AACE 2018 Advanced Endocrine Neck Ultrasound and UGFNA Course

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1 AACE 2018 Advanced Endocrine Neck Ultrasound and UGFNA Course

2 Describe the sonographic appearance of diffuse thyroid diseases: autoimmune thyroid disease Review non thyroidal findings that can be encountered by endocrinologists Conscious of other metastatic diseases that can present within the thyroid gland

3 No reason to perform US studies in most (almost all) patients with diffuse thyroid disease- dependent upon physical exam US is primarily to identify surgical diseases The use of US cannot accurately differentiate between Graves vs Thyroidits Possible use in Amiodarone thyroid disease Only reason to perform US is in a subject with palpable nodules or follow up of nodules identified fortuitously on other imaging

4 Goiter Iodine deficient Physiologic goiters (puberty, pregnancy) Hashimoto s thyroiditis Organification defects Lymphoma Riedel s thyroiditis (IgG 4 disease) Miscellaneous Malformations Vascular Other unusual masses encountered in the vicinity of thyroid

5 Worldwide leading cause of goiter Volume of thyroid can estimate iodine status of region Rare in developed world Increasing deficiency seen with popularity of designer salts Goiter is diffuse in the initial stages, chronically multinodular

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7 Hashimoto s Thyroiditis Graves Disease Both autoimmune disease Opposite ends of the spectrum. Ultrasonographic appearance is very similar Hypoechoic and heterogeneous Numerous variations

8 Hypoechoic and heterogeneous Developing fibrosis Multiple prominent nodes in central and lateral neck is the norm. Matted clustered nodes. Often with abnormal shape and loss of hilar line. Paratracheal nodes. Increased frequency of Papillary Cancer in Hashimoto s.

9 Mildly Hypoechoic and Heterogeneous Micronodular Swiss Cheese Macropseudonodular Profoundly hypoechoic Hyperechoic Speckled

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19 nodule

20 Nodule clearly defined in both planes

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25 Multiple prominent nodes in the central and lateral neck is the norm Matted clustered nodes may be seen Often with loss of hilar line Paratracheal lymph nodes

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28 Graves Disease Thyroid Inferno Hypervascular high velocity flow Subacute, painless, postpartum Full spectrum from avascular to hypervascular In thyrotoxic patient the absence of flow suggests thyroiditis, but high intensity flow can be seen in either Graves or thyroiditis

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31 Graves

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33 Graves Disease

34 Graves Disease TSH <0.01 miu/l, Free T4 6.6 ng/dl Hashimoto s Thyroiditis TSH miu/l, Free T4 0.3 ng/dl

35 Tender thyroid gland, or radiating pain to ears Varying degree of goiter Preexisting and inflammatory Systemic Symptoms Transient thyrotoxic phase Subsequent hypothyroid phase 95% recovery May be focal Painless, postpartum variants

36 At presentation Six month follow-up

37 Arises in thyroid already affected by Hashimoto s thyroiditis Ultrasonographic appearance deeply hypoechoic. Appearance not significantly different than in Hashimoto s Rapid growth of goiter should raise suspicion Diagnosis by cytology and flow cytometry

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40 Causes of goiter include iodine deficiency, organification defects, and autoimmune thyroiditis Autoimmune thyroiditis is very common and has a myriad of appearances. Hypoechoic and heterogeneous is most common Progressive growth of goiter short duration in a subject with history of Hashimoto s thyroiditis think lymphoma

41 Malformations Hemiagenesis Thyroglossal Duct Cyst Vascular Varicosities Hemangioma Anatomical Variants

42 Hashimoto s with Hemiagenesis SCM strap R lobe strap SCM C C

43 Isthmus Right Lobe Trachea

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46 Multinodular Goiter???

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48 Enhancement

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51 Lateral aberrant thyroid J C TR Transverse Longitudinal

52 Mass in Neck Biopsy Normal thyroid / Nodular goiter

53 Mass in Neck Metastatic Squamous Cell Carcinoma Rim of normal thyroid tissue

54 Transverse Longitudinal

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57 Lipoma overlying strap muscle?? The patient had a nodule buldging out of the neck. Did not

58 ??? Sebaceous cyst

59 Transverse Longitudinal

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61 Selectively perform US if palpation findings indicate abnormality Gold standard to differentiate Hashimoto s vs Graves is NOT US but I 131 uptake study Be aware of non thyroid etiologies that one encounters during neck US studies