which originates from the isthmus medially and superiorly below thyroid cartilage//5 x 2 x 2 cm
- 2 x 1 cm in newborn.///Volume M-20 ml/ F-19 ml
- The thyroid develops from the 1st and 2nd pharyngeal pouches at the foramen caecum in the midline in the region of tongue in the embryonic period and descends to its final position.. Since the thyroid gland travels from base of toungue to its position in the neck
- Plain radiographs of the neck can be done in both (AP) and lateral projections show the enlarged thyroid in the pretracheal location//Plain chest X-ray (CXR) demonstrating a retrosternal thyroid mass displacing the trachea.
- Easy,cheap procedure// supine position with neck in hyperextension/PSV-20-40cm/sec
- Recent advantages âcontrast enhanced / usg elastographhy
- better delineation of lesions within the thyroid Paraspinal muscles, esophagus, trachea and carotid sheath
- Take part in hormonal syntehesis, taken up by gland///focal thyroid mass// gamma camera//The normal thyroid gland shows homogeneous radionuclide uptake and distribution // Tc preferred sincea higher dose cab be administered so better resolution// I contrast agents interfere
- cold nodule has slightly higher chance of malignancy// hot uptake more than normal
- Presents with congenital hypothyroidism
- CT showing round-shaped thyroid gland (arrow) contains an irregular, low-attenuation area, likely caused by nodule degeneration; curved arrow, mandible.
- These are due to // rest are due to adenomas and carcinomas//Longitudinal ultrasound images. A, Oval homogeneous nodule (arrows) with thin, uniform halo.
- Diffuse non nodular enlargement of thyroid// secondary to iodine deficiency //normal homogenous thyroid echogenicity////diffuse glandular enlargement and hyperemia //A transverse ultrasound image through the isthmus of a euthyroid patient shows a moderately to markedly enlarged thyroid gland with. Notice that both thyroid lobes extend lateral to the carotid artery.Â
- Often if untreated diffuse progresses to micronodule and micronodule (formation multinodular goiter)//Transverse dual ultrasound image shows enlargement of thyroid lobes and isthmus and multiple hyperechoic solid nodules with uniform thin halo (arrows). Mixed solid and cystic thyroid nodule in the left lobe. Tr: tracheal gas shadow. B. Transverse sonogram and color-doppler mode scan show a well-defined isoechoic thyroid nodule with thin complete hypoechoic halo, intranodular cystic/colloid space and peripheral vascularity, //numerous interfaces between cells and colloid substance
- areas that reflect regions of haemorrhage, cyst formation, or necrosis.
- Heterogeneously mild increased uptake in the right lobe of the thyroid without discrete hot or cold nodule evident.//Hyperplastic nodule function may have decreased, may have remained normal, or may have increased (toxic nodules).
- 30% of nodules show cystic component seen in colloid nodule undergone degeneration/ hemorhage//On transverse section on sonography//a well-defined oval with central cystic part in the lobe of thyroid with internal echoes within benign nodule//a well marginated, multiseptated, cystic lesion. FNAC: Colloid goiter
- Fibrous capsule/ compressed blood vessel/ surrounding edema
- Large and coarse// fine and punctate//CT scan showing a nodule in the isthmus of thyroid gland with dense peripheral calcification.
- Bright echogenic foci with comet-tail artifacts are likely caused by microcrystals or aggregates of colloid substance Thin, intracystic septations probably correspond to attenuated strands of thyroid tissue.
- Conventional B-mode sonogram in longitudinal plane demonstrates a nodule (arrow) arising from the posterior wall. D, Contrast-enhanced longitudinal sonogram shows that the nodule remains visible, indicating enhancement after contrast enhancement. The lesion was a cystic papillary carcinoma.//SonoVue//sulphur hexafluoride microbubbles//perfluorocarbon or nitrogen gas
- simple thyroid cyst. //solid nodule with central cyst//spongiform nodule. . isoechoic or heteroechoic, non-encapsulated, expansile vascular nodules
- slightly hyperechoic nodule with small cysts and peripheral vascularity //Hashimotoâs
- US scans show features indicative of malignancy, including (a) hypoechogenicity ( = strap muscle, arrows = nodule); (b) microcalcifi cations (arrows); (c) marked hypoechogenicity ( = strap muscle, arrows = nodule), microlobulated margin, and taller-than-wide shape; and (d) irregular margin (arrows = nodule). TIRADS 4a:Â one suspicious feature TIRADS 4b:Â two suspicious features TIRADS 4c:Â three/four suspicious features TIRADS 5: all five suspicious features
- TI-RADS 4b: nodule with two sonographically suspicious criteria for malignancy: hypoechogenicity and internal vascularity. //TI-RADS 4c: nodule with microcalcifications, irregular borders and taller than wide shape (greater in its anteroposterior diameter than in its transverse diameter
- Geneneralised enlargement without any palpable nodule// all these diseases occur in acute- (self limiting )// Chronic â (progressive)
- Acute suppurative thyroiditis is a rare inflammatory disease usually caused by bacterial infection and affecting children.
- preceded by upper respiratory tract viral infection //neck ppain// euthyroid//show ill-defined hypoechoic lesions involving right lobe //no cervical lymphadenopathy was detected.
- <2%(n 20-40%)
- Painless diffuse thyroid enlargement
- diffusely enlarged thyroid gland //The thyroid parenchyma looks abnormal and unhealthy, elicit heterogeneous echogenicity with numerous minute hypodensities within that represent tiny hypoechoic nodulesprominent reactive cervical nodes may be present, especially in level VI, ///patients are at higher risk for papillary thyroid carcinoma, so a discrete nodule should be considered for biopsy//Both lobes of the thyroid gland are of decreased size. . They are separated by fibrous echogenic septa. The gland parenchyma shows increased vascularity on Doppler study. No detectable masses could be seen. micronodules represent lobules of thyroid parenchyma that have been infiltrated by lymphocytes and plasma cells.
- /Thyroid Ultrasound image of right thyroid lobe showing a diffuse swelling of the lobe, which has a rather hypo-echoic appearance and a slightly lobulated contour.//multiple small areas of colour flow seen diffusely throughout the gland representing increased vascularity and arteriovenous shunting.Â
- Visualization of pyramidal lobe (remnant of the thyroglossal duct) projecting cephalad from isthmus (red arrow). The pyramidal lobe is usually not seen (because it is small) unless the gland is overly stimulated. Anterior distant image obtained with Tc-99m-pertechtenate shows that the gland is enlarged. Activity throughout gland is increased relative to the background due to hyperfunctionality of the gland. Â
- Follicular and parafollicular origin// All of these tumors occur more commonly in females except anaplastic
- 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)// Females in third decade old history of radiation exposure// enlarged ly//
- Enlarged Cystic nodes on the right side of the neck with a heterogeneous thyroid gland. Probable vertebral body met also. //invasion into adjacent structures MRI choline peak
- large nodule displaying extensive cystic change//SUBTYPE : Cystic variety with mural nodule /hypervascular excrescences
- Minimaly invasive Low grade malignancy associated with iodine deficiency// hematogenous// lacks cystic invasion
- //calcification may be seen both within the primary thyroid lesion as well as metastatic regional lymph nodes
- assessment of tumour invasion 1 as well as metastatis//might happen as a result of a desmoplastic reaction. since the tumour does not arise from thyroid follicular cells
- Aggressive tumor/ Transverse image shows large hypoechoic mass (arrows) involving the entire gland, greater on the left, which causes deviation of the trachea to the right; Tr
- CT/MRI less enhancement//arge mass arising from left lobe of thyroid gland resulting in tracheal deviation and compression. The calcification of the trachea on the left is lost and there is extraluminal air consistent with direct invasion.
- Unenhanced axial T1- and T2-weighted MR images show the normal appearance of the thyroid gland which is homogeneously hyperintense to the neck musculature. The vessels, carotid artery and jugular vein are seen as signal void posterolateral to the lobes of thyroid