New emerging tools in ultrasound in cases of small thyroid papillary cancer

1. A small thyroid papillary cancer
The role of Shear Wave Elastography
Antonio Pio Masciotra
Campobasso – Molise – Italy
Website www.masciotra.net
YouTube Channel
https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ
51 years old asymptomatic woman at her first thyroid US exam.
Two small nodules were found in her left lobe, one in the lower pole, the other near the isthmus.

2. This is the lower pole nodule, slightly
hypoechoic wth a few intranodular
vessels at powerdoppler.
At Shear Wave Elastography it shows a
stiffness substantially not different from
the one of surrounding normal
parenchyma.

3. This is the second nodule (8 mm in diameter and 0,2 ml in volume).
It is inhomogenehously hypoechoic, with undefined borders, taller than wide,
with small calcification and many intranodular vessels.
10-2 Mhz Linear probe 15-4 MHz Linear probe 16-5 MHz Linear Probe

4. This is the 3D US study
also in elastography

5. 10-2 Mhz probe 15-4 MHz probe 16-5 MHz probe
Left lobe paraisthmic
nodule (kPa)
10-2 MHz 15-4 MHz 16-5 MHz
Mean stiffness 72-104 58-72 51-71
Maximum stiffness 95-133 76-111 87-91
Minimum stiffness 71-89 26-41 1-49
Standard Deviation 9-13 9-20 11-23
Ratio 1,4-3,4 2,4-4,3 1,8-3,8

6. Lower pole nodule Paraisthmic nodule
15-4 MHZ Probe
SWE Features (kPa)
Lower pole
nodule
Paraisthmic
nodule
Mean stiffness 31-33 58-72
Maximum stiffness 36-43 76-111
Minimum stiffness 25-31 26-41
Standard Deviation 1-3 9-20
Ratio 1,0-1,4 2,4-4,3

7. This is the FNA cytology of the left lobe’s
paraisthmic nodule classified TIR 5* (corresponding
to Thy VI in the Bethesda Classification), diagnostic
for PTC.
At surgery this nodule was confirmed PTC, while the
lower pole nodule was benign (simply hyperplastic).
* ITALIAN CONSENSUS GROUP FOR THE CLASSIFICATION AND REPORTING OF THYROID CYTOLOGY
Francesco Nardi, Fulvio Basolo, Anna Crescenzi, Guido Fadda, Andrea Frasoldati, Fabio Orlandi, Lucio Palombini, Enrico Papini, Alfredo Pontecorvi, Paolo Vitti (2013)
TIR1: Not diagnostic.
TIR1C: Not diagnostic - Cyst.
TIR2: Not neoplastic.
TIR3A: Low risk follicular lesion.
TIR3B: High risk follicular lesion.
TIR4: Suspicious for malignancy.
TIR5: Diagnostic of malignancy.

8. Two more small thyroid papillary cancers
The role of Sonoelastography
Antonio Pio Masciotra
Campobasso – Molise – Italy
Website www.masciotra.net
YouTube Channel
https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ
37 years old asymptomatic woman at her first thyroid US exam.
Two small nodules were found, one in the right lobe near the isthmus, the other in the lower pole of the left lobe.

9. This is the right lobe’s paraisthmic
nodule, slightly hypoechoic with
intranodular vessels at powerdoppler.
At Shear Wave Elastography it shows
stiffness features substantially not
different from the ones showed by the
right lobe’s paraisthmic nodule.

10. This is the lower pole nodule, slightly
hypoechoic with a few intranodular
vessels at powerdoppler.
At Shear Wave Elastography it shows
stiffness features substantially not
different from the ones showed by the
right lobe’s paraisthmic nodule.

11. Right lobe paraisthmic
nodule (kPa)
10-2 MHz 15-4 MHz 16-5 MHz
Mean stiffness 42-45 42-71 15-36
Maximum stiffness 47-59 68-77 20-47
Minimum stiffness 19-42 15-63 8-13
Standard Deviation 1,4-7,7 4,0-11,2 2,8-9,3
Ratio 1,4-2,1 2,9-5,2 1,0-2,6
Left lobe nodule
(kPa)
10-2 MHz 15-4 MHz 16-5 MHz
Mean stiffness 19-30 28-66 15-16
Maximum stiffness 21-41 32-69 20-23
Minimum stiffness 16-17 11-63 1-8
Standard Deviation 0,8-7,8 1,2-9,7 2,8-7,1
Ratio 1,0-2,9 1,2-3,8 1,0-1,6

12. Left lobe nodule features S 2000
Diameter (cm) 0.6
El/B Ratio >1
Strain Ratio 12.44
Strain Elastograhy final indication Biopsy
Stiffness at Virtual Touch Imaging Limited
Mean SW speed (m/s) 1.04
SW speed Ratio (Nod/Parenchyma) 0.8
Final indication Surveillance
Right lobe nodule features S 2000
Diameter (cm) 0.8
El/B Ratio >1
Strain Ratio 3.71
Strain Elastograhy final indication Biopsy
Stiffness at Virtual Touch Imaging Mixed Hard
Mean SW speed (m/s) 2.62
SW speed Ratio (Nod/Parenchyma) 1.7
ARF final indication Biopsy
The same patient was examined also with an Acuson
S 2000.
The unit performs sonoelastography both in Strain
modality and in Acoustic Radiation Force (both Imaging
– with displacement analisys - and Quantification of the
Shear Waves speed in m/s).
The indications given by the two different techniques
are discordant because Strain elastography indicates
the biopsy for both the nodules, while ARF indicates
biopsy for right lobe nodule and surveillance policy for
the left lobe nodule.

13. This is the FN cytology of the right lobe’s
paraisthmic nodule classified TIR 4* (corresponding
to Thy V in the Bethesda Classification), suspicious
for PTC.
At surgery both nodules were PTC.
* ITALIAN CONSENSUS GROUP FOR THE CLASSIFICATION AND REPORTING OF THYROID CYTOLOGY
Francesco Nardi, Fulvio Basolo, Anna Crescenzi, Guido Fadda, Andrea Frasoldati, Fabio Orlandi, Lucio Palombini, Enrico Papini, Alfredo Pontecorvi, Paolo Vitti (2013)
TIR1: Not diagnostic.
TIR1C: Not diagnostic - Cyst.
TIR2: Not neoplastic.
TIR3A: Low risk follicular lesion.
TIR3B: High risk follicular lesion.
TIR4: Suspicious for malignancy.
TIR5: Diagnostic of malignancy.

14. Case n.2
SSI SWE Features (15-4 MHz Probe) Right lobe nodule Left lobe nodule
Mean stiffness (kPa) 42-71 28-66
Maximum stiffness (kPa) 68-77 32-69
Minimum stiffness (kPa) 15-63 11-63
Standard Deviation (kPa) 4-11 1-9
Ratio 2,9-5,2 1,2-3,8
Acuson S 2000 Features (9-4 MHz Probe) Right lobe nodule Left lobe nodule
Elasto/B image Ratio >1 >1
Strain Ratio 3,71 12,44
Stiffness at Virtual Touch Imaging Mixed Hard Almost Isostiff
Mean SW speed (m/s) 2,62 1,04
SW speed Ratio (Nodule/Parenchyma) 1,7 0,8
Acuson S 2000 Final Indication Biopsy Biopsy (Strain)
Surveillance (ARF)
SSI SWE Final Indication Biopsy Biopsy
FNA Citology TIR 4 (Thy V) Not performed
Pathological diagnosis Malignant (PTC) Malignant (PTC)

15. The TIRADS LEXIC
To each nodule, the radiologist has to specify its:
1. Shape
“taller-than-wide” (greater in its antero-posterior dimension than in its transverse
dimension) and “wider-than-tall”.
2. Internal component
solid, mixed or cystic
3. Margins
well circumscribed, lobulated or irregular
4.Echogenicity
“hyperechogenicity”, “isoechogenicity”, “hypoechogenicity” and “marked
hypoechogenicity”.
Isoechogenicity was defined as an echogenicity similar to that of the adjacent healthy
thyroid gland.
A nodule was classified as “marked hypoechogenicity” if the echogenicity was less
than that of the superficial surrounding neck muscles.
5.Evidence of calcifications
Micro-calcifications (< 3 mm)
Macrocalcifications (> 3 mm with acoustic shadowing))
6. Stiffness Features

16. TIRADS classification
(modified Russ classification)
TIRADS 1 - Normal thyroid
TIRADS 2 - Benign aspects (0% chance of malignancy)
Simple cyst
Spongiform nodule
‘White Knight’ aspect
Isolated macrocalcification
Typical sub acute thyroiditis
TIRADS 3 - Probably benign aspects (<5% chance of malignancy)
None of the highly suspicious aspects
Isoechogenic
Hyperechogenic
TIRADS 4A - Low suspicious aspects (5-10% chance of malignancy)
None of the highly suspicious aspects
Moderately hypoechogenic
TIRADS 4B / 5: High suspicious aspects
Taller than wide shape
Irregular or microlobulated margins
Microcalcifications
Marked hypoéchogenicity
High stiffness index with elastography (if available ) * 4B: 1 or 2 signs and no adenopathy (10-80% chance of malignancy)
* 5: 3 or more signs and/or adenopathy (>80% chance of malignancy)
TIRADS 6 – Biopsy proven malignant nodules
All studies show that most cancers were found in the TIRADS 3, 4 and 5 categories.

17. Left lobe paraisthmic Feature Left lobe lower pole
Taller
than wide
Shape
‘Taller-than-wide’ and “wider-than-tall”
Wider
than tall
Solid
Internal component
solid, mixed or cystic
Solid
Irregular
Margins
Well circumscribed, lobulated or irregular
Well
circuscribed
0.10
Echogenicity (B Ratio Nodule/Parenchyma)
“hyperechogenicity”,“isoechogenicity”,
“hypoechogenicity”and “marked hypoechogenicity”
0.80
Micro and
Macro
Evidence of calcifications
Micro-calcifications (< 3 mm)
Macrocalcifications (> 3 mm with acoustic shadowing)
No
Both
Vessels
Perinodular
Intranodular
Peri
76 - 111 Mean Stiffness (kPa) 31 - 33
9 - 20 Standard Deviation (kPa) 1 -3
2,4 - 4,3 Stiffness Ratio (Nodule/Parenchyma) 1,0 – 1,4
5 TIRADS 3
Biopsy Final indication Surveillance
Case n.1

18. Right lobe Feature Left lobe
Wider
than tall
Shape
‘Taller-than-wide’ and “wider-than-tall”
Wider
than tall
Solid
Internal component
solid, mixed or cystic
Solid
Lobulated
Margins
Well circumscribed, lobulated or irregular
Lobulated
0.45
Echogenicity (B Ratio Nodule/Parenchyma)
“hyperechogenicity”,“isoechogenicity”,
“hypoechogenicity”and “marked hypoechogenicity”
0.59
Micro and
Macro
Evidence of calcifications
Micro-calcifications (< 3 mm)
Macrocalcifications (> 3 mm with acoustic shadowing)
Micro
Both
Vessels
Perinodular
Intranodular
Both
42 -71 Mean Stiffness (kPa) 28 - 66
4,0 - 11,2 Standard Deviation (kPa) 1,2 - 9,7
2,9 – 5,2 Stiffness Ratio (Nodule/Parenchyma) 1,2 – 3,8
5 TIRADS 4B
Biopsy Final indication Biopsy
Case n.2

19. SSI 15-4 MHz Probe Case n.1 Case n.2
SWE Features Paraisthmic nodule Lower pole nodule Right lobe nodule Left lobe nodule
Mean stiffness (kPa) 58-72 31-33 42-71 28-66
Maximum stiffness (kPa) 76-111 36-43 68-77 32-69
Minimum stiffness (kPa) 26-41 25-31 15-63 11-63
Standard Deviation (kPa) 9-20 1-3 4-11 1-9
Ratio 2,4-4,3 1,0-1,4 2,9-5,2 1,2-3,8
TIRADS 5 3 5 4B
Final indication Biopsy Surveillance Biopsy Biopsy
FNA TIR 5 (Thy VI) Not performed TIR 4 (Thy V) Not performed
Pathological diagnosis Malignant (PTC) Benign Malignant (PTC) Malignant (PTC)
Keypoints of the cases and ‘take home messages’
 Shear wave elastography one more time shows its reliability in identifying stiff thyroid nodules also
with small volume (< 1 cm) and in the guidance of the FNAC, like in this cases of three small PTCs.
 It correctly characterize as ‘soft’ the only one benign nodule (one on four).

20. Keypoints of the cases and ‘take home messages’
 While Papillary cancers are usually stiff, Follicular cancers can be soft.
 This cases show one more time that small nodules can be cancer, while large nodules can be benign.
 Uptodate my impression is that we cannot rely on absolute number because they change depending
on too many variables (frequency of the probe, speed of sound selected, grade of compression you
do with your hand, depth of the lesion and surrounding environment, and so on) and , sure, because
we well know that cancers can be 'soft' and benign lesions can be stiff.
 My actual belief is that large more reliable in addressing our impression are two other parameters
(or features) : 1) Standard Deviation (higher in malignant lesions cause of their almost constant inhomogeneity)
2) Elasticity Ratio Vs a standard reference tissues.
 Well, while the kPa's numbers (E-mean, min and max) can be very variable, SD and Ratio remain
unmodified, unconditioned by the above mentioned factors.
 I think that international guidelines on the indications to thyroid biopsy should be rediscussed
(at least regarding the dimensions) and that, on the other side, we should analyze the real risk
of overdiagnosis and overtreatment in these situations.
 In conclusion nowadays advanced ultrasonography offers so many tools that it would be
unsafe to rely the diagnostic workup only on one of the US modes (B-mode, Doppler and
sonoelastography).
 Uptodate TIRADS is based on all these informations that make ultrasonography to deserve
in full the definition of ‘Multiparametric Diagnostic Modality’.

21. Ultrasonography of thyroid focal diseases : a true Multiparametric Diagnostic Modality
Mode Features Informations
B Mode
Shape
‘Taller-than-wide’ and “wider-than-tall”
Morphology
and
Structure
Internal component
solid, mixed or cystic
Margins
Well circumscribed, lobulated or irregular
Echogenicity (B Ratio Nodule/Parenchyma)
“hyperechogenicity”,“isoechogenicity”,
“hypoechogenicity”and “marked hypoechogenicity”
Evidence of calcifications
Micro-calcifications (< 3 mm)
Macrocalcifications (> 3 mm with acoustic shadowing)
Doppler Mode
CDI, PDI , dPDI Number, density and distribution of the vessels Vascular
Pulsed Wave Blood flow characterisation and quantification Blood Flow – Functional (?)
Sonoelastography
Strain Relative Stiffness
Mechanical properties
Shear Wave Relative stiffness and Stiffnes quantification

22. Antonio Pio Masciotra
Campobasso – Molise – Italy
Website www.masciotra.net
YouTube Channel
https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ
Thanks for your attention