DOI: 10.1148/rg.273065038
US Features of Thyroid Malignancy: Pearls and Pitfalls1
Jenny K. Hoang, MBBS, FRANZCR,
Wai Kit Lee, MBBS, FRANZCR,
Michael Lee, MBBS,
Daryl Johnson, MBBS, and
Stephen Farrell, MBBS, FRACS
1 From the Departments of Medical Imaging (J.K.H., W.K.L., M.L.), Pathology (D.J.), and Surgery (S.F.), St Vincent’s Hospital Melbourne, University of Melbourne, 41 Victoria Parade, Fitzroy 3065, Victoria, Australia. Recipient of a Certificate of Merit award for an education exhibit at the 2005 RSNA Annual Meeting. Received March 22, 2006; revision requested July 7 and received August 7; accepted August 14. All authors have no financial relationships to disclose.
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Figure 2a. Papillary thyroid carcinoma in a 42-year-old man. (a) Photomicrograph (original magnification, x 400; hematoxylineosin stain) shows a psammoma body (arrow), a round laminar crystalline calcification. (b) Transverse sonogram of the right lobe of the thyroid demonstrates punctate echogenic foci without posterior acoustic shadowing, findings indicative of microcalcifications (arrows).
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Figure 2b. Papillary thyroid carcinoma in a 42-year-old man. (a) Photomicrograph (original magnification, x 400; hematoxylineosin stain) shows a psammoma body (arrow), a round laminar crystalline calcification. (b) Transverse sonogram of the right lobe of the thyroid demonstrates punctate echogenic foci without posterior acoustic shadowing, findings indicative of microcalcifications (arrows).
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Figure 3a. Medullary thyroid carcinoma in a 32-year-old man. (a) Transverse sonogram of the right lobe of the thyroid shows a large nodule with coarse calcification and posterior acoustic shadowing (arrows). (b) Axial computed tomographic (CT) image shows the nodule with an internal focus of coarse calcification (arrows).
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Figure 3b. Medullary thyroid carcinoma in a 32-year-old man. (a) Transverse sonogram of the right lobe of the thyroid shows a large nodule with coarse calcification and posterior acoustic shadowing (arrows). (b) Axial computed tomographic (CT) image shows the nodule with an internal focus of coarse calcification (arrows).
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Figure 4. Benign thyroid nodule in a 51-year-old woman. Transverse sonogram of the right lobe of the thyroid shows a colloid nodule with a ring-down artifact (arrow), a finding indicative of inspissated colloid calcification.
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Figure 5a. Anaplastic thyroid carcinoma in an 84-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows an advanced tumor with infiltrative posterior margins (arrows) and invasion of prevertebral muscle. (b) Axial contrast-enhanced CT image shows a large tumor that has invaded the prevertebral muscle (arrows).
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Figure 5b. Anaplastic thyroid carcinoma in an 84-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows an advanced tumor with infiltrative posterior margins (arrows) and invasion of prevertebral muscle. (b) Axial contrast-enhanced CT image shows a large tumor that has invaded the prevertebral muscle (arrows).
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Figure 6a. Infiltrative primary leiomyosarcoma of the thyroid in a 90-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a tumor (between calipers) with infiltration from the posterior tumor margin into the prevertebral space (arrows). (b) Axial unenhanced CT image shows the large size of the tumor and the extent of invasion (arrows). (c) Photomicrograph (original magnification, x 100; hematoxylineosin stain) shows tumor invasion beyond the capsule (arrows).
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Figure 6b. Infiltrative primary leiomyosarcoma of the thyroid in a 90-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a tumor (between calipers) with infiltration from the posterior tumor margin into the prevertebral space (arrows). (b) Axial unenhanced CT image shows the large size of the tumor and the extent of invasion (arrows). (c) Photomicrograph (original magnification, x 100; hematoxylineosin stain) shows tumor invasion beyond the capsule (arrows).
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Figure 6c. Infiltrative primary leiomyosarcoma of the thyroid in a 90-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a tumor (between calipers) with infiltration from the posterior tumor margin into the prevertebral space (arrows). (b) Axial unenhanced CT image shows the large size of the tumor and the extent of invasion (arrows). (c) Photomicrograph (original magnification, x 100; hematoxylineosin stain) shows tumor invasion beyond the capsule (arrows).
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Figure 7a. Papillary carcinoma and cystic lymph node metastasis in a 28-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows an irregular hypoechoic tumor with microcalcifications. (b) Longitudinal sonogram of the right neck shows a cystic level 5 nodal metastasis with internal septation and foci of calcification (arrows). (c) Axial contrast-enhanced CT image shows the metastasis (arrow).
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Figure 7b. Papillary carcinoma and cystic lymph node metastasis in a 28-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows an irregular hypoechoic tumor with microcalcifications. (b) Longitudinal sonogram of the right neck shows a cystic level 5 nodal metastasis with internal septation and foci of calcification (arrows). (c) Axial contrast-enhanced CT image shows the metastasis (arrow).
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Figure 7c. Papillary carcinoma and cystic lymph node metastasis in a 28-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows an irregular hypoechoic tumor with microcalcifications. (b) Longitudinal sonogram of the right neck shows a cystic level 5 nodal metastasis with internal septation and foci of calcification (arrows). (c) Axial contrast-enhanced CT image shows the metastasis (arrow).
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Figure 8a. Papillary carcinoma and vascular lymph node metastasis in a 27-year-old woman. (a) Transverse sonogram shows a tumor that has infiltrated the entire right lobe of the thyroid (arrows). (b) Transverse sonogram of the right neck shows a level 3 lymph node metastasis with increased vascularity (arrow). (c) Axial contrast-enhanced CT image shows a vascular lymph node with a targetlike appearance (arrow).
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Figure 8b. Papillary carcinoma and vascular lymph node metastasis in a 27-year-old woman. (a) Transverse sonogram shows a tumor that has infiltrated the entire right lobe of the thyroid (arrows). (b) Transverse sonogram of the right neck shows a level 3 lymph node metastasis with increased vascularity (arrow). (c) Axial contrast-enhanced CT image shows a vascular lymph node with a targetlike appearance (arrow).
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Figure 8c. Papillary carcinoma and vascular lymph node metastasis in a 27-year-old woman. (a) Transverse sonogram shows a tumor that has infiltrated the entire right lobe of the thyroid (arrows). (b) Transverse sonogram of the right neck shows a level 3 lymph node metastasis with increased vascularity (arrow). (c) Axial contrast-enhanced CT image shows a vascular lymph node with a targetlike appearance (arrow).
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Figure 10. Papillary carcinoma in an 87-year-old man. Transverse sonogram of the thyroid isthmus shows a poorly defined tumor with marked hypoechogenicity and irregular margins (arrows) and without a hypoechoic halo.
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Figure 11a. Renal cell carcinoma metastases to the thyroid in a 69-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows a round hypoechoic nodule (arrows) and an irregular-shaped hypoechoic nodule (arrowheads). (b) Color Doppler sonogram of the round nodule shows increased internal vascularity.
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Figure 11b. Renal cell carcinoma metastases to the thyroid in a 69-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows a round hypoechoic nodule (arrows) and an irregular-shaped hypoechoic nodule (arrowheads). (b) Color Doppler sonogram of the round nodule shows increased internal vascularity.
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Figure 13. B cell lymphoma of the thyroid in a 73-year-old woman with Hashimoto thyroiditis. Transverse sonogram of the left lobe of the thyroid shows a large heterogeneous mass (between calipers) with marked hypoechogenicity when compared with the strap muscles (SM). A normal isthmus (arrow) also is visible. IJV = internal jugular vein.
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Figure 14a. Large toxic follicular adenoma in a 45-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a 4.5-cm nodule (arrows) that was benign despite its size. (b) Coronal scintigram obtained with technetium 99m pertechnetate shows a hyperfunctioning adenoma (arrow).
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Figure 14b. Large toxic follicular adenoma in a 45-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a 4.5-cm nodule (arrows) that was benign despite its size. (b) Coronal scintigram obtained with technetium 99m pertechnetate shows a hyperfunctioning adenoma (arrow).
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Figure 15. Papillary carcinoma and cystic lymph node metastasis in a 44-year-old woman with a multinodular thyroid. Transverse sonogram of the right lobe of the thyroid shows a hypoechoic carcinoma in the isthmus, with microcalcifications and absence of a halo (arrowheads). The right lobe of the thyroid is displaced anteriorly by a large, partially cystic, level 6 (paratracheal) nodal metastasis (arrows), which appears to be within the thyroid and which was mistaken for a benign thyroid nodule. Because several solid benign nodules were present, the initial diagnosis was benign multinodular thyroid. The cystic nodal metastasis was confirmed at surgery. CCA = common carotid artery.
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Figure 16a. Medullary thyroid carcinoma and calcified nodal metastases in a 57-year-old man. (a) Transverse sonogram shows a lymph node metastasis with coarse calcifications (arrows) immediately inferior to the left lobe of the thyroid. The metastasis was mistaken for a benign calcified hyperplastic thyroid nodule. Several truly benign thyroid nodules also were found at US, and these findings led to an incorrect diagnosis of multinodular thyroid. CCA = common carotid artery. (b) Sagittal sonogram obtained at follow-up US shows two other calcified lymph node metastases (arrows) on the left side, at level 2. (c) Coronal unenhanced CT image shows the calcified nodal metastases in both locations (arrows).
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Figure 16b. Medullary thyroid carcinoma and calcified nodal metastases in a 57-year-old man. (a) Transverse sonogram shows a lymph node metastasis with coarse calcifications (arrows) immediately inferior to the left lobe of the thyroid. The metastasis was mistaken for a benign calcified hyperplastic thyroid nodule. Several truly benign thyroid nodules also were found at US, and these findings led to an incorrect diagnosis of multinodular thyroid. CCA = common carotid artery. (b) Sagittal sonogram obtained at follow-up US shows two other calcified lymph node metastases (arrows) on the left side, at level 2. (c) Coronal unenhanced CT image shows the calcified nodal metastases in both locations (arrows).
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Figure 16c. Medullary thyroid carcinoma and calcified nodal metastases in a 57-year-old man. (a) Transverse sonogram shows a lymph node metastasis with coarse calcifications (arrows) immediately inferior to the left lobe of the thyroid. The metastasis was mistaken for a benign calcified hyperplastic thyroid nodule. Several truly benign thyroid nodules also were found at US, and these findings led to an incorrect diagnosis of multinodular thyroid. CCA = common carotid artery. (b) Sagittal sonogram obtained at follow-up US shows two other calcified lymph node metastases (arrows) on the left side, at level 2. (c) Coronal unenhanced CT image shows the calcified nodal metastases in both locations (arrows).
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Figure 17a. Hürthle cell (follicular) carcinoma in a 60-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a partially cystic tumor with solid internal projections (arrows) and thick walls. (b) Color Doppler sonogram (shown in black and white) depicts increased vascularity in the solid parts of the tumor (arrow).
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Figure 17b. Hürthle cell (follicular) carcinoma in a 60-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a partially cystic tumor with solid internal projections (arrows) and thick walls. (b) Color Doppler sonogram (shown in black and white) depicts increased vascularity in the solid parts of the tumor (arrow).
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Figure 18a. Rare cystic papillary thyroid carcinoma in a 55-year-old woman. (a) Transverse sonogram of the right lobe of the thyroid shows a complex cystic lesion with thick walls and solid components (arrows). (b) Color Doppler sonogram shows vascularity in a small part of the lesion margin (arrow). (c) Axial contrast-enhanced CT image shows the tumor (arrows) but does not clearly depict its complexity.
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Figure 18b. Rare cystic papillary thyroid carcinoma in a 55-year-old woman. (a) Transverse sonogram of the right lobe of the thyroid shows a complex cystic lesion with thick walls and solid components (arrows). (b) Color Doppler sonogram shows vascularity in a small part of the lesion margin (arrow). (c) Axial contrast-enhanced CT image shows the tumor (arrows) but does not clearly depict its complexity.
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Figure 18c. Rare cystic papillary thyroid carcinoma in a 55-year-old woman. (a) Transverse sonogram of the right lobe of the thyroid shows a complex cystic lesion with thick walls and solid components (arrows). (b) Color Doppler sonogram shows vascularity in a small part of the lesion margin (arrow). (c) Axial contrast-enhanced CT image shows the tumor (arrows) but does not clearly depict its complexity.
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Figure 19a. Diffuse follicular variant of papillary thyroid carcinoma in a 37-year-old woman with thyrotoxicosis mistaken for Graves disease. (a) Transverse sonogram of the left lobe of the thyroid shows a heterogeneously hypoechoic enlarged thyroid (arrows) with no residual normal thyroid tissue. (b) Color Doppler image shows diffuse increased parenchymal vascularity. (c) Transverse sonogram of the right neck shows a lymph node metastasis inferior to the right lobe of the thyroid (arrow) with coarse calcification. This finding aroused suspicion about the possible presence of a primary thyroid carcinoma. Histopathologic analysis of the surgical specimen showed replacement of the thyroid gland by a diffuse follicular variant of papillary thyroid carcinoma. CCA = common carotid artery.
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Figure 19b. Diffuse follicular variant of papillary thyroid carcinoma in a 37-year-old woman with thyrotoxicosis mistaken for Graves disease. (a) Transverse sonogram of the left lobe of the thyroid shows a heterogeneously hypoechoic enlarged thyroid (arrows) with no residual normal thyroid tissue. (b) Color Doppler image shows diffuse increased parenchymal vascularity. (c) Transverse sonogram of the right neck shows a lymph node metastasis inferior to the right lobe of the thyroid (arrow) with coarse calcification. This finding aroused suspicion about the possible presence of a primary thyroid carcinoma. Histopathologic analysis of the surgical specimen showed replacement of the thyroid gland by a diffuse follicular variant of papillary thyroid carcinoma. CCA = common carotid artery.
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Figure 19c. Diffuse follicular variant of papillary thyroid carcinoma in a 37-year-old woman with thyrotoxicosis mistaken for Graves disease. (a) Transverse sonogram of the left lobe of the thyroid shows a heterogeneously hypoechoic enlarged thyroid (arrows) with no residual normal thyroid tissue. (b) Color Doppler image shows diffuse increased parenchymal vascularity. (c) Transverse sonogram of the right neck shows a lymph node metastasis inferior to the right lobe of the thyroid (arrow) with coarse calcification. This finding aroused suspicion about the possible presence of a primary thyroid carcinoma. Histopathologic analysis of the surgical specimen showed replacement of the thyroid gland by a diffuse follicular variant of papillary thyroid carcinoma. CCA = common carotid artery.
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Copyright © 2007 by the Radiological Society of North America.
