Introduction to imaging

modalities used for evaluation

of thyroid, breast and testes
 Imaging of thyroid
 Plain radiograph
 Ultrasound (US)
 Computed tomography (CT)
 Magnetic resonance imaging (MRI)
 Nuclear scintigraphy

US, CT and MRI – anatomic information

Nuclear scintigraphy – functional information
 Plain Radiograph
 Soft tissue radiograph of neck – AP & lateral
 Shows:
- enlarged thyroid in pretracheal location
- associated calcification within the mass
- deviation and narrowing of trachea
- retrosternal extension of thyroid mass and
any associated bony destruction (neck +
upper chest X-ray)
 Ultrasound
 Gray scale, Doppler and Contrast enhanced
 HR US – first line imaging modality
 Excellent visualization of thyroid parenchyma
 Highly sensitive in detecting small nodules, calcifications,
septations and cysts (distinguishing cystic from solid lesion)
 Guiding fine needle aspiration (FNA) biopsy
 Accessible, inexpensive, non-invasive, free of radiation and
no use of iodinated contrast
 Limitations:
- difficulty in evaluation of retrotracheal and
mediastinal lesion
- inferior in identifying lymphadenopathy or
extension into soft tissues of neck & chest
 Evaluation of various nodular and diffuse thyroid
diseases.
 Nodular thyroid diseases: US evaluation:
- determine location of palpable neck mass
- characterize benign vs malignant nodule features
- detect occult nodule in patient with h/o head &
neck irradiation or MEN II syndrome
- determine extent of known thyroid malignancy
- detect residual, recurrent or metastatic carcinoma
- guide FNA of thyroid nodule or cervical LN
 US features predictive of malignant thyroid
nodules:
- Taller than wide (vs wider than tall)
- Spiculated / irregular margin ( vs well defined)
- Markedly hypoechoic nodule (vs hyperechoic)
- Predominantly solid composition
- Microcalcification (vs egg-shell or coarse)
- Absent or thick, incomplete halo (vs thin uniform
complete halo)
- Internal flow pattern (vs peripheral flow pattern)
 CT & MRI
 Better delineation of lesions within thyroid
 Detection of lymphnode metastases
 Extension of thyroid disease to adjacent
tissues in the neck (paraspinal musculature,
esophagus, trachea & carotid sheath) and into
mediastinum (retrosternal extension)
 Evaluation of recurrent disease following
treatment of thyroid cancer
 Advantages of MRI over CT:
- no ionizing radiation
- excellent soft tissue contrast and multiplanar
capabilities
- lack of beam hardening artifacts
- non interference of contrast agent (gadolinium)
with iodine uptake or organification by the
thyroid
 Iodinated contrast agents (used in CECT) will
alter radioactive iodine uptake measurements
for up to 6 weeks following study.

Hence, either contrast should not be

administered for CT study or nuclear imaging
should be performed prior to CT scan.
 Nuclear Scintigraphy
 Images of thyroid gland by use of
radiopharmaceutical agents

 Provides excellent functional information

about the thyroid gland
 Indications:
1. Investigation of thyroid nodules
2. Assessment of goitre
3. Localisation of ectopic thyroid tissue (lignual)
4. Assessment of neonatal hypothyroidism
5. Evaluation of neck and substernal mass (confirm that
the mass is functioning thyroid tissue)
6. Assessment of thyroid uptake prior to
radioiodine therapy
7. In patient with thyroid cancer
- whole body scan for distant metastases
- estimation of local residual thyroid post
thyroidectomy
- follow up for tumor recurrence
 Radiopharmaceutical agents used:

Iodine-123
Iodine-131
Tc-99m pertechnetate
Thallium-201

 Images taken with gamma camera.

 Patient preparation:
- ensure patient is not pregnant or lactating
- Avoidance of interfering materials
- medications such as thyroid hormone or

antithyroid agents, amiodarone

- Iodine containing food
 Normal thyroid gland – diffuse, even uptake
 Very active area – increased uptake
 Less active area – decreased uptake
 Entire gland overactive (Grave’s disease) – diffuse
increase uptake
 Entire gland underactive (Hashimoto’s thyroiditis) –
diffuse decrease uptake
 Focal areas of increase and decrease uptake –
different part of gland acting differently – probably
multinodular goitre
 Nodule : hot, warm or cold
- hot: more uptake than normal thyroid gland
- warm: some activity but not as much as
normal gland
- cold: No or little uptake

Risk of cold nodule being malignant higher

than hot nodule.
 Imaging of Breast
 Film screen mammography
 Ultrasonography
 Computed tomography
 Magnetic resonance imaging
 Nuclear medicine, PET
 Breast ductography
 Mammography
 Indications:
1. Screening of asymptomatic women
2. Screening high-risk women, e.g family h/o
carcinoma breast, atypical hyperplasia of lobule,
papillomatosis
3. Follow up of patients after cancer surgery
4. Investigation of benign breast diseases
with eczematous skin, nipple discharge, skin
thickening
5. Investigation of breast lump
6. Investigation of occult primary with
secondaries
7. Male breast evaluation
 85-95% sensitive – used as screening
technique for breast masses, but due to its
relatively low specificity as compared to US
and MRI it is not very useful to characterize
the lesion.
 It’s ability to guide stereotatic biopsy – added
advantage
 Examination consists of two standard views:

1. Craniocaudal projection (CC view)

2. Mediolateral oblique projection (MLO
view)
 Breast imaging reporting and data system
(BIRADS)

- designed to standardize breast imaging

reporting and to reduce confusion in breast
imaging interpretations
 Ultrasound
 Important adjunct to screen film
mammography in evaluation of breast disease
 Advantage:
- Wide availability
- Radiation free
- Highest accuracy in differentiating cystic
from solid lesions
 Indications of Breast US

• Breast lump –to differentiate cystic from solid lesions

• To evaluate mammographically dense glandular breasts
• To evaluate palpable masses in pregnant or lactating women
• As a primary modality of breast imaging for women less
than 30 years of age
• To evaluate asymmetrical or questionable densities seen on
mammogram
• To evaluate postsurgical breasts (lumpectomy and
augmentation)
• To provide guidance for interventional procedures.
 MRI

Indications of MRI of the Breast
• To detect or exclude primary carcinoma (as a
supplement to mammography) in mammographically dense
breast.

• To detect recurrence after reconstructive surgery,

especially in patients with implants or those with presence of
extensive scarring where mammography has a limited
value.

• Non-contrast MRI is now the method of choice to verify

or exclude defects in breast implants
 CT scan
 Pre and post contrast – lesion detection and
localization. Malignant lesion – enhancement
 Useful in 3D localization of lesion
 Evaluation of local spread to retromammary
area, rib involvement and intrathoracic
extension
 Breast Ductography
 Evaluate lesion causing nipple discharge –
papilloma, duct ectasia, fibrocystic disease and
breast cancer
 Location, extent and number of intraductal
lesions can be reliably demonstrated
 Duct opening located – opening cannulated
with 30G cannula – 0.5 ml water soluble
contrast injected – CC &MLO films obtained –
additional contrast if needed
 Complications:

- Duct perforation: extravasation of contrast

into breast parenchyma
- Pain or a burning sensation
- Infection
 Nuclear Medicine
 Scintimammography: 99m Tc – Sestamibi
 PET: 18 – FDG
- Detection of breast cancer in dense breast (in
mammogram), those with implants and those
presenting with occult primary when other
imaging modalities fail
- Main role: staging and treatment monitoring
- Correctly estimate local and distant extent of the
disease
 Imaging of testes
 Ultrasonography
 Magnetic resonance imaging
 Nuclear scan
 Computed tomography
 Ultrasonography
 HR US – imaging modality of choice for
examination of testes and scrotum
 Gray scale and Doppler studies
 MRI
 Used as problem solving modality
 More sensitive than US for detection of
testicular tumor
 Staging work up of testicular tumor when CT
is inconclusive or contraindicated
 Useful for follow up after cancer treatment
 Localization of testis - cryptorchidism
 CT scan
 Most commonly used modality in evaluation
of tumor spread, staging and follow up

 Detection of enlarged retroperitoneal or

mediastinal lymph nodes as well as extranodal
metastases in lung and liver
 PET
 FDG –PET : testicular tumor
 Less sensitive in initial staging than CT
 Usually – to look for metabolic activity within
residual lymphadenopathy or extranodal
metastases
 Cryptorchidism:
- US primary imaging modality for localization of
undescended testes and for follow up after orchiopexy
- MRI & CT also helps (CT – not routinely done due to
radiation)
- MRI – best cross sectional imaging modality to assess
cryptorchidism (replacing CT), higher sensitivity &
specificity than US
- Intraabdominal testes – difficult to locate on US &MRI
 Acute scrotal pain:
- US primarily used
- Acute epididymitis, acute orchitis, acute
epididymo-orchitis
- Testicular torsion
- Trauma
- Abscess
 Chronic epididymitis, orchitis
 Testicular tumor
 Benign lesions – cysts, epidermoid
 Varicocele, Hydrocele