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(BQ) Part 2 book Thyroid ultrasound and ultrasound guided FNA presents the following contents: Ultrasound in themanagement of thyroid cancer, parathyroid ultrasonography, contrast enhanced ultrasound in the management of thyroid nodules, percutaneous ethanol injection (pei) - thyroid cysts and other neck lesions, laser and radiofrequency ablation procedures,....
Chapter Ultrasound in the Management of Thyroid Cancer H Jack Baskin INTRODUCTION The strategic value of ultrasound in the postoperative surveillance of patients with thyroid cancer and in the preoperative surgical planning of patients undergoing thyroid cancer surgery has become increasingly appreciated over the past decade In this chapter we will focus on how to recognize and differentiate malignant lymph nodes from benign lymphadenopathy Once you become familiar with the appearance of metastatic lymph nodes in thyroid cancer, you will find that ultrasound is a more specific tool for separating benign from malignant lymph nodes than it is for separating benign and malignant thyroid nodules However, we still must rely on ultrasound-guided FNA for a definitive diagnosis POSTOPERATIVE SURVEILLANCE FOR THYROID CANCER Ultrasound has assumed a primary role in the management of patients who have been treated for thyroid cancer In spite of better surgical techniques, the acceptance of total and near-total thyroidectomy, and the increasing use of radioiodine, the mortality rate from well-differentiated thyroid cancer has changed very little over the past thirty years Because of its propensity to occur at any age, even in the very young, and to recur many years later, thyroid cancer must be monitored for the lifetime of the patient Surveillance of these patients in a cost-effective manner has been a challenge Until the 1990s the only diagnostic tool available was a 131I whole body scan (WBS) done after withdrawing the patient from thyroid hormone replacement The sensitivity of a WBS in the early detection of residual, recurrent, or metastatic thyroid cancer is poor This is apparent 111 112 H.J BASKIN from the many patients who have increased thyroglobulin (Tg) but negative diagnostic scans who are treated with 131I and have positive post-treatment scans (1–4) Park et al have also shown that the doses of 131I used for WBS can stun the uptake of iodine in metastatic lesions and interfere with the subsequent treatment dose of 131I (5) The expense, poor sensitivity, and risk of stunning with a WBS make it an unsatisfactory test with which to follow patients with thyroid cancer In the last decade several new probes have been developed that aid in the early detection of recurrent thyroid cancer These include: (1) sensitive, reliable, reproducible Tg assays that biochemically detect the earliest sign of cancer recurrence; (2) development of recombinant TSH (rhTSH) that allows scanning and Tg stimulation without thyroid hormone withdrawal; and (3) high-resolution ultrasound of the postoperative neck to identify early lymph node recurrence Using these new tools, especially neck ultrasound combined with UG FNA of suspicious lymph nodes, has greatly improved the sensitivity of cancer surveillance in these patients Hopefully, their use will result in lower mortality from thyroid cancer Physical examination of the neck of a patient who has undergone a thyroidectomy for thyroid cancer is seldom helpful in the early detection of a recurrence The scar tissue following surgery, combined with the propensity of metastatic lymph nodes to lie deep in the neck beneath the sternocleidomastoid muscle, make palpation of enlarged lymph nodes in the neck difficult Even lymph nodes several centimeters in diameter are often not palpable High-resolution ultrasound has solved this problem by proving to be a very sensitive method to find and locate early recurrent cancer and lymph node metastasis Frasoldati et al (6) studied 494 patients with a history of low risk well-differentiated thyroid cancer by a withdrawal WBS, stimulated Tg, and ultrasound, and found by at least one test that 51 had had a recurrence The WBS was positive in 23 patients (45%), the Tg was positive in 34 patients (67%), and the ultrasound with FNA was positive in 48 patients (94%) Since most thyroid cancer metastasizes to the neck, it is rare for it to spread elsewhere without neck lymph node involvement Therefore, neck ultrasound has proven to be the most sensitive test available in locating early recurrent disease, even before serum Tg is elevated ULTRASOUND OF THE POSTOPERATIVE NECK Identifying and evaluating lymph nodes should be done with high-resolution ultrasound using a 10–15MHz transducer with power Doppler capability to assess vascularity When performing ULTRASOUND MANAGEMENT OF THYROID CANCER 113 ultrasound of the neck in a patient who has undergone a thyroidectomy, one sees that the carotid artery and jugular vein have migrated medially close to the trachea, and that the thyroid bed has been filled with a varying amount of hyperechoic connective tissue that appears white (dense) on ultrasound This serves well in demarcating a recurrence of cancer or a metastatic lymph node, which will appear dark or hypoechoic Someone unfamiliar with the appearance of the postoperative neck on ultrasound should begin by examining the neck of someone who underwent a thyroidectomy or hemithyroidectomy for benign disease This allows one to become accustomed to the neck structures and the altered anatomy of the postoperative neck without worrying about recurrent thyroid cancer The commonest areas for detecting cancer are the thyroid bed and the jugular chain of lymph nodes, but metastatic lymph nodes may occur anywhere in the neck In performing ultrasound looking for metastatic lymph nodes, the entire length of the internal jugular vein from the head of the clavicle up to the mandible is searched, paying close attention to the area between the carotid artery and the jugular vein Special attention should be given to the thyroid bed and the central compartment medial to the common carotid artery Malignant paratrachael lymph nodes in this area are likely to metastasize more quickly to the mediastinum and lungs FIG 8.1 Normal postoperative left neck Note that the common carotid artery and the internal jugular vein have migrated medially next to the trachea The vein is anterior to the artery but closely adhered to it Hyperechoic connective tissue has filled in the thyroid bed 114 H.J BASKIN FIG 8.2 Normal postoperative right neck In this patient the vein remains lateral to the artery, but still lies adjacent to it The strap muscles (sm) have helped fill in the space left by removal of the thyroid The normal neck contains approximately 300 lymph nodes Except for the pharyngeal area, they are usually less than 0.5 cm in their short axis and flattened or oval in the transverse view of the neck, with a long axis two or more times the short axis If they become inflamed or hyperplastic, they enlarge but generally maintain this flattened or oval shape High-resolution ultrasound often shows a white line of fat and intranodal blood vessels running through the center of the lymph node referred to as a hilar line The hilar line is present in most benign lymph nodes greater than 0.5cm and is also more prominent in older patients A hilar line is seldom seen in malignant lymph nodes Because lymph node hyperplasia is so common in the neck, only those lymph nodes >0.5cm in the short axis are usually biopsied Those with a short axis 0.5cm (0.8cm in the pharyngeal area) or less should have their location marked and be reexamined in six months Metastatic lymph nodes generally have a fuller or more rounded appearance in the transverse view with a short/long axis ratio >0.5 Postoperative ultrasound surveillance for cancer is done in the transverse view, since all lymph nodes may appear elongated in the longitudinal view In addition to a rounded shape and the absence of a hilar line, there are other ultrasound findings that suggest a lymph node is malignant (7) (Table 8.1) The internal jugular vein ULTRASOUND MANAGEMENT OF THYROID CANCER 115 TABLE 8.1 Neck lymph node characteristics Benign Short/Long Axis Hilar line Jugular Deviation or Compression Microcalcifications Cystic Necrosis Vascularity 0.5 Absent Present Present Present Chaotic/peripheral FIG 8.3 Benign lymph node The normal neck contains scores of lymph nodes, some of which are easily seen with ultrasound This lymph node (calipers) appears benign because it is flat with a short/ long axis ratio 1) strongly suggest that it is malignant, which was confirmed by UG FNA FIG 8.11 Although this lymph node (arrow) measures only 2.5mm, its location and shape lead to UG FNA, and Tg was found in the needle washout, confirming metastatic thyroid cancer but they have varying degrees of echogenicity Early papillary metastases are sometimes dense and may be relatively hyperechoic As they enlarge up to 1cm they develop cystic necrosis and become hypoechoic Therefore, echogenicity may not be helpful in determining malignancy Matting of lymph nodes 120 H.J BASKIN FIG 8.12 This irregular rounded lymph node (arrow) was discovered because of the separation of the jugular from the carotid The calcification at 3:00 o’clock indicates it is malignant, but UG FNA is necessary before surgery FIG 8.13 Transverse view of a metastatic lymph node (calipers) in right neck beneath the sternocleidomastoid muscle (scm) and lateral to the carotid artery The node is impinging upon the jugular vein (J) The short/long axis ratio is >0.5 and no hilar line is seen UG FNA had positive cytology, and Tg was found in the needle washout occurs with malignancy but is not a helpful sign, since it is also seen with inflammation or in patients who have had radiation 234 O ESNAULT AND L LEENHARDT the recurrent laryngeal nerve was the most serious complication in this study (3.3%) Ethanol injection was reported to be more effective in cystic nodules These side effects and invasiveness of such procedures raise questions and lead to proposed HIFU treatment in solid or mixed nodules CONCLUSION The technical treatment parameters leading to a precise necrosis of the targeted nodule by HIFU were determined in feasibility studies The ultimate goal of HIFU treatment is to induce a significant reduction in the volume of thyroid nodules, perhaps leaving scarring in longer term Since other thermal therapies such as laser show that the decreases in nodule volume are fully visible after three months, it can be expected that a similar result will be obtained with HIFU technology Ongoing studies are underway to confirm the efficacy and safety of HIFU treatment of thyroid nodule, parathyroid adenoma, cervical lymph nodes and thyroid cancer recurrences References Fry WJ, Barnard JW, Fry FJ, Brennan JF (1955) Ultrasonically produced localized selective lesions in the central nervous system American Journal of Physical Medicine 34(3):413–23 Fry WJ, Mosberg WH, Jr., Barnard JW, Fry FJ (1954) Production of focal destructive lesions in the central nervous system with ultrasound Journal of Neurosurgery 11(5):471–8 Fry FJ, Johnson LK (1978) Tumor irradiation with intense ultrasound Ultrasound in Medicine & Biology 4(4):337–41 Moore WE, Lopez RM, Matthews DE, et al (1989) Evaluation of high-intensity therapeutic ultrasound irradiation in the treatment of experimental hepatoma Journal of Pediatric Surgery 24(1):30– 3; discussion Yang R, Reilly CR, Rescorla FJ, et al (1991) High-intensity focused ultrasound in the treatment of experimental liver cancer Arch Surg 126(8):1002–9; discussion 9–10 Chapelon JY, Margonari J, Theillere Y, et al (1992) Effects of highenergy focused ultrasound on kidney tissue in the rat and the dog European Urology 22(2):147–52 Chapelon JY, Margonari J, Vernier F, Gorry F, Ecochard R, Gelet A (1992) In vivo effects of high-intensity ultrasound on prostatic adenocarcinoma Dunning R3327 Cancer Research 52(22):6353–7 Margonari J, Chapelon JY, Gelet A, Cathignol D, Bouvier R, Gorry F (1992) Tumor ablation with focalized ultrasound In vivo HIGH INTENSITY FOCUSED ULTRASOUND 10 11 12 13 14 15 16 17 18 19 20 21 (HIFU) 235 experiment with prostatic adenocarcinoma R3327 Mat-Ly-Lu Prog Urol 2(2):207–19 Valeix P, Zarebska M, Bensimon M, et al (2001) Ultrasonic assessment of thyroid nodules, and iodine status of French adults participating in the SU.VI.MAX study Ann Endocrinol (Paris) 62(6):499–506 Mazzaferri EL (1993) Management of a solitary thyroid nodule The New England Journal of Medicine 328(8):553–9 Gharib H, Goellner JR, Johnson DA (1993) Fine-needle aspiration cytology of the thyroid A 12-year experience with 11,000 biopsies Clinics in Laboratory Medicine 13(3):699–709 Bennedbaek FN, Perrild H, Hegedus L (1999) Diagnosis and treatment of the solitary thyroid nodule Results of a European survey Clinical Endocrinology 50(3):357–63 Castro MR, Caraballo PJ, Morris JC (2002) Effectiveness of thyroid hormone suppressive therapy in benign solitary thyroid nodules: a meta-analysis J Clin Endocrinol Metab 87(9):4154–9 Cooper DS, Doherty GM, Haugen BR, et al (2006) Management guidelines for patients with thyroid nodules and differentiated thyroid cancer Thyroid 16(2):109–42 Wemeau JL, Caron P, Schvartz C, et al (2002) Effects of thyroidstimulating hormone suppression with levothyroxine in reducing the volume of solitary thyroid nodules and improving extranodular nonpalpable changes: a randomized, double-blind, placebocontrolled trial by the French Thyroid Research Group J Clin Endocrinol Metab 87(11):4928–34 Poissonnier L, Chapelon JY, Rouviere O, et al (2007) Control of prostate cancer by transrectal HIFU in 227 patients European Urology 51(2):381–7 Beerlage HP, Thuroff S, Debruyne FM, Chaussy C, de la Rosette JJ (1999) Transrectal high-intensity focused ultrasound using the Ablatherm device in the treatment of localized prostate carcinoma Urology 54(2):273–7 Rebillard X, Gelet A, Davin JL, et al (2005) Transrectal highintensity focused ultrasound in the treatment of localized prostate cancer Journal of Endourology / Endourological Society 19(6):693–701 Blana A, Walter B, Rogenhofer S, Wieland WF (2004) Highintensity focused ultrasound for the treatment of localized prostate cancer: 5-year experience Urology 63(2):297–300 Thuroff S, Chaussy C, Vallancien G, et al (2003) High-intensity focused ultrasound and localized prostate cancer: efficacy results from the European multicentric study Journal of Endourology / Endourological Society 17(8):673–7 Beerlage HP, van Leenders GJ, Oosterhof GO, et al (1999) Highintensity focused ultrasound (HIFU) followed after one to two weeks by radical retropubic prostatectomy: results of a prospective study Prostate 39(1):41–6 236 O ESNAULT AND L LEENHARDT 22 Esnault O, Franc B, Monteil JP, Chapelon JY (2004) High-intensity focused ultrasound for localized thyroid-tissue ablation: preliminary experimental animal study Thyroid 14(12):1072–6 23 Hegedus L (2004) Clinical practice The thyroid nodule The New England Journal of Medicine 351(17):1764–71 24 Nygaard B, Hegedus L, Nielsen KG, Ulriksen P, Hansen JM (1999) Long-term effect of radioactive iodine on thyroid function and size in patients with solitary autonomously functioning toxic thyroid nodules Clinical Endocrinology 50(2):197–202 25 Erdogan MF, Kucuk NO, Anil C, et al (2004) Effect of radioiodine therapy on thyroid nodule size and function in patients with toxic adenomas Nuclear Medicine Communications 25(11):1083–7 26 Dossing H, Bennedbaek FN, Hegedus L (2005) Effect of ultrasound-guided interstitial laser photocoagulation on benign solitary solid cold thyroid nodules - a randomised study Eur J Endocrinol 152(3):341–5 27 Amabile G, Rotondi M, Chiara GD, et al (2006) Low-energy interstitial laser photocoagulation for treatment of nonfunctioning thyroid nodules: therapeutic outcome in relation to pretreatment and treatment parameters Thyroid 16(8):749–55 28 Dossing H, Bennedbaek FN, Hegedus L (2006) Effect of ultrasound-guided interstitial laser photocoagulation on benign solitary solid cold thyroid nodules: one versus three treatments Thyroid 16(8):763–8 29 Papini E, Guglielmi R, Bizzarri G, et al (2007) Treatment of benign cold thyroid nodules: a randomized clinical trial of percutaneous laser ablation versus levothyroxine therapy or follow-up Thyroid 17(3):229–35 30 Zieleznik W, Kawczyk-Krupka A, Barlik MP, Cebula W, Sieron A (2005) Modified percutaneous ethanol injection in the treatment of viscous cystic thyroid nodules Thyroid 15(7):683–6 31 Lee SJ, Ahn IM (2005) Effectiveness of percutaneous ethanol injection therapy in benign nodular and cystic thyroid diseases: long-term follow-up experience Endocrine Journal 52(4):455–62 32 Kim YS, Rhim H, Tae K, Park DW, Kim ST (2006) Radiofrequency ablation of benign cold thyroid nodules: initial clinical experience Thyroid 16(4):361–7 Chapter 14 Ultrasound Elastography of the Thyroid Robert A Levine It has long been recognized that palpably hard thyroid nodules are suspicious for cancer (1) Conventional ultrasound provides information regarding characteristics shown to be correlated with risk of cancer, such as shape, echogenicity, edge definition, calcification, and vascular flow However, it does not provide direct information corresponding to the hardness of a nodule Elastography is a newly developed technique that utilizes ultrasound to analyze the stiffness of a nodule by measuring the amount of distortion that occurs when the nodule is subjected to external pressure The technique was first described ten years ago, but has only recently been tested on thyroid nodules Preliminary results have shown an excellent correlation between the hardness of a nodule determined by elastography and subsequent pathology determined by biopsy or excision Two techniques have been employed to provide external pressure and strain to a nodule The most common technique is to apply external pressure using the transducer After placing a linear transducer over the region of interest, the ultrasonographer manually applies light pressure with the transducer Multiple sites within and around the nodule are analyzed, and the ultrasound software compares the deformation of the nodule to the surrounding tissue (strain index) The relative stiffness is shown on a color display, superimposed on a B-mode image An alternative technique uses pulsation from the carotid artery as the compression source This may be useful, particularly when the nodule is in the lateral aspect of the gland, near the carotid One preliminary study has indicated that carotid pulsation can be used as the pressure source for elastography (2) On the other hand, artifacts introduced by carotid pulsation have been reported to adversely affect image quality on real-time elastograms (3) 237 238 R.A LEVINE Ultrasound elastography has been used to analyze nodules and predict malignant potential in breast, prostate (4), pancreas, and lymph nodes (5) It has been used to measure liver fibrosis (5), as well as stiffness of cardiac tissue following myocardial infarction It remains an ancillary technique in these organs with clinical application still predominantly in the research setting Early experience with breast nodules has shown great promise for elastography in prediction of malignant potential Early reports showed close to 100% sensitivity and specificity for this technique However, as discussed below, this may be misleading and due to a bias in sample selection A large study looking at breast elastography has shown a sensitivity of 86% and a specificity of 90% (7) These values suggest that the technique may be useful in selecting which nodules require biopsy However, as with all ultrasonographic characteristics, the sensitivity may not be sufficient to eliminate the need for biopsy of a nodule In 2007, there were only two published studies regarding thyroid elastography Both reported extremely promising results Lyshchik et al (8) performed a prospective study involving 52 thyroid nodules in 31 consecutive patients Of the 52 nodules, 22 were malignant and 30 were benign They utilized both real-time elastography, and off-line processed ultrasound elastograms The strain of the nodule was compared to the strain of the surrounding normal thyroid tissue The results for the off-line analysis were far superior to the real-time studies They reported that the off-line processed elastogram was the strongest independent predictor of thyroid gland malignancy, with 96% specificity and 82% sensitivity However, they also report that off-line strain image processing is time-consuming and labor intensive Rago et al (9) recently published a study of real-time ultrasound elastography in 96 consecutive patients with a solitary thyroid nodule undergoing surgery for compressive symptoms or suspicion of malignancy on prior fine-needle aspiration biopsy Tissue stiffness was scored from to based on subjective analysis of the elastogram image They reported that scores of or were found in 49 cases—all benign lesions A score of was found in thirteen cases with one case of carcinoma, and twelve from benign lesions Thirty cases had scores of or 5, and all were carcinomas They reported a sensitivity of 97% and a specificity of 100% for a score of or being predictive of malignancy The general applicability of both of the above studies is limited due to selection bias In the studies, the incidence of ULTRASOUND ELASTOGRAPHY OF THE THYROID 239 malignancy was 31 – 43% Most studies show an incidence of malignancy of 2–5% in nodules selected for biopsy, and the incidence of malignancy is much lower in all unselected nodules (1) The predictive value of the test will vary with the incidence of malignancy in the population studied, and will need to be studied in an unselected population with thyroid nodules A single study has evaluated the utility of elastography in the assessment of cervical lymph nodes suspected of containing metastatic cancer Lyshchik et al (5) examined 141 peripheral lymph nodes in 43 consecutive patients referred for surgical treatment of suspected thyroid or hypopharyngeal cancer By comparing the strain of lymph nodes and surrounding neck muscles, a strain index was calculated An index cutoff of 1.5 resulted in a 98% specificity and 85% sensitivity The results were superior to conventional grey-scale ultrasound criteria utilizing the short to long axis ratio Figs 14.1 – 14.5 provide illustration of the images provided by elastography Fig 14.1 shows a papillary carcinoma of the thyroid with peripheral psammomatous calcification As would be expected, this nodule was very firm on physical examination The figure shows that areas of the nodule are very hard, and very suggestive of a malignant nodule Note the scale at the right edge of the image indicating a color scale ranging from soft (SF) to hard (HD) Fig 14.2 shows a nodule with soft consistency on the elastogram Figs 14.3 and 14.4 are from the same patient Bilateral nodules were present The FIG 14.1 This nodule has several suspicious features including peripheral microcalcifications, scalloped margins and hypervascularity on power Doppler (not shown) The elastogram shows significant areas indicated as “Hard” (see scale located on the right of the image HD = Hard, SF = Soft.) The pathology confirmed a papillary carcinoma 240 R.A LEVINE FIG 14.2 This hypoechoic nodule appears very soft on elastography, suggesting a lower risk of malignancy FIG 14.3 This 34 year old woman had bilateral nodules The figure shows the left nodule, which was the larger of the two, and was previously biopsied with benign cytology The elastogram shows the nodule to be predominately soft larger left (dominant) nodule had previously demonstrated benign aspiration cytology It had a soft texture on elastography The right-sided nodule had more suspicious sonographic features (echotexture, irregular margins, and microcalcifications), as well as a hard testure at elastography, and proved to be a papillary carcinoma Fig 14.5 is from a 38-year old male with diffusely multifocal infiltrative tall cell variant of papillary carcinoma—stage T3N1BM0 Multiple areas of hard tissue are shown on the elastogram ULTRASOUND ELASTOGRAPHY OF THE THYROID 241 FIG 14.4 In the same patient as Image 14.3, the right nodule was smaller, but had several suspicious features including a heterogeneous echotexture, irregular margins, and microcalcifications The elastogram shows the nodule to have a hard composition Fine needle aspiration cytology demonstrated papillary carcinoma FIG 14.5 This image is from a 38 year old male with diffusely multifocal infiltrative tall cell variant of papillary carcinoma, stage T3N1BM0 Multiple areas of hard tissue are shown on the elastogram Not all nodules are amenable to elastography Due to an inability of the ultrasound beam to penetrate the nodule, elastography cannot be performed on nodules with peripheral rim calcification Complex nodules with a large cystic component may provide misleading results because the elasticity is more dependent on the liquid content than the solid portion of the nodule Rago included four cases in which intranodular cysts 242 R.A LEVINE made up less than 20% of the total nodule volume and did not appear to adversely affect the results Small nodules probably can be measured accurately with elastography, but the limits of acceptable size have not been tested The impact of background Hashimoto’s thyroiditis or other abnormalities of the thyroid parenchyma has not been adequately assessed There are two potential roles for elastography in the analysis of thyroid nodules The first is indicating the need for biopsy in a nodule that otherwise would be considered low suspicion and not be biopsied Current guidelines state that nodules smaller than 1.5 cm with no suspicious features (indistinct margins, microcalcifications, taller than wide shape, extreme hypoechogenicity, or strong vascular flow) can be monitored without biopsy However, if the positive predictive value of elastography is high, an otherwise nonsuspicious nodule demonstrated to be hard by elastography should be biopsied On the other hand, if the negative predictive value of elastography is adequate, it could be used to help determine which nodules can be safely observed without biopsy Approximately 4% of the population has a palpable thyroid nodule, and over 50% has a small nodule detectable by ultrasound (1) Clearly, all nodules found by physical examination—or as an incidental finding during other neck studies—cannot undergo fine needle biopsy Any technique used to determine which nodules can be safely monitored without biopsy needs to have a sensitivity close to 100% In each of the studies reported to date, the prevalence of malignancy far exceeded that found in an unselected population with thyroid nodules While the initial reports of elastography of thyroid lesions are very exciting, additional large studies on unselected populations with thyroid nodules will be needed to determine whether the technique has sufficient sensitivity and predictive value to obviate the need for biopsy References Cooper D, Doherty G, Haugen B, et al (2006) American Thyroid Association Guidelines Task force 2006 Management guidelines for patients with thyroid nodules and differentiated thyroid cancer Thyroid Feb 2:2–33 Bae U, Dighe M, Dubinsky T, et al (2007) Ultrasound Thyroid Elastography Using Carotid Artery Pulsation: Preliminary Study J Ultrasound Med June 26(6): 797–805 Lyshchik A, Tatsuya H, Ryo A, et al (2004) Ultrasound Elastography in Differential Diagnosis of Thyroid Gland Tumors: Initial Clinical Results RSNA Abstract ULTRASOUND ELASTOGRAPHY OF THE THYROID 243 Pallwein L, Mitterberger M, Struve P et al (2007) Real-time Elastography for Detecting Prostate Cancer: Preliminary Experience BJU Int July 100(1):42–47 Lyshchik A, Higashi T, Asato R, et al (2007) Cervical Lymph Node Metastases: Diagnosis at Sonoelastography-Initial Experience Radiology April 243(1):258–267 Friedrich-Rust M, Ong M, Herrman E, et al (2007) Real-Time Elastography for Noninvasive Assessment of Leiver Fibrosis in Chronic Viral Hepatitis Am J Roentgenol March 188(3):758–764 Itoh A, Venu E, Tohno E et al (2006) Breast Disease: Clinical applications of US Elastography for Diagnosis Radiology May 239(2):341–350 Lyshchik A, Higashi T, Asato R, et al (2005) Thyroid Gland Tumor Diagnosis at US Elastography Radiology 237(1):202–211 Rago T, Santini F, Scutari M, et al (2007) Elastography: New Developments in Ultrasound for Predicting Malignancy in Thyroid Nodules J Clin Endocrinol Metab Aug 92:2917–2922 Index A A-mode images, 13–15 A-mode imaging, 2, 3, Acoustic enhancement, 15–18 Acoustic impedance, Acoustic shadowing, 15–17 Air microbubbles, 153–158 American Association of Clinical Endocrinologists (AACE), American Institute of Ultrasound Medicine (AIUM), Anesthesia, 102 Anterioposterior-totransverse diameter (A/T) ratio, 89 Attenuation, 22–23 Autoimmune thyroid disease (AITD), 63; see also Thyroiditis diagnosis, 63 Autonomously functioning thyroid nodules (AFNT); see also Nodules percutaneous ethanol injection, 173–174 percutaneous laser ablation, 213–215 Avascular nodules, 30, 31 Azimuthal plane, 104 B B-mode images, 15 B-mode imaging, 2, 3, “Bag of marbles,” 66 Baskin, H Jack, Benign masses, 53–57; see also Nodules Biopsy; see also Fine-needle aspiration biopsy Doppler imaging prior to, 38, 40 C Calcification(s), 86 eggshell, 18–19 Cancer cystic papillary, 84 testicular (metastatic), 60 thyroid, 111, 133 postoperative surveillance for, 111–112 risk factors, 78–79 ultrasound of postoperative neck, 112–130 ultrasound of preoperative neck, 131–133 Cancer detection, 3–5, 60 commonest areas of detecting cancer, 113 Doppler ultrasound for, 30–33, 40, 41 follicular carcinoma, 30 indications for use of ultrasound for, 78–79 malignant masses, 57 sensitivities of sonographic features, 78 Cat’s eye artifact, 22, 23; see also “Comet tail” artifacts 245 246 INDEX Closed suction, “free hand” technique, 106, 108 Color-flow Doppler (CFD), 28–30, 87–88 “Comet tail” artifacts, 20–23 Contrast-enhanced ultrasonography (CEUS), 152, 166, 168–169 in assessment of efficacy of thermal ablation treatments, 165–167 clinical use, 159–160 evaluation of nodules with CEUS timeintensity curves, 160–164 technical background, 153–159 Cysts, 53 D Doppler shift, 27, 28 Doppler ultrasound, 39–40 development, for image clarification, 38–39 physical principles, 27–30 prior to biopsy, 38, 40 of thyroid nodules, 30–35 of thyroiditis, 35–38 Dussic, Karl Theodore, E Echogenic strands, 69 Echogenicity, 82–85; see also Hypoechogenicity when it may be challenging to determine, 84 Edge artifacts, 19, 20 Eggshell calcification, 18–19 Elastography, 5–6, 237–242 nodules not amenable to, 241–242 roles in the analysis of nodules, 242 Enhancement: see Acoustic enhancement Esophageal diverticulum, 55 Ethanol injection: see Percutaneous ethanol injection F Fibrosis, 68 Fine-needle aspiration (FNA) of nodules, 78 palpation used to determine accuracy of, 78 Fine-needle aspiration biopsy (FNAB), 152, 219 ultrasound-guided, Follicular carcinoma, 30 G Goiter, diffuse, 48–49 Graves’ disease, 5, 36, 50, 63, 64, 80, 81 Gray scale display, 3–4 “Ground glass” architectural pattern, 66, 67 H Halo, 86–87 Hashimoto’s lymphocytic thyroiditis, 79, 80 Hashimoto’s thyroiditis, 63–67, 71–73, 79 Hashitoxicosis, 36–38 Hemangioma, 58 Hemiagenesis of thyroid, 49–52 High intensity focused ultrasound (HIFU) ablation therapy, 219, 234 animal trials, 222–223 INDEX first trials (proving feasibility), 223 second trial (adjustment of treatment parameters), 224–225 applications, 221–222 for benign nodules, 228 HIFU lesions, 227, 228 human trials, 225–226 human feasibility study, 226 ongoing studies, 228 operator’s interface, 227 rationale, 219–220 role in management of thyroid diseases, 228–234 technology/principle of, 220–222 for toxic nodules, 228 Hilar line, 114 Hilum, 116 “Honeycomb” pattern, 84 Hypoechogenicity, 64–65; see also Echogenicity Hypoechoic nodules, 90 I Isoechoic nodules, 88 L Levothyroxine therapy, 232–234 Lymph nodes, 38, 40, 115 characteristics, 115 enlarged/inflamed, 56–57, 125 malignant, 41, 117–123, 126–130, 132 Lymphoma, 73 M Mechanical index (MI), 154 Microbubbles, 153–158 247 Modified lateral neck dissection (MLND), 131 Muscle anomaly, 57 N Neck, normal postoperative, 113–114 “Needle only” technique, 108 Needles used for UGFNA, 101 Nodules, thyroid, 77, 132, 151; see also Autonomously functioning thyroid nodules; specific topics algorithm for cost-effective evaluation and treatment of, 233 avascular, 30, 31 evaluation with CEUS time-intensity curves, 160–164 hypoechoic, 90 isoechoic, 88 measuring volume of, 48 palpable, 77–78 treatment of benign, 230–234 ultrasound characteristics, 78, 81–82 calcifications, 86 change in size, 91–92 echogenicity, 82–85 elastography, 89–90; see also Elastography halo, 86–87 margins, 86 taller than wide, 89 vascularity, 87–88 vascular, 30 P Papillary carcinoma, 41 Parathyroid adenomas, 42, 136–138, 142–145, 214 248 INDEX Parathyroid adenomas (continued) sonographic features, 139–140 Parathyroid glands, anatomy of, 135–136 Parathyroid hormone (PTH), 144, 146–148, 184 Parathyroid incidentaloma, 140, 142 Parathyroid lesions, ultrasound-guided FNA of, 144–148 Parathyroid (PT) cyst, 142, 145 Parathyroid ultrasound, technique of, 138–140 Percutaneous ethanol injection (PEI), 165–167 of cysts, 179–181 of lesions autonomous functioning nodules, 173–174 cold solid nodules, 173–174 cysts, 174–179 of neck lesions, 185–187 of parathyroid cysts, 184–185 side effects, 182–184 technical aspects, 179–181 Percutaneous laser ablation (PLA), 165–167, 192, 194–197, 215 advantages and limitations, 215 in autonomous nodules, 213–215 clinical results and indications, 203, 206–214 changes in nodule volume, 206–209 ellipsoid ablation, 196–197 history, 192 multiple fiber technique for laser ablation volume increase, 196 needle electrodes used for, 192, 193 PLA intervention, 197–206 side effects, 213 Power Doppler (PD), 28–30, 87–88 Primary hyperparathyroidism (PHPT), 135 localization studies, 136–138 Pseudonodules, 68, 70 Pulsed waves, 11 R Radiation exposure, 79 Radiofrequency (RF) ablation (RFA), 165, 191–192 Radioiodine, 231 Reflection, 13 Refraction, 22 Reverberation artifacts, 19–21 Ringdown artifact, 22; see also “Comet tail” artifacts S Shadowing: see Acoustic shadowing Sound and sound waves, 9–13, 25–26 sound wave propagation, 9–10 speed of sound, 9–11, 13 “Spongiform” pattern, 84, 85, 89 Squamous cell carcinoma, 60 Stepladder artifact, 22; see also “Comet tail” artifacts INDEX Strepta, 69 “Swiss cheese” appearance of thyroid, 68 T Testicular cancer, metastatic, 60 Three-dimensional (3D) ultrasound, Thymus gland, undescended, 56 Thyroglossal duct, 53, 55 Thyroid; see also specific topics aberrant, 52–53 lateral, 54 anatomy (normal), 45–48 failed bifurcation of, 52, 53 longitudinal view of, 48 in transverse view, 46 Thyroid anomalies, 49–53 Thyroid disorders; see also specific disorders diffuse, 79–81 Thyroid lobe, measurement of, 47 Thyroid nodule (N): see Nodules Thyroidectomy, 124–127, 230–231 Thyroiditis, 63, 73 atrophic, 73 pathology, 64 postpartum, 36, 37 subacute, 37, 38, 81 ultrasonography, 64–73 Doppler ultrasound, 35–38 249 Thyrotoxicosis, 35–36 Tomogram, U Ultrasound, thyroid; see also specific topics history, 1–7 resolution, Ultrasound elastography: see Elastography Ultrasound-guided FNA (UGFNA), 97–98, 109 aspiration and non-aspiration techniques, 106–109 materials, 100–102 of micronodules, 98–99 parallel approach, 104–105 of parathyroid lesions, 144–148 perpendicular approach, 106, 107 preparation, 99 technique, 103–104 Ultrasound image, creation of an, 13–14 Ultrasound imaging, usefulness of artifacts in, 14–26 Ultrasound technique, 45 W Whole body scan (WBS), 111, 112 Z Zajdela technique, 108 ... present, and there is overlap in the ultrasound appearance of benign and malignant lymph nodes, UG FNA of suspicious lesions is essential for a definitive diagnosis and 122 H.J BASKIN FIG 8.16 This 2cm... non-detectable, and ULTRASOUND MANAGEMENT OF THYROID CANCER 127 FIG 8 .26 Ultrasound of a 57-year-old female 13 years after a thyroidectomy shows a small oval node (calipers) in the left central compartment... with aspirate slides prepared and sent for cytology interpretation ULTRASOUND MANAGEMENT OF THYROID CANCER 125 FIG 8 .22 Larger lymph node found in the lateral compartment of the same patient