The Neck - Thyroid & Non-Thyroid Pathology PDF

The Neck Thyroid and Non-Thyroid Pathology and Interventions Dalhousie School of Health Sciences DMUT 2030 – Topic 2  Thyroid Gland Pathology Congenital Abnormalities Nodular Thyroid Disease Agenesis/Aplasia Benign and malignant nodules Ectop...

The Neck Thyroid and Non-Thyroid Pathology and Interventions Dalhousie School of Health Sciences DMUT 2030 – Topic 2  Thyroid Gland Pathology Congenital Abnormalities Nodular Thyroid Disease Agenesis/Aplasia Benign and malignant nodules Ectopic thyroid Hyperplasia, adenomas, carcinomas, Hypoplasia metastases Congenital Hypothyroidism Congenital cysts Diffuse Thyroid Disease Thyroiditis Grave’s disease Multinodular goitre  Thyroid Lab/Imaging Tests Thyroid Nuclear Medicine T3 and T4 Scintigraphy Increased - Hyperthyroidism Decreased - Hypothyroidism Thyroid function “Hot” or “Cold” nodule “Hot” nodule TSH ? thyroid dysfunction or pituitary dysfunction Loading… -black Hyperfunctioning I uptake More likely to be benign benign “Cold” nodule Monitor response to thyroid Nonfunctioning medications uptake bloodwork- More likely to be malignant CT and MRI may be useful to assess the overall extent of a mass that extends below the clavicle Congenital Abnormalities Thyroid Agenesis/Aplasia Ectopic Thyroid Absent gland Abnormal location Hemi-agenesis = 1 lobe missing Lingual and suprahyoid Well defined ovoid structure with thyroid echotexture and vascularity Thyroid Rumack Fig 18-6, 48-25, 48-26 agenesis Nuclear Medicine scans may be required to confirm the absence of (or abnormally located) thyroid tissue  Congenital Abnormalities Thyroid Hypoplasia Congenital Hypothyroidism Varying degrees Varying degrees partial size of gland More common in females or I size of gland complete Loading… can occur after X treatment Rumack Fig 18- 6 Normal RT lobe, hypoplastic LT lobe  Congenital Abnormalities Congenital Cysts Rare Most cystic thyroid masses are nodules with cystic degeneration Simple cyst criteria May be complexities Nodular Thyroid Disease Benign and malignant nodules Hyperplasia, adenomas, carcinomas, metastases  Nodular Thyroid Disease May present as palpable abnormality OR May be an incidental discovery Carotid ultrasounds Occur in 4-7% of adult population Females > males  Nodular Thyroid Disease Etiologies Benign Malignant Focal thyroid hyperplasia Thyroid carcinoma Benign follicular adenomas Papillary severity Follicular Medullary vary Anaplastic Thyroid Lymphoma Thyroid metastases Previous exposure to ionizing radiation is an important risk factor 20-30% of this population have nodules  Benign VS Malignant Thyroid Nodules Controversial management Thyroid cancer is rare ( males Peak age 35-50 y.o. May be hereditary or caused by iodine deficiency Decreased, increased or normal lab test function There is a diffuse form of this pathology as well – Multinodular Goiter  Thyroid Hyperplasia (Nodule) Sonographic Appearance Usually single nodule May see: Isoechoic (most common) Hypoechoic halo May be hyperechoic if large Peri-nodular vascularity Thin septations Echogenic foci with comet-tail Cystic degeneration is common Calcifications Simple cyst appearance Coarse or egg-shell (peri-nodular) Not true cysts (true cysts are rare) +/- shadowing Anechoic fluid = colloid Solid papillary projections AKA Colloid cyst Internal vascularity Echogenic fluid = hemorrhage Honey-comb appearance  Hypoechoic halo Papillary projections and internal vascularity Honeycomb  appearance Eggshell calcification Rumack Fig 19-8 to 19-12, 48-32, Video 19-1 Colloid cysts with echogenic foci and comet-tail  Benign Follicular Adenomas Benign neoplasm of the thyroid follicular cells 5 -10% of nodular disease Females > males Normal thyroid function Compresses adjacent tissues grow big Diagnosis must be histologic Biopsy/FNA is useless Indistinguishable from follicular type of thyroid carcinoma Most are surgically removed  Benign Follicular Adenomas Sonographic Appearance adx for any void nodule Solid mass thy Single or multiple Variable echogenicity Hypoechoic, hyperechoic or isoechoic Peripheral hypoechoic halo Thick and smooth Due to compression of adjacent tissue Peripheral vascularity May be internal vascularity as well – spoke wheel pattern Rumack Fig 19-13, 48-34, Video 19-3  Thyroid Carcinoma Primary malignancy of the thyroid gland All are more common in females Types Loading… Papillary carcinoma Follicular carcinoma Medullary carcinoma Anaplastic carcinoma  Papillary Carcinoma Most common Sonographic Appearance 75-90% of thyroid carcinomas Solid hypoechoic mass (90%) Microcalcifications 2 peaks Tiny, punctate echogenic foci 30th decade and 70th decade With or without shadowing Hypervascularity (90%) Least aggressive (4-8% 20yr MR) Color Doppler 25% will have cervical lymphadenopathy Spread is lymphatic With our without microcalcifications Metastases to: May be cystic necrosis (rare) Cervical lymph nodes (most common) Mediastinum and lung (less commonly( slow growing , not the cause of death Papillary Carcinoma Power Doppler Rumack Fig 19-14 to 19-16, Videos 19-4, 19-5, Fig 48-36, 48-37 Lymphadenopathy with microcalcifications  Follicular Carcinoma 2nd most common Sonographic Appearance 5-15% of thyroid carcinomas Solid mass Single or multiple Variable echogenicity 2 Types Hypoechoic, hyperechoic or isoechoic Minimally invasive Peripheral hypoechoic halo Widely invasive Thick and irregular Compression of adjacent tissue 20yr MR ~20-30% Peripheral vascularity May be internal vascularity as well Spread is hematogeneous Metastases to: thro blood Bone, lung, brain, liver Follicular Carcinoma predominantly Rumack Fig 19-22, 19- 23 solid  Follicular Adenoma vs Follicular Carcinoma 'Benign Same sonographic appearance Margins and halo may be irregular with carcinoma Diagnosis must be histologic soFNA Biopsy/FNA is useless too similar needed Most are surgically removed IS  Medullary Carcinoma 5% of thyroid carcinomas Sonographic Appearance Solid, hypoechoic mass Derived from parafollicular (C) cells Calcifications Secretes calcitonin Coarse Lin blood +/- shadowing Cervical lymphadenopathy +/- calcifications More aggressive than papillary and follicular Metastases to cervical lymph nodes Associated with MEN II Syndrome (Sipple Syndrome) Pheochromocytomas lesions all More likely to be bilateral nodules over body Medullary Carcinoma hypoechoic w/macro calcif. Rumack Fig 19-24, 19- 25  Anaplastic Carcinoma Least common Sonographic Appearance 2% of thyroid carcinomas Hypoechoic Rapidly enlarging Elderly population Encase or invade vessels and muscles Associated with papillary or follicular May need other imaging (CT, MRI) carcinoma due to large size Dedifferentiation Most aggressive 5yr MR > 95% Spread is via local invasion Metastases to muscles and vessels of neck Anaplastic Carcinoma extend outside Rumack Fig 19- 26 +G  Thyroid Lymphoma Lymphoma can affect ANY organ Sonographic Appearance Usually non-Hodgkin’s type Extremely hypoechoic Prognosis is variable and depends on Lobulated mass stage at diagnosis Cystic necrosis of lesion 5yr MR 5-95% Encasement of adjacent structures Hypovascularity Often rapidly growing mass that causes dyspnea and dysphagia Fig 19-27  Thyroid Metastases Malignant spread to the thyroid from a Sonographic Appearance known primary Solitary, solid nodule Rare Well-circumscribed Hypoechoic Usually occurs late in primary disease No calcification progression Primary sites Melanoma (39%) Breast (21%) RCC (10%) Pt with RCC Rumack Fig 19- 28 Diffuse Thyroid Disease Thyroiditis Grave’s disease Multinodular goitre  Diffuse Thyroid Disease Characterized by diffuse gland enlargement Symmetric or asymmetric thickness of isthmus > 6mm May be focal nodules in presence of diffuse disease Etiologies Thyroiditis Grave’s disease Diffuse Thyroid Hyperplasia Multinodular Goiter (MNG)  Thyroiditis Inflammation or infection of the thyroid gland Characterized by: Pain Fever emerg/pediatric Enlarged and edematous gland Feeling of fullness in the throat tenderness Variety of types and causes Acute suppurative de Quervain’s Hashimoto’s  Thyroiditis Acute Suppurative Thyroiditis Sonographic Appearance Rare Enlarged gland Diffusely hypoechoic Bacterial infection Decreased vascularity Pediatric population May see abscess formation Ill-defined, hypoechoic mass with or without debris/gas/septations Inflammatory lymph nodes are commonly seen in neck de Quervain’s Thyroiditis Viral infection look out for abscess E Thyroiditis papable tender , thyroid Abscess formation Air in abscess Rumack Fig 19-44  Hashimoto’s Thyroiditis Most common type of gland inflammation Often painless, diffuse enlargement of gland Females > males Young or middle-aged Associated with hypothyroidism ↓ T3T4 Most common cause of hypothyroidism in North America Lab Tests ↓ T3 and T4 May be caused by: Autoimmune diseases Antibodies to thyroglobulin Pregnancy and/or post-partum period  Hashimoto’s Thyroiditis Sonographic Appearance Enlarged gland May eventually progress to small, atrophic gland Decreased echogenicity true nodules's background sep. Heterogeneous echotexture Micronodulation of Multiple, tiny (< 6mm) nodules Multiple echogenic fibrous septations Not true , just croaseness gland May be benign or malignant nodules as well FNA for diagnosis Normal or decreased vascularity on colour Doppler May progress to atrophied, small, heterogeneous gland over time Hashimoto’s Thyroiditis echo trans tell can't always borders Enlarged, hypoechoic and heterogeneous Vascular t with fibrous septations causing nodular appearance Rumack Fig 19-45 to 19-49, 48-30, Video 19-47  Grave’s Disease AKA - Thyrotoxicosis Clinical Symptoms Common cause of diffuse gland Heat intolerance enlargement Weight loss No known cause Tachycardia Exophthalmos Associated with hyperthyroidism Abnormal protrusion of the eyeballs Lab Tests T3 and T4  Grave’s Disease Sonographic Appearance Enlarged gland Heterogeneous echotexture Decreased echogenicity May see large intraparenchymal blood vessels Hypervascular on Color Doppler *Thyroid Inferno* sign ↳ Remember Grave’s Disease compared to He s a vascular Enlarged, heterogeneous “Inferno” sign Rumack Fig 19-51, 48-31  Diffuse Thyroid Hyperplasia AKA – Multinodular Goiter (MNG) Diffuse overgrowth of thyroid tissue tyroid enlarge Most common thyroid abnormality No Norm. May be hereditary or caused by iodine deficiency parenchyma Females > males >50 y.o.  Multinodular Goiter Sonographic Appearance Enlarged thyroid camera May extend into mediastinum Diffusely heterogeneous carete mind Multiple indistinguishable nodules throughout gland everydiffuse ov canin Y see Preck Rumack Fig 18-29, 48-35 The Neck Non-Thyroid Pathology Parathyroid Gland Pathology Ectopic Parathyroid Glands Parathyroid Masses Hyperparathyroidism  Ectopic Parathyroid Locations v/s not the modality choice Intrathyroid Retrotracheal 1 e. nuc med.. Uncommon Posterior or posterolateral to the trachea Within the thyroid tissue Turn pt’s head to opposite side, angle medially Well visualized on US Only a portion may be visualized (due to tracheal DDx – thyroid nodules shadowing) Carotid Sheath Mediastinal Superior and lateral Low in neck or superior in mediastinum Near carotid bifurcation Maximal hyperextension of the neck, angle DDx – lymph nodes inferiorly May not be visualized Inferior glands are more likely to be ectopic Locations can be anywhere from submandibular to the mediastinum Rumack Figs 20-10 to 20-13 and Videos 20-9 to 20-12  Parathyroid Masses Parathyroid Adenoma Parathyroid Carcinoma Benign neoplasm Malignant neoplasm Usually single Rare Rumack Fig. 20-2 to 20-10 like a asddy Parathyroid Hyperplasia Benign overgrowth All look mass. solid Usually multiple (all) Associated with MEN I Adenomas, hyperplasia and carcinoma are generally indistinguishable on ultrasound  Parathyroid Masses Sonographic Appearance Usually posterior to thyroid May be ectopic Variable size 1.5 - 5cm Oval or oblong, solid mass Homogeneously hypoechoic May see cystic degeneration or (rarely) calcifications Hypervascular on color Doppler  Parathyroid Masses Sonographic Appearance Generally indistinguishable on ultrasound Hyperplasia or multiple adenomas (Fig 20-6, Videos 20-3, 20-4) Multiple glands are affected Carcinoma (Fig. 20-7) >2 cm dif Taller than wide Lobulated contour Heterogeneous Cystic degeneration (not reliable) Invasion of adjacent structures (most reliable)  Parathyroid Masses pararoc Round- ens Hypervascula r oval hypoechoic Linf edge. ord & tissue plane for Carcinom adenoma Multiple is usually a >2 cm of sep hyperplasia  Parathyroid Masses Sonographic Pitfalls Cervical lymph nodes TR Esophagus (Fig 20-8b) Central echogenic hilum Concentric ring May be indistinguishable Turn LONG on it FNA for Dx Elongates to a tubular structure Ask the patient to swallow Posterior thyroid nodules (Fig 20-16, Video 20-14) Echogenic bubbles Demonstrate echogenic plane of tissue separation Parathyroid mass TR Longus colli muscle Turn LONG on it Small adjacent vein Elongates to a tubular structure Turn LONG on it Compare to opposite side Elongates to a tubular structure Valsalva maneuver Color Doppler Longus Colli and Esophagus TR RT mena SAG RT ~ see when Longus Esophagu Colli s Tissue Plane of Separation Echogenic plane No echogenic plane Thyroid nodule Echogenic plane Parathyroid nodules  Primary Hyperparathyroidism Endocrine disorder Risk Factors Females > males Prior radiation >50 y.o. MEN I (hyperplasia) Long term lithium therapy Caused by parathyroid masses Parathyroid adenomas Treatment 80-90% Medical Parathyroid hyperplasia Hypocalcemic agents like calcitonin 10-20% Surgical excision is preferred Parathyroid carcinoma