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Dr. masciotra sonoelastography and us in the diagnosis of small thyroid papillary cancers

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New emerging tools in ultrasound in cases of small thyroid papillary cancer

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Dr. masciotra sonoelastography and us in the diagnosis of small thyroid papillary cancers

  1. 1. A small thyroid papillary cancer The role of Shear Wave Elastography Antonio Pio Masciotra Campobasso – Molise – Italy Website www.masciotra.net YouTube Channel https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ 51 years old asymptomatic woman at her first thyroid US exam. Two small nodules were found in her left lobe, one in the lower pole, the other near the isthmus.
  2. 2. This is the lower pole nodule, slightly hypoechoic wth a few intranodular vessels at powerdoppler. At Shear Wave Elastography it shows a stiffness substantially not different from the one of surrounding normal parenchyma.
  3. 3. This is the second nodule (8 mm in diameter and 0,2 ml in volume). It is inhomogenehously hypoechoic, with undefined borders, taller than wide, with small calcification and many intranodular vessels. 10-2 Mhz Linear probe 15-4 MHz Linear probe 16-5 MHz Linear Probe
  4. 4. This is the 3D US study also in elastography
  5. 5. 10-2 Mhz probe 15-4 MHz probe 16-5 MHz probe Left lobe paraisthmic nodule (kPa) 10-2 MHz 15-4 MHz 16-5 MHz Mean stiffness 72-104 58-72 51-71 Maximum stiffness 95-133 76-111 87-91 Minimum stiffness 71-89 26-41 1-49 Standard Deviation 9-13 9-20 11-23 Ratio 1,4-3,4 2,4-4,3 1,8-3,8
  6. 6. Lower pole nodule Paraisthmic nodule 15-4 MHZ Probe SWE Features (kPa) Lower pole nodule Paraisthmic nodule Mean stiffness 31-33 58-72 Maximum stiffness 36-43 76-111 Minimum stiffness 25-31 26-41 Standard Deviation 1-3 9-20 Ratio 1,0-1,4 2,4-4,3
  7. 7. This is the FNA cytology of the left lobe’s paraisthmic nodule classified TIR 5* (corresponding to Thy VI in the Bethesda Classification), diagnostic for PTC. At surgery this nodule was confirmed PTC, while the lower pole nodule was benign (simply hyperplastic). * ITALIAN CONSENSUS GROUP FOR THE CLASSIFICATION AND REPORTING OF THYROID CYTOLOGY Francesco Nardi, Fulvio Basolo, Anna Crescenzi, Guido Fadda, Andrea Frasoldati, Fabio Orlandi, Lucio Palombini, Enrico Papini, Alfredo Pontecorvi, Paolo Vitti (2013) TIR1: Not diagnostic. TIR1C: Not diagnostic - Cyst. TIR2: Not neoplastic. TIR3A: Low risk follicular lesion. TIR3B: High risk follicular lesion. TIR4: Suspicious for malignancy. TIR5: Diagnostic of malignancy.
  8. 8. Two more small thyroid papillary cancers The role of Sonoelastography Antonio Pio Masciotra Campobasso – Molise – Italy Website www.masciotra.net YouTube Channel https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ 37 years old asymptomatic woman at her first thyroid US exam. Two small nodules were found, one in the right lobe near the isthmus, the other in the lower pole of the left lobe.
  9. 9. This is the right lobe’s paraisthmic nodule, slightly hypoechoic with intranodular vessels at powerdoppler. At Shear Wave Elastography it shows stiffness features substantially not different from the ones showed by the right lobe’s paraisthmic nodule.
  10. 10. This is the lower pole nodule, slightly hypoechoic with a few intranodular vessels at powerdoppler. At Shear Wave Elastography it shows stiffness features substantially not different from the ones showed by the right lobe’s paraisthmic nodule.
  11. 11. Right lobe paraisthmic nodule (kPa) 10-2 MHz 15-4 MHz 16-5 MHz Mean stiffness 42-45 42-71 15-36 Maximum stiffness 47-59 68-77 20-47 Minimum stiffness 19-42 15-63 8-13 Standard Deviation 1,4-7,7 4,0-11,2 2,8-9,3 Ratio 1,4-2,1 2,9-5,2 1,0-2,6 Left lobe nodule (kPa) 10-2 MHz 15-4 MHz 16-5 MHz Mean stiffness 19-30 28-66 15-16 Maximum stiffness 21-41 32-69 20-23 Minimum stiffness 16-17 11-63 1-8 Standard Deviation 0,8-7,8 1,2-9,7 2,8-7,1 Ratio 1,0-2,9 1,2-3,8 1,0-1,6
  12. 12. Left lobe nodule features S 2000 Diameter (cm) 0.6 El/B Ratio >1 Strain Ratio 12.44 Strain Elastograhy final indication Biopsy Stiffness at Virtual Touch Imaging Limited Mean SW speed (m/s) 1.04 SW speed Ratio (Nod/Parenchyma) 0.8 Final indication Surveillance Right lobe nodule features S 2000 Diameter (cm) 0.8 El/B Ratio >1 Strain Ratio 3.71 Strain Elastograhy final indication Biopsy Stiffness at Virtual Touch Imaging Mixed Hard Mean SW speed (m/s) 2.62 SW speed Ratio (Nod/Parenchyma) 1.7 ARF final indication Biopsy The same patient was examined also with an Acuson S 2000. The unit performs sonoelastography both in Strain modality and in Acoustic Radiation Force (both Imaging – with displacement analisys - and Quantification of the Shear Waves speed in m/s). The indications given by the two different techniques are discordant because Strain elastography indicates the biopsy for both the nodules, while ARF indicates biopsy for right lobe nodule and surveillance policy for the left lobe nodule.
  13. 13. This is the FN cytology of the right lobe’s paraisthmic nodule classified TIR 4* (corresponding to Thy V in the Bethesda Classification), suspicious for PTC. At surgery both nodules were PTC. * ITALIAN CONSENSUS GROUP FOR THE CLASSIFICATION AND REPORTING OF THYROID CYTOLOGY Francesco Nardi, Fulvio Basolo, Anna Crescenzi, Guido Fadda, Andrea Frasoldati, Fabio Orlandi, Lucio Palombini, Enrico Papini, Alfredo Pontecorvi, Paolo Vitti (2013) TIR1: Not diagnostic. TIR1C: Not diagnostic - Cyst. TIR2: Not neoplastic. TIR3A: Low risk follicular lesion. TIR3B: High risk follicular lesion. TIR4: Suspicious for malignancy. TIR5: Diagnostic of malignancy.
  14. 14. Case n.2 SSI SWE Features (15-4 MHz Probe) Right lobe nodule Left lobe nodule Mean stiffness (kPa) 42-71 28-66 Maximum stiffness (kPa) 68-77 32-69 Minimum stiffness (kPa) 15-63 11-63 Standard Deviation (kPa) 4-11 1-9 Ratio 2,9-5,2 1,2-3,8 Acuson S 2000 Features (9-4 MHz Probe) Right lobe nodule Left lobe nodule Elasto/B image Ratio >1 >1 Strain Ratio 3,71 12,44 Stiffness at Virtual Touch Imaging Mixed Hard Almost Isostiff Mean SW speed (m/s) 2,62 1,04 SW speed Ratio (Nodule/Parenchyma) 1,7 0,8 Acuson S 2000 Final Indication Biopsy Biopsy (Strain) Surveillance (ARF) SSI SWE Final Indication Biopsy Biopsy FNA Citology TIR 4 (Thy V) Not performed Pathological diagnosis Malignant (PTC) Malignant (PTC)
  15. 15. The TIRADS LEXIC To each nodule, the radiologist has to specify its: 1. Shape “taller-than-wide” (greater in its antero-posterior dimension than in its transverse dimension) and “wider-than-tall”. 2. Internal component solid, mixed or cystic 3. Margins well circumscribed, lobulated or irregular 4.Echogenicity “hyperechogenicity”, “isoechogenicity”, “hypoechogenicity” and “marked hypoechogenicity”. Isoechogenicity was defined as an echogenicity similar to that of the adjacent healthy thyroid gland. A nodule was classified as “marked hypoechogenicity” if the echogenicity was less than that of the superficial surrounding neck muscles. 5.Evidence of calcifications Micro-calcifications (< 3 mm) Macrocalcifications (> 3 mm with acoustic shadowing)) 6. Stiffness Features
  16. 16. TIRADS classification (modified Russ classification) TIRADS 1 - Normal thyroid TIRADS 2 - Benign aspects (0% chance of malignancy) Simple cyst Spongiform nodule ‘White Knight’ aspect Isolated macrocalcification Typical sub acute thyroiditis TIRADS 3 - Probably benign aspects (<5% chance of malignancy) None of the highly suspicious aspects Isoechogenic Hyperechogenic TIRADS 4A - Low suspicious aspects (5-10% chance of malignancy) None of the highly suspicious aspects Moderately hypoechogenic TIRADS 4B / 5: High suspicious aspects Taller than wide shape Irregular or microlobulated margins Microcalcifications Marked hypoéchogenicity High stiffness index with elastography (if available ) * 4B: 1 or 2 signs and no adenopathy (10-80% chance of malignancy) * 5: 3 or more signs and/or adenopathy (>80% chance of malignancy) TIRADS 6 – Biopsy proven malignant nodules All studies show that most cancers were found in the TIRADS 3, 4 and 5 categories.
  17. 17. Left lobe paraisthmic Feature Left lobe lower pole Taller than wide Shape ‘Taller-than-wide’ and “wider-than-tall” Wider than tall Solid Internal component solid, mixed or cystic Solid Irregular Margins Well circumscribed, lobulated or irregular Well circuscribed 0.10 Echogenicity (B Ratio Nodule/Parenchyma) “hyperechogenicity”,“isoechogenicity”, “hypoechogenicity”and “marked hypoechogenicity” 0.80 Micro and Macro Evidence of calcifications Micro-calcifications (< 3 mm) Macrocalcifications (> 3 mm with acoustic shadowing) No Both Vessels Perinodular Intranodular Peri 76 - 111 Mean Stiffness (kPa) 31 - 33 9 - 20 Standard Deviation (kPa) 1 -3 2,4 - 4,3 Stiffness Ratio (Nodule/Parenchyma) 1,0 – 1,4 5 TIRADS 3 Biopsy Final indication Surveillance Case n.1
  18. 18. Right lobe Feature Left lobe Wider than tall Shape ‘Taller-than-wide’ and “wider-than-tall” Wider than tall Solid Internal component solid, mixed or cystic Solid Lobulated Margins Well circumscribed, lobulated or irregular Lobulated 0.45 Echogenicity (B Ratio Nodule/Parenchyma) “hyperechogenicity”,“isoechogenicity”, “hypoechogenicity”and “marked hypoechogenicity” 0.59 Micro and Macro Evidence of calcifications Micro-calcifications (< 3 mm) Macrocalcifications (> 3 mm with acoustic shadowing) Micro Both Vessels Perinodular Intranodular Both 42 -71 Mean Stiffness (kPa) 28 - 66 4,0 - 11,2 Standard Deviation (kPa) 1,2 - 9,7 2,9 – 5,2 Stiffness Ratio (Nodule/Parenchyma) 1,2 – 3,8 5 TIRADS 4B Biopsy Final indication Biopsy Case n.2
  19. 19. SSI 15-4 MHz Probe Case n.1 Case n.2 SWE Features Paraisthmic nodule Lower pole nodule Right lobe nodule Left lobe nodule Mean stiffness (kPa) 58-72 31-33 42-71 28-66 Maximum stiffness (kPa) 76-111 36-43 68-77 32-69 Minimum stiffness (kPa) 26-41 25-31 15-63 11-63 Standard Deviation (kPa) 9-20 1-3 4-11 1-9 Ratio 2,4-4,3 1,0-1,4 2,9-5,2 1,2-3,8 TIRADS 5 3 5 4B Final indication Biopsy Surveillance Biopsy Biopsy FNA TIR 5 (Thy VI) Not performed TIR 4 (Thy V) Not performed Pathological diagnosis Malignant (PTC) Benign Malignant (PTC) Malignant (PTC) Keypoints of the cases and ‘take home messages’  Shear wave elastography one more time shows its reliability in identifying stiff thyroid nodules also with small volume (< 1 cm) and in the guidance of the FNAC, like in this cases of three small PTCs.  It correctly characterize as ‘soft’ the only one benign nodule (one on four).
  20. 20. Keypoints of the cases and ‘take home messages’  While Papillary cancers are usually stiff, Follicular cancers can be soft.  This cases show one more time that small nodules can be cancer, while large nodules can be benign.  Uptodate my impression is that we cannot rely on absolute number because they change depending on too many variables (frequency of the probe, speed of sound selected, grade of compression you do with your hand, depth of the lesion and surrounding environment, and so on) and , sure, because we well know that cancers can be 'soft' and benign lesions can be stiff.  My actual belief is that large more reliable in addressing our impression are two other parameters (or features) : 1) Standard Deviation (higher in malignant lesions cause of their almost constant inhomogeneity) 2) Elasticity Ratio Vs a standard reference tissues.  Well, while the kPa's numbers (E-mean, min and max) can be very variable, SD and Ratio remain unmodified, unconditioned by the above mentioned factors.  I think that international guidelines on the indications to thyroid biopsy should be rediscussed (at least regarding the dimensions) and that, on the other side, we should analyze the real risk of overdiagnosis and overtreatment in these situations.  In conclusion nowadays advanced ultrasonography offers so many tools that it would be unsafe to rely the diagnostic workup only on one of the US modes (B-mode, Doppler and sonoelastography).  Uptodate TIRADS is based on all these informations that make ultrasonography to deserve in full the definition of ‘Multiparametric Diagnostic Modality’.
  21. 21. Ultrasonography of thyroid focal diseases : a true Multiparametric Diagnostic Modality Mode Features Informations B Mode Shape ‘Taller-than-wide’ and “wider-than-tall” Morphology and Structure Internal component solid, mixed or cystic Margins Well circumscribed, lobulated or irregular Echogenicity (B Ratio Nodule/Parenchyma) “hyperechogenicity”,“isoechogenicity”, “hypoechogenicity”and “marked hypoechogenicity” Evidence of calcifications Micro-calcifications (< 3 mm) Macrocalcifications (> 3 mm with acoustic shadowing) Doppler Mode CDI, PDI , dPDI Number, density and distribution of the vessels Vascular Pulsed Wave Blood flow characterisation and quantification Blood Flow – Functional (?) Sonoelastography Strain Relative Stiffness Mechanical properties Shear Wave Relative stiffness and Stiffnes quantification
  22. 22. Antonio Pio Masciotra Campobasso – Molise – Italy Website www.masciotra.net YouTube Channel https://www.youtube.com/channel/UCgCj21nKGAhR997Ia3-QegQ Thanks for your attention

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