1. The impact of new emerging tools in Ultrasound technology in a case of thyroid follicular carcinoma Antonio Pio Masciotra Campobasso Molise Italy Website www.masciotra.net YouTube Channel https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ 51 years old asymptomatic woman at her first thyroid US exam. Two nodules were found : The first in her right lobe, mixed (solid and cystic components), 25 mm in diameter The second solid in her left lobe at the lower pole, 6 mm in diameter 2. In the following slides videoclips of right nodules Color, directional PD and Powerdoppler are shown with different linear probes (16-5, 15-4 and 10-2 Mhz) and with different presets (breast, thyroid, vascular carotid and venous) are shown. The last clip refers to the Shear Wave Elastography acquisition. 3. SLV 16-5 MHz Probe Breast preset SL 15-4 MHz Probe Carotid preset SL 10-2 MHz Probe Carotid preset 4. SL 10-2 MHz Probe Venous preset SL 10-2 MHz Probe Thyroid preset SL 10-2 MHz Probe SWE Thyroid preset 5. SL 10-2 MHz Probe Carotid preset Very nice performance of the UltraFast Powerdoppler acquisition with optimal detection of the frames with Peak Systolic, Mean and Maximum Velocities and spectral analysis of the flow in three different vessels 6. SL 10-2 MHz Probe Peripheral venous preset Very nice performance of the UltraFast Colordoppler acquisition with optimal detection of the frames with Peak Systolic, Mean and Maximum Velocities and spectral analysis of the flow in three different vessels 7. The diagnostic workup was then addressed according to the TIRADS guidelines assigning a score to all the features (morphologic, vascular and mechanic as emerging at Shear Wave Elastography). 8. The TIRADS LEXIC To each nodule, the radiologist has to specify its: 1. Shape taller-than-wide (greater in its antero-posterior dimension than in its transverse dimension) and wider-than-tall. 2. Internal component solid, mixed or cystic 3. Margins well circumscribed, lobulated or irregular 4.Echogenicity hyperechogenicity, isoechogenicity, hypoechogenicity and marked hypoechogenicity. Isoechogenicity was defined as an echogenicity similar to that of the adjacent healthy thyroid gland. A nodule was classified as marked hypoechogenicity if the echogenicity was less than that of the superficial surrounding neck muscles. 5.Evidence of calcifications Micro-calcifications (< 3 mm) Macrocalcifications (> 3 mm with acoustic shadowing)) 6. Stiffness Features 9. TIRADS classification (modified Russ classification) TIRADS 1 - Normal thyroid TIRADS 2 - Benign aspects (0% chance of malignancy) Simple cyst Spongiform nodule White Knight aspect Isolated macrocalcification Typical sub acute thyroiditis TIRADS 3 - Probably benign aspects (80% chance of malignancy) TIRADS 6 Biopsy proven malignant nodules All studies show that most cancers were found in the TIRADS 3, 4 and 5 categories. 10. Right lobe Feature Left lobe Wider than tall Shape Taller-than-wide and wider-than-tall Wider than tall Mixed Internal component solid, mixed or cystic Solid Well circumscribed Margins Well circumscribed, lobulated or irregular Well circumscribed 0.45 Echogenicity (B Ratio Nodule/Parenchyma) hyperechogenicity,isoechogenicity, hypoechogenicityand marked hypoechogenicity 0.70 Micro Evidence of calcifications Micro-calcifications (< 3 mm) Macrocalcifications (> 3 mm with acoustic shadowing) Absent Both Vessels Perinodular Intranodular Both 72,8 Mean Stiffness (kPa) 20,3 5,0 Standard Deviation (kPa) 1,8 2,9 Stiffness Ratio (Nodule/Parenchyma) 0,9 4B TIRADS 4A Biopsy Final indication Surveiilance 11. SSI 15-4 MHz Probe Nodule SWE Features Right lobe Left lobe Mean stiffness (kPa) 72,8 20,3 Maximum stiffness (kPa) 80,1 24,8 Minimum stiffness (kPa) 63,9 17,6 Standard Deviation (kPa) 5,0 1,8 Ratio 2,9 0,9 TIRADS 4B 4A Final indication Biopsy Surveillance FNA TIR 3 (Thy III) Not performed Pathological diagnosis Malignant (Follicular Carcinoma) Benign (Hyperplastic) The TIRADS analysis of the two nodules did show only a little difference in its assignment (4B to the right lobes nodule Vs 4A to the left lobes nodule) and even the FNA cytologic diagnosis of the right lobes nodule was indeterminate (Class III). A great difference among the two nodules was evident at Shear Wave Elastography that gave the indication to the surgery cause of the high stiffness of the right lobes nodule. Final diagnosis on the right lobes nodule was Follicular Carcinoma (while left lobes nodule was simply hyperplastic). 12. The right indication to the surgery was given by 3D Shear Wave Elastography that well shows the peripheral very stiff sites with an impressive correspondence to the sites of capsular invasion (the only feature differentiating follicular carcinoma from benign follicular adenoma). We know that thyroid follicular cancer diagnosis is often difficult and challenging even for the pathologists. 13. Encapsulated, relatively homogeneous and indistinguishable from adenoma Apparently encapsulated Multifocal capsular and vascular invasion Thyroid follicular carcinoma pathologic features 14. Follicular carcinoma in a multinodular goiter. Arrows mark focal capsular invasion. Multiple nodules in the same cancer Most of the tumor is bound by a capsule (irregular whitish band around the lighter central nodule). The capsule is breached and there is tumor growth outside it (marked with a star). Thyroid follicular carcinoma pathologic features 15. Tumor has distinct border, but separate foci of invasive tumor lye beyond the border. Thyroid follicular carcinoma pathologic features 16. "Histopathology Thyroid--Follicular carcinoma by John R. Minarcik, M.D. 17. Keypoints of the case and take home messages This case shows one more time that TIRADS based only on the classical features can be limited. Shear Wave Elastography in this case gives the right indication to the surgery both in 2D (with all its stiffness informations) and first of all in 3D (with the detection of the stiffest spots at the periphery corresponding to the sites of capsular invasion, distinguishing feature of the follicular carcinoma) In conclusion nowadays advanced ultrasonography offers so many tools that it would be unsafe to rely the diagnostic workup only on one of the US modes (B-mode 2D and 3D, Doppler and 2D and 3D sonoelastography). Uptodate TIRADS has to be based on all these informations that make ultrasonography to deserve in full the definition of Multiparametric Diagnostic Modality. 18. Ultrasonography of thyroid focal diseases : a true Multiparametric Diagnostic Modality Mode Features Informations B Mode Shape Taller-than-wide and wider-than-tall Morphology and Structure Internal component solid, mixed or cystic Margins Well circumscribed, lobulated or irregular Echogenicity (B Ratio Nodule/Parenchyma) hyperechogenicity,isoechogenicity, hypoechogenicityand marked hypoechogenicity Evidence of calcifications Micro-calcifications (< 3 mm) Macrocalcifications (> 3 mm with acoustic shadowing) Doppler Mode CDI, PDI , dPDI Number, density and distribution of the vessels Vascular Pulsed Wave Blood flow characterisation and quantification Blood Flow Functional (?) Sonoelastography Strain Relative Stiffness Mechanical properties Shear Wave Relative stiffness and Stiffnes quantification 19. Antonio Pio Masciotra Campobasso Molise Italy Website www.masciotra.net YouTube Channel https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ Conclusion The contribute offered by the new emerging tools in Ultrasound technology in this case are really innovative in : Ultrafast doppler acquisition (with detection of low resistivity flow in more vessels) 2D Shear Wave Elastography (with qualitative and quantitative information on elasticity) 3D Shear Wave Elastography (with information on the topographical distribution of the stiffest sites) Thanks for your attention