dissertation - repository-tnmgrmu.ac.inrepository-tnmgrmu.ac.in/4760/1/200824217anupriya.pdf · by...

SONOGRAPHIC EVALUATION OF THYROID LESIONS WITH FNAC CORRELATION

THE TAMILNADU Dr. M.G.R MEDICAL UNIVERSITY

In partial fulfilment of the requirements forthe award of the degree of

M.D RADIODIAGNOSIS


Dissertation

Submitted to


In partial fulfilment of the requirements for the award of the degree of

M.D RADIODIAGNOSIS

Branch VIII

APRIL 2017



CERTIFICATE

This is to certify that this dissertation entitled “Sonographic

evaluation of thyroid lesion with FNAC correlation” is a bonafide record

of the work done by Dr. Anu Priya J.T under guidance and supervision in

the Department of Radiodiagnosis during the period of her postgraduate study

for M.D Radiodiagnosis [Branch-VIII] from 2014-2017.

Dr. S. Sathish Babu, MD [Co-guide] Associate Professor Department of Radiodiagnosis, Sree Mookambika Institute of Medical Sciences [SMIMS] Kulasekharam [K.K District] Tamil Nadu -629161

Dr. G. Vijayakumar, MD [Guide] Professor and HOD Department of Radiodiagnosis, Sree Mookambika Institute of Medical Sciences [SMIMS] Kulasekharam [K.K District] Tamil Nadu -629161

Dr. Rema V. Nair, M.D., D.G.O.,

Director Sree Mookambika Institute of Medical Sciences [SMIMS] Kulasekharam [K.K District] Tamil Nadu -629161

DECLARATION

In the following pages is presented a consolidated report of

“Sonographic evaluation of thyroid lesion with FNAC correlation” a

cross sectional study, on cases studied by me at Sree Mookambika Institute of

Medical Sciences, Kulasekharam from 2015-2016. This thesis is submitted to

the Dr. M.G.R. Medical University, Chennai in partial fulfilment of the rules

and regulations for the award of MD Degree examination in Radiodiagnosis.

Dr. Anu Priya J.T

Junior Resident Department of Radiodiagnosis, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari District. Tamil Nadu 629161.

ACKNOWLEDGEMENT

I thank God almighty, for giving me the strength, confidence and

perseverance to complete the study.

I express my heartfelt gratitude to our Director Dr. Rema V. Nair and

our Chairman Dr. Velayudhan Nair for providing me the infrastructure and

for permitting me to carry out the study in this institution. They are the

founders and pillars of the various activities initiated in our institution.

I thank my HOD and Guide Dr. G. Vijayakumar, for the creative

suggestions, timely advice and constant encouragement. It has been a

tremendous and wonderful experience to work under his guidance.

I thank my Co-guide Dr S. Sathish Babu for his valuable help,

suggestions and supervision throughout the study. He lent his full support in

all times of difficulties. His encouragement from the inception of this research

to its culmination has been profound.

I humbly thank Dr. Saritha V, Dr. Reshmi C.P, Dr. Arun A and

Dr Vinod S whose support, guidance, help, critical views and comments kept

me in full swing throughout my study period. Their suggestions were very

valuable at each stage of my dissertation work. I am indebted to them for their

guidance and support throughout my post graduate days.

I thank Dr. Karthik R Nair, Dr. Ajit Deshmuk, and Dr. Aneesh M.M

for their guidance during my initial study period.

I thank Dr. Mahtab Yeganegi, my co-pg, for her valuable and timely

help to complete my study on time. I am grateful to my junior post graduates

Dr. Bhupinderjit Singh Soori, Dr. Sakshi Mittal, Dr. Shyam Sudharsan and

Dr. Sparsh Yadav for the various technical aspects of my study.

I also extend my sincere thanks to our senior technicians Mr. Kamal

Chandran and Mr. Nappagam and all the staff members of Radiology for their

support.

Lastly I would like to express my heartfelt deepest gratitude to my

family for their continuing love and encouragement. All these where possible

with their constant support and sacrifice.

Dr. Anu Priya J.T.

LIST OF CONTENTS

Sl. No. Contents Page No

1. Introduction 1

2. Aims and Objectives 3

3. Hypothesis and Scientific Justification 4

4. Review of Literature 5

5. Materials and Methods 34

6. Analysis and Interpretations 41

7. Discussion 67

8. Conclusion 71

9. Summary 74

10. Bibliography

11. Appendices

LIST OF TABLES

Sl. No Tables Page No

1 Statistical parameters 40

2 Family history of thyroid disorder 42

3 Thyroid function test 42

4 Thyroid swelling 43

5 Size of thyroid gland 43

6 Echo texture of thyroid parenchyma 43

7 Vascularity of thyroid parenchyma 44

8 Nodules on thyroid parenchyma 44

9 Number of nodules 44

10 Size of thyroid lesions 45

11 Shape of thyroid lesions 45

12 Margins of thyroid lesions 45

13 Echogenecity of thyroid lesion 46

14 Halo in thyroid lesion 46

15 Contents of thyroid lesion 46

16 Calcification in the thyroid lesion 47

17 Vascularity of thyroid lesion 47

18 Ultrasound diagnosis of thyroid lesions 48

19 FNAC diagnosis of thyroid lesions 48

20 Matching of ultrasound and FNAC diagnosis 49

21 Comparison of ultrasound diagnosis with FNAC diagnosis 49

22 FNAC with size of nodule 50

23 FNAC with margins 51

24 FNAC with echogenicity 52

25 FNAC with halo 53

26 FNAC with contents 54

27 FNAC with calcification 55

28 FNAC with vascularity of nodule 56

29 Thyroid disorder and age 57

LIST OF FIGURES

Sl. No Figures Page No

1 Thyroid gland and its relation 6

2 Blood supply of thyroid 7

3 Thyroid hormones 10

4 Ultrasound of neck for thyroid 15

5 Normal thyroid ultrasound image 16

6 Position of needle 38

7 Ultrasound image of tip of needle within lesion 38

8 Gender distribution 41

9 Age distribution 42

10 FNAC with size of nodule 50

11 FNAC with margins 51

12 FNAC with echogenicity 52

13 FNAC with halo 53

14 FNAC with content 54

15 FNAC with calcification 55

16 FNAC with vascularity of nodule 56

Introduction

Introduction

Page 1

INTRODUCTION

The thyroid gland is an endocrine gland. It is a large gland and is the

only gland which is amenable to direct clinical examination. It is located

superficially. The superficial location of the thyroid gland helps in excellent

visualization. Superficial location also helps in the evaluation of its normal

anatomy, normal anatomical variants and pathological conditions by high

resolution real-time grey-scale sonography.1

The location of the thyroid gland makes high-resolution real time grey-

scale and color Doppler sonography. By USG, normal thyroid anatomy and

pathologic conditions can be demonstrated with remarkable clarity. The

thyroid gland has multiple critical functions such as regulating metabolic

functions of the body like cardiac output, skeletal growth and thermogenesis.

High resolution sonography is the best imaging modality for thyroid gland.

By USG normal anatomical and pathological features such as size, margin

number of nodules etc can be demonstrated2.

Thyroid gland is primarily evaluated clinically by palpation, and

determination of the levels of thyroid hormones. Surgical intervention may be

indicated when there is presence of a hypofunctional, or so-called “cold”

nodule, when malignant cells are detected by FNAC or when there is a large

thyroid lesion that cause symptoms such as dysphagia or hoarseness of voice.3

Introduction

Page 2

On USG thyroid, the nodules are evaluated. The size of nodule,

location of nodule in the thyroid gland, echotexture of the nodule, margins of

the nodule, presence of halo around the nodule, calcification within the

nodule, vascularity of the nodule, accessory nodules and associated cervical

nodes and contents of the nodule (solid, cystic or mixed) are characterized in

order to differentiate from benign and malignant nodule.4

Diffuse enlargement of the thyroid gland, thyroid nodules, thyroid

mass are seen sonographically and it may be palpable lesion or non palpable

lesion. The lesions may be symptomatic or asymptomatic. Multinodular goiter

was the commonest pathology and was seen in 40% of the cases. The females

were most commonly affected by multinodular goiter and constituted 90% of

goiter cases. Similarly colloid cyst was more common in females and they

constituted 20% of colloid cyst cases. Females also constituted 87% cases of

diffuse thyroid hyperplasia. By high frequency ultrasonography even the

smaller lesions which are not palpable can be identified. Certain ultrasound

characteristics of nodules (e.g., hypoechogenicity, microcalcifications, and

blurred & nodular margins) are associated with malignancy. Thyroid diseases

are predominant in females than males.2

Aims & Aims & Objectives

bjectives

Aims & Objectives

Page 3

AIMS AND OBJECTIVES

1. To study the ultrasonographic features of various thyroid lesions in

patients with thyroid disorders.

2. Correlate the sonographic findings with FNAC in the diagnosis of

thyroid lesions.

Hypothesis &

Justification

Hypothesis & Scientific Justification

Page 4

HYPOTHESIS AND SCIENTIFIC JUSTIFICATION

HYPOTHESIS

Null hypothesis states that sonography has specificity and sensitivity

similar to FNAC, in the detection of thyroid lesions.

SCIENTIFIC JUSTIFICATION

Thyroid disorders are endemic all over the world and in India also.

Sonographic evaluation is non invasive and it can be done on all age. By

using colour flow and Doppler the vascularity of the gland can be

demonstrated which is important in identifying the type of lesion. Thyroid

nodules are very common in the general population, but malignancy is

relatively rare.1 The goal of the ultrasound guided FNAC evaluation of non

palpable thyroid nodules is the early detection of malignant lesions and to

save the overt spread of malignancies, while identifying and avoiding

unnecessary surgery in those with benign, asymptomatic thyroid nodules.

This can be correlated with FNAC to confirm the type of lesion. UGS is very

helpful in locating the non-palpable thyroid nodules for FNAC and increases

the quality of diagnosis which is helpful for the clinical management of such

patients. USG can differentiate solid from cystic lesions solitary nodule

multinodular and diffuse enlargement and also extra thyroidal lesions.4

Review of Literature


Page 5

REVIEW OF LITERATURE

Development:

The thyroid gland is develops from the median diverticulum. The

median diverticulum is seen around fourth week. It grows in downward and

backward direction. It is seen as a tubular structure, which bifurcates and

subsequently subdivides into a series of cellular cord like structures. From this

cord like structures isthmus and right and left lobes of the thyroid gland

develops. This connection when it is present between diverticulum and the

pharynx, it is called the thyroglossal duct. The thyroglossal duct undergoes

degeneration, its upper end forms the foramen cecum of the tongue, and its

lower end forms the pyramidal lobe of the thyroid gland.10

Anatomy of thyroid:

Thyroid gland is the superficially situated endocrine gland. It has two

lobes and it is situated in the lower neck drapped around the trachea on either

side. Centrally there is a band of tissue which connects the two lobes of

thyroid called isthumus.

The relation of thyroid gland to adjacent structure is anteriorly strap

muscles (sternohyoid, sternothyroid and omohyoid). The longus colli muscle

is located posterior to thyroid gland and the trachea is medial to the thyroid

lobe. Lateral relation to the thyroid gland is the large sternocleiodomastoid


Page 6

muscle on both sides, the carotid artery on both sides and the internal jugular

vein on both sides. Esophagus is located posteriorly on the side of left lobe11.

Thyroid Size: The normal measurement of thyroid lobes are 4–6 cm in

craniocaudal length and 1.3–1.8cm in the anterioposterior and transverse

dimension is 2.5 – 3 cm. The normal isthmus has an anterioposterior thickness

of up to 3 mm.11

Fig 1. Diagramatic representation of cross section of thyroid gland and its relation to other structures

Around 10% to 40% patients have a pyramidal thyroid lobe which is

arising superiorly from the isthmus and laying in front of the thyroid cartilage.

Usually seen in young patients and atrophies in adulthood and becomes

invisible. 12

Fig 2. Diagramatic

Blood supply:

Upper pole of thyroid is supplied by 1

which is the superior thyroid artery and its accompanying vein, this vein

drains into the internal jugular vein

thyrocervical trunk and

gland is supplied by several branches which arise from inferior thyroid artery.

Inferior thyroid vein drains the lower border of gland. Middle

drains the middle thyroid gland

the carotid artery and enter the internal jugular vein.

is small and runs from brachiocephalic trunk in front of trachea

Review of

Fig 2. Diagramatic representation of blood supply of thyroid gland

Upper pole of thyroid is supplied by 1st branch of the external carotid


drains into the internal jugular vein.12 The inferior thyroid artery arises from

and passes behind the carotid sheath. Deep surface of the

supplied by several branches which arise from inferior thyroid artery.

Inferior thyroid vein drains the lower border of gland. Middle thyroid vein

drains the middle thyroid gland and courses laterally to pass in front or behind

the carotid artery and enter the internal jugular vein. The thyroidea ima artery

uns from brachiocephalic trunk in front of trachea13.


Page 7

representation of blood supply of thyroid gland

branch of the external carotid


inferior thyroid artery arises from

Deep surface of the

supplied by several branches which arise from inferior thyroid artery.

thyroid vein

and courses laterally to pass in front or behind

The thyroidea ima artery


Page 8

Lymphatics:

Major: Middle and Lower jugular, posterior triangle nodes.

Lesser: Pretracheal and para tracheal, Superior mediastinal nodes. The

lymphatic vessels end in the thoracic and right lymphatic trunk13

Nerve supply:

Superior cervical sympathetic ganglia, middle cervical sympathetic

ganglia and inferior cervical sympathetic ganglia.

The important structures that are important to note for surgery of

thyroid gland are the recurrent laryngeal nerves, the external laryngeal nerves

and the parathyroid glands14

Measurement of thyroid gland:

Thyroid gland measurement is important. It is done by taking three

measurements: They are the width, depth and length. Width of the thyroid

gland is measured by drawing an imaginary vertical line along the edge of

trachea laterally on the thyroid gland.

Depth is obtained by measuring the maximum anterior posterior

diameter in the same screen. Length of the thyroid gland is measured from the

cranial to caudal part of the lobe.15

Congenital anomalies of thyroid gland:

Hemiagenesis:

Thyroid gland is formed partially and this condition is called

hemiagenesis. It is a common anomaly. It can be diagnosed by USG.


Page 9

Aberrant thyroid:

Aberrant thyroid is another anomaly of thyroid gland, which can occur

in neck along the track of formation of thyroid gland. From the base of tongue

thyroid gland develops and descends to the larynx. Then it divides into two

and forms two lobes and isthumus of thyroid gland. Sometimes this descent is

failing to occur or interrupted, leads to failed bifurcation.

On USG lateral aberrant thyroid may show a pedicle or some kind of

attachment to thyroid. A fine-needle aspiration may be necessary to rule out a

metastatic lymph node from a nonvisualized microcarcinoma of the thyroid.

Thyroglossal duct:

When the thyroid gland is developing, thyroid gland descends from

base of the tongue to the larynx, a duct is formed. Rarely this duct may persist

and it is called as thyroglossal duct. The duct which is near isthumus persist

as pyramidal lobe.

Thyroglossal duct cyst:

Sometimes the entire thyroglossal duct persists, and protein material

secreted by the lining epithelium may form a thyroglossal duct cyst that

manifests itself clinically as a midline mass in the anterior aspect of the neck

above the isthmus. Brachial cleft cysts may look similar but its location is

more lateral in the neck.15,16


Page 10

Fig 3. Thyroid Hormones

REGULATION OF THYROID HORMONES 14,18

Secretion of the thyroid hormone depends upon two major factors.

� HPT axis ( hypothalamus-pitutary-thyroid )

� Negative feedback mechanism.

HPT axis:

Thyrotropin releasing hormone (TRH) is secreated from the median

eminence of hypothalamus. It is a bipeptide molecule of weight 28,000

daltons. This TRH stimulating the thyrotropes of anterior pituitary to secrete

and release TSH. TSH stimulates the follicular cells of thyroid gland and

stimulates every step of thyroid hormone synthesis.


Page 11

The ability of TSH to trap iodine depends to some extent, on the blood

iodine concentration. If the concentration of blood iodine high in high iodine

intake, the presence of adequate TSH, iodine trapping by follicular cells is

poor. If the food iodine intake is very low, TSH causes iodine trapping.

Negative feedback mechanism:

If food iodine content is very low, a little or no T4 is found. By the

negative feedback mechanism, TSH secretion increases leading to goiter and

this condition is called as iodine deficiency goiter. In case of hypothyroidism,

the serum concentration of TSH increases. In hyperthyroidism, the TSH

concentration of serum should be very low or nil.

Effects of TSH19, 20, 21:

� Increases proteolysis of thyroglobulin.

� Increases activity of iodine pump.

� Increases iodination of tyrosine.

� Increases size, number and secretory activity of the thyroid cells.

a) Effect of thyroid hormone on growth:

Thyroid hormone is necessary for growth & maturation. For this, the

action of T4 & T3 is helped by Insulin like growth factor & growth hormone,

T3 & T4 are required even in fetal life for maturation of growth centres.

Thyroid hormones also stimulates the process of bone remodelling. Thyroid

hormone are required for normal functioning of skeletal muscles18.


Page 12

b)Effect of thyroid hormone on CNS:

Presence of T3 & T4 is essential in the fetal brain during infancy for

proper development of brain, T3 & T4 are required for growth of cerebrum,

cerebellum, proliferation and branching of nerve fibers, along with

myelination.

The nerve fiber branching requires the presence of NGF (nerve growth

factor). If thyroid deficiency is not corrected within few months of birth, it

leads to cretinism.18 The hyperthyroid individual is likely to have extreme

nervousness and many psychoneurotic tendencies, such as anxiety

complexes, extreme worry and paranoia.14

c) Stimulation of fat metabolism

Thyroid hormone mobilizes lipid from fat tissue. This decreases the fat

stores in the body. This also increases the free fatty acid concentration in the

plasma and greatly accelerates the oxidation of free fatty acids by the cells.14

d) Stimulation of carbohydrate metabolism

Thyroid hormones stimulate all aspects of carbohydrate metabolism,

including uptake of glucose by the cells, enhanced glycolysis, enhanced

gluconeogenesis, increased rate of absorption from GIT, and even increased

insulin secretion and its resultant effect on carbohydrate metabolism. All this

effect probably results from the overall increase in the cellular metabolic

enzymes caused by thyroid hormone.14


Page 13

e) Effect on plasma and liver:

Increase in thyroid hormone decreases the concentration of cholesterol,

phospholipids and triglycerides in the plasma. It increases the free fatty acids

and vice versa. The large increase in circulating plasma cholesterol in

prolonged hypothyroidism is associated with atherosclerosis.14

f) Effect on basal metabolic rate:

Thyroid hormone increases the metabolism in almost all the cells of

the body. Therefore excessive quantities of hormone can occasionally

increase the BMR from 60% to 100% above normal. Conversely, when no

thyroid hormone is produced, BMR falls almost to one half of normal.18,19

g) Effect on Cardiovascular system.19

• Increases blood flow and cardiac output

• Increases heart rate

• Increases heart strength

• Normal arterial pressure.

h) Effect on sympathetic system:

Thyroid hormones facilitate all the three actions of catecholamines which

include glycogenolysis, adipose tissue lipolysis and neoglucogenesis. Thyroid

hormones increase the β1 adrenergic receptors of heart, hence in thyrotoxicosis

catecholamine response to heart (eg:tachycardia, palpitation) is enhanced,

therefore in thyrotoxicosis along with anti-thyroid drugs β-blockers are used.14,19


Page 14

i) Effect on the function of the muscles:

Increase in thyroid hormone usually makes the muscle react with

vigor, but with excessive hormone production, the muscles become

weakened because of excessive protein catabolism. Conversely lack of

thyroid hormone causes the muscles to become sluggish, they relax slowly

after a contraction.19

j) Effect on Gastrointestinal motility:

Hyperthyroidism often results in diarrhoea and hypothyroidism often

results in constipation.19

k) Effect on menstrual and reproductive function:

Lack of the thyroid hormone causes menorrhagia, polymenorrhoea,

irregular menses, amenorrhoea. They are also required for follicular

development, ovulation as well as for proper progress of pregnancy.14,19

l) Effect on sleep:

Due to the exhausting effects of thyroid hormone on the musculature

and on CNS, the hyperthyroid subject often has a feeling of constant

tiredness. But because of the excitable effect of thyroid hormones on the

synapses, it is difficult to sleep. Conversely extreme somnolence is a

characteristic of hypothyroidism, with sleep sometimes lasting from 12 to 14

hours a day.


Page 15

Iodine is an essential micronutrient for the synthesis of thyroid

hormones. T4 and T3 contains 4 and 3 atoms of iodine respectively. Iodine

is essential in minute amounts for normal growth and development of

humans22.

Imaging modalities of thyroid:

Ultrasound examination:

High frequency (7-15 MHz) linear-array transducer is used. Since

thyroid is located superficial sonography is the best imaging modality for

evaluation of thyroid. Scanning is done both in transverse and longitudinal

planes. Real time imaging of thyroid gland is done, it is performed using both

gray-scale and color Doppler techniques.

Fig 4. Picture shows the position of probe over the neck for ultrasound imaging


Page 16

Fig 5. This image shows the normal thyroid gland on ultrasound examination

Advanced ultrasound techniques:

Ultrasound elastography is a newer technique. It is a dynamic

technique which estimates stiffness of tissues by measuring the degree of

distortion under external pressure. It is used to study the elasticity/ hardness

of a thyroid nodule by which it can be differentiated as benign and malignant.

On compression benign nodules are softer and gets deformed easily whereas

malignant nodules are less deformed on compression. The elastographic

image (elastogram) is displayed in the B-mode image as a color scale. Based

on the local tissue elasticity it is seen as (i) very soft - blue color (tissue with

greatest elastic strain) (ii) very hard - red color ( tissue with no strain).

Another latest technique is real-time shear elastography which

characterizes and quantifies tissue stiffness. It is better than conventional

elastography. The disadvantage of elastography is, it cannot assess the

nodules which are not surrounded by thyroid tissues.


Page 17

Contrast-enhanced ultrasound (CE-US) is another newer technique. It

helps in characterizing a thyroid nodule as benign or malignant. For this

technique ultrasound specific contrast (e.g. Sono Vue) is used. Ultrasound

specific contrast with pulse inversion harmonic imaging improves the efficacy

of ultrasound in diagnosing malignant thyroid nodule. Depending on the

enhancement patterns the nodules can be differentiated as benign and

malignant lesions. Benign lesion shows ring enhancement, whereas

heterogeneous enhancement is seen in malignant lesions.23

Computed Tomography:

CT imaging involves multidetector acquisition from the base of the skull

to the bifurcation of trachea with or without contrast. Multiplanar 2-mm

axial, coronal and sagittal images are obtained. CT imaging is more useful in

malignant condition for characterizing the lesion and seeing the extent, to

evaluate the cervical lymphnodes and characterize the nodes. Relationship of

thyroid nodule to adjacent structures can also be evaluated. Lateral neck

nodal disease sometimes not well investigated by US, as well as nodal

disease in the parapharyngeal, retrolaryngeal, retrotracheal and retrosternal

regions, are clearly and reliably seen on contrast CT. Combination of US and

contrast CT produces an effective preoperative nodal map24.

Magnetic Resonance Imaging

Magnetic resonance imaging is used in some conditions. A neck

receiver coil is used to provide optimal image with optimal spatial resolution


Page 18

and signal to noise ratio. The images are taken in all three planes, axial,

coronal and sagittal. Slices are taken with thickness of around 3 to 5mm. T1

weighted, T2 weighted images are taken. Presaturation pulse sequence is

taken to reduce the flow artefact. The major indication of MRI imaging is to

evaluate the retrosternal extension of thyroid, invasion in cases of

malignancy. But MRI does not provide information about specific nodules.25

Scintigraphy:

Scintigraphy is done to assess thyroid nodules. It is used in patients with

suppressed TSH level in whom scintigraphy allows assessment of the functional

activity of a thyroid nodule and activity of the whole gland. A functioning, or

“hot,” thyroid nodule is not malignant mostly, only few cases were reported as

malignancy. Although a nonfunctioning, or “cold,” nodule at scintigraphy is

commonly thought to indicate an increased risk of thyroid malignancy, as many

as 77% of cold thyroid nodules may be benign. Thyroid scintigraphy therefore is

not so helpful for differentiating a benign nodule from a malignant nodule.11

Benign lesions11

(i) Thyroiditis

• Chronic lymphocytic (Hashimoto) thyroiditis

(ii) Benign follicular nodule

• Adenomatoid nodule.

• Colloid nodule


Page 19

(iii) Follicular adenoma

• Hurthle cell adenoma

Malignant lesions

(i) Papillary carcinoma

(ii) Follicular carcinoma

• Hürthle cell carcinoma

• Poorly differentiated carcinoma

(iii) Anaplastic/undifferentiated carcinoma

(iv) Medullary carcinoma

(v) Lymphoma

(vi) Metastasis

Benign lesion:

The sonographic characteristic of benign nodules are ovoid or flat

shape, smooth margin, isoechogenicity and peripheral vascularity. Peripheral

vascularity on sonography is defined as vascular predominance in the

periphery of the nodule in a color Doppler.26

Thyroiditis:

Lymphocytic thyroiditis is also known as hashimotos thyroiditis. It can

be diffuse or focal nodule. Diffuse is seen as heterogenous hypoechogenicity

with micronodulations. Focal thyroid nodule is seen as solid, ill defined

hypoechoic nodule. Lymphocytic thyroiditis has predisposition to develop as


Page 20

papillary thyroid carcinoma. Sonographic features evaluated in the lesion are

internal component, margin, echogenicity , shape and calcifications. An

internal components were classified based on four categories: 1) solid mass,

2) mass that has a solid portion of more than 50%, 3) mass that has a solid

portion of less than 50%, and 4) cyst. Sonographic features suspicious of

malignancy were defined as marked hypoechogenicity (decreased echogenicity

on comparing with the surrounding strap muscle), microlobulated or irregular

margin, microcalcification, hyperechoic foci, either with or without acoustic

shadows), or nonparallel shape (anteroposterior diameter greater than the

transverse diameter). As disease progresses micronodules can increase in size

and it can be seen as large hypoechoic mass on sonography.

Focal nodules which was proved to be thyroiditis was seen as

hypoechoic nodules with ill defined margins, so it is difficult to differentiate

from papillary thyroid carcinoma and lymphoma. On cytology the lesion is

diagnosed as lymphocytic thyroiditis when it shows grouped, monolayer sheets

or scattered follicular and Hurthle cells and scattered lymphocytes; scanty

colloid; follicular cells showed nuclear atypia with nuclear enlargement.13

Benign Follicular Nodule

Nodular goiter, colloid nodules, adenomatoid or hyperplastic nodules,

nodules in Graves disease, and macrofollicular subtype follicular adenoma

are the different types of benign follicular nodule.


Page 21

It is caused due to hyperplasia of the gland. Etiology are iodine

deficiency (endemic), disorders of hormonogenesis (hereditary familial

forms), and poor utilization of iodine. More common in females than males in

the age group 35 to 50. There is increase in the size of the gland. Hyperplastic

nodules undergo liquefactive degeneration and there is accumulation of blood,

serous fluid, and colloid substance.27

Sonographically the hyperplastic nodules are isoechoic to normal

thyroid tissue but can become hyperechoic because of the interfaces between

cells and colloid substance. Rarely seen as hypoechoic sponge like or

honeycomb pattern. A thin peripheral hypoechoic halo is seen around the

nodule , which is caused by the blood vessels and compression of adjacent

normal parenchyma. Echogenic foci with comet-tail artifacts which are

caused by microcrystals or aggregates of the colloid substance. These colloid

substances move like snowflakes, within the fluid collection28.

Follicular adenoma:

It is a benign neoplastic growth contained within a capsule. Adenoma

implies specific benign new tissue growth with gland like cellular structure.

More frequent in females. Causes can be thyroid radiation, chronic TSH

stimulation etc. The benign follicular adenoma is a true neoplasm of thyroid

which is characterized by compression of adjacent tissues and fibrous

encapsulation. Based on the type of cell proliferation it is classified into

subtypes as the fetal adenoma, Hurthle cell adenoma, and embryonal


Page 22

adenoma. Most are solitary but sometimes it can be multiple also.

Sonographically adenomas are seen as hyperechoic, isoechoic or hypoechoic

solid masses with a peripheral hypoechoic halo that is smooth and thick.

Mostly the halo is complete and it is due to the fibrous capsule and blood

vessels, which is seen by color Doppler. Vessels are seen passing from the

periphery to the central regions of the nodule, which is seen as a "spoke-and-

wheel-like" appearance. Follicular carcinoma and follicular adenoma cannot

be differentiated by ultrasound or by cytological evaluation.29,30

Malignant lesions:

US features, such as marked hypoechogenicity, irregular margin,

microcalcifications, and a taller-than-wide shape have been introduced as

potential predictors for the presence of thyroid malignancies.26

Papillary carcinoma:

Females are more affected than males and the peak age group is 3rd

decade and 7th decade. Spread is through lymphatics and mostly seen in

adjacent cervical lymphnode.

Sonographic features are

a. Hypoechogenicity (seen in 90% of cases), which is due to closely

packed cell content, and minimal colloid substance.

b. Microcalcifications, seen as tiny, punctuate hyperechoic foci, with or

without acoustic shadowing microcalcifications may be the only


Page 23

sonographic sign of aggressive cases of papillary carcinomas of

childhood which is rare, even without the evidence of a nodular lesion.

c. Hypervascularity (seen in 90% of cases), with disorganized

vascularity, is mostly seen.

d. Cervical lymph node metastases is seen, which contains tiny, punctate

echogenic foci which is caused by microcalcifications. Retraction of

capsule can be seen. Papillary carcinomas rarely show cystic changes31.

Follicular Carcinoma:

More common in females than males and accounts for 5% to 15% of

thyroid cancer. It can be minimally invasive and widely invasive follicular

carcinoma. Minimally invasive follicular carcinoma is encapsulated and there

is focal invasion of capsular blood vessels of the fibrous capsule

histologically. Widely invasive follicular carcinoma is not well encapsulated,

and the invasion of vessels and adjacent thyroid is seen. Both the variants of

follicular carcinoma spreads hematogenously and distant metastasis is more

common. Brain, lung, liver and bone are more prone to metastases than

cervical lymph node. Sonographic features of follicular carcinoma are

irregular tumor margins, a halo which is thick and irregular .On color Doppler

imaging internal blood vessels shows tortuous or chaotic arrangement.32,43

Medullary Carcinoma:

Medullary carcinoma arises from parafollicular C cells of thyroid gland

which is derived from the neural crest. So it is a neuroendocrine tumor and is


Page 24

classified as part of apudomas. More common in females than males and peaks

age group is 40 to 65 years. Associated with MEN 2 syndromes. Sonographic

features are hypoechogenicity, internal vascularity, spiculated margins, and

calcifications. Longitudinal diameter of nodules are greater than transverse

diameter. These nodules are larger and more cystic and shows homogenous

echotexture in the solid component of the lesion. These lesions outgrow their

blood supply and this leads to necrosis and cystic degeneration. Nodal

metastasis is seen in nodes with irregular margins or bulging outlines,

heterogeneous echotexture, calcifications (micro or macrocalcifications), cystic

foci, and abnormal vascularity. Distant metastases is also seen and the common

distant metastatic sites are the liver, lung and mediastinum and bone.33

Lymphoma:

PTL is a rare pathology and constitutes about 5% of all thyroid

malignancies. It is more common in females than males; most patients are

diagnosed in their 6th or 7th decade of life. Based on the sonography lymphoma

is classified as nodular, diffuse, and mixed types. Posterior acoustic enhancement

is useful in discriminating PTL from severe Hashimoto’s thyroiditis. Rapid

growth , painless thyroid enlargement, and pressure symptoms are the common

clinical presentations of Lymphoma. Multifocal, markedly hypoechoic, goiter,

hypervascular and absence of calcification, were features of non-diffuse type of

lymphoma. Due to the extremely low level of internal echoes, nodular PTLs

have been described as ‘‘pseudocysts’’ in previous studies. 34


Page 25

Metastasis

Metastatic disease is suspected when a solid thyroid nodule is found in

patient with a known nonthyroid malignancy.

Description of thyroid nodule:

Benign and malignant thyroid nodules have different features which

helps in differentiating the lesion as benign or malignant. The features are as

follows.

Benign lesion

US features suggestive of a benign nodule are an ovoid-to-round

shape, a well-defined smooth margin, isoechogenicity, and a spongiform

appearance. Calcifications can be there. Rim calcification without cortical

break43.

Malignant characteristic of thyroid nodule:

High-resolution ultrasonography is commonly used to evaluate the

thyroid gland. Microcalcifications are one of the most specific US findings of

a thyroid malignancy. Other US features are marked hypoechogenicity,

irregular margins, and the absence of a hypoechoic halo around the nodule.

Lymphadenopathy and local invasion of adjacent structures are specific

features of thyroid malignancy. Thyroid malignancies are relatively rare.

Multiple features of thyroid malignancy if appears in combination it is

possible to make an accurate prediction.35,43


Page 26

Direct tumor invasion of adjacent soft tissue, extracapsular extension

and metastases to lymph nodes are highly specific for thyroid malignancy.

Pressure effects such as dysponea, hoarseness and dysphagia are caused by

invasion of the trachea or larynx, the recurrent laryngeal nerve, or the

esophagus35.

Calcification:

Microcalcification is commonly seen in papillary carcinoma. It has a

specificity of 85% to 95%. Coarse calcifications are more common in

medullary carcinoma it can be seen on papillary carcinoma. Inspissated

colloid calcifications may mimic microcalcification. It is distinguished by ring

down artifact/reverberation artifact/ comet tail artifact. Peripheral calcification

is more common in multinodular goiter. Break in peripheral calcification is

suggestive of malignant transformation of the underlying goiter28.

Margins, contour and shape:

Hypoechoic halo is suggestive of benignity. It is composed of

pseudocapsule of fiberous connective tissue or compressed thyroid

parenchyma. In some lesions the margin is not well defined. Ill defined

margins indicate infiltration to adjacent parenchyma. Shape is ovoid to round

is chareteristic of benign lesion and taller than wide is suggestive of malignant

lesion. Contour of the lesion is smooth and rounded in benign and irregular

jagged edges are seen in malignant lesions.36


Page 27

Echogenicity:

Malignant lesions are markedly hypoechoic compared to the strap

muscles. Malignant nodules are hypoechoic with predominantly solid

components, some of the malignant lesion can have cystic content. Benign

lesions are hyperechoic or iso echoic commonly. Contents can be cystic or

solid37.

Vascularity:

Marked intrinsic hypervascularity is seen in malignant lesion in which

flow in the central part of lesion is more than the flow in the surrounding area.

Benign nodules can show perinodal vascularity or it can be avascular37.

Lymphnode metastasis.

US features that are suspicious about lymph node metastases are a

rounded bulging shape, increased size, replaced fatty hilum, irregular

margins, heterogeneous echotexture, calcifications, cystic areas and

vascularity throughout the lymphnode instead of normal central hilar vessels

at Doppler imaging35.

Ankush Dhanadia et al evaluated that out of 100 cases, 8% were

malignant, 66% were benign and 26% were indeterminate lesions on grey

scale ultrasound. All the 8 malignant cases were correctly diagnosed as

malignant on pathology. Out of 66 benign cases, 2 benign cases proved to be

malignant on pathology as papillary carcinoma. Both cases on USG

presented as a hypo echoic lesion with well defined margin and coarse


Page 28

calcification. Due to coarse calcification they were diagnosed as benign on

ultrasonography but turned out to be malignant on pathology as papillary

carcinoma1.

Hiren.R. Panchal et al evaluated that sonography proves to be the best

tool of diagnosis in benign pathologies of thyroid such as multinodular

goitre, diffuse hyperplasia of thyroid, follicular adenoma and Thyroglosal

cyst.2

Hee Jung Moon et al evaluated that lymphocytic thyroiditis can show

variable features on sonography. When a nodule shows probably benign

features on sonography, follow-up with sonography is sufficient. However, if

a nodule shows suspicious malignant features on sonography and shows no

change or increase in size on follow-up examination, follow-up sonography-

guided FNAC should be performed.

Mallikarjunappa et al study revealed that features like hypoechoic

nodule with microcalcification, coarse calcification in a hypoechoic nodule,

well marginated oval shape nodule with hypoechoic halo, irregular solid

nodule with hypervascularity with local invasion, distant lymph node

metastasis are more specific for malignancy or are potentially malignant and

should undergo FNAC. Nodules of irregular margins of hypoechoic, with

intervening halo, nodule with colloid goitre, well defined hypoechoic

nodules with internal echo’s, with well defined borders, with avascular

nodule need not to be biopsied, should be left alone and followed up.3


Page 29

Mary C. Frates et al had done a retrospective cohort study for eight

years from 1995 – 2003 in a tertiary hospital. The aim of the study was to

compare the risk of thyroid cancer in patients with solitary nodules to that in

patients with multiple nodules. This study done on 3200 patients showed that

solitary nodule has a higher risk of malignancy than multiple nodules.

Multiple nodules which were of size more than 1cm had multifocal

distribution on cancer. Sonographic characteristics can be used to prioritize

nodules for FNAC based on their individual risk of cancer. Study also

showed that a patient with one or more thyroid nodules larger than 10 mm in

diameter, the likelihood of thyroid cancer per patient is independent of the

number of nodules, whereas the likelihood per nodule decreases as the

number of nodules increases. For exclusion of cancer in a thyroid with

multiple nodules larger than 10 mm, upto four nodules should be considered

for FNAC.38

Jenny K. Hoang et al studied that Thyroid nodules are common and

occur in up to 50% of the adult population; however, less than 7% of thyroid

nodules are malignant. High-resolution ultrasonography is commonly used

to evaluate the thyroid gland, but US is frequently misperceived as unhelpful

for identifying features that distinguish benign from malignant nodules.

Microcalcifications are one of the most specific US findings of a thyroid

malignancy. Other useful US features include a marked hypoechogenicity,

irregular margins, and the absence of a hypoechoic halo around the nodule.


Page 30

Lymphadenopathy and local invasion of adjacent structures are highly

specific features of thyroid malignancy but are less commonly seen. The

number, size, and interval growth of nodules are nonspecific characteristics.

Suspicious US features may be useful for selecting patients for fine-needle

aspiration cytology when incidental nodules are discovered and when

multiple nodules are present.35

Sreeramulu et al evaluated the usefulness of clinical examination, Fine

Needle Aspiration Cytology (FNAC) and ultrasonography thyroid in the

management of thyroid nodule and compare the efficacy of FNAC and USG.

Thyroid nodules are common in females of age group 31-40 yrs, all 200

patients presented with swelling in front of the neck. A total of 200 cases of

solitary nodule thyroid evaluated from October 2007 to December 2011 at

the RL Jalappa hospital and research center, Kolar, was studied. The

sensitivity and specificity of FNAC were 74% and 100% respectively.

The sensitivity and specificity of USG were 73% and 85.3%

respectively, hence with the use of USG along with FNAC will improve the

diagnostic accuracy to a higher level. Solitary nodule thyroid (SNT) more in

females (M: F 1:2.2). Duration of swelling prior to the presentation was from

6 months to 3 yrs. The incidence of malignancy in our series in SNT is18%.

On FNAC majority were benign with being more common. All the lesions

suspicious on FNAC (31.3%) proved to be a malignant indicating need for

surgery.39


Page 31

Amita K et al studied the Sensitivity, specificity and accuracy of S-

FNAC were 50%, 97.36% and 92.85% respectively, while for USG-FNAC

they were 87.5%, 100% and 98.21% in similar order. False negative and

false positive rates for S-FNAC were 4.76% and 2.3% respectively, while for

USG-FNAC they were 1.81% and 0% respectively.36

Jain G et al did a prevalance study of Thyroid function changes in

HIV infection at various stages of the illness. 50 subjects belonging to both

sexes, all newly diagnosed HIV positives were enrolled for the study. Results

showed a direct correlation between CD4 count and Free T3 and Free T4

values and an inverse correlation of CD4 counts with serum thyroid

stimulating hormone(TSH) levels. They concluded that thyroid dysfunction is

frequent in HIV infection and with progression of disease there is a primary

hypothyroid like stage40.

TIRADS

Su Yeon Ko et al in his study stated that Thyroid Imaging Reporting

and Data System was developed for risk stratification of thyroid nodules by

using US features. Even though several studies have suggested that TI-RADS

helps to avoid confusion among physicians and patients and it reduces

unnecessary benign cytologic results, there is difficulty in applying this

approach in daily practice because of its complexity. TI-RADS is categorized

as category 3 (probably benign) when there are nodules with no suspicious

US feature, category 4a (low suspicion for malignancy) when there is nodule


Page 32

with one suspicious US feature, category 4b (intermediate concern for

malignancy) when there are nodules with two suspicious US features,

category 4c (moderate concern but not classic for malignancy) when there are

nodules with three or four suspicious US features, and category 5 (highly

suggestive of malignancy) when there are nodules with five suspicious US

features. The suspicious US features are, a solid component,

hypoechogenicity, marked hypoechogenicity, microlobulated or irregular

margins a solid component.41

The society of radiologist and other specialist has created a consensus

statement for the management of thyroid nodules which were identified on

ultrasound weather the nodule should undergo FNAC or no need of FNAC.

Even though the benign and malignant sonographic characters overlap thyroid

gland should be subjected for ultrasound evaluation prior to surgery and if the

nodules were larger than 1cm with microcalcification and solid contents then

it is strongly recommended for FNAC. If the lesion is mixed solid cystic then

it can be considered for FNAC and if the lesion is cystic then FNAC is not

probably necessary42.

Bonavita et al had studied in 1232 patients. In their study they had the

ultrasound images and cytopathology report. First 500 nodules were reviewed

and grouped as reproducible patterns of morphology or different pattern

recognition. This pattern recognition was better in the identifying the nodules

which are benign. From the study four specific patterns were identified. They


Page 33

are i) spongiform configuration, ii) cyst with colloid clot, iii) giraffe pattern,

and iv) diffuse hyperechogenicity. This pattern recognition had a 100%

specificity for benign nodules. When a pattern recognition of nodules are used

this can prevent a large number of FNAC which is invasive and painful

compared to ultrasound. If the nodules does not have any of these four

patterns then the nodule should be subjected to FNAC regardless of the

individual features of the nodule.44

Most of the nodules in hashimotos thyroiditis are benign but there are

possibilities of these nodules being malignant such as lymphoma or papillary

carcinoma. Nodules which are present with thyroiditis should be subjected to

FNAC.47

Palanniappan et al studied on 300 patients which showed nodular

goiter is a cause of enlarged thyroid. Their study also stated thyroid disorders

are more common in females and concluded that FNAC is safe, simple

method which helps in decision making in surgery of thyroid nodules.48

Materials & Methods

Materials & Methods

Page 34

MATERIALS AND METHODS

STUDY DESIGN

This is a Cross sectional study.

STUDY SETTINGS

Radiodiagnosis outpatient department and pathology department in

Sree Mookambika Institute of Medical Science, Kulaseharam.

APPROXIMATE DURATION OF THE STUDY

1 year (June 2015 to June 2016)

DETAILED DESCRIPTION OF THE STUDY GROUP:

Patients with thyroid lesions on sonography of age group from 10-75

years.

SAMPLE SIZE OF THE STUDY

Using the formula, 4pq/d² (the Ankush Dhanadia et al study, the study

within India and with the lowest prevalence, from the studies used as

reference, taken as the value of p), the sample size was calculated to be – 62

Sample size (n) = 4pq/d2,

Where

p = prevalence

q = 1 – prevalence

d = precision is 15%

Substituting in the formula, (n) = 4pq/d2

Materials & Methods

Page 35

= 4 x 74 x 26 / 11.12

= 7696 / 123.2

= 62

The sample size was calculated to be 62.

SAMPLING TECHNIQUE

Convenient sampling technique

INCLUSION CRITERIA:

i. Age group10-75 years

ii. Patients with thyroid disorder with USG showing thyroid lesion

iii. Patient giving consent

EXCLUSION CRITERIA

i. Patients with bleeding disorders

ii. Patient refusal for FNAC

STUDY METHOD

After approval by institutional ethical committee, patients of age group

between 10 to 75 years of both gender (males and females) who had thyroid

disorders which were clinically symptomatic (viz dysphagia, hoarseness of

voice, weight gain, altered menstrual cycles etc.) with altered levels of

thyroid hormones or clinically symptomatic but with normal thyroid

hormone levels or clinically suspected cases with no specific symptoms and

had thyroid lesions on ultrasonography were enrolled in the study with a

written informed consent.

Materials & Methods

Page 36

Sonographic evaluation:

Convenient sampling technique is used to select 62 patients with

thyroid lesions which were referred to the Department of Radio diagnosis;

Sree Mookambika Institute of medical sciences. All scans are done using

Siemens Acuson X 300, Siemens Acuson X 600, colour Doppler equipment

with a linear array high frequency (3-12 MHz) transducer. Patients who were

fulfilling the inclusion criteria of age group, thyroid disorders underwent

sonographic evaluation. Sonography characterizes if thyroid gland is enlarged

or not, if the echogenicity of thyroid gland is homogenous or heterogenous,

vascularity of the thyroid gland, if there is any nodule in the thyroid gland. If

nodules are present then it should be identified as single or multiple and the

size of the nodule should be measured. Nodules smaller than 5mm were not

characterized. Nodules larger than 5mm were characterized based on the

echogenicity, shape of the nodule, margins of the nodule, contents within the

nodule, calcifications in the nodule and vascularity in the nodule. The patients

who had lesions in thyroid were subjected to FNAC with informed written

consent.

FNAC OF THYROID:

FNA biopsy equipment is simple and inexpensive.

Materials required to collect the specimen5

1) Consent

2) Gauze pads

Materials & Methods

Page 37

3) Container with ehtanol

4) glass slides

5) 10-mL plastic syringes,

6) Disposable 23- or 27-gauge needles, 1 1/2 inches long

7) Gloves

8) Laboratory slips with the patient’s name, OP number, biopsy sites, and

other relevant information to be transferred to the cytology laboratory

9) local anesthetic Lidocaine (if needed)

Collection of Specimen:5,6

Patient is placed in supine position with neck extended. Skin is first

cleaned with povidone iodine, and it is draped. The patient is instructed not do

any voluntary act of swallowing. Then the lesion is focused with the help of

ultrasound. USG gel is not used. Povidone iodine acts as coupling agent.

Local anesthetic may be used if needed.

A 23to 27 gauge needle is used, which is attached to a 10ml syringe.

The transducer is placed over the thyroid gland and the lesion is localized

and its relation to adjacent vessel is identified. The needle is inserted

parallel or perpendicular to the transducer. Needle tip is monitored and

when it reaches the lesion aspiration is done atleast twice and material is

collected.7

Materials & Methods

Page 38

Fig 6. Diagram depicting the parallel positioning of the needle

Fig 7. Ultrasound image showing tip of the needle within the lesion

Materials & Methods

Page 39

Materials obtained from aspiration biopsy were expelled onto

glass slides and smeared. All smears were placed immediately in 95%

ethanol for Papanicolaou staining. Then the specimen is sent to pathology

for reporting.

Thyroid lesions based on ultrasonographic charecteristics is identified

as thyroiditis, Multinodular goiter, colloid goiter, thyroiditis with

multinodular goiter, papillary carcinoma, medullary carcinoma etc.

Ultrasound character of the lesion is correlated with the FNAC. Follicular

neoplasm and follicular adenoma is difficult to differentiate by both

ultrasound and FNAC. So in ultrasound these follicular lesions are classified

as adenomatous nodules and on FNAC these are classified as follicular

neoplasm.

Sensitivity and Specificity8:

The specificity or true negative rate (TNR) is defined as the percentage

of patients who are correctly identified as being healthy

Specificity = TN/ TN+ FP

The sensitivity or true positive rate (TPR) is defined as the percentage

of patients who are correctly identified as having the disease

Sensitivity =TP /TP+ FN

Positive predictive value

The positive predictive value (PPV) of a test is defined as the

proportion of people with a positive test result who actually have the disease.

Materials & Methods

Page 40

Negative predictive value

The NPV of a test is the proportion of people with a negative test result

who do not have disease.

Sensitivity of FNAC is upto 94% and specificity is upto 98% for

diagnosis of malignant lesions and nearly 90% accurate in the identification

of malignancy, other than follicular lesion.

Table:1 Statistical parameter

Sl. No Statistical parameter Formula

1 Sensitivity TP/(TP+FN)x100

2 Specificity TN/(TN+FP)x100

3 Positive predictive value TP/(TP+FP)x100

4 Negative predictive value TN/(TN+FN)x100

5 Diagnostic accuracy TN+TP/(TP+FN+TN+FP)x100

Analysis &

Interpretation

Analysis &

Interpretation

ANALYSIS

This study, in patients with thyroid disorders was completed in a period

of one year in the Department of Radiology

Medical Sciences, Padanilam, Kulasekharam, Kanyakumari District. A total

of 65 patients were taken in the study and out of these 2 patients had

hemorrhagic sample and one patient was not willing for FNAC. The study

was done for 62 patients who were within the age group of 10 to 75years.

Both males and female patients were included in the study.

Statistical analysis: The data was expressed in number and percentage. Chi

square test applied to find the statistical significant. P value less than 0.05

considered statistically significant at 95% confidence interval.

Demographic data

Fig. 8: Distribution of patients based

0

10

20

30

40

50

60

Num

ber

Analysis & Interpretation

ANALYSIS AND INTERPRETATION

in patients with thyroid disorders was completed in a period

he Department of Radiology, Sree Mookambika Institute of


were taken in the study and out of these 2 patients had


or 62 patients who were within the age group of 10 to 75years.

Both males and female patients were included in the study.

The data was expressed in number and percentage. Chi


considered statistically significant at 95% confidence interval.

: Distribution of patients based on gender

Male Female

2

60

Gender

& Interpretation

Page 41

in patients with thyroid disorders was completed in a period

Sree Mookambika Institute of


were taken in the study and out of these 2 patients had


or 62 patients who were within the age group of 10 to 75years.

The data was expressed in number and percentage. Chi


Fig. 9: Distribution of patients based on the age

Table-2: Distribution of patients based on family history of thyroid

disorder

Family history of thyroid disorder

Yes

No

Table-3: Distribution of

Thyroid function test

Normal

Hypothyroidism

Hyperthyroid

41

43.55 %


: Distribution of patients based on the age

: Distribution of patients based on family history of thyroid

Family history of thyroid Number Percentage (%)

20 32.26

42 67.74

: Distribution of patients based on thyroid function test

Thyroid function test Number Percentage (%)

23 37.10

21 33.87

18 29.03

>20 Y

4.84 %

21-40 Y

41.94 %

41-60 Y

43.55 %

< 60 Y

9.68 %

& Interpretation

Page 42

: Distribution of patients based on family history of thyroid

Percentage (%)

Percentage (%)

37.10

33.87

29.03


Page 43

Table-4: Distribution of patients based on thyroid swelling

Thyroid swelling Number Percentage (%)

Yes 45 72.58

No 17 27.42

SONOGRAPHIC EVALUATION

Table-5: Distribution of patients based on size of thyroid gland

Size of thyroid gland Number Percentage (%)

Normal 15 24.19

Enlarged 47 75.81

Table-6: Distribution of patients based on echo texture of thyroid

parenchyma

Echo texture of thyroid parenchyma

Number Percentage (%)

Homogenous 27 43.55

Heterogeneous 35 56.45


Page 44

Table-7: Distribution of patients based on vascularity of thyroid

parenchyma

Vascularity of thyroid parenchyma Number Percentage (%)

Normal 26 41.94

Increased 36 58.06

Table-8: Distribution of patients based on nodule

Nodule Number Percentage (%)

Absent 9 14.52

Present 53 85.48

Description of nodule

Table-9: Distribution of thyroid lesions based on number of nodules

Number of nodules Number Percentage (%)

Single 17 30.36

Multiple 39 69.64

Total 56 100.00


Page 45

Table-10: Distribution of thyroid lesions based on size of the nodule

Size Number Percentage (%)

<5 mm 19 33.93

5 mm-1 cm 9 16.07

>1 cm 28 50.00

Total 56 100

Table-11: Distribution of thyroid lesions based on shape of the nodule

Shape Number Percentage (%)

Ovoid to round (Benign) 32 84.21

Taller and wide (Malignant) 6 15.79

Total 38 100.00

Table-12: Distribution of thyroid lesions based on margins of the nodule

Margins Number Percentage (%)

Well defined smooth 26 68.42

Well defined spiculated 3 07.89

Ill defined 9 23.69

Total 38 100.00


Page 46

Table-13: Distribution of thyroid lesions based on echogenicity of the

nodule

Table-14: Distribution of thyroid lesions based on halo of the nodule

Halo Number Percentage (%)

Absent 14 38.89

Complete 21 58.33

Incomplete 03 8.33

Total 38 100.00

Table-15: Distribution of thyroid lesions based on contents of the nodule

Contents Number Percentage (%)

Predominantly solid 21 58.33

Predominantly Cystic 6 16.67

Comet tail artifact 11 30.56

Total 38 100.00

Echogenicity Number Percentage (%)

Anechoic 10 26.32

Hypoechogenic 07 18.42

Isoechogenic 13 34.21

Hyperechogenic 08 21.05

Total 38 100.00


Page 47

Table-16: Distribution of thyroid lesions based on calcification within the

nodule

Calcification Number Percentage (%)

Absent 18 47.37

Rim Calcification 07 18.42

Macrocalcification 05 13.16

Microcalcification 08 21.05

Total 38 100.00

Table-17: Distribution of thyroid lesions based on vascularity of the

nodule

Vascularity Number Percentage (%)

Avascular 12 31.58

Intrinsic hypervascular 06 15.79

Perinodal Vascularity 11 28.95

Both intrinsic and perinodal vascularity 09 23.68

Total 38 100.00


Page 48

Table-18: Distribution of thyroid lesions based on ultrasound diagnosis

Table-19: Distribution of thyroid lesions based on FNAC diagnosis

Ultrasound diagnosis Number Percentage (%)

Thyroiditis 25 40.32

Colloid goiter 17 27.42

MNG 09 14.52

Medullary carcinoma 01 1.61

Papillary carcinoma 01 1.61

Adenomatous nodule 06 9.68

MNG with thyroiditis 03 4.84

Total 62 100.00

Ultrasound diagnosis Number Percentage (%)



MNG 07 11.29




MNG with thyroiditis 00 00.00

Total 62 100.00


Page 49

Table-20: Matching of ultrasound diagnosis with FNAC diagnosis

Table-21: Comparison of ultrasound diagnosis with FNAC diagnosis

Type Number Percentage (%)



MNG 07 12.96




Total 54 100.00

Type Positive

predictive value

Negative predictive

value Sensitivity Specificity

Thyroiditis 92.59 07.41 86.20 90.00

Colloid goiter 94.12 05.88 88.89 72.00

MNG 100.00 00.00 100.00 100.00

Medullary carcinoma 100.00 00.00 100.00 100.00

Papillary carcinoma 66.67 33.33 85.00 75.00

Adenomatous nodule 66.67 33.33 85.00 75.00


Size of nodule Number

5 mm-1 cm 9

>1 cm 25

Total 35

(*p<0.05 significant compared benign with malignant)

Fig. 10: Distribution of thyroid lesions

0

5

10

15

20

25

Benign

Num

ber


: Distribution of thyroid lesions based on FNAC with size of nodule

Benign Malignant

Number Percentage (%) Number Percentage (%)

9 25.71 0*

25 74.29 3* 100.00

35 100 3


thyroid lesions based on FNAC with size of nodule

Benign Malignant

5 mm-1 cm >1 cm

& Interpretation

Page 50

based on FNAC with size of nodule

Malignant

Percentage (%)

00.00

100.00

100

based on FNAC with size of nodule


Margins

Well defined smooth

Well defined spiculated

Ill defined

Total


Fig. 11: Distribution of

0

10

20

30

40

50

60

70

Per

cent

age

(%)

Well defined smooth


: Distribution of thyroid lesions based on FNAC with margin

Benign Malignant


Number Percentage

24 68.57 1*

Well defined spiculated 2 5.71 2

9 25.71 0*

35 100 3


: Distribution of thyroid lesions based on FNAC with margin

Benign Malignant

Well defined smooth Well defined spiculated Ill defined

& Interpretation

Page 51

based on FNAC with margin

Malignant

Percentage (%)

33.33

66.67

00.00

100

based on FNAC with margin

Ill defined


echogenicity

Echogenicity Number

Anechoic

Hypoechogenic

Isoechogenic

Hyperechogenic

Total



0

2

4

6

8

10

12

Num

ber

Anechoic Hypoechogenic


: Distribution of thyroid lesions based on FNAC with

Benign Malignant


Number Percentage

10 28.57 0* 00.00

5 14.29 2* 66.67

12 34.29 1* 33.33

8 22.86 0* 00.00

35 100 3


: Distribution of thyroid lesions based on FNAC with echogenicity

Benign Malignant

Hypoechogenic Isoechogenic Hyperechogenic

& Interpretation

Page 52

based on FNAC with

Malignant

Percentage (%)

00.00

66.67

33.33

00.00

100

based on FNAC with echogenicity

Hyperechogenic


Halo Number

Absent 13

Complete 21

Incomplete 1

Total 35

(*p<0.05 significant


0

10

20

30

40

50

60

70

Per

cent

age

(%)

Absent


: Distribution of thyroid lesions based on FNAC with halo

Benign Malignant


Number Percentage

13 37.14 1* 33.33

21 60.00 0* 00.00

1 2.86 2 66.67

35 100 3


: Distribution of thyroid lesions based on FNAC with halo

Benign Malignant

Absent Complete Incomplete

& Interpretation

Page 53

based on FNAC with halo

Malignant

Percentage (%)

33.33

00.00

66.67

100

based on FNAC with halo


Contents

Predominantly solid

Predominantly Cystic

Comet tail artifact

Total



0

2

4

6

8

10

12

14

16

18

Num

ber

Predominantly solid


: Distribution of thyroid lesions based on FNAC with contents

Benign Malignant

Number Percentage

(%) Number Percentage

18 51.43 3

Predominantly Cystic 6 17.14 0

11 31.43 0

35 100 3


: Distribution of thyroid lesions based on FNAC with contents

Benign Malignant

Predominantly solid Predominantly Cystic Comet tail artifact

& Interpretation

Page 54

based on FNAC with contents

Malignant

Percentage (%)

100.00

00.00

00.00

100

contents

Comet tail artifact


calcification

Calcification Number

Absent

Rim Calcification

Macrocalcification

Microcalcification

Total



02468

1012141618

Num

ber

Absent

Macrocalcification


: Distribution of thyroid lesions based on FNAC with

Benign Malignant

Number Percentage (%) Number Percentage

17 48.57 1 33.33

7 20.00 0 00.00

4 11.43 1 33.33

7 20.00 1 33.33

35 100 3


: Distribution of thyroid lesions based on FNAC with calcification

Benign Malignant

Absent Rim Calcification

Macrocalcification Microcalcification

& Interpretation

Page 55

based on FNAC with

Malignant

Percentage (%)

33.33

00.00

33.33

33.33

100

based on FNAC with calcification


of nodule

Vascularity

Avascular

Intrinsic hypervascular

Perinodal Vascularity

Both intrinsic and perinodal vascularity

Total



of nodule

0

2

4

6

8

10

12

Num

ber


: Distribution of thyroid lesions based on FNAC with vascularity

Benign Malignant

Number Percentage

(%) Number

Percentage

12 34.29 0

5 14.29 1

10 28.57 0

8 22.86 2

35 100 3


: Distribution of thyroid lesions based on FNAC with vascularity

Benign Malignant

Avascular

Intrinsic hypervascular

Perinodal Vascularity

Both intrinsic and perinodal vascularity

& Interpretation

Page 56

based on FNAC with vascularity

Malignant

Percentage (%)

00.00

33.33

00.00

66.67

100

based on FNAC with vascularity


Page 57

Table-29: Distribution of thyroid lesions based on thyroid disorder and

age

Type >20

years 21-40 years

41-60 years

<60 years

Thyroiditis 04 14 07 00

Colloid goiter 00 05 11 01

MNG 00 03 04 02

Medullary carcinoma 00 01 00 00

Papillary carcinoma 00 01 00 00

Adenomatous nodule 00 02 04 00

MNG with thyroiditis 00 00 03 00


Page 58

Demographic data

Figure 8 shows distribution of patients with thyroid diseases based on

the gender. Female predominance (96%) was observed in this study.

Figure 9 depicts the distribution of patients based on age group. In this

study patients of age group from age group of 10 to 75 were taken and out of

that 17 year old female was the youngest patient in the study and 68 year old

was the oldest patient in the study group. 43% of patients were of the age

group of 40 to 60 years and 41.9% of patients belonged to age group of 20 to

40 years. Patients above 60 years was 9.6% and that of age group below 20

years was 4.8%

Table 2 is based on family history of thyroid disorder in which 32% of

people had positive family history and 67% of patients had negative family

history.

Table 3 is based on thyroid function test. It was done for all patients in

the study group and 37 % of the patients had normal level of thyroid

hormones, 33% of the study group had hypothyroidism and 29% study

population had hyperthyroidism.

Table 4 shows that 72 % of the study group had swelling of thyroid

gland which was diffuse in some and focal in some patients of the study

group. In this study group 27% did not have swelling.


Page 59

Sonographic evaluation

Table 5: Distribution of thyroid lesions based on size of thyroid gland

This shows that 24.19% of patients had normal size of thyroid gland

and 75.81% of patients had enlarged thyroid gland.

Table 6: Distribution based on the echotexture of thyroid gland

parenchyma.

It was an important variant in sonographic evaluation. In the study

group 43.55% of patients had homogenous echotexture of the thyroid gland

parenchyma and 56.45% had heterogenous echotexture.

Table 7: Distribution of thyroid lesions based on vascularity of thyroid

parenchyma

The vascularity of thyroid gland parenchyma is normal in 41.94% of

the patients and was increased in 58.06% of patients. Out of the 58% patients

with increased vascularity 40% patients were diagnosed to have Hashimotos

thyroiditis.

Table 8: Distribution of thyroid lesions based on presence or absence

nodule

Based on the presence and absence of the nodules almost 85.48% of

patients had nodules and 14.52% of patients did not have nodules.


Page 60

Description of nodule

Table 9: Distribution of thyroid lesions based on number of nodules

Nodules were found in most of the lesions. Out of 62 patients 56

patients had nodules in the thyroid gland. In these 56 patients 17 patients i.e

30.36% of thyroid lesions were solitary nodule and 39 patients i.e., 69.64%

were multiple nodules.

Table 10: Distribution of thyroid lesions based on size

The nodules which were solitary or multiple were characterized based

on the size of the nodules. Based on the size nodules less then 5mm were

considered as micronodules. In this study out of 56 patients 19 patients had

micronodulations which is about 33.93%, 9 patients had nodules of 5mm to

1cm which corresponds to 16.07% and nodules more than 1cm is seen in 28

patients which is about 50%.

Table 11: Distribution of thyroid lesions based on shape

The nodules which are less than 5mm were not characterized. The

nodules which are greater than 5mm were characterized sonographically

based on the shape of the nodule to differentiate between benign and

malignant. Nodules of size more than 5mm were seen in 38 patients out of

which 32 patients had nodules of ovoid to round shape which corresponds to

about 84.21% and nodules of taller and wide shape was identified in about 6

patient which corresponds to 15.79%. In these nodules, the nodules with


Page 61

ovoid to round shape was seen in benign lesions and nodules with taller and

wide shape was found in malignant lesion.

Table 12: Distribution of patients based on margins of the nodule

The nodules which were more than 5mm were characterized based on

margins of the nodules. The margins were well defined smooth in 68.42% of

the patients, well defined spiculated in 7% of the patients and 23.69% of the

patients had ill defined margins.

Table 13: Distribution of thyroid lesions based on echogenicity of the

nodule

Nodules larger than 5mm were characterized based on echogenicity of

the nodule within the thyroid gland. Out of 38 patients with nodules more

than 5mm 10 patients i.e., 26.32% of patients had anechoic nodules , 7

patients i.e., 18.42% of patients had hypoechogenic nodules,13 patients i.e.,

34% of patients had isoechoic nodules and 8 patients i.e., 21% of patients had

hyperechogenic nodules.

Table 14: Distribution of thyroid lesions based on halo of the nodule

In patients with thyroid nodules, based on halo around the nodule it is

characterized. In this study, nodule without any halo was found in around

38.89% of patients and nodule with complete halo was found in 58.33% of

patients and nodule with incomplete halo was found in 8.33% of patients.


Page 62

Table 15: Distribution of thyroid lesions based on contents of the nodule

Based on the contents of the nodule it is characterized as nodules

which are predominantly solid, predominantly cystic and nodules which had

comet tail artifact. The nodules which were more than 5mm were considered

and the nodule which had contents predominantly solid were 58.33% and the

nodules which had contents predominantly cystic was 16.67% and the

nodules which had comet tail artifact was around 30.56%.

Table 16: Distribution of thyroid lesions based on calcification of the

nodule

The calcification in the nodule which is more than 5mm is

characterized. 18.42% of the nodules had rim calcification, 13.16% had

macrocalcification, 21% had microcalcification and the nodules without

calcification was seen in 47.37% of patients.

Table 17: Distribution of thyroid lesions based on vascularity of the

nodule

Based on the vascularity within the nodule the it is characterized as

nodules without any vascularity was corresponding to 31.58% , the nodules

with intrinsic hypervascularity was corresponding to 15.79% , the nodules

with perinodal vascularity was around 28.95% and the nodules with both

intrinsic and perinodal vascularity was 23.68%.


Page 63

Table 18: Distribution of thyroid lesions diagnosed on ultrasonography

Most common lesion that was diagnosed on USG was thyroiditis,

40.3% of the patients followed by colloid goiter in 27.4% of the patients.

Multinodular goiter was seen in 14.5% of the patients . the remaining lesions

were papillary carcinoma (1.6%) medullary carcinoma (1.6%), adenomatous

nodules (9.7%) and MNG with thyroiditis (4%)

Table 19: Distribution of thyroid lesions based on FNAC diagnosis

The main lesions seen were thyroiditis in 46.8% of the patients, colloid

goiter in 29% MNG in 11.3% and adenomatous nodule 8% of the patiens.

The other lesions were medullary carcinoma and papillary carcinoma(1.6%

and 3.2% respectively).

Table 20: Matching of ultrasound diagnosis with FNAC diagnosis

Matching of ultrasound diagnosis with FNAC diagnosis was seen in

46.3% of the cases of thyroditis, 29.6% of colloid goiter cases, 12.9% of MNG

cases, 7.4% adenomatous nodules and 1.8% of medillary and papillary

carcinoma cases.

Table 21: Comparison of ultrasound diagnosis with FNAC diagnosis:

On comparison with USG diagnosis and FNAC, the positive predictive

value to detect thyoiditis by ultrasound was 92.5% in this study. In this study

ultrasound is 86.2% sensitive and 90% specficity in detecting thyroiditis.

And the positive predictive value for detecting medullary carcinoma was

100% and papillary carcinoma was 66%. Ultrasound has 94% positive


Page 64

predictive value for adenomatous nodule. Positive predictive value for colloid

goiter was 94 % and that of MNG was 100%. Ultrasound has 80% sensitivity

and 75% specificity in detecting malignant nodules.

Table 22: Distribution of thyroid lesions based on FNAC with size of nodule

Table 22 and figure 10 shows that all the malignant nodules which were

identified as malignant by ultrasound and FNAC were more than 1cm, and the

lesions which were in benign and those were more than 1cm was 74.29% and

the lesion of size 5mm to 1cm was found in 25.71% of patients with nodules.

Table 23: Distribution of thyroid lesions based on FNAC with margin of

the nodule

Based on Table 23 and Figure 11, on comparing FNAC and the

margins of the lesion in ultrasound, around 68% of the lesion was well

defined smooth and it was seen in benign nodules. 66% of the lesion had well

defined spiculated margins which was seen in malignant nodules. Ill defined

margins were seen in around 25.71% of cases. All the cases with ill defined

margins were found in benign lesion.

Table 24: Distribution of thyroid lesions based on FNAC with

echogenicity of the nodule

Based on table 24 and Figure 12, on correlating the echogenicity of the

lesions with FNAC, all the anechoic nodules(28.5%) which were identified as

benign in ultrasound was found to be benign in FNAC. Hypoechoic

nodules(66.6%) were found in both benign and malignant nodules In that


Page 65

majority of the hypoechoic lesion was malignant. Isoechoic (34.2%) lesions

were found both in benign and malignant nodule. Hyperechoic nodules

(22.8%) were seen in benign lesions, and not found in malignant lesions.

Benign lesions are predominantly hyperechoic and anechoic.

Table 25: Distribution of thyroid lesions based on FNAC with halo

Table 25 and Figure 13 shows the distribution of patients based on

FNAC with halo. Halo in a lesion corresponds to the capsule of the lesion. On

comparing the FNAC of the lesion with the presence of halo in the lesion,

complete halo was seen 60% of nodules which were benign. Incomplete halo

was predominantly seen in malignant lesion which was around 66.6% and

halo was absent in some of the benign lesion and malignant lesion.

Table 26: Distribution of thyroid lesions based on FNAC with contents

Table 26 and Figure 14 shows the comparison based on the FNAC and

the contents noted within the nodules. FNAC shows the nodules which were

malignant and had predominantly solid contents was 100% matching with

FNAC of the lesions. Benign lesion had predominantly cystic contents which

comprised about 17.14% and the lesion which had comet tail artifact was

about 31.43%.

Table 27: Distribution of thyroid lesions based on FNAC with calcification

Table 27 and Figure 15 depicts the distribution of presence and type of

calcification seen on ultrasound in the lesions diagnosed as benign and


Page 66

malignant on FNAC. Calcification was absent 48.57% of benign lesions and

in 33.33% of malignant lesion. Rim calcification was seen in 20% of benign

lesion. Lesions with micro and macro calcification was found in both benign

and malignant nodules.

Table 28: Distribution of thyroid lesions based on FNAC with vascularity

of nodule

Table 28 and Figure 16 shows the comparison of vascularity and the

FNAC of the particular nodule. 34.29% of lesions were avascular and they

were benign, Intrinsic hypervascularity was seen in both benign and

malignant lesions. Perinodal vascularity was seen in 28.57% of benign

patients. Both intrinsic and perinodal vascularity was seen in both benign and

malignant nodules.

Table-29: Distribution of thyroid lesions based on thyroid disorder and age

Table 29 shows that thyroiditis was more prevalent in the age group of

20 years to 40 years. Most of the cases in the study group comprised of

thyroiditis. Colloid goiter was predominantly seen in the age group of 40

years to 60 years.

Discussion

Discussion

Page 67

DISCUSSION

Our study comprised of patients who were sent for the evaluation of

thyroid disorders with any of the following criteria

i) clinically symptomatic (viz dysphagia, hoarseness of voice, dyspnoea,

weight gain, altered menstrual cycles etc.) with altered levels of

thyroid hormones

ii) clinically symptomatic but with normal thyroid hormone levels.

iii) clinically suspected cases with no specific symptoms.

On comparison with USG diagnosis and FNAC, the positive predictive

value to detect thyroiditis by ultrasound was 92.5% in this study. Yeh et al45

showed that micronodulation on sonography is useful for diagnosing diffuse

lymphocytic thyroiditis because of a high positive predictive value which was

94.7%. Venkatachalapathy et al39 found that the overall sensitivity for FNAC

in their series was 81.3% for benign lesions. In this study ultrasound was

86.2% sensitive and 90% specificity in detecting thyroiditis. Features

considered in this study were heterogenous thyroid parenchyma with

increased vascularity and micronodulations.

The positive predictive value for detecting medullary carcinoma was

100% and for papillary carcinoma it was 66%. Ultrasound has 94% positive

predictive value for adenomatous nodule. Positive predictive value for colloid

goiter was 94 % and that of MNG was 100%.

Discussion

Page 68

Vikas et al23 has stated in his study that the overall sensitivity of

thyroid ultrasound for diagnosing a malignant nodule is 83.3%. In this study it

was identified that ultrasound has 80% sensitivity and 75% specificity in

detecting malignant nodules based on the sonographic findings.

In this study ultrasound has 100 % sensitivity in detecting Multinodular

goiter.

71.8% (P< 0.05) of patients had nodules with well defined smooth

margins which were diagnosed as benign in ultrasound and FNAC. Moon et

al3 stated in his study that 78.8% vs 65.4% (P<0.001) showed well defined

margins which was characteristic of benign nodule.

In this study, it is observed that 31.25% of nodules were anechoic. All

these anechoic nodules were diagnosed as benign on USG and it was

confirmed by FNAC. In a study by Antti et al,46 where 253 patients were

randomly screened for thyroid ultrasound and 69 patients had thyroid lesions

which were followed up for 5 years. All the anechoic nodules were found to

be benign in USG and in FNAC even after follow up of 5 years. Some of the

lesions had disappeared without any treatment.

In this study majority of the hypoechoic nodules(66. 67 %) were found

to be malignant nodules, in a similar study Pedro Weslley et al47 studied

features of papillary carcinoma in 106 nodules which revealed hypo-

echogenicity in 90.5% no calcification in 59.4% and micro calcification in

26.4%. In this study 83% of hypoechogenic nodules turned out to be

Discussion

Page 69

malignant nodules. All the cases which were detected as malignant by

ultrasound were confirmed as malignant on FNAC.

Isoechoic lesions were seen in both benign and malignant lesions.

Most of the benign lesions were hyperechoic.

In this study 95% of the cases were benign and only 5% of the cases

were malignant. Similarly in a study conducted by Bonovita et al44 the sample

size was 1232 patients. Among these patients malignant cases were only

about 3% to 7%, rest of the cases were benign lesions.

Out of 62 patients, 60 cases were diagnosed as benign cases, one case

which was hypoechoic with comet tail artifact and well defined margins was

diagnosed as benign nodule in ultrasound and this was diagnosed as papillary

carcinoma on FNAC, similarly in a study done by Ankush Danadia et al1 on

100 cases in Gujarat showed 66 benign cases, 8 malignant cases and 26 cases

were indeterminate on USG. Out of these 66 benign cases 2 cases which were

diagnosed as benign turned out to be malignant on FNAC (as papillary

carcinoma).

Margins of the nodules were well defined and smooth in 68% of

patients and ill defined in 23.6% in a similar study done by Ankush Danadia

et al1, margin was well defined in 77.7% and ill defined in 22.3% of nodules.

Well defined spiculated margin of nodules are seen in malignant

nodules. In this study 66.6% of malignant nodules had well defined spiculated

margins.

Discussion

Page 70

Mary C.Frates et al38 has conducted a study on 3200 patients over a

period of eight years which showed that solitary nodule more than 1cm size

has increased risk of being malignant. In this study, the lesions which were

characterized by ultrasound as malignant nodules were more than 1cm in size

and 66.6% of the nodules were solitary. These lesions were confirmed as

malignant on FNAC also.

In a study by Ahuja A et al1 all 100% patients with comet tail artifact

proved to be benign by FNAC. In this study comet tail artifact was found in

31.4% of patients and these were proven as benign lesion by FNAC also.

Conclusion

Conclusion

Conclusion

Page 71

CONCLUSION

In this study of sonographic evaluation of thyroid lesions with FNAC

correlation which was done in Sree Mookambika Institute of medical

Sciences, Kulasekharam for a period of 1 year had led to the following

conclusions:

• There is female preponderance for thyroid lesions.

• All the anechoic nodules were benign lesion.

• Ultrasound has 80% sensitivity and 75% specificity in detecting malignant

nodules.

• The nodules which were characterized as malignant in ultrasound was

confirmed as malignant nodules in FNAC.

• Ultrasound is an excellent modality for diagnosing benign conditions such

as thyroiditis, Multinodular goiter and malignant conditions such as

medullary carcinoma. Certain cases such as small nodules of papillary

carcinoma is difficult to differentiate from small colloid nodules.

• Papillary carcinoma is the most common type of thyroid malignancy.

• Ultrasound is a better modality of investigating the thyroid gland as a

whole and non invasive when compared to FNAC.

• Ultrasound is the best imaging modality which can characterize the

number of nodules, size of each nodule, margins of the nodule and

contents of the nodule.

Conclusion

Page 72

• Ultrasound can predict if the lesion is benign or malignant, but when it is

combined with ultrasound guided FNAC, then it can give an accurate

diagnosis.

• Around 95% of the lesions were benign, and 5% of the lesions were

malignant.

• When multiple nodules were present in a thyroid gland the nodule which

had suspicious features were identified on ultrasound evaluation and fine

needle aspiration was done from the suspicious nodule by ultrasound

guidance.

Conclusion

Page 73

LIMITATIONS:

� Smaller malignant lesions can be mistaken as benign lesion on ultrasound

(eg. Small papillary carcinoma can be mistaken as colloid goiter).

� There can be inter observer variation on ultrasound evaluation.

� Follicular adenoma and follicular neoplasm is difficult to differentiate on

ultrasound.

� Even though there are specific characters of benignity and malignancy on

ultrasound, it may overlap in some cases. So USG guided FNAC should

be done for an accurate diagnosis.

Summary

Summary

Summary

Page 74

SUMMARY

This study of Sonographic evaluation of thyroid lesions with FNAC

correlation was done in Sree Mookambika Institute of medical Sciences,

Kulasekharam for a period of 1 year. The patients who were fulfilling the

inclusion and exclusion criteria were included in the study and the study

group comprised 62 patients.

These 62 patients were subjected for ultrasound and then with

ultrasound guidance FNAC was done for the thyroid lesions.

Sonographic findings were correlated with the obtained FNAC results.

From this study the results we have obtained are as follows:

• Thyroid lesions have female preponderance.

• All the anechoic nodules were benign lesion.

• 95% of the thyroid lesions in this study was benign and only 5% of the

lesions were malignant.

• Ultrasound has 80% sensitivity and 75% specificity in detecting

malignant nodules.

• The nodules which were characterized as malignant in ultrasound were

confirmed as malignant on FNAC.

• Ultrasound is an excellent modality for diagnosing benign conditions

such as thyroiditis, multinodular goiter and malignant conditions such as

Summary

Page 75

medullary carcinoma. Certain cases such as small nodules of papillary

carcinoma is difficult to differentiate from small colloid nodules.

• Papillary carcinoma is the most common type of thyroid malignancy.

• Ultrasound is a better modality of investigating the thyroid gland as a

whole and non invasive when compared to FNAC.

• Ultrasound is the best imaging modality which can characterize the

number of nodules, size of each nodule, margins of the nodule,

contents of the nodule.

• Ultrasound can predict if the lesion is benign or malignant, but when it

is combined with ultrasound guided FNAC, then it can give an

accurate diagnosis.

Bibliography

Bibliography

i

BIBLIOGRAPGY

1. Dhanadia A, Shah H, Dave A. Ultrasonographic and FNAC correlation of

thyroid lesions. Gujarat Med J 2014; 69:75-81.

2. Hiren R, Panchal, Kulkarni DS, Gandage SG, Kachewar SG. Int J of Biomed

Res 2013; 1: 197-202.

3. Moon HJ, Kim E. Fine-Needle Aspiration Biopsy of Focal Thyroid Nodules.

Am J Roentgenol. 2009; 345-9.

4. Mallikarjunappa B, Ashish SR. Ultrasound Evaluation of Thyroid Nodules

and its Pathological Correlation. JIMSA 2014; 27: 93-5.

5. Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg.

1930;92:169-81.

6. Chavan US, Patil A, Mahajan SV. Cytological Profile of Thyroid Lesions

and it’s Correlation with Clinical and Ultrasonography Finding. MVP J Med

Sci 2016;3(1):28-32.

7. Kim MJ, Kim EK, Park SI, Kim BM, Kwak JY, Kim SJ, et al. US-guided

Fine-Needle Aspiration of Thyroid Nodules: Indications, Techniques, Results.

RadioGraphics 2008; 28:1869-89.

8. Neuhauser, C. Sensitivity and Specificity. November 8, 2009 :1-9

9. Palaniappan V, Arunalatha K, Chandramouleshwari, RajeshNatraj,

Mahalakshmi. Cyto-histology and clinical correlation of thyroid gland lesions

using Bethesda system: 3 month study in a tertiary hospital. Int J innovative

Res studies 2015; 4(2):25-42.

10. Chowdary Sujit, The Thyroid, Medical Physiology 6th edition, 2008; 276-281

Bibliography

ii

11. Nachiappan AC, Metwalli ZA, Hailey BS, Patel RA, Ostrowski ML, Wynne

DM. The Thyroid: Review of Imaging Features and Biopsy Techniques with

Radiologic-Pathologic Correlation. Radio Graphics 2014;34:276-93.

12. Rogers WM. Anomalous development of the thyroid. In: Werner SC, Ingbar

SH, editors. The thyroid. New York: Harper & Row;1978. p. 416-420.

13. Khatawkar AV, Awati SM. Thyroid gland Historical aspects, Embryology,

Anatomy and Physiology. IAIM 2015; 2(9):165-71.

14. Guyton & Hall, Thyroid Metabolic Hormones. Textbook of Medical

Physiology, 11th edition,2006;931-943.

15. Thyroid Ultrasound and Ultrasound-Guided FNA Second Edition, H. Jack

Baskin, M.D., MACE Orlando, FL, USA Daniel S. Duick, M.D., FACE

Phoenix, AZ, USA Robert A. Levine, M.D., FACE Nashua, NH, USA.

.chapter 4 page no 45 to 61

16. Baskin HJ. Thyroid ultrasonography-a review. Endocr Pract 1997; 3(3):153-7.

17. Baskin HJ. New applications of thyroid and parathyroid ultrasound. Minerva

Endocrinol 2004;29:195–206.

18. Zhou A, Wei Z, Read RJ, Carrell RW. Structural mechanism for the carriage

and release of thyroxine in the blood. Proc Natl Acad Sci

USA. 2006;103(36):13321-6.

19. Kasper DL, Braunwald E et al. Disorders of Thyroid Gland. Harrison’s

Principles of Internal Medicine, 16th edition, vol 2, 2005; 2104-2126.

20. Glinoer D, de Nayer P, Bourdoux P, Lemone M, Robyn C, van Steirteghem

A, et al. Regulation of maternal thyroid during pregnancy. J Clin Endocrinol

Metab 1990;71(2):276-87.

Bibliography

iii

21. Kurioka H, Takahasshi K, Miyazaki K. Maternal thyroid function during

pregnancy and puerperal period. Endocr J. 2005;52(5):587-91.

22. Park’s text book of preventive and social medicine 23rd edition. India.

Banarsidas Bhanot publishers. 2015.624

23. Chaudhary V, Bano S. Thyroid ultrasound. Indian Journal of Endocrinology

and Metabolism 2013;17(2):

24. Slough CM, Randolph GW. Workup of Well-Differentiated Thyroid.

Carcinoma Cancer Control 2006;13(2):99-106.

25. Vijay M Rao, Adem E Flenders, Berry M Tom MRI and CT atlas of

correlative imaging in otolaryngology, United Kingdom, first edition 1992.

page no 178

26. Lee YH, Kim DW, In HS et al. Differentiation between Benign and

Malignant Solid Thyroid Nodules Using an US classification system. Korean

J Radiol 2011;12(5):559-67.

27. Hennemann G. Non-toxic goitre. Clin Endocrinol Metab 1979;8:167-79.

28. Ahuja A, Chick W, King W, Metreweli C. Clinical significance of the comet-

tail artifact in thyroid ultrasound. J Clin Ultrasound 1996;24:129-33.

29. Christopher R. McHenry Roy Phitayakorn The Oncologist 2011;16:585-593

30. Kerr L. High-resolution thyroid ultrasound: the value of color Doppler.

Ultrasound Q 1994;12:21-43.

31. Ahuja AT, Ying M, Yuen HY, Metreweli C. Power Doppler sonography of

metastatic nodes from papillary carcinoma of the thyroid. Clin Radiol

2001;56:284-8.

Bibliography

iv

32. Grebe SK, Hay ID. Follicular cell–derived thyroid carcinomas. Cancer Treat

Res 1997;89:91-140.

33. Ganeshan D, Paulson E Duran C et al Current Update on Medullary Thyroid

Carcinoma AJR 2013; 201:W867–W876

34. Xia Y, Wang L, Jiang Y, Dai Q, Li X, et al. (2014) Sonographic Appearance

of Primary Thyroid Lymphoma-Preliminary Experience. PLoS ONE 9(12):

e114080. doi:10.1371/journal.pone. 0114080

35. Hoang KJ, Franzcr, Lee WK, Lee M, Johnson D, Farrell S, et al. US Features

of Thyroid Malignancy: Pearls and Pitfalls. Radio Graphics 2007; 27:847-65.

36. Amita K, Hingway S. Evaluation of the efficacy of Ultrasound guided fine

needle Aspiration Cytology in the Diagnosis of Thyroid Lesions. Inter J

Health Sci Res 2012; 2:21-30.

37. Cooper SD, Doherty GM, Haugen BR, Mazzaferri EL, Mciver B, Pacini F, et

al. Revised American Thyroid Association Management Guidelines for

Patients with Thyroid Nodules and Differentiated Thyroid Cancer. 2009; 19

38. Frates MC, Benson CB, Doubilet PM, Kunreuther E, Contreras M, Cibas ES,

et al. Prevalence and distribution of carcinoma in patients with solitary and

multiple thyroid nodules on sonography. J Clin Endocrinol Metab

2006;91(9):3411–7.

39. Sreeramulu PN, Venkatachalapathy TS, Prathima S, Kumar K. A

prospective study of clinical, sonological and pathological evaluation of

thyroid Nodule. J Biosci Tech 2012; 3:474-78.

Bibliography

v

40. Jain G, Devpura G, Gupta BS. Abnormalities in the thyroid function tests as

surrogate marker of advancing HIV infection in infected adults. JAPI

2009:57:508-510

41. Ko SY, Lee HS, Kim EY, Kwak JY. Application of the Thyroid Imaging

Reporting and Data System in thyroid ultrasonography interpretation by less

experienced physician. Ultrasonography 2014;33:49-57.

42. Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman

BG, et al. Management of thyroid nodules detected at US: Society of

Radiologists in Ultrasound consensus conference statement.

Radiology 2005;237(3):794-800.

43. Rumack CM, Wilson SR, Charboneau JW, Levine D, Diagnostic

Ultrasonund. 4th edition. Philadelphia: Elsevier;2011.p709

44. Bonavita JA, Mayo J, Babb J, Bennett G, Oweity T, Macari M, et al.

Pattern recognition of benign nodules at ultrasound of the thyroid:

which nodules can be left alone? Am J Roentgenol 2009;193(1):207-13.

45. Muller HW, Schroder S, Schneider C, Seifert G. Sonographic tissue

characterisation in thyroid gland diagnosis: a correlation between

sonography and histology. Klin Wochenschr 1985;63:706-10.

46. Schueller-Weidekamm C, Kaserer K, Schueller G, Scheuba C, Ringl H,

Weber M, et al. Can quantitative diffusion-weighted MR imaging

differentiate benign and malignant cold thyroid nodules? Initial results

in 25 patients. Am J Neuroradiol 2009; 30(2):417-22.

Bibliography

vi

47. Anderson L, Middleton WD, Teefey SA, Reading CC, Langer

JE, Desser T, Szabunio MM, Mandel SJ, Hildebolt CF, Cronan JJ.

Hashimoto thyroiditis: Part 2, sonographic analysis of benign and

malignant nodules in patients with diffuse Hashimoto thyroiditis. AJR

Am J Roentgenol 2010;195(1):216-22.

48. Bamanikar S, Soraisham P, Jadhav S, Kumar H, Jadhav P, Bamanikar

A. Cyto-histology and clinical correlation of thyroid gland lesions: A 3

year study in a tertiary hospital. Clin Cancer Investig J 2014;3:208-12

49. Yeh HC, Futterweit W, Gilbert P. Micronodulation: ultrasonographic

sign of Hashimoto thyroiditis. J Ultrasound Med 1996; 15:813-819

50. Brander AEE, Viikinkoski VP, Nickels JI, Kivisaari LM. Importance

of thyroid abnormalities detected at us screening: a 5-year follow-up.

Radiology 2000; 215:801-806.

51. do Rosario PWS, Fagundes Ta et al. USG features of papillary thyroid

carcinoma. J Ultra Med 2004;23:572-78.

Appendices

CONSENT FORM

PART 1 OF 2

INFORMATION FOR PARTICIPANTS OF THE STUDY

Dear Volunteers, We welcome you and thank you for your keen interest in participating in this research project. Before you participate in this study, it is important for you to understand why this research is being carried out. This form will provide you all the relevant details of this research. It will explain the nature, the purpose, the benefits, the risks, the discomfort, the precautions and the information about how this project will be carried out. It is important that you can read and understand the contents of the form carefully. This form may contain certain scientific terms and hence, if you have any doubts or if you want more information, you are to ask the study personnel or the contact person mentioned below before you give your consent and also at any time during the entire course of the project.

1. Name of the Principal Investigator : Dr.Anu Priya J T Postgraduate-M.D Radiodiagnosis

Sree Mookambika Institute of Medical Sciences,

Kulaseharam

2. Name of the Guide : Dr.VijayKumar.G Professor and HOD

Department of Radiodiagnosis Sree Mookambika Institute of Medical Sciences,

Kulasekharam

3. Name of the co-guide : Dr. Satish Babu Associate Professor

Department of Radiodiagnosis Sree Mookambika Institute of Medical Sciences Kulasekharam

4. Institute: details with Address : Sree Mookambika Institute of Medical Sciences,

Kulasekharam, Kanyakumari District-629161 Tamil Nadu

5. Title of the study: Sonographic Evaluation of Thyroid Lesions with FNAC Correlation.

6. Background Information: Thyroid disorders are endemic and they need evaluation for the further

management. Ultrasound is an important imaging modality to detect the lesions.1 Ultrasound is conducted to know the types of lesions and to know the nature and distribution of thyroid lesions. The ultrasound findings will be correlated with FNAC to know the sensitivity and specificity.4

7. Aims and Objectives: i. To study the ultrasonographic features of various thyroid lesions in

patients with thyroid disorders. ii. Correlate the sonographic findings with FNAC in the diagnosis of

thyroid lesions.

8. Scientific justification of the study: Thyroid disorders are endemic all over the world and in India also.

Sonographic evaluation is non invasive and it can be done on all age. By using colour flow and Doppler the vascularity of the gland can be demonstrated which is important in identifying the type of lesion. This can be correlated with FNAC to confirm the type of lesion. Thyroid nodules are very common in the general population, but malignancy is relatively rare lesions.

9. Procedure of the study: All patients with valid consent will undergo the following : 1. Ultrasound examination of the thyroid will be done 2. Utrasound guided fine needle aspiration will be done and the aspirated

material from the thyroid will be sent for pathological examination. After all the tests, the FNAC will be correlated for the study purposes.

10.Expected risk of the participants:

The risks of the procedure are minimal. One risk is minor bleeding which may occur in the lesion or under the skin and may result in swelling and bruise, mild discomfort and mild pain. T his generally is limited if firm pressure is applied to the aspirated site following removal of needle.

11. Expected benefits of the research for the participants: Detect any thyroid lesions.

12. Maintenance of confidentiality: All data collected for the study will be kept confidentially. No personal

details will be revealed.

13. Why have I been chosen to be in this study: Since clinical features suggestive of thyroid disease are present and future

investigations are necessary.

14. How many people will be in the study: 62

15. Agreement of compensation to the participants: No

16. Anticipated prorated payment, if any, to the participants of the study: Nil

17. Can I withdraw from study at any time during the study period: Yes

18. If there is any new finding/information, would I be informed: Yes

19. Expected duration of the participants participation in the study: Single visit.

20. Any other pertinent information: No

21. Whom do I contact for further information:

Place:

Date:

Signature of the Participant Signature of Principal Investigator

For any study related queries, you are free to contact Dr Anu Priya J T -Post Graduate Department of Radiodiagnosis

Sree Mookambika Institute of Medical Sciences, Kulasekharam629161

Mobile Number: 9488022380 e-mail : [email protected]

PART 2 OF 2

PARTICIPANTS CONSENT FORM

The details of the study have been explained to me in writing and details have been fully explained to me. I am aware that the results of the study may not be directly beneficial to me but will help in the advancement of medical sciences. I confirm that I have understood the study and had the opportunity to ask questions. I understand that my participation in the study is voluntary and that I am free to withdraw at any time, without giving any reasons, without the medical care that normally be provided by the hospital being affected. I agree not to restrict the use of any data or results that arise from this study provided such a use is only for scientific purpose(s). I have given details of the study. I fully consent to participate in the

study titled “Sonographic Evaluation of Thyroid Lesions with FNAC Correlation.”

Serial no/Reference no:

Name of the participant:

Address of the Participant:

Contact number of the Participant:

Signature/Thumb impression of the participant/Legal guardian

Witness

1.

2.

Date:

Place:

CASE RECORD FORM

1. Serial No.

2. Name

3. Age in years

4. Sex

5. Address and phone no.

6. Family history of thyroid disorder [01-No, 02- Yes] 7. Thyroid function test [01 –Normal, 02- Hypothyroidism, 03- Hyperthyroidism] 8. Clinical examination – thyroid swelling [01- No, 02- Yes] SONOGRAPHIC EVALUATION 9. Size of thyroid gland [01- Normal, 02- Enlarged] 10. Echo texture of thyroid parenchyma [01- Homogenous, 02-Heterogenous] 11.Vascularity of thyroid parenchyma [01- Normal, 02- Increased] 12. Nodule [01- Absent, 02- Present] 13. Description of Nodule i) No. of nodules [01- Single, 02- Multiple] ii) Size [01- <5mm, 02- 5mm to 1cm, 03- >1cm]

iii) Description of nodules >5mm a) Shape [01- Ovoid to round, 02-Taller and wide] b) Margins [01- Well defined smooth, 02- Well defined spiculated, 03- Ill defined] c) Echogenicity [01-Anechoic 02- Hypoechogenic, 03- Isoechogenic, 04- Hyperechogenic] d) Halo [01- Absent, 02- Complete, 03- Incomplete] e) Contents [01- Predominantly solid, 02- Predominantly Cystic, 03- Comet tail artifact] f) Calcification [01- Absent, 02- Rim Calcification, 03- Macrocalcification, 04- Microcalcification] g) Vascularity [01- Avascular, 02- Intrinsic hypervascular, 03- Perinodal Vascularity 04- both intrinsic and perinodal vascularity ]

14) Ultrasound diagnosis 15) FNAC report

LIST OF ABBREVATIONS USED

cm - centimeter

mm - millimeter

USG - ultrasonography

US - ultrasound

TSH - Thyroid stimulating hormone

T3 - Tri iodothyronine

T4 - Thyroxine

mHz - megahertz

CNS - Central Nervous System

Β - Beta

CT - Computed tomography

MRI - Magnetic Resonance Imaging

FNAC - Fine Needle Aspiration Cytology

PTL - Primary thyroid lymphoma

TIRADS - Thyroid Imaging Reporting and Data System

S- FNAC - Standard FNAC

USG- FNAC - Ultrasound guided FNAC

MNG - Multi Nodular Goitre

STN - Solitary nodule thyroid

S-FNAC - Standard FNAC

USG-FNAC - USG guided FNAC

TP - True positive

TN - True negative

FP - False positive

FN - False negative

CASE 1

Well defined spiculated hypoechoic nodule with few specks of microcalcification – s/o Papillary carcinoma

CASE 2

Well defined anechoic (cystic) nodule – s/o colloid goiter.

CASE 3

Well defined isoechoic nodule with increased perinodal vascularity.

CASE 4

Thyroid gland showing heterogenous echotexture with increased vascularity – s/o thyroiditis

CASE 5

Well defined hypoechoic lesion in the left lobe of thyroid gland was diagnosed as colloid goiter on USG. On FNAC this lesion was diagnosed as papillary

carcinoma.

CASE 6

Well defined smooth margin, hyperechoic, solitary nodule on the right lobe of thyroid – s/o adenomatous nodule.

CASE 7

Well defined cystic lesion with comet tail artifact – colloid goiter

CASE 8

Well defined lesion with speculated margins and macrocalcification noted in the left lobe of thyroid gland – medullary carcinoma.

CASE 9

Well defined smooth margin hypo echoic nodules – Multinodular goiture

CASE 10

Enlarged thyroid gland with heterogeneous echotexture and increased vascularity – s/o thyroiditis.

FNAC

Colloid nodule Colloid nodule

Hashimotos

Hashimotos

MNG

Papillary CA Thyroid



MASTER CHART

Sl. No AGE SEX FAMILY H/O TFT THYROID

SWELLING TSIZE OF THYROID

GLAND ECHOTEXTURE OF THYROID

PARENCHYMA

VASCULARITY OF THYROID

PARENCHYMA NODULE

NO.OF NODULE

SIZE

1 22 F 2 3 2 2 2 2 2 2 1

2 37 F 1 1 2 2 1 1 2 2 3

3 42 F 1 2 2 2 2 2 2 2 3

4 55 F 1 2 2 2 2 2 2 1 3

5 35 F 1 2 2 2 1 1 2 2 3

6 64 F 2 1 2 2 1 1 2 2 3

7 28 F 1 3 1 2 2 2 1

8 65 F 2 1 2 1 1 1 2 2 3

9 35 F 1 1 1 1 2 2 2 2 3

10 50 F 1 3 1 2 2 2 2 2 1

11 18 F 2 3 1 2 2 2 1

12 59 F 1 2 2 2 2 2 2 2 1

13 47 F 1 1 1 1 1 1 2 2 3

14 35 F 2 3 2 2 1 2 2 1 3

15 41 F 1 1 2 2 1 1 2 1 3

16 60 F 2 2 2 2 1 1 2 2 3

17 19 F 1 3 2 2 2 2 2 2 1

18 20 F 1 3 2 2 2 2 1

19 35 F 1 1 2 2 2 2 2 2 2

20 33 F 1 1 2 2 2 2 2 2 1

21 36 F 1 2 1 2 2 2 2 2 3

22 40 F 2 1 2 2 2 2 2 1 2

23 37 F 1 1 2 2 1 1 2 2 1

24 45 F 2 2 2 2 1 1 2 1 3

25 35 F 1 1 1 2 2 2 2 2 1

26 36 F 1 1 1 2 2 2 2 1 3

27 17 F 2 2 1 2 2 2 2 2 1

28 50 F 1 3 2 2 2 2 2 1 3

29 28 F 2 1 1 2 2 2 2 2 1

30 25 F 1 3 2 2 2 2 2 2 1

31 50 F 2 2 2 2 2 2 2 1 3

32 25 F 1 2 1 2 2 2 1

33 44 F 2 1 2 1 1 1 2 2 3

34 39 F 1 2 2 1 1 1 2 1 2

35 51 F 1 3 2 1 1 1 2 1 2

36 26 F 1 3 1 2 2 2 2 2 1

37 68 F 1 1 2 1 1 1 2 2 2

38 32 M 1 3 2 2 1 1 2 2 2

39 44 F 2 2 2 2 2 2 2 2 1

40 60 F 1 2 2 2 2 2 2 2 3

41 47 F 2 2 2 2 1 1 2 1 2

42 27 F 1 3 2 2 1 1 2 1 3

43 48 F 1 1 1 1 1 1 2 1 2

44 23 F 1 2 2 2 2 2 2 2 1

45 50 F 2 3 2 1 1 1 2 2 3

46 60 F 2 1 2 1 1 1 2 2 3

47 58 F 1 1 2 1 2 2 2 2 3

48 39 F 2 3 1 2 2 2 2 2 1

49 22 F 1 3 2 2 2 2 1

50 47 F 1 2 2 1 1 1 1 1 3

51 28 F 1 3 2 2 2 2 2 2 1

52 48 F 1 2 2 2 2 2 2 2 1

53 30 F 2 1 2 1 1 1 1 1 3

54 29 F 1 2 2 2 2 2 2 2 1

55 45 F 1 3 2 1 1 1 1 1 2

56 55 F 1 1 2 2 2 2 2 2 1

57 31 F 2 1 1 1 1 1 2 2 3

58 41 F 1 2 1 2 2 2 2 2 1

59 45 F 2 2 2 2 1 1 2 1 3

60 53 F 1 1 1 2 1 1 2 2 3

61 42 M 1 1 2 2 1 1 2 2 3

62 52 F 1 2 2 2 2 2 1

Sl. No SHAPE MARGINS ECHOGENICITY HALO CONTENTS CALCIFICATION VASCULARITY ULTRASOUND DIAGNOSIS FNAC REPORT

1 THYROIDITIS THYROIDITIS

2 1 1 3 2 3 1 1 COLLOID GOITER COLLOID GOITER

3 1 1 2 2 1 2 3 MNG MNG

4 1 1 3 1 1 1 2 COLLOID GOITRE PAPILLARY CARCINOMA

5 2 2 2 3 1 3 4 MEDULLARY CARCINOMA MEDULLARY CARCINOMA

6 1 1 1 2 3 1 3 COLLOID GOITER COLLOID GOITRE

7 - - - - - - - THYROIDITIS THYROIDITIS

8 1 1 2 2 1 3 3 MNG MNG

9 1 3 4 1 1 1 1 MNG THYROIDITIS




13 1 3 4 2 1 2 4 MNG MNG

14 2 2 2 3 1 4 4 PAPILLARY CARCINOMA PAPILLARY CARCINOMA

15 1 1 4 1 1 1 3 ADENOMATOUS NODULE COLLOID GOITRE

16 1 3 3 2 3 1 1 COLLOID GOITER C0LLOID GOITER



19 1 3 3 1 1 4 1 MNG MNG


21 2 1 4 2 1 2 3 MNG MNG

22 1 3 3 1 1 1 1 THYROIDITIS THYROIDITIS

23 - - - - - - - THYROIDITIS COLLOID GOITER

24 2 2 2 3 2 3 4 ADENOMATOUS NODULE FOLLICULAR NEOPLASM


26 1 1 3 2 1 1 4 ADENOMATOUS NODULE THYROIDITIS







33 1 1 3 2 1 3 3 MNG MNG




37 1 1 4 2 1 2 4 MNG MNG



40 1 3 4 2 1 3 4 MNG WITH THYROIDITIS COLLOID GOITER

41 1 1 3 2 1 2 3 MNG WITH THYROIDITIS FOLLICULAR NEOPLASM






47 1 3 4 2 1 2 3 MNG WITH THYROIDITIS THYROIDITIS










57 1 1 1 1 2 1 COLLOID GOITER COLLOID GOITER




61 1 3 3 2 1 2 3 MNG THYROIDITIS


dissertation - repository-tnmgrmu.ac.inrepository-tnmgrmu.ac.in/4760/1/200824217anupriya.pdf · by...

Documents