Atlas of Thyroid Ultrasound Images - Author: Dr. Mihai-Sorin Iacob, MD ISBN 978-973-39-0923-1 by Mihai Iacob

Atlas of Thyroid Ultrasound Images Editor: Dr. Mihai-Sorin IACOB, MD, Senior Medical Expert, Thyroscreen Project.

EDITURA MEDICALA 2022

Atlas of Thyroid Ultrasound Images Editor: Dr. Mihai-Sorin Iacob, MD Senior Medical Expert. Thyroscreen Project. EUVEKUS President.

Co-authors: Octavian Neagoe, MD, PhD Mihaela Ionica, MD, PhD Emergency Municipal Clinical Hospital Timisoara, EDITURA MEDICALA, 2022

Editura Medicala, Bucuresti, Strada Pache Protopopescu, nr.90 0040212525187

Editor: Iacob, Mihai-Sorin

Descriere CIP a Bibliotecii Nationale a Romaniei, Atlas of thyroid Ultrasound Images Editor Dr. Mihai Sorin Iacob Co-authors: Dr. Octavian Constantin Neagoe, Dr. Mihaela Ionica.

All rights to this edition are reserved. The partial or complete reproduction of the text, on any medium, without the written consent of the authors is prohibited and will be sanctioned according to the laws in force.

Toate drepturile asupra acestei ediţii sunt rezervate. Reproducerea parţială sau integrală a textului, pe orice suport, fără acordul scris al autorilor este interzisă şi se va sancţiona conform legilor în vigoare. ISBN 978-973-39-0923-1

Foreword The Point of Care Ultrasonography - performed by the clinician at the site of patient care, both in the medical office or at home, is an important tool to guide the case management for the early diagnosis and increase diagnostic accuracy. It represents an extension and complement, to the clinical examination of the physician, to achieve an accurate positive and differential diagnosis. POC-US is now an investigation in development, which can complement the physical examination of the family doctors and can guide the case management to the bedridden patients. We need training and quality standards, to ensure, that this will be done in a way with positive benefits for our patients, being useful, to the implementation of ultrasound standards and practice guidelines of the primary care level. It involves personal contact between doctor and patient at "bedside", it is a fast in real-time method, repetitive, cheap, and harmless but dependent on the experience and expertise of the examiner. A new opportunity for PoC-US represents the application in primary care of the medical projects related to „telemedicine” connections among specialists and family doctors for enhanced patient management. The Educational Needs of GPs on the new methods and technologies are increasing, but the resources and infrastructure are limited now. It is thus necessary, the collaboration among the family physicians trainers, or academics, on the one hand, and the other, of the specialty physicians in the preparation and continuing medical education in family medicine. Early diagnosis can help to save many patients in primary care, based on notions of good clinical practice. Therefore, we will involve, to inform family physicians about the latest diagnostic and treatment protocols in clinical ultrasound. Presentation of the „thyro-screen project” - the first interdisciplinary integrated thyroid screening substantiated on the final results of the study in the western region of Romania achieved through a smart computerized diagnostic algorithm used to stratify the risk of thyroid pathology at the primary care level. This project was launched five years ago and has three main stages. The first step was the development of a computerized diagnostic algorithm, titled "Smart Thyroid Ultrasound Software", used to stratify the risk in thyroid pathology, based on conventional gray-scale ultrasound, Doppler ultrasound, and Strain-Elastography. It set the optimum time for thyroid puncture (FNAB) and cytological examination for early diagnosis of malignant lesions. We have used the latest international classifications, as well as a "scoring" made by us, correlated with the cytological or histopathological results obtained from patients operated as the "Gold Standard method". The second stage included a targeted thyroid screening at a high-risk population, conducted in a single medical clinic in the western region of the country, statistically significant. The third stage we launched was an Interdisciplinary Multicentric Screening titled “Thyroscreen”. The prevalence of malignant thyroid nodules is growing, mostly being 80% papillary microcarcinomas. We tried to analyze this, using multimodal ultrasonography with conventional ultrasound B-gray, Doppler triplex ultrasound and were made the Strain Elastography to identify the stiffness of the tumor. Multimodal thyroid ultrasound used as a screening method can diagnose both diffuse thyroid disorders such as malformations, multinodular goiter or thyroiditis, and especially thyroid focal lesions (benign and malignant tumors). Diagnosis and early treatment of the diffuse and focal thyroid pathology by screening on the high-risk population and second to evaluate prospectively the diagnostic accuracy of the thyroid imaging reporting and data system (TI-RADS), to compare with data obtained to Strain Elastography (Real-Time Elastography), finally to create an Ultrasound Score and to compare with results obtained to the FNAB. How to improve early diagnosis and differentiation of thyroid diseases by GPs, to the high-risk populations? We aimed to prospectively assess the applicability of the Strain sonoelastography in the differentiation of benign versus malignant tumor, as well as in the differentiation of the various types of thyroiditis (acute thyroiditis, subacute thyroiditis, chronic thyroiditis), and to identify which ultrasonographic feature or a combination of features is the best predictor of thyroid pathology. As an initial diagnostic method, Thyroid Ultrasound Screening was the main investigation technique. If screening was positive, we performed additional diagnostic tests to confirm or exclude malignancy.

This "Atlas of Thyroid Ultrasound Images" is the result of more than 25 years of intensive research in the field of clinical ultrasound in outpatient medical practice, together with a wonderful team of specialists, with whom we managed to make a unique screening project aimed at the high-risk population for thyroid pathology, both at national and European level. The uniqueness of this project called Thyroscreen is due both to the fact that it is a multidisciplinary type in which several specialties were involved, namely: family medicine, endocrinology, general surgery, oncology, morphopathologists, and by co-opting three medical levels represented by levels of primary, secondary and tertiary healthcare. We followed a large number of patients clinically and ultrasound in both the western region of Romania and the eastern region of the Republic of Serbia, being a Cross-Border Project that involved in addition to modern reference technology and a new field of interest, namely Artificial Intelligence. We managed to stratify the degree of oncological risk at the population level through an initial ultrasound screening performed in primary medicine and the selection of the high-risk population based on questionnaires distributed to 20,000 people in this geographical region. We want to share the experience gained through hard work in this project and add to the multimodal ultrasound investigation to increase the diagnostic accuracy in primary medicine and prevent the cancer risk of the population through these new working methods. How many personal US examinations one should have performed before feeling confident in the field of thyroid ultrasound, is a good question. We recommend at least 300-500 personal ultrasound examinations of the thyroid! However, this number should be correlated with personal ability. On the other hand, a thyroid examination must be always a „full” neck examination, meaning that all neck regions must be seen and evaluated and, of course, described. Finally, we wish you success in learning this wonderful method, the source of a lot of important information for the examiner, in a very short time, much needed for the future management of a medical case.

Dr. Mihai Iacob, MD, senior medical expert.

Content

Chapter 1 – Normal thyroid ultrasonography............................................................07 Chapter 2 – Ultrasound thyroid semiology................................................................23 Chapter 3 – Thyroid multimodal ultrasonography.................................................... 25 Chapter 4 - Thyroid pathology : diffuse and focal thyroid diseases……………………..…..35 Chapter 5 - Diffuse thyroid disease........................................................................... 37 Chapter 6 - Thyroid malformations…………………………………………………………………….……39 Chapter 7 - Multinodular goiter (MNG) .................................................................... 42 Chapter 8 – Acute and subacute thyroiditis.............................................................. 48 Chapter 9 - Chronic autoimmune Hashimoto's thyroiditis ………………………………..…….58 Chapter 10 - Graves disease.......................................................................................67 Chapter 11 – Focal thyroid disease – TIRADS risk stratifications.................................73 Chapter 12 – Cyst, Colloid nodule..............................................................................75 Chapter 13 – Benign nodules: Hyperplastic nodules, Follicular adenomas, Hashimoto thyroiditis nodules, Subacute thyroiditis nodules.....................................................81 Chapter 14 – Malignant tumors: papillary carcinomas, follicular carcinomas, medullary carcinomas, anaplastic thyroid cancer, Hurthle-cell carcinoma……………………….………90 Chapter 15. Parathyroid pathology……………………………………………………………………….102 Chapter 16. Final remarks……………………………………………………………………………………..105 References…………………………………………………………………………………………………….……...106

Chapter 1. Normal thyroid ultrasound 1.1.Introduction. In recent decades in Europe, after the nuclear accident at Chernobyl, we observe a clear increase over ten times of thyroid diseases predominantly because of multinodular goiter and autoimmune thyroiditis. The prevalence of malignant thyroid nodules is growing, mostly being 80% papillary microcarcinomas. We tried to analyze this, using Doppler ultrasound and then were made the Strain Elastography to identify tumors stiffness. Doppler ultrasound used as a screening method can diagnose both diffuse thyroid disorders such as malformations, multinodular goiter or thyroiditis, and especially focal lesions (benign and malignant tumors). Did you know that: • About 38-40% of the high-risk population has thyroid diseases. • Thyroid cancer can be present, in up to 3%, of the high-risk population. • When was diagnosed in the early stages, thyroid cancer is curable in almost 98% of cases, and the late diagnosis could reduce 5-year survival to 37%. What is the main purpose of the targeted thyroid screening? ►Early diagnosis of diffuse and focal thyroid lesions. ►Early diagnosis of thyroid cancer at the high-risk populations.

1.2.Clinical indications. Indications for thyroid US, following the American Asociation of Clinical Endocrinologists are: Thyroid sonography is recommended in: 1. All patients with a palpable thyroid nodule or with multinodular goiter (MNG). 2. High risk patients for thyroid malignancy : history of familial thyroid cancer, MEN type II and irradiated neck in childhood. 3. Patients with palpable cervical adenopathy suspiscious of malignancy. Thyroid sonography is not recommended in: 1. Patients with a normal thyroid on palpation and low risk of thyroid cancer. 2. As a screening test in the general population. Defining thyroid risk classes is based on: 1. Hereditary-collateral antecedents 2. Pathological personal history 3. Clinical examination We did an epidemiological questionnaire containing some risk group inclusion criteria performed either by selfassessment or by the family doctor to establish the risk classes if the patients had presented one major factor or more than three minor factors.

1.3. Risk assessment questionnaire. Our risk assessment questionnaire for the patients was:History: □ 1. History of thyroid cancer in one or more first-degree relatives. □ 2. Exposure to ionizing radiation (e.g. external beam radiation). □ 3. Exposure to chemical or biological risk factors. □ 4. Prior hemithyroidectomy with the discovery of thyroid cancer. □ 5. Presence of diabetes or other autoimmune diseases (rheumatoid arthritis, vitiligo) □ 6. Deficient and/or excess dietary iodine or use of drugs containing iodine. □ 7. The persistence of dysphonia, dysphagia, or dyspnea without a stated cause. □ 8. Hoarseness due to vocal cord paralysis. □ 9. Sensitivity prolonged throat or a sore throat. □10. Symptoms suggestive for hyperthyroidism/hypothyroidism. □11. Pregnant women, or who have given birth in the last 6 months.

□12. Smoking, chronic alcoholism, and an unbalanced diet. Clinical examination: □ 1. Diffuse or localized swelling of the anterior cervical region of the neck. □ 2. Firm, irregular and fixed thyroid nodule. □ 3. Tumour invasion into adjacent structures. □ 4. Rapid growth (evidence of nodule growth either sonographically or on palpation, increases more than 20% of the nodule volume in a few months (3-6 months). □ 5. The prolonged presence of abnormal lymph nodes. □ 6. Cervical or others neck region lymphadenopathy. □ 7. Exophthalmia,

1.4.Ultrasound Thyroid Evaluation. The role of thyroid US may be resumed into 3 main issues: •To detect thyroid and cervical masses, including relapse in the thyroid bed and cervical adenopathy after thyroidectomy. •To differentiate between possible benign and probably malignant masses, based on their sonographic appearance. •To guide the performance of FNA biopsy and percutaneous treatment. 1.4.1.Indications for thyroid USG, following the American Association of Clinical Endocrinologists (AACE): •To confirm the presence of a thyroid nodule when the physical examination is equivocal or in multinodular goiter MNG. •To characterize a thyroid nodule(s), i.e. to measure the dimensions accurately and to identify internal structure and vascularization. •To differentiate between benign and malignant thyroid masses, based on their sonographic appearance. •To differentiate between thyroid nodules and other cervical masses like lymphadenopathy, thyroglossal cyst, and cystic hygroma. •To evaluate diffuse changes in thyroid parenchyma. •To detect a post-operative residual or recurrent tumor in the thyroid bed or metastases to neck lymph nodes. •To screen high-risk patients for thyroid malignancy like patients with a history of familial thyroid cancer, multiple endocrine neoplasias (MEN) type II, and irradiated neck in childhood. •To guide diagnostic (FNA cytology/biopsy) and therapeutic interventional procedures. 1.4.2. Ultrasound evaluation – what to look for? 1. Thyroid gland identification two lobes and isthmus. 2. Thyroid gland volume measurement. 3. Echogenicity evaluation. 4. Homogeneity evaluation. 5. Focal/diffuse lesion characterization. 6. Focal/diffuse parenchyma vascularization. 7. Focal/diffuse parenchyma stiffness. 8. Regional lymph nodes evaluation

1.5.Technical guidelines The patient is examined supine, the neck hyperextended (a pillow may be placed below the shoulders to achieve neck hyperextension), with a high-frequency linear transducer (7-15 MHz) that provides enough penetration (about 5-6 cm depth) and good resolution. Images are performed on grayscale, Doppler Triplex and Strain Elastography. If the probe has a low frequency of only 5 MHz the image could be improved using an interface device or an infusion bag with saline for a better resolution of the thyroid. The thyroid ultrasound examination protocol we used was: 1. Transverse scans performed at the base of the neck, with visualization of the whole gland at the upper, mid, lower poles and the isthmus, and side-by-side images of each lobe, to compare echogenicity and size of both lobes. Each lobe width and anteroposterior diameters are measured.

2. Longitudinal scan with a slightly oblique disposition to the outside, through each lobe, on medial, mid, and lateral planes. The length or craniocaudal diameter of the lobes is measured. 3. First identify the shape, contour, size of the lobes and the isthmus, and the entire thyroid parenchyma followed by the identification of possible focal lesions, measure the main lesions, and identify the dominant one (according to size). 4. Identify the presence of enlarged lymph nodes or thrombosed jugular vein both in the anterior region of the neck and in the supraclavicular area. 5. We used multimodal thyroid examination in both grayscale and Doppler triplex ultrasound or strain elastography if diffuse or focal thyroid lesions were previously identified. Standardized US reporting criteria should be followed indicating: position, contour, shape, size, margins, content, echogenicity, homogeneity, calcification, tissue stiffness, and vascular pattern of the whole gland and, when present, the focal lesions. Nodules with malignant potential should be identified, and FNA biopsy should be suggested to the referring physician. The identifiable anatomical elements or landmarks in each cross-sectional ultrasound scans are the following: SK = skin, PM = platysma muscle, FC = fascia cervicalis, SHM = sterno-hyoid muscle, STM = sterno-thyroid muscle, SCM = sterno-cleido-mastoid muscle (both = SM: strap muscles), ISM = isthmus, TH = trachea, RTL = right thyroid lobe, LTL = left tyhyroid lobe, JV = jugular vein, CA = carotid artery, ESP = esophagus, LCM = longus colli muscle.

1.1. Thyroid - normal US aspects

1.1.1 Thyroid measurement on transverse scan: RL: right lobe. LL: left lobe. I:isthmus. E:esophagus. B. T: trachea. SM:strap muscles. SCM:sterno-cleido-mastoid muscle. JV: jugular vein. CCA: common carotid artery.

1.1.2 Normal thyroid – longitudinal scan – lenght diameter measurment or cranio-caudal diameter of the right thyroid lobe. The icon always indicates the position of the ultrasound probe.

1.1.3 Normal thyroid – transverse scan – the AP/H and transverse diameters of both thyroid lobes

1.1.4 Normal thyroid – longitudinal scan, craniocaudal (lenght) diameter measurments.

1.1.5 Normal thyroid- transverse scan – the AP/H and transverse diameters of both thyroid lobes

1.1.6 Normal thyroid– longitudinal scan, craniocaudal (lenght) diameter measurments of right lobe.

1.1.7 Normal thyroid - transverse scan: RL: right lobe. LL: left lobe. I:isthmus. T: trachea. SM:strap muscles. JV: jugular vein. CCA: common carotid artery.

1.1.8 Normal thyroid - longitudinal scans, craniocaudal (lenght) diameter measurment of right lobe.

1.1.9 Normal thyroid – transverse scan -isthmus

1.1.10 Normal thyroid – longitudinal scan – lenght

1.1.11 Normal thyroid- transverse scan – the AP/H and transverse diameters (width) of both thyroid lobes

1.1.12 Normal thyroid- longitudinal scan, craniocaudal (lenght) diameter measurment of right lobe.

1.1.13 Normal thyroid - transverse scans – the AP/H and transverse diameters (width) of both thyroid lobes

1.1.15 Normal thyroid- ransverse scan – the AP/H and transverse diameters (width) of both thyroid lobes

1.1.14 Normal thyroid- longitudinal scan, craniocaudal (lenght) diameter measurment of right lobe.

1.1.16 Normal thyroid – longitudinal scan – lenght diameter, normal vascularization of the parenchyma.

1.1.17 Normal thyroid- transverse scan – the AP/H and

1.1.18 Normal thyroid - longitudinal scans, cranio-

transverse diameters (width) of both thyroid lobes

caudal (lenght) diameter measurment of right lobe.

1.1.19 Normal thyroid- transverse scan – the AP/H and

1.1.20 Normal thyroid - longitudinal scan, cranio-

transverse diameters (width) of both thyroid lobes

caudal (lenght) diameter measurment of right lobe.

1.1.21 Normal thyroid- transverse scan – the AP/H and

1.1.22 Normal thyroid – longitudinal scan – lenght

transverse diameters (width) of both thyroid lobes

diameter, normal vascularization of the parenchyma

1.1.23 Normal thyroid - transverse scan – the AP/H and

1.1.24 Normal thyroid - longitudinal scan, cranio-

transverse diameters (width) of both thyroid lobes and isthmus.

caudal (lenght) diameter measurment of right lobe.

1.1.25 Normal thyroid - transverse scan: RL: right lobe. LL: left lobe. I:isthmus. T: trachea. SM:strap muscles. JV: jugular vein. CCA: common carotid artery.

diameter, normal vascularization of the parenchyma

1.1.27 Normal thyroid - transverse scan – the AP/H and

1.1.28 Normal thyroid - longitudinal scan, cranio-

transverse diameters (width) of both thyroid lobes and isthmus. Different anatomical variants of the thyroid shape.

caudal (lenght) diameter measurment thyroid lobe.

1.1.29 Normal thyroid – transverse scan -isthmus and both

1.1.30 Normal thyroid – transverse scan – normal

thyroid lobes homogeneous with normal ecodensity.

1.1.26 Normal thyroid – longitudinal scan – lenght

vascularization of the right lobe parenchyma

1.1.31 Normal thyroid - transverse scan – the AP/H and

1.1.32 Normal thyroid – transverse scan – normal

transverse diameters of both thyroid lobes and isthmus.

vascularization of the right lobe parenchyma

1.1.33 Normal thyroid - transverse scan – the AP/H and

1.1.34 Normal thyroid - longitudinal scan, cranio-

transverse diameters of right thyroid lobe

caudal (lenght) diameter measurment of the lobe.

1.1.35 Normal thyroid – transverse scan – normal

1.1.36 Normal thyroid – longitudinal scan – lenght

vascularization of the right lobe parenchyma

diameter, normal vascularization of the parenchyma

1.1.37 Normal thyroid – transverse scan – normal

1.1.38 Normal thyroid – longitudinal scan – lenght

vascularization of the right lobe parenchyma

diameter, normal vascularization of the parenchyma

1.1.39 Normal thyroid - transverse scan – the AP/H and

1.1.40 Normal thyroid – transverse scan – normal

transverse diameters of right thyroid lobe

vascularization of the left lobe parenchyma

1.1.41 Normal thyroid - transverse scan – the AP/H and

1.1.42 Normal thyroid – transverse scan – normal

transverse diameters of right thyroid lobe

vascularization of the left lobe parenchyma

1.1.43 Normal thyroid – transverse scan – normal

1.1.44 Normal thyroid – longitudinal scan – lenght

vascularization of the right lobe parenchyma

diameter, normal vascularization of the parenchyma

1.1.45 Normal thyroid - transverse scan – the AP/H and

1.1.46 Normal thyroid – longitudinal scan – lenght

transverse diameters of both thyroid lobes and isthmus.

diameter, normal vascularization of the left lobe

1.1.47 Normal thyroid - transverse scan – the AP/H and

1.1.48 Normal thyroid - longitudinal scan, cranio-

transverse diameters of both thyroid lobes and isthmus.

caudal (lenght) diameter measurment of the left lobe.

1.1.43 Normal thyroid - transverse scan – the AP/H

1.1.44 Normal thyroid - longitudinal scan, cranio-caudal

and transverse diameters of both thyroid lobes and isthmus.

(lenght) diameter measurment of the left lobe.

1.1.45 Normal thyroid - transverse scan – the AP/H

1.1.46 Normal thyroid - longitudinal scan, cranio-caudal

and transverse diameters of both thyroid lobes and isthmus.

1.1.47 Normal thyroid - transverse scan – the AP/H and transverse diameters of both thyroid lobes

(lenght) diameter measurment of the left lobe.

1.1.48 Normal thyroid - longitudinal scan, cranio-caudal (lenght) diameter measurment of the left lobe.

1.1.49 Normal thyroid - transverse scan – the AP/H and

1.1.50 Normal thyroid - longitudinal scan, cranio-

transverse diameters of the thyroid isthmus.

caudal (lenght) diameter measurment of the left lobe.

1.1.51 Normal thyroid - transverse scan – the AP/H and

1.1.52 Normal thyroid – transverse scan – normal

transverse diameters of right thyroid lobe, homogeneous with normal ecodensity

vascularization of the right lobe parenchyma, with 5-6 color Doppler spots

1.1.53 Normal thyroid - transverse scan – the AP/H and

1.1.54 Normal thyroid – transverse scan – normal

transverse diameters of the left thyroid lobe.

vascularization of the left lobe parenchyma

1.1.55 Thyroid measurement on the transverse scan: RL:

1.1.56 Normal thyroid - longitudinal scan, cranio-

right lobe. LL: left lobe. I:isthmus. E:esophagus. B. T: trachea. SM:strap muscles. SCM:sterno-cleido-mastoid muscle. JV: jugular vein. CCA: common carotid artery.

caudal (lenght) diameter measurment of the left lobe, homogeneous with normal ecodensity.

1.1.57 Normal thyroid - the AP/H and transverse

1.1.58 Normal thyroid – transverse scan – normal

diameters of both thyroid lobes and isthmus, homogeneous with normal ecodensity

vascularization of the left thyroid lobe, with 5-6 color Doppler spots

1.1.59 Normal thyroid - the AP/H and transverse

1.1.60 Normal thyroid – transverse scan – normal

diameters of both thyroid lobes and isthmus, homogeneous with normal ecodensity

vascularization of the right thyroid lobe, with 5-6 color Doppler spots.

Chapter 2. Ultrasound thyroid semiology 2.1. Basic concepts IMPEDANCE represents the tissue resistance to the propagation of ultrasound waves ((depending on the density of biological tissue or crossed environment). The normal thyroid is consists of two lobes and the isthmus, bridging the lobes, ahead of the trachea. Size and shape are variable, according to age. It has a medium to high-level echogenicity. The relationships with the surrounding structures are as follows: ahead, the strap muscles and Sterno-cleido-mastoid muscle, behind, the trachea and longus colli muscles, on both sides, the common carotid artery, and jugular vein and lastly, the esophagus, behind the left thyroid lobe. The good quality of the ultrasound image requires the US waves to be perpendicular to the tissue separation surface. The loss of ultrasonic energy from the surface to the depth is called the attenuation phenomenon. We can evaluate both the echogenicity and the homogeneity of the thyroid parenchyma in the lobes and isthmus. 1. ECHOGENICITY: • REFLECTOGENIC STRUCTURES: ►hyperechoic, hypoechoic, isoechoic, or / -echogenic • ANECHOIC OR TRANSONIC STRUCTURES: ►fluid, blood, secretions, cysts. • MIXED STRUCTURES: ►the combination of the first two. 2. ECHO-STRUCTURE: ►Homogeneous. ►Inhomogeneous localized in focal thyroid lesions. ►Diffuse inhomogeneous which can be: macronodular or micronodular. Color and/or power Doppler US is useful to evaluate the vascularity of the thyroid gland and focal masses. The thyroid gland is a richly vascularized organ. The arterial supply is provided on each side by the superior thyroid artery (a branch of the external carotid artery), and the inferior thyroid artery (a branch of the thyrocervical trunk, which is a branch of the subclavian artery). The thyroid arteries could be localized on color or power Doppler. A low resistance flow is demonstrated on spectral Doppler in these visceral arteries. A peak systolic velocity in the intrathyroidal arteries is in the range of 15-30 cm / second and is the highest velocity found in any superficial organ. 2.2. Ultrasonographic in grayscale(B-mode) conventional description of diffuse thyroid diseases: ►The thyroid volume: Height, Width, Length–of the right and left thyroid lobe. The volume represents the sum of the two lobes. If the isthmus thickness is above 3 mm must be added to the total. •NORMAL 15 -25 ml ♀ / 18 -30 ml ♂. •Increased: De Quervain's thyroiditis, macronodular goiter, premenstrual, pregnancy, iodine deficit, autoimmune thyroid disease (Hashimoto's Thyroiditis, Graves disease), altered hormone genesis, lithium/amiodarone therapy, focal lesions. •Decreased: hypothyroidism, Riedel's thyroiditis, physiologic variation, thyroid atrophy, surgery, congenital. ►ECHOGENICITY •ISOECHOIC - NORMAL •HYPERECHOGENIC = HYPERECHOIC (Brighter). •HYPOECHOGENIC = HYPOECHOIC (Darker). ►ECHOSTRUCTURE = HOMOGENEITY •HOMOGENEOUS - NORMAL •INHOMOGENEOUS = + Nodules – Focal lesion. •MICRONODULAR Hashimoto's Thyroiditis •MACRONODULAR Macronodular Goiter ►PARENCHYMAL VASCULARITY– TRIPLEX DOPPLER = - normal Color Doppler appears 5-6 vascular spots on a lobe. The measured systolic velocity of pulsed Doppler does not exceed 30 cm / sec in the thyroid supply. •Increased: Hashimoto's Thyroiditis, Graves disease. •Decreased: hypothyroidism, Riedel's Thyroiditis

► THE ELASTICITY of the parenchyma can be assessed by Strain Elastography. The stiffness or elasticity of the parenchyma of both thyroid lobes is normally homogeneous with soft stiffness. In pathological conditions with chronic inflammation in chronic autoimmune diseases through the process of chronic inflammation and fibrosis can occur a diffuse hard stiffness especially in forms over 10 years old. 2.3. Ultrasonographic features of focal lesions or thyroid nodules: 1. ECHOGENICITY: ►SOLID: ISOECHOGENIC, HYPERECHOGENIC, HYPOECHOGENIC ►CYSTIC: ANECHOIC, TRANSONIC or ►MIXED (SPONGIFORM). 2. ECHOSTRUCTURE = ECHOTEXTURE: ►HOMOGENEOUS ►FOCAL INHOMOGENEOUS, ►DIFFUSE INHOMOGENEOUS: MICRONODULAR, MACRONODULAR 3. SHAPE ►ROUND ►OVAL: "MORE TALLER THAN WIDE" ►OVAL: "MORE WIDER THAN TALL" 4. CONTOUR, MARGINS, HALO. ►REGULATED, SMOOTH OR THIN HALO HYPOECHOGENIC ►THICK INCOMPLETE HALO ►IRREGULAR MARGINS, POORLY DELIMITED, SPICULATED. 5. CALCIFICATION: ►MICROCALCIFICATIONS, COARSE CALCIFICATIONS ►MACROCALCIFICATIONS: "EGGSHELL", ACOUSTIC SHADOW (COMET TAIL). 6. VASCULARIZATION: ►TYPE I: no flow detected within the nodule. ►TYPE II: peripheral arterial flow pattern. ►TYPE III: peripheral and central flow pattern (inside the nodule), multiple vascular poles, chaotic arrangement. 7. CERVICAL OR SUPRACLAVICULAR LYMPH NODES, ►Absent or presence of a lymph node, small, oval, homogeneous, avascular in acute inflammations. ►The presence of lymph nodules, over 5 mm, hypoechogenic, oval, inhomogeneous, with a single vascular pole in chronic inflammations. ►The presence of lymph nodules, over 5 mm, round, inhomogeneous, rough, with multiple vascular poles - the spider with malignant suspicions. 8. TUMOR STIFFNESS: depends on the presence of the load with malignant cells and fibrous tissue, being with hard stiffness in malignant tumors and predominantly with soft stiffness in benign tumors. 9. TUMOR VOLUME: V elipsoid = 4π/3 x axbxc NODULES VOLUME(cm3)=lenght(a) X width(b) X depth(c)X 0,5234.

Chapter 3. Thyroid multimodal ultrasonography We did the multimodal thyroid ultrasonography to all high-risk patients included in our targeted screening and performed the following: 3.1. The conventional gray-scale ultrasonography for the initial detection of diffuse and focal thyroid lesions. 3.2. Power and Doppler Duplex and Triplex Doppler US of the thyroid as a screening method could represent the best diagnostic tools in the initial assessment of thyroid pathology. We used TIRADS classifications by Russ & all modified for standardization and accuracy of reporting, for ease of communication among practitioners, and to indicate when fine-needle aspiration biopsy (FNAC) should be performed. Doppler ultrasound has a high value in thyroid screening for the early detection of tumors and for diagnosis of angiogenesis with the development of a vascular network with fractal geometry in tumors, certifying malignancy. The TIRADS Score over 3 requires special attention and further investigations. 3.3. Strain Elastography is based on the principle that abnormal tissue, affected with fibrosis, inflammatory infiltration, or malignant process, tends to be stiffer than healthy tissue (hard stiffness). We used qualitative classification of the color-coded image of the thyroid tumor obtained by Strain Elastography proposed by Rago & all in five types of elasticity (stiffness), and also we used the Strain Ratio (SR) a semi-quantitative marker of stiffness. Our cut off value obtained from SR for malignant thyroid tumors was over 2.5‼ Strain Elastography brings us important details in the differential diagnosis "benign versus malignant", so thyroid tumors with hard stiffness, classified in 4 or 5 - after Rago Scores and with SR over 3, are predominantly malignant. EFSUMB elastography guidelines recommend the use of Thyroid Strain Elastography: Recommendation 7 Ultrasound elastography of the thyroid should be used as part of nodule characterization, particularly with the use of semi-quantitative methods. (LoE 1A, GoR A) (For 17, Abstain 3, Against 0). 3.4. Malignant Ultrasound Score(MUS) for assessing the thyroid tumors. It is a score designed by us (Jacob's score) based on the pathological parameters and features of the focal lesion identified at the multimodal ultrasonography. 3.5. Gold Method remain histopathology - FNAC The aim of multimodal ultrasound screening to the high-risk population was to assess the applicability of both Doppler and Strain Elastography in differentiating “benign versus malignant” tumors, as well as in the differentiation of the various types of diffuse thyroid pathology and ►to design a diagnostic scoring system and ►a computerized algorithm for performing thyroid ultrasonography. Table 0: Doppler Parameter values in thyroid arteries. (Doppler Triplex US) Superior thyroid artery Mean Range Systolic peak velocity 25,8 cm/s 17,1-34,5 cm/s Resistive index 0,62 0,55-0,69 Pulsatility index 1,04 0,8-1,20 Inferior thyroid artery Mean Range Systolic peak velocity 21,5 cm/s 13,8 -30 cm/s Resistive Index 0,57 0,5-0,64 Pulsatility index 0,88 0,7 -1 At the qualitative assessment of strain elastography we used the Strain elastographic scores by Rago et al. : Score 1 - indicated even elasticity in the whole nodule.(A) Score 2 - indicated elasticity in a large part of the nodule.(B) Score 3 - indicated elasticity only at the peripheral part of the nodule.(C) Score 4 - indicated no elasticity in the nodule.(D)

Score 5 - indicated no elasticity in the nodule or the area showing posterior shadowing.(E)

Fig.1. Strain elastographic scores by Rago et al.

The semi-quantitative approach: the strain ratio (SR) In an attempt to perform a standardized and objective assessment of stiffness, a numerical parameter, the SR ratio, was introduced. The SR report is a semi-quantitative analysis comparing rigidity or elasticity on two different areas within the same image: two regions of interest (ROI) are manually applied on the screen, one on the target lesion (tracked) and the second on the normal thyroid reference, which allow to calculate their real-time ratio with the immediate SR analysis automatically by the ultrasound.

Each patient was examined after an "Ultrasound Protocol" designed by us. The risk stratification for each focal lesion was calculated, based on the latest classifications: ACR TIRADS, EU-TIRADS, TIRADS after Russ-modified, and the multimodal ultrasonographic malignancy score achieved by us - Jacob score. Statistical analysis was performed with MedCalc program 15.8 / 2018. We have made a diagnostic algorithm software, correlated with results from FNAB, for performing Thyroid Ultrasound Screening by the family physicians named - "The Smart Thyroid Ultrasound Software". If there is a suspicion of malignancy then the FNAB or histopathological test is required as the Gold Standard Diagnostic Method.

Table 2. Tirads classification after Russ and all modified used in our screening for risk stratification. We used this score after Russ and collaborators modified to which we added a new significant risk factor, namely the vascularization of the focal thyroid lesion obtained by color Doppler and Power Doppler ultrasonography using the classification of tumor vascularization of three types, namely: Type 1: absence of vascularity in the nodule. Type 2: Presence of peripheral vascularity in the nodule. Type 3: Presence of peripheral and intratumoral vascularization.

2.1. Thyroid Multimodal Ultrasound - normal US aspects

2.1.1 Thyroid measurement on the transverse scan: RL:

2.1.2 Normal thyroid - longitudinal scan, cranio-caudal

right lobe. LL: left lobe. I:isthmus. E:esophagus. B. T: trachea. SM:strap muscles. SCM:sterno-cleido-mastoid muscle.CCA: common carotid artery.

(lenght) diameter measurment of the left lobe, homogeneous with normal ecodensity and normal Doppler Duplex vascularization.

2.1.3 Normal thyroid - the AP/H and transverse

2.1.4 Normal thyroid – transverse scan – normal

diameters of both thyroid lobes, homogeneous with normal ecodensity and normal vascularization.

vascularization of the left thyroid lobe, with 5-6 color Doppler spots.

2.1.5 Normal thyroid - the AP/H and transverse

2.1.6 Normal thyroid - longitudinal scan, cranio-caudal

diameters of right thyroid lobe and isthmus, homogeneous with normal ecodensity, vasc.normally.

(lenght) diameter measurment of the left lobe, with normal color Doppler spots.

2.1.7 Normal thyroid - transverse scan – with normal

2.1.8 Normal thyroid - transverse scan –with normal

vascularization of the right thyroid lobe, in Power Doppler.

vascularization of the left thyroid lobe, in Power Doppler.

2.1.9 Normal thyroid - transverse scan – the AP/H and

2.1.10 Normal thyroid - longitudinal scan, cranio-

transverse diameters of both thyroid lobes and isthmus.

caudal (lenght) diameter measurment of the left lobe.

2.1.11 Longitudinal scan. Arterial vascularization of the thyroid gland. On color Doppler, the superior thyroid artery is seen. On spectral display, a low resistance flow with a high systolic velocity is obtained.

2.1.12 Longitudinal scan. Arterial vascularization of the thyroid gland. On color Doppler, the inferior thyroid artery is seen. On spectral display, a low resistance flow with a high systolic velocity is obtained.

2.1.13 Transverse scan. Arterial vascularization of the

2.1.14 Longitudinal scan. Arterial vascularization of the

thyroid gland. On color Doppler, the inferior thyroid artery is seen. On spectral display, a low resistance flow with a high systolic velocity is obtained.

thyroid gland. On color Doppler, the superior thyroid artery is seen. On spectral display, a low resistance flow with a high systolic velocity is obtained.

2.1.15 Normal thyroid – transverse scan – normal

2.1.16 Normal thyroid - transverse scan –with normal

vascularization of the right lobe parenchyma, homogeneous with normal ecodensity

vascularization of the right thyroid lobe, in Power Doppler.

2.1.17 Normal thyroid – transverse scan – normal

2.1.18 Transverse scan –with normal vascularization

vascularization of the right lobe parenchyma.

of the left thyroid lobe, in Power Doppler.

2.1.19 Normal thyroid – transverse scan – normal

2.1.20 Normal thyroid - longitudinal scan, cranio-

vascularization, homogeneous with normal ecodensity of both thyroid lobes.

caudal (lenght) diameter measurment of the left lobe, homogeneous with normal ecodensity and vascularity.

2.1.21 Female after birth at two weeks - transverse scan - slightly increased vascularization, with normal ecodensity of both thyroid lobes.

1.1.22 Longitudinal scan. Arterial vascularization of the

1.1.23 Female after birth at two weeks -transverse scan -the AP/H and transverse diameters of both

1.1.24 Longitudinal scan. Arterial vascularization of the

thyroid lobes and isthmus, homogeneous with normal ecodensity.

thyroid gland. On color Doppler, the superior thyroid artery is seen. On spectral display, a low resistance flow with a high systolic velocity is obtained.

thyroid gland. On color Doppler, the inferior thyroid artery is seen. On spectral display, a low resistance flow with a high systolic velocity is obtained.

2.1.25 Normal thyroid – transverse scan – normal

2.1.26 Normal thyroid – transverse scan –at the Strain

vascularization, homogeneous with normal ecodensity of right thyroid lobe.

Elastography the right lobe appears with a uniform, homogeneous parenchyma with completely soft stiffness (coded in green).

2.1.27 Normal thyroid – transverse scan – normal

1.1.28 Normal thyroid – transverse scan –at the Strain

vascularization, homogeneous with normal ecodensity of left thyroid lobe.

Elastography the left lobe appears with a uniform, homogeneous parenchyma with completely soft stiffness (coded in green).

2.1.29 Normal thyroid - longitudinal scan, cranio-

2.1.30 Longitudinal scan. At the Strain Elastography the

caudal (lenght) diameter measurment of the left lobe, with normal color Doppler spots.

left lobe appears with a uniform, homogeneous parenchyma with completely soft stiffness (coded in green). Normal - Strain Ratio(SR) of 1,05.

2.1.31 Normal thyroid – transverse scan – female after birth at two weeks - transverse scan - slightly increased vascularization, with normal ecodensity of both thyroid lobes.

2.1.32 Normal thyroid – transverse scan –at the Strain

2.1.33 Normal thyroid – transverse scan – normal

2.1.34 Normal thyroid – transverse scan –at the Strain

homogeneous parenchyma with normal ecodensity of left thyroid lobe with normal vascularization of the left thyroid lobe, in Power Doppler.

Elastography the right lobe appears with a uniform, homogeneous parenchyma with completely soft stiffness (coded in green).

2.1.35. Normal thyroid – transverse scan –at the Strain Elastography the left lobe appears with a uniform, homogeneous parenchyma with completely soft stiffness (coded in green).

2.1.36 Longitudinal scan. At the Strain Elastography the

Elastography the both lobes appears with a uniform, homogeneous parenchyma with completely soft stiffness (coded in green).

left lobe appears with a uniform, homogeneous parenchyma with completely soft stiffness (green coded).

Chapter 4. Thyroid pathology : diffuse and focal thyroid diseases Thyroid pathology includes both focal lesions and diffuse thyroid lesions 4.1. Etiologies of thyroid patholgy. A. DIFFUSE THYROID DISORDERS: that could cause functional manifestations of hypothyroidism or hyperthyroidism. 1. Thyroiditis: ►Acute thyroiditis (AT) - Acute suppurative thyroiditis. ►Subacute thyroiditis (SAT)- De Quervain's subacute thyroiditis ►Chronic autoimmune thyroiditis (CAT) - Hashimoto's Thyroiditis 2. Thyroid malformations - Congenital anomalies 3. Macronodular goiter. 4. Grave′s Disease B. FOCAL THYROID INJURIES: 1. Benign nodules: ►Hyperplastic nodules ►Follicular adenomas ►Hashimoto thyroiditis nodules ►Subacute thyroiditis nodules ►Cyst, Colloid nodule 2. Malignant tumors: ►Papillary carcinomas - 78% ►Follicular carcinomas - 17% ►Medullary carcinomas - 4% ►Anaplastic thyroid cancer -1% ►Hurthle cell carcinoma - 0.5% ►Thyroid Metastases - Rare ►Thyroid Lymphoma - rare C. NONTHYROID FORMATIONS: ►Lymph Node ►Parathyroid Cyst or tumor ►Cystic Hygroma, dermoid, teratoma ►Laryngocele ►Thyroglossal duct cyst 4.2. Ultrasound characterization of thyroid lesions. The US in diffuse injuries: ultrasonography does not allow the detection of thyroid dysfunction, but it allow the monitoring of thyroid lesion evolution only orientation value. ►Assess the level of vascularization of the parenchyma. ►Hypoechoic US signal improvement ►Thyroid volume progression, ►Tissue stiffness changes. ►Requires clinical and laboratory exploration The US in focal lesions: assess lesions and have a major role in diagnosis: ►volumes ►positions ►appearance ►Capsule integrity ►Tumor invasion ►Lateral-cervical lymphadenopathies

Diagnostic algorithm of focal thyroid lesions - after Jacob's score Worldwide, we observed an increased incidence of thyroid cancer. Detailed guidelines provide an evidence-based framework for the diagnosis and management of thyroid cancer. •FNA should be recommended based on the ultrasound risk stratification model. •Cytological results should be reported according to the Bethesda cytology system. •Molecular markers start to complement cytology in the diagnosis of indeterminate results. •Surveillance needs to be individualized, and the response to therapy needs to be stratified •Thyroid nodules are prevalent conditions where the priority in the workup is to exclude the possibility of malignancy •A systematic stepwise approach that involves a detailed focused history and P.E., biochemical testing with TSH, imaging with an ultrasound, and fine-needle aspiration cytology is essential for proper diagnosis •The management of differentiated thyroid cancer must be individualized depending on the risk assessment and must be regularly re-assessed for subsequent courses of action

Chapter 5. Diffuse thyroid disease 5.1. Congenital anomalies Congenital agenesis or hypoplasia of the thyroid gland may include the whole gland or just one of the lobes. Ectopic thyroid, a deficit in migration of the thyroid gland to the lower neck from its origin at the base of the tongue, develops most commonly at a sublingual or a suprahyoid position. Ectopic thyroid may be easily detected on radionuclide scans. The thyroglossal cyst, forming from a persistent thyroglossal duct, appears as a neck lump at the midline. The normally placed thyroid gland must be searched for to exclude thyroid agenesia. In the absence of normal thyroid, the cyst will be the only present thyroid tissue.

5.2. Multinodular goiter (MNG) Multinodular goiter is the common pathological condition of the thyroid. Also known as thyreopathic endemic goiter. Multiple nodules within produce enlarged the whole thyroid. It is frequently associated with iodine deficiency in water and food. An assessment of retrosternal extension should be carried out as part of the examination by scanning inferiorly to the level of the manubrium, if necessary while asking the patient to swallow for identify the lower margin of the thyroid. If the retrosternal extension is detected, CT would be required to define the limits of the mediastinal extent. The ultrasound features are: • Iso-or hyperechoic nodules with cystic degeneration • The well-defined halo surrounding nodules-due to compressed adjacent tissue • Colloid component of cystic elements- "ring down" sign • Heterogenous background echotexture of the thyroid • Calcification-nodules often contain florid dysplastic central calcification or well-defined peripheral curvilinear calcification. • Assessment of retrosternal extension should be carried out as part of the examination by scanning inferiorly to the level of the manubrium. • Vascularization of the parenchyma may be normal or slightly increased. • Tissue stiffness is predominantly increased inhomogeneously at the Strain Elastography.

5.3. Acute suppurative thyroiditis Thyroiditis is defined as the inflammation of the thyroid gland and can be classified as either acute/subacute or autoimmune thyroiditis. Suppurative acute thyroiditis is a rare condition, which affects mainly children and young adults, representing less than 1% of all thyroid diseases. It is usually caused by bacterial infections but can in some cases be related to other etiologies such as fungus, mycobacteria, or even parasites. Patients usually present with fever, anterior neck pain, hoarseness, dysphagia and dysphonia, and anterior neck swelling. Ultrasound findings are usually in the left side upper pole (which can be related to pyriform sinus), and present as illdefined hypoechoic areas of low vascularization, which can progress to the intrathyroidal abscess. In more severe cases the infection can extend either to more superficial planes or the deep spaces of the neck.The entire parenchyma is inhomogeneous, containing hypoechoic nodules with the formation of inflammatory microabscesses and tissue necrosis. Infective and/or reactive adjacent lymph nodes may also be seen.

5.4. De Quervain's sub acute thyroiditis The clinical scenario differs in that the patient characteristically presents with painful swelling in the lower neck, fever, redness of the skin and lethargy; typically following a viral illness. Numerous cases of subacute thyroiditis have been reported in SARS COV 2 infections. The biochemistry in the acute phase is that of thyro-toxicity, usually followed by a period of hypothyroidism. Typically (after six months from acute onset) the patient recovers and becomes euthyroid. Ultrasound features : ►Acute phase - A hypoechoic ill-defined mass, usually tender. The adjacent thyroid tissue is heterogeneous in echotexture. Vascularization of the parenchyma is frequently increased. The parenchyma of the thyroid lobes is inhomogeneous with predominantly soft stiffness.

►Subacute phase - The hypoechoic area increases in size to involve the ipsilateral thyroid lobe and sometimes extends to the contralateral lobe. Vascularization of the parenchyma is increased. ►Recovery phase - Thyroid appearances return to normal or atrophy may develop. Vascularization of the parenchyma is often low or absent. Postpartum thyroiditis: Postpartum thyroiditis usually occurs in the first year after delivery and can be present in up to 7% of woman and has a strong association with the presence of positive antithyroid antibodies, even before gestation, and lymphocytic infiltrate, suggesting an autoimmune etiology. The parenchyma of the thyroid lobes is inhomogeneous with predominant soft stiffness and increased vascularity. Ultrasound findings include a diffusely hypoechoic gland or multiple hypoechoic foci in the thyroid parenchyma. Postpartum thyroiditis is considered painless subacute thyroiditis. Most patients recover normal thyroid function within a year, but these patients have a higher risk of developing hypothyroidism afterward.

5.5. Chronic autoimmune thyroiditis- Hashimoto's thyroiditis The autoimmune diseases of the thyroid gland represent a spectrum of various disorders that have in common the presence of lymphocytic infiltrate of variable intensity in the thyroid parenchyma and production of antithyroid antibodies. It is defined by the detection of the following antithyroid antibodies: TgAb-thyroglobulin antibodies and TPOAb-thyroperoxidase antibodies. Hashimoto's thyroiditis is the most common of chronic thyroiditis. Chronic autoimmune lymphocytic thyroiditis stands out as the most common cause of hypothyroidism and one of the most frequent organ-specific autoimmune diseases affecting humans. The biochemical picture can be that of hyperthyroidism in the acute, initial phase. • Acute phase: Focal nodular thyroiditis - small hypoechoic nodules with ill-defined margin- seems to represent lymphocytic infiltration starts in the anterior portion and isthmus. • Subacute phase: The infiltration proceeds to involve the whole of the thyroid gland, the gland is enlarged and slightly rounded in outline. It can be hypervascular on color flow imaging. • Chronic phase: Enlarged, slightly lobular outline, the thyroid is diffusely hypoechoic with fine echogenic septae within. Small atrophic gland with heterogeneous echogenicity.

5.6. Graves disease Graves disease is frequently associated with some extra-thyroid manifestations, the most common of which is thyroid-associated orbitopathy, whereby some or all of the extra-ocular muscles become enlarged, resulting in proptosis. Other manifestations are thyroid dermopathy (pretibial myxoedema), and thyroid acropachy (rare, causing finger clubbing and periosteal reaction along with the tubular bones of the hands and feet). The normal thyroid is uniformly enlarged, heterogeneous and hypoechoic on ultrasound – an example of this is provided below for comparison. The typical biochemical thyrotoxic profile is matched by diffuse enlargement of the thyroid gland with rounding of the normal angular outline. The gland is diffusely hypoechoic and color flow imaging reveals an often spectacular "thyroid inferno" with marked hypervascularity. Hypervascularity identified in early Graves disease – appearances nonspecific can be seen in any acute thyroiditis (anterior distribution could be seen in early Hashimoto's for example). The ultrasound picture can be indistinguishable from Hashimoto's thyroiditis in the sub-acute phase or could be indistinguishable from de Quervain's thyroiditis if both lobes are involved. For establishing the positive diagnosis it is necessary to determine the Thyroid-stimulating immunoglobulin (TSI). The presence of this antibody is diagnostic for Graves disease, Thyroid-stimulating hormone receptor antibody TRAb.

5.7. Ultrasound Reporting Criteria: When reporting the thyroid sonography, some general rules should be fulfilled: • Describe a- size; b- echogenicity; c- echostructure d- vascularity, of the whole gland parenchyma. • Describes: a- position; b- shape; c- size; d- margins; e-content; f- echogenic pattern g- vascular characteristics, h-stiffness of the nodules. • Identify the nodule at high risk for malignancy. • Risk stratification by TIRADS classification establishes the optimal momentum for performing FNA of thyroid nodules based on US features and follow-up.

Chapter 6 - Congenital anomalies

6.1.2 Transverse scan – Thyroid malformations Left thyroid lobe agenesis

Left thyroid lobe agenesis with normal vascularization of the right thyroid lobe, in Duplex Doppler.

6.1.3 Transverse scan –Gray Scale- Thyroid

6.1.4 Transverse scan – Thyroid malformations

malformations: Congenital left thyroid lobe hypoplasia, isoechoic, homogenous.

Congenital left thyroid lobe hypoplasia, isoechoic, inhomogenous.

6.1.5 Transverse scan – Thyroid malformations Left thyroid lobe agenesis, the AP/H and transverse diameters of right thyroid lobe, inhomogeneous with normal ecodensity.

6.1.6 Transverse scan – Thyroid malformations Left thyroid lobe hypoplasia with normal vascularization of the right thyroid lobe, in Duplex Doppler.

6.1.1 Transverse scan – Thyroid malformations

Congenital anomalies

6.1.7 Transverse scan – Thyroid malformations

6.1.8 Transverse scan – Thyroid malformations at the

Left thyroid lobe hypoplasia – In Gray scale the right lobe Strain Elastography the right lobe appears with a uniform, inhomogeneous parenchyma with completely appears isoechoic with inhomogeneous parenchyma. soft stiffness (coded in green).

6.1.10 Longitudinal scan, cranio-caudal (lenght) scan –Gray Scale- Thyroid diameter measurment of the both lobes, homogeneous malformations: Congenital left thyroid lobe hypoplasia, with normal ecodensity. Congenital left thyroid lobe isoechoic, homogenous. hypoplasia, isoechoic, inhomogenous. 6.1.9

Transverse

6.1.11Transverse scan – Thyroid malformations 6.1.12Transverse scan – Thyroid malformations Left thyroid lobe agenesis, the AP/H and transverse Left thyroid lobe agenesis with normal vascularization of diameters of right thyroid lobe, inhomogeneous with the right thyroid lobe, in Power Doppler. normal ecodensity.

Congenital anomalies

6.1.13 Longitudinal scan, cranio-caudal (lenght) 6.1.14 Longitudinal scan,– Congenital anomalies lateral diameter measurment of the right lobe, homogeneous branchial cyst at the Strain Elastography the right lobe with normal ecodensity. – Congenital anomalies: lateral appears with a uniform, homogeneous parenchyma with branchial cyst, located laterally posterior to the thyroid completely soft stiffness (coded in green).

6.1.15 Longitudinal scan - congenital anomalies: lateral 6.1.16 Longitudinal scan - congenital anomalies: lateral branchial cyst, located laterally posterior to the thyroid branchial cyst, located laterally posterior to the thyroid with normal vascularization of the right thyroid lobe, in with normal vascularization of the right thyroid lobe, in Power Doppler. Duplex Doppler.

6.1.17 Transverse scan – Thyroid malformations thyroid lobes hypoplasia, the AP/H and transverse diameters of right thyroid lobe, inhomogeneous with normal ecodensity.

6.1.18 Transverse scan – Thyroid malformations thyroid agenesis, the AP/H and transverse diameters of right thyroid lobe, inhomogeneous with normal ecodensity.

Chapter 7. Multinodular goiter (MNG)

7.1.1 Transverse scan – MNG- the AP/H and transverse 7.1.2 Longitudinal scan– MNG- the cranio-caudal diameters increased with both lobes with increased diameter increased of both lobes with increased volume, volume, heterogeneous containing hyperechoic heterogeneous containing hyperechoic nodules with cystic degeneration. nodules with cystic degeneration.

7.1.3 Transverse scan – MNG – Left lobe with increased 7.1.4 Longitudinal scan - MNG –Left lobe with increased volume, heterogeneous containing hyper-echoic volume heterogeneous, containing hyperechoic nodules nodules with cystic degeneration and calcification with calcification with posterior acoustic shadowing in nodules contain well-defined peripheral curvilinear gray scale. calcification, with posterior acoustic shadowing.

7.1.5 Transverse scan– MNG- right lobe with increased volume heterogeneous containing hyperechoic nodules with a moderate increase of vascularization in the parenchyma at color Doppler mode.

7.1.6 Longitudinal scan - MNG –Left lobe with increased volume heterogeneous containing hyperechoic nodules with cystic degeneration, with a moderate increase of vascularization in the parenchyma at color Doppler mode.

Multinodular goiter (MNG)

7.1.8 Transverse scan - MNG – Left lobe with increased volume, heterogeneous containing hyperechoic 7.1.7 Transverse scan– MNG- right lobe with increased nodules. At the elastography the right lobe appears volume, heterogeneous containing hyperechoic nodules inhomogeneous with predominance in the with a moderate increase of vascularization in the parenchyma of soft stiffness (green coded) and the parenchyma at Power Doppler mode. appearance of nodules with hard stiffness(blue).

7.1.9 Longitudinal scan - MNG – Left lobe with increased volume heterogeneous containing hyperechoic nodule with a moderate increase of vascularization in the parenchyma at color Doppler mode.

7.1.10 Longitudinal scan - Left lobe with increased volume heterogeneous containing hyperechoic nodule which appears elastographically with hard stiffness having a Strain Ratio of 1.17 for benignity.

7.1.11 Longitudinal scan – MNG- right lobe with increased volume heterogeneous containing hyperechoic nodules with a moderate increase of vascularization in the parenchyma at Power Doppler mode.

7.1.12 Longitudinal scan - MNG –Left lobe with increased volume heterogeneous containing hyperechoic nodule, with a moderate increase of vascularization in the parenchyma at color Doppler mode. The nodule is not vascularized - type 1.

Multinodular goiter (MNG)

7.1.13 Transverse scan – MNG- the AP/H and transverse diameters increased with both lobes with increased volume heterogeneous containing hyperechoic nodules with cystic degeneration.

7.1.14 Transverse scan – MNG-increased volume, heterogeneous containing hyperechoic nodules with cystic degeneration. Ultrasonographic panoramic image to fully capture the plunging goiter in the mediastinum.

7.1.15 Transverse scan - MNG – Right lobe with the AP/H and transverse diameters increased, heterogeneous containing hyperechoic nodule and plunging into the mediastinum.

7.1.16 Transverse scan - MNG-increased volume, heterogeneous containing homogeneous hyper-echoic nodules, with a wider oval shape and peripheral halo in gray scale.

7.1.17 Transverse scan – MNG- right lobe with increased volume, heterogeneous, containing hyperechoic nodules with a moderate increase of vascularization in the parenchyma at Duplex Doppler mode with peripheral vascularization of the nodule (vascular type 2)..

7.1.18 Longitudinal scan - MNG –Right lobe with increased volume heterogeneous containing hyperechoic nodule appears elastographically with soft stiffness having a Strain Ratio of 1.20 for benignity.

Multinodular goiter (MNG)

7.1.19 Transverse scan– MNG- right lobe with increased volume heterogeneous containing contains a colloidal cyst with a moderate increase of vascularization in the parenchyma at Duplex Doppler mode.

7.1.20 Transverse scan - MNG – Left lobe with increased volume heterogeneous containing contains a colloidal cyst, with a moderate increase of vascularization in the parenchyma at Power Doppler mode.

7.1.21Longitudinal scan - MNG – Left lobe with increased 7.1.22 Longitudinal scan - Left lobe with increased volume, heterogeneous containing a colloidal cyst with a volume heterogeneous containing a colloidal cyst which moderate increase of vascularization in the parenchyma at appears with a moderate increase of vascularization in color Doppler mode. the parenchyma at Duplex Doppler mode.

7.1.23 Transverse scan – MNG- the AP/H and transverse diameters increased with both lobes with increased volume heterogeneous containing hyperechoic nodules with normal vascularization of the parenchyma at Duplex Doppler

7.1.24 Longitudinal scan - MNG –Left lobe with increased volume, heterogeneous containing hyperechoic nodule, with a moderate increase of vascularization in the parenchyma at color Doppler mode. The nodule is not vascularized - type 1.

Multinodular goiter (MNG)

7.1.25 Transverse scan - MNG – Right lobe with increased volume, heterogeneous containing hypoechoic nodule. At the elastography the right lobe appears inhomogeneous with predominance in the parenchyma of hard stiffness (blue coded) and the appearance of nodules with soft stiffness(green).

7.1.26 Transverse scan – MNG-increased volume, heterogeneous containing hyperechoic homougenous nodules. At the elastography the left lobe appears inhomogeneous with predominance in the parenchyma of hard stiffness (blue coded) and the appearance of nodules with hard stiffness(blue).

7.1.28 Transverse scan - MNG- right lobe with increased 7.1.27 Transverse scan – MNG- the AP/H and transverse volume, heterogeneous with a moderate increase of diameters increased with both lobes with increased vascularization in the parenchyma at Color Doppler volume, heterogeneous with cystic degeneration. mode.

7.1.29 Transverse scan - MNG – Right lobe with increased volume heterogeneous with a moderate increase of vascularization in the parenchyma at Power Doppler mode.

7.1.30 Transverse scan - MNG –Right lobe with increased volume, heterogeneous appears elastographically with predominance of hard stiffness in the entire parenchyma (blue coded).

Multinodular goiter (MNG)

7.1.32 Longitudinal scan – MNG- Left lobe with increased 7.1.31 Transverse scan – MNG- the AP/H and transverse volume, heterogeneous containing cystic degeneration. diameters increased with both lobes with increased It has a small, well-defined anechoic image - a simple volume heterogeneous containing cystic degeneration. colloid cyst in gray scale.

7.1.33 Transverse scan - MNG – left lobe with increased 7.1.34 Transverse scan - MNG- Left lobe with increased volume, heterogeneous with normal vascularization in the volume, heterogeneous with normal vascularization in the parenchyma at Power Doppler mode. parenchyma at Color Doppler mode.

7.1.35 Longitudinal scan – MNG- left lobe with increased 7.1.36 Longitudinal scan - MNG –Left lobe with increased volume heterogeneous with normal vascularization in the parenchyma at Duplex Doppler mode with peripheral volume heterogeneous containing a simple colloid cyst appears elastographically with soft stiffness. vascularization of the simple colloid cyst

Chapter 8 – Acute and subacute thyroiditis

8.1.2 Longitudinal scan– Acute thyroiditis - the cranio8.1.1 Transverse scan – Acute thyroiditis (AT)- both caudal diameter increased of both lobes with increased lobes had increased volume, heterogeneous containing volume heterogeneous, containing hypoechoic nodules hypoechoic nodules with the formation of with the formation of inflammatory microabscesses and inflammatory microabscesses and tissue necrosis. tissue necrosis in gray scale.

8.1.3 Transverse scan – AT – Left lobe with the AP/H and 8.1.4 Longitudinal scan - AT – Left lobe with increased transverse diameters increased, heterogeneous volume heterogeneous containing hypoechoic nodule containing hypo-echoic nodules with the formation of with the formation of inflammatory microabscesses and inflammatory microabscesses and tissue necrosis tissue necrosis

8.1.6 Transverse scan - AT –right lobe with increased 8.1.5 Transverse scan– AT- right lobe with increased volume, heterogeneous containing hypoechoic nodules volume heterogeneous containing hypoechoic nodule with irregular edges, with a moderate increase in perilesional vascularization of the nonvascular with a round shape with undefined edges hypoechoic nodule in Power Doppler mode.

Acute and subacute thyroiditis

8.1.8 Transverse scan - AT– both lobes with increased 8.1.7 Transverse scan– AT- left lobe with increased volume volume, heterogeneous containing hypoechoic heterogeneous containing hypoechoic nodules with a nodules. The measurements showed an moderate increase of vascularization in the perilesional inhomogeneous, hypoechoic isthmus with large parenchyma at Power Doppler mode. diameters (over 3 mm AP diameter) in gray scale US.

8.1.9 Transverse scan – AT – Left lobe with the AP/H and transverse diameters increased, heterogeneous with hypervascular areas arranged inhomogeneously in the periphery of hypoechoic areas to Color Doppler

8.1.10 Transverse scan - Left lobe with increased volume heterogeneous containing hypoechoic nodule which appears elastographically with soft stiffness related to the surrounding parenchyma.

8.1.12 Transverse scan - AT –Right lobe with increased 8.1.11 Transverse scan – AT – Right lobe with the AP/H and volume, heterogeneous containing hyperechoic nodule transverse diameters increased, heterogeneous with appears elastographically with soft stiffness having a hypervascular areas arranged inhomogeneously in the Strain Ratio of 0.95 for benignity. periphery of hypoechoic areas to Color Doppler

De Quervain's sub acute thyroiditis

8.2.1 Transverse scan– SAT- left lobe with increased volume, heterogeneous containing hypoechoic nodules with an inhomogeneous, hypoechoic isthmus with large diameters (over 3 mm AP diameter) in gray scale US.

8.2.2 Longitudinal scan–SAT- Subacute thyroiditis : the cranio-caudal diameter increased of both lobes with increased volume heterogeneous containing hypoechoic nodules with with cystic degeneration in gray scale.

8.2.3 Transverse scan – SAT – Both lobes with the AP/H and transverse diameters increased, heterogeneous with hypervascular areas arranged inhomogeneously in the periphery of hypoechoic areas to Color Doppler

8.2.4 Longitudinal scan - SAT –Left lobe with increased volume, heterogeneous containing hypoechoic micronodules, with a moderate increase of vascularization in the parenchyma at Doppler mode.

8.2.5 Transverse scan – SAT – Right lobe with the AP/H and transverse diameters increased, heterogeneous with hypervascular areas arranged inhomogeneously in the periphery of hypoechoic areas to Color Doppler

8.2.6 Transverse scan - SAT –Right lobe with increased volume, heterogeneous containing hypoechoic nodule appearing elastographically with mixed areas of hard and soft stiffness of parenchyma.

De Quervain's sub acute thyroiditis

8.2.7 Transverse scan– SAT- left lobe with increased volume, heterogeneous containing hypoechoic nodules with a moderate increase of vascularization in the perilesional parenchyma at color Doppler mode.

8.2.8 Transverse scan - SAT– left lobe with increased volume, heterogeneous containing hypoechoic nodules appearing elastographically with mixed areas of hard and soft stiffness of thyroid parenchyma.

8.2.9 Transverse scan – SAT – Both lobes with the AP/H and transverse diameters increased, heterogeneous containing hypoechoic nodules with hypervascular areas arranged inhomogeneously in the periphery of hypoechoic areas to Color Doppler

8.2.10 Transverse scan -SAT- Left lobe with increased volume, heterogeneous, containing hypoechoic nodule with a moderate increase of vascularization in the perilesional parenchyma at Power Doppler mode

8.2.11 Transverse scan – SAT- the AP and transverse diameters increased with both lobes with increased volume, inhomogeneous, containing hyperechoic nodules with cystic degeneration in the recovery phase.

8.2.12 Transverse scan– SAT- Both lobes with increased volume, inhomogeneous, containing hypoechoic nodules with an inhomogeneous, hypoechoic isthmus with large diameters (over 3 mm AP diameter) in gray scale US.

De Quervain's sub acute thyroiditis

8.2.13 Transverse scan– SAT- left lobe with increased volume, heterogeneous containing a hyperechoic homogeneous solid area, imprecisely delimited that appears as an atrophy area of the parenchyma in the recovery phase.

8.2.14 Transverse scan - SAT– left lobe with increased volume heterogeneous, containing hyperechoic homogeneous solid area with hypervascular areas arranged inhomogeneously in the periphery to Color Doppler

8.2.15 Longitudinal scan – SAT – Right lobe with the AP and transverse diameters increased, inhomogeneous, with moderate hypervascular areas arranged in the periphery of a homogeneous round solid isoechoic node with a peripheral halo to the Color Doppler.

8.2.16 Longitudinal scan - SAT - Right lobe with increased volume heterogeneous, with a homogeneous solid isoechoic node with a peripheral halo, medial localized which on elastography appears with a predominance of hard stiffness due to atrophy.

8.2.17 Transverse scan – SAT – Right lobe with the AP/H and transverse diameters increased heterogeneous with of a homogeneous round solid isoechoic node with a peripheral halo.

8.2.18 Transverse scan - SAT –Right lobe with increased volume heterogeneous, containing a homogeneous round solid isoechoic node with a peripheral halo and without intranodal vascularization at color Doppler mode.

De Quervain's sub acute thyroiditis

8.2.20 Transverse scan - SAT– Right lobe with increased 8.2.19 Transverse scan– SAT- left lobe with increased volume, heterogeneous containing hypoechoic nodule volume heterogeneous containing an isoechoic nodule which appears elastographically with a predominance with a moderate increase of vascularization in the of hard stiffness over 50% of the surface. The rest of thyroid parenchyma with mixed areas of hard and soft perilesional parenchyma at Power Doppler mode. stiffness.

8.2.21 Transverse scan - SAT –Left lobe with increased volume heterogeneous, containing a hyperechoic homogeneous solid area, imprecisely delimited that appears as an atrophy area without vascularization at the color Doppler mode.

8.2.22 Longitudinal scan – SAT – Left lobe with craniocaudal diameter increased heterogeneous with moderate hypervascular areas arranged in the periphery of a inhomogeneous round solid hyperechoic node imprecisely delimited to Doppler.

8.2.23 Longitudinal scan – SAT – Left lobe with the increased volume heterogeneous, with some inhomogeneous round solid hyperechoic nodes imprecisely delimited to gray scale.

8.2.24 Transverse scan - SAT –Right lobe with increased volume heterogeneous , containing hyperechoic area appears elastographically with hard stiffness having a Strain Ratio of 2.39 for benignity.

De Quervain's sub acute thyroiditis

8.2.25 Transverse scan - SAT– both lobes with increased volume heterogeneous containing hypo and hyperechoic nodules. The measurements showed an inhomogeneous, hypoechoic isthmus with large diameters (over 3 mm AP diameter) in gray scale US.

8.2.26 Transverse scan– SAT- Boths lobe with increased volume heterogeneous containing hypoechoic nodules with a moderate increase of vascularization in the perilesional parenchyma at Color Doppler mode.

8.2.27 Transverse scan – SAT – Right lobe with the AP/H and transverse diameters increased, heterogeneous with hypervascular areas arranged inhomogeneously in periphery of the hypoechoic area to Power Doppler

8.2.28 Transverse scan-SAT - Left lobe with increased volume heterogeneous containing hypoechoic nodule with hypervascular areas arranged inhomogeneously in periphery of the hypoechoic area to Power Doppler

8.2.29 Transverse scan – SAT – Both lobes with the AP/H and transverse diameters increased, heterogeneous containing hyperechoic nodules with moderate hypervascularization to the periphery and some hypoechoic areas at the Color Doppler mode.

8.2.30 Transverse scan – SAT – Left lobe with the increased volume heterogeneous containing hyperechoic nodules with moderate hypervascularization to the periphery and some hypoechoic areas at the Color Doppler mode.

De Quervain's sub acute thyroiditis

8.2.31 Transverse scan – SAT – Both lobes with the volume increased heterogeneous containing hyperechoic nodules with hypervascular area arranged inhomogeneously in the periphery to Color Doppler.

8.2.32 Transverse scan - SAT –Right lobe with increased volume heterogeneous containing hyperechoic area with imprecise edges appears elastographically with hard stiffness having a Strain Ratio of 1.08 for benignity.

8.2.33 Transverse scan – SAT – Left lobe with the increased volume heterogeneous with a solid, round homogeneous hyperechoic node bordered by a peripheral halo to grayscale.

8.2.34 Longitudinal scan – SAT – Left lobe with craniocaudal diameter increased heterogeneous with hyper and hypoechoic areas of subacute inflammation and atrophic areas and moderate hypervascular areas .

8.2.35 Longitudinal scan – SAT – Left lobe with increased volume heterogeneous with moderate hypervascular areas arranged in the periphery of an inhomogeneous round solid hyperechoic node imprecisely delimited to color Doppler mode.

8.2.36 Longitudinal scan – SAT –Left lobe with increased volume heterogeneous containing a hyperechoic nodule appears elastographically with soft stiffness having a Strain Ratio of 0.47 for benignity.

Subacute thyroiditis - Postpartum thyroiditis

8.2.37 Transverse scan -SAT- both lobes with increased volume heterogeneous showing a diffusely hypoechoic gland with multiple hyperechoic nodules and atrophy areas in the posterior thyroid parenchyma in the recovery phase.

8.2.38 Transverse scan -SAT- both lobes with increased volume heterogeneous containing hypoechoic area showing moderate diffuse hypervascularization and atrophy area in the posterior thyroid parenchyma in the recovery phase at Doppler.

8.2.39 Transverse scan - SAT –Right lobe with increased volume heterogeneous, containing a hyperechoic inhomogeneous solid area, imprecisely delimited that appears as an atrophy area in recovery phase of the postpartum thyroiditis in gray-scale US.

8.2.40 Longitudinal scan – SAT – Left lobe with craniocaudal diameter increased heterogeneous with a hyperechoic inhomogeneous solid area, imprecisely delimited that appears as an atrophy area posterior located at the postpartum thyroiditis.

8.2.41 Transverse scan - SAT – The right lobe has 8.2.42 Transverse scan - SAT - The right lobe has

increased heterogeneous volume with intense increased heterogeneous volume with intense diffuse parenchyma vascularization on Power diffuse parenchyma vascularization on Duplex Doppler ultrasound. Doppler ultrasound.

Sub acute thyroiditis - Postpartum thyroiditis

8.2.43 Transverse scan - SAT –Left lobe with increased volume heterogeneous, containing a hyperechoic inhomogeneous solid area, imprecisely delimited that appears as an atrophy area in recovery phase of the postpartum thyroiditis in gray-scale US.

8.2.44 Longitudinal scan – SAT – Left lobe with craniocaudal diameter increased heterogeneous with a hyperechoic inhomogeneous solid area, imprecisely delimited that appears as an atrophy area posterior located at the postpartum thyroiditis.

8.2.45 Longitudinal scan – SAT –Right lobe with increased volume heterogeneous containing a hyperechoic nodule with well-defined edges and appears elastographically with soft stiffness(green coded). The rest of thyroid parenchyma with mixed areas of hard and soft stiffness.

8.2.46 Longitudinal scan – SAT – Left lobe with craniocaudal diameter increased heterogeneous with a hyperechoic inhomogeneous solid area, imprecisely delimited that appears as an atrophy area posterior located at the postpartum thyroiditis.

8.2.47 Transverse scan - SAT - Left lobe has increased

8.2.48 Transverse scan - SAT - Left lobe with

increased heterogeneous volume with intense heterogeneous volume with intense diffuse diffuse parenchyma vascularization on Power parenchyma vascularization on Duplex Doppler Doppler in acute phase of postpartum thyroiditis. ultrasound in acute phase of postpartum thyroiditis.

Chapter 9 - Chronic autoimmune Hashimoto's thyroiditis

9.1.1.Transverse scan - CAT– both lobes with heterogeneous increased volume, containing hypoechoic nodules. The measurements showed an inhomogeneous, hypoechoic isthmus with large diameters (over 3 mm AP diameter) and lobulated thyroid contour.

9.1.3Transversescan–CAT:right lobe with heterogeneous increased volume, containing macronodular structure with intense and diffuse hypervascularization of the parenchyma at Power Doppler.

9.1.2 Longitudinal scan – CAT – Left lobe with increased cranio-caudal diameter, heterogeneous with hyper and hypoechoic areas of chronic lymphocytic infiltrate and and intense and diffuse hypervascularization of the entire parenchyma at Color Doppler mode.

9.1.4 Transverse scan– CAT- left lobe with increased volume, heterogeneous containing macronodular structure with intense and diffuse hypervascularization of the parenchyma at Color Doppler.

9.1.6 Longitudinal scan – CAT – Right lobe with 9.1.5 Transverse scan – CAT – both lobes with the AP/H increased cranio-caudal diameter, heterogeneous with and transverse diameters increased, heterogeneous with macronodular structure and intense and diffuse intense and diffuse hypervascularization to Color Doppler hypervascularization of the entire parenchyma.

Chronic autoimmune Hashimoto's thyroiditis

9.1.7 Transverse scan - CAT – Both lobe has increased heterogeneous volume, hypoechoic with intense diffuse parenchyma vascularization on Duplex Doppler ultrasound in acute phase of Hashimoto's thyroiditis.

9.1.8 Longitudinal scan – CAT – Left lobe with craniocaudal diameter increased heterogeneous with macronodular structure intense diffuse parenchyma vascularization on Duplex Doppler ultrasound.

9.1.9 Transverse scan - CAT – Left lobe has increased heterogeneous volume with intense diffuse parenchyma vascularization on Duplex Doppler ultrasound in acute phase of Hashimoto's thyroiditis.

9.1.10 Transverse scan - CAT – Left lobe has increased heterogeneous volume, hypoechoic with intense diffuse parenchyma vascularization on Power Doppler ultrasound in acute phase of Hashimoto's thyroiditis.

9.1.11 Transverse scan - CAT - Right lobe has increased heterogeneous volume, hypoechoic with intense diffuse parenchyma hypervascularization on Power Doppler ultrasound in acute phase of Hashimoto's thyroiditis.

9.1.12 Transverse scan - CAT - Right lobe with increased heterogeneous volume, hypoechoic with macronodular structure and intense diffuse parenchyma hypervascularization on Color Doppler in acute phase of Hashimoto's thyroiditis.

Chronic autoimmune Hashimoto's thyroiditis

9.1.13 Transverse scan -CAT – The infiltration proceeds to involve the whole of the thyroid gland, the gland is enlarged and slightly rounded in outline. Right lobe has a heterogeneous increased volume with macronodular structure in subacute phase of the Hashimoto's thyroiditis.

9.1.14 Transverse scan - CAT– left lobe with increased volume, heterogeneous containing hypoechoic nodule. The rest of thyroid parenchyma with mixed areas of hard and soft stiffness at the Strain Elastography.

9.1.15 Longitudinal scan – CAT –Right lobe with craniocaudal diameter increased heterogeneous with macronodular structure and intense diffuse parenchyma hypervascularization on Duplex Doppler ultrasound in acute phase of the Hashimoto's thyroiditis.

9.1.16 Longitudinal scan – CAT –Left lobe was heterogeneous with cranio-caudal diameter increased with macronodular structure and intense diffuse parenchyma hypervascularization on Duplex Doppler ultrasound.

9.1.17 Transverse scan - CAT – Both lobe has increased heterogeneous volume, hypoechoic with the AP/H and transverse diameters increased, and intense diffuse parenchyma hypervascularization on Duplex Doppler ultrasound in acute phase of Hashimoto's thyroiditis.

9.1.18 Transverse scan - CAT - Both lobe with increased heterogeneous volume with intense diffuse parenchyma hypervascularization on Duplex Doppler in acute phase of Hashimoto's thyroiditis.

Chronic autoimmune Hashimoto's thyroiditis

9.1.20 Transverse scan - CAT – Both lobes has increased 9.1.19 Transverse scan - CAT - Both lobes with increased heterogeneous volume, hypoechoic, micronodular heterogeneous volume with moderate diffuse structure with lobulated thyroid contour and moderate parenchyma hypervascularization on Power Doppler in diffuse parenchyma hypervascularization on Duplex subacute phase of Hashimoto's thyroiditis. Doppler in subacute phase of Hashimoto's thyroiditis.

9.1.21 Transverse scan - CAT– both lobes with increased volume, heterogeneous containing hypoechoic nodules. The rest of thyroid lobes with mixed areas of hard and soft stiffness with a mosaic appearance of the parenchyma.

9.1.22 Transverse scan - CAT– left lobe with increased volume, heterogeneous containing hypoechoic nodule The rest of thyroid parenchyma with mixed areas of hard and soft stiffness at the Strain Elastography.

9.1.23 Transverse scan - CAT - Both lobe with increased heterogeneous volume, lobulated thyroid contour with moderate diffuse parenchyma vascularization on Duplex Doppler in subacute phase of Hashimoto's thyroiditis.

9.1.24 Longitudinal scan – CAT –Right lobe with craniocaudal diameter increased, heterogeneous with macronodular structure, and moderate diffuse parenchyma hypervascularization on Duplex Doppler in subacute phase of the Hashimoto's thyroiditis.

Chronic autoimmune Hashimoto's thyroiditis

9.1.25 Longitudinal scan - CAT –Left lobe is enlarged, slightly lobular outline, heterogeneous, diffusely hypoechoic with fine echogenic septae within, containing a hypoechoic homogeneous solid area. Small atrophic gland with heterogeneous echogenicity in chronic phase.

9.1.26 Longitudinal scan – CAT –Left lobe with increased volume heterogeneous containing a round hypoechoic nodule appears elastographically with soft stiffness having a Strain Ratio of 0.99 for benignity.

9.1.27 Transverse scan - CAT - Right lobe with increased heterogeneous volume, diffuse hypoechoic with moderate diffuse parenchyma hypervascularization on Power Doppler in subacute phase of Hashimoto's thyroiditis.

9.1.28 Longitudinal scan – CAT –Right lobe with craniocaudal diameter increased, heterogeneous with micronodular structure, and moderate diffuse parenchyma hypervascularization on Duplex Doppler in subacute phase of the Hashimoto's thyroiditis.

9.1.29 Longitudinal scan - CAT - Left lobe has cranio-caudal diameter increased, heterogeneous with macronodular structure, with small hypoechoic nodules with ill-defined margin- seems to represent lymphocytic infiltration.

9.1.30 Longitudinal scan - CAT - Left lobe with increased heterogeneous volume, hypoechoic with moderate diffuse parenchyma vascularization on Power Doppler in chronic phase of Hashimoto's thyroiditis.

Chronic autoimmune Hashimoto's thyroiditis

9.1.31 Transverse scan - CAT - Both lobe with increased heterogeneous volume, lobulated thyroid contour with moderate diffuse parenchyma vascularization on Duplex Doppler in subacute phase of Hashimoto's thyroiditis.

9.1.32 Longitudinal scan – CAT –Right lobe increased heterogeneous volume with micronodular structure, hypoechoic and moderate diffuse parenchyma hypervascularization on Duplex Doppler

9.1.27 Transverse scan - CAT - Right lobe with increased heterogeneous volume, diffuse hypoechoic with moderate diffuse parenchyma vascularization on Power Doppler in subacute phase of Hashimoto's thyroiditis.

9.1.28 Longitudinal scan – CAT –Right lobe with craniocaudal diameter increased, heterogeneous with micronodular structure, and moderate diffuse parenchyma vascularization on Duplex Doppler in subacute phase of the Hashimoto's thyroiditis.

9.1.29 Transverse scan - CAT – Left lobe has increased heterogeneous volume with moderate diffuse parenchyma vascularization on Duplex Doppler ultrasound in subacute phase of Hashimoto's thyroiditis.

9.1.30 Transverse scan - CAT - Left lobe with increased heterogeneous volume, hypoechoic with diffuse hard stifness of parenchyma on Strain Elastography in subacute phase of Hashimoto's thyroiditis.

Chronic autoimmune Hashimoto's thyroiditis

9.1.32 Longitudinal scan – CAT –Right lobe increased heterogeneous volume with micronodular structure, hypoechoic and moderate diffuse parenchyma hypervascularization on Duplex Doppler

9.1.33 Transverse scan - CAT - Right lobe with increased heterogeneous volume, diffuse hypoechoic with moderate intense parenchyma vascularization on Duplex Doppler in acute phase of Hashimoto's thyroiditis.

9.1.34 Longitudinal scan – CAT –Left lobe with craniocaudal diameter increased, heterogeneous with micronodular structure, and diffuse parenchyma hypervascularization on Duplex Doppler in acute phase of the Hashimoto's thyroiditis.

9.1.35 Transverse scan - CAT – Right lobe has increased heterogeneous volume with intense diffuse parenchyma vascularization on Duplex Doppler ultrasound in subacute phase of Hashimoto's thyroiditis.

9.1.36 Longitudinal scan - CAT - Left lobe with increased heterogeneous volume, hypoechoic with diffuse hard stifness of parenchyma on Strain Elastography in subacute phase of Hashimoto's thyroiditis.

Chronic autoimmune Hashimoto's thyroiditis

9.1.37 Transverse scan - CAT - Both lobe with increased heterogeneous volume, lobulated thyroid contour with moderate diffuse parenchyma vascularization on Duplex Doppler in subacute phase of Hashimoto's thyroiditis.

9.1.38 Longitudinal scan – CAT –Left lobe increased heterogeneous volume with micronodular structure, hypoechoic and moderate diffuse parenchyma hypervascularization on Duplex Doppler

9.1.39 Transverse scan - Longitudinal scan - CAT – Both lobes has cranio-caudal diameter increased, heterogeneous with macronodular structure, with small hypoechoic nodules with ill-defined margin- seems to represent lymphocytic infiltration in chronic phase.

9.1.40 Longitudinal scan - CAT - Left lobe has craniocaudal diameter increased, heterogeneous with macronodular structure, with small hypoechoic nodules with ill-defined margin- seems to represent lymphocytic infiltration in chronic phase.

9.1.35 Transverse scan - CAT – Both lobes has increased heterogeneous volume with intense diffuse parenchyma vascularization on Duplex Doppler ultrasound in chronic phase of Hashimoto's thyroiditis.

9.1.36 Transverse scan - CAT - Left lobe with increased heterogeneous volume, hypoechoic with diffuse hard stifness of parenchyma on Strain Elastography in chronic phase of Hashimoto's thyroiditis.

Chronic autoimmune Hashimoto's thyroiditis

9.1.38 Longitudinal scan – CAT –Left lobe increased heterogeneous volume with micronodular structure, hypoechoic and moderate diffuse parenchyma hypervascularization on Duplex Doppler

9.1.40 Longitudinal scan - CAT - Left lobe has cranio9.1.39 Transverse scan -CAT– Both lobes has increased caudal diameter increased, heterogeneous with heterogeneous volume with macronodular structure, with macronodular structure, with small hypoechoic small hypoechoic nodules with ill-defined margins- seems nodules with ill-defined margin- seems to represent to represent lymphocytic infiltration in chronic phase. lymphocytic infiltration in chronic phase.

9.1.41 Transverse scan - CAT – Both lobes has increased heterogeneous volume with intense diffuse parenchyma vascularization on Duplex Doppler ultrasound in chronic phase of Hashimoto's thyroiditis.

9.1.42 Transverse scan - CAT - Left lobe with increased heterogeneous volume, hypoechoic with diffuse hard stifness of parenchyma on Strain Elastography in chronic phase of Hashimoto's thyroiditis.

Chapter 10 - Graves' Disease

10.1.1 Transverse scan – GD – both lobes with heterogeneous increased volume, diffusely hypoechoic. The measurements showed an inhomogeneous, hypoechoic isthmus with large diameters (over 3 mm AP diameter) and lobulated thyroid contour.

10.1.2 Longitudinal scan – GD –Left lobe increased heterogeneous volume with micronodular structure, diffusely hypoechoic, with lobulated thyroid contour and diffuse parenchyma hypervascularization on Doppler to a patient with Graves ’ophthalmopathy.

10.1.3 Transverse scan - GD – Both lobes have increased, heterogeneous volume with macronodular structure, with small hypoechoic nodules with ill-defined margins, lobulated thyroid contour and diffuse parenchyma hypervascularization on Color Doppler mode

10.1.4 Longitudinal scan - GD - Left lobe has craniocaudal diameter increased, heterogeneous with macronodular structure with a predominance of diffuse soft stiffness of parenchyma on Strain Elastography.

10.1.5 Transverse scan - GD – Both lobes have increased heterogeneous volume with intense diffuse parenchyma vascularization on Duplex Doppler ultrasound to a patient positively detected with Thyroid-stimulating hormone receptor antibody TRAb.

10.1.6 Longitudinal scan - GD -Right lobe with increased heterogeneous volume, hypoechoic with with intense diffuse parenchyma vascularization on Duplex Doppler ultrasound with visualization of the superior and inferior thyroid arteries, due to increased velocity.

Graves disease

10.1.8 Longitudinal scan – GD –Right lobe increased 10.1.7 Transverse scan - GD - Both lobe with increased heterogeneous volume with micronodular structure, heterogeneous volume, lobulated thyroid contour with hypoechoic and intense diffuse parenchyma with marked hypervascularity -"thyroid inferno". hypervascularization on Power Doppler.

10.1.9 Transverse scan – GD – both lobes with heterogeneous increased volume, diffusely hypoechoic. The measurements showed an inhomogeneous, hypoechoic isthmus with large diameters (over 3 mm AP diameter) and lobulated thyroid contour.

10.1.10 Transverse scan – GD – Right lobe has heterogeneous increased volume with macronodular structure, diffusely hypoechoic with marked hypervascularity -"thyroid inferno" on Color Doppler mode which is a pattern for Graves' Disease.

10.1.11 Transverse scan - GD – Both lobes has increased heterogeneous volume diffusely hypoechoic with intense diffuse parenchyma vascularization -"thyroid inferno" and visualization of the superior and inferior thyroid arteries on Power Doppler ultrasound.

10.1.12 Transverse scan - GD - Both lobes with increased heterogeneous volume, diffusely hypoechoic with intense diffuse parenchyma vascularization "thyroid inferno" and visualization of the superior and inferior thyroid arteries on Color Doppler ultrasound.

Graves disease

10.1.13 Transverse scan – GD – both lobes with heterogeneous increased volume, diffusely hypoechoic. The measurements showed a homogeneous, hypoechoic isthmus with large diameters (over 3 mm AP diameter) and lobulated thyroid contour.

10.1.14 Transverse scan – GD –Left lobe has increased heterogeneous volume with micronodular structure, hypoechoic and intense diffuse parenchyma hypervascularization on Duplex Doppler. The thyroid lobes plunging towards mediastin.

10.1.15 Transverse scan - GD – Right lobe has increased heterogeneous volume with macronodular structure, with small hypoechoic nodules with ill-defined margin- seems to represent lymphocytic infiltration, hypoechoic and hypervascularization on Duplex Doppler.

10.1.16 Longitudinal scan-GD - Right lobe has increased heterogeneous volume with macronodular structure, hypoechoic and intense diffuse parenchyma hypervascularization on Duplex Doppler.

10.1.17 Transverse scan - GD – Right lobe has increased heterogeneous volume diffusely hypoechoic with intense diffuse parenchyma vascularization -"thyroid inferno" and visualization of the superior and inferior thyroid arteries on Power Doppler ultrasound.

10.1.18 Transverse scan - GD - Right lobe with increased heterogeneous volume, hypoechoic with predominantly diffuse hard stifness of parenchyma on Strain Elastography in severe forms of GD.

Graves disease

10.1.19 Transverse scan - GD – Both lobes have increased heterogeneous volume with macronodular structure, diffusely hypoechoic with small hypoechoic nodules with ill-defined margins seems to represent lymphocytic infiltration, and isthmus with enlarge diameters.

10.1.20 Longitudinal scan - GD - Right lobe has craniocaudal diameter increased, heterogeneous with macronodular structure, diffusely hypoechoic with small hypoechoic nodules with ill-defined margins, with a lobulated contour and the capsule appearing hypercogenic.

10.1.21 Transverse scan-GD- Left lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic and small hypoechoic nodules with ill-defined margins showing hypervascularization in Duplex Doppler.

10.1.22 Transverse scan-GD- Left lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic and small hypoechoic nodules with ill-defined margins showing hypervascularization in Power Doppler .

10.1.24 Transverse scan - GD - Left lobe with increased 10.1.23 Transverse scan - GD - Right lobe with increased heterogeneous volume, diffusely hypoechoic with heterogeneous volume, diffusely hypoechoic with predominantly diffuse combination of soft and hard predominantly diffuse hard stifness of parenchyma on stifness with „mosaic look” of parenchyma on Strain Strain Elastography in severe forms of GD. Elastography

Graves disease

10.1.25 Transverse scan - GD – Left lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic with small hypoechoic nodules with ill-defined margins and isthmus with enlarge diameters.

10.1.26 Longitudinal scan-GD - Left lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic and intense diffuse parenchyma hypervascularization on Duplex Doppler.

10.1.27 Transverse scan-GD- Right lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic and small hypoechoic nodules with ill-defined margins showing hypervascularization in Duplex Doppler.

10.1.28 Longitudinal scan - GD - Right lobe with increased heterogeneous volume, diffusely hypoechoic with predominantly diffuse hard stifness of parenchyma on Strain Elastography in severe forms of GD.

10.1.29 Transverse scan - GD – Right lobe has increased heterogeneous volume diffusely hypoechoic with intense diffuse parenchyma vascularization -"thyroid inferno" and visualization of the superior and inferior thyroid arteries on Power Doppler ultrasound.

10.1.30 Longitudinal scan - GD - Right lobe has craniocaudal diameter increased, heterogeneous with macronodular structure, diffusely hypoechoic with small hypoechoic nodules with ill-defined margins, with a lobulated contour and the capsule appearing hypercogenic.

Graves disease

10.1.31 Transverse scan-GD- Right lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic and small hypoechoic nodules with ill-defined margins showing hypervascularization-"thyroid inferno" in Duplex Doppler.

10.1.32 Transverse scan-GD- Right lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic and small hypoechoic nodules with ill-defined margins showing hypervascularization"thyroid inferno" in Power Doppler .

10.1.33 Transverse scan - GD – Right lobe has increased heterogeneous volume diffusely hypoechoic with intense diffuse parenchyma vascularization -"thyroid inferno" and visualization of the superior and inferior thyroid arteries on Power Doppler ultrasound.

10.1.34 Longitudinal scan-GD - Left lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic, the thyroid capsule appearing hypercogenic and intense diffuse parenchyma hypervascularization on Duplex Doppler

10.1.35 Longitudinal scan-GD - Right lobe has increased heterogeneous volume with macronodular structure, diffusely hypoechoic, the thyroid capsule appearing hypercogenic and intense diffuse parenchyma hypervascularization on Duplex Doppler

10.1.36 Transverse scan - GD - Both lobes with increased heterogeneous volume, diffusely hypoechoic with intense diffuse parenchyma vascularization "thyroid inferno" and visualization of the superior and inferior thyroid arteries on Color Doppler ultrasound.

Chapter 11 – Focal thyroid disease – TIRADS risk stratifications 11.1. Ultrasound differential diagnosis benign versus malign focal lesions Attempts to differentiate probably benign from probably malignant thyroid nodules is based on the following eight parameters: 1. Internal consistency (solid, mixed-solid, and cystic, purely cystic). 2. Echogenicity (hyperechogenic, isoechogenic, hypoechogenic). 3. Margins (smooth-well differentiated, poorly differentiated). 4. Surrounding halo (thin, thick, incomplete, no halo). 5. Calcifications (eggshell, coarse, microcalcifications). 6. Vascularization (absent, peripheral, internal flow pattern). 7. Presence or absence of abnormal lymph nodes. 8. Tumor stiffness ( soft or hard stiffness) 11.2. Ultrasound pattern of malignancy •Sonographic features associated with thyroid cancer are: 1. Solid (highest sensitivity but low positive predictive value). 2. Hypoechogenic. 3. Nodule shapes are frequently „taller than wide”. 4. Irregular margins, lobulated, extra-thyroidal extension, and absence of halo. 5. Microcalcifications, punctate echogenic foci (highest positive predictive value (PPV) but low sensitivity- feature present in 26-59% of cancers). 6. Peri or/and intranodal vascularity. 7. The presence of cervical adenopathies 8. Hard stiffness. 11.3. Ultrasound aspects of benignity and malignancy of the Thyroid Tumors (M. Iacob).

Right thyroid lobe – probably benign focal lesion

Left thyroid lobe – probably malignant focal lesions.

11.4. Dynamic evaluation of focal lesions – at a maximum of six months •Growth of nodules in dynamics more than 20% •Changing the risk category - upgrade or downgrade. •Postoperative relapse •Assessment of the dynamics of adenopathy. 11.5. TIRADS risk stratifications: Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) help differentiate between benign and malignant thyroid nodules by offering a risk stratification model. Depending on the pattern or number of suspicious ultrasound features, a fine-needle biopsy is recommended. It is a common interdisciplinary communication language and shows us the level of risk for certain focal lesions with a high risk of malignancy depending on the ultrasonographic criteria detected in the patient and the optimal time to perform the cytological examination by FNAC. Currently, this risk classification does not take into account the functional status of the thyroid, which is an important criterion. Hyperfunctioning thyroid nodules (HTNs) were presumed to exclude malignancy with a very high negative predictive value.

Several thyroid imaging reporting and data systems (TIRADS) have been proposed to stratify the malignancy risk of thyroid nodules by ultrasound. The TIRADS by the European Thyroid Association, namely EU-TIRADS, was the last one published.

Russ . Eur Thyroid J. 2017. 6(5):225 -EU- TIRADS for malignancy risk stratification

Chapter 12 – Cyst, Colloid nodule

12.1.1 Transverse scan – CC – right lobe with normal heterogeneous volume, isoechoic. It has a small welldefined anechoic cyst without calcifications or ring down artifacts. Most thyroid cysts are pseudocysts or hyperplatic nodules that have undergone degeneration, necrosis and hemorrhage.

12.1.2 Longitudinal scan – CC – right lobe with normal heterogeneous volume, isoechoic. It has a small welldefined anechoic cyst without calcifications or ring down artifacts. The differential diagnosis with the superior thyroid artery is made by Duplex Doppler by the absence of the vascular signal in the cyst.

12.1.3 Transverse scan - CC – Both lobes have normal heterogeneous volume, isoechoic with small anechoic cysts well-defined without calcifications or ring down artifacts, and no vascular signal in color Doppler.

12.1.4 Longitudinal scan - CC - Left lobe has normal cranio-caudal diameter, heterogeneous with small anechoic cysts well-defined and no vascular signal in color Doppler.

12.1.5 Transverse scan - CC – Both lobes have normal heterogeneous volume, isoechoic with small anechoic cysts well-defined without calcifications or ring down artifacts. In the left lobe there is also a small colloidal cystic node that contains a precipitated hyperechoic material.

12.1.6 Longitudinal scan - CC - Right lobe with normal heterogeneous volume, isoechoic containing a multiseptate cyst that has several rings down artifacts with no vascular signal or calcifications with normal diffuse parenchyma vascularization on Duplex Doppler.

Cyst, Colloid nodule

10.1.7 Transverse scan - CC – Right lobe has normal heterogeneous volume, isoechoic with small anechoic cysts well-defined without calcifications or ring down artifacts, and no vascular signal in color Doppler.

10.1.8 Longitudinal scan - CC - Left lobe has normal cranio-caudal diameter, heterogeneous with small anechoic cysts well-defined, which presents a ring down artifact.

10.1.10 Longitudinal scan – CC – right lobe with normal 10.1.9 Transverse scan – CC – right lobe with normal heterogeneous volume, isoechoic. It has a round wellheterogeneous volume, isoechoic. It has a round welldefined anechoic cyst without calcifications or ring defined anechoic cyst with ring down artifacts. down artifacts located laterally in the lower floor.

10.1.11 Transverse scan - CC – Both lobes have normal heterogeneous volume, isoechoic with small anechoic cysts well-defined without calcifications or ring down artifacts. In the right lobe there is also a small colloidal cystic node that contains a precipitated hyperechoic material.

10.1.12 Longitudinal scan - CC - Left lobe has normal cranio-caudal diameter, heterogeneous with small anechoic cysts well-defined and near a small colloidal cystic node that contains a precipitated hyperechoic material and no vascular signal in color Doppler.

Cyst, Colloid nodule

10.1.13 Transverse scan – CC – right lobe with normal heterogeneous volume, isoechoic. It has a large oval anechoic cyst that compresses part of the right thyroid gland, well-defined, without calcifications or ring down artifacts.

10.1.14 Longitudinal scan – CC – right lobe with normal heterogeneous volume, isoechoic. It has a large oval anechoic cyst that compresses the lower floor of the right thyroid lobe, well-defined, without calcifications or ring down artifacts.

10.1.15 Longitudinal scan – CC – right lobe with normal heterogeneous volume, isoechoic. It has a large oval anechoic cyst that compresses the lower floor of the right thyroid lobe, well-defined, without vascular signal.

10.1.16 Longitudinal scan - CC - Left lobe has normal cranio-caudal diameter, heterogeneous with small anechoic cysts well-defined and no vascular signal in color Doppler.

10.1.17 Transverse scan - CC – Right lobe has normal 10.1.18 Transverse scan - CC – Right lobe has normal heterogeneous volume, isoechoic with small anechoic heterogeneous volume, isoechoic with small anechoic cysts well-defined with ring down artifacts and no cysts well-defined with ring down artifacts. vascular signal in color Doppler.

12.1.19 Transverse scan – CC – Left lobe with normal heterogeneous volume, isoechoic. It has a large round anechoic cyst that compresses part of the left thyroid gland, well-defined, without calcifications or ring down artifacts.

12.1.20 Transverse scan – CC – Left lobe with normal heterogeneous volume, isoechoic has a large round anechoic cyst that compresses part of the left thyroid gland, well-defined, without calcifications, ring down artifacts and vascular signal on Color Doppler.

12.1.21 Longitudinal scan - CC - Left lobe has normal cranio-caudal diameter, heterogeneous, isoechoic with a round anechoic cysts well-defined without calcifications, and ring down artifacts.

12.1.22 Longitudinal scan - CC - Left lobe has normal cranio-caudal diameter, heterogeneous with a round anechoic cysts well-defined presenting soft stiffness of the entire parenchyma and partial lack of signal and bordered with soft stiffness around the colloid cyst which is a typical pattern in Strain Elastography.

12.1.23 Transverse scan - CC – Left lobe has normal heterogeneous volume, isoechoic with small anechoic cysts well-defined which contains a precipitated hyperechoic material peripherally bordered by a thickened capsule with increased vascularization.

12.1.24 Transverse scan - CC – Left lobe has normal heterogeneous volume, isoechoic with small anechoic cysts well-defined which contains a precipitated hyperechoic material peripherally bordered by a thickened capsule with increased vascularization on Power Doppler.

12.2.1 Transverse scan – SC –Left lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule with internal microcystic appearance involving more than 50% of the lesion. The nodule has a classic spongiform shape with a honeycomb pattern.

12.2.2 Transverse scan – SC –Left lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule with internal microcystic appearance with a honeycomb pattern vascularized centrally and peripherally on Power Doppler.

12.2.3 Longitudinal scan - SC –Left lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule with internal microcystic appearance with a honeycomb pattern, well-defined, and vascularized centrally and peripherally on color Doppler.

12.2.4 Longitudinal scan - SC –Left lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule with internal microcystic appearance presenting soft stiffness of the entire spongiform cyst, and bordered peripherally with hard stiffness around the nodule which is a typical pattern on Strain Elastography.

12.2.5 Transverse scan - SC –Right lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule with internal microcystic appearance with a honeycomb pattern, well-defined, and vascularized peripherally on color Doppler.

12.2.6 Longitudinal scan - CC - Right lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule with internal microcystic appearance with a honeycomb pattern, well-defined, located in the middle floor.

Spongiform nodule, colloid nodule

10.2.7 Transverse scan - SC –Right lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule with internal microcystic appearance with a honeycomb pattern, well-defined, and vascularized peripherally on Power Doppler.

10.2.9 Transverse scan – SC –Right lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule with internal microcystic appearance with a honeycomb pattern, well-defined, and vascularized peripherally on Color Doppler.

10.2.11 Transverse scan - CC – left lobe has heterogenous increased volume, containing a very large, well-defined colloidal cyst containing a peripheral hyperechoic precipitate, with ring down artifact and compressing the surrounding parenchyma.

10.2.8 Longitudinal scan - SC –Left lobe with normal heterogeneous volume, isoechoic which contains a spongiform cyst presenting soft stiffness of the entire nodule, and bordered peripherally with hard stiffness which is a typical pattern on Strain Elastography with SR 0.51

10.2.10 Transverse scan - SC – right lobe with normal heterogeneous volume, isoechoic which contains a spongiform benign nodule presenting soft stiffness and bordered peripherally with hard stiffness which is a typical pattern on Strain Elastography.

10.2.12 Transverse scan - CC – left lobe has heterogenous increased volume, containing a very large colloidal cyst containing a peripheral hyperechoic precipitate, compressing the surrounding parenchyma inside with soft stiffness and peripheral hard stiffness all around and at the level of the precipitated colloid.

Chapter 13 – Benign nodules: Hyperplastic nodules, Follicular adenomas, Hashimoto thyroiditis nodules, Subacute thyroiditis nodules

13.1.2 Longitudinal scan – Follicular adenoma – right 13.1.1 Transverse scan – Follicular adenoma – right lobe lobe with normal heterogeneous volume, isoechoic. It with normal heterogeneous volume, isoechoic. It has a has a homogeneous, hypoechoic solid nodule, with homogeneous, hypoechoic solid nodule, with well-defined well-defined margins, with thin halo, more „wider than regular margins, more wider than tall. tall” shape and nonvascularized on color Doppler.

13.1.3 Transverse scan – Follicular adenoma – right lobe with normal heterogeneous volume, isoechoic. It has a homogeneous, hypoechoic solid nodule, with well-defined regular margins, more wider than tall, and no vascular signal in color Doppler.

13.1.4 Longitudinal scan - Follicular adenoma –Right lobe with normal heterogeneous volume, isoechoic presenting homogeneous soft stiffness of the entire hypoechoic solid nodule, on Strain Elastography with SR 0.26.

13.1.5 Transverse scan – Follicular adenoma – left lobe with normal heterogeneous volume, isoechoic. It has a homogeneous, hypoechoic solid nodule, with well-defined regular margins, more wider than tall, and no vascular signal in color Doppler.

13.1.6 Transverse scan - Follicular adenoma – left lobe with normal heterogeneous volume, isoechoic. It has a homogeneous, hypoechoic solid nodule, with welldefined margins, with thin halo, more „wider than tall” shape and nonvascularized on color Doppler.

Benign nodules

13.1.7 Longitudinal scan scan - Follicular adenoma – Left lobe has normal heterogeneous volume, isoechoic with small homogeneous, hypoechoic solid nodule, welldefined, with peripheral vascularization type 2 at color Doppler.

13.1.8 Longitudinal scan - Follicular adenoma – Left lobe has normal heterogeneous volume, isoechoic with small homogeneous, hypoechoic solid nodule, welldefined, with predominance of soft stiffness RAGO 2, SR=1,02 at the Strain Elastography.

13.1.9 Transverse scan – Hyperplastic nodule – left lobe with normal heterogeneous volume, isoechoic. It has a homogeneous, isoechoic solid nodule, more „wider than tall” shape, with well-defined regular margins and thin halo, located laterally in the lower floor.

13.1.10 Longitudinal scan– Hyperplastic nodule – left lobe with normal heterogeneous volume, isoechoic with a homogeneous, isoechoic solid nodule, with welldefined regular margins, more „wider than tall” shape, located laterally in the lower floor.

13.1.11 Transverse scan – Hyperplastic nodule – left lobe with normal heterogeneous volume, isoechoic. It has a homogeneous, isoechoic solid nodule, more „wider than tall” shape, with well-defined regular margins and thin halo, located laterally in the lower floor, with peripheral vascularization (type 2) at color Doppler.

13.1.12 Transverse scan – Hyperplastic nodule – Left lobe has normal heterogeneous volume, isoechoic with small homogeneous, isoechoic solid nodule, welldefined, with predominance of soft stiffness RAGO1, SR=0.56 at the Strain Elastography.

Benign nodules

13.1.13 Transverse scan – Hyperplastic nodule – left lobe with normal heterogeneous volume, isoechoic with a homogeneous, isoechoic solid nodule, more „wider than tall” shape, with well-defined regular margins and thin halo, located medially in the lower floor.

13.1.14 Longitudinal scan– Hyperplastic nodule – left lobe with normal heterogeneous volume, isoechoic with a homogeneous, isoechoic solid nodule, with welldefined regular margins, more „wider than tall” shape, located medially in the lower floor.

13.1.15 Transverse scan – Hyperplastic nodule – Right lobe with normal heterogeneous volume, isoechoic with a homogeneous, isoechoic solid nodule, more „wider than tall” shape, with well-defined regular margins and thin halo, located laterally in the lower floor, with peripheral vascularization (type 2) at color Doppler.

13.1.16 Longitudinal scan - Hyperplastic nodule – Right lobe has normal heterogeneous volume, isoechoic with small homogeneous, isoechoic solid nodule, welldefined, with predominance of soft stiffness RAGO 1, SR=0,61 at the Strain Elastography.

13.1.17 Transverse scan – Follicular adenoma – right lobe with normal heterogeneous volume, isoechoic with a homogeneous, hypoechoic solid nodule, well-defined regular margins, thin halo, more „wider than tall” shape, located medially in the middle floor.

13.1.18 Longitudinal scan – Follicular adenoma – right lobe with normal heterogeneous volume, isoechoic with a homogeneous, hypoechoic solid nodule, with well-defined margins, with thin halo, more „wider than tall” shape, located medially in the middle floor.

Benign nodules

13.1.19 Transverse scan – Follicular adenoma – right lobe with normal heterogeneous volume, isoechoic with a homogeneous, hypoechoic solid nodule, more „wider than tall” shape, with well-defined regular margins and thin halo, located located medially in the middle floor, with peripheral vascularization (type 2) at color Doppler.

13.1.20 Longitudinal scan - Follicular adenoma – Right lobe has normal heterogeneous volume, isoechoic with small homogeneous, hypoechoic solid nodule, welldefined, with predominance of soft stiffness RAGO 2, SR=1,02 at the Strain Elastography.

13.1.21 Transverse scan – Hyperplastic nodule – left lobe with normal heterogeneous volume, isoechoic with a homogeneous, isoechoic solid nodule, round shape, welldefined regular margins and thin halo, located laterally in the middle floor, with peripheral vascularization (type 2) at color Doppler.

13.1.22 Longitudinal scan– Hyperplastic nodule – left lobe with normal heterogeneous volume, isoechoic with a homogeneous, isoechoic solid nodule, with welldefined regular margins, round shape, located laterally in the middle floor and peripheral vascularization (type 2) at color Doppler.

13.1.23 Transverse scan – Hyperplastic nodule – left lobe with normal heterogeneous volume, isoechoic. It has a homogeneous, isoechoic solid nodule, round shape, with well-defined regular margins, with peripheral vascularization (type 2) at color Doppler.

13.1.24 Transverse scan – Hyperplastic nodule – Left lobe has normal heterogeneous volume, isoechoic with small homogeneous, isoechoic solid nodule, welldefined, with predominance of soft stiffness RAGO 2, SR=1.08 at the Strain Elastography.

Benign nodules

13.1.25 Transverse scan – Follicular adenoma – left lobe with normal heterogeneous volume, hypoechoic with a inhomogeneous, hypoechoic solid nodule, with a small central necrosis, well-defined margins, more „taller than wide” shape, located laterally in the upper floor.

13.1.26 Longitudinal scan– Follicular adenoma – left lobe with normal heterogeneous volume, isoechoic with a inhomogeneous, hypoechoic solid nodule, with a small area of central necrosis, well-defined regular margins, more „taller than wide” shape, located laterally in the upper floor. Follow-up at 6 months.

13.1.27 Longitudinal scan– Follicular adenoma – left lobe with normal heterogeneous volume, isoechoic with a inhomogeneous, hypoechoic solid nodule, with a small central necrosis, well-defined margins, more „taller than wide” shape, located laterally in the upper floor, with peripheral vascularization (type 2) at Power Doppler.

13.1.28 Longitudinal scan - Follicular adenoma – Left lobe has normal heterogeneous volume, isoechoic with small homogeneous, hypoechoic solid nodule, welldefined, with predominance of soft stiffness RAGO 1, SR=1.05 at the Strain Elastography.

13.1.29 Transverse scan – Follicular adenoma – both lobes with normal heterogeneous volume, isoechoic with a homogeneous, hypoechoic solid nodules, well-defined regular margins, thin halo, more „wider than tall” shape, located laterally in the lower floor.

13.1.30 Longitudinal scan – Follicular adenoma – right lobe with normal heterogeneous volume, isoechoic with a homogeneous, hypoechoic solid nodule, with well-defined margins, with thin halo, more „wider than tall” shape, located laterally in the lower floor..

Benign nodules

13.1.31 Transverse scan – Follicular adenoma – left lobe with normal heterogeneous volume, very hypoechoic with a homogeneous, hypoechoic solid nodule, round shape, well-defined regular margins with complete eggshell calcification, located laterally in the middle floor, with peripheral vascularization (type 2) at Color Doppler.

13.1.32 Longitudinal scan– Follicular adenoma – left lobe with normal heterogeneous volume, isoechoic with a homogeneous, very hypoechoic solid nodule, roundshape, with complete eggshell calcification which produced acoustic shadow and predominance of hard stiffness RAGO 4, SR=3.84 at the Strain Elastography.

13.1.33 Transverse scan– macrocalcifications – left lobe with normal heterogeneous volume, isoechoic with a complete eggshell calcification and posterior acoustic shadowing produced by the calcific ring.

13.1.34 Longitudinal scan - macrocalcifications – Left lobe has normal heterogeneous volume, isoechoic with small nodule with eggshell calcification and posterior acoustic shadowing with normal vascularization of the parenchyma at the color Doppler.

13.1.36 Transverse scan – macrocalcifications – left 13.1.35 Longitudinal scan - macrocalcifications – Left lobe lobe with normal heterogeneous volume, isoechoic has normal heterogeneous volume, isoechoic with small with a complete eggshell calcification and posterior nodule with eggshell calcification and posterior acoustic acoustic shadowing produced by the calcific ring with hard stiffness at Strain Elastography (blue coded). shadowing.

Benign nodules: Hashimoto thyroiditis nodules

13.2.1 Transverse scan – Hashimoto's nodule – left lobe with increased heterogeneous volume, hyperechoic with a homogeneous, hypoechoic solid nodule, round shape, with well-defined regular margins and thin halo, located medially in the middle floor, in a patient diagnosed with chronic Hashimoto's thyroiditis.

13.2.2 Transverse scan – Hashimoto's nodule – left lobe with increased heterogeneous volume, hyperechoic with a homogeneous, hypoechoic solid nodule, round shape, with well-defined regular margins, located medially in the middle floor, with peripheral vascularization (type 2) at color Doppler.

13.2.3 Longitudinal scan- Hashimoto's nodule – left lobe with increased heterogeneous volume, hyperoechoic with a homogeneous, hypoechoic solid nodule and cystic degeneration round shape, with well-defined regular margins, located medially in the middle floor, with peripheral vascularization (type 2) at color Doppler.

13.2.4 Longitudinal scan - Hashimoto's nodule – Left lobe has normal heterogeneous volume, hyperechoic with small homogeneous, hypoechoic solid nodule, well-defined, with predominance of soft stiffness RAGO 1, SR=0,90 at the Strain Elastography. The rest of the parenchyma has predominantly hard stiffness, being a chronic thyroiditis.

13.2.5 Transverse scan – Hashimoto's nodule – right lobe with increased heterogeneous volume, hyperoechoic with a homogeneous, hypoechoic solid nodule, round shape, with well-defined regular margins and thin halo, with peripheral vascularization (type 2) at color Doppler.

13.2.6 Transverse scan – Hashimoto's nodule – Right lobe has normal heterogeneous volume, isoechoic with small homogeneous, isoechoic solid nodule, welldefined, with predominance of soft stiffness RAGO 1, SR=1.46 at the Strain Elastography.

Benign nodules: Hashimoto thyroiditis nodules

13.2.7 Transverse scan – Hashimoto's nodule – right lobe with increased heterogeneous volume, hyperechoic with a homogeneous, isoechoic solid nodule, round shape, with well-defined regular margins, located laterally in the lower floor, in a patient with chronic Hashimoto's thyroiditis.

13.2.8 Longitudinal scan – Hashimoto's nodule – right lobe with normal heterogeneous volume, isoechoic with a homogeneous, isoechoic solid nodule, with well-defined margins, with thin halo, round shape, located laterally in the lower floor.

13.2.9 Longitudinal scan- Hashimoto's nodule – left lobe with increased heterogeneous volume, hyperechoic with a homogeneous, isoechoic solid nodule, round shape, with well-defined regular margins, with peripheral vascularization (type 2) at color Doppler.

13.2.10 Longitudinal scan - Hashimoto's nodule – Left lobe has normal heterogeneous volume, hyperechoic with a homogeneous, isoechoic solid nodule, welldefined, with the predominance of soft stiffness RAGO 1, SR=0,51 at the Strain Elastography. The rest of the parenchyma has predominantly hard stiffness.

13.2.11 Transverse scan – Hashimoto's nodule – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hyperechoic solid nodule, with an irregular shape, with irregular margins, and the presence of fibrous septa and glandular atrophy, with peripheral vascularization (type 2) at color Doppler.

13.2.12 Longitudinal scan – Hashimoto's nodule – right lobe with normal heterogeneous volume, isoechoic with an inhomogeneous, hyperechoic solid nodule, with irregular shape, with irregular margins, and the presence of fibrous septa and glandular atrophy, located medially in the middle floor.

Benign nodules: Hashimoto thyroiditis nodules

13.2.13 Longitudinal scan – Hashimoto's nodule – right lobe with increased heterogeneous volume, isoechoic with an inhomogeneous, hyperechoic solid nodule, with irregular shape, with irregular margins, and the presence of fibrous septa and glandular atrophy, with peripheral vascularization (type 2) at color Doppler.

13.2.14 Longitudinal scan - Hashimoto's nodule – Right lobe has increased heterogeneous volume, hyperechoic with an inhomogeneous, hyperechoic solid nodule, with irregular margins, with the predominance of soft stiffness RAGO 1, SR=0,95 at the Strain Elastography.

13.2.15 Transverse scan - Hashimoto's nodules – left lobe with decreased heterogeneous volume, hyperechoic with an inhomogeneous, hyperechoic solid nodule and cystic degeneration, round shape, with well-defined regular margins, located laterally in the lower floor, with peripheral vascularization (type 2) at color Doppler.

13.2.16 Transverse scan – Hashimoto's nodules – left lobe has decreased heterogeneous volume, isoechoic, with an inhomogeneous, hyperechoic solid nodule, round shape, with well-defined, with predominance of soft stiffness RAGO 3, at the Strain Elastography. The rest of the parenchyma has hard stiffness.

13.2.17 Longitudinal scan - Hashimoto's nodules – left lobe with decreased heterogeneous volume, hyperechoic with an inhomogeneous, hyperechoic solid nodule and cystic degeneration, round shape, with well-defined regular margins, located laterally in the lower floor.

13.2.18 Longitudinal scan – Hashimoto's nodules – left lobe with decreased heterogeneous volume, hyperechoic with an inhomogeneous, hyperechoic solid nodule and cystic degeneration, round shape, with welldefined regular margins, with predominance of soft stiffness RAGO 1, SR=1.46 at the Strain Elastography.

Chapter 14 – Malignant tumors: papillary carcinomas, follicular carcinomas, medullary carcinomas, anaplastic thyroid cancer, Hurthle-cell carcinoma

14.1.1 Transverse scan – Papillary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, „taller than wide” shape, with irregular spiculated margins, lobulated, and microcalcifications, located laterally in the lower floor.

14.1.2 Longitudinal scan – Papillary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, with irregular spiculated margins, lobulated, and microcalcifications, located laterally in the lower floor.

14.1.3 Transverse scan – Papillary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, lobulated, and the presence of microcalcifications, with hypervascularization of the entire nodule (type 3) at Power Doppler mode.

14.1.4 Transverse scan – Papillary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, lobulated, with hard stiffness RAGO=5, SR=3,44, at the Strain Elastography. The rest of the parenchyma has predominantly hard stiffness.

14.1.5 Transverse scan – Papillary carcinomas – detected in right lobe an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, lobulated, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.6 Longitudinal scan – Papillary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, lobulated, with hypervascularization of the entire nodule (type 3) at Power Doppler mode.

Malignant tumors

14.1.7 Transverse scan – Papillary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, with irregular margins, and the presence of microcalcifications, located laterally in the lower floor.

14.1.8 Longitudinal scan – Papillary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, with irregular margins, lobulated, and microcalcifications, located laterally in the lower floor.

14.1.9 Transverse scan – Papillary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, with irregular margins, the presence of microcalcifications and extracapsular extension.

14.1.10 Transverse scan – Papillary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, lobulated, with hard stiffness RAGO=5, SR=2.96, at the Strain Elastography. The rest of the parenchyma has hard stiffness.

14.1.11 Transverse scan – Papillary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, with irregular margins, and the presence of microcalcifications, with moderate peripheral and intranodal vascularization (type 3) at color Doppler mode.

14.1.12 Longitudinal scan – Papillary carcinomas – detected in the right lobe an inhomogeneous, hypoechoic solid nodule, round shape, with irregular margins, and the presence of microcalcifications, with moderate peripheral and intranodal vascularization (type 3) at color Doppler mode.

Malignant tumors

14.1.13 Transverse scan – Papillary carcinomas – left lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, very hypoechoic solid nodule, more „taller than wide” shape, irregular margins, and with microcalcifications, located laterally in the lower floor.

14.1.14 Longitudinal scan – Papillary carcinomas – left lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, very hypoechoic solid nodule, „taller than wide” shape, with irregular margins, and microcalcifications, located laterally in the lower floor.

14.1.15 Transverse scan – Papillary carcinomas – detected in left lobe an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.16 Longitudinal scan –Papillary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with hard stiffness RAGO=5, SR=3.33, at the Strain Elastography. The rest of the parenchyma has soft stiffness.

14.1.17 Longitudinal scan – Papillary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, 14.1.18 Longitudinal scan – Papillary carcinomas – more „taller than wide” shape, irregular margins, Laterocervical secondary lymphadenopathy was lobulated, with hypervascularization of the entire nodule detected at Color Doppler mode. (type 3) at Color Doppler mode.

Malignant tumors

14.1.19 Transverse scan – Follicular carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, and with microcalcifications, located laterally in the middle floor.

14.1.20 Longitudinal scan – Folicullar carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, with irregular margins, and microcalcifications, located laterally in the middle floor.

14.1.21 Transverse scan – Follicular carcinomas – detected in right lobe an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.22 Transverse scan – Follicular carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, with hard stiffness RAGO=5, at the Strain Elastography. The rest of the parenchyma has soft stiffness.

14.1.23 Transverse scan – Follicular carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, and with microcalcifications, located laterally in the middle floor.

14.1.24 Longitudinal scan – Papillary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, lobulated, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

Malignant tumors

14.1.25 Transverse scan – Follicular carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, very hypoechoic solid nodule, round shape, irregular margins, and with microcalcifications, located laterally in the upper floor.

14.1.26 Longitudinal scan – Follicular carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, very hypoechoic solid nodule, round shape, with irregular margins, and microcalcifications, located laterally in the lower floor.

14.1.27 Transverse scan – Follicular carcinomas – detected in right lobe an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.28 Longitudinal scan – Follicular carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with hard stiffness RAGO=5, SR=2.86, at the Strain Elastography. The rest of the parenchyma has soft stiffness.

14.1.29 Longitudinal scan – Follicular carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, lobulated, with hypervascularization of the entire nodule (type 3) at Power Doppler mode.

14.1.30 Longitudinal scan – Follicular carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, lobulated, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

Malignant tumors

14.1.31 Transverse scan – Papillary carcinomas – left lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins and with presence of microcalcifications, located laterally in the middle floor.

14.1.32 Longitudinal scan – Papillary carcinomas – left lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, with irregular margins, and microcalcifications, located laterally in the middle floor.

14.1.33 Transverse scan – Papillary carcinomas – detected in left lobe an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.34 Transverse scan – Papillary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with hard stiffness RAGO=5, SR=3.53, at the Strain Elastography. The rest of the parenchyma has soft stiffness.

14.1.35 Transverse scan – Papillary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with microcalcifications, with hypervascularization of the entire nodule (type 3) at Power Doppler mode.

14.1.36 Longitudinal scan – Papillary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

Malignant tumors

14.1.37 Transverse scan – Follicular carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, and with microcalcifications, located laterally in the middle floor.

14.1.38 Longitudinal scan – Folicullar carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, with irregular margins, and microcalcifications, located laterally in the middle floor.

14.1.39 Transverse scan – Follicular carcinomas – detected in right lobe an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, extracapsular extension with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.40 Transverse scan – Follicular carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, with hard stiffness RAGO=5, SR=2.19 at the Strain Elastography. The rest of parenchyma has soft stiffness.

14.1.41 Transverse scan – Follicular carcinomas –detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, extracapsular extension, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.42 Transverse scan – Follicular carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape and irregular margins. An enlarged area of necrosis was detected which is a pattern for malignant tumors, which can give wrong values to SR. Nodule with hard stiffness RAGO=5.

Malignant tumors

14.1.43 Transverse scan – Medullary carcinomas – left lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, extrathyroidal extension and with central dense shadowing calcifications, located laterally in the lower floor.

14.1.44 Longitudinal scan – Medullary carcinomas – left lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, with irregular margins, and central dense shadowing calcifications, located laterally in the lower floor.

14.1.45 Transverse scan –Medullary carcinomas – detected in left lobe an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, central coarse calcifications, with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.46 Transverse scan – Medullary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, central coarse calcifications, acoustic shadowing, with hard stiffness RAGO=5, SR=3.92 at the Strain Elastography.

14.1.47 Transverse scan – Medullary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, with central dense shadowing calcifications, with hypervascularization of the entire nodule (type 3)

14.1.48 Transverse scan – Medullary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, extrathyroidal extension, with hypervascularization of the entire nodule (type 3) at PowerDoppler mode.

Malignant tumors

14.1.49 Transverse scan – Medullary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, and with central dense shadowing calcifications, located laterally in the middle floor.

14.1.50 Longitudinal scan – Medullary carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, with irregular margins, and central dense shadowing calcifications, located laterally in the middle floor.

14.1.51 Transverse scan –Medullary carcinomas – detected in right lobe an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, central coarse calcifications, with moderate vascularization of the entire nodule (type 3) at Doppler.

14.1.52 Transverse scan – Medullary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, central coarse calcifications, acoustic shadowing, with hard stiffness RAGO=5, SR=2.88 at the Strain Elastography.

14.1.53 Transverse scan – Medullary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, with central coarse calcifications in right lobe with increasing serum thyrocalcitonin levels.

14.1.54 Transverse scan – Medullary carcinomas – detected an inhomogeneous, hypoechoic solid nodule, more „taller than wide” shape, irregular margins, with hypervascularization of the entire nodule (type 3) at Power Doppler mode.

Malignant tumors

14.1.55 Transverse scan – Hurthle cell carcinomas – left lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins and extra-thyroidal extension located laterally in the upper floor.

14.1.56 Longitudinal scan – Hurthle cell carcinomas – left lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, with irregular margins, and extra-thyroidal extension, located laterally in the upper floor.

14.1.57 Transverse scan – Hurthle cell carcinomas – detected in left lobe an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, extra-thyroidal extension, with hypervascularization of the entire nodule (type 3) at Doppler.

14.1.58 Transverse scan – Hurthle cell carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, extra-thyroidal extension, with hard stiffness RAGO=5, SR=7.84 at the Strain Elastography.

14.1.59 Transverse scan – Hurthle cell carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with extra-thyroidal extension with an extensive area of tumor necrosis that appears anechoic.

14.1.60 Transverse scan – Hurthle cell carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, extracapsular extension, with hypervascularization of the entire nodule (type 3) at Power Doppler mode.

Malignant tumors

14.1.61 Transverse scan – Hurthle cell carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, isoechoic solid nodule, round shape, irregular margins and extra-thyroidal extension located laterally in the lower floor.

14.1.62 Longitudinal scan – Hurthle cell carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, isoechoic solid nodule, round shape, with irregular margins, and extrathyroidal extension, located laterally in the lower floor.

14.1.57 Longitudinal scan – Hurthle cell carcinomas – detected in right lobe an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, extrathyroidal extension, with moderate vascularization of the entire nodule (type 3) at Doppler.

14.1.59 Transverse scan – Hurthle cell carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, extra-thyroidal extension with moderate peripheral nodular vascularization (type 2) at Color Doppler mode.

14.1.60 Transverse scan – Hurthle cell carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, extracapsular extension, with moderate vascularization of the entire nodule (type 3) at Power Doppler mode.

Malignant tumors

14.1.37 Transverse scan – Follicular carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, and with microcalcifications, located laterally in the middle floor.

14.1.38 Longitudinal scan – Folicullar carcinomas – right lobe with increased heterogeneous volume, hyperechoic with an inhomogeneous, hypoechoic solid nodule, round shape, with irregular margins, and microcalcifications, located laterally in the middle floor.

14.1.39 Transverse scan – Follicular carcinomas – detected in right lobe an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, extracapsular extension with hypervascularization of the entire nodule (type 3) at Color Doppler mode.

14.1.40 Longitudinal scan scan – Follicular carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with hard stiffness RAGO=4, SR=3.72 at the Strain Elastography. The rest of parenchyma has soft stiffness.

14.1.41 Transverse scan – Follicular carcinomas –detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, extracapsular extension, with hypervascularization of the entire nodule (type 3) at Power Doppler mode.

14.1.42 Longitudinal scan – Follicular carcinomas – detected an inhomogeneous, hypoechoic solid nodule, round shape, irregular margins, with hard stiffness RAGO=4, SR=3.34 at the Strain Elastography.

Chapter 15. Parathyroid pathology

14.1.1 Transverse scan – Parathyroid adenoma – right lobe with normal homogeneous volume, isoechoic with a homogeneous, very hypoechoic solid nodule, round shape, well-defined regular margins, located medially in the lower floor, outside the thyroid capsule and below it.

14.1.2 Longitudinal scan - Parathyroid adenoma – right lobe with normal homogeneous volume, isoechoic with a homogeneous, very hypoechoic solid nodule, round shape, well-defined, located medially in the lower floor, outside the thyroid capsule and posterior to it.

14.1.3 Longitudinal scan - Parathyroid adenoma – detected a very hypoechoic solid nodule, round shape, well-defined regular margins, located medially in the lower floor, outside the thyroid capsule and posterior to it, with peripheral vascularization (type 2) at Doppler.

14.1.4 Longitudinal scan - Parathyroid adenoma – detected a very hypoechoic solid nodule, round shape, well-defined regular margins, located medially in the lower floor, posterior of the thyroid capsule, with hard stiffness RAGO=3, SR=1.52 at the Strain Elastography.

14.1.6 Transverse scan – Parathyroid adenoma – 14.1.5 Transverse scan – Parathyroid adenoma – detected detected a very hypoechoic solid nodule, round shape, a very hypoechoic solid nodule, round shape, well-defined well-defined, located medially in the lower floor, regular margins, located medially in the lower floor of outside and below of the thyroid capsule, with hard right lobe, outside the thyroid capsule and below it. stiffness RAGO=3, at the Strain Elastography.

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Parathyroid pathology

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14.1.7 Transverse scan – Parathyroid adenoma – right lobe with normal heterogeneous volume, hyperechoic with a homogeneous, very hypoechoic solid nodule, round shape, well-defined regular margins, located medially in the middle floor, outside the thyroid capsule and below it.

14.1.8 Longitudinal scan - Parathyroid adenoma – right lobe with normal heterogeneous volume, hyperechoic with a homogeneous, hypoechoic solid nodule, round shape, well-defined, located medially in the middle floor, outside the thyroid capsule and posterior to it.

14.1.9 Longitudinal scan - Parathyroid adenoma – detected a hypoechoic solid nodule, round shape, regular margins, located medially in the middle floor, outside the thyroid capsule and posterior to it, with peripheral moderate vascularization (type 2) at the Color Doppler.

14.1.10 Longitudinal scan - Parathyroid adenoma – detected a hypoechoic solid nodule, round shape, welldefined regular margins, located medially in the middle floor, posterior of the thyroid capsule, with hard stiffness RAGO=4, SR=2.51 at the Strain Elastography.

14.1.11 Longitudinal scan – Parathyroid adenoma – right lobe with normal heterogeneous volume, hyperechoic with a homogeneous, very hypoechoic solid nodule, round shape, well-defined, located medially in the middle floor, outside the thyroid capsule and posterior to it, with hypervascularization of the entire parenchyma.

14.12 Longitudinal scan – Parathyroid adenoma – both lobes with normal heterogeneous volume, hyperechoic with a homogeneous, hypoechoic solid nodule, round shape, well-defined, located medially in the middle floor, outside the thyroid capsule and posterior to it, with hypervascularization of the entire parenchyma.

Parathyroid pathology

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14.1.13 Transverse scan – Parathyroid adenoma – right lobe with normal homogeneous volume, isoechoic with a homogeneous, very hypoechoic solid nodule, round shape, well-defined regular margins, located medially in the lower floor, outside the thyroid capsule and below it.

14.1.14 Longitudinal scan - Parathyroid adenoma – right lobe with normal homogeneous volume, isoechoic with a homogeneous, very hypoechoic solid nodule, round shape, well-defined, located medially in the lower floor, outside the thyroid capsule and posterior to it.

14.1.15 Longitudinal scan - Parathyroid adenoma – detected a very hypoechoic solid nodule, round shape, well-defined regular margins, located medially in the lower floor, outside the thyroid capsule and posterior to it, with peripheral vascularization (type2) at ColorDoppler.

14.1.16 Longitudinal scan - Parathyroid adenoma – detected a very hypoechoic solid nodule, round shape, well-defined regular margins, located medially in the lower floor, posterior of the thyroid capsule, with hard stiffness RAGO=4, SR=1.52 at the Strain Elastography.

14.1.17 Transverse scan – Parathyroid adenoma – detected a very hypoechoic solid nodule, round shape, well-defined regular margins, located medially in the lower floor of right lobe, outside the thyroid capsule with peripheral hypervascularization (type2) at Color Doppler.

14.1.18 Transverse scan – Parathyroid adenoma – detected a very hypoechoic solid nodule, round shape, well-defined, located medially in the lower floor, outside and below of the thyroid capsule.

14.2. Parathyroid pathology. Although the normal parathyroid gland is not usually seen on ultrasound, parathyroid lesions such as hyperplasia, adenomas, or cysts may be seen near the posterior or inferior thyroid lobe. Parathyroid cysts appear as anechoic lesions located posterior and inferior to the thyroid lobes. Usually, parathyroid adenoma appears as a well-circumscribed, round, or oval hypoechoic node. Not common, but parathyroid adenoma can develop cystic degeneration and may contain calcifications, and if this type of pathology is also present, it can lead to a misdiagnosis. We can detect by multimodal ultrasound in thyroid adenomas: a peripheral hypervascularization and also an increase in tissue stiffness appearing entirely with hard-stiffness of the lesion.

Final remarks

Ultrasonography proves to be a very efficient method with a high value in thyroid screening with very good accuracy for the early detection of diffuse diseases and tumors of the thyroid in the asymptomatic stage. Performing Doppler triplex ultrasound besides Strain Elastography has the best sensitivity and specificity in differentiating benign versus malignant thyroid tumors in primary care. Finding at the ultrasound scan of markers for thyroid malignancies: ► Inhomogeneous solid tumor. ► The marked hypoechogenicity. ► Irregular margins, spiculate or lobular contour ► The presence of microcalcifications or central course calcifications. ► Oval - "taller than wide„ shape ► Entire nodule hypervascularization (type 3 vasculature). ► Hard-stiffness of entire nodule with SR more than 3 at strain elastography. ►The presence of cervical lymph nodes. If there is a suspicion of thyroid malignancy then the FNA is required to diagnose or exclude it as the Gold-Standard diagnostic method. Shear-wave Elastography will bring additional elements in the future but is an expensive method. We believe that actually in primary care it will be useful to use only the Strain Elastography as a means of electronically palpating the tumors for determining tissue stiffness. The diagnostic performance of thyroid ultrasound may be limited by the various imaging traps associated with ultrasonographic techniques, the performance, and the misinterpretation of normal structures or non-thyroid lesions. We invite you to examine clinically-ultrasound each patient who has an increased risk of thyroid pathology and will be surprised to find that more than 40% of them may have focal or diffuse thyroid disease mostly will be benign conditions requiring their investigation subsequent in specialty services.

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Atlas of Thyroid Ultrasound Images - Author: Dr. Mihai-Sorin Iacob, MD ISBN 978-973-39-0923-1

Articles inside

Chapter 12 – Cyst, Colloid nodule

Chapter 15. Parathyroid pathology

Chapter 13 – Benign nodules: Hyperplastic nodules, Follicular adenomas, Hashimoto thyroiditis nodules, Subacute thyroiditis nodules

Chapter 11 – Focal thyroid disease – TIRADS risk stratifications

Chapter 10 - Graves disease

Chapter 3 – Thyroid multimodal ultrasonography

Chapter 9 - Chronic autoimmune Hashimoto's thyroiditis

Chapter 5 - Diffuse thyroid disease

Chapter 2 – Ultrasound thyroid semiology

Chapter 4 - Thyroid pathology : diffuse and focal thyroid diseases

Chapter 7 - Multinodular goiter (MNG

Chapter 8 – Acute and subacute thyroiditis

Chapter 1 – Normal thyroid ultrasonography