Overview of thyroid imaging

Imaging Thyroid Nodule(s)
Durr-e-Sabih
MBBS. MS. FRCP. FANMB
Chair, Asian Nuclear Medicine Board
Multan Ultrasound Service
Jail Road- Multan
dsabih@yahoo.com

19-67% of the general
population has a thyroid
nodule on an ultrasound
up to 7-9% can be
malignant 1,2
1) Welker MJ, Orlov D. Thyroid Nodules. An Fam Physician. 2003. Feb 1; 67(3):559-567
2) Ross DS. Overview of Thyroid Nodule Formation. UpToDate, July 10, 2013

History
o 2700 BC… Mentioned in China
o 1600 BC…Ayuverdic medicine “Gala
Ganda”
o First thyroidectomy was done in 1872 by
Theodor Kocher and was awarded the
Nobel Prize for his work in 1909
Langer P. Vol. 44. Geneva: WHO; 1960. History of goiter. In: Endemic Goiter; p. 9. Hormones
(Athens). 2004 Oct-Dec;3(4):268-71.

First contact!
o Present with nodule(s)
o Incidental*
*19-67% of the general population has a thyroid nodule on an ultrasound
up to 7% can be malignant 1,2
1) Welker MJ, Orlov D. Thyroid Nodules. An Fam Physician. 2003. Feb 1; 67(3):559-567
2) Ross DS. Overview of Thyroid Nodule Formation. UpToDate, July 10, 2013

Is this malignant?
o Male gender
o Solitary
o Growing, recent rapid increase in size
o Big (>4cm)
o Hard
o Fixity
o Hoarseness
Michael RT, Homer L, and Burch HB. Clinical Features Associated with an Increased Risk of Thyroid
Malignancy in Patients with Follicular Neoplasia by Fine-Needle Aspiration . Thyroid. May 1998, 8(5):
377-383. doi:10.1089/thy.1998.8.377.

Is this malignant?
o Almost twice as many women as men
(2.2:1)
o 97 patients, only 3 had solitary nodule
o 72% had a mass size >3cm
o No correlation between tumor size and local
invasion, nodal involvement or distant
metastases
Zuberi LM, Yawar A, Jabbar A. Clinical Presentation of Thyroid Cancer patients in Pakistan.
AKUH experience. JPMA 54:526; 2004.

Solitary Nodule vs. Multinodular
Goiter
o Prevalence of thyroid cancer is similar in
multinodular goiters as it is for solitary thyroid
nodules 1,2,3
1 Zuberi LM, Yawar A, Jabbar A. Clinical Presentation of Thyroid Cancer patients in Pakistan. AKUH
experience. JPMA 54:526; 2004.
2 McCall A, Jarosz H, Lawrence AM, et al. The incidence of thyroid carcinoma in solitary cold nodule and
in multinodular goiter. Surgery 1986;100:1128.
3 Franklyn JA, Daykin J, Young J, et al. Fine needle aspiration cytology in diffuse multinodular goiter
compared to solitary thyroid nodules. BMJ. 1993;307:240.

Size of Nodule
o 494 consecutive patients with non-palpable
thyroid nodules (8-15mm)
o 9.2% of solitary nodules and 6.3% of
nodules in MNG were malignant
o Cancer prevalence and nodal spread similar
in nodules greater or lesser than 10 mm
Papini E, Guglielmi R, Bianchini A et al. Risk of Malignancy in Nonpalpable Thyroid Nodules: Predictive
Value of Ultrasound and Dolor-Doppler Features. Jr. Clin. Endo. Metab, May 2002, 87(5):1941-1946

Conventional Nuclear Medicine
o In some countries, for almost 70 years,
radionuclide thyroid scanning has been the
mainstay of initial thyroid nodule imaging
using Tc-99m
o In one centre of Pakistan, there were 7082
patients of thyroid scan out of a total of
14240 patients (49.73%) in 2018

Conventional Nuclear Medicine
o A thyroid scan is useless unless there is a low
TSH1,2
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan; furthermore, these studies add
considerable cost3
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited4
12015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated
Thyroid Cancer. THYROID Volume 26, Number 1, 2016
2When and how to manage thyroid nodules. Michel Procopiou. Reveu therapeutique 68(6):285-9. June 2011. PMID
1656485
3Oh #*$%#! Another pesky incidental thyroid nodule! Mancusso AA. AJNR Am J Neuroradiol. 2005 Nov-ec;26(10):2444-5.
4Hoang JK, Lee WK, Lee M, et al. US Features of Thyroid Malignancy; Pearls and Pitfalls.

Nodule Uptake and Malignancy
Is a hot nodule always good news?
o Solitary hot nodule, incidence of cancer, 3.1% -11% 1- 2
o Cold nodule 16% 3
o Warm nodule 9% 3
o Hot nodule with suppressed TSH, treat hyperthyroidism without
cytology 4
1Mirfakhraee et al. A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma: review of the
literature. Thyroid Research 2013 6:7 doi:10.1186/1756-6614-6-7
2 Daumerie C et al. Prevalence of thyroid cancer in hot nodules. Ann Chir. 1998;52(5):444-8.
3 Daniel J Kelley, Evaluation of Solitary Thyroid Nodule . emedicine.medscape.com/article/850823-
overview#aw2aab6b7 .Aug 21, 2013
4 American Thyroid Association Guidelines for Thyroid nodule evaluation, 2015.

PET Imaging
o Benign as well as malignant nodules take up
18F-FDG…Benign low SUV, Malignant high SUV…
very variable results1
o Uptake in negative radio-iodine scans and rising TG,
positive in de-differentiated and anaplastic ca-thyroid.
Ga-DOTATOC and F-18 DOPA are also useful2
o Uptake is not TSH dependent3
1Bertagna F, Treglia G, Giubinni. Diagnostic and Clinical Significance of F-18-FDG-PET/CT Thyroid
Incidentalomas. J. Clin Endocrinol Metab 97: 2012. 3866-3875
2 Mosci C, Iaqaru A. PET/CT imaging of thyroid cancer. Clin Nucl Med. 2011 Dec; (12):e 180-5
3 Iaqaru A, Kalinyak JE, Mc Dougall IRF-18 FDG PET/CT for the management of thyroid cancer
Clin Nucl Med 2007 Sept; 32(9) 690-5

SUV: 3.7 SUV:11.2
Papillary carcinoma
SUV:2.7 Prim Tumour
SUV:1.6 metastatic deposit
© Jun Hatazawa. Osaka, Japan

Benign nodule (follicular nodule)
SUV 10.5
© Jun Hatazawa. Osaka, Japan

MR and CT
All roads lead to ….
Duke’s 3 tiered system of reporting
incidental thyroid nodules on CT/MR
o Cat 1. Locally invasive or suspicious nodes
• Go to Ultrasound
o Cat 2. Solitary Nodule in patient <35
o Cat 3. Solitary Nodule in patient >35
o MNG
Hoang JK, Raduazo P, Yousem DM, et al. What to do with incidental thyroid nodules on imaging?
An approach for the radiologist. Semin Ultrasound CT MR 2012;33:150-157

Why Ultrasound
o Exquisite detail
o Non palpable nodules
o Precise needle tip guidance for biopsy
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or not suspicious findings
o Differentiate thyroidal from non-thyroidal neck
masses
o In MNG, the nodules with the highest probable
yield

Anatomy
Thyroid
Trachea
Oesophagus
Cervical Vertebra
C-6
CCA Int Jug vein
Sternocleidomastoid
Sternohyoid
Sternothyroid
Longus coli
Scalenus anterior

Smallest size
resolvable
o Solid ~ 2-3 mm
o Simple cyst 2mm
Depends on neck
thickness and length
SC fat

Ultrasound
extensive armamentarium
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast

Ultrasound
o TIRADS1,2,3,4 (Thyroid Imaging Reporting and
Data System)
o TIRADS 2, French TIRADS, ACR TI-RADS
o ATA guidelines, AACE, ACE, AME
o BMUS, FSE, KTA/KSThR, NCCN, SRU
guidelines
1 Horwath E, Majlis S, Rossi R et al. An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management. J. Clin. Endocrinol. Metab. 2009;94 (5): 1748-51
2 Park JY, Lee HJ, Jang HW, et al. A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma. Thyroid 2009 19 1257-1264.
3Russ G, Bigorgne C, Rouxel A. Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography. Eur J. Endocrinol. April 2013
4 Kwak JY, Han KH, Yoon JH et al. Thyroid Imaging Reporting and Data System for US Features of
Nodules: A step in Establishing Better Stratification of Cancer Risk. Radiology 260 (3) September 2011.
892-899

Grey-scale ultrasound features of
thyroid nodules
Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities* Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY, Han KH, Yoon JH et al. Thyroid Imaging Reporting and Data System for US Features of Nodules: A step in
Establishing Better Stratification of Cancer Risk. Radiology 260 (3) September 2011. 892-899
*Society of Radiologists in Ultrasound consensus conference Statement. Radiology Vol 237 (3). 2005. 794-800

Probability of malignancy calculated using
number of suspicious US features
Kwak JY, Han KH, Yoon JH et al. Thyroid Imaging Reporting and Data System for US Features of Nodules:
A step in Establishing Better Stratification of Cancer Risk. Radiology 260 (3) September 2011. 892-899

Epidemic of thyroid cancer
Ahn HS, M.D., Kim HJ, M.P.H., Welch HG, Korea’s Thyroid-Cancer “Epidemic” —
Screening and Overdiagnosis. N Engl J Med 371;19 nejm.org November 6, 2014.
Udelsman R, Zhang Y. The Epidemic of Thyroid Cancer in the United States: The Role of
Endocrinologists and Ultrasounds Thyroid. 2014 Mar 1; 24(3): 472–479. doi:10.1089/thy.2013.0257
Vaccarella S et al Worldwide Thyroid-Cancer Epidemic? The Increasing Impact of Overdiagnosis
N Engl J Med 2016; 375:614-617August 18, 2016.DOI: 10.1056/NEJMp1604412
Increase of 25%
per year!
Thyroid cancer incidence and mortality in the USThyroid cancer incidence and mortality in S. Korea

Threshold for FNAB
US feature 2009* Feature 2016**
High risk history of
Th. Cancer in first
deg relatives, history
of childhood radiation
to neck, previous
cancer in contralateral
lobe. FDG avidity
Solid, suspicious features:
Microcalcification , hypoechoic, irregular,
taller than wide on transverse view
> 5mm Not considered in the
main document but does
state that in the context
of increased risk for
example with radiation,
a lower threshold is
prudent
No suspicious features 0.5-1.5cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic >1 cm Hypo+ 1
suspicious
feature
>1cm
Hyperechoic >1.5 cm >1.5cm
Mixed solid-cystic With suspicious features 1.5-2.0 cm Mixed + or -
suspicious
features
> 1.5cm
Without suspicious features > 2.0 cm
Spongiform No
unless node
> 2cm or
observe
Purely cystic No No
*American Thyroid Association Guidelines for Thyroid nodule evaluation, Nov 2009.
**American Thyroid Association Guidelines for Thyroid nodule evaluation, Jan 2016.

Threshold for FNAB
MNG, other
US feature Threshold 2009 2016
MNG Normal intervening
parenchyma
Biopsy ~4 nodules if
suspicious, biopsy largest
if all look benign
Each nodule over 1cm
should be evaluated
according to features
No intervening normal
parenchyma
Follow Biopsy largest if all look
benign
Enlarging
nodule or
diffusely
enlarging goiter
All All
American Thyroid Association Guidelines for Thyroid nodule evaluation, Nov 2009.
American Thyroid Association Guidelines for Thyroid nodule evaluation, Jan 2016.

Consensus Statements and
Guidelines
Society of Radiologists in
Ultrasound. USA (2004)
Solitary Microcalcification >1.5cm
Solid or coarse calcification >1.5cm
Mixed or Cystic with mural nodule >2 cm
Entirely cystic don’t (?)
Korean Society of
Radiology. Korea (2010)
Solitary Any one suspicious finding, any size,
even
<5mm
British Thyroid
foundation (2014)
U1-U5. Suspicious (U4-U5)
includes hypo or intensely
hypoechoic, irregular and with
calcification. Central vascularity,
tall, lymph nodes
Any size

The problem with guidelines
“very few thyroid nodules will escape biopsy under each set of guidelines. Each of the
guidelines recommends biopsy for the vast majority of nodules, even those without
suspicious features, when they are larger than 1 cm in diameter…... many patients will
undergo biopsy and a surgical procedure for a disease that possibly would not have an
adverse outcome if simply followed without intervention.”
Robert A. Levine. Current Guidelines for the Management of Thyroid Nodules
Endocr Pract. 2012;18(4):596-599.

When to not biopsy according to
guidelines
o American Thyroid Association (ATA)
o <5mm solid nodule even if suspicious
o < 1.5- 2cm complex cyst, even if suspicious features present
o American Association of Clinical Endocrinologists (AACE)
o <10mm, solid nodule if no suspicious features
o Hot nodule
o Korean Society of Thyroid Radiology (KSTR)
o <10mm, if no suspicious features
o <2cm if simple cyst or spongiform nodule

Different guidelines, different
performances
Ahn, S. S., et al. (2010). "Biopsy of thyroid nodules: comparison of three sets of guidelines."
AJR Am J Roentgenol 194(1): 31-37.
ATA guidelines not included because term
“Suspicious features” was not defined

Can we diagnose benign
nodules?
o Pure cyst
o Colloid Cyst
o Spongiform
o White knight (Uniformly hyperechoic)
o Giraffe skin
Bonavita JA, et al. Pattern recognition of benign nodules at ultrasound of the thyroid: which
nodules can be left alone? AJR 2009; 193:207-21

Are we there yet?
o Meta-analysis 31 studies, 18,288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules!
Brito JP, Gionfriddo MR, Al Nofal A, et al. The accuracy of thryoid nodule ultrasound to predict
thyroid cancer:systematic review and meta-analysis. J. Clin Endocrinology Metabolism. 2014.
Apr. 99(4): 1253-63

Very Bold View!!
Don’t use ultrasound if you can’t palpate
anything1
o Most thyroid cancers are papillary, with a 10 year
survival of 99% and a 30 year survival of 95%
o Non-palpable thyroid cancer has little biological
significance
o Using Autopsy data, occult papillary cancer might
be considered a “normal finding”.. Present in 36%
of one autopsy series2
1John J. Cronan . Thyroid Nodules: Is It Time to Turn Off the US Machines? Radiology 2008 247:3, 602-604
2Harach HR. Occult papillary carcinoma of the thyroid: a “normal” finding in Finland—a systemic autopsy
study. Cancer 1985;56(3):531–538

Another view
Ito, Y. et al. Low-risk papillary microcarcinoma of the thyroid: A review of active surveillance
trials. European Journal of Surgical Oncology, March 2018. Volume 44, Issue 3, 307 - 315
“We think that it is better to cytologically diagnose suspicious nodules
as PMC and clearly disclose a diagnosis of carcinoma to patients.
This is to discourage the occurrence of patients going to another
hospital, being diagnosed there as having thyroid carcinoma,
and undergoing unnecessary surgical treatment by non-experts who
assume that all thyroid carcinoma should be surgically removed. ”

Light at the end of the tunnel?
Photo from; https://briefingsforbrexit.com/light-at-the-end-of-the-tunnel-sir-peter-marshall/

Wake up, take a deep breath and
look at what I have brought you!

ACR TI-RADS
o Pattern based
o Selected components are analysed and
points ascribed:
o Composition
o Echogenicity
o Shape
o Margins
o Echogenic foci

TI-RADS Calculator
http://tiradscalculator.com/

What do the different TR scores
mean
o Risk of malignancy
Score Risk
TR1 0.09%
TR2 1.5%
TR3 4.8%
TR4 9.1%
TR5 35%

When cysts become complex,
these become mixed solid cystic

Tall or wide
o Spherical nodules (both diameters within 1mm of each other) are
considered variants of wide nodules but some authors have noted a
slight association with malignancy so the score for round nodules
might increase

Vascularity
o Grade I. Avascular
o Grade II. Perinodular flow
o Grade III. Internal flow… highly suggestive
of malignancy 1
With recent technology vascularity can be seen in
any nodule but significant internal vascularity
might favour a significant lesion (42%) 2
1.Lagalla R. Echo-Doppler couleru et pathologie thyroidienne. J Echograph Med Ultrasons. 1992;13:44–7.
2.Frates MC. Er al.Can color Doppler sonography aid in the prediction of malignancy of thyroid nodules?
J Ultrasound Med. 2003 Feb; 22(2):127-31; quiz 132-4.

Vascularity
o Superb Micro Vascular Imaging (Toshiba
TM) might find a place in diagnosing
thyroid cancers when integrated into a grey-
scale assessment scheme like TI-RADS.
Kong, J., et al. (2017). "Role of Superb Micro-Vascular Imaging in the Preoperative Evaluation of Thyroid
Nodules: Comparison With Power Doppler Flow Imaging." J Ultrasound Med 36(7): 1329-1337.

Vascularity
o Accuracy of detecting malignant thyroid
nodules by combining gray scale and
Doppler is higher than either of them alone.
o The color characteristics of a thyroid
nodule, cannot be used to exclude
malignancy, because 14% of solid non-
hypervascular nodules were malignant.
Palaniappan, M. K., et al. (2016). "Role of Gray Scale, Color Doppler and Spectral Doppler in Differentiation
Between Malignant and Benign Thyroid Nodules." J Clin Diagn Res 10(8): Tc01-06.
Frates MC. Er al.Can color Doppler sonography aid in the prediction of malignancy of thyroid nodules?
J Ultrasound Med. 2003 Feb; 22(2):127-31; quiz 132-4.

Work sheet and reporting template
https://app.box.com/s/70nk1hu4n91rzgeps6ycrez7dwnv1ybz
https://app.box.com/s/iuvnykvgrkv7fgzs4kt50hpj997o8b20

Elastography
o While elastography is a promising
technique in some organs such as the breast
and the liver, there have been conflicting
results of its additional value in predicting
thyroid malignancy
o I am not a fan… yet
Kwak JY, Kim EK. Ultrasound elastography for thyroid nodules: recent advances.
Ultrasonography. 2014;33(2):75–82. doi:10.14366/usg.13025

Tip
o Don’t diagnose consistency or margin on a
single section… run through the whole
volume on real-time to get an impression

Tips
o If there is MNG and all nodules appear
similar, don’t do FNA
o If one nodule is different and suspicious in a
background of MNG, do an FNA
o If different types of calcification are present
all types are summed up

Tips
o Score up to 4 nodules in a MNG with
varying nodule scores
o FNA up to 2 nodules with the highest score
o Don’t obsess over nodule margins,
lobulated and irregular margins have the
same score
o Isoechoic and hyperechoic nodules have the
same score

Tips
o Taller than wide or wider than tall is
determined on a transverse view
o Always look for nodes and family history
and any radiation exposure
o Punctate calcification from colloid
differentiation depends:
o upon size of comet tail >1mm is colloid,
<1mm is punctate calcification
o Predominantly cystic, possibly colloid,
predominantly solid, possibly punctate
calcifications

Panoramic imaging
o Large lesions
o Extrathyroidal lesions with relation to
thyroid and other neck structures

Why is size important?
o There is very little knowledge about the
aggressiveness of individual thyroid cancers
o Many small nodules can be malignant (in
fact autopsy series show up to 36% small
foci of thyroid carcinoma in normal
population who died of non thyroid causes)
but will remain latent and not become
clinically significant
Machens, A., et al. (2005). "The prognostic value of primary tumor size in papillary and follicular
thyroid carcinoma." Cancer 103(11): 2269-2273.

Why is size important
o The cumulative risk of distant metastasis
increases once the primary tumor size > 20
mm.
Machens, A., et al. (2005). "The prognostic value of primary tumor size in papillary and follicula
thyroid carcinoma." Cancer 103(11): 2269-2273.

Tumour size and survival
Nguyen, X. V., et al. (2013). "Incidental Thyroid Nodules on CT: Evaluation of 2
Risk-Categorization Methods for Work-Up of Nodules." American Journal of
Neuroradiology 34(9): 1812.

Risk of mortality and metastatic
disease with size
Nguyen, X. V., et al. (2018). Effect of Tumor Size on Risk of Metastatic Disease and Survival for
Thyroid Cancer: Implications for Biopsy Guidelines. Thyroid, 28(3), 295–300.doi:10.1089
N= 112,128

Active surveillance
o Tumours <10mm, biopsy positive, no mets,
o 1235 patients, 10 year follow-up, no surgery
vs. appropriate surgery
o Enlargement in 8%, nodes in 3.8%
o No deaths, no distant mets, same recurrence
rates
o Rescue surgery outcomes as good as initial
surgery
Ito Y, Miyauchi A. A therapeutic strategy for incidentally detected papillary microcarcinoma of the
thyroid. Nat Clin Pract Endocrin. Metab 2007;3:240–8.
Ito, Y. et al (2018). Low-risk papillary microcarcinoma of the thyroid: A review of active
surveillance trials . European Journal of Surgical Oncology, Volume 44, Issue 3, 307 - 315

Threshold modifiers
Lower threshold
o Growing nodule
o Suspicious nodes
o Posteriorly located, adjacent
to oesophagus and trachea or
in isthmus
o FDG positive
o Known parathyroid adenoma
o Paediatric population
o History of childhood
radiation
o Patient or physician
preference
o MEN type 2
Raise threshold
o History
o Low TSH
o Long standing stability
(continue monitoring)
o Mostly Bleed
o Thyroiditis

Growing thyroid nodule is
suspicious.
What is growth?
20% increase in at least two nodule-
diameters and at least 2 mm1/3mm2 growth
in size
Or
>50% increase in volume
1Durante C et al. The natural history of benign thyroid nodules. JAMA. 2015 Mar
3;313(9):926-35. doi: 10.1001/jama.2015.0956.
2Ito, Y. et al.(2018) Low-risk papillary microcarcinoma of the thyroid: A review of active
surveillance trials . European Journal of Surgical Oncology, Volume 44, Issue 3, 307 - 315

Rapidity of Growth
o If growth in a few minutes or hours…
Haemorrhage
o In one or a few days…… Thyroiditis
o Months to years….Malignant or Benign

How long should you monitor for
growth
o Annually1/6monthly2 for 5 years for a
highly suspicious nodule
o Less frequently but also for 5 years for less
suspicious nodules
o If the nodule has remained stable for 5 (10?)
years, monitoring can be stopped
1Durante C et al. The natural history of benign thyroid nodules. JAMA. 2015 Mar 3;313(9):926-35
. doi: 10.1001/jama.2015.0956.
2Ito, Y. et al. Low-risk papillary microcarcinoma of the thyroid: A review of active surveillance
trials European Journal of Surgical Oncology, Volume 44, Issue 3, 307 - 315

Lymph nodes of the neck in
thyroid cancer

Lymph nodes
o Lymph node evaluation is not part of the
ACR TI-RADS but ATA guidelines recommend
pre-operative as well as post operative lymph node
mapping.
o Decisions to biopsy and surgical extent based on
ultrasound lymph node mapping is standard of care
in many institutions.
Davit Kocharyan. The relevance of preoperative ultrasound cervical mapping in patients with
thyroid cancer. Can J Surg. 2016 Apr; 59(2): 113–117. doi: 10.1503/cjs.011015

Lymph nodes
o Commonest site of lymph node involvement in
thyroid cancer is the central compartment, level
VI, but all levels can be involved (level 1 is
uncommon)
© A.Prof Frank Gaillard,
Radiopaedia.org, rID: 9618
https://radiologykey.com/normal-cervical-lymph-node-
appearance-and-anatomic-landmarks-in-neck-ultrasound/

Lymph nodes
o Ultrasound is more sensitive for lateral compartment
nodes, CT appears to be more sensitive for central
compartment nodes
o Rounded, > 5-8mm short axis, effaced fatty hilum,
expanded irregular fatty hilum, focal echogenicities
chaotic vascularity, presence of colloid, cystic
changes or microcalcification, indenting internal
jugular vein.
o Post operative annual scanning is part of ATA
guidelines and can be more sensitive for disease
progression than TG levels
Davit Kocharyan. The relevance of preoperative ultrasound cervical mapping in patients with
thyroid cancer. Can J Surg. 2016 Apr; 59(2): 113–117. doi: 10.1503/cjs.011015

Lymph nodes
Yeh MW, et al. American Thyroid Association statement on preoperative imaging for thyroid
cancer surgery. Thyroid. 2015;25(1):3–14. doi:10.1089/thy.2014.0096

Sentinel node biopsies in PTC
o Up to 97% accuracy
o 49% upstaged from N0 to N1
Higino SJ.et al. (2018). Accuracy of sentinel lymph node mapping in detecting occult neck
metastasis in papillary thyroid carcinoma. Archives of Endocrinology and Metabolism,
62(3), 296-302. Epub May 17, 2018.https://dx.doi.org/10.20945/2359-3997000000038

What's the use of ultrasound?
o Identify those in whom biopsy can be
deferred
o Reduce FNAs …by up to a third!
o More accurate needle placement
o Follow-up to document stability or growth

o FNA is not required for thyroid nodules less than 1 cm that
appear to be confined to the thyroid;
o Active surveillance can be considered as an alternative to
immediate surgery in patients with very low risk tumors
o Restrict surgery (currently the Standard of Care) to
lobectomy and avoid radioactive iodine in those with low
risk features
o Conduct further research to define the role of active
surveillance instead of surgery for patients with low risk
tumors and the role of other tools, such as molecular
markers and imaging, in better cancer diagnosis and
prognosis.
AMERICAN THYROID ASSOCIATION
Management Guidelines for Adult Patients with
Thyroid Nodules and Differentiated Thyroid Cancer
(Thyroid, 2016) recommendations/suggestions:

www.acr.org/Clinical-Resources/Reporting-and-Data-Systems/TI-RADS
oWebinars
oPapers
oCalculators
oReporting template/work sheet
www.thyroid.org/professionals/ata-professional-guidelines/
app.box.com/s/70nk1hu4n91rzgeps6ycrez7dwnv1y
app.box.com/s/iuvnykvgrkv7fgzs4kt50hpj997o8b20

Biopsy of very small nodules
~2mm

Unanswered questions
o Effect of age, co-morbidities or life
expectancy on decision to biopsy
o Risk stratification of complex cysts
o Should more intermediate/low risk nodules
be observed?
o Risk of missing a low-grade thyroid cancer
vs. risk of surgical procedure for malignant
or benign thyroid disease
Robert A. Levine. Current Guidelines for the Management of Thyroid Nodules
Endocr Pract. 2012;18(4):596-599.

Different guidelines, different
performances
Comparison of 7 guidelines
Ha, E. J., et al. (2018). "US Fine-Needle Aspiration Biopsy for Thyroid Malignancy: Diagnostic
Performance of Seven Society Guidelines Applied to 2000 Thyroid Nodules."
Radiology 287(3): 893-900.

Overview of thyroid imaging

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