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Imaging Thyroid Nodule(s)
Durr-e-SabihMBBS MSc FRCP FANMB
Director MINAR- Multan
Past President Pakistan Society of Nuclear
Medicine
First Contact
o Present with nodule(s)
o Incidental
19-67of the general population has a thyroid nodule on an ultrasound
up to 7 can be malignant 12
1 Welker MJ Orlov D Thyroid Nodules An Fam Physician 2003 Feb 1 67(3)559-567
2 Ross DS Overview of Thyroid Nodule Formation UpToDate July 10 2013
Is this malignant
o Male gender
o Solitary
o Growing recent rapid increase in size
(gt4cm)
o Hard
o Fixity
o HoarsenessMichael RT Homer L and Burch HB Clinical Features Associated with an Increased Risk of Thyroid
Malignancy in Patients with Follicular Neoplasia by Fine-Needle Aspiration Thyroid May 1998 8(5)
377-383 doi101089thy19988377
Is this malignant
o Male gender
o Solitary
o Growing recent rapid increase in size
(gt4cm)
o Hard
o Fixity
o HoarsenessMichael RT Homer L and Burch HB Clinical Features Associated with an Increased Risk of Thyroid
Malignancy in Patients with Follicular Neoplasia by Fine-Needle Aspiration Thyroid May 1998 8(5) 377-
383 doi101089thy19988377
Is this malignant
o Almost twice as many women as men
(221)
o 97 patients only 3 had solitary nodule
o 72 had a mass size gt3cm
o No correlation between tumor size and local
invasion nodal involvement or distant
metastases
Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan
AKUH experience JPMA 54526 2004
Solitary Nodule vs Multinodular
Goiter
o Prevalence of thyroid cancer is similar in
multinodular goiters as it is for solitary thyroid
nodules 123
1 Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan AKUH
experience JPMA 54526 2004
2 McCall A Jarosz H Lawrence AM et al The incidence of thyroid carcinoma in solitary cold nodule and
in multinodular goiter Surgery 19861001128
3 Franklyn JA Daykin J Young J et al Fine needle aspiration cytology in diffuse multinodular goiter
compared to solitary thyroid nodules BMJ 1993307240
Size of Nodule
o 494 consecutive patients with non-palpable
thyroid nodules (8-15mm)
o 92 of solitary nodules and 63 of
nodules in MNG were malignant
o Cancer prevalence and nodal spread similar
in nodules greater or lesser than 10 mm
Papini E Guglielmi R Bianchini A et al Risk of Malignancy in Nonpalpable Thyroid Nodules Predictive
Value of Ultrasound and Dolor-Doppler Features Jr Clin Endo Metab May 2002 87(5)1941-1946
Conventional Nuclear Medicineo A thyroid scan is useless unless there is a low TSH1
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan furthermore these studies add
considerable cost2
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited3
1 When and how to manage thyroid nodules Michel Procopiou Reveu therapeutique 68(6)285-9
June 2011 PMID 21656485 2Oh $ Another pesky incidental thyroid nodule Mancusso AA AJNR Am J Neuroradiol
2005 Nov-Dec26(10)2444-53Hoang JK Lee WK Lee M et al US Features of Thyroid Malignancy Pearls and Pitfalls
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
First Contact
o Present with nodule(s)
o Incidental
19-67of the general population has a thyroid nodule on an ultrasound
up to 7 can be malignant 12
1 Welker MJ Orlov D Thyroid Nodules An Fam Physician 2003 Feb 1 67(3)559-567
2 Ross DS Overview of Thyroid Nodule Formation UpToDate July 10 2013
Is this malignant
o Male gender
o Solitary
o Growing recent rapid increase in size
(gt4cm)
o Hard
o Fixity
o HoarsenessMichael RT Homer L and Burch HB Clinical Features Associated with an Increased Risk of Thyroid
Malignancy in Patients with Follicular Neoplasia by Fine-Needle Aspiration Thyroid May 1998 8(5)
377-383 doi101089thy19988377
Is this malignant
o Male gender
o Solitary
o Growing recent rapid increase in size
(gt4cm)
o Hard
o Fixity
o HoarsenessMichael RT Homer L and Burch HB Clinical Features Associated with an Increased Risk of Thyroid
Malignancy in Patients with Follicular Neoplasia by Fine-Needle Aspiration Thyroid May 1998 8(5) 377-
383 doi101089thy19988377
Is this malignant
o Almost twice as many women as men
(221)
o 97 patients only 3 had solitary nodule
o 72 had a mass size gt3cm
o No correlation between tumor size and local
invasion nodal involvement or distant
metastases
Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan
AKUH experience JPMA 54526 2004
Solitary Nodule vs Multinodular
Goiter
o Prevalence of thyroid cancer is similar in
multinodular goiters as it is for solitary thyroid
nodules 123
1 Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan AKUH
experience JPMA 54526 2004
2 McCall A Jarosz H Lawrence AM et al The incidence of thyroid carcinoma in solitary cold nodule and
in multinodular goiter Surgery 19861001128
3 Franklyn JA Daykin J Young J et al Fine needle aspiration cytology in diffuse multinodular goiter
compared to solitary thyroid nodules BMJ 1993307240
Size of Nodule
o 494 consecutive patients with non-palpable
thyroid nodules (8-15mm)
o 92 of solitary nodules and 63 of
nodules in MNG were malignant
o Cancer prevalence and nodal spread similar
in nodules greater or lesser than 10 mm
Papini E Guglielmi R Bianchini A et al Risk of Malignancy in Nonpalpable Thyroid Nodules Predictive
Value of Ultrasound and Dolor-Doppler Features Jr Clin Endo Metab May 2002 87(5)1941-1946
Conventional Nuclear Medicineo A thyroid scan is useless unless there is a low TSH1
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan furthermore these studies add
considerable cost2
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited3
1 When and how to manage thyroid nodules Michel Procopiou Reveu therapeutique 68(6)285-9
June 2011 PMID 21656485 2Oh $ Another pesky incidental thyroid nodule Mancusso AA AJNR Am J Neuroradiol
2005 Nov-Dec26(10)2444-53Hoang JK Lee WK Lee M et al US Features of Thyroid Malignancy Pearls and Pitfalls
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Is this malignant
o Male gender
o Solitary
o Growing recent rapid increase in size
(gt4cm)
o Hard
o Fixity
o HoarsenessMichael RT Homer L and Burch HB Clinical Features Associated with an Increased Risk of Thyroid
Malignancy in Patients with Follicular Neoplasia by Fine-Needle Aspiration Thyroid May 1998 8(5)
377-383 doi101089thy19988377
Is this malignant
o Male gender
o Solitary
o Growing recent rapid increase in size
(gt4cm)
o Hard
o Fixity
o HoarsenessMichael RT Homer L and Burch HB Clinical Features Associated with an Increased Risk of Thyroid
Malignancy in Patients with Follicular Neoplasia by Fine-Needle Aspiration Thyroid May 1998 8(5) 377-
383 doi101089thy19988377
Is this malignant
o Almost twice as many women as men
(221)
o 97 patients only 3 had solitary nodule
o 72 had a mass size gt3cm
o No correlation between tumor size and local
invasion nodal involvement or distant
metastases
Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan
AKUH experience JPMA 54526 2004
Solitary Nodule vs Multinodular
Goiter
o Prevalence of thyroid cancer is similar in
multinodular goiters as it is for solitary thyroid
nodules 123
1 Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan AKUH
experience JPMA 54526 2004
2 McCall A Jarosz H Lawrence AM et al The incidence of thyroid carcinoma in solitary cold nodule and
in multinodular goiter Surgery 19861001128
3 Franklyn JA Daykin J Young J et al Fine needle aspiration cytology in diffuse multinodular goiter
compared to solitary thyroid nodules BMJ 1993307240
Size of Nodule
o 494 consecutive patients with non-palpable
thyroid nodules (8-15mm)
o 92 of solitary nodules and 63 of
nodules in MNG were malignant
o Cancer prevalence and nodal spread similar
in nodules greater or lesser than 10 mm
Papini E Guglielmi R Bianchini A et al Risk of Malignancy in Nonpalpable Thyroid Nodules Predictive
Value of Ultrasound and Dolor-Doppler Features Jr Clin Endo Metab May 2002 87(5)1941-1946
Conventional Nuclear Medicineo A thyroid scan is useless unless there is a low TSH1
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan furthermore these studies add
considerable cost2
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited3
1 When and how to manage thyroid nodules Michel Procopiou Reveu therapeutique 68(6)285-9
June 2011 PMID 21656485 2Oh $ Another pesky incidental thyroid nodule Mancusso AA AJNR Am J Neuroradiol
2005 Nov-Dec26(10)2444-53Hoang JK Lee WK Lee M et al US Features of Thyroid Malignancy Pearls and Pitfalls
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Is this malignant
o Male gender
o Solitary
o Growing recent rapid increase in size
(gt4cm)
o Hard
o Fixity
o HoarsenessMichael RT Homer L and Burch HB Clinical Features Associated with an Increased Risk of Thyroid
Malignancy in Patients with Follicular Neoplasia by Fine-Needle Aspiration Thyroid May 1998 8(5) 377-
383 doi101089thy19988377
Is this malignant
o Almost twice as many women as men
(221)
o 97 patients only 3 had solitary nodule
o 72 had a mass size gt3cm
o No correlation between tumor size and local
invasion nodal involvement or distant
metastases
Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan
AKUH experience JPMA 54526 2004
Solitary Nodule vs Multinodular
Goiter
o Prevalence of thyroid cancer is similar in
multinodular goiters as it is for solitary thyroid
nodules 123
1 Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan AKUH
experience JPMA 54526 2004
2 McCall A Jarosz H Lawrence AM et al The incidence of thyroid carcinoma in solitary cold nodule and
in multinodular goiter Surgery 19861001128
3 Franklyn JA Daykin J Young J et al Fine needle aspiration cytology in diffuse multinodular goiter
compared to solitary thyroid nodules BMJ 1993307240
Size of Nodule
o 494 consecutive patients with non-palpable
thyroid nodules (8-15mm)
o 92 of solitary nodules and 63 of
nodules in MNG were malignant
o Cancer prevalence and nodal spread similar
in nodules greater or lesser than 10 mm
Papini E Guglielmi R Bianchini A et al Risk of Malignancy in Nonpalpable Thyroid Nodules Predictive
Value of Ultrasound and Dolor-Doppler Features Jr Clin Endo Metab May 2002 87(5)1941-1946
Conventional Nuclear Medicineo A thyroid scan is useless unless there is a low TSH1
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan furthermore these studies add
considerable cost2
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited3
1 When and how to manage thyroid nodules Michel Procopiou Reveu therapeutique 68(6)285-9
June 2011 PMID 21656485 2Oh $ Another pesky incidental thyroid nodule Mancusso AA AJNR Am J Neuroradiol
2005 Nov-Dec26(10)2444-53Hoang JK Lee WK Lee M et al US Features of Thyroid Malignancy Pearls and Pitfalls
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Is this malignant
o Almost twice as many women as men
(221)
o 97 patients only 3 had solitary nodule
o 72 had a mass size gt3cm
o No correlation between tumor size and local
invasion nodal involvement or distant
metastases
Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan
AKUH experience JPMA 54526 2004
Solitary Nodule vs Multinodular
Goiter
o Prevalence of thyroid cancer is similar in
multinodular goiters as it is for solitary thyroid
nodules 123
1 Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan AKUH
experience JPMA 54526 2004
2 McCall A Jarosz H Lawrence AM et al The incidence of thyroid carcinoma in solitary cold nodule and
in multinodular goiter Surgery 19861001128
3 Franklyn JA Daykin J Young J et al Fine needle aspiration cytology in diffuse multinodular goiter
compared to solitary thyroid nodules BMJ 1993307240
Size of Nodule
o 494 consecutive patients with non-palpable
thyroid nodules (8-15mm)
o 92 of solitary nodules and 63 of
nodules in MNG were malignant
o Cancer prevalence and nodal spread similar
in nodules greater or lesser than 10 mm
Papini E Guglielmi R Bianchini A et al Risk of Malignancy in Nonpalpable Thyroid Nodules Predictive
Value of Ultrasound and Dolor-Doppler Features Jr Clin Endo Metab May 2002 87(5)1941-1946
Conventional Nuclear Medicineo A thyroid scan is useless unless there is a low TSH1
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan furthermore these studies add
considerable cost2
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited3
1 When and how to manage thyroid nodules Michel Procopiou Reveu therapeutique 68(6)285-9
June 2011 PMID 21656485 2Oh $ Another pesky incidental thyroid nodule Mancusso AA AJNR Am J Neuroradiol
2005 Nov-Dec26(10)2444-53Hoang JK Lee WK Lee M et al US Features of Thyroid Malignancy Pearls and Pitfalls
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Solitary Nodule vs Multinodular
Goiter
o Prevalence of thyroid cancer is similar in
multinodular goiters as it is for solitary thyroid
nodules 123
1 Zuberi LM Yawar A Jabbar A Clinical Presentation of Thyroid Cancer patients in Pakistan AKUH
experience JPMA 54526 2004
2 McCall A Jarosz H Lawrence AM et al The incidence of thyroid carcinoma in solitary cold nodule and
in multinodular goiter Surgery 19861001128
3 Franklyn JA Daykin J Young J et al Fine needle aspiration cytology in diffuse multinodular goiter
compared to solitary thyroid nodules BMJ 1993307240
Size of Nodule
o 494 consecutive patients with non-palpable
thyroid nodules (8-15mm)
o 92 of solitary nodules and 63 of
nodules in MNG were malignant
o Cancer prevalence and nodal spread similar
in nodules greater or lesser than 10 mm
Papini E Guglielmi R Bianchini A et al Risk of Malignancy in Nonpalpable Thyroid Nodules Predictive
Value of Ultrasound and Dolor-Doppler Features Jr Clin Endo Metab May 2002 87(5)1941-1946
Conventional Nuclear Medicineo A thyroid scan is useless unless there is a low TSH1
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan furthermore these studies add
considerable cost2
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited3
1 When and how to manage thyroid nodules Michel Procopiou Reveu therapeutique 68(6)285-9
June 2011 PMID 21656485 2Oh $ Another pesky incidental thyroid nodule Mancusso AA AJNR Am J Neuroradiol
2005 Nov-Dec26(10)2444-53Hoang JK Lee WK Lee M et al US Features of Thyroid Malignancy Pearls and Pitfalls
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Size of Nodule
o 494 consecutive patients with non-palpable
thyroid nodules (8-15mm)
o 92 of solitary nodules and 63 of
nodules in MNG were malignant
o Cancer prevalence and nodal spread similar
in nodules greater or lesser than 10 mm
Papini E Guglielmi R Bianchini A et al Risk of Malignancy in Nonpalpable Thyroid Nodules Predictive
Value of Ultrasound and Dolor-Doppler Features Jr Clin Endo Metab May 2002 87(5)1941-1946
Conventional Nuclear Medicineo A thyroid scan is useless unless there is a low TSH1
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan furthermore these studies add
considerable cost2
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited3
1 When and how to manage thyroid nodules Michel Procopiou Reveu therapeutique 68(6)285-9
June 2011 PMID 21656485 2Oh $ Another pesky incidental thyroid nodule Mancusso AA AJNR Am J Neuroradiol
2005 Nov-Dec26(10)2444-53Hoang JK Lee WK Lee M et al US Features of Thyroid Malignancy Pearls and Pitfalls
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Conventional Nuclear Medicineo A thyroid scan is useless unless there is a low TSH1
o Radionuclide studies are essentially useless in the
vast majority of patients because such studies are
rarely definitive and they do not alter the therapy or
the follow-up plan furthermore these studies add
considerable cost2
o Unhelpful in differentiating benign from malignant
and utility for routine evaluation is limited3
1 When and how to manage thyroid nodules Michel Procopiou Reveu therapeutique 68(6)285-9
June 2011 PMID 21656485 2Oh $ Another pesky incidental thyroid nodule Mancusso AA AJNR Am J Neuroradiol
2005 Nov-Dec26(10)2444-53Hoang JK Lee WK Lee M et al US Features of Thyroid Malignancy Pearls and Pitfalls
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Nodule Uptake and Malignancy
Is a hot nodule always good newso Solitary hot nodule incidence of cancer 31 -11 1- 2
o Cold nodule 16 3
o Warm nodule 9 3
o Hot nodule with suppressed TSH treat hyperthyroidism without
cytology 4
1Mirfakhraee et al A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma review of the
literature Thyroid Research 2013 67 doi1011861756-6614-6-72 Daumerie C et al Prevalence of thyroid cancer in hot nodules Ann Chir 199852(5)444-83 Daniel J Kelley Evaluation of Solitary Thyroid Nodule emedicinemedscapecomarticle850823-
overviewaw2aab6b7 Aug 21 2013 4 American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
PET Imaging
o Benign as well as malignant nodules take up
F-18hellipBenign low SUV Malig High
SUVhellipvery variable results1
o Uptake in negative radio-iodine scans and
rising TG positive in de-differentiated and
anaplastic ca-thyroid Ga-DOTATOC and
F-18 DOPA are also useful 2
o Uptake is not TSH dependent 3
1Bertagna F Treglia G Giubinni Diagnostic and Clinical Significance of F-18-FDG-PETCT Thyroid
Incidentalomas J Clin Endocrinol Metab 97 2012 3866-38752 Mosci C Iaqaru A PETCT imaging of thyroid cancer Clin Nucl Med 2011 Dec (12)e 180-53 Iaqaru A Kalinyak JE Mc Dougall IRF-18 FDG PETCT for the management of thyroid cancer
Clin Nucl Med 2007 Sept 32(9) 690-5
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
MR and CT
Dukersquos 3 tiered system of reporting
incidental thyroid nodules on CTMRo Cat 1 Locally invasive or suspicious nodes
bull Go to Ultrasound
o Cat 2 Solitary Nodule in patient lt35bull Go to Ultrasound
o Cat 3 Solitary Nodule in patient gt35bull Go to Ultrasound
o MNGbull Go to Ultrasound
Hoang JK Raduazo P Yousem DM et al What to do with incidental thyroid nodules on imaging
An approach for the radiologist Semin Ultrasound CT MR 201233150-157
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Why Ultrasound
o Non palpable nodules
o Precise needle tip guidance
o Accurate measurement for interval growth
o Cervical nodes
o Suspicious or no suspicious findings
o In MNG the nodules with the highest
probable yield
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Ultrasound
o Suspicious features on gray-scale
o Doppler
o Elastography
o Contrast
o TIRADS1234
1 Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-512 Park JY Lee HJ Jang HW et al A proposal for a thyroid imaging reporting and data system for
ultrasound features of thyroid carcinoma Thyroid 2009 19 1257-1264 3Russ G Bigorgne C Rouxel A Prospective evaluation of thyroid imaging reporting and data system on
4550 nodules with and without elastography Eur J Endocrinol April 2013
4 Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of
Nodules A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011
892-899
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
TIRADS
Group Significance ( probability of malignancy)
TIRADS 1 Normal
TIRADS 2 Benign (0)
TIRADS 3 Probably benign (lt5)
TIRADS 4 4 A Suspicious (5-10)
4 B Suspicious (10-80)
TIRADS 5 Probably Malignant (gt80)
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
TIRADS Benign
Group Significance (
probability of
malignancy)
US Pattern
TIRADS 2 Benign (0) Colloid 1 Anechoic avascular echogenic spots
Colloid 2 Nonencapsulated mixed non expansile
hyperechognic spots vascularized
spongiform
TIRADS 3 Probably benign
(lt5)
Colloid 3 Non-encapsulated solidcystic
isohyperecohgenic expansile
vascualzed hyperechoic spots
Hashimoto
pseudonodule
Hyperisohypoechogenic partially
encapsulated peripheral vascularity in
background of Hashimotos thyroiditis
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules
stratifying cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
TIRADS MalignantGroup Significance (
probability of
malignancy)
US Pattern
TIRADS 4 4A Suspicious (5-
10)
Simple
neoplastic
Solid or heterogeneous nodule with thin
capsule
De Quervain
pattern
Hypoechoic ill defined lesion without
calcification
4B Suspicious
(10-80)
Suspicious
neoplastic
Hyperisohypoechoic hypervascularized
thick capsule calcification
Malignant A Hypoechoic nonencapsulated irregular
penetrating vessels calcification
TIRADS 5 Probably Malignant
(gt80)
Malignant B Isohypoechoic nonencapsulated multiple
peripheral calcifications and increased
vascularity
Malignant C Malignant A without calcification
TIRADS 6 Biopsy Proven
Horwath E Majlis S Rossi R et al An Ultrasonogram reporting system for Thyroid nodules stratifying
cancer risk for clinical Management J Clin Endocrinol Metab 200994 (5) 1748-51
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Ultrasound features of thyroid
nodules Benign Malignant
Uniform Halo Microcalcification
Predominantly Cystic Extension beyond thyroid
Avascular Metastatic nodes
Reverberating echogenicities Taller than Wide
Hypoechoic
Irregular Margin
Solid
Increased Central Vascularity
Probability of malignancy increases with number of suspicious findings and most
malignant nodules have two or more features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules A step in
Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005 794-800
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Probability of malignancy calculated using
number of suspicious US features
Kwak JY Han KH Yoon JH et al Thyroid Imaging Reporting and Data System for US Features of Nodules
A step in Establishing Better Stratification of Cancer Risk Radiology 260 (3) September 2011 892-899
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
When to biopsy
When not to biopsy
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Threshold for FNAB
Solitary NodulesUS feature Threshold
High risk history of
Th Cancer in first deg
relatives history of
childhood radiation to
neck previous cancer
in contralateral lobe
FDG avidity
Solid suspicious features
Microcalcification hypoechoic irregular
taller than wide on transverse view
gt 5mm
No suspicious features 05-15cm
Abnormal nodes All
Microcalcification All
Solid Nodule Hypoechoic gt1 cm
Hyperechoic gt15 cm
Mixed solid-cystic With suspicious features 15-20 cm
Without suspicious features gt 20 cm
Spongiform Not indicated but FNA node
if present
Purely cystic Not indicated
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Threshold for FNAB
MNG other
US feature Threshold
MNG Normal intervening parenchyma Biopsy lt4 nodules if suspicious
biopsy largest if all look benign
No intervening normal parenchyma Follow
Enlarging nodule or
diffusely enlarging
goiter
All
American Thyroid Association Guidelines for Thyroid nodule evaluation Nov 2009
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Higher threshold
o Retrospective case-control study with 8806
patients who had 11618 US exams 105 had
confirmed cancer
o Three characteristics were used entirely
solid size gt2cm microcalcification
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Higher threshold
o If one characteristic was used there would
be an 88 sensitivity with a 44 false
positive and for every cancer 56 biopsies
would be needed
o If two were used there would be a decline
in sensitivity to 52 a false positive of 7
and only 16 biopsies would be needed to get
one cancer
Smith-Bindman R Lebda P Feldstein VA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-1795
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Higher threshold
o Reduce biopsy by 90
o Residual cancer rate in those without biopsy
would be 05
Commentary on this paper warns against
using the high cut-off of 2 cm1
Smith-Bindman R Lebda P FeldsteinVA et al Risk of Thyroid Cancer Based on Thyroid
Ultrasound Imaging Characteristics JAMA Intern Med Oct 28 2013173(19)1788-17951Alexander Ekm Cooper D The Importance and Important Limitations of Ultrasound Imaging
for Evaluation Thyroid Nodules JAMA Intern Med Oct 28 2013173(19)1796-1797
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Whats the use
o Identify those in whom biopsy can be
deferred
o Reduce FNAs hellipby up to a third
o More accurate needle placement
o Follow-up to document stability or growth
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Take home
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Complex and has a learning curve
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Validate
Validate before deciding ldquonot to biopsyrdquo
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Normal Thyroid
TIRADS 1
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Benign Colloid nodule
Colloid cyst
Haemorrhagic cyst
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Thyroiditis
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Suspicious
TIRADS 4A
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Papillary Carcinoma
o Hypoechoic
o Irregular
o Microcalcification
TIRADS 4B
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Papillary Carcinoma
o Hypoechoic
o Irregular
o No halo
o Vascular
TIRADS 4B
(Malignant A)
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-images com
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Follicular Carcinoma
o Hypoechoic
o Vascular
o Minimally
irregular
o Reverberating
echogenicities
Image courtesy Dr Ravi Kadasne Al Ain UAE
Via wwwultrasound-imagescom
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Medullary Carcinoma
Image courtesy Dr Joe Antony Kerala India wwwultrasound-imagescom
o Irregular
o Hypoechoic
o Very Vascular
o Coarse Calcification
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
In a MNG target the largest or
most suspicious nodule
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Thank you
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Is this Malignant
o Meta-analysis of 19 studies with 3494
patients
o Males Pooled OR (Odds Ratio) of 15068
in females
o Size gt 4cm OR of 21
o Agehellip Wide variation
Trimboli P Treglia G Guidobaldi L et al Clinical characteristics as predictors of malignancy in
patients with indeterminate thyroid cytology a meta-analysis Endocrine May 2014 Volume 46
Issue 1 pp 52-59
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Ultrasound Terms
Isoechoic hyperechoic
Hypoechoic
Markedly hypoechoic
Same as or more than thyroid
Less than thyroid
Less than strap muscles
Predominantly Cystic
Mixed Cystic and Solid
Predominantly Solid
75-100 of volume is cystic
26-74
0-25
Microcalcifications Psammoma bodies
Microcalcifications
Macrocalcificaions rim calcifications
lt1mm no shadowing
gt1mm may cause shadowing
Reverberating echogenicities Colloid crystals
Society of Radiologists in Ultrasound consensus conference Statement Radiology Vol 237 (3) 2005
794-800
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
Are we out of the woods yet
o Meta-analysis 31 studies 18288 nodules
o Biopsy can be avoided for spongiform and
purely cystic nodules
Brito JP Gionfriddo MR Al Nofal A et al The accuracy of thryoid nodule ultrasound to predict
thyroid cancersystematic review and meta-analysis J Clin Endocrinology Metabolism 2014
Apr 99(4) 1253-63
