Practical Approach to Thyroid Nodules:Ultrasound Criteria for Performing FNA Revisited

Transcription

1 Practical Approach to Thyroid Nodules:Ultrasound Criteria for Performing FNA Revisited Poster No.: C-0100 Congress: ECR 2013 Type: Educational Exhibit Authors: S. Kuzmich, S. Sritharan, S. MUKUNDHAN, M. Farrugia, C. Padmanathan, H. Kamel, J. Subramaniam, K. L. Tan, T. Ashok; London/UK Keywords: Thyroid / Parathyroids, Head and neck, Interventional nonvascular, Ultrasound, Ultrasound-Colour Doppler, Screening, Biopsy, Education, Cancer DOI: /ecr2013/C-0100 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 34

2 Learning objectives To become familiar with a pattern recognition approach for discriminating potentially malignant thyroid nodules that warrant FNA from likely benign ones, and gain understanding of ultrasound criteria utilized in busy radiology department settings. Background Detection of a thyroid nodule is now a clear indication for ultrasound (US) with potential fine needle aspiration biopsy (FNA). However, thyroid nodules are extremely common, and their incidental detection rate is rising through the use of US, CT or MR imaging. But which nodules should trigger FNA and which ones are best left alone? Although some controversy still exists, accumulated knowledge suggests that certain morphological criteria related to shape, margin, echogenicity, and presence of calcifications on US are helpful in discriminating potentially malignant nodules from those that are likely benign. For this exhibit, we reviewed our experience and thoroughly sifted through the current scientific evidence and guidelines from North America, United Kingdom and Europe. Because selecting those nodules that warrant FNA requires a methodical approach and can be difficult, we propose a simplified illustrated algorithm based on pattern recognition approach to help the busy radiologist in this task. Imaging findings OR Procedure details We propose an illustrated algorithm (Fig. 1) that filters the nodules into "Worrying", "Indeterminate", and "Likely Benign" categories based on recognizable patterns related to nodule size, composition, shape, margins, presence of calcifications, and vascularity. Rapidity of growth or lack of it is used as a criterion for nodules evaluated on follow up US. In accordance with the common scenarios when the radiologist needs to decide whether FNA is necessary, all nodules are segregated into 3 main streams: 1. Newly detected nodules Page 2 of 34

3 2. 3. Nodules in multinodular goitre (MNG) Nodules being followed up This approach, of course, is not inflexible but may also permit greater consistency in thyroid nodule management, both across the radiology department and multidisciplinary clinical team involved. Note: Our algorithm concerns nodules greater than 1.0 cm in diameter. We prefer to consider FNA unnecessary in nodules smaller than 1.0cm unless there is strong clinical concern for thyroid malignancy or presence of abnormal cervical lymph nodes in which case FNA is pursued regardless of nodule size or other criteria. Fig. 1: Proposed illustrated algorithm References: Dr S Kuzmich 1. Nodules that warrant FNA Page 3 of 34

4 1.1 Newly detected nodules Worrying US morphology (Fig. 2-5): Solid with microcalcifications and/or coarse calcifications Cystic-solid with microcalcifications and/or coarse calcifications Irregular/infiltrative margins Solid hypoechoic Taller than wide orientation of the nodule Florid intranodular vascularity Fig. 2: US morphology of worrying nodules References: Dr S Kuzmich Page 4 of 34

5 Fig. 3: Papillary thyroid carcinoma arising in right thyroid lobe References: Radiology, Newham University Hospital - London/UK Page 5 of 34

6 Fig. 4: Solid hypoechoic vascular thyroid nodule with irregular halo: FNA is indicated References: Radiology, Newham University Hospital - London/UK Page 6 of 34

7 Fig. 5: Predominantly solid hypoechoic vascular thyroid nodule with microcalcifications: FNA is indicated References: Radiology, Newham University Hospital - London/UK 1.2 Nodules in MNG: nodule with any worrying feature as above or clearly dominant nodule greater than 2.0 cm in diameter (Fig.6) Page 7 of 34

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9 Fig. 6: Nodules targeted in MNG References: Dr S Kuzmich Note: # Worrying nodule is also targeted, even if smaller than the dominant one! (Fig. 7) Fig. 7: Nodules in MNG. Left thyroid nodule is hypoechoic hence worrisome eventhough it is smaller than the dominant nodule in the right thyroid lobe. References: Radiology, Newham University Hospital - London/UK 1.3 Nodules being followed up: nodule with any worrying feature as above or substantial rapid growth (>20%) (Fig. 8) Page 9 of 34

10 Fig. 8: Selecting suspicious nodule on interval US scan References: Dr S Kuzmich 2. Indeterminate nodules # US follow up is preferred in the following cases 2.1 Newly detected nodules: solid iso- or hyperechoic nodules smaller than 2.0 cm with or without cystic change (Fig. 9,10) Page 10 of 34

11 Fig. 9: US morphology of indeterminate nodules References: Dr S Kuzmich Fig. 10: US morphology of indeterminate nodule References: Radiology, Newham University Hospital - London/UK Page 11 of 34

12 2.2 Nodules in MNG: dominant nodule smaller than 2.0 cm all nodules have similar appearance 2.3 Nodules being followed up: minimal less than 3mm growth in over 6 months # FNA should be considered if any of the following factors is present: family history of thyroid cancer history of radiation exposure prior hemithyroidectomy with thyroid cancer confirmed multiple endocrine neoplasia familial medullary thyroid cancer younger age other factors may apply in selected cases 3. Likely Benign: FNA is unnecessary 3.1 Newly detected nodules: entirely cystic thin-walled nodule with or without comet tail echoes (Fig. 11) sponge-like nodule (Fig. 12) cystic nodule with thin avascular septations (Fig. 13) cystic nodule with debris (Fig. 14) cystic nodule with thin walls and depended sediment suggesting haemorrhage (Fig. 15) Page 12 of 34

13 Fig. 11: Cystic nodule with comet tail echoes (colloid crystals): FNA is unnecessary References: Radiology, Newham University Hospital - London/UK Page 13 of 34

14 Fig. 12: Sponge-like nodule (composed of multiple small cystic spaces): FNA is unnecessary References: Radiology, Newham University Hospital - London/UK Page 14 of 34

15 Fig. 13: Cystic nodule with thin avascular septations: FNA is unnecessary References: Radiology, Newham University Hospital - London/UK Page 15 of 34

16 Fig. 14: Cystic nodule with debris and colloid crystals: FNA is unnecessary References: Radiology, Newham University Hospital - London/UK Page 16 of 34

17 Fig. 15: Cystic nodule with depended sediment/debris: FNA is unnecessary References: Radiology, Newham University Hospital - London/UK 3.2 Nodules in MNG: no dominant nodule and all nodules are similar in appearance (Fig. 16) Page 17 of 34

18 Fig. 16: Similar appearing nodules in MNG: FNA is unnecessary References: Radiology, Newham University Hospital - London/UK 3.3 Nodules being followed up: static appearances on serial US scans Images for this section: Page 18 of 34

19 Fig. 1: Proposed illustrated algorithm Page 19 of 34

20 Fig. 2: US morphology of worrying nodules Fig. 3: Papillary thyroid carcinoma arising in right thyroid lobe Page 20 of 34

21 Fig. 4: Solid hypoechoic vascular thyroid nodule with irregular halo: FNA is indicated Page 21 of 34

22 Fig. 5: Predominantly solid hypoechoic vascular thyroid nodule with microcalcifications: FNA is indicated Page 22 of 34

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24 Fig. 6: Nodules targeted in MNG Fig. 7: Nodules in MNG. Left thyroid nodule is hypoechoic hence worrisome eventhough it is smaller than the dominant nodule in the right thyroid lobe. Page 24 of 34

25 Fig. 8: Selecting suspicious nodule on interval US scan Fig. 9: US morphology of indeterminate nodules Page 25 of 34

26 Fig. 10: US morphology of indeterminate nodule Page 26 of 34

27 Fig. 11: Cystic nodule with comet tail echoes (colloid crystals): FNA is unnecessary Page 27 of 34

28 Fig. 12: Sponge-like nodule (composed of multiple small cystic spaces): FNA is unnecessary Page 28 of 34

29 Fig. 13: Cystic nodule with thin avascular septations: FNA is unnecessary Page 29 of 34

30 Fig. 14: Cystic nodule with debris and colloid crystals: FNA is unnecessary Page 30 of 34

31 Fig. 15: Cystic nodule with depended sediment/debris: FNA is unnecessary Page 31 of 34

32 Fig. 16: Similar appearing nodules in MNG: FNA is unnecessary Page 32 of 34

33 Conclusion When thyroid nodules are evaluated at US, the pattern approach can be used to differentiate potentially malignant nodules from benign ones and thus determine whether to perform or defer FNA. References Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19: British Thyroid Association, Royal College of Physicians: British Thyroid nd Association Guidelines for the management of thyroid cancer. 2 edition [ 3. Gharib H, Papini E, Paschke R, et al. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and European Thyroid Association medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract. 2010;16(suppl 1): Moon WJ, Jung SL, Lee JH, et al. Benign and malignant thyroid nodules: US differentiation--multicenter retrospective study. Radiology 2008;247: Frates MC, Benson CB, Charboneau JW, et al. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 2005;237: Ahn SS, Kim EK, Kang DR, et al. Biopsy of thyroid nodules: comparison of three sets of guidelines. AJR 2010;194: Bonavita JA, Mayo J, Babb J, et al. Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules can be left alone? AJR 2009;193: Baier ND, Hahn PF, Gervais DA, et al. Fine-needle aspiration biopsy of thyroid nodules: experience in a cohort of 944 patients. AJR 2009;193: Kim MJ, Kim EK, Park SII et al. US-guided Fine-Needle Aspiration of Thyroid Nodules: Indications, Techniques, Results. RadioGraphics 2008; 28: Titton RL, Gervais DA, Boland GW et al. Sonography and Sonographically Guided Fine-Needle Aspiration Biopsy of the Thyroid Gland: Indications and Techniques, Pearls and Pitfalls. AJR 2003;181: Personal Information Page 33 of 34

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