Evaluation of thyroid nodules: prediction and selection of malignant nodules for FNA (cytology)

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1 Evaluation of thyroid nodules: prediction and selection of malignant nodules for FNA (cytology) Poster No.: C-0221 Congress: ECR 2014 Type: Authors: Keywords: DOI: Scientific Exhibit E. Papadaki, I. Tritou, E. Mastorakis, E. Sfakianaki; Iraklion/GR Thyroid / Parathyroids, Ultrasound, Diagnostic procedure, Neoplasia /ecr2014/C-0221 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Aims and objectives To report the sonographic(us) criteria for the differential diagnosis of benign vs malignant thyroid nodules for accurate selection only of suspicious for malignancy nodules and further investigation with ultrasound guided fine needle aspiration(fna) and cytologic examination. Methods and materials In this retrospective study, 523 thyroid nodules, which were examined with FNA- cytology examination, were evaluated for US features for malignancy. Results Benignity criteria The well defined margins of the nodule demonstrated the highest sensitivity and specificity for benignity (se=0.3 ### sp=0.64). Additionally, the lack of calcifications showed high sensitivity but low specificity (se=0.83 and sp=0.44), whereas high specificity but low sensitivity for benignity was observed with the following criteria: the cystic composition (se=0.21 and sp=0.98) and the peripheral halo or hypoechoic rim (se=0.35 and sp=0.9). See fig.1 for our study's results and in fig.2-6 benign nodules with various sonographic appearance. Malignancy criteria Markedly hypoechoic solid nodules showed the highest sensitivity and specificity for the detection of malignancy (se=0.84, sp=0.71) as well as the ill defined margins (se=0.64 and sp=0.93). High specificity but low sensitivity was observed with the following criteria: when the nodule's antero-posterior diameter was bigger than the transverse(taller than wide)(se=0.24, sp=0.98), the presence of micro/coarse calcifications (se=0.38/0.08 and sp=0.94/0.9 respectively) and the nodule with central hypervascularity on color Doppler (se=0.1 and sp=0.97). See in fig.7-13 malignant nodules with suspicious sonographic appearance. Page 2 of 12

3 Images for this section: Fig. 1: Table showing the study's results Fig. 2: Hyperplastic nodule: Slightly hyperechoic nodule with well defined margins, thin hypoechoic rim, absence of calcifications and peripheral vascularity. Page 3 of 12

4 Fig. 3: Pure cystic nodule with posterior acoustic enhancement (left) and a small cystic nodule with colloid deposit (right). Fig. 4: Cystic nodule with hemorrhagic components and absence of internal blood flow. Page 4 of 12

5 Fig. 5: Ultrasound scan of a patient with Hashimoto thyroiditis shows homogeneous hyperechoic nodule ( "white knight"). Page 5 of 12

6 Fig. 6: Ultrasound scan of a patient with Hashimoto thyroiditis shows nodule with hyperechoic areas separated by hypoechoic bands ( pattern of a giraffe's hide). Page 6 of 12

7 Fig. 7: Papillary carcinoma: Hypoechoic solid nodule with well defined margins and peripheral hypoechoic rim (in our study about 10% of the papillary carcinoma cases had hypoechoic rim) Fig. 8: Papillary carcinoma: Hypoechoic solid nodule with irregular margins. Page 7 of 12

8 Fig. 9: Papillary carcinoma: Nodule with typical features of malignancy including focal capsular invasion, taller than wide diameter, irregular margins, micro-calcifications and intrinsic vascularity. Fig. 10: Micro- and coarse calcifications: First and middle images show a papillary carcinoma with micro-calcifications (diameter less than 2mm) and internal blood flow, whereas the right image depicts a papillary carcinoma with coarse calcifications. Page 8 of 12

9 Fig. 11: Papillary carcinoma: Nodule with peripheral and disrupted coarse calcifications, which is a feature of malignancy. Note also the intrinsic vascularity of the nodule. Page 9 of 12

10 Fig. 12: Cystic Variant of Papillary Carcinoma: A solid nodule with cystic components and a diameter larger than 2cm. Small hyperechoic foci arise the suspicion of microcalcifications' presence. Page 10 of 12

11 Fig. 13: Follicular carcinoma: A large inhomogeneous malignant process of the thyroid gland (first and middle image) accompanied with pathologic inhomogeneous (echogenicity similar to the neoplasm) enlargement of the regional lymph nodes (right image). Page 11 of 12

12 Conclusion With the limitations of this study and with the exception of local invasiveness, none of the above criteria observed individually are sufficient to make an accurate prediction. The combination of the suggested US criteria may lead to the selection of suspicious malignant nodules which should be further examined with cytology, avoiding unnecessary invasive procedures. Ultrasound criteria to predict benignity can be the well defined margins, the absence of calcifications, the cystic composition and the peripheral hypoechoic rim (halo). In contrast, nodules with decreased echogenicity and solid composition, irregular margins, with taller than wide diameter and microcalcifications should be suspicious for malignancy and lead to further investigation with FNA and cytology, limiting the number of unnecessary FNA examinations[1]. Special consciousness is needed when evaluating an infracentrimentric nodule. In a study that was published in Eur Radiol (2007) showed that the incidence of malignancy in infracentimentric nodules is about 2,6%, although this is a relatively low percentage, the postoperative histological results revealed extended disease in 70% of them, which had one or more of the findings of multifocality, metastatic lymph nodes, or extracapsular involvement. The results of that study indicate that thyroid microcarcinomas have clinical significance and should be taken seriously if there are suspicious signs of malignancy in ultrasound examination[2]. Personal information References 1. Min Jung Kim, Eun-Kyung Kim, Sung Il Park, Byung Moon Kim, Jin Young Kwak, Soo Jin Kim, Ji Hyun Youk, and Sung Hee Park. US-guided Fine-Needle Aspiration of Thyroid Nodules: Indications, Techniques, Results. RadioGraphics 2008; 28: Reha Butros, Fatih Boyvat, Umut Ozyer, Banu Bilezikci, Zubeyde Arat, Cuneyt Aytekin, Nilgün Güvener, Beyhan Demirhan. Management of infracentimetric thyroid nodules with respect to ultrasonographic features. Eur Radiol (2007) 17: Page 12 of 12

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