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DR RAJ BUMIYA First Year Resident Dept. of Radiodiagnosis S.S.G. Hospital, Baroda.

INDIA 24/03/2011
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Clinical applications of high resolution usg.


1. Detection of thyroid and other cervical masses before

and after thyroidectomy. 2. Differentiation of benign from malignant masses.


y

Ultrasound detects the presence, size, site, number, characteristics of thyroid nodules .
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3. FNA Guidance

Technique
y With high frequency transducer(7.5 to 15Mhz) y Examination-supine position with neck extended. y A small pad may be placed under the shoulders to provide

better exposures of neck.


y Lower pole imaging is enhanced by asking the pt. to

swallow, so the gland moves upward.


y Examined thoroughly in transverse and longitudinal

planes.
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y Multiple oblique and angled projections may be taken if

necessary.

Examined: SUPERIORLY: to identify Submandibular adenopathy INFERIORLY : to identify Supraclavicular adenopathy

Normal ultrasound anatomy of thyroid


y It is located anterior and lateral to trachea below the level of thyroid cartilage and above the sternal notch. (infrahyoid compartment)
y DIVISION :

 RIGHT AND LEFT LOBES,  ISTHMUS  PYRAMIDAL LOBE (10-40 %)

Normal thyroid parenchyma has homogenous medium to high level echogenicity & bounded by a thin hyperechoic line(the thyroid capsule). Landmarks to be identified: Midline -Trachea and oesophagus. Laterally- Common Carotid artery, IJV Anterolaterally:Strap muscles of the neck
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y The superior thyroid Vessels

are found at upper pole of each lobe and inferior thyroid vein is found at lower pole whereas the inferior thyroid artery is located posterior to lower third of each lobe.

y Anteriorly-Sternohyoid & omohyoid muscles,

As hypoechoic bands. y Lateral- Sternocleidomastoid As large oval band y Posterior- Longus colli muscle
y Recurrent laryngeal nerve & inferior thyroid artery pass in

the angle between trachea, oesophagus & thyroid lobe.

y On longitudinal scans, recurrent laryngeal nerve & inferior

thyroid artery may be seen as hypoechoic bands between the thyroid lobe & oesophagus on left , thyroid lobe & longus colli on right.
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Oesophagus y laterally & towards the left y Target appearance on transverse plane y Peristaltic movements On swallowing. Trachea y Posteriorly y Identified by lack of sound transmission and ring down artifacts.

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Inferior thyroid artery along the posterior surface

Inferior thyroid vein branches seen at the lower pole


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NORMAL DIMENSIONS OF THYROID LOBES


A-P
NEWBORN INFANT ADULT 8-9mm 12-15mm 13-18mm

LENGTH
18-20mm 25mm 40-60mm

Normal Mean Thyroid Volume (LxWxTHICKNESSx0.52) : 18.64.5 MALE-UPTO 23gm IS NORMAL FEMALE- UPTO 22gm IS NORMAL. Mean thickness of isthmus 4 to 6mm
y A-P diameter is most precise because relatively independent of possible dimensional asymemetry between two lobes. y When AP diameter- > 2cm --- Enlarged gland.

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CONGENITAL ABNORMALITIES
y AGENESIS/HYPOPLASIA y ECTOPIC

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EMBRYOLOGY
y Thyroid gland is originated from epithelial cells of

floor of pharynx.
y It descends from pharynx & remains connected to

pharynx through a tract,known as thyroglossal duct.


y The gland reaches to its normal location by 7 weeks

of gestational age.
y Then after duct involutes.
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THYROID AGENESIS USG : Abnormal echogenic tissue in the expected location of the thyroid, without any normal flow on color Doppler imaging. There is no evidence of ectopic thyroid tissue. Pertechnetate scintigraphy demonstrates no functioning thyroid tissue. 17

Sonography of the thyroid in this 1 yr. old female child revealed congenital absence of the entire thyroid. Note the empty fossae where the right and left lobes would normally lie. The carotid artery and jugular vein of both sides are seen in the color doppler images. These ultrasound and color doppler images suggest congenital agenesis of the thyroid. 18

ECTOPIC THYROID
The thyroid gland develops as a median angle from a diverticulum of the foramen cecum. Normally, it descends to its typical location anterior to the cervical trachea via the thyroglossal duct. Anomalies of descent can lead to a lingual or sublingual position of the gland. Nuclear medicine scintigraphy with sodium iodine-123 or pertechnetate99m is used to evaluate the neck for the presence of thyroid tissue. Diagnosis of lingual thyroid is made when uptake is seen at the tongue base but not in the thyroid bed. Further evaluation can be done using CT & MRI imaging.
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CT image- round mass at tongue base which enhances after contrast administration. A pertechnetate-99m scan shows uptake corresponding to mass at tongue base without uptake in the thyroid bed.

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Thyroid disorders
Thyroid disorders can be divided into
y Nodular thyroid disease y Diffuse thyroid disease.

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Nodular thyroid disease


y Hyperplasia and goiter y Adenoma y Carcinoma y Lymphoma y Metastases
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Hyperplasia and Goitre:


Etiology: Iodine deficiency, dishormonogenesis(familial),poor utilization of Iodine.
y F:M-3:1 ,more between 35-50 years. y Hyperplasia leads to an overall increase in size or volume of the gland. y Hyperplastic nodules often undergo liquefactive degeneration with the accumulation of blood, serous fluid and colloid substance, reffered to as hyperplastic,adenomatous, or colloid nodules. y Coarse and perinodular calcification occur.
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Sonography y Most hyper plastic or adenomatous nodules are isoechoic compared to normal thyroid tissue. y As Size of the mass increases, it may become hyperechoic. y Less frequently hypo echoic SPONGElike OR HONEY COOMB CYSTIC pattern is seen. y When nodule is hyperechoic or isoechoic, a thin peripheral hypoechoic halo is commonly seen-due to perinodular blood vessels and edema or compression of adjacent normal parenchyma. y Perinodular, intranodular vascularity on colour Doppler. DEGENERATIVE CHANGES: y Purely anechoic -due to serous/colloid fluid. y Echogenic fluid/moving fluid-fluid levels due to hemorrhage. y Bright echogenic foci with comet tail artifacts due to dense colloid material/microcrystals. y Eggshell(thin peripheral) or coarse calcification.
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Sonogram of the left lobe of the thyroid gland in the transverse plane showing a rounded lobe of a goiter. L=enlarged lobe, I= widened isthmus,T=trachea,C=carotid artery,J=jugular vein, S=Sternocleidomastoid muscle, m=strap muscles, E=esophagus.25

Hyperplastic nodules
y Oval homogenous isooechoic nodule with well defined peripheral halo.

y Multiple hyperechoic nodules

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Cystic degenerative changes in adenomatous nodules

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Adenoma
y F:M 7:1 y Solitary or as a part of multinodular goiter.

Sonography
y Hyperechoic, iso or hypoechoic solid masses . y Have Peripheral hypoechoic halo which is thick & smooth-

due to fibrous capsule and blood vessels. y Typical spoke and wheel type of appearance on color doppler.
y D/D : FOLLICULAR CARCINOMA where vascular and

capsular invasion are hallmarks.

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Isoechoic solid mass with thick irregular complete halo. Power doppler spoke and wheel like appearance FOLLICULAR ADENOMA

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multiple nodular densities in cervical region that are palpable on physical examination.CT scan obtained 9 months before sonogram shows absent left thryoid lobe and enlarged right thryoid lobe with small low-attenuation lesion.
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Carcinoma:
y Most primary thyroid cancers are of epithelial origin and

are derived from either the follicular or the parafollicular cells.Most are well differentiated. y Papillary carcinoma- 75-90% . y Medullary/Follicular/anaplastic car. -10-25%
Papillary cancer

y 3rd and 7th decade.F>M y The major route of spread is through lymphatics to nearby

cervical lymph nodes. y Distant metastasis is rare (2-3%) and occurs to mediastinum and lungs. y HISTOLOGY: PSAMMOMA BODIES

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Sonography
y Hypoechoic nodules with microcalcifications

(tiny punctuate hyperechoic foci with or without acoustic shadowing).


y Disorganized hypervascularity on color doppler,Mostly in

well encapsulated form.


y Cervical lymphnode metatasis which may contain tiny

punctate echogenic foci due to microcalcifications.


y Cystic lymph node metatasis in neck occur almost

exclusively with papillary carcinoma.

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Hypoechoic solid nodule with punctate calcification

Isoechoic nodule & punctate echogenic foci within it

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Two rounded hypoechoic nodes Hetrogenous oval nodes typical of metastasis to cervical containing microcalcifications nodes

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y Longitudinal and transverse sonographic images of the thyroid gland reveal a normal left lobe and

thyroid isthmus. Multiple small punctate calcifications are seen scattered through the mass in right lobe.
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Punctate echogenicities in thyroid nodules. (a) Sagittal US image of nodule


containing multiple fine echogenicities with no comet-tail artifact. These are highly suggestive of malignancy.FNA and surgery confirmed papillary carcinoma. (b) Transverse US image of nodule containing cystic areas with punctate echogenicities and comet-tail artifact consistent with colloid crystals in a benign nodule.
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Role of color Doppler US. (a) Transverse gray-scale image of Predominantly solid thyroid nodule (b) Addition of color Doppler modeshows marked internal vascularity,indicating increased likelihood that nodule is malignant. This was a papillary carcinoma.
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Woman with history of papillary thyroid cancer - underwent thyroidectomy & radioiodine ablation. Two years later, patient presented with thyroglobulin level of 6.1 ng/mL (TSH suppressed) and negative findings on 131I WBS. 18F-FDG PET (A) demonstrates small foci of increased 18F-FDG uptake corresponding to small lymph nodes in right lower neck on CT (B). These are clearly visualized on fused 18F-FDG PET/CT (C) and were subsequently proven to be thyroid cancer metastases.

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Follicular Carcinoma

y 5 -15% (2 variants-widely invasive and minimally invasive) y Hematogenous spread to bone/lung/brain/liver


WIDELY INVASIVE FORM -Not well encapsulated -Invasion of vessels and adjacent thyroid is more easily demonstrated. -Metastasis is in 20-40% cases MINIMALLY INVASIVE FORM -Well encapsulated -No gross invasion seen. Only focal histologic invasion noted. -5-10% cases.

Sonography:Cant be differentiated from follicular adenoma So treatment for both is surgical excision. y Hypoechoic nodule with irregular tumor margins y Thick, irregular halo. y Tortuous or chaotic arrangement of internal blood vessels on color doppler. PATHOLOGY: Vascular & capsular invasion. 39

Heterogenous solid mass with peripheral and internal flow follicular carcinoma

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Medullary Carcinoma
y only 5 % thyroid cancer. y Derived from parafollicular or C cells y secretes calcitonin.- useful serum marker. y Frequently familial and Associated with MEN II syndrome. y Bilateral in 90% of familial cases. y High incidence of metastatic to lymphnodes.

y Sonography
- Similar to papillary carcinoma-hypoechoic solid mass with calcifications(often, but coarse than papillary carcinoma). -Local invasion and cervical lymphadenopathy are also more common.
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Heterogenous nodule with multiple punctate foci of calcification within it medullary carcinoma

Isoechoic nodule & punctate echogenic foci within it

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Longitudnal color and power doppler hypervascularity

intranodular

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Anaplastic thyroid carcinoma


y Occurs in elderly y < 5% tumors y worst prognosis y Presents as a rapidly enlarging mass extending beyond gland and invading adjacent structures. y Show aggressive local invasion of muscle and vessels.

Sonography Hypoechoic masses often seen to encase or invade blood vessel and neck muscles(CT or MRI demonstrates the tumor more accurately owing to their large size) .
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Longitudnal scan solid hypoechoic mass extending into the upper mediastinum anaplastic carcinoma

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Aggressive thyroid cancer in left neck with spread to lungs


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Lymphoma
y 4% of all thyroid malignancies. y Mostly non-Hodgkins type y Elder females y In 70-80% cases arises from pre-existing chronic lymphocytic thyroiditis(HASHIMOTOS thyroiditis) with subclinical or overt hypothyroidism.

Sonography y Markedly Hypoechoic lobulated mass . y Hypovascular or show blood vessels with chaotic distribution and arteriovenous shunts. y Large areas of cystic necrosis may occur as well as encasement of adjacent neck vessels. y Adjacent thyroid parenchyma heterogenous due to associated 47 chronic thyroiditis.

Nodule within a cystic lesion. No flow within the nodule

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Isotope scan of thyroid demonstrating a photopenic area within the left lobe. Axial contrast enhanced CT of the same patient shows a solid mass within left lobe of thyroid . Lymphoma was proven by biopsy.
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Differentiation
Feature Internal contents Purely cystic Cystic with thin septae Mixed solid and cystic Comet tail artifact Benign malignant ++++ ++++ +++ +++ + + ++ +

Echogenicity Hyperechoic Isoechoic hypoechoic

++++ +++ +++

+ ++ +++
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Feature

Benign

malignant

Halo Thin Thick incomplete Margin Well defined Poorly defined Calcification Eggshell Coarse calcification Microcalcification

++++ +

++ +++

+++ ++

++ +++

++++ +++ ++

+ + ++++
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Feature

Benign

malignant

Doppler Peripheral flow Internal flow

+++ ++

++ +++

y + rare (<1%) y ++ low probability (<15%) y +++ intermediate probability(16 to 84%) y ++++ high probability (>85%)
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Sagittal image of predominantly cystic Sagittal image of predominantly nodule (calipers), which proved to be solid nodule , which proved to be benign at cytologic examination. benign at cytologic examination.
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Transverse US images of mostly cystic thyroid nodule with a mural component containing flow. (a) Gray-scale image shows predominantly cystic nodule with small solid-appearing mural component (b) Addition of color Doppler mode demonstrates flow within mural component , confirming that it is tissue and not debris. US-guided FNA can be directed into this area. The lesion was benign at cytologic examination.

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Peripheral coarse calcification with acoustic shadowing favours benign nature

Peripheral egg shell calcification

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HYPERPLASTIC NODULAR

ADENOMA Hyper/iso/hypoechoic Thick peripheral halo Spoke wheel Appearance

LYMPHOMA Elder NHL Dyspnoea,Dysphagia Hashimotos thyroditis Hypovascular/chaotic vasc.

METS Homogenous Hypoechoic No calcification Primary-Rcc/breast/ Melanoma

Iso/hyperechoic hypoechoic-honey coomb Thin peripheral halo Peri & intranodular vascula.

CARCINOMA
PAPILARY 3RD,7TH Decade Psammoma bodies Cervical LN HYPERECHOIC PUNCTATE CALCIFICATION Disorganised hypervascularity Cystic LN Mets FOLLICULAR Hyperechoic Thick irregular halo Tortous vessels Hematogenous spread To Bone/lung/ brain/liver MEDULARY ANAPLASTIC

Famillial MEN type-2 Calcitonnin LN METS-HIGH HYPOECHOIC COARSE CALCIFICA

Elder Aggressive Invasion= muscles,vessels Worst prognosis

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Evaluation of nodules incidentally detected by sonography


y Nodules<1.5cm : followed by palpation at time of next

physical examinaton
y Nodules > 1.5cm : evaluation usually by FNA y Any nodule with malignant features like

microcalcifications, irregular margin , thick halo , or internal flow: FNA

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Biopsy guidance
INDICATIONS


Nonpalpable suspected nodule with inconclusive physical examination. Patients at high risk of developing thyroid cancer, normal gland by physical examination but sonography demonstrates a nodule. Previous non diagnostic / inconclusive biopsy.
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DIFFUSE THYROID DISEASE

1.THYROIDITIS
CHRONIC AUTOIMMUNE LYMPHOCYTIC THYROIDITS (HASHIMOTO S THYROIDITIS) SUBACUTE GRANULOMATOUS THYROIDITIS (DE QUERVAIN S DISEASE) ACUTE SUPPURATIVE THYROIDITIS SILENT/ PAINLESS THYROIDITIS INVASIVE FIBROUS THYROIDITIS

2.ADENOMATOUS OR COLLOID GOITRE

3. GRAVE S DISEASE

Diffuse Thyroid disease


y Characterised by Generalized enlargement of gland and

no palpable nodules.
y Diagnosis is usually based on clinical and laboratory

finding and occasion by FNA.


y Sonography helpful when underlying disease causes

asymmetric thyroid enlargement.


y Sonographic diagnosis of diffuse thyroid disease is made

when isthmus may be up to 1 cm or more thickness.


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Diffuse enlargement of the isthmus and both lobes

Diffuse enlargement heterogenous gland with multiple nodules

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ACUTE SUPPURATIVE THYRODITIS

y Rare inflammatory disease caused by bacteria affecting

children. y Sonography useful in selected cases to detect thyroid abscess-ill defined hypoechoic mass with debris and/or septa and gas.
SUBACUTE GRANULOMATOUS THYROIDITIS(DE QUERVAINS) y Spontaneously remitting inflammatory disease probably

caused by viral infection.


y C/F :fever, enlargement of gland ,Tenderness y Sonography enlarged hypoechoic gland with normal or

decreased vascularity due to edema.

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Ill defined hypoechoic area focal area of subacute thyroiditis resolved after 4 wks of medical therapy

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Sagittal sonogram of left lobe of thyroid shows solid, predominately hyperechoic, poorly marginated nodule in lower pole corresponding to palpable abnormality.Fine-needle aspiration of this lesion was consistent with thyroiditis.Background of thyroid was heterogeneous,with geographic regions of hypoechogenicity.
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Chronic autoimmune lymphocytic (Hashimotos) thyroiditis


y As a painless diffuse enlargement of thyroid y often associated with hypothyroidism. y genetic tendency . y F:M 8 : 1 .Young woman are affected. y Lymphocytic infiltration of thyroid gland. y Sonography y Diffuse coarsened hypoechoic glandular enlargement
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y Multiple discrete hypoechoic micronodules

of 1-6 mm size is strongly suggestive of chronic thyroiditis. Surrounded by multiple linear echogenic fibrous septations- giving pseudo lobulated appearance.
y Normal or hypovascular.Occasionally hypervascular . y Often Cervical lymphadenopathy may be present. y In end stage, atrophy of gland occurs when thyroid gland

is small with ill defined margins and heterogenous echotexture with absent blood flow.
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Various appearances of Hashimotos disease

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Nodule was predominantly hyperechoic, with both solid and cystic-appearing Fine-needle aspiration of this 28 mm palpable nodule was consistent with lymphocytic thyroiditis.
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Sagittal sonogram of right lobe obtained at time of diagnosis of left-sided thyroid carcinoma shows 11-mm hypoechoic solid nodule with ill-defined margins (delineated by electronic calipers) in upper pole of right lobe. Sonographically guided fine-needle aspiration of this nodule and surgical pathology findings were consistent with lymphocytic thyroiditis.

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Painless thyroiditis
y Thyroid enlargement in early phase followed by hypothyroidism. y Clinical findings are similar to subacute thyroiditis y Histologic and sonographic pattern of chronic autoimmune thyroiditis.

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Graves disease
y Diffuse abnormality of thyroid gland with associated

thyrotoxicosis

Sonography
y Diffusely hypoechoic or inhomogenous texture y Color Doppler shows hypervascular pattern known as

thyroid inferno. 70cm/sec.

y Spectral Doppler shows peak velocities exceeding


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Graves disease diffuse hypervascularity and peak systolic velocity of 80cm\sec

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Pinhole images from a Tc-99m pertechnetate thyroid exam demonstrate diffuse thyroid enlargement with decreased background activity.
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Invasive fibrous thyroiditis (Riedels struma)


y Female y Tends to progress to complete destruction

USG Diffusely enlarged thyroid gland Inhomogenous parenchymal echo texture May have associated mediastinal or retroperitoneal fibrosis or sclerosing cholangitis. D/D : From Anaplastic thyroid carcinoma.by biopsy.
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Role of CT and MRI in thyroid disorders


y To demonstrate- Extent of local invasion

- regional LN metastasis
y To determine recurrence following Surgery. y Detection of retrosternal & retrotracheal extension of the

thyroid enlargement.
y Confirm the location of mass within the gland, evaluating

nodal disease and assessing the airway.


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CT signs suggesting the thyroid origin of mediastinal mass include


y Intimate association of the superior pole of mass with thyroid

gland & close proximity to the trachea.


y Hyperdensity of lesion compared to surrounding tissue. y Presence of calcification. y Persistent enhancement of the mass.

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y Differentiation of benign and malignant primary thyroid

masses is impossible on imaging, although the associated lymphadenopathy, vocal cord paralysis and bone or cartilage invasion obviously suggests malignancy.
y MRI helps to differentiate scar from residual or

recurrent tumor.
y Tumor - hypointense to isointense on T1WI

iso to hyperintense on T2WI y scar - hypointense on both T1 and T2WI.


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GOITER -Enhancing heterogenous soft tissue mass orignated in thyroid and causing deviation of the trachea

Large heterogenous soft tissue mass replacing the thyroid with speck of calcification,causing deviation of the trachea medullary carci.

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Cystic metastasis from thyroid carcinoma

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Role of radionuclide thyroid scintigraphy y To determine functional status of the nodules.


y Nodules may be cold, warm or hot depending on the

uptake of tracer as compared to the normal thyroid tissue.


y Thyroid nodules concentrate less radioiodine (only 1%)

than normal thyroid tissue hence appear cold. y Most cold nodules are adenomas, colloid nodules or foci of thyroiditis or rarely intrathyroid lymphnodes, lymphoma or metastases.
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y Approximately 10 to 20 % of cold solitary thyroid nodules

are malignant. y Cold nodules further require FNAC or biopsy.


y The demonstration of hot nodule on scintigraphy is not

synonymous with autonomy, as it often represents spared focus of normal thyroid tissue in gland otherwise involved in destructive process.
y The more important role is of 131 I whole body

scintigraphy to identify most functioning metastases, usually in the neck, lungs or bone, following total thyroidectomy.
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y TYPES

USG

RADIOACTIVE IODINE UPTAKE

HASHIMOTOS THYROIDITIS

HYPOECHOIC COARSENED MICRONODULATION HYPOECHOIC N/HYPOVASCULAR INHOMOGENOUS HYPERVASCULAR

VARIABLE

SUBACUTE GRANULOMATOUS GRAVES DISEASE

DECREASED INCREASED

INVASIVE FIBROUS

INHOMOGENOUS EXTRATHYROID INFLAMMATION VESSEL ENCASEMENT

VARIABLE
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MCQs

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1. GIVE THE DIAGNOSIS

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2. Egg cell calcifications are more common in which type of tumor?

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3.Which type of carcinoma has such appearance ?

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4. GIVE THE DIAGNOSIS

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5.GIVE THE DIAGNOSIS

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THANK YOU
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