ECOGRAFIA TIROIDIANA

SI PARATIROIDIANA

Clinica Medicala I
Constanta
Anatomie tiroidiana

• doi lobi de forma piramidala

– diam. longitudinal (inaltimea) = 4-8 cm
– diam. ant-post = 2-4 cm
– diam. transversal = 5-7 cm
• istm
– inaltime = 1 cm
– diam. ant-post = 0,5 cm
– diam. transversal = 1 cm
Raporturile tiroidei

• Anterior
– planurile superficiale ale gatului si m. SCM
• Medial
– vasele tiroidiene si conductul laringo-traheal
• Posterior
– pachetul vasculo-nervos al gatului (ACC, VJI)
Anatomia paratiroidelor

• Glande mici (4-8 mm / 2-4 mm / 1-2 mm)

• Situate pe fata post. a lobilor tiroidieni
(superior si inferior)
Anatomie ecografica
• Sectiune transversala - tiroida are aspect de haltera:
– la extremitati sunt cei doi lobi
– la mijloc istmul
• Ecostructura omogena
• Mai hiperecogena decat musculatura din jur de care se
diferentiaza cu usurinta
• In centru, traheea apare ca o structura puternic
ecogena, cu un intens con de umbra posterior generat
de aerul din interior.
• Lateral de lobii tiroidieni se vizualizeaza vasele gatului
(intern: ACC, extern: VJI) sub forma unor imagini
transsonice, circulare, pulsatile.
Anatomie ecografica

• Pe sectiune longitudinala lobul tiroidian

are forma triunghiulara.
• Pe aceasta sectiune se pot identifica
glandele paratiroide (desi, daca sunt
normale nu sunt vizibile), sub forma unor
structuri omogene, mai hipoecogene decat
tiroida.
Metodologie de examinare
• Transductoare de 7-10 MHz, lineare
• Decubit dorsal cu o perna sub umeri -> hiperextensie a
gatului -> acces usor la tiroida
• Se evalueaza:
– simetria glandei
– modificarile de structura (difuze sau circumscrise, localizare,
numar, dimensiuni, dlimitare)
– dimensiunile glandei (in trei axe) si volumul sau (normal = 15-17
cmc)
– relatia cu organele de vecinatate
– existenta unei strume retrosternale
– prezenta adenopatiilor laterocervicale
Patologie. Afectiuni tiroidiene
benigne.
• Adenoamele foliculare
– formatiuni nodulare cu dimensiuni variate.
– mai frecv. hipoecogene
– uneori transsonice (continut lichidian)
– exista si adenoame hiperecogene
– delimitarea lor este neta
– ocazional nodulii pot fi circumscrisi de un
halou transsonic
 Patologie. Afectiuni tiroidiene
benigne.
• Chistele hemoragice
– apar dupa traumatisme cervicale sau dupa sangerari ale
adenoamelor foliculare
– noduli transsonici, uneori cu ecouri in interior (cheaguri)
• Chiste simple
– formatiune bine delimitata, transsonica, cu intarire
acustica posterioara
– unice sau multiple
– dg. d: formatiuni solide cu lichefierea continutului
(infarctizare, hemoragie, necroza), tiroidita acuta
supurata, tiroidita subacuta pseudochistica
Patologie. Afectiuni tiroidiene
benigne.
• Gusa multinodulara
– cresterea dimensiunilor tiroidiene
– structura difuz neomogena
– pot apare plaje ecogene separate de
parenchim normal
– calcificari frecvente: imagini intensecogene cu
con de umbra
Patologie. Afectiuni tiroidiene
benigne.
• Tiroidita Hashimoto
– dimensiunile glandei sunt crescute
– structura difuz modificata
– ecogenitate global redusa
– apar noduli parenchimatosi
– pot sa apara calcificari
Patologie. Afectiuni tiroidiene
maligne.
• Carcinomul tiroidian primitiv (papilar, folicular, medular,
anaplazic) sau metastatic
– mare varietate de aspecte ecografice
– de la nodul tumoral solid cu halou circular (care nu e
caracteristic tumorilor maligne) -> pana la formatiuni chistice
– Semne de alerta asupra malignitatii unui nodul tiroidian:
• nodul unic hipoecogen
• delimitare imprecisa
• invadarea tesuturilor de vecinatate
• cresterea rapida in dimensiuni
• adenopatii laterocervicale
Tumorile paratiroidiene

• Adenom / Adenocarcinom.
– Nodul hipoecogen slab delimitat
– dilatarea asimetrica, unilaterala, a vaselor
tiroidiene inferioare consecutiv aportului
vascular tumoral crescu
HYPERPLASTIC NODULE
 HYPERPLASTIC NODULE

Female, 26 y.o.
Transverse (upper) and longitudinal (lower) section of the right lobe of the thyroid.
Nodule in the lower pole (mm 11.4x14.1x24.6): hypoechoic and dishomogeneous
structure, regular borders with halo sign.
Fine needle aspiration: hyperplastic nodule.
HYPERPLASTIC NODULE
 HYPERPLASTIC NODULE

Female, 29 y.o.
Transverse (lower) and longitudinal (upper) section of the right lobe of the thyroid.
Nodule in the lower pole (mm 15.4 x 21.0 x 27.2): hysoechoic and dishomogeneous
structure, regular borders with halo sign.
Fine needle aspiration: hyperplastic nodule.
 HYPERPLASTIC NODULE

Woman, 26 y.o.
Large (14 cc) solitary hard nodule entirely filling the right lobe; the borders are
definite, the structure is dishomogeneous with microcolliquations and a large
calcification.
The nodule was growing despite the therapy with thyroxine.
 THYROID ADENOMA

Woman, 32 y.o.
Solitary nodule (mm 12x17x25) in the apex of the right lobe, hypoechoic,
dishomogeneous owing to interior hyperechoid and hypoechoid areas; borders are
regular.

FNA: follicular neoplasm.

Histological examination: microfollicular adenoma with trabecular aspects.
 THYROID ADENOMA

Woman, 25 y.o.
Solitary nodule (mm 18x23x36, 7.5 cc) in the apex of left lobe, hypoechoic,
dishomogeneous owing to interior hypoechoid areas; borders are regular.
Transversal (left) and longitudinal (right) section.
FNA: follicular neoplasm.
Histological examination: follicular fetal adenoma.
 THYROID ADENOMA

Woman, 32 y.o.
Solitary nodule (mm 12x17x25) in the apex of the right lobe, hypoechoic,
dishomogeneous owing to interior hyperechoid and hypoechoid areas; borders are
regular.

FNA: follicular neoplasm.

Histological examination: microfollicular adenoma with trabecular aspects.
COLLOID CYSTIC NODULE
 COLLOID CYSTIC NODULE

Woman, 46 y.o.
Large nodule in the left lobe of the thyroid (mm 28.2 x 28.8 x 28.6), very
hypoechoic, with echoes beside the vall and inside, and posterior enhancement;
microcalcification in the lower pole.
Fine needle aspiration: very dense colloid cystic nodule.
 COLLOID CYSTIC NODULE

Woman, 17 y.o.
Large nodule (31.8 x 40.3 x 45.1 mm) in the left lobe of the thyroid.
The structure is very echopoor with internal thick echoes and posterior wall
enhancement.
 COLLOID CYST
ALCOHOLIZATION
 COLLOID CYST
ALCOHOLIZATION

Woman, 46 y.o.
Cyst (17 x 23 x 32 mm, 6,5 cc) of the left lobe.
Two previous aspiration with relapsing.
After aspiration, alcohol 95° (3 cc) was injected.
Upper: the cyst before the treatment.
Lower: two months after the alcoholization, little (0,2 cc) residual hypoechoic area.
FNAB: colloid cyst.
 LARGE
COLLOID CYST

Left: trasversal section of the left lobe. Right: longitudinal section

 LARGE
COLLOID CYST

Left: transversal section of the left lobe. Right: longitudinal section.

Man, 28 y.o.
Large nodule in the left lobe (mm 41x46x69, 65 cc), very echopoor with
posterior echoes enhancement.
Aspiration of about 65 cc of very thick brown
COLLOID CYST

Woman, 23 y.o.
Large cyst (25.4 x
28.8 x 42.9 mm) in
the left lobe.
The nodule is very
echopoor with
posterior echoes
enhancement.
FNA: colloid cyst.
CYSTIC NODULE

Transverse section
 CYSTIC NODULE
Longitudinal section

Woman, 19 y.o.
Nodule in the right lobe of the thyroid (mm 15.7 x 20.3 x 25.5), very
hypoechoic, with few echoes inside, and posterior wall enhancement.
Fine needle aspiration: macrophaguses, digested red blood cells, without
thyroid cells.
CYSTIC NODULE

Woman, 17 y.o.
Large nodule in the left lobe of the thyroid gland.
The structure is very echopoor with posterior echoes enhancement.
Upper: the nodule before the aspiration.
Center: the tip of the needle is just in the center of the nodule.
Lower: the nodule after the aspiration.
HURTHLE CELL ADENOMA

Longitudinal section of the right lobe

 HURTHLE CELL ADENOMA

Transverse section of
the right lobe

Man, 44 y. o.
Large nodule (30.5 x 43.6 x 44.2 mm) in the right lobe and in the isthmus; the
borders are regular, the structure is hypoechoic, dishomogeneous with echo-free
areas (colliquations) and a small calcification with posterior acoustic shadow.
Fine needle aspiration: Hurthle cells lesion.
Histological examination: Hurthle cells adenoma.
 PARENCHYMAL
CALCIFICATIONS

Woman, 74 y.o.
Large calcification in the base of the right lobe.
Highly echogenic band with posterior acoustic shadow owing to total reflection of
the ultrasound beam.
PARENCHYMAL
CALCIFICATIONS

Transverse section
 PARENCHYMAL
CALCIFICATIONS

Longitudinal section

Man, 73 y.o.
Large nodular goiter; micro calcification in thyroid tissue, with posterior acoustic
shadow.
 THYROID AGENESIS

Female, 14 y. o.
Congenital hypothyroidism owing to thyroid agenesis.
The precocious diagnosis and therapy did not produce neurologic damage
Transverse section of the neck: no visible echoes of thyroid tissue.
THYROID AGENESIS

Right transverse section

THYROID AGENESIS

Left transverse section.

Man, 25 y. o.
Congenital hypothyroidism by thyroid agenesis.
Therapy with T4 was started in the seventh month of life; neurologic damages
occurred.
Transverse section of the neck: no visible echoes of thyroid tissue.
A- Jugular vein;B- Carotid;C- Windpipe;D- Prethyroid muscle;E- SCM
 AGENESIS OF THE LEFT LOBE

Woman, 48 y.o.
Chance report of agenesis of the left lobe.
The right lobe is only just enlarged; no echoes referable to the left lobe.
Normal thyroid function.
AGENESIS OF THE LEFT LOBE

Woman, 45 y.o.
Hyperplasia of the right lobe, with dishomogeneous echo pattern.
The left lobe is absent.
 INTRAPARENCHYMAL
HEMORRHAGE

Woman, 34 y.o.
Nodular goiter in treatment with thyroxine.
Sudden pain in the right side of the neck, with a very painful swelling.
Nodule in the right lobe, with irregular borders, 22x21x23 mm (5.7 cc); very
hypoechoic, with echoes stratifications on the posterior wall, as for intraparenchymal
hemorrage.
That nodule was absent in a previous exam.
 PLUMMER' DISEASE

Woman, 37 y. o.
Nodule in the left lobe of the thyroid (mm 17.1x18.7x30.8); presence of
peripheric halo.
The nodule is relatively hyperechoic with reference to the surrounding
parenchyma, owing to autoimmune chronic thyroiditis.
 PLUMMER' DISEASE

Woman, 29 y. o.
Nodule in the left lobe of the thyroid (12 cc) almost entirely filling the lobe.
The borders are regular; small colliquations.;
 HURTHLE CELL ADENOMA

Woman, 46 y.o.
Nodule (20 x 25 x 38 mm) in the right lobe; the borders are not well defined,
the structure is hypoechoic, dishomogeneous.
Fine needle aspiration: Hurthle cells lesion.
Histological examination: Hurthle cells adenoma.
 GRAVES' DISEASE

Man, 52 y.o.
Enlarged gland. Echopoor structure
Tireotossicosi da malattia di Graves.
Ghiandola tiroidea di volume aumentato, ipoecogena, diffusamente disomogenea con
segni di flogosi (alternanza irregolare di areole ipoecogene e altre iperecogene); alla
base del lobo destro piccolo nodulo relativamente iperecogeno.
Nornal size of the gland; the borders are shaded; very echopoor structure due to the
presence of oedema.
GRAVES' DISEASE
 GRAVES' DISEASE

Woman, 44 y.o.
Nornal size of the gland; the borders are shaded; very echopoor structure
due to the presence of oedema
HASHIMOTO'S THYROIDITIS

Right lobe, transverse section

 HASHIMOTO'S THYROIDITIS

Left lobe,
longitudinal
section

Woman, 51 y. o.
Enlarged gland; very echopoor structure due to the presence of oedema, with
echogenic bands due to fibrosis.
Increased TSH with normal thyroxine (subclinical hypothyroidism); strongly positive
thyroid peroxidase antibodies.
HASHIMOTO'S THYROIDITIS
 HASHIMOTO'S THYROIDITIS

Woman, 78 y. o.
Thyroid with increase of the anterior-posterior and lateral diameters and shortening of
the longitudinal diameter; very echopoor structure, also in relation with the
sternocleidomastoid muscle, pseudonodular, with echogenic bands due to fibrosis.
Serious hypothyroidism with strongly positive thyroid peroxidase antibodies.
HASHIMOTO'S THYROIDITIS
 HASHIMOTO'S THYROIDITIS

Woman, 76 y. o.
Very enlarged gland, with irregular surface. Very firm consistence.
Strong echopoor structure, pseudonodular, with echogenic bands due to fibrosis.
Serious hypothyroidism with strongly positive thyroid peroxidase antibodies.
FNA: lymphoid inflammatory infiltration; oncocytes without atypias. Thyrocytes in
active proliferation with chromatin clarification and overlapping nuclei.
Histologic exam: Hashimoto's thyroiditis.
 HASHIMOTO'S THYROIDITIS
(OUTCOME)

Woman, 68 y.o.
Serious hypothyroidism, in replacement therapy.
Small residues (few mm) of the lobes; echopoor structure, with hyperechoic
bands due to fibrosis; irregulars borders.
Strongly positive thyroid peroxidase antibodies.
DE QUERVAIN'S THYROIDITIS
 DE QUERVAIN'S THYROIDITIS

Man, 57 y.o.
Enlarged thyroid in the right lobe; very increased firmness; painful palpation with
irregular surface.
The borders of the gland are indistinct; very irregular echo pattern, with echopoor
shaded areas due to the presence of oedema and pseudonodular appearance.
Laboratory tests: poor hyperthyroidism, very high flogistic indexes.
FNA: giant Langhans cells, acute and chronic flogistic cells, many fibroblasts.
DE QUERVAIN'S THYROIDITIS
 DE QUERVAIN'S THYROIDITIS

Woman, 34 y.o.
Normal sized gland; very increased firmness; irregular and pseudonodular surface;
painful palpation.
The borders of the thyroid are indistinct; very irregular echo pattern with echopoor
shaded areas due to the presence of oedema and pseudonodular appearance.
Laboratory tests: very high flogistic indexes; slight hyperthyroidism.
GRANULOMATOUS NODULES
GRANULOMATOUS NODULES
 GRANULOMATOUS NODULES

Woman, 31 y.o.
Two years before total thyroidectomy for papillary neoplasia with capsular infiltration
and laterocervical lymph node metastasis (T4 N1 M0).
Right laterocervical nodule, (mm 3.8 x 9.0 x 10.2), just beside the jugular vein, left
laterocervical nodules (mm 8.3 x 9.2 x 17.5 and 5.0 x 8.2 x 12.2), all dishomogeneous,
hypoechoic with echogenic bands and spots, irregular borders with no halo sign.
Fine needle aspiration in all the nodules: epithelioid and giant cells as a foreign body
granuloma.
No thyroglobulin in the needle washing.
 ULTRASOUND GUIDED FINE
NEEDLE ASPIRATION

Woman, 51 y.o.
Nodule in the right lobe of the thyroid, strongly hypoechoic, with irregular
margins and microcalcifications.
 ULTRASOUND GUIDED FINE
NEEDLE ASPIRATION

Picture taken just after the needle insertion.

The tip of the needle is just in the center of the nodule, on the fourth dot of
the guide.
Cytologic exam: benign cistic nodule.
PAPILLARY CARCINOMA

Transverse section.
PAPILLARY CARCINOMA

Longitudinal section

Female, 29 y.o.
Large nodule in the right lobe and in the isthmus of the thyroid gland, that alter
the anterior capsular profile; the borders are irregular, the structure is
dishomogeneous, echopoor.
Evident laterocervical lymphadenopathy.
Fine needle aspiration: papillary carcinoma.
Histological examination: multifocal papillary carcinoma var. follicular with
capsular invasion and lymph node metastasis.
 PAPILLARY CARCINOMA

Woman, 23 y.o.
Small nodule in the right lobe of the thyroid (mm 12.1 x 16.0 x 19.3), hypoechoic,
dishomogeneous, with small hyperechoid spots, without posterior acoustic shadow.
The borders (particularly the posterior) are irregular and the anterior capsular profile
is altered.
Fine needle aspiration: papillary carcinoma.
Histologic confirmation.
PAPILLARY CARCINOMA

Female, 48 y.o.
Transverse (upper) and longitudinal (lower) section of the right lobe of the thyroid.
Small nodule in the lower pole (mm 15.0 x 18.3 x 25.9), with hyperechoic pattern
and apparently regular border, but without halo sign.
Histological examination: papillary carcinoma.
MULTIFOCAL PAPILLARY
CARCINOMA

Right lobe, transversal section.

MULTIFOCAL PAPILLARY
CARCINOMA

Right lobe, longitudinal section.

MULTIFOCAL PAPILLARY
CARCINOMA

Right lobe, transversal section.

MULTIFOCAL PAPILLARY
CARCINOMA

Right lobe, longitudinal section.

 MULTIFOCAL PAPILLARY
CARCINOMA

Base of the right lobe, transversal sect.

Woman, 34 y.o.
Multiple, hypoechoic, shaded lesions, all smaller than 10 mm, in normal sized thyroid.
Fine needle aspiration in two nodules: papillary carcinoma.
Histological examination: multifocal papillary carcinoma (four nodules in the right
lobe, with one infiltrating the capsule, two focuses in the left lobe (max 3 mm);
regressive nodule in the left lobe.