• Ultrasonography

    Ultrasonography (US) is the most common and most useful way to imagine the thyroid gland and the surrounding tissues of the neck to the level of clavicles, especially when information concerning blood flow is added to the signal by employing the Doppler effect. It facilitates the diagnosis of clinically apparent and a multitude of clinically imperceptible abnormalities, especially nodules most of which are benign, and is completely safe using high frequency sound waves in the megahertz range (ultrasound). During examination, which takes only several minutes, the patient remains comfortable, does not require discontinuation of any medication, or preparation. The procedure is usually done with the patient reclining and with the neck hyperextended. Any necklases and other accessories should be removed from the neck before the test is started. Some gel or liquid must be applied between the probe and the skin. Ultrasonography of the thyroid is used to:describe the anatomy of the neck in the thyroid regionassess the comparative size of palpable and non-palpable nodules, lymph nodes, or goiters in patients who are under observation or therapygive clues about the likelihood of malignancy and thyroiditisfacilitate fine needle aspiration biopsyevaluate for recurrence of a thyroid mass after surgerymonitor thyroid cancer patients. It is important to bear in mind that performance and interpretation of thyroid sonograms are quite subjective and reflect probabilities, not certainty. Especially in large goiters and nodules there may be considerable differences between sonologist in estimating their size.

  • Fine needle aspiration

    Fine needle aspiration (FNA) of thyroid nodules and enlarged lymph nodes is a vital diagnostic tool that is safe and reliable with side effects very uncommon. Direct, real-time ultrasound (US) guidance is used to improve accuracy in punctuating the nodule. The tip of the needle is seen as a very bright spot and must be within the nodule during aspiration.  The specimen is then examined by a pathologist according to the Bethesda System for Reporting Thyroid Cytology – see below.It is not obvious which nodule in a goiter to biopsy. Guidelines include: Clinical features:history of head and neck irradiation in youthfamily history of medullary or papillary thyroid cancerunusual firmness without calcificationgrowth of noduleenlarged lymph nodesUltrasonic features (at least two):hypoechoic nodule with one of the following: irregular / blurred margins, central vascularity, microcalcifications, taller rather than wide shape, enlargement compared to prior examinationslymphadenopathyBiopsy a “suspicious” nodule rather than the largest oneThe size and number of nodules do not correlate directly with risk factors. There is limited ability to aspirate a nodule or node even with ultrasound guidenance. Diagnostic yield is usually not higher than 85% for nodules 10mm or larger. To improve accuracy of FNA as well as for safety reasons it is advisable to discontinue antiplatelet and anticoagulant medication prior to biopsy. In case FNA is not diagnostic it should be repeated after a period of time. When growth of a nodule or emergence of adenopathy is observed or symptoms appear that suggest pressure on cervical structures FNA should be repeated even after previous benign result. To address the terminology and other issues related to thyroid FNA, the National Cancer Institute (NCI) hosted the “the NCI Thyroid Fine Needle Aspiration State of the Science conference” in 2007 at Bethesda, Maryland. The conclusions of the meeting led to the Bethesda Thyroid Atlas Project and formed the framework for The Bethesda System for Reporting Thyroid Cytology (TBSRTC). These are the recommended diagnostic categories and management: I - Nondiagnostic or unsatisfactory - cystic fluid only, virtually acellular specimen, other like obscuring blood, collecting artifacts, etc.II – Benign  - consistent with a benign follicular nodule (includes adenomatoid nodule, colloid nodule etc.), lymphocytic (Hashimoto) thyroiditis in the proper clinical context, granulomatous  (subacute) thyroiditis, and otherIII - Atypia of undetermined significance or follicular lesion of undetermined significanceIV - Follicular neoplasm or suspicious for a follicular neoplasm, specify if Hurthle cell (oncocytic type)V - Suspicious for malignancy: papillary carcinoma, medullary carcinoma, metastatic carcinoma,  lymphoma, otherVI – Malignant: papillary thyroid carcinoma, poorly differentiated carcinoma, medullary thyroid carcinoma, undifferentiated (anaplastic) carcinoma, squamous cell carcinoma, carcinoma with mixed features (specify), metastatic carcinoma, non-Hodgkin’s lymphoma, other

  • Percutaneous ethanol injection (PEI)

    Percutaneous ethanol injection (PEI) - procedure aimed to reduce the size of the thyroid nodule.Benign cysts and predominantly cystic thyroid nodules have an estimated risk of malignancy smaller than 1% and 3%, respectively. They can be qualified for PEI by an endocrinologist based on their ultrasonographic (US) features and / or results of a fine needle biopsy (FNA). In these particular types of nodules PEI is effective and safe. Therefore it is dedicated to patients who would like to avoid thyroid surgery and do accept an extremely small (below 3%) risk of residual malignancy.For PEI the patient does not have to be admitted to hospital. The whole Procedure takes several minutes and is similar to FNA:  after the skin of the neck is sterilized a thin needle is inserted into the selected nodule with US guidance, some fluid is aspirated, and then a small volume of 95-99% ethyl alcohol solution is injected. Alcohol causes coagulative necrosis of the tissue within the nodule. The succes rate after PEI i.e. nodular size regression is 75-85%. Sometimes a single ethanol injection in insufficient and it has to be repeated after several months. There are few possible complications of the Procedure including: mild to moderate burning pain, flushing, dizziness, and dysphonia. These side effects may last several days. As the influence of the injected ethanol on concentration is uncertain patients should refrain from driving a car or similar activities for 24 hours.

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