thyriod gland imaging part 3 (benign malignant thyriod nodule) Dr Ahmed Esawy

‫هللا‬ ‫بسم‬
‫الرحيم‬ ‫الرحمن‬
Dr Ahmed Esawy

Dr. Ahmed Eisawy
MBBS M.Sc MD
Dr Ahmed Esawy

BENIGNTHYRIOD
NODULES/ MASSE
IMAGING
Dr Ahmed Esawy

Investigations
 Ultrasound – Best modality
 USG guided FNAC
 CT
 MRI
 Technetium-99m pertechnetate or 131/123I
scintigraphy
 Ga68 DOTA scintigraphy
 PET-CT
Dr Ahmed Esawy

Nodules are not a single disease but are a
manifestation of different diseases including
adenomas, carcinomas,inflammations, cysts, fibrotic
areas, vascular regions, and accumulations of colloid.
Dr Ahmed Esawy

USG descriptors of thyroid nodules
Echogenicity
Shape
Hyperechoic (> thyroid), Isoechoic (= thyroid),
Hypoechoic (< strap muscles)
Taller > wide
Calcification
Margin
Microcalcification = / < 1mm
Circumscribed, Microlobulated, Irregular
Vascularity Central or peripheral
Composition Solid, Cystic, Mixed
Dr Ahmed Esawy

Uniform halo around nodule Enlarged thyroid with
multiple nodules
Peri-nodular or spoke-and-wheel like
appearance of vessels
Or avascular
Predominantly
cystic
Avascular
US features of benign nodules
Dr Ahmed Esawy

NODULESWHICH ARE LIKELY BENIGN
entirely cystic nodule
Nearly entirely cystic nodule with no flow
or calcification in the solid part (under 2 cm)
Inspissated colloid calcifications
Honeycomb or spongiform nodule without
calcification (under 2 cm)
Iso /hyperechioc
Uniform halo around nodule
Smooth margins
Avascular or peripheral vascularity
Pseudo nodules in autoimmune thyroid disease
(chronic lymphocytic thyrioditis)
Mixed cystic and solid nodules with a functioning
solid component (any size)
Dr Ahmed Esawy

Features of Benign/Malignant
Nodules Feature Benign Malignant
InternalContents
PurelyCystic
Cystic withThin Septa
Mixed Solid and Cystic
CometTail Artifact
++++
++++
+++
+++
+
+
++
+
Echogenicity
Hyperechoic
Isoechoic
Hypoechoic
++++
+++
+++
+
++
+++
Halo
Thin Halo
Thick Incomplete Halo
++++
+
++
+++
Margin
Well Defined
Poorly Defined
+++
++
++
+++
Calcification
Eggshell
Course
Microcalcifications
++++
+++
++
+
+
++++
Doppler Flow Pattern
Peripheral
Internal
+++
++
++
+++
Dr Ahmed Esawy

Calcification
Although calcification can be seen in both benign and malignant processes, it is
the ultrasound feature most closely associated with malignancy.
microcalcifications
punctate echogenic foci without posterior shadowing
most specific finding associated with malignancy (~95%) 2
associated with papillary thyroid carcinoma
colloid (in benign colloid nodules) shows ring-down (comet tail) artefact; if an
echogenic focus is not definitely colloid, biopsy is warranted
coarse calcifications
can be seen in both benign and malignant nodules
associated with both papillary thyroid carcinoma and medullary thyroid
carcinoma
peripheral rim calcification
can be seen in both benign and malignant nodules
Dr Ahmed Esawy

1. Calcifications
Microcalcifications
 Psammoma bodies
 Common in
papillary carcinoma
 Specificity 86%–
95%
 Positive Predictive
Value: 42 – 94 %
Coarse
calcifications
• MC in medullary
carcinomas
• May coexist with
microcalcificatio
ns in papillary
cancers
Inspissated colloid
calcifications
• May mimic
microcalcifications
• Distinguished by ring
down/reverberation
artefact
Peripheral
calcification
Most common in MNG
Break in peripheral
calcification – malignant
change in an underlying
multinodular goitre
Dr Ahmed Esawy

2. Margins, contour and shape
Hypoechoic halo
 highly suggestive of
benignity
 pseudocapsule of fibrous
connective tissue or
compressed thyroid
parenchyma
 specificity 95%
Shape
• taller than wide
• 93% specificity for
malignancy
Ill-defined margins
• > 50% of its border is
not clearly demarcated
• indicate infiltration of
adjacent parenchyma
• sensitivity: 53%– 89%
and specificity 7%–97%
• Hence frank invasion
beyond the capsule has
to be demonstrated on
HPE
Contour
• Smooth and
rounded
• Irregular/jag
ged edges
Dr Ahmed Esawy

Echogenicity
hypoechoic solid nodule
most papillary thyroid carcinomas
nearly all medullary thyroid carcinomas
benign nodules can be hypoechoic
if no other malignant features (e.g. calcifications) then hypoechoic nodules are
typically biopsied after reaching size criteria
isoechoic solid nodule: 25% (follicular and medullary)
hyper echoic solid nodule: 5% chance of being malignant
large cystic component favors a benign entity although a significant proportion of
papillary carcinomas will have a cystic component
while a halo around a well-marginated hypoechoic or isoechoic nodule is typical of
a follicular adenoma , it is absent in >50% of benign nodules ; what is more, up to
24% of papillary thyroid carcinomas may have a halo, be it complete or incomplete
Dr Ahmed Esawy

3. Echogenicity
of the nodule
 Malignant nodules are
solid and hypoechoic
 Sensitivity 87% but low
specificity 15-27%
 Marked hypoechogenicity
 Darker than strap muscle
 Specificity 94%
4. Vascularity
Marked intrinsic hypervascularity
• Flow in the central part of tumour >
surrounding thyroid parenchyma
Benign nodules
• Perinodular vascularity – 25% of
circumference
• Complete avascularity is a more
useful sign
These features are more useful in selecting
a nodule for FNAC in multinodular goitre
Dr Ahmed Esawy

Lymph nodes
enlarged regional lymph nodes are suspicious for thyroid malignancy, esp. papillary
thyroid carcinoma
microcalcifications in regional lymph nodes are highly suspicious
lymph nodes with cystic change are highly suspicious
loss of normal fatty hilum, irregular node appearance
increased colour Doppler flow is suspicious
no threshold criteria for lymph node biopsy
biopsy if suspicious features
consider biopsy if >8 mm
Dr Ahmed Esawy

5. Local invasion and
lymph node metastasis
Features of nodal
involvement
• Rounded bulging shape
• Increased size
• Replaced fatty hilum
• Irregular margins
• Heterogeneous
echotexture
• Calcifications / Cystic areas
• Vascularity throughout the
lymph node instead of
normal central hilar vessels
Dr Ahmed Esawy

Selected BenignThyroid Lesions
Benign lesions
Benign follicular nodule
Toxic nodule
Adenomatoid nodule
Colloid nodule
Follicular adenoma
Hürthle cell adenoma
Thyroiditis
Chronic lymphocytic (Hashimoto) thyroiditis
Dr Ahmed Esawy

THYPES OFTHYRIOD NODULES
Adenoma neoplastic Carcinoma Colloid nodule
Macro follicular
adenoma (simple
colloid)
Papillary (75 percent) Dominant nodule in a multinodular
goiterFollicular (10 percent)
Micro follicular
adenoma (fetal)
Medullary (5 to 10 percent) Other
Embryonal
adenoma
(trabecular)
Anaplastic (5 percent) Inflammatory thyroid disorders
Hürthle cell
adenoma
(oxyphilic,
oncocytic)
Other Subacute
thyroiditis
Thyroid
lymphoma 5
percent)
Chronic
lymphocytic
thyroiditis
Atypical adenoma Cyst Granulomatous
disease
Adenoma with
papillae
Simple cyst Developmental abnormalities
Signet-ring
adenoma
Cystic/solid tumors (hemorrhagic,
necrotic)
Dermoid
Rare unilateral lobe agenesis
Dr Ahmed Esawy

TIRADS - Thyroid image
reporting and data system
 TIRADS 1 - normal thyroid gland
 TIRADS 2 - benign lesions
 TIRADS 3 - probably benign lesions
 TIRADS 4 - suspicious lesions (4a, 4b, and 4c with increasing risk
of malignancy)
 TIRADS 5 - probably malignant lesions (> 80% risk of malignancy)
 TIRADS 6 - biopsy proven malignancy
Dr Ahmed Esawy

TIRADS 2 – Colloid nodules
- 0% risk of malignancy
Avascular anechoic
lesion with echogenic
specks (colloid type I)
Vascular
heteroechoic non-
expansile, non-
encapsulated nodules
with peripheral halo
(colloid type II)
Isoechoic or
heteroechoic, non-
encapsulated, expansile
vascular nodules (colloid
type III)
TIRADS 3
Hyperechoic, iso-echoic or
hypoechoic nodules, with partially
formed capsule and peripheral
vascularity
<5% risk of malignancy
Dr Ahmed Esawy

Combined solid and cystic lesion
13% - 26% of thyroid cancers
show cystic components
Benign : Halo – fibrous pseudocapsule
however 10%-24% of papillary have incomplete halos
Dr Ahmed Esawy

Benign characteristic HALO
Dr Ahmed Esawy

Iso/hyperechoic, halo, smooth margins,
peripheral vascularity
Dr Ahmed Esawy

“Spongiform” nodules
Dr Ahmed Esawy

Benign Masses
Cysts and Cystic Nodules
 Sonographic Appearance
 Purely anechoic areas (serous / colloid fluid), well-
defined walls, & distal enhancement.
 Fluid levels (hemorrhage)
 FNA / Ethanol Injection
Degenerative Colloid Cysts
Dr Ahmed Esawy

Sonograms showing longitudinal (left panel) and transverse (right panel) images of
the left lobe containing a degenerated thyroid nodule. Note the thick wall and
irregularity. N=nodule, H=hemorrhagic degenerated region.
Benign Masses
Cysts and Cystic Nodules
Dr Ahmed Esawy

Sonogram of the neck in the longitudinal plane showing a hypoechogenic nodule that
was surrounded by an echo free rim, called a halo. Doppler examination demonstrated
great vascularity in the halo, identified as bright spots. Small blood vessels are also
seen elsewhere. N=nodule, L=heterogenous thyroid lobe, m=muscle.
Dr Ahmed Esawy

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.
Dr Ahmed Esawy

Sagittal image of predominantly solid nodule (arrowheads), which proved to be
benign at cytologic examination
Dr Ahmed Esawy

Transverse image of mixed solid and cystic nodule (calipers), which proved to be
benign at cytologic examination
Dr Ahmed Esawy

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.
Dr Ahmed Esawy

COLLIOD NODULE
Colloid nodules, also known as adenomatous
nodules
Colloid nodules are the most common thyroid
nodules
Benign overgrowth of normal thyroid tissue ,
noncancerous enlargement of thyroid tissue.
The patient may have just one colloid nodule or many
Although they may grow large
they are not malignant
they will not spread beyond the thyroid gland.
Dr Ahmed Esawy

Incidentally detected left-sided colloid nodule of the thyroid in a 74-year-old woman. (a)
AxialT2-weighted MR image shows a well-circumscribed, hyperintense 2.2-cm nodule
(arrow). Colliod nodule Dr Ahmed Esawy

Colloid nodule.Transverse US image shows a predominantly anechoic cystic lesion (*) with a
thin wall, well-circumscribed margins, and mild posterior acoustic enhancement. Note the
linear echogenic colloid crystals suspended within the fluid (arrow).These are all benign US
features. Dr Ahmed Esawy

Benign thyroid nodule in a 51-year-old woman.Transverse sonogram of the right
lobe of the thyroid shows a colloid nodule with a ring-down artifact (arrow), a finding indicative
of inspissated colloid calcification
Dr Ahmed Esawy

Benign characteristic Comet tail
Dr Ahmed Esawy

Benign thyroid nodule in a 51-year-old woman.
Transverse sonogram of the right lobe of the thyroid shows a colloid nodule with a
ring-down artifact (arrow), a finding indicative of inspissated colloid calcification
Dr Ahmed Esawy

Benign Masses
Adenomas
 Most common solid thyroid mass
 Encapsulated nodule
 compression of adjacent tissues
 fibrous encapsulation
 Clinical Features
 Most patients euthyroid or hyperthyroid
 Slow growing – must be 0.5 – 1 cm to be palpated
 Sonographic Appearance
 Variable sonographic appearance
 Follicular carcinoma is indistinguishable from an
adenoma
Dr Ahmed Esawy

Toxic Nodular goiter
Toxic adenoma
PLUMMER DISEASE = autonomous function of
one/more thyroid adenomas
Follicular adenoma is benign
Dr Ahmed Esawy

Adenomas
 Well circumscribed; circular
shaped
 Peripheral halo (edema of
compressed tissue)
 Increased Color Flow
 Cystic Degeneration
 Rim Calcification
 Homogeneous with
variable size; Hyperechoic
 Slow growing unless
hemorrhage occurs
(sudden painful
enlargement)
Dr Ahmed Esawy

Follicular adenoma in a 30-year-old
woman.Transverse sonogram of the left lobe of the thyroid
shows a follicular adenoma with a hypoechoic halo (arrows).
Dr Ahmed Esawy

Follicular adenoma in a 36-year-old woman. Longitudinal color Doppler
sonogram of the right lobe of the thyroid shows perinodular flow around a
follicular adenoma
Dr Ahmed Esawy

Follicular adenoma in a 30-year-old woman.Transverse sonogram of the left lobe of
the thyroid shows a follicular adenoma with a hypoechoic halo (arrows).
Dr Ahmed Esawy

Follicular adenoma in a 36-year-old woman. Longitudinal color Doppler sonogram of the
right lobe of the thyroid shows perinodular flow around a follicular adenoma.
Dr Ahmed Esawy

Large toxic follicular adenoma in a 45-yearold woman. (a) Transverse sonogram of the left
lobe of the thyroid shows a 4.5-cm nodule (arrows) that was benign despite its size. (b)
Coronal scintigram obtained with technetium 99m pertechnetate shows a hyperfunctioning
adenoma (arrow).
Dr Ahmed Esawy

Adenomatous nodule in a 66-year-old man with a low thyroid-stimulating hormone level of 0.1
mIU/mL. (a) Transverse US image shows a predominantly solid 2.4-cm nodule with well-
circumscribed margins and a surrounding halo (benign US features). (b) Scintigraphic image
obtained with 123I shows increased uptake in a hot nodule and relative photopenia of the
adjacent normal thyroid tissue.The outline of the neck is not well visualized.
Dr Ahmed Esawy

Autonomous functioning
thyroid adenoma
Dr Ahmed Esawy

Calcified left lobe of thyroid, with deviation
of trachea to right
calcified adenoma
Hyperthyriodism since ten years
Dr Ahmed Esawy

non-enhanced CT showing eggshell calcification of a thyroid adenoma in the right
thyroid lobe
Dr Ahmed Esawy

Enhanced axial neck CT in a different patient shows a 1.3-cm low-density mass in the left
thyroid lobe (arrows).This is nonspecific regarding benign (i.e., goiter or adenoma) versus
malignant disease (cancer).
Dr Ahmed Esawy

Sub sternalThyroid (CT)
Dr Ahmed Esawy

Sonograms of the right thyroid
lobe in the longitudinal plane
showing a 2.7 x 3.2 mm
hypoechoic nodule that is
delineated in the lower panel by
the xx and ++ symbols. Note the
linear hypoechoic structure
below that (arrow). In the upper
panel the bright structure is a
Doppler signal and indicates a
blood vessel below the nodule.
The nodule is not vascular
Dr Ahmed Esawy

a–d. A 72-year-old man
with a recently diagnosed lingual
thyroid. Unenhanced CT image (a)
shows a round, well-defined, and
heterogeneously dense soft tissue
mass at the tongue base (arrows).
T2-weighted MR image (b) shows
slightly increased signal intensity
in the lesion (arrows). Contrast
enhancedT1-weighted MR image
(c) shows strong
heterogeneous
enhancement of the mass
(arrows).
The airway passage is nearly
obstructed by the lingual
thyroid at the oropharynx in
all images. A transverse US
(d) reveals a smooth
hypoechoic tumor with cystic
areas.
Dr Ahmed Esawy

MNG
Antero posterior chest radiograph of an 86-year-old woman who had been unwell for a few months
and was losing weight.The radiograph shows a right superior mediastinal mass.
Dr Ahmed Esawy

MNG
Ten-millimeter computed
tomography section through the
thorax shows a heterogeneous mass
(m) at the root of the neck, on the left,
that displaces the trachea to the right.
The mass appears to be growing in the
caudal direction and is reaching the
arch of the aorta
Dr Ahmed Esawy

Thyroid nodules. CT scan shows a mass
in the posterior mediastinum (P),
which displaces the air-filled
esophagus to the right (arrow)
Thyroid nodules. Iodine-123 thyroid scan shows that
a mass is a multinodular goiter (G).The posterior
mediastinal mass is a hiatus hernia (H); the stomach
(S) is shown. Further investigation revealed that
thyrotoxicosis was the cause of the patient's
symptoms
Dr Ahmed Esawy

MALIGNANTTHYRIOD
NODULES MASSE
Dr Ahmed Esawy

Ultrasound characteristics
associated with an increased
thyroid cancer risk
1.Hypoechoic
2.Microcalcifications
3.Central vascularity
4.Irregular margins
5.Incomplete halo
6.Tall>wide
7.Documented enlargement of a nodule
Should not be used singly
Dr Ahmed Esawy

Ultrasound characteristics
associated with a low
thyroid cancer risk
1.Hyperechoic
2. Large, coarse calcifications (except medullary)
3.Periperal vascularity
4.Looks like puff pastry or Naponeon, Non-hypervascular
Spongiform appearance
5.Comet-tail shadowing
Dr Ahmed Esawy

1.6% of patients with thyroid nodules will have thyroid
cancers
Approx. 96% of thyroid cancers are papillary and
follicular cancers which each have excellent prognosis
Dr Ahmed Esawy

Specific features
 Microcalcifications
 Markedly hypoechoic
 Taller than wide in
transverse plane
 Extension beyond thyroid
margin
 Cervical lymph node
metastasis
Less specific features
 No halo around nodule
 Ill-defined or irregular
margin
 Solid
 Increased central
vascularity
US features of malignant nodules
Dr Ahmed Esawy

Selected MalignantThyroid Lesions
Papillary carcinoma
Follicular carcinoma
Hürthle cell carcinoma
Poorly differentiated carcinoma
Anaplastic/undifferentiated carcinoma
Medullary carcinoma
Lymphoma
Metastasis
Dr Ahmed Esawy

TIRADS 4 & 5
Based on five features:
1. solid component
2. markedly hypoechoic nodule
3. microlobulations or irregular
margins
4. microcalcifications
5. taller-than-wider shape
 TIRADS 4a - one suspicious
feature
 TIRADS 4b - two suspicious
features
 TIRADS 4c - 3-4 suspicious
features
 TIRADS 5 - all five suspicious
features
4a - 5-10% risk of
malignancy
4b & 4c - 10-80% risk of
malignancy
5 - >80% risk of
malignancy
Dr Ahmed Esawy

Hypoechoic, irregular margins, punctate
microcalcifications, intra-nodular flow
Dr Ahmed Esawy

Thyroid US-Risk
Stratification
Dr Ahmed Esawy

Malignant characteristic
Hypo-echoic
• Poorly defined
• No halo
Dr Ahmed Esawy

Micro calcifications
Dr Ahmed Esawy

OVERLAPPING FINDINGS
Benign hyperplastic nodule
Papillary ca
Dr Ahmed Esawy

Malignant
Masses
 Carcinoma of the thyroid is rare!
 Risk of malignancy decreases with multiple nodules
 A solitary thyroid nodule in the presence of cervical adenopathy
on the same side suggests malignancy
 Clinical Findings
 Asymptomatic nodule
 Hoarseness
 History of exposure to low dose ionizing radiation
 Solitary fixed, rapidly enlarging nodule in patient under 14 years or over
65 years of age Dr Ahmed Esawy

Papillary Carcinoma
Dr Ahmed Esawy

Papillary Carcinoma
 Most common thyroid malignancy
 Sonographic Findings
 Hypo echoic
 Microcalcifications
 Hypervascularity
 Possible cervical
lymph node metastasis
Dr Ahmed Esawy

PAPILLARY CARCINOMA
Dr Ahmed Esawy

39-year-old man (a false-positive). A and B,Transverse and longitudinal sonographic
images of the thyroid show mild hypoechogenicity, coarse echogenicity, and the
presence of a microlobulated margin, but the thyroid pathology results showed a
papillary thyroid carcinoma in the left lobe and normal thyroid parenchyma after
thyroid surgery
Dr Ahmed Esawy

PAPILLARY CARCINOMA
Hypoechoic
• Poor halo
• Margins poorly defined.
Dr Ahmed Esawy

Papillary carcinoma in a 60-year-old woman with nontoxic multinodular goiter. (a)
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), both of which are
suspicious US features. A shadowing macrocalcification is also noted (arrowhead). (b)
Longitudinal US image of the right lobe shows three additional nodules: a 1.1-cm solid
nodule (left), a 1.2-cm solid nodule (middle), and a 2.3-cm mixed cystic and solid nodule
(right). In the right lobe, only the 2.3-cm nodule meets the US criteria for FNAB
Dr Ahmed Esawy

Punctate echogenicities in thyroid nodules. (a)
Sagittal US image of nodule (arrowheads)
containing multiple fine echogenicities (arrow)
with no comet-tail artifact.
papillary carcinoma
US image of nodule (arrowheads) containing
cystic areas with punctate echogenicities and
comet-tail artifact (arrow) consistent with
colloid crystals in a benign nodule
Dr Ahmed Esawy

A)predominantly solid thyroid nodule (calipers).
(b) marked internal vascularity,This was a papillary carcinoma
Dr Ahmed Esawy

Papillary thyroid carcinoma in a 42-year-old man. Transverse sonogram of the
right lobe of the thyroid demonstrates punctate echogenic foci without posterior
acoustic shadowing, findings
indicative of microcalcifications (arrows).
Dr Ahmed Esawy

Transverse post-contrast CT demonstrating small bilateral papillary carcinomas, both showing
substantial cystic change centrally. Small calcific foci are also discernible (arrowheads).
Dr Ahmed Esawy

3-year-old woman with Graves’ disease and diffuse sclerosing variant of papillary
carcinoma.
A and B, Transverse and longitudinal sonograms of right thyroid gland reveal
scattered microcalcifications (arrows) and underlying heterogeneous
hypoechogenicity
PapillaryThyroid Carcinoma
Manifested Solely as Microcalcifications on Sonography
Dr Ahmed Esawy

47-year-old woman with thyroid papillary carcinoma and ipsilateral neck node metastasis.
Lesion suspected to be thyroid carcinoma was incidentally discovered
during sonography intended for evaluation of palpated cervical nodules, which were proven
to be benign lymph nodes.
A, Longitudinal sonogram of left thyroid gland reveals multiple microcalcifications (arrows)
at low pole and underlying heterogeneous hypoechogenicity.
B, Transverse sonogram reveals lymph node located at left level IV, measuring 0.7 cm in
length, without identifiable structure, indicating fatty hilum (arrows).
Manifested Solely as Microcalcifications on SonographyDr Ahmed Esawy

44-year-old woman with thyroid papillary carcinoma incidentally found on thyroid
sonography during health examination.
A and B, Transverse and longitudinal sonograms of right thyroid gland reveal clustered
linear microcalcifications (arrows) and underlying heterogeneous hypoechogenicity.
Manifested Solely as Microcalcifications on SonographyDr Ahmed Esawy

Rare cystic papillary thyroid
carcinoma in a 55-year-old
woman
(c) Axial contrastenhanced CT image shows the tumor (arrows) but does not
clearly depict its complexity.
Dr Ahmed Esawy

Diffuse follicular variant of papillary thyroid carcinoma in a 37-year-old woman with
thyrotoxicosis mistaken for Graves disease.
(a) Transverse sonogram of the left lobe of the thyroid shows a heterogeneously
hypoechoic enlarged thyroid (arrows) with no residual normal thyroid tissue. (b)
Color Doppler image shows diffuse increased parenchymal vascularity
Dr Ahmed Esawy

thyrotoxicosis mistaken for Graves disease.
(c) Transverse sonogram of the right neck shows a lymph node metastasis inferior to the
right lobe of the thyroid (arrow) with coarse calcification.This finding aroused suspicion
about the possible presence of a primary thyroid carcinoma. Histopathologic analysis of
the surgical specimen showed replacement of the thyroid gland by a diffuse follicular
variant of papillary thyroid carcinoma. CCA common carotid artery
Dr Ahmed Esawy

Sagittal image of solid nodule (arrowheads),
which proved to be papillary carcinoma
Dr Ahmed Esawy

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.
Dr Ahmed Esawy

Papillary carcinoma in an 87-year-old man.Transverse sonogram of the thyroid isthmus
shows a poorly defined tumor with marked hypoechogenicity and irregular margins (arrows)
and without a hypoechoic halo. Dr Ahmed Esawy

Thyroid microcalcifications are psammoma bodies, which are 10–100-m round
aminar crystalline calcific deposits .They are one of the most specific
features of thyroid malignancy, with a specificity of 85.8%–95% (2,15–17) and a
positive predictive value of 41.8%–94.2%
Papillary thyroid carcinoma in a 42-year-old man. (a) Photomicrograph (original
magnification, 400; hematoxylin-eosin stain) shows a psammoma body (arrow), a
round laminar crystalline calcification
Dr Ahmed Esawy

Papillary carcinoma of the thyroid. CT reveals an enhancing
thyroid mass extending into the left neck. A central hypodense
region is noted. A tissue plane separates tumor from trachea (t).
e, esophagus.
Dr Ahmed Esawy

Coronal MRI scans demonstrating papillary
carcinoma lymph node metastases. In the first
example there is a dominant markedly
enlarged left level III lymph node
(A, STIR sequence) showing loss of normal
architectural pattern and considerable
heterogeneity.TheT1 weighted sequence
(B) shows the classic high signal cystic areas
within the diseased node mass;
heterogeneous appearances with high signal
cystic areas are also demonstrated on theT2
weighted sequence
(C).The second patient shows more extensive
bilateral lymph node
metastases, especially on the right.They are
easily visible on the STIR sequence
(D) while theT1 weighted sequence (E) once
again demonstrates the high signal cystic
areas characteristic of this condition.
Dr Ahmed Esawy

A 24-year-old woman with metastatic papillary carcinoma including a Delphian nodal
metastasis. She presented with a right neck mass. Axial enhanced CT image
shows a large mass in the right lobe of the thyroid.There
are heterogeneously enhancing right level IV nodal masses
(arrows) and an enlarged Delphian node (arrowhead).
Dr Ahmed Esawy

Papillary carcinoma arising in thyroglossal duct cyst. A
multilobated cystic mass is seen anterior to the supraglottic
portion of the larynx. Focal areas of calcification (arrows) and
thickened soft-tissue septa (arrowheads) are seen within the mass.
C, common carotid artery; J, internal jugular vein.
Dr Ahmed Esawy

 Trachea, stenosis. Papillary carcinoma in a multinodular goiter
(MNG) shows the compression and deviation of trachea (green
arrow); the red arrow indicates the esophagus.
Dr Ahmed Esawy

A 58-year-old man with papillary thyroid carcinoma presenting with large cystic nodal
metastases and occult primary on imaging. (a) Axial enhanced CT image shows bilateral
neck cystic masses, larger on the left (arrows).The thyroid had normal appearance on CT
without focal lesions.The gland was also normal on sonography (not shown).
(b) Coronal reformatted enhanced CT image shows multiple complex solid cystic masses in
lateral nodal groups, levels II, III and IV on the left and level IV on the right (arrows).There
are similar smaller cystic masses inferior to both lobes of the thyroid gland in keeping with
levelVI nodes (curved arrows). Dr Ahmed Esawy

A 61-year-old man with papillary thyroid carcinoma in both thyroid lobes and bilateral
nodal metastases of varying morphological appearance and size. Coronal enhanced
CT image shows the primary tumor as a large heterogeneous mass in the inferior left
thyroid lobe with areas of coarse and eggshell calcifications (arrowheads).There is a
large heterogeneous left level III nodal metastasis (asterisk).The inferior right lobe of
the thyroid has a subtle low attenuation region (black arrow), which was also
malignant on the total thyroidectomy specimen.There are small cystic nodal
metastases in the right levelVI and level II nodal groups (curved arrows) of different
morphology from the large left neck mass. Dr Ahmed Esawy

A 19-year-old woman with papillary thyroid carcinoma presenting with cystic nodal
metastases. Axial enhanced CT image shows a radiographically simple cyst (arrowheads)
that actually represents a right level IV nodal metastasis.The right internal jugular vein is
compressed anterior to the cyst indicating this lesion lies in the carotid space.There is a 1
cm solid primary tumor in the right lobe of the thyroid with fine calcifications (arrow).The
differential for a cystic neck mass in a young patient and particularly in a female is a cystic
nodal metastasis from thyroid carcinoma, SCCa and a congenital cyst such as a branchial
cleft cyst Dr Ahmed Esawy

A 52-year-old woman with papillary carcinoma and a retropharyngeal metastasis. She had a history of
fibromyalgia and presented with 1 year of right-sided neck pain. On clinical examination, she was found
to have right neck adenopathy and an enlarged right thyroid lobe, subsequently proven to contain
papillary thyroid carcinoma.
A contrast-enhanced CT scan was performed before thyroid carcinoma was suspected. (a) Axial enhanced
CT image shows subtle asymmetry of the prevertebral muscles (arrows). (b)The same axial enhanced CT
image with narrowed window width shows a metastatic right retropharyngeal node (arrow) to be much
more conspicuous.This case highlights the subtlety of retropharyngeal nodes on CT, which may be even
more problematic when contrast is not given. Dr Ahmed Esawy

A 68-year-old woman with papillary thyroid carcinoma with nodal metastatic disease
invading the trachea. (a) AxialT2-weighted image shows aT2 hyperintense mass in the
right paratracheal region (arrow) with soft tissue signal in the right tracheal cartilage and
an intraluminal mass (arrowhead). (b) CoronalT2-weighted image shows the
mass encasing the right brachiocephalic artery (BCA) with loss of the fat plane.There is
also a right level IV nodal metastasis (curved arrow). She was treated with radioactive
iodine and tracheal stenting. Four months later she presented with massive hemoptysis.
CT images at presentation showed progression of disease.Dr Ahmed Esawy

A 41-year-old woman with treated papillary carcinoma and a cystic nodal recurrence. She was
initially treated with thyroidectomy and a central neck dissection followed by ablative 131I
therapy. Serum thyroglobulin levels were not increased on follow-up, but a palpable low neck
mass was evident. (a) AxialT1-weighted MRI demonstrates a rounded hyperintense lesion
(arrow) with a posterior solid nodule (arrowhead) anterior to the right trapezius muscle
corresponding to levelVb.The lesion has similar signal intensity to adjacent fat. (b) AxialT2-
weighted MRI shows the lesion to beT2 hyperintense (arrow) except for the solid posterior
nodule (arrowhead).This was resected and found to be a predominantly cystic papillary thyroid
nodal recurrence.TheT1 andT2 hyperintense signal likely represents high protein content in
the cyst from colloid, thyroglobulin or blood products. Intrinsically hyperintense nodal
metastases can be difficult to appreciate onT1 and non-fat-saturated T2 and post-contrast
sequences, especially when they are small nodal metastases. Cystic metastases may also be
negative on 131I and PET imaging. Dr Ahmed Esawy

A, AxialT2-weighted image
shows small mass located in left
thyroid lobe (arrows) slightly
hyperintense to abutting
sternocleidomastoid muscle.
B, Apparent diffusion coefficient
(ADC) map shows low ADC value
(0.89 × 10−3 mm2/s) in lesion
(arrows).
66-year-old woman with papillary thyroid carcinoma.
Dr Ahmed Esawy

Medullary Carcinoma C - Cells
Dr Ahmed Esawy

Medullary Carcinoma
C - Cells
 Clinical Findings
 Hard, bulky mass
 Abnormal serum calcitonin
levels
 Solid mass
 Calcifications
 Lymphadenopathy
Dr Ahmed Esawy

Medullary Carcinoma
Dr Ahmed Esawy

Medullary thyroid carcinoma in a 32-year-old
man. (a) Transverse sonogram of the right
lobe of the thyroid shows a large nodule with
coarse calcification and posterior acoustic
shadowing (arrows).
(b) Axial computed tomographic (CT) image
shows the nodule with an internal focus of
coarse calcification (arrows).
Dr Ahmed Esawy

Medullary thyroid carcinoma and calcified nodal metastases in
a 57-year-old man. (a) Transverse sonogram shows a lymph node metastasis with coarse
calcifications (arrows) immediately inferior to the left lobe of the thyroid.The metastasis
was mistaken for a benign calcified hyperplastic thyroid nodule. Several truly benign
thyroid nodules also were found at US, and these findings led to an incorrect diagnosis of
multinodular thyroid. CCA common carotid artery
(b) Sagittal
sonogram
obtained at
follow-up US
shows two other
calcified lymph
node
metastases
(arrows) on the
left side, at
level 2
Dr Ahmed Esawy

 Medullary carcinoma of thyroid gland.A large anterior neck soft-tissue
mass replaces the entire normal thyroid gland on CT.The trachea (asterisk)
is displaced to the right. Small flecks of calcium (arrowhead) are deposited
throughout the mass.
Dr Ahmed Esawy

Thyroid nodules. Plain radiograph of the upper abdomen shows multiple conglomerates of punctate calcification
in the right hypochondrium encroaching on the left hypochondrium.The final diagnosis was a medullary
carcinoma of the thyroid (calcified), lymph node metastases at the root of the neck (calcified), right superior
mediastinal metastases, and gross hepatomegaly with multiple calcified hepatic metastases
Dr Ahmed Esawy

Medullary carcinoma in a 36-year-old woman with a right-sided thyroid nodule. (a) Transverse
duplex US image shows a 2.6-cm solid nodule with an ill-defined lateral margin and
extracapsular extension beyond the thyroid margin (arrow).The nodule has a taller-than-wide
appearance and is markedly hypoechoic. All of these are suspiciousUS features.
Dr Ahmed Esawy

 Medullary thyroid carcinoma.Well-defined partially enhancing right
paratracheal mass (arrowheads) is seen on the enhanced CT scan.Trachea
(asterisk) is displaced to the left.The lesion abuts the right common
carotid artery (arrow).
Dr Ahmed Esawy

Medullary thyroid carcinoma in a 32-year-old man. (a) Transverse sonogram of the right
lobe of the thyroid shows a large nodule with coarse calcification and posterior acoustic
shadowing (arrows).
(b) Axial computed tomographic (CT) image shows the nodule with an internal focus of coarse
calcification (arrows).
Dr Ahmed Esawy

 Thyroid nodules.
A 56-year-old
man underwent
subtotal
thyroidectomy
for a familial
medullary
carcinoma 2 years
previously On
routine follow-up
examination, a
mass was felt in
the thyroid.
Coronal short-tau inversion recovery MRI
shows carcinoma recurrence (R) and lymph
node (L) metastases.
CoronalT1-weighted MRI
shows a carcinoma
recurrence (R) and lymph
node (L) metastases.
Dr Ahmed Esawy

 Trachea, stenosis.
MRI of a patient with
medullary thyroid
carcinoma shows
important
compression and
invasion of the
trachea.
Dr Ahmed Esawy

 Trachea, stenosis. Axial MRI shows
posterolateral invasion of the trachea.
Dr Ahmed Esawy

MRI scan 4 years after thyroidectomy
for medullary thyroid carcinoma.The
post-contrast transverseT1 weighted
image (A) demonstrates a substantial
enhancing mass of recurrent
tumour (arrowheads) lying against the
trachea at the thoracic inlet.This is
seen as a heterogeneous but
predominantly high signal mass on the
STIR sequence (B), which also
demonstrates recurrent disease in the
lymph node drainage (arrows).
Dr Ahmed Esawy

A 57-year-old man with MTC and coarsely
calcified nodal metastases. Coronal
reformatted unenhanced CT image shows a
large coarsely calcified left levelVI nodal mass.
This is immediately inferior to the left lobe
of the thyroid and was mistaken for a benign
calcified hyperplastic thyroid nodule on initial
ultrasonography before the CT. Several truly
benign thyroid nodules were also found on
ultrasonography leading to an incorrect
diagnosis of multinodular goiter. CT showed
other left level Iia and III nodal masses with
coarse calcification, also representing MTC
metastases (arrowheads).
Dr Ahmed Esawy

A 65-year-old man with locally invasive and metastatic MTC with tracheal invasion. He presented with a neck mass and
had increased calcitonin levels. (a) Axial enhanced CT image shows a large left thyroid lobe mass that mildly narrows the
trachea (asterisk), and abuts the esophagus (black arrow) with loss of the fat plane.The mass contacts the
vertebral body (arrow), which was concerning for prevertebral space invasion.There is also a large left level IV nodal
metastasis that displaces and indents the internal jugular vein (IJV) anteriorly and the common carotid artery (CCA)
medially. (b) Coronal reformatted enhanced CT image shows tenting on the inner margin of the left trachea (arrow)
suggesting intraluminal tumor extension. At surgery, there was frank invasion of the left trachea and prevertebral space,
which precluded curative resection.
Dr Ahmed Esawy

Anaplastic (Undifferentiated) Carcinoma
Dr Ahmed Esawy

T categories for anaplastic thyroid cancer
All anaplastic thyroid cancers are consideredT4 tumors at
the time of diagnosis.
T4a:The tumor is still within the thyroid.
T4b:The tumor has grown outside the thyroid.
Dr Ahmed Esawy

Anaplastic (Undifferentiated)
Carcinoma
 Clinical signs
 > 50 years of age
 Hard, fixed
 Rapid growth
 Pain, pressure,
tenderness
 Locally invasive
 Sonographic
Findings
 Hypoechoic mass,
possibly irregular
 Diffuse glandular
involvement
 Invasion of
surroundings
Dr Ahmed Esawy

Thyroid nodules. Postero anterior chest radiograph shows a large, lytic, expanding
metastasis in the anterior aspects of the right fifth and sixth ribs secondary to an
anaplastic thyroid carcinoma in an 85-year-old woman. Note displacement of the
trachea to the left by a mass lesion at the root of the neck.
Dr Ahmed Esawy

Anaplastic Carcinoma
Dr Ahmed Esawy

Poorly differentiated carcinoma in an 81-year-old man with a right-sided thyroid mass
that was discovered at neck CT. (a) Transverse US image shows a predominantly
hypoechoic 5.4-cm solid nodule with ill-defined margins (a suspicious US feature) and no
normal adjacent thyroid parenchyma.
Dr Ahmed Esawy

Anaplastic thyroid carcinoma in an 84-year-old woman. (a) Transverse sonogram
of the left lobe of the thyroid shows an advanced tumor with infiltrative posterior margins
(arrows) and invasion of prevertebral muscle.
(b) Axial contrast-enhanced CT image
shows a large tumor that has invaded the prevertebral muscle (arrows).
Dr Ahmed Esawy

Anaplastic thyroid carcinoma in an 84-
year-old woman. (a) Transverse
sonogram of the left lobe of the
thyroid shows an advanced tumor with
infiltrative posterior margins
(arrows) and invasion of prevertebral
muscle..
(b) Axial contrast-enhanced CT image shows
a large tumor that has invaded the
prevertebral muscle (arrows)
Dr Ahmed Esawy

Transverse MRI scan (T2 weighted) through the thyroid and neck.The remaining normal
thyroid gland is seen as relatively low signal compared with the ill-defined mass of
anaplastic carcinoma arising from the posterior aspect of the right lobe
(A).The tumor extends posteriorly, coming
to lie against the prevertebral muscles and
laterally to encase the carotid artery
(arrow).Posteromedially the tumor extends
ound the back of the trachea, which it
invades posteriorly (arrowhead), and abuts
the esophagus (arrowhead), which is also
probably invaded. For comparison a
transverse post-contrast CT scan
(B) on the same patient demonstrates the
irregular tumor enhancing poorly compared
with the intensely enhancing normal thyroid.
Once again carotid artery encasement is seen
(arrow) and also invasion of the
sternocleidomastoid muscle (arrowheads).
Further inferiorly at the level of the thoracic
inlet
Dr Ahmed Esawy

(C) the trachea is grossly narrowed by
extensive tumor, the airway (arrowheads) reduced to a narrow slit.
Transverse MRI scan (T2 weighted) through the thyroid and neck.The remaining normal
thyroid gland is seen as relatively low signal compared with the ill-defined mass of
anaplastic carcinoma arising from the posterior aspect of the right lobe
Dr Ahmed Esawy

non-enhanced CT demonstrating diffuse hypodensity of the thyroid gland
reflecting areas of cystic necrosis of anaplastic carcinoma
Dr Ahmed Esawy

A 61-year-old man with anaplastic thyroid carcinoma with invasion of the recurrent laryngeal nerve. He presented with hoarseness. (a) Axial
enhancedT1-weighted MRI shows a heterogeneous enhancing mass (arrowheads) in the right lobe of the thyroid.There is loss of the fat
plane in the tracheoesophageal groove.The mass abuts the trachea but the mass is5180 around the trachea.There is posterior displacement
of the esophagus (arrow), but there is no circumferential mass. (b)Axial enhancedT1-weighted MRI at the level of the true vocal cords shows
a dilated right laryngeal ventricle (curved arrow) and anteromedial positioning of the right arytenoid cartilage suggesting vocal cord
paralysis. At surgery there was invasion of the right recurrent laryngeal nerve, and perichondrium of the cricoid and 1st
to 3rd tracheal rings without deep tracheal invasion. Biopsies of the esophagus were egative.The patient had a total thyroidectomy,
followed by chemoradiotherapy.One and two years later he had resection of a right adrenal metastasis and two lung metastases,
respectively.
Dr Ahmed Esawy

Follicular carcinoma
Dr Ahmed Esawy

A 51-year-old woman with follicular carcinoma with venous invasion. She presented with an
enlarging neck mass. (a) Axial enhanced CT image demonstrates a heterogeneously enlarged
thyroid gland (arrows), displacing the trachea to the right.This was biopsied and determined to
be follicular carcinoma.There was no evidence of neck adenopathy, and what resembles a node
in the left neck (arrowheads) represents intravenous extension of tumor in the left internal
jugular vein (IJV). (b) Coronal reformatted enhanced CT image better delineates extension of
tumor in the left IJV (arrowheads). Dr Ahmed Esawy

contrast-enhanced CT showing heterogeneous nodule of the left thyroid gland,
histologically proven follicular carcinoma
Dr Ahmed Esawy

Hurthle cell (follicular) carcinoma in a 60-year-
old woman.
(a) Transverse sonogram of the left
lobe of the thyroid shows a partially cystic
tumor with solid internal projections
(arrows) and thick walls.
(b) Color Doppler sonogram
(shown in black and white) depicts
increased vascularity in the solid
parts of the tumor (arrow).
Dr Ahmed Esawy

B cell lymphoma of the thyroid in a 73-yearold woman with Hashimoto thyroiditis.
Transverse sonogram of the left lobe of the thyroid shows a large heterogeneous
mass (between calipers) with marked hypoechogenicity when compared with the strap
muscles (SM). A normal isthmus (arrow) also is visible. IJV internal jugular vein.
Marked hypoechogenicity is very suggestive of malignancy
Dr Ahmed Esawy

 Thyroid lymphoma. A, B: Proton density-weighted MR images demonstrate an
extensive tumor infiltrating the left and right neck. Both common carotid arteries
(large arrows) are displaced posterolaterally.The left carotid is encased by tumor.The
left internal jugular vein is not visualized and is most likely occluded.The posterior
wall of the trachea (T) is infiltrated with tumor.The cricoid cartilage (small arrows) is
well visualized because of the high signal from medullary fat. J, right jugular vein; e,
esophagus; SCM, sternocleidomastoid muscle; arrowhead, enlarged lymph node.
Dr Ahmed Esawy

Primary thyroid lymphoma in a 54-year-old woman with long-standing goiter and a 1-
month history of progressive neck swelling. (a) Longitudinal US image shows a diffusely
enlarged and abnormally heterogeneous thyroid without normal intervening parenchyma.
Note the infiltrative appearance and evidence of extracapsular extension (arrow), a
suspicious US feature. (b) Axial CT image shows diffuse replacement of the thyroid
parenchyma. Note the associated narrowing of the trachea and lateral displacement of
the adjacent vascular structures. Mildly enlarged abnormal left cervical lymph nodes (*)
are also evident
Dr Ahmed Esawy

Transverse MRI (T2 weighted image) demonstrating a homogeneous mass of lymphoma
arising from the right lobe of an atrophic thyroid (long-standing Hashimoto’s disease)
and extending widely in the right supraclavicular fossa and posterior to the thyroid.
Dr Ahmed Esawy

Coronal MRI scan (STIR sequence) showing
heterenormous enlargement of the thyroid
gland by lymphoma
(A).Tumor extends in all directions, including
into the mediastinum but also superomedially
into the larynx and pharynx (arrowhead).
Tumor can be seen on the transverseT2
weighted image
(B) extending into the posterior aspect of the
right vocal cord
and the hypopharynx (arrowheads).
Dr Ahmed Esawy

Hürthle cell neoplasm in a 53-year-old man with a palpable thyroid nodule at physical
examination. (a) Transverse US image shows a predominantly hypoechoic 1.5-cm solid nodule
(arrow) that meets the criteria for biopsy
Dr Ahmed Esawy

Infiltrative primary leiomyosarcoma of the thyroid in a 90-year-old woman. (a) Transverse
sonogram of the left lobe of the thyroid shows a tumor (between calipers) with infiltration
from the posterior tumor margin into the prevertebral space (arrows).
Dr Ahmed Esawy

Malignant Lymph Nodes
Dr Ahmed Esawy

US features that should arouse suspicion about lymph node metastases include a
rounded bulging shape,
increased size,
replaced fatty hilum,
irregular margins,
heterogeneous echotexture,
calcifications,
cystic areas
vascularity throughout the lymph node instead of normal central hilar
vessels at
Doppler imaging
A completely uniform halo around a nodule is highly suggestive of benignity, with a
specificity of 95%
Dr Ahmed Esawy

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.
papillary Carcinoma
Dr Ahmed Esawy

(7) Papillary carcinoma and cystic lymph node metastasis in a 28-year-old
woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows an irregular
hypoechoic tumor with microcalcifications.
(b) Longitudinal sonogram of the right neck shows a cystic level 5 nodal metastasis with
internal septation and foci of calcification (arrows).
(c) Axial contrast-enhanced CT image shows the metastasis (arrow).Dr Ahmed Esawy

(8) Papillary carcinoma and vascular lymph node metastasis in a 27-year-old woman. (a)
Transverse sonogram shows a tumor that has infiltrated the entire right lobe of the thyroid
(arrows).
(b) Transverse sonogram of the right neck shows a level 3 lymph node metastasis with
increased vascularity (arrow).
(c) Axial contrast-enhanced CT image shows a vascular lymph node with a targetlike
appearance (arrow). Dr Ahmed Esawy

Papillary carcinoma and cystic lymph node metastasis in a 44-year-old woman with a
multinodular thyroid.Transverse sonogram of the right lobe of the thyroid shows a hypoechoic
carcinoma in the isthmus, with microcalcifications and absence of a halo (arrowheads).The
right lobe of the thyroid is displaced anteriorly by a large, partially cystic, level 6 (paratracheal)
nodal metastasis (arrows), which appears to be within the thyroid and which was mistaken for a
benign thyroid nodule. Because several solid benign nodules were present, the initial diagnosis
was benign multinodular thyroid.The cystic nodal metastasis was confirmed at surgery.CCA
common carotid artery. Dr Ahmed Esawy

Transverse MRI scan through the thyroid (T2 weighted image) showing a relatively centrally
placed papillary carcinoma of the thyroid (arrows) with central cystic change.
Multiple abnormal lymph nodes are seen bilaterally (arrowheads) in the internal jugular and
posterior cervical chains, also showing cystic change and representing metastatic diseaseDr Ahmed Esawy

Metastasis to
Lymph Nodes
How does the appearance of a
normal lymph node differ
from an abnormal lymph
node?
Normal
Dr Ahmed Esawy

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.
Dr Ahmed Esawy

 Thyroid carcinoma. Axial contrast-enhanced CT
scan shows a solitary mass (M) within the thyroid
gland, lymphadenopathy (N), and infiltration of
adjacent tissues.
Dr Ahmed Esawy

Metastases to thyroid
Dr Ahmed Esawy

(a) Transverse sonogram of the
left lobe of the thyroid shows a tumor
(between calipers) with infiltration from the
posterior tumor margin into the prevertebral
space (arrows).
(b) Axial unenhanced CT image shows the
large size of the tumor
and the extent of invasion (arrows).
Infiltrative primary leiomyosarcoma of the thyroid in a 90-year-old woman
Dr Ahmed Esawy

Metastatic lung carcinoma in a 63-year-old man with known lung carcinoma in whom a
new thyroid nodule was discovered at staging CT. Longitudinal duplex US image shows
a mildly heterogeneous, hypoechoic 3-cm solid nodule with increased peripheral and
central vascularity. Increased central vascularity is a suspicious US feature.
Dr Ahmed Esawy

Renal cell carcinoma metastases to the thyroid in a 69-year-old woman.
(a) Longitudinal sonogram of the right lobe of the thyroid shows a round hypoechoic
nodule (arrows) and an irregular-shaped hypoechoic nodule (arrowheads). (b) Color
Doppler sonogram of the round nodule shows increased internal vascularity
Dr Ahmed Esawy

Renal cell carcinoma metastases to the thyroid
in a 69-year-old woman.
(a) Longitudinal sonogram of the right lobe of
the thyroid shows a round hypoechoic nodule
(arrows) and an irregular-shaped hypoechoic
nodule (arrowheads)..
(b) Color Doppler sonogram
of the round nodule shows increased
internal vascularity
Dr Ahmed Esawy

B cell lymphoma of the thyroid in a 73-yearold woman with Hashimoto thyroiditis.
Transverse sonogram of the left lobe of the thyroid shows a large heterogeneous mass
(between calipers) with marked hypoechogenicity when compared with the strap
muscles (SM). A normal isthmus (arrow) also is visible. IJV internal jugular vein.
Dr Ahmed Esawy

Coronal MRI (STIR sequence) demonstrating squamous cell carcinoma metastasis to the
right lobe of thyroid showing the characteristic necrotic appearance of this process.
There is a large right upper cervical nodal metastasis (arrow) showing similar necrosis and a
halo of high signal edema (arrowhead) indicating extranodal extension.Dr Ahmed Esawy

 Thyroid carcinoma. Postcontrast CT image shows a large,
irregular, low-density mass (M) destroying the left thyroid
lamina and invading the left true vocal cord (arrowheads). More
caudal images showed the mass arising from the left lobe of the
thyroid.
Dr Ahmed Esawy

 Thyroid carcinoma.A: EnhancedCT image demonstrates a large mass
(M) infiltrating the right side of the neck and involving the right
recurrent laryngeal nerve, resulting in right true vocal cord paralysis
(white arrowheads). B: Similar findings are seen onT1-weighted MR
image. Black arrowhead, common carotid artery; arrow, internal
jugular vein; SCM, sternocleidomastoid muscle.
Dr Ahmed Esawy

 Thyroid carcinoma. A: Enhanced CT image demonstrates a large mass (M)
infiltrating the right side of the neck and involving the right recurrent laryngeal
nerve, resulting in right true vocal cord paralysis (white arrowheads). B: Similar
findings are seen onT1-weighted MR image. Black arrowhead, common carotid
artery; arrow, internal jugular vein; SCM, sternocleidomastoid muscle.
Dr Ahmed Esawy

 Cystic metastasis from thyroid carcinoma.A multiloculated,
inhomogeneous, low-density mass (arrows) is seen posterior
to the left internal jugular vein (J) and sternocleidomastoid
muscle (SCM).C, common carotid artery; arrowheads,
clinically unsuspected thyroid carcinoma.
Dr Ahmed Esawy

Differentiation of thyroid nodules whether benign or
malignant can be done using the diffusion-weighted
MR technique . using ADC values depending on MRI
diffusion weighted imaging
Dr Ahmed Esawy

Magnetic Resonance Imaging
 Arterial spin labeling (ASL)
 Differentiation of autoimmune thyroid conditions
 Treatment response evaluation in Graves disease
 Diffusion weighted imaging (DWI)
 Apparent diffusion coefficient (ADC) can be used
to differentiate benign from malignant nodules
(Schueller)
 Benign = low signal intensities on DWI + high ADC
 Malignant = high signal intensities on DWI + low
ADC
Dr Ahmed Esawy

37 year old female presented with papillary thyroid cancer: CoronalT1: shows large
heterogeneous nodule mainly involving the right lobe, nodule shows multiple hyper intense
foci that denote . . .hemorrhagic foci, encroached upon the air column. AxialT1 shows ill
heterogeneous nodule mainly involving the right lobe. It shows restricted diffusion
Dr Ahmed Esawy

Differentiated thyroid
cancer:Radioiodine Whole
Body Scan pre-ablation
• Radioiodine scanning remains the mainstay of staging for differentiated thyroid cancer.
• Thyroid cancer surveys are possible only after neonatal thyroidectomy and are not
appropriate for patients who have only undergone hemithyroidectomy.
• Star artifact due to substantial thyroid remnant
• I 123 or I 131
Dr Ahmed Esawy

THYROID INCIDENTALOMA
A Radiology term for a mass found incidentally on imaging studies performed for
unrelated reasons.
• Common incidentalomas seen in practice include:Thyroid, lung, liver, Adrenal, Renal.
• Thyroid incidentalomas are the most common form of endocrine incidentalomas.
• Thyroid incidentaloma is described as a mass identified on an imaging study including
the neck for reasons other thanThyroid disease.
All solid - 15 – 27% chance of malignancy
Dr Ahmed Esawy

 Thyroid nodules are common
• Majority >95% are benign
• About 50% of population have thyroid nodules.
• Majority ofThyroid cancers approx. 96% are
Papillary or Follicular cancers.
• Papillary and follicular cancers have near 100%
5 year survival for stage 1 and stage 2.
• Observed thyroid nodules has increased rapidly
in last several decades however mortality is
stable.
Dr Ahmed Esawy

 Nonspecificity of hypodense thyroid lesions on CT.A: A relatively low-
attenuation mass (arrows), due to nodular hyperplasia, is seen in the
right lobe of the thyroid gland.C, common carotid artery; J, internal
jugular vein;Th, left lobe of thyroid. B: Another patient presents with a
similar-appearing low-attenuation nodule (arrow), due to metastatic
adenocarcinoma, in the right lobe of the thyroid gland.C, carotid
artery; J, jugular vein.
Dr Ahmed Esawy

 Nonspecificity of hypodense thyroid lesions on CT. A: A relatively low-attenuation mass
(arrows), due to nodular hyperplasia, is seen in the right lobe of the thyroid gland. C,
common carotid artery; J, internal jugular vein;Th, left lobe of thyroid. B: Another
patient presents with a similar-appearing low-attenuation nodule (arrow), due to
metastatic adenocarcinoma, in the right lobe of the thyroid gland. C, carotid artery; J,
jugular vein.
Dr Ahmed Esawy

Sonogram in the transverse plane after thyroidectomy for cancer from a muscular man.
There was no palpable mass.The image shows a rounded lymph node that was cancer.
C=carotid artery, m=muscle, ++ marks the node.
Dr Ahmed Esawy

Three patients with incidental thyroid nodules that were similar in size but were reported
differently. A, A 46-year-old man with a 12-mm incidental nodule in the left thyroid lobe
detected on chest CTA performed to evaluate an abdominal aortic aneurysm.The nodule was
reported only in the “Findings” section of the report without a recommendation.
B, A 47-year-old woman with a 10-mm incidental nodule in the right thyroid lobe detected on
chest CTA performed to evaluate chest pain.The nodule was reported in the “Impression”
section without a recommendation.
C, A 63-year-old man with several incidental thyroid nodules detected on cervical spine CT
performed to evaluate neck injury.The largest was in the left thyroid lobe and measured 10 mm.
The nodule was reported in the “Impression” section with a recommendation for
sonography. Dr Ahmed Esawy

Pitfalls in the Diagnosis of Malignancy
Dr Ahmed Esawy

CysticVariant of Papillary Carcinoma
Hu¨ rthle cell (follicular) carcinoma in a 60-year-old woman. (a)Transverse sonogram of the left
lobe of the thyroid shows a partially cystic tumor with solid internal projections (arrows) and
thick walls. (b) Color Doppler sonogram (shown in black and white) depicts increased
vascularity in the solid parts of the tumor (arrow)
Dr Ahmed Esawy

 Cystic component occurs in 13-26%
 Predominant cystic appearance is rare
 Can mimic benign cystic hyperplastic
nodule
Cystic variant of papillary carcinoma
Look for
• Solid components with vascularity
• Solid excrescences protruding into
the cyst
• Angle of contact by the solid
component with the cyst wall
• Acute – malignancy
• Obtuse – degenerating cyst (colloid)
• Microcalcifications
Dr Ahmed Esawy

Rare cystic papillary thyroid carcinoma in a 55-
year-old woman. (a)Transverse sonogram of
the right lobe of the thyroid shows a complex
cystic lesion with thick walls and solid
components (arrows). (b) Color Doppler
sonogram shows vascularity in a small part of
the lesion margin (arrow). (c) Axial
contrastenhanced CT image shows the tumor
(arrows) but does not clearly depict its
complexity. A cystic component occurs in 13%–26% of all
thyroid malignancies
Dr Ahmed Esawy

Cystic or Calcified Lymph Node Metastases
Medullary thyroid carcinoma and calcified nodal metastases in a 57-year-old man. (a)
Transverse sonogram shows a lymph node metastasis with coarse calcifications (arrows)
immediately inferior to the left lobe of the thyroid.The metastasis was mistaken for a benign
calcified hyperplastic thyroid nodule. Several truly benign thyroid nodules also were found at
US, and these findings led to an incorrect diagnosis of multinodular thyroid. CCA common
carotid artery. (b) Sagittal sonogram obtained at follow-up US shows two other calcified lymph
node metastases (arrows) on the left side, at level 2. (c) Coronal unenhanced CT image shows
the calcified nodal metastases in both locations (arrows).Dr Ahmed Esawy

Diffusely Infiltrative
HypervascularTumor
thyrotoxicosis mistaken for Graves disease. (a)Transverse sonogram of the left lobe of the
thyroid shows a heterogeneously hypoechoic enlarged thyroid (arrows) with no residual normal
thyroid tissue. (b) Color Doppler image shows diffuse increased parenchymal vascularity. (c)
Transverse sonogram of the right neck shows a lymph node metastasis inferior to the right lobe
of the thyroid (arrow) with coarse calcification.This finding aroused suspicion about the
possible presence of a primary thyroid carcinoma. Histopathologic analysis of the surgical
specimen showed replacement of the thyroid gland by a diffuse follicular variant of papillary
thyroid carcinoma. CCA common carotid artery.
Dr Ahmed Esawy

Diffusely infiltrative
hypervascular tumour
 This variant can be seen in papillary, follicular
carcinomas and lymphoma
 Mimics autoimmune conditions Ex. Graves /
thyroiditis
 De Quervain’s thyroiditis – hypoechoic nodule,
may be taller than wide / may have
microcalcification
 Short duration of history of pain
 Soft on Elastography
Case of thyroid lymphoma –
markedly hypoechoic and
diffusely enlarged thyroid gland
in a 62 year old man
Look for
Echogenicity – markedly hypoechoic
History
Microcalcifications
Dr Ahmed Esawy

INDICATIONS FOR PERFORMING
ULTRASOUND-GUIDED FNA BIOPSY OF A
THYROID NODULE
MANY INVESTIGATORS HAVE SHOWN A MARKED
DECREASE IN INADEQUATE SPECIMENS WHEN FNA
BIOPSY IS DONE UNDER ULTRASOUND GUIDANCE.
UG FNA BIOPSY IS INDICATED IN:
 NON-PALPABLE NODULES (e.g. HIGH SUBSTERNAL).
 SMALL NODULES (<1.5 CM).
 POSTERIOR NODULES.
 CYSTIC OR COMPLEX NODULES (TO BIOPSY MURAL
COMPONENT).
 OBESE, MUSCULAR, OR LARGE FRAME PATIENT.
 DOMINANT NODULE IN MULTINODULAR GOITER.
 PREVIOUS UNSUCCESSFUL FNA BIOPSY.
Dr Ahmed Esawy

US/Clinical Features Indication/Threshold for FNAB
Solitary nodule
Solid nodule with suspicious US features, particularly ≥1 cm
microcalcifications
Solid nodule without suspicious US features ≥1.5 cm
Mixed cystic-solid nodule with suspicious US features ≥1.5 cm
Mixed cystic-solid nodule without suspicious US features ≥2 cm
Spongiform nodule ≥2 cm
Simple cyst with none of the aforementioned characteristics FNAB not necessary
Substantial growth (>50%) since previous US examination FNAB indicated
Suspicious cervical lymph node FNAB lymph node with or without a nodule
Multiple nodules
Normal intervening parenchyma FNAB of up to four suspicious nodules, with selection based on criteria for a
solitary nodule; if no suspicious nodule is present, biopsy of the largest nodule
may be considered
No normal intervening parenchyma FNAB not necessary
Diffuse rapid enlargement of thyroid FNAB indicated to exclude anaplastic carcinoma, lymphoma, or metastasis
Clinically high risk of thyroid cancer Threshold for FNAB is lower due to high risk of thyroid cancer (eg, threshold >0.5
cm for a suspicious solid nodule)
History of radiation exposure in childhood or adolescence
FDG-avid nodule at PET
Age <15 y or >45 y, particularly in males
First-degree relative with thyroid cancer or type 2 MEN
Personal history of thyroid cancer at lobectomy
Personal history of thyroid cancer–associated conditions (familial adenomatous polyposis, Carney complex, Cowden
syndrome, or type 2 MEN)
Guidelines for FNAB Indications Based on US and Clinical Features
Dr Ahmed Esawy

Drawing illustrates FNAB technique, with parallel positioning of the needle relative to the
US transducer and the thyroid
Dr Ahmed Esawy

Capillary technique for FNAB. (a) Photograph shows proper positioning of the biopsy needle,
which is oriented parallel to the US transducer. Note that no syringe is attached to the 27-
gauge biopsy needle (Movie 1 [online]). (b) Transverse US image demonstrates the hyperechoic
needle along its length.The needle tip is positioned within the superficial portion of the
hypoechoic left-sided thyroid nodule
Dr Ahmed Esawy

In general, for an FNAB to be considered diagnostic (adequate), a minimum of six groups of
ten follicular cells must be present upon totaling all slides
If there are multiple suspicious nodules, up to four such nodules should be considered for
FNAB
We suggest that core biopsy be performed in addition to FNAB for the sampling of
nodules with a prior nondiagnostic or indeterminate FNAB
follicular adenoma and follicular carcinoma cannot usually be distinguished with FNAB
alone and are reported as a follicular neoplasm .The histologic distinction between follicular
adenoma and follicular carcinoma can be made only upon surgical excision, by assessing for
the absence (adenoma) or presence (carcinoma) of capsular-vascular invasion.
Dr Ahmed Esawy

Aspiration technique for FNAB. (a) Photograph shows proper positioning of the biopsy
needle, which is oriented perpendicular to the US transducer. Aspiration is achieved by
means of gentle suction with a 10-mL syringe (Movie 3 [online]). (b) Transverse US
image depicts the needle tip, which is identified as a hyperechoic focus (arrow) within
the center of the nodule
Dr Ahmed Esawy

Neck Masses
Thyroglassal Duct Cyst
 Congenital anomaly
 Midline & anterior to
trachea
 Remnant of tubular dev’t
of thyroid gland
persisting between the
base of the tongue and
the hyoid bone
 Clinical Signs
 Palpable midline mass
 Pain associated with
hemorrhage or infection
 Cystic mass in the midline
anterior to the trachea
 Internal echoes caused by
hemorrhage or infection
 Oval, spherical
Dr Ahmed Esawy

Brachial Cleft Cyst
 Anterior to CCA
 Along the border of the
sternocleidomastoid
muscle
 Definite separation from
the thyroid gland
Dr Ahmed Esawy

EACH LOBE, AND ISTHMUS
A. DIMENSIONS OF LOBES (CM)
B. SHAPE OF LOBES, (conventional shape or
indentations and where they are)
C. ECHOGENICITY OF LOBES
Hyperechoic
Hypoechoic
isoechoic
D.VASCULARITY OF LOBES
Physiologic
Increased
Decreased
Avascular
Dr Ahmed Esawy

E. NODULE (S) IN EACH LOBE OR ISTHMUS
Location
Number of Nodules( 1 or 2, a few, multinodular)
Do all nodules have uniform characteristics
Does one nodule have noteworthy characteristics? *
MARGINS
Distinct
ill-defined
halo
continuous
discontinuous
Echogenicity
Hyperechoic
Hypoechoic *
Isoechoic *
Composition
Solid
Cystic
Complex (solid with cystic component)
Shape
Globular
Irregular
Taller than wide
Vascularity
Physiologic
Decreased
Avascular
Increased
Periperal
Central *
Calcifications
Punctate *
Coarse
Egg-shell
Other features
Puff-pastry “Napolean-like” layers
Bright spot with “comet tail shadowing”
Dr Ahmed Esawy

2. LYMPH NODES *
LOCATION
Ipsolateral to nodule
Contralateral to nodule
Relation to another anatomic structure
SHAPE
Oval
Globular *
HILUM
Fatty
Vascular
Absence *
MARGIN
Well-defined
Ill-defined *
VASCULARITY
increased
Physiologic
BLOOD-FLOW FROM PERIPHERY RATHERTHAN HILUM *
CALCIFICATIONS
Punctate *
Coarse
Egg-shell
COMPOSITION
Solid
Complex with cystic component *
IMPACT ON SURROUNDINGSTRUCTURES
Deforms *
No impact
Dr Ahmed Esawy

3. EXTRA-THYROID BED MASS
ANATOMIC SITE (THYROGLOSSAL? SUB-LINGUAL?)
ULTRASONIC CHARACTERISTICS
4. COMPARISON WITH PRIOR EXAMINATION
PRIOR DATE
COMPARISON BASED ON REPORT OR IMAGES?
TECHNICALLY COMPARABLE?
COMPARE CHARACTERISTICS OF LOBES
COMPARE CHARACTERISTICS OF NODULES
COMPARE CHARACTERISTICS OF NODES
Dr Ahmed Esawy

TNM CLASSIFICATION
T categories for thyroid cancer
(other than anaplastic thyroid cancer)
TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor.
T1:The tumor is 2 cm (slightly less than an inch) across or smaller and has not grown out of
the thyroid.
T2:The tumor is more than 2 cm but not larger than 4 cm (slightly less than 2 inches) across
and has not grown out of the thyroid.
T3:The tumor is larger than 4 cm across, or it has just begun to grow into nearby tissues
outside the thyroid.
T4a:The tumor is any size and has grown extensively beyond the thyroid gland into nearby
tissues of the neck, such as the larynx (voice box), trachea (windpipe), esophagus (tube
connecting the throat to the stomach), or the nerve to the larynx.This is also
called moderately advanced disease.
T4b:The tumor is any size and has grown either back toward the spine or into nearby large
blood vessels.This is also called very advanced disease.
Dr Ahmed Esawy

TNM CLASSIFICATION
N categories for thyroid cancer
NX : Regional (nearby) lymph nodes cannot be assessed.
N0 :The cancer has not spread to nearby lymph nodes.
N1 :The cancer has spread to nearby lymph nodes.
Dr Ahmed Esawy

TNM CLASSIFICATION
M categories for thyroid cancer
MX: Distant metastasis cannot be assessed.
M0:There is no distant metastasis.
M1:The cancer has spread to other parts of the body, such as distant lymph
nodes, internal organs, bones, etc
Dr Ahmed Esawy

T:Tumour
Tx: primary tumour cannot be assessed
T0: no evidence of primary tumour
T1: tumour ≤2 cm in greatest dimension limited to the thyroid
T1a: tumour ≤1 cm, limited to the thyroid
T1b: tumour >1 cm but ≤2 cm in greatest dimension, limited to the thyroid
T2: tumour >2 cm but ≤4 cm in greatest dimension, limited to the thyroid
T3: tumour >4 cm in greatest dimension limited to the thyroid or any tumour with minimal
extrathyroid extension (e.g. extension to sternothyroid muscle or perithyroid soft tissues)
T4: advanced disease
T4a: moderately advanced disease - tumour of any size extending beyond the thyroid
capsule to invade subcutaneous soft tissues, larynx, trachea, oesophagus, or
recurrent laryngeal nerve
T4b: very advanced disease - tumour invades prevertebral fascia or encases carotid
artery or mediastinal vessels
cT4a: intrathyroidal anaplastic carcinoma
cT4b: anaplastic carcinoma with gross extrathyroid extension
Dr Ahmed Esawy

N: Nodes
Nx: regional lymph nodes cannot be assessed
N0: no regional lymph node metastasis
N1: regional lymph node metastasis
N1a: metastases to levelVI (pretracheal, paratracheal, and
prelaryngeal/Delphian lymph nodes)
N1b: metastases to unilateral, bilateral, or contralateral cervical (levels I, II, III, IV,
orV) or retropharyngeal or superior mediastinal lymph nodes (levelVII)
Dr Ahmed Esawy

M: Metastases
Mx: distant metastases cannot be assessed
M0: no distant metastasis
M1: distant metastasis
Dr Ahmed Esawy

thyriod gland imaging part 3 (benign malignant thyriod nodule) Dr Ahmed Esawy

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