Incremental benefits of ordering

a CT scan in identifying elusive lymph node

and
revisiting cross sectional anatomy in thyroid
cancer 
 Role of the radiologist

Assessment of patients presenting with thyroid cancer

Extent of the primary thyroid cancer

Regional nodal and distant metastases

Normal Anatomy
 Differentiated thyroid cancer (DTC)-
Uncomplicated
• Palpable isolated asymptomatic thyroid mass/ Incidental mass on
imaging being performed for other reasons
• No associated palpable lateral neck lymphadenopathy

• Ultrasonography -primary imaging modality-ACR TI-RADS-TR1-

(benign) to TR5 (high suspicion of malignancy).
Composition, Echogenicity, Shape, Margin, Echogenic Foci

• Suitability for FNA under ultrasound guidance

 When to perform preoperative
CT and MR imaging ??
• Contained intrathyroidal masses (benign/malignant)-Non-specific
CT appearances. CT – Normal/benign-appearing nodule/mass with
irregular margins

Clinical Presentation (locoregional invasive )

• Fixed, immobile thyroid mass

• Symptomatic including palpable cervical adenopathy
• Hoarseness, Dysphagia
• Respiratory symptoms, rapid enlargement

• Clinical or sonographic evidence of an invasive primary tumor

• Large primary tumor or bulky nodal disease incompletely imaged
with ultrasound
 Extent of the primary tumor 
 CT of the neck should be performed with arms down and
neck extended.

 What to look in CT or MR imaging

 Spread outside the thyroid capsule to the soft tissues of the

neck (strap and sternocleidomastoid muscles)
 Vascular invasion (jugular vein)
 Spread to the prevertebral muscles or bone
 Spread to the larynx and/or trachea
 Esophageal invasion
 Mediastinal extension (lower extent)
Mediastinal extension

significant predictive factors for sternotomy

 Posterior mediastinal extension,

 Extension below the carina,
 Extension below the aortic arch,
 Compressing and invovling the mediastinal
structures
 Central structures-T4a
• Trachea, esophagus, larynx and pharynx, and recurrent
laryngeal nerve.

• Mass contacts the circumference of the airway or esophagus

by >180° - suspicious for invasion

• Deformity of the lumen, focal mucosal irregularity, or

mucosal thickening- more specific.

• Invasion of the recurrent laryngeal nerve- effaced fatty tissue

in the tracheoesophageal groove for > 3 axial images and
signs of vocal cord dysfunction.
Optimal thresholds for tumor invasion is
90 degrees or more for the cartilage (94% accuracy) and esophagus (86%
accuracy),
135 degrees or more for the trachea (86% accuracy),
225 degrees or more for the carotid artery (90% accuracy).
Staging system by Shin and colleagues
depth of tracheal invasion

Otolaryngol Clin North Am. 2008 December 

Central structures
 Surrounding structures-T4b
• Vascular structures-
Internal jugular vein- occluded/effaced by the tumor
without invasion.
Arteries- Mass contacting >180°-suspicious. Deformity or
narrowing – more suspicious for invasion.

• Strap muscle invasion- Asymmetry and tumor on the

external surface of the muscle.

• Prevertebral musculature invasion- Difficult to evaluate -

large tumors can compress the muscle and even result in
signal changes on MR imaging without invasion
 Extracapsular extension

USG is more accurate than CT in predicting

Extrathyoidal tumour extension and bilobar disease
Vascular structures and strap muscles
Assessment for nodal metastatic disease
Regional lymph nodes- Central compartment (level VI)
lateral nodal groups (levels II–V)- Papillary and medullary thyroid
carcinomas-

Sensitivity of CT was better than US for the evaluation central

and lateral compartment lymph nodes examined together
(77% vs 62%, p = 0.002).

Sensitivities of MRI and PET for the detection of cervical lymph

node metastases are relatively low (30%–40%).
 
 Identifying elusive lymph node
• Areas poorly assessed by ultrasonography- deep structures
and those acoustically shielded by air or bone.
(retropharynx, mediastinum, low level IV).
Identifying elusive lymph node
 If cross-sectional imaging is thought to be
necessary
• In patients undergoing (Iodine-131) WB Staging Scans for DTC.

• Water-soluble iodinated contrast agents- Generally cleared within 6

 weeks- Post thyroidectomy patients requiring radioiodine therapy can
be scanned with radioactive iodine within one and half month of the
contrast CT.

Options include
• Performing MR imaging instead of CT
• Performing CT without intravenous contrast administration.
• Performing CT following nuclear scintigraphy

• Risk versus benefit

 Advantages of MR imaging
• No concerns about iodinated contrast agents. 

• High protein content -thyroglobulin, colloid, blood products-

MR imaging (hyperintense on unenhanced T1-weighted
imaging) even if normal in size.
MR imaging
Imaging the Treated Neck with
Rising Thyroglobulin
Imaging the Treated Neck
 Summary
 Asymptomatic thyroid mass/ Incidental Thyroid mass without
palpable nodes – USG -preoperative setting, best operative
planning, and postoperative management and surveillance.

 Symptomatic thyroid mass /invasive and bulky primary mass

on USG--supplemental role of cross sectional imaging to know
extent of mass and elusive nodes.
• Preoperative  surgical counseling is more informed.
• Optimal regional lymphadenectomy with minimal morbidity.

 Post thyroidectomy patients requiring radioiodine therapy

-within one and half month of the contrast CT.
Thank you