21/11/2016

1

DIFFUSE THYROID CONDITIONS

Dr Anil D RaoConsultant

Department of SurgeryKTPH

DIFFUSE THYROID ENLARGEMENT – NORMAL FUNCTION AND ECHOGENECITY

21/11/2016

2

DIFFUSE GOITER

ADENOMATOUS GOITER – CONFLUENT OR INDISTINCT NODULES

21/11/2016

3

DIFFUSE INFLAMMATORY THYROID DISEASE

CHRONIC LYMPHOCYTIC THYROIDITIS (HASHIMOTOS)

21/11/2016

4

EVOLUTION

PATCHY

21/11/2016

5

PROGRESSION OF INFLAMMATION

ENDPOINT

21/11/2016

6

GRAVES DISEASE

GRAVES DISEASE

21/11/2016

7

ROLE OF ULTRASOUND

SUBACUTE THYROIDITIS – “De Quervains”

21/11/2016

8

MIDDLE AGED LADY WITH A SWOLLEN AND PAINFUL THYROID !

LYMPHOMA

21/11/2016

9

DIAGNOSTIC ULTRASOUND FOR THYROID NODULES

• CONFIRM SONOGRAPHICALLY IDENTIFIABLE NODULE CORRESPONDING TO PALPABLE NODULE (16% NON CORRESPONDENCE)

• DETECTION OF ADDITIONAL NODULES

1. SOLITARY NODULE

2. DOMINANT NODULE

• IDENTIFICATION OF SONOGRAPHIC FEATURES FOR FNA SELECTION

• SIZE

ECHOGENECITY

• NORMAL THYROID IS HOMOGENOUSLY HYPERECHOIC COMPARED TO STRAP MUSCLES

• NODULE ECHOGENECITY IS DEFINED RELATIVE TO NORMAL THYROID

1. ISOECHOIC / HYPERECHOIC – grouped together

2. HYPOECHOIC

21/11/2016

10

HYPOECHOIC NODULES

BENIGN HYPERPLASTIC NODULE PAPILLARY CANCER

HYPOECHOIC NODULES

21/11/2016

11

ISO / HYPERECHOIC NODULES

BENIGN HYPERPLASTIC NODULEFOLLICULAR CANCER

Thyroid Imaging Reporting And Data Systems ( TIRADS)CLASSIFICATION

• TIRADS 1 – Normal thyroid gland

• TIRADS 2 – Benign lesions : 0% RISK

• TIRADS 3 – Probably benign lesions : < 5% RISK

• TIRADS 4 – Suspicious lesions

1. 4a (score 1) – UNDETERMINED : 5-10% RISK

2. 4b (score 2) – SUSPICIOUS : 10-50% RISK

3. 4c (score 3-4) – HIGHLY SUSPICIOUS : 50-85% RISK

• TIRADS 5 (score 5)- Probably malignant lesions ( > 85% RISK)

• TIRADS 6 – Biopsy proven

21/11/2016

12

SONOGRAPHIC FEATURES

1. Solid component.

2. Markedly hypoechoic nodule

3. Microlobulations or irregular margins

4. Microcalcifications

5. Taller-than-wider shape

TIRADS 2

CYST

21/11/2016

13

TIRADS 2

SOLID NODULEWITH CENTRAL CYST

TIRADS 2

NODULEWITHHOMOGENOUS PERIPHERAL CALCIFICATION

21/11/2016

14

TIRADS 2

AVASCULAR ANECHOIC NODULE WITH ECHOGENIC SPECKS

TIRADS 2

VASCULAR AND HETEROECHOIC WITH HALO

21/11/2016

15

TIRADS 2

SPONGIFORM NODULES

TIRADS 2

CYSTIC NODULES

21/11/2016

16

TIRADS 3

HYPERECHOICISOECHOIC

TIRADS 4 AND 5

MARKEDLY SOLID COMPONENT

MARKEDLY HYPOECHOIC

21/11/2016

17

TIRADS 4 AND 5

MICROCALCIFICATION

TIRADS 4 AND 5MARGINS

21/11/2016

18

TIRADS 4 AND 5MARGINS

TIRADS 4 AND 5

TALLER THANWIDER

21/11/2016

19

CLINICAL SCENARIO - 1

A 36 year old female patient is noted to have a incidental finding of a 2 cm size right sided thyroid nodule at pre-employment check.

She has no family history of thyroid ailments and is clinically & biochemically euthyroid.Bedside ultrasound scan is shown below

SPONGIFORM NODULE< 2% RISK OF CANCER

21/11/2016

20

CLINICAL SCENARIO - 2

A 44 year old male patient presented to your clinic with a slow growing left sided thyroid nodule. You order an ultrasound scan for him which shows a large 3 cm size nodule. He is worried about cancer

PURELY CYSTIC LESIONS. IDEALLY TREATED BY ASPIRATION /EXCISION (excision> 4 cm diameter / recurrent)

NOT SUITABLE FOR FNAC

CLINICAL SCENARIO - 3

A 26 year old female patient presented to your clinic with a incidental finding of a right sided thyroid nodule. She is asymptomatic and has no family history of thyroid ailments. Her bedside ultrasound scan is as below

9 MM COMPLEX CYST

21/11/2016

21

CLINICAL SCENARIO - 4

A 44 year old female patient presented to your clinic with a recently diagnosed leftthyroid nodule.She is asymptomatic and has a positive family history of thyroid ailments.Her bedside ultrasound scan shows multiple small nodules with one dominant noduleshown below

HYPOECHOIC NODULE

CLINICAL SCENARIO - 5

A 65 year old lady presents to your gp clinic with mild recent onset discomfort in herneck.She has a longstanding goiter and has been told in the past that she has HashimotosThyroiditis. Her family members have noted a recent increase in size of the goiter

EXTREMELY HYPOECHOIC NODULE

21/11/2016

22

CLINICAL SCENARIO - 6

A asymptomatic 44 year old housewife is following up for a small right thyroid nodule.She has declined treatment in the past and is now worried.The latest scan of the nodule shows some calcification as shown below.

COMPLETE CURVILINEAR CALCIFICATION –USUALLY BENIGN

CLINICAL SCENARIO - 7

A 38 year old man presents to your GP clinic with a slow growing right thyroid nodule.Ultrasound scan is shown below. The finding of concern here is

IRREGULAR MARGIN