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Pattern Recognition of Benign Nodules at Ultrasound of

the Thyroid: Which Nodules Can Be Left Alone?

Pembimbing
Dr. Novita Sp.Rad

Clinical applications of high resolution usg.


1. Detection of thyroid and other cervical masses

before
and after thyroidectomy.
2. Differentiation of benign from malignant
masses.
. Ultrasound detects the presence, size,

site, number, characteristics of thyroid nodule


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Normal ultrasound anatomy of thyroid


It is located anterior

and lateral to trachea


below the level of
thyroid cartilage and
above the sternal
notch. (infrahyoid
compartment)
DIVISION :
RIGHT AND LEFT LOBES,
ISTHMUS
PYRAMIDAL LOBE (10-40

%)

Normal thyroid
parenchyma has
homogenous medium to
high level echogenicity &
bounded by a thin
hyperechoic line(the
thyroid capsule).
Landmarks to be
identified:
Midline -Trachea and
oesophagus.
Laterally- Common
Carotid artery, IJV
Anterolaterally:Strap
muscles of the neck

NORMAL DIMENSIONS OF THYROID LOBES


A-P
NEWBORN
INFANT
ADULT

8-9mm
12-15mm
13-18mm

LENGTH
18-20mm
25mm
40-60mm

MALE-UPTO 23gm IS NORMAL


FEMALE- UPTO 22gm IS NORMAL.

Sonogram of the left lobe of the thyroid gland in the transverse plane
showing a rounded lobe of a goiter. L=enlarged lobe, I= widened
isthmus,T=trachea,C=carotid artery,J=jugular vein,
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S=Sternocleidomastoid muscle, m=strap muscles, E=esophagus.

Pattern Recognition of Benign Nodules at


Ultrasound of the Thyroid: Which Nodules Can Be
Left Alone?
John A. Bonavita, Jason Mayo, James Babb,
Genevieve Bennet, Thaira Oweity, Michael
Macari, Joseph Yee

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OBJECTIVE
The purpose of this study was to evaluate morphologic
features predictive of benign thyroid nodules.

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MATERIALS AND METHODS. From a registry of

the records of 1,232 fine-needle aspiration biopsies


performed jointly by the cytology and radiology
departments at a single institution between 2005 and
2007, the cases of 650 patients were identified for
whom both a pathology report and ultrasound
images were available. From the alphabetized list
generated, the first 500 nodules were reviewed. We
analyzed the accuracy of individual sonographic
features and of 10 discrete recognizable
morphologic patterns in the prediction of benign
histologic findings.

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Fig. 1AIndividual ultrasound features of nodules.


85-year-old woman with subcentimeter papillary
carcinoma. Ultrasound scan shows hypoechoic
nodule

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Fig. 1B Individual ultrasound features of nodules. 46-yearold woman with papillary carcinoma. Ultrasound scan shows
nodule with ill-defined borders

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Fig. 1CIndividual ultrasound features of nodules.


36-year-old man with papillary carcinoma. Ultrasound
scan shows microcalcifications (arrow), which are
easily confused with comet-tail shadowing. Important
finding is hypoechogenicity of nodule

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Fig. 1D Individual ultrasound features of nodules.


37-year-old woman with medullary carcinoma.
Ultrasound scan shows macrocalcification.

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Fig. 1E Individual ultrasound features of


nodules. 37-year-old woman with papillary
carcinoma. Color Doppler ultrasound image
shows hypervascular nodule.

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Fig. 2A Morphologic patterns. 41-year-old man


with colloid nodule. Ultrasound scan shows
spongiform nodule. Similarity of nodule to waterfilled sponge is evident

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Fig. 2B Morphologic patterns. 52-year-old man


with colloid cyst. Ultrasound scan shows cyst with
colloid clot. When cystic portion of nodule is
subtracted, type 1 or spongiform nodules remain

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Fig. 2C Morphologic patterns. 21-year-old woman


with Hashimoto's thyroiditis. Ultrasound scan shows
nodule that looks like giraffe hide, having light
blocks separated by black bands

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Fig. 2D Morphologic patterns. 34-year-old woman


with Hashimoto's thyroiditis. Ultrasound scan shows
white knight, or hyperechoic, nodule.

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Fig. 2E Morphologic patterns. 61-year-old


woman with follicular adenoma. Color
Doppler ultrasound image shows red light,
or hypervascular, nodule.

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Fig. 2F Morphologic patterns. 29-year-old woman


with papillary carcinoma. Ultrasound scan shows
hypoechoic nodule.

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Fig. 2G Morphologic patterns. 70-year-old


woman with papillary carcinoma. Ultrasound
scan shows isoechoic nodule without halo.
Coincidental microcalcifications (arrows) are
evident

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Fig. 2H Morphologic patterns. 25-year-old man


with nodular goiter. Ultrasound scan shows
isoechoic nodule with halo

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Fig. 2I Morphologic patterns. 55-year-old woman


with hyperplastic nodule. Color Doppler ultrasound
image shows ring of fire, or peripheral
hypervascularity.

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RESULTS.

We found that grouping of thyroid nodules into


reproducible patterns of morphology, or pattern
recognition, rather than analysis of individual
sonographic features, was extremely accurate
in the identification of benign nodules. Four
specific patterns were identified: spongiform
configuration, cyst with colloid clot, giraffe
pattern, and diffuse hyperechogenicity, which
had a 100% specificity for benignity. In our
series, identification of nodules with one of
these four patterns could have obviated more
than 60% of thyroid biopsies.
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CONCLUSION.

Recognition of specific morphologic


patterns is an accurate method of
identifying benign thyroid nodules that
do not require cytologic evaluation.
Use of this approach may substantially
decrease the number of unnecessary
biopsy procedures.

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THANK YOU
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