Journal List > Int J Thyroidol > v.9(1) > 1082733

Na and Lee: Ultrasonography Diagnosis of Thyroid Nodules and Cervical Metastatic Lymph Nodes

Abstract

Ultrasonography (US) has been a primary tool for assessing malignancy risk, fine-needle aspiration (FNA) decision, and management after FNA in patients with thyroid nodules. US also has an essential role for preoperative evaluation of primary tumor and cervical lymph nodes, for surveillance of postoperative patients with thyroid cancer, and for imaging guidance for nonsurgical ablation therapy. In the revised re-commendations of Korean Society of Thyroid Radiology (KSThR), Korean Thyroid Imaging Reporting and Data System (K-TIRADS), a revised risk stratification system of thyroid nodules, was suggested to increase the efficacy of FNA and provide supplementary information for thyroid nodules after FNA. The role of US assessment of cervical lymph node needs to be emphasized for optimal management decision of thyroid nodules, preoperative staging, and postoperative surveillance of patients with thyroid cancers, and CT has a complementary role for the diagnosis of metastatic nodes in patients with thyroid carcinomas.

References

1. Naterional Comprehensive Cancer Network. NCCN Clinical practice guidelines in oncology. Thyroid carcinoma. Version 2.2014. Version 2.2014.
2. Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard Ba G, et al. Guidelines for the management of thyroid cancer. Clin Endocrinol (Oxf). 2014; 81(Suppl 1):1–122.
crossref
3. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: The American Thyroid Association Guidelines Task Force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016; 26(1):1–133.
crossref
4. Moon WJ, Baek JH, Jung SL, Kim DW, Kim EK, Kim JY, et al. Ultrasonography and the ultrasound-based management of thyroid nodules: consensus statement and recommendations. Korean J Radiol. 2011; 12(1):1–14.
crossref
5. Yi KH, Park YJ, Koong S-S, Kim J-H, Na DG, Ryu J-S, et al. Revised Korean Thyroid Association Management Guidelines for patients with thyroid nodules and thyroid cancer. J Korean Thyroid Assoc. 2010; 3(2):65–96.
crossref
6. Park JY, Lee HJ, Jang HW, Kim HK, Yi JH, Lee W, et al. A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. Thyroid. 2009; 19(11):1257–64.
crossref
7. Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011; 260(3):892–9.
crossref
8. Kwak JY, Jung I, Baek JH, Baek SM, Choi N, Choi YJ, et al. Image reporting and characterization system for ultrasound features of thyroid nodules: multicentric Korean retrospective study. Korean J Radiol. 2013; 14(1):110–7.
crossref
9. Horvath E, Majlis S, Rossi R, Franco C, Niedmann JP, Castro A, et al. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab. 2009; 94(5):1748–51.
crossref
10. Russ G, Royer B, Bigorgne C, Rouxel A, Bienvenu-Perrard M, Leenhardt L. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. Eur J Endocrinol. 2013; 168(5):649–55.
crossref
11. Seo H, Na DG, Kim JH, Kim KW, Yoon JW. Ultra-sound-based risk stratification for malignancy in thyroid nodules: a four-tier categorization system. Eur Radiol. 2015; 25(7):2153–62.
crossref
12. Henrichsen TL, Reading CC, Charboneau JW, Donovan DJ, Sebo TJ, Hay ID. Cystic change in thyroid carcinoma: Prevalence and estimated volume in 360 carcinomas. J Clin Ultrasound. 2010; 38(7):361–6.
crossref
13. Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, et al. Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab. 2002; 87(5):1941–6.
crossref
14. Cappelli C, Castellano M, Pirola I, Cumetti D, Agosti B, Gandossi E, et al. The predictive value of ultrasound findings in the management of thyroid nodules. QJM. 2007; 100(1):29–35.
crossref
15. Na DG, Baek JH, Sung JY, Kim JH, Kim JK, Choi YJ, et al. Thyroid imaging reporting and data system risk stratification of thyroid nodules: categorization based on solidity and echogenicity. Thyroid. 2016. [Epub ahead of print].
crossref
16. Lee MJ, Kim EK, Kwak JY, Kim MJ. Partially cystic thyroid nodules on ultrasound: probability of malignancy and sonographic differentiation. Thyroid. 2009; 19(4):3416.
crossref
17. Kim DW, Lee EJ, In HS, Kim SJ. Sonographic differentiation of partially cystic thyroid nodules: a prospective study. AJNR Am J Neuroradiol. 2010; 31(10):19616.
crossref
18. Vera MI, Merono T, Urrutia MA, Parisi C, Morosan Y, Rosmarin M, et al. Differential profile of ultrasound findings associated with malignancy in mixed and solid thyroid nodules in an elderly female population. J Thyroid Res. 2014; 2014:761653.
crossref
19. Ito Y, Miyauchi A, Inoue H, Fukushima M, Kihara M, Higashiyama T, et al. An observational trial for papillary thyroid microcarcinoma in Japanese patients. World J Surg. 2010; 34(1):28–35.
crossref
20. Ito Y, Miyauchi A, Kihara M, Higashiyama T, Kobayashi K, Miya A. Patient age is significantly related to the progression of papillary microcarcinoma of the thyroid under observation. Thyroid. 2014; 24(1):27–34.
crossref
21. Takami H, Ito Y, Okamoto T, Onoda N, Noguchi H, Yoshida A. Revisiting the guidelines issued by the Japanese Society of Thyroid Surgeons and Japan Association of Endocrine Surgeons: a gradual move towards consensus between Japanese and western practice in the management of thyroid carcinoma. World J Surg. 2014; 38(8):2002–10.
crossref
22. Oda H, Miyauchi A, Ito Y, Yoshioka K, Nakayama A, Sasai H, et al. Incidences of unfavorable events in the management of low-risk papillary microcarcinoma of the thyroid by active surveillance versus immediate surgery. Thyroid. 2016; 26(1):150–5.
crossref
23. Brito JP, Ito Y, Miyauchi A, Tuttle RM. A clinical framework to facilitate risk stratification when considering an active surveillance alternative to immediate biopsy and surgery in papillary microcarcinoma. Thyroid. 2016; 26(1):144–9.
crossref
24. Roti E, Rossi R, Trasforini G, Bertelli F, Ambrosio MR, Busutti L, et al. Clinical and histological characteristics of papillary thyroid microcarcinoma: results of a retrospective study in 243 patients. J Clin Endocrinol Metab. 2006; 91(6):2171–8.
crossref
25. Davies RJ, Pring M, Aw J, Hughes CW, Thomas SJ. Isolated submandibular metastasis from a contralateral thyroid papillary microcarcinoma: an unusual case. Dentomaxillofac Radiol. 2009; 38(8):546–9.
crossref
26. Lecumberri B, Alvarez-Escola C, Martin-Vaquero P, Nistal M, Martin V, Riesco-Eizaguirre G, et al. Solitary hemorrhagic cerebellar metastasis from occult papillary thyroid microcarcinoma. Thyroid. 2010; 20(5):563–7.
crossref
27. Jeon MJ, Kim WG, Choi YM, Kwon H, Lee YM, Sung TY, et al. Features predictive of distant metastasis in papillary thyroid microcarcinomas. Thyroid. 2016; 26(1):161–8.
crossref
28. Ghossein R, Ganly I, Biagini A, Robenshtok E, Rivera M, Tuttle RM. Prognostic factors in papillary microcarcinoma with emphasis on histologic subtyping: a clinicopathologic study of 148 cases. Thyroid. 2014; 24(2):245–53.
crossref
29. Mercante G, Frasoldati A, Pedroni C, Formisano D, Renna L, Piana S, et al. Prognostic factors affecting neck lymph node recurrence and distant metastasis in papillary microcarcinoma of the thyroid: results of a study in 445 patients. Thyroid. 2009; 19(7):707–16.
crossref
30. Buffet C, Golmard JL, Hoang C, Tresallet C, Du Pasquier Fediaevsky L, Fierrard H, et al. Scoring system for predicting recurrences in patients with papillary thyroid microcarcinoma. Eur J Endocrinol. 2012; 167(2):267–75.
crossref
31. Noguchi S, Yamashita H, Uchino S, Watanabe S. Papillary microcarcinoma. World J Surg. 2008; 32(5):747–53.
crossref
32. Kim E, Park JS, Son KR, Kim JH, Jeon SJ, Na DG. Preoperative diagnosis of cervical metastatic lymph nodes in papillary thyroid carcinoma: comparison of ultrasound, computed tomography, and combined ultrasound with computed tomography. Thyroid. 2008; 18(4):411–8.
crossref
33. Lesnik D, Cunnane ME, Zurakowski D, Acar GO, Ecevit C, Mace A, et al. Papillary thyroid carcinoma nodal surgery directed by a preoperative radiographic map utilizing CT scan and ultrasound in all primary and reoperative patients. Head Neck. 2014; 36(2):191–202.
crossref
34. Leenhardt L, Erdogan MF, Hegedus L, Mandel SJ, Paschke R, Rago T, et al. 2013 European thyroid association guidelines for cervical ultrasound scan and ultrasoundguided techniques in the postoperative management of patients with thyroid cancer. Eur Thyroid J. 2013; 2(3):147–59.
crossref
35. Korean Society of Thyroid Radiology. Thyroid imaging and intervention. 2nd ed.Seoul, Korea: Il Cho Kak;2013.
36. Randolph GW, Duh QY, Heller KS, LiVolsi VA, Mandel SJ, Steward DL, et al. The prognostic significance of nodal metastases from papillary thyroid carcinoma can be stratified based on the size and number of metastatic lymph nodes, as well as the presence of extranodal extension. Thyroid. 2012; 22(11):1144–52.
crossref
37. Leboulleux S, Girard E, Rose M, Travagli JP, Sabbah N, Caillou B, et al. Ultrasound criteria of malignancy for cervical lymph nodes in patients followed up for differentiated thyroid cancer. J Clin Endocrinol Metab. 2007; 92(9):3590–4.
crossref
38. Rosario PW, de Faria S, Bicalho L, Alves MF, Borges MA, Purisch S, et al. Ultrasonographic differentiation between metastatic and benign lymph nodes in patients with papillary thyroid carcinoma. J Ultrasound Med. 2005; 24(10):1385–9.
39. Ito Y, Tomoda C, Uruno T, Takamura Y, Miya A, Kobayashi K, et al. Preoperative ultrasonographic examination for lymph node metastasis: usefulness when designing lymph node dissection for papillary microcarcinoma of the thyroid. World J Surg. 2004; 28(5):498–501.
40. Rondeau G, Fish S, Hann LE, Fagin JA, Tuttle RM. Ultrasonographically detected small thyroid bed nodules identified after total thyroidectomy for differentiated thyroid cancer seldom show clinically significant structural progression. Thyroid. 2011; 21(8):845–53.
crossref
41. Robenshtok E, Fish S, Bach A, Dominguez JM, Shaha A, Tuttle RM. Suspicious cervical lymph nodes detected after thyroidectomy for papillary thyroid cancer usually remain stable over years in properly selected patients. J Clin Endocrinol Metab. 2012; 97(8):2706–13.
crossref
42. Tufano RP, Clayman G, Heller KS, Inabnet WB, Kebebew E, Shaha A, et al. Management of recurrent/persistent nodal disease in patients with differentiated thyroid cancer: a critical review of the risks and benefits of surgical intervention versus active surveillance. Thyroid. 2015; 25(1):15–27.
crossref

Table 1.
Malignancy risk stratification according to the Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and FNA indications
  Category US feature Malignancy risk (%) Calculated malignancy risk (%) Overall (LV, HV) Calculated Sensitivity for malignancy (%) Overall (LV, HV) FNA c
5 High suspicion Solid hypoechoic nodule with any of 3 suspicious US features a >60 79.3 (60.9, 84.9) 51.3 (35.9, 56.7) ≥1 cm (>0.5 cm, selective)
4 Intermediate suspicion 1) Solid hypoechoic nodule without any of 3 suspicious US features a or
2) Partially cystic or isohyperechoic nodule with any of 3 suspicious US features a
15–50 25.4 (15, 33.6) 29.5 (29.9, 29.4) ≥1 cm
3 Low suspicion Partially cystic or isohyperechoic nodule without any of 3 suspicious US features a 3–15 7.8 (6, 10.3) b 19.2 (34.2, 13.9) ≥1.5 cm
2 Benign Spongiform <3 0 0 ≥2 cm
    Partially cystic nodule with comet tail artifact Pure cyst <1 0 0 NA
1 No nodule NA

LV and HV indicate low and high cancer volume data, respectively. Solid hypoechoic nodules include solid nodules with marked or mild hypoechogenicity. FNA: fine-needle aspiration, NA: not applicable for FNA

a Microcalcification, nonparallel orientation (taller than wide), spiculated/microlobulated margin

b Malignancy risk calculated from nodules excluding spongiform or partially cystic nodules with comet tail artifacts

c FNA is indicated regardless of the size and US feature of a nodule in the presence of poor prognostic factors including suspected lymph node metastasis by US or clinical evaluation, suspected gross extrathyroidal tumor extension, patients with diagnosed distant metastasis from thyroid cancer. Modified from the published data (15)

Table 2.
Imaging-based risk stratification of the neck lymph nodes for nodal metastasis
Category US CT
Suspicious a Cystic change Cystic change
Calcification (micro/macro) Calcification (micro/macro)
Hyperechogenicity (focal or diffuse) Heterogeneous enhancement
Abnormal vascularity (peripheral or diffuse) Strong enhancement (focal or diffuse)
Indeterminate b Loss of central hilar echo and absence of central hilar vascularity Loss of central hilar fat and absence of central hilar vessel enhancement
Benign c Central hilar echo Central hilar fat
Central hilar vascularity Central hilar vessel enhancement

a Lymph nodes with any imaging feature for suspicious lymph nodes are included for this category regardless of the presence of any imaging feature for benign or indeterminate lymph nodes

b Lymph nodes not included in the suspicious or benign categories

c Lymph nodes with any imaging feature of either central hilar fat or central hilar vessels are considered as benign category if there is no imaging feature of suspicious lymph nodes

TOOLS
Similar articles