Diseases Of Thyroid Gland
The incidence of all thyroid diseases is higher in females than in males. Nodular thyroid disease is the most common cause of thyroid enlargement. Majority of patients with thyroid disease present with midline neck swelling, occasionally causing dysphagia and hoarseness of voice. Broadly the thyroid diseases are classified into three categories: benign thyroid masses, malignant tumors of thyroid gland, and diffuse thyroid enlargement.
Comparison Of Clinicopathologic Features Of Patients With L
According to the ultrasound criteria for risk evaluation, 23 out of 78 cases were classified as l-MTC and 55 out of 78 cases as m-MTC. The comparison of the clinicopathologic features of patients with l-MTC and m-MTC was shown in Table . The proportion of female in l-MTC was higher than in m-MTC . The mean rank of preoperative Ct/tumor size in m-MTC is larger than that in l-MTC. Cervical lymph node metastasis were more frequent in m-MTC than that of l-MTC. The preoperative serum Ct level in m-MTC is higher than that in l-MTC . The proportion of biochemical cure in l-MTC was significantly higher than in m-MTC. The other variables, such as age, tumor size, multifocality, extrathyroid extension, T staging and M staging did not show a significant difference between the two groups.
Table 1 Comparison of clinical characteristics of patients with l-MTC and m-MTC
What Is A Thyroid Nodule
A thyroid nodule is a collection of cells within the thyroid that grow and produce a lump. Sometimes these lumps can be felt by physical examination of the thyroid gland, but oftentimes they are detected as an incidental finding on radiology studies done for an unrelated reason. Fortunately, about 90-95% of thyroid nodules are benign .
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Ultrasound Features Of Thyroid Nodules
The vast majority of thyroid nodules are benign, and the role of a radiologist in assessment of the thyroid gland is to differentiate a malignant thyroid nodule from the more commonly seen benign ones. It is therefore important to evaluate the sonographic features of thyroid nodules as these aid in their characterization.
The incidence of malignancy is 4% when a solid thyroid nodule is hyperechoic. If the lesion is hypoechoic , the incidence of malignancy rises to 26% . However, hypoechogenicity alone is inaccurate in predicting malignancy, and if used as a sole predictive sign, it has a relatively poor specificity and positive predictive value .
Longitudinal grey scale sonogram shows a solid, hypoechoic thyroid nodule with ill-defined margins anteriorly. Histology: papillary carcinoma.
A malignant thyroid nodule tends to have ill-defined margins on ultrasound . A peripheral halo of decreased echogenicity is seen around hypoechoic and isoechoic nodules and is caused by either the capsule of the nodule or compressed thyroid tissue and vessels . The absence of a halo has a specificity of 77% and sensitivity of 67% in predicting malignancy .
Longitudinal grey scale sonogram shows coarse calcifications with dense shadowing within a thyroid nodule suggestive of benign calcification.
Comet tail sign
Colour flow patterns
In general there are three patterns of vascular distribution within a thyroid nodule :
Rte Versus Swe Elastography
As mentioned in the EFSUMB guidelines and showed in literature data, both SE and SWE represent a useful tool in thyroid nodule stratification of malignancy risk, complementary to gray-scale evaluation .
Different studies have reported a wide range of values for Se and Sp when comparing the two-elastographic methods.
A big meta-analysis on 71 studies with a total of 16,624 patients showed that RTE is slightly better in differentiating benignancy from malignancy in thyroid lesions, with pooled Se = 82.9% for RTE Se = 78.4% for SWE and Sp = 82.8% for RTE and Sp = 82.4% for SWE .
A head-to-head comparison of two elastographic methods was made only in a few studies.
In a publication by Liu et al., 49 patients underwent both SWE and RTE evaluation and results were compared to pathology results. For SE, qualitative assessment was made using Rago classification and for SWEmin and max mean elasticity were measured, cutoff mean value was 38.3 kPa, with Sp = 68.4% Se = 86.7% NPV = 86.7% PPV = 68.4% for SWE and Sp = 79% Se = 84.4% NPV = 83.3% PPV = 64.7% for RTE. The study established that SWE is a promising method for the evaluation of thyroid malignancy risk, with similar value to RTE, its sensitivity being a little lower and its specificity a little higher .
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How Common Are Thyroid Nodules
Thyroid nodules are very common, especially in the U.S. In fact, experts estimate that about half of Americans will have one by the time theyre 60 years old. Some are solid, and some are fluid-filled cysts. Others are mixed.
Because many thyroid nodules dont have symptoms, people may not even know theyre there. In other cases, the nodules can get big enough to cause problems. But even larger thyroid nodules are treatable, sometimes even without surgery.
What Does The Equipment Look Like
Ultrasound machines consist of a computer console, video monitor and an attached transducer. The transducer is a small hand-held device that resembles a microphone. Some exams may use different transducers during a single exam. The transducer sends out inaudible, high-frequency sound waves into the body and listens for the returning echoes. The same principles apply to sonar used by boats and submarines.
The technologist applies a small amount of gel to the area under examination and places the transducer there. The gel allows sound waves to travel back and forth between the transducer and the area under examination. The ultrasound image is immediately visible on a video monitor. The computer creates the image based on the loudness , pitch , and time it takes for the ultrasound signal to return to the transducer. It also considers what type of body structure and/or tissue the sound is traveling through.
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How Does The Procedure Work
Ultrasound imaging uses the same principles as the sonar that bats, ships, and fishermen use. When a sound wave strikes an object, it bounces back or echoes. By measuring these echo waves, it is possible to determine how far away the object is as well as its size, shape, and consistency. This includes whether the object is solid or filled with fluid.
Doctors use ultrasound to detect changes in the appearance of organs, tissues, and vessels and to detect abnormal masses, such as tumors.
In an ultrasound exam, a transducer both sends the sound waves and records the echoing waves. When the transducer is pressed against the skin, it sends small pulses of inaudible, high-frequency sound waves into the body. As the sound waves bounce off internal organs, fluids and tissues, the sensitive receiver in the transducer records tiny changes in the sound’s pitch and direction. A computer instantly measures these signature waves and displays them as real-time pictures on a monitor. The technologist typically captures one or more frames of the moving pictures as still images. They may also save short video loops of the images.
Medical History And Physical Exam
If you have any signs or symptoms that suggest you might have thyroid cancer, your health care professional will want to know your complete medical history. You will be asked questions about your possible risk factors, symptoms, and any other health problems or concerns. If someone in your family has had thyroid cancer or tumors called pheochromocytomas, it is important to tell your doctor, as you might be at high risk for this disease.
Your doctor will examine you to get more information about possible signs of thyroid cancer and other health problems. During the exam, the doctor will pay special attention to the size and firmness of your thyroid and any enlarged lymph nodes in your neck.
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What Will I Experience During And After The Procedure
Most ultrasound exams are painless, fast, and easily tolerated.
An ultrasound of the thyroid is usually completed within 30 minutes.
During the exam, you may need to extend your neck to help the sonographer examine your thyroid with ultrasound. If you suffer from neck pain, inform the technologist so that they can help situate you in a comfortable position for the exam.
When the exam is complete, the technologist may ask you to dress and wait while they review the ultrasound images.
After an ultrasound exam, you should be able to resume your normal activities immediately.
How Is The Procedure Performed
For most ultrasound exams, you will lie face-up on an exam table that can be tilted or moved. Patients may turn to either side to improve the quality of the images.
A pillow may be placed behind the shoulders to extend the area to be scanned for a thyroid ultrasound exam. This is especially important for a small child with very little space between the chin and the chest.
The radiologist or sonographer will position you on the exam table. They will apply a water-based gel to the area of the body under examination. The gel will help the transducer make secure contact with the body. It also eliminates air pockets between the transducer and the skin that can block the sound waves from passing into your body. The sonographer places the transducer on the body and moves it back and forth over the area of interest until it captures the desired images.
There is usually no discomfort from pressure as they press the transducer against the area being examined. However, if the area is tender, you may feel pressure or minor pain from the transducer.
Once the imaging is complete, the technologist will wipe off the clear ultrasound gel from your skin. Any portions that remain will dry quickly. The ultrasound gel does not usually stain or discolor clothing.
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What Is Molecular Profiling
At UCLA, thyroid nodules with indeterminate biopsies are sent out for an additional molecular marker test. An indeterminate biopsy result is the gray zone where the risk of cancer is intermediate but cannot be ignored.
Sometimes the biopsy result is reported as indeterminate. This means the cells are not normal, but there are not definite signs of cancer. When biopsies are indeterminate, the risk of thyroid cancer is 15-30%.
In the past, to avoid missing a cancer, we recommended thyroid lobectomy to establish a definitive diagnosis. Now, we use molecular profiling. This refers to commercial DNA or RNA tests made specifically for indeterminate thyroid nodules. If the genetic profile appears benign, patients can avoid surgery and we simply watch the nodule over time with neck ultrasound.
Lab Tests Of Biopsy Samples
In some cases, doctors might use molecular tests to look for specific gene changes in the cancer cells. This might be done for different reasons:
- If FNA biopsy results arent clear, the doctor might order lab tests on the samples to see if there are changes in the BRAF or RET/PTC genes. Finding one of these changes makes thyroid cancer much more likely.
- For some types of thyroid cancer, molecular tests might be done to see if the cancer cells have changes in certain genes , which could mean that certain targeted drugs might be helpful in treating the cancer.
These tests can be done on tissue taken during a biopsy or surgery for thyroid cancer. If the biopsy sample is too small and all the molecular tests cant be done, the testing may also be done on blood that is taken from a vein, just like a regular blood draw.
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Diagnosis Of Thyroid Cancer
There are different tests a doctor may use to diagnose thyroid cancer, including an ultrasound and a fine needle aspiration.
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If you have symptoms of thyroid cancer, you will usually start by seeing your GP, who will examine you. They will refer you to a hospital for specialist advice and treatment if they:
- are unsure what the problem is
- think your symptoms could be caused by cancer.
If they think it could be cancer, you should be seen at the hospital within 2 weeks.
The doctor will ask you about your general health, family history and any previous medical problems you have had. They will also examine you. You may have some of the following tests.
But What If Its Thyroid Cancer
A cancer diagnosis is always worrisome, but even if a nodule turns out to be thyroid cancer, you still have plenty of reasons to be hopeful.
Thyroid cancer is one of the most treatable kinds of cancer. Surgery to remove the gland typically addresses the problem, and recurrences or spread of the cancer cells are both uncommon. People who undergo thyroid gland surgery may need to take thyroid hormone afterward to keep their body chemistry in balance.
Whether its benign or not, a bothersome thyroid nodule can often be successfully managed. Choosing an experienced specialist can mean more options to help personalize your treatment and achieve better results.
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Uses For A Thyroid Ultrasound
A thyroid ultrasound may be ordered if a thyroid function test is abnormal or if you doctor feels a growth on your thyroid while examining your neck. An ultrasound can also check an underactive or overactive thyroid gland.
You may receive a thyroid ultrasound as part of an overall physical exam. Ultrasounds can provide high-resolution images of your organs that can help your doctor better understand your general health. Your doctor may also order an ultrasound if they notice any abnormal swelling, pain, or infections so that they can uncover any underlying conditions that might be causing these symptoms.
Ultrasounds may also be used if your doctor needs to take a biopsy of your thyroid or surrounding tissues to test for any existing conditions.
What Are Some Common Uses Of The Procedure
An ultrasound of the thyroid is typically used:
- to determine if a lump in the neck is arising from the thyroid or an adjacent structure
- to analyze the appearance of thyroid nodules and determine if they are the more common benign nodule or if the nodule has features that require a biopsy. If biopsy is required, ultrasound-guided fine needle aspiration can help improve accuracy of the biopsy.
- to look for additional nodules in patients with one or more nodules felt on physical exam
- to see if a thyroid nodule has substantially grown over time
Because ultrasound provides real-time images, doctors may use it to guide procedures, including needle biopsies. Biopsies use needles to extract tissue samples for lab testing. Doctors also use ultrasound to guide insertion of a catheter or other drainage device. This helps assure safe and accurate placement.
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Why The Test Is Performed
A thyroid ultrasound is usually done when physical exam shows any of these findings:
- You have a growth on your thyroid gland, called a thyroid nodule.
- The thyroid feels big or irregular, called a goiter.
- You have abnormal lymph nodes near your thyroid.
Ultrasound is also often used to guide the needle in biopsies of:
- Thyroid nodules or the thyroid gland — In this test, a needle draws out a small amount of tissue from the nodule or thyroid gland. This is a test to diagnose thyroid disease or thyroid cancer.
- The parathyroid gland.
- Lymph nodes in the area of the thyroid.
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Are Thyroid Nodules Common
Yes, thyroid nodules can be detected with ultrasonography in nearly 40- 50% of otherwise completely healthy adults. Most nodules are so small that they are never noticed by the patient or doctor. However, the wide spread use of CT, MRI, and neck ultrasonography has led to the detection of many very small, asymptomatic thyroid nodules that may or may not require further evaluation.
Understanding Thyroid Ultrasound Results
Your doctor usually analyzes the results before consulting with you about possible follow-up tests or conditions that may be indicated by the ultrasound. In some cases, your ultrasound may show images of nodules that may or may not be cancerous or contain microcalcifications, which is often associated with cancer. But according to
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Elastography: Place In Indeterminate Cytology Results
Nondiagnostic and indeterminate cytology represent the great limitations of FNAC and gray-scale US can sometimes be poorly predictive. About half of these nodules can avoid surgery by performing a second biopsy . There was one study that reported higher prevalence of cancer on repeat FNAB, maybe as a consequence of the class of high-risk nodules that underwent second FNAB .
For the clearance of this cytological category, there is currently a general proposal to use molecular markers, but there is still no consensus regarding which panel should be used .
Several molecular markers have been studied in indeterminate FNAB cytology findings. The most studied mutations/rearrangements include BRAF, RAS, RET/PTC, and PAX8/PPAR. These markers can predict malignancy with very high sensitivity, having a high positive predictive value but if they are not present, malignancy cannot be ruled out, having a low sensitivity and negative predictive value .
Currently, there is no individual molecular marker that can certainly rule out malignancy in indeterminate nodules and it is still debatable if there is a cost-effective combination of these markers that can be used .
Elastography has been suggested to define more accurately the presurgical malignancy risk in this cytological category to help clinicians decision whether to repeat biopsy or follow-up .