11 pictures to identify the nature of thyroid nodules

*Only for medical professionals to read and refer to the picture to identify thyroid disease.
When you meet a patient, you find thyroid nodules after the examination, but there is no other discomfort or pressure, and you deny the history of thyroid disease and related family history.
Personal history also does not show radiation exposure.

As a clinician, what should you do next? Previously, Medscape published a clinical treatment guide for similar situations, let us learn it together.

 Analyze color Doppler ultrasound, can you make a differential diagnosis? Color Doppler ultrasound of the thyroid and neck is the most important method for clinically distinguishing benign and suspicious nodules.
Combined with the guidelines of the American Thyroid Association (ATA) and the American College of Radiology Thyroid Image Reporting and Data System (ACR TI-RADS), it helps us to guide our identification.
And diagnosis.

The ATA guidelines classify nodules as benign, very unlikely, low, moderate, or highly suspect based on ultrasound images.

 1.
Benign: Consists of pure cystic nodules with no solid content.
The risk of cancer is less than 1%.
No biopsy is required.
If relevant indications are available, cyst drainage can be performed.

2.
Very low possibility: including spongy (>50% of nodules are composed of microcystic spaces) and partial cystic nodules, lacking any highly suspected features (Figure 1, 2), cancer risk <3%, yes Confirmation without biopsy, but it is worth noting that biopsy should be considered when nodules> 2cm.

 Figure 1 The ultrasound image shows that the typical spongy nodules are mainly composed of microcystic spaces.
Figure 2 The spongy nodules with echogenic foci represent the enhancement behind the microcystic cavity and are usually mistaken for microcalcification.
3.
Low level of suspicion: including Iso-echoic and hyperechoic solid nodules, and some cystic nodules with eccentric solid wall components, but still do not have highly suspected features (Figure 3).

The risk of cancer is about 5%-10%.
ATA recommends that if the nodule is larger than 1.
5cm, a biopsy can be performed.Figure 3 Low-risk isoechoic solid nodules 4.
Moderate suspicion: Excluding hypoechoic solid nodules with high suspicion characteristics (Figure 4), the risk of cancer is about 10%-20%.
ATA recommends that if the nodule is greater than 1.
0 cm, then Biopsy can be performed.

 Figure 4 Moderately hypoechoic solid nodules 5.
High suspicion: including solid or partially cystic hypoechoic nodules with irregular edges, microcalcifications, tall and wide in shape, edge calcifications with small protrusions or extra thyroid expansion (Figure 5, 6) The risk of cancer is about 70%-90%.
ATA recommends that if the knot saves 1.
0cm, a biopsy can be performed.

It is worth noting that this category includes suspicious cervical lymph nodes on ultrasound (Figures 7 and 8), highlighting the critical role of assessing anterior cervical lymph nodes as part of the assessment of each thyroid nodule.

 Figure 5 High suspicion: Hypoechoic nodules that are higher than solid state, microcalcification Figure 6 Highly suspected hypoechoic nodules, with microcalcifications, and may invade the band muscle Figure 7 Right cervical cystic lymph node (LN), Common carotid artery (CCA), internal jugular vein (IJV) Figure 8 In the horizontal (left) and longitudinal (right) views, microcalcification of the left lymph node and compression of the jugular vein can be seen in the patient’s ultrasound examination.
Nodules (Figure 9) are classified as low suspicion, so it is appropriate to monitor this nodule only by ultrasound.

 Figure 9 A static image of a 2.
5 cm nodule with non-specific echogenic foci (arrow), which is usually interpreted as microcalcification (high suspicion).

However, real-time imaging shows that these are bright spots behind the small cystic space within the spongy/hyperplastic nodules.

 After studying the color Doppler ultrasound above, let’s take the iron while it’s hot and let’s take a look at the following case: Case Express A 58-year-old woman was newly admitted to the hospital.
Her recent carotid ultrasound showed thyroid nodules (Figure 10).

The nodules are about 3.
1 cm long, hypoechoic, with regular borders, no calcification, and no suspicious lymph nodes are seen.

 Figure 10 Mild hypoechoic nodules with no suspicious features.
This woman denied any previous history of thyroid nodules, did not have any symptoms of compression, and had never taken antithyroid drugs.

After inquiring about the medical history again, it was discovered that the woman was born in Romania and had experienced the Chernobyl nuclear accident.
Her mother had previously suffered from hypothyroidism.  Doctor thinking: Based on the above information, what is your judgment? These characteristics suggest that the nodule belongs to the moderately suspected category, and the risk of cancer is 10%-20%.

Based on this result, the doctor performed a fine needle aspiration to rule out thyroid cancer, but the biopsy cytology result is still inaccurate.

 Can a thyroid biopsy be diagnosed after it is done? At work, doctors often encounter such situations.
Although they have done a needle biopsy for the patient, the results still do not have a clear indication.

At this time, the doctor still has to carefully analyze the results of the pathology report and make a decision on whether the patient needs to be biopsy again in the future.

 At present, thyroid cell pathology examinations are often divided into 6 categories using Bethesda Thyroid Cell Pathology Reporting System (TBSRTC): 1.
Specimen cannot be diagnosed or unsatisfactory.
The satisfaction assessment of specimens mainly includes the quantity and quality of cells and glial components; and Specimen with only cystic fluid, almost no cells, blood covering, etc.
are undiagnosable and unsatisfactory specimens, but the following three conditions should be excluded: solid nodules with atypical cytology; solid nodules with inflammation ; Glia nodules.

 Clinical significance and precautions: l The risk of malignancy is 1%-4%; l When the first puncture specimen is unsatisfactory or cannot be diagnosed, the puncture should be repeated, but the time interval should not be less than 3 months; l The diagnosis can be obtained by the second puncture The number of cases with sexual results is 60%; l Two consecutive specimens are unsatisfactory or cannot be diagnosed, ultrasound follow-up or surgery should be considered.

 2.
Benign lesions include benign follicular nodules, thyroiditis (Hashimoto's thyroiditis, subacute thyroiditis), etc.

 Clinical significance and precautions: l The risk of malignancy is 0-3%; l The clinical follow-up interval is 6-18 months, and the follow-up is continuous for 3-5 years; l If the nodule is significantly enlarged or the ultrasound examination finds an abnormality, it is recommended to do it again Fine needle puncture.

 3.
Cellular atypical lesions of ambiguous significance, or follicular lesions of ambiguous significance, including uncertain cellular atypical lesions (AUS) of ambiguous significance, and follicular lesions of ambiguous significance (FLUS).
).

 Clinical significance and precautions: l The risk of malignancy is 5%-15%; l Repeat biopsy (20%-25% is still unclear).

 4.
Pathological specimens of follicular tumors or suspected follicular tumors are composed of follicular cells, which are characterized by obvious crowding of cells and/or formation of cellular microfollicles.

Such as the characteristics of papillary carcinoma nucleus, it does not belong to this category.

 Clinical significance and precautions: l The risk of malignancy is 15%-30%; l 27%-68% is papillary carcinoma; l surgical resection.

 5.
The suspected malignant tumor specimens have some of the characteristics of malignant tumors, and malignant tumors are suspected, but they are not enough to make a clear diagnosis.

It is manifested as patchy nucleus alteration, insufficient nuclear alteration, insufficient follicular cell number and cystic transformation.

 Clinical significance and precautions: l The risk of malignancy is 60%-75%; l surgical resection; l suspicious medullary carcinoma, the auxiliary examination is of great significance (serum CT level and immunohistochemistry).

 6.
The pathological diagnostic criteria for malignant tumors of papillary carcinoma are mainly based on the characteristics of the nucleus: enlarged nucleus, oval or irregular nucleus, and sometimes nuclear crowding and overlapping longitudinal nuclear grooves, nuclear pseudo-inclusion bodies, and chromatin dust Shape, pale nucleus, single or multiple small nucleoli located around the nucleus.

However, the above characteristics are not sufficient for diagnosis when they appear alone, and only when they appear simultaneously can they be meaningful for the diagnosis of papillary thyroid carcinoma.

 Clinical significance and precautions: l malignant risk 97%-99%; l surgical resection.

 Based on the above system report, let’s study this case again: Case Courier A 47-year-old man with a history of thyroid nodules.
A thyroid nodule was found on a physical examination ten years ago.
A biopsy was performed at that time, but the result was that the specimen could not be diagnosed (thyroid gland).
Insufficient cells).

The biopsy is indeed very painful, and the patient has always resisted follow-up follow-up.

Over time, the patient developed discomfort in swallowing and torsion of the neck.
During this period, he was not exposed to the radiation area and received no anti-thyroid therapy.

After examination, it was found that the thyroid nodule was a partial cystic nodule of about 2 cm, with smooth, hard and movable edges.
Its eccentric and irregular wall components contained microcalcifications.
The right cystic thyroid nodule showed solid content.
Microcalcification. In the lateral view (right image), there is a slight Doppler blood flow (Figure 11).

 Figure 11 Patient results The doctor thinks: What kind of judgment will you make based on this? The above results are considered to be highly suspect, and try to persuade the patient to undergo a biopsy again.
The result showed that the thyroid papillary carcinoma was followed by a total thyroidectomy.

 Summary In fact, in clinical evaluation of biopsy results and monitoring of nodules, in addition to ultrasound characteristics and nodule size, other factors, such as patient age, preference, and the impact of other diseases, should also be considered.

 For benign nodules and very low-risk nodules, ultrasound follow-up may not be required.
However, under appropriate circumstances, nodules with low, moderate, and high suspicion should be monitored and followed up.

 At present, the assessment of thyroid nodules is mainly performed by experts (specialists with rich clinical experience or radiologists who specialize in thyroid examination), which can avoid many unnecessary biopsies, and can quickly find some high-risk features to judge the prognosis of the patient .

 The pictures in the article are from "Assessing Thyroid Nodules: A Clinician's Guide" References: [1]Assessing Thyroid Nodules: A Clinician's Guide-Medscape-Dec 11, 2020.
[2] Syed Z.
Ali, Edmund S.
Cibas.
Thyroid cell disease Science Bethesda Report System[M].
Beijing Science and Technology Press, 2010.