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Computed
Tomography
in
the Evaluation
of Thyroid
Disease
Paul M. Silverman1
Glenn
E. Newman
Melvyn
Korobkin
Joseph
B. Workman
Arl V. Moore
R. Edward
Coleman
Traditionally,
thyroid
using radionuclide
scanin 18 patients
to
evaluate
the CT appearance
of various thyroid abnormalities
including
diffuse toxic
goiter, multinodular
goiter, Hashimoto thyroiditis, thyroid adenoma,
and malignant thyroid
tumors. CT images of the thyroid were correlated
with radionuclide
scanning,
surgical
fling.
High-resolution
imaging
computed
tomography
and laboratory
(CT)
results.
primarily
was
performed
findings,
and clinical
evaluation
precisely
structures
CT provided
a complementary
method
for
Radionuclide
imaging
of the thyroid
remains
the primary
radiologic
imaging
procedure
for evaluating
functioning
thyroid
tissue. High-resolution
real-time
sonography
has provided
additional
information
in the evaluation
of patients
with
thyroid disease,
especially
in differentiating
cystic from solid thyroid nodules
[1].
Limited experience
has been obtained
in evaluating
the thyroid gland by computed
tomography
(CT), with the primary emphasis
being the detection
of intrathoracic
thyroid tissue [2-6].
We describe
the morphologic
and anatomic
CT appearance
of the abnormal
thyroid gland and correlate
these results with radionuclide
imaging
and clinical and surgical findings.
Materials
and
Methods
A retrospective
neck
masses
analysis
suspected
clinically
radionuclide
examination
of the thyroid. Surgical or autopsy confirmation
was available in 11
of 1 8 patients.
The final diagnosis
in the other seven was based on careful review of the
history, physical examination,
and laboratory
and radiologic
results.
CT examinations
were performed
using a Siemens Somatom
II or GE 8800 CT/T scanner
with the patient in the supine position and the neck extended.
All scans were obtained
using
contiguous
1 cm or 5 mm collimated
sections
through
the neck and thyroid gland tissue
without
the
scans
were
size,
use
of intravenous
continued
homogeneity,
contrast
calcifications,
and
retrotracheal
extension.
The radionuclide
examinations
(eight
Received
September
6, 1 983;
revision December
20, 1983.
accepted
after
141:897-902,
0361 -803X/84/1
May
1984
425-0897
C American Roentgen
Ray Society
patients)
collimator
and
neck extended.
as indicated
gland
extension.
The CT
location
of
of the thyroid
were
thyroid
were
An anterior
of suspected
mediastinal
assessed
tissue,
including
performed
with
thyroid,
for thyroid
gland
substernal
or
seTcpertechnetate
1311
size, homogeneity
radioactive
In cases
The images
or
views (anterior,
material.
on
were
of tracer
the
then
skin
uptake,
location
superimposed
correlated
with
sitting
or lateral
Aadionuclide
of palpable
on
the
radionuclide
image,
images,
views
were
obtained
substernal
results
for
as demonstrated
or
of physical
by
posterior
exami-
898
SILVERMAN
TABLE
1: Radionuclide
Pathology:
Case
and CT Findings
in Thyroid
Disease
Radionuciide(s):
goiter:
ssmTc,
1 (61,F).
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AL.
No.
(age gender)
Multinodular
ET
1311:
Enlarged,
ci
Findings
right-lobe
focal
mass, substernal
2(76,F)
3(87,M)
inhomogeneous,
4(47,F)
sternal
ssmTc, 1311: Enlarged,
5(65,M)
substernal
1311: Substemal,
sub-
inhomogeneous,
CT-Radionuclide
Findings
Correlation
Good
NA
cal
Enlarged,
cal
Enlarged,
inhomogeneous,
Good
inhomogeneous,
Good
substemal
inhomogeneous
Cal, substemal,
neous
homoge-
Good
NA
Inhomogeneous
NA
1311:
Homogeneous
Enlarged, inhomogeneous,
cal
Enlarged, inhomogeneous,
Retrotracheal
only by CT
Retrotracheal
only by CT
6(55,M)
7(72,F).
8(73,F).
Homogeneous
seTc: Enlarged, inhomogeneous
9(64,F)
NA
NA
cal, retrotracheal
Tc:
Poor uptake
seTc: Enlarged, inhomogeneous,
sternal
10(53,F)
ii (73,F)
12(71,F)
Graves disease:
13(19,F)
14 (49,F)
sub-
1311: Homogeneous
Tc:
Enlarged, homogeneous
Enlarged, inhomogeneous
Enlarged,
cal, substemal
Substemal
Enlarged,
inhomogeneous,
Good
substernal
Homogeneous
Good
Enlarged,
homogeneous
Good
Enlarged,
inhomogeneous,
substernal
Hashimoto thyroiditis:
15 (56,F)
seTc:
Enlarged,
inhomogeneous,
Enlarged,
17 (33,F)
18 (67,F)
=
Note.-Histoiog
calcifications;
nation,
1311:
Enlarged,
homogeneous
NA
NA
conhrmation
was achieved
not applicable.
and surgical
findings
to assess
the significance
Thyroid
of the abnor-
malities detected.
Results
Multinodular
Goiter
masses
Discrepancy
retrotracheal
trotracheal
CT identified
Calcified
in cases 2. 4. 6-8,
homogeneous,
substemal,
1311:
only by CT
sub-
sternal
Thyroid masses:
16(35,M)
Substemal
only by CT
mass
inhomogeneous
carcinoma
glands
were
Focal
NA
re-
only by CT
lymphadenopathy
mass by CT
found
in homogeneity;
on both
caronoma
radionuclide
and
AJR:142,
Fig.
rod
CT
May 1984
scan.
-Case
1,
Enlarged
neous
distribution
pofunctioning
multinodular
thyroid
OF
THYROID
DISEASE
899
goiter. A. l thy.
with inhomogeand focal area of hy-
gland
of activity
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on radionuclide
study.
A
Fig. 2.-Case
7. multinodular
goiter. A, 1311 thy
view. Anterior
marker indicates
sternal notch (5), posterior
marker is placed over
spinous
processes
in back of neck (arrows).
No
abnormal
tissue is noted between
posterior
marker
and normal thyroid tissue (fl to suggest retrotracheal thyroid. B, CT scan. Retrotracheal
component
number
of thyroid
tissue
is 1 00 H. T
/OOH
trachea.
1i ::
:
Graves
Disease
(Diffuse
Goiter)
Hashimoto
Thyroiditis
Thyroid
Masses
Two patients
had thyroid
neoplasm,
one with papillary
carcinoma
and a second
with anaplastic
carcinoma.
In the
patient with the anaplastic
carcinoma,
the radionuclide
study
showed
a cold nodule
in the left lobe of the thyroid
that
corresponded
to a low-density
mass displacing
the normal
higher density thyroid gland on CT scanning.
The CT scan
more completely
defined the anatomic
extent of tumor, with
extension
into the neck and metastatic
lymphadenopathy
(fig.
4). At surgery
local lymph node metastases
and extension
into the soft tissues of the neck were confirmed.
In the patient
with papillary carcinoma,
the radionuclide
examination
of the
thyroid gland demonstrated
a slightly enlarged
gland without
areas of decreased
radioactivity.
CT scanning
demonstrated
a focal area of irregular low attenuation
medially in both lobes
and the region
of the thyroid
isthmus.
This area of low
attenuation
corresponded
(fig. 5) identified
One patient
to the patients
at surgery.
had a CT scan
showing
papillary
a densely
carcinoma
calcified
SILVERMAN
900
ET AL.
AJR:142,
May 1984
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Fig. 3.-Case
5, multinodular
goiter. A, l thyreid scan. Normal thyroid tissue (1) and large inhomogeneous
substemal
component
(arrows). B, CT at
level of thyroid. Normal thyroid gland (1). C, 2 cm
below thyroid gland. Thin extension
ofthyroid
tissue
with calcification
(arrows). D, Level of great vessels.
Displacement
laterally of great vessels by substernal thyroid (T). Caudad to this level substernal
thyroid extended
anterior and posterior
to aortic arch.
S = sternum;
lv = innominate
veins:
Ca = carotid
artery; Sa = subclavian
artery.
...
A
Fig. 4.-Case
1 6. A, l thyroid scan. Large hypofunctioning
mass (arrows)
lobe corresponds
to palpable
mass (surgically
proven anaplastic
carciB. CT scan. Normal right thyroid lobe; left lobe is markedly
expanded
in left
noma).
by mass
medially
along periphery
(H). Soft-tissue
AJR:142,
CT
May 1984
OF
THYROID
901
DISEASE
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Fig. 5.-Case
17. A, 1311 scan. Slightly enlarged
thyroid gland without
definite mass. B. CT scan at
level of thyroid isthmus.
Area of relative low attenuation (arrows) compared
with rest of thyroid (papillary carcinoma
of thyroid).
A
mass in the thyroid consistent
with a benign
A radionuclide
study was not performed.
thyroid
adenoma.
thyroidal
vessels,
they
excision.
Large
masses,
significant
Discussion
Thyroid
imaging
using radionuclides
method
for evaluating
the functioning
nuclide
lution
thyroid
and
imaging,
is accurate
however,
only
has
been
the
primary
in evaluation
of nodules
larger
than
posterior
can
usually
deep
be resected
intrathoracic
mediastinal
component
may
roid,
many
tinal
masses
tion
identification
as thyroid tissue.
CT allowed
the definition
of retrotracheal
between
nuclide
goiters,
the
appearance
of the
gland
radionuclide
studies
corresponded
of decreased
density on CT.
CT demonstrated
the relation
mal
thyroid
mediastinal
structures
closely
with multinodular
tracer activity on
to multiple
of substernal
in eight
on radio-
patients
thyroid
in our
regions
to norstudy.
Substernal
thyroid tissue is usually an intrathoracic
extension
of goiterous
thyroid tissue and is most common
in the anterior
mediastinum,
with typical histopathologic
features
of cystic
areas, focal calcifications,
inflammatory
changes,
and fibrosis.
Significant
substernal
goiter
itself
is an indication
for resection
to prevent
potential
complications
of mediastinal
or tracheal
compression
as a result of cystic degeneration
or hernorrhage. Since these lesions are usually an intrathoracic
extension of goiterous
thyroid
and have a vascular
supply from
or a
necessitate
supplementary
median sternotomy
or thoracotomy
[i2, 13j.
CT often aids in the preoperative
assessment
of the location
and extent of intrathoracic
tissue and its relation to the major
vascular
structures
in the mediastinum
(fig. 3D).
Although
radionuclide
scanning
is probably
the preferred
initial method of examination
for suspected
mediastinal
thy-
1.
by a cervical
extension,
patients
are referred
of uncertain
for CT evaluation
etiology.
In these
of medias-
cases
the
appre-
of the CT appearance
of substernal
thyroid is important
in establishing
the benign
nature of the mass. The often
decreased
density
of the substernal
extension
of thyroid
tissue compared
with normal thyroid tissue may occasionally
create some difficulty
in distinguishing
tissue of thyroid origin
from other mediastinal
masses. In these cases identifying
the
continuity
of the mediastinal
component
with the thyroid gland
ciation
in the
neck
may
be helpful
in confirming
its thyroidal
origin.
Small punctate
or coarse
calcifications
were noted in six
patients with multinodular
goiter. The calcifications
were often
diffusely
distributed
through the thyroid gland in the neck as
well
nents
as within
in three
the
substernal
patients.
This
component,
extension
which
may
aided
thyroid
not
in its
compo-
be detected
radionuclide
imaging
[i 41. The demonstration
of a retrotracheal
component
of the thyroid gland is important
in the
preoperative
assessment
of these patients.
The knowledge
of posterior
tracheal extension
narrowing
the tracheal lumen
may be useful to the anesthesiologist
in selecting
the proper
endotracheal
tube for endotracheal
intubation
[15].
In two patients
with thyroid carcinoma
the areas of abnormality appeared
as poorly defined areas of decreased
density
clearly demarcated
from the rest of the higher-density
thyroid
gland. In one patient CT demonstrated
a thyroid
mass not
visualized
on the radionuclide
study; in the second patient CT
showed
an additional
soft-tissue
mass in the neck that corresponded
to metastatic
lymphadenopathy.
with
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902
SILVERMAN
The identification
of lymphadenopathy
is important
in the
surgical assessment
of patients
with thyroid carcinoma.
The
thyroid
gland lies in the visceral
compartment
of the neck
bounded
posteriorly
by prevertebral
fascia and anteriorly
by
pretracheal
fascia. These fascial layers fuse laterally
at the
carotid sheath. The deep cervical nodes, however,
lie laterally
in a separate
compartment
bounded
by prevertebral
fascia.
Thus, total thyroidectomy
with radical neck dissection
involves surgical manipulation
of two compartments
and is thus
not a single en-bloc dissection
but rather removal of an organ
and an associated
regional node dissection
[1 6]. Whether
or
not to perform a neck dissection
is controversial
and depends
on the histologic
type and extent of tumor. Especially
in well
differentiated
tumors
(papillary,
follicular),
the decision
is
based on the identification
of enlarged lymph nodes on clinical
examination.
In the absence
of palpable lymphadenopathy,
a
cervical
lymph
node dissection
is not performed
[1 7, 1 8]. CT
provides
a potentially
valuable technique
for the detection
of
cervical lymphadenopathy
and may aid surgical
planning.
In
the case of questionable
lymphadenopathy,
a biopsy of cervical lymph
nodes
determines
the need of node dissection.
CT scanning
in thyroid diseases
provides a complementary
technique
to radionuclide
scanning,
which remains the primary
imaging method in the detection
and characterization
of various thyroid
abnormalities.
In patients
with a significant
amount
of substernal
extension
of goiter
by radionuclide
examination,
CT provides
a precise anatomic
display of the
sites of substernal
extension
before surgical intervention.
CT
may be used as a major radiologic
staging
method
in the
evaluation
of the extent
of cervical
and mediastinal
adenopathy
in patients
with thyroid
carcinoma
prior to radical
surgery.
CT scanning
can be used in conjunction
with sonography
as the primary
imaging
study in the evaluation
of
thyroid disease
in patients
in whom recent intravenous
iodinated contrast
material
has made radionuclide
imaging suboptimal.
In our study, the appearance
of the thyroid
parenchyma
showed
good correlation
between
radionuclide
examination
and CT in diffuse thyroid disease.
Areas of decreased
tracer
uptake generally
corresponded
to areas of decreased
attenuation on CT scanning.
CT provided
additional
anatomic
information
not available on radionuclide
imaging by defining
the extent of retrotracheal
and substemal
extension,
its relation to normal
anatomic
structures,
and the presence
of
metastatic
lymphadenopathy
in the neck.
ET
AL.
ACKNOWLEDGMENTS
We thank Pamelia Neal, Connie Faison, and Rose Boyd for assistance in manuscript
preparation.
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