Patologia nodulare della tiroide - SIEMG VALCAVI 19 giu 2010r.pdf · Direttore SC di Endocrinologia e Centro Malattie della Tiroide Arcispedale Santa Maria Nuova, Reggio Emilia Parma,

Roberto Valcavi

Direttore SC di Endocrinologia e Centro Malattie della Tiroide Arcispedale Santa Maria Nuova, Reggio Emilia

www.asmn.re.it

Parma, 23 Febbraio 2008

Patologia nodulare della tiroide

30° Corso di Ecografia Generalista FIMMG-METIS

Alberobello, 20 Giugno 2010

1sabato 16 aprile 2011

AACE - American Association of Clinical EndocrinologistsAME - Associazione Medici Endocrinologi

ETA - European Thyroid Association

Medical Guidelines for Clinical Practice for the Diagnosis and Management

of Thyroid Nodules

Hossein Gharib, MD, MACP, MACE Enrico Papini, MD, FACE

Ralf Paschke, MDDaniel S. Duick, MD, FACP, FACE

Roberto Valcavi, MD, FACE Laszlo Hegedüs, MD

Paolo Vitti, MDfor the AACE/AME/ETA Task Force on Thyroid Nodules

www.aace.comwww.associazionemediciendocrinologi.it


Nodulo tiroideoParametri ecografici ! Sede, numero, dimensioni! Ecogenicità: iso, ipo, iperecogeno, anecoico! Struttura: cistica, spongiforme, mista, solida (omogenea/disomogenea)! Margini: regolari, alone, irregolari, invasione! Calcificazioni: presenza/assenza, grossolane, a guscio (integro/interrotto), puntate! Vascolarità: assente, perinodulare, intranodulare regolare, intranodulare caotica

Nuovi parametri! Elastografia (elastico, rigido al centro, rigido nella maggior parte, rigido –Fukunari) ! CEUS! 3D/4D


High risk history with suspicious US features

Abnormal cervical lymph nodes, extracapsular invasion

Microcalcifications, Irregular margins

Solid hypoechoicMixed cystic / solid

Spongiform Purely cystic

US criteria for FNAB threshold


Spongiform Echotexture. “Leave it alone nodule”


Spongiform structure. Very low risk


Cystic nodule with thin wall. Very low riskvideo



Cystic Nodule with Thick Wall.


Modest hypoechogenecity.Low risk.


Isoechoic/spongiform nodule with halo sign. Low risk


Hypoechoic hypervascular noduleScinti scan: hot nodule. Low risk

video



Isoechoic nodule with liquid area.Low risk. Risk for follicular lesion.


Coarse calcification in thyroidparenchyma. Low Risk


Eggshell calcification without shadowing.


Eggshell Calcifications with Shadowing

Smooth EggshellReassuring

Interrupted EggshellNot reassuring


Suspicious US Features of Thyroid nodules



Hypoechoic



Hypoechoic

No Halo



Hypoechoic

No Halo

Irregular margins



Hypoechoic

No Halo

Irregular margins

Microcalcifications



Hypoechoic

No Halo

Irregular margins

Microcalcifications

Hypervascular color flow mapping



Hypoechoic

No Halo

Irregular margins

Microcalcifications

Hypervascular color flow mapping

Size“More tall than wide”


Papillary Carcinoma


Papillary Carcinoma1. Marked Hypoechogenecity


Papillary Carcinoma1. Marked Hypoechogenecity2. No halo


Papillary Carcinoma1. Marked Hypoechogenecity2. No halo3. Irregular margins


Papillary Carcinoma1. Marked Hypoechogenecity2. No halo3. Irregular margins4. Microcalcifications


Papillary Carcinoma1. Marked Hypoechogenecity2. No halo3. Irregular margins4. Microcalcifications5. Scanty vascularity


Papillary Carcinoma1. Marked Hypoechogenecity2. No halo3. Irregular margins4. Microcalcifications5. Scanty vascularity6. Round shaped (as tall as wide)


Papillary micro carcinomaBulky aspect. Suspicious

video



Papillary carcinomaMultifocal, microcalcification

video



Modest hypoechogenecityBenign nodule


Halo sign, hypervascularityPapillary carcinoma

video



Chronic autoimmune thyroiditis with papillary carcinoma


Papillary carcinoma 4 cm.


Medullary carcinomaHypoechoic with punctate spots


Inhomogeneous. Follicular Carcinoma


Extra-thyroidal tumor Schwannoma


Thyroid lymphoma


Anaplastic tumor, left lobe

Video soft tissue invasionVideo Jugular Vein thrombosis



Thyroid Tumor Recurrence


Hurthle cell carcinomaRecurrence on thyroid cartilage

video



Neck Lymph NodesUltrasonographic diagnosis


Neck Lymph Nodes Levels


Neck compartments

CENTRAL COMPARTMENT

Levels VI-VII

LATERAL COMPARTMENT Levels II-III-IV-V 40sabato 16 aprile 2011

Reactive vs metastatic lymph node


Metastatic lymph nodes


Cystic central neck compartment metastatic lymph node

video



Papillary tumor. Mixed metastatic lymph node level III


Papillary carcinoma, upper left throid lobe. Level III metastases

video



Right central neck compartment metastatic lymph node

video



VII level Metastatic Lymph node.Tg + WBS -

video



Lymph node mass involving large vessels. Jugular vein thrombosis


Thyroid tumors: ultimate diagnosisUltrasound guided FNA cytology

In selected cases: ultrasound guided CNB histology


US features and thyroid malignancyMalignant Benign

Margins Irregular, invasion Well definedShape Irregular RegularMicrocalcifications Yes NoEchogenicity Hypo Iso/HyperStructure Solid

InhomogeousSpongiformdMixed/cystic

Color flow mapping Intranodular PeripheralMore tall than wide Yes NoPathologic l.nodes Yes No


US characteristics(references)

Sensitivity (%) Specificity (%) Positive Predictive Value (%)

Negative Predicitve Value (%)

Microcalcifications (1-5)

26-59 86-95 24-71 42-94

Hypoechogenicity

(2-5)

27-87 43-94 11-68 74-94

Irregular margins or no halo (2-5)

17-78 39-85 9-60 39-98

Solid (4-6)

69-75 53-56 16-27 88-92

Intranodule vascularity (3,6)

54-74 79-81 24-42 86-97

US characteristics associated with thyroid cancer

Society of Radiologists in Ultrasound Consensus StatementFrates et al. Radiology 2005

1.Khoo et al. Head Neck 20022.Kim et al. Am J Roentgenol 20023.Papini et al. J Clin End Metab 2002

4.Pacini et al. J Endocrinol Invest 20025.Frates et al. Radiological Society of Noth America 20046.Frates et al. J Ultrasound Med 2003



AME-AACE-ETA guidelines, March 2010


AME-AACE-ETA guidelines, March 2010FNA is recommended for nodules



• of any size, in patients with history of neck irradiation or family history of PTC, MTC or MEN II




• of any size, when US findings suggestive of extracapsular growth or metastatic cervical lymph nodes are present




• of any size, when US findings suggestive of extracapsular growth or metastatic cervical lymph nodes are present

• smaller than 10 mm with no high-risk history: only if suspicious US findings are present (grade C, BEL 4)


Probability of a benign FNAB to identify a „truly benign“ nodule

!90% probability of benign histology after one FNAB!in 570 patients who underwent surgery

!98% probability of benign histology after repeat FNAB!In 126 (of 1277) patients who underwent surgery

Oertel et al, Thyroid, 2007many previous studies


Ways to minimize false-negative results

• Use UGFNA biopsy (grade C; 1)

• Aspirate multiple nodule sites (grade D; 1)

• Follow up cytologically benign nodule(s) (grade D; 1)

• Consider repeat UGFNA biopsy for follow-up of benign nodules (grade D; 1)

• For multiple nodules, prioritize according to US findings (grade D; 1)

• For cystic lesions, sample solid areas with UGFNA biopsy and submit cyst fluid for examination (grade D; 1)

• Review slides with an experienced cytopathologist (grade D; 1)



Follow-up


Follow-up

•Cytologically benign nodules should be followed-up


Follow-up


•Repeat clinical and US examination and TSH measurement in 6 to 18 months


Follow-up



•Repeat UGFNA in cases of appearance of clinical or US suspicious features or a greater than 50% increase in nodule volume


Follow-up



•Repeat UGFNA in cases of appearance of clinical or US suspicious features or a greater than 50% increase in nodule volume

•Consider routine a repeat UGFNA in 6 to 18 months, even in patients with initially benign cytologic results


Thyroid ultrasoundNew perspectives (1)

! Nodular blood flow ! Sensitive Doppler! B-flow technology

! Compound technology! Enhanced visualization of borders and interfaces! Speckle noise cut down

! Deep masses detection! tissue harmonic! microconvex array transducers


Nodular Blood FlowSensitive Doppler

2000 2008


Autoimmune chronic thyroiditis.Sensitive color flow mapping

2000 2009



Compound technologyBorder enhancementSpickle artifact reducedWithout compound With Compound


Tissue harmonicDeep masses detection

video



Microconvex array probe

video



Thyroid ultrasoundNew perspectives (2)

! Extended view! Digital compound reconstruction! Continuous scan reconstruction

Contrast media enhancement ! Volume ultrasound! Ultrasound tomography! 3D/4D anatomical reconstruction with rotating planes

!Elastography! Neoplastic tissue stiffness


Extended viewDigital Compound

video



Extended view Continuous scan reconstruction


Contrast enhanced ultrasound

Bartolotta et al, Eur Radiol 2006; 16:2234-41


Volume UltrasoundUltrasound tomography


Biopsy with Ultrasound Tomography


Volume Ultrasound3D/4D Ultrasound


Thyroid Elastography: Papillary Carcinoma VIDEO



Thyroid Elastography: Cystic and Mixed Nodules


Thyroid Elastography: Tissue Stiffness 2 years after Laser Ablation

VIDEO



SERVIZIO SANITARIO REGIONALE EMILIA ROMAGNA

Azienda Ospedaliera di Reggio Emilia Arcispedale S. Maria Nuova

http://www.asmn.re.it/

Dr. Roberto ValcaviDirettoreSC Endocrinologia


Thyroid Tumors Ultrasound Diagnosis


La patologia nodulare della tiroide.

Parametri ecografici ! Sede, numero, dimensioni! Ecogenicità: iso, ipo, iperecogeno, anecoico! Struttura: solida, mista, cistica! Margini: regolari, irregolari, alone! Calcificazioni: presenza/assenza, grossolane o puntate! Vascolarità: mappatura colore


US-guided Not US-guided

Sensitivity 96% 88%

Specificity 91% 90%

Accuracy 94% 94%

Positive Predictive Value 96% 95%

Negative Predictive Value 91% 75%

Impact of US guidance on FNAB diagnostic performance

Takashima et al J Clin Ultrasound 22:535,199485sabato 16 aprile 2011

Tiroidite Cronica Autoimmune

!Pattern ipoecogeno: Mild - Dark!Tessitura diffusamente disomogena!Evidenza della trama interstiziale!Pseudonoduli!Linfonodi ricorrenziali reattivi!Pattern colore

Hashimoto’s= intenso, medio, scarsoGraves’= intenso/diffuso (“inferno”)


Tiroidite subacuta (De Quervain)

!Aree iposoniche a margini indefiniti!Aree di tessuto normale!Andamento migrante!Flusso vascolare intraparenchimale scarso!Restitutio ad integrum con la guarigione


Ten tips for good clinical thyroid ultrasound

1.Good resolution instrument is critical: minimum requirement is digital technology, 10-14 mHz linear probe, doppler facility

2.Sit comfortably in front of the US system, have all the switchboard at hand 3.Have the patient supine with hyper-extended neck.4.Do not be too anxious to start examination. Be mentally neutral. 5.Hold the probe firm in your hand, move it gently and slowly. Examine the whole

neck from clavicle to jaw.


6.Always use the same procedure. Take transverse scans, rotate the probe clockwise at 90°until having longitudinal images.

7.Take pictures of standard projections plus all the relevant findings. Indicate where the probe was placed.

8.Measure the three dimensions of nodular findings. Use volume calculation to make more reproducible serial measurements.

9.Be concise and thorough in your report. 10.Operator enthusiasm may overlook unpredicted pathology. Expect for

unexpected findings.

Ten tips for good clinical thyroid ultrasound


Documents

Patologia nodulare della tiroide - SIEMG VALCAVI 19 giu 2010r.pdf · Direttore SC di Endocrinologia e Centro Malattie della Tiroide Arcispedale Santa Maria Nuova, Reggio Emilia Parma,