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Thyroid Imaging

Mar 06 | 5:30 AM

Nuclear medicine, ultrasound, CT, and MRI are some of the imaging techniques that can be used to assess the thyroid gland. All of these procedures reveal the thyroid gland's structure as well as the location and size of thyroid nodules. Join us live with Dr Megha Sanghvi, consultant radioogist at Zydus Hospital, to understand the imaging procedures involved in the thyroid.

[Music] a very good morning to all my respected friends and beloved doctors this is your host dr iris chilholi and it gives me immense pleasure on behalf of the entire team of netflix to welcome you to today the 6th of march 2022 you create another interesting and very important session of imaging for thyroid so let certain break international women's day and give a whole hearted welcome to dr megha sangri and let's hear how we can solve today's thyroid issues and not just women men women children and all so thank you dr megha the stage is all yours and everybody rightly said thyroid is a very important endocrine gland of our body and the hormones are very essential for optimum functioning in our day-to-day life we leave the clinical part of it to the clinicians but as a radiologist i would like to enlighten you as to what are the imaging techniques that are of use that are important in the thyroid imaging how we can pick up the nodules at early stages and you know whether they require an fnac or not whether they require some intervention or not and as far as thyroid imaging is concerned out of ultrasound cat scans and mris ultrasound is the prime modality of investigation for thyroid cat scans and mri do not have any significant role for thyroid when do we order a thyroid ultrasound when does the clinician write for a thyroid ultrasound in a patient with a palpable thyroid module with multinodule or goiter in a patient presenting with a clinically palpable cervical lymphadenopathy for follow-up and monitoring of existing or a known case of thyroid nodule and those patients who have a high risk for thyroid malignancy for example those with a family history of thyroid cancer those with a history of mental syndrome in the families or history of neck irradiation in the childhood ah also there are also the clinical signs based on which the clinician might be suspecting the patient to be hypothyroid or hypothyroid and even those patients can be referred to us for a thyroid ultrasound what do we see in a thyroid ultrasound there are three modalities of ultrasound that we use for imaging the thyroid a b mode ultrasound doppler mode and elastography b mode is a grayscale ultrasound it measures the acoustic impedance and thereby gives us a clear delineation of the anatomy of the thyroid plan then comes the doppler mode which measures the motion of the rbc within the blood cells so precisely it gives us an idea about the vascularity of the thyroid gland as well as the nodule in the thyroid and elastography it has mechanic it measures the mechanical properties of the nodule or the gland per se and thereby gives us an idea about the tissue stiffness let's begin with ultrasound features that are important what do we look when we see when we when as a radiologist i go for a thyroid ultrasound of a patient what are the key points that i keep in mind first the shape the margin the halo the echogenicity of the nodule composition of the nodule echogenic foci and vascular pattern let's begin with composition it means whether the nodule is predominantly cystic first whether it is completely cystic predominantly cystic predominantly solid with few cystic component within and entirely solid echogenicity whether it is an anechoic neural then it is a cyst if it is a hyperechoic isoechoic hypoechoic or very high i'll run you through the slides of the images wherein i'll be able to tell you more about the echogenicity and all the individual features the shape whether it is a wider than taller nodule or a taller than wider nodule margins if it's a regular margin globulated irregular or showing an extra thyroid extension the peripheral halo if there is no halo there is a thin irregular and vascular peripheral halo or a thick irregular avascular halo echogenic foci if they are comet tail artifacts or peripheral rim or external calcification they may again be interrupted peripheral rim or complete peripheral rim calcification then macro calcifications which are greater than one millimeter in size showing acoustic shadow and micro calcifications which are less than equal to one millimeter without any acoustic shadowing vascular pattern whether it's a peripheral vascularity intra nodular or both peripheral and intranodular we'll go through the features individually uh how should a radiologist report a thyroid nodule we need to have a diagrammatic representation like this wherein ah this is the right lobe this is the left lobe as i have labeled it it and it shows the cranial caudal and enteroposterior um sides as well so whenever there is a nodule we precisely calculate the number of nodules the location of the nodules we we draw it in the diagram the size of the nodule in three dimension and we either write all of these but it's too tedious to write all of this in that diagram so rather we report our thyroids reporting tr one nodule tr two nodule that is how an ideal thyroid ultrasound report should look like why so because if the patient does not come to you for follow-up and the patient goes elsewhere even then this would be a standard system to follow for all radiologists so the next radiologist can look at the image look at the diagram and exactly follow the nodules the way you have mentioned it before um so yeah now moving on to thyroid nodule risk stratification so which nodules are really concerning worrisome and suspicious of malignancy that is what we need to see so that we can follow up those nodules uh there have been many systems over the years ultrasound system for the thyroid nodule risk stratification uh example the first steroids the korean thyroids the eu classification of british thyroid association american thyroid association and the last which is currently in use everywhere worldwide is 2017 uh american um so acr t rates which is thyroid imaging reporting and data system by the american college of radiology this is what we follow now according to the acr tirades the feature that there are the points you know given to the individual feature so the five features are taken into account composition echogenicity shape margin and echogenic foci two features are removed the peripheral halo and the vascularity they are not taken into consideration as far as the acr tyrant scoring system is concerned uh we can we can always report it in our report it it has an additional value uh it so as we run through the slides i'll tell you what is their importance but these are the five key features that we use in the uh scoring system as you can see there has been a point given to each of the uh individual aspects so uh beginning from zero one two and three the maximum is three points the minimum is zero point and after we individually characterize uh characterize the nodules like this we get a sum total of the score and that is called the acr tirades score this is how a tirade score would look like 0 2 3 4 to 6 points and greater than equal to 7 points so if the nodule gets a total score of zero point it is considered a benign nodule it is called tr1 nodule and no fna is required it can just be follow up followed up on a routine ultrasound six monthly second if it's when is it called the tr-2 nodule when the score total score of tirades comes to two points then it is not suspicious and again it can be taken on a six monthly follow-up ultrasound basis no if any or no further investigation is required uh when is it a tr three nodule when the score is three and that means it is a mildly suspicious nodule wherein the fna is indicated if the nodule is greater than equal to 2.5 centimeter and for nodules which is less than that size and has a tier 3 uh scoring it can be followed up on a three monthly ultrasound uh for a nodule which has a score between four to six points it is considered moderately suspicious it is called a tr4 nodule and the fna is indicated in it if the size of the nodule is greater than equal to 1.5 centimeters again if the nodule is tr4 but the size is less than 1.5 you can still follow it up on ultrasound on a three monthly ultrasound um if the nodule has a total score of seven point then it is highly suspicious for malignancy it is called a tr5 nodule and the fna is indicated when the size is greater than equal to one centimeter this is what is the standard acr t rate system which is followed worldwide ah and hence it is of prime importance for all radiologists for all ultrasound ultrasonologists to report their uh you know thyroid report on the acr tyres scoring system so that a standard systematic format is followed based on which the further course of action for the patient can be decided the advantage uh it has a standard term or lexicon which is used for ultrasound reporting it's very easy to characterize each of the points that they have given uh i'll show you the slides wherein you'll be able to understand what i exactly mean by this it is not complex it does not vary from person to person it's not person specific you know it has quantitative criteria and you know if it's a cyst it's a system if it's a solid it's a solid there is no overlapping in either of the scores that they have mentioned hence it is dependable it is reliable it is able to classify almost all thyroid nodules the only disadvantage being there is a high size threshold for fna in the mild and moderate suspicious lesions as we notice in tier for the interior iii the size if it is greater than equal to 2.5 only then and fna is recommended and for tr4 if the size is greater than equal to 1.5 centimeter so that's a little high size threshold which means that even if the nodule is less than two point five centimeter and tr3 it could still turn out to be malignant so that's a little dicey part about the aesir thyroids and it does not take into consideration the thyroid nodule vascularity or the elastography which is invoked these days so this is just a schematic diagram showing how the risk of malignancy increases um from you know bottom to the top the cystic lesions and these spongy form lesions are being more uh benign towards the benign side whereas the solid and those with punctuated calcification and irregular margins being more on the malignant side now let's run you through a series of images which uh you know also which will help you as to understand the individual features that are taken into account in the acr tyraet scoring system first the composition of the nodule as we discussed there are four different types of nodules which that are you know classified one violacistic second predominantly system but some solid nodule or some solid septa within third predominantly solid with few internal cystic areas and four uh completely solid nodule so this is how a completely cystic nodule would look like showing posterior acoustic shadowing to the right top we see uh there is a layering of debris within the cyst there is a pair there is a fluid level you know and there is a peripheral thin rim of vascularity so this is a hemorrhage excess which is again considered purely benign the third image down shows omit tail or bring down artifact which is classical of colloid cyst these are the cystic nodules so the second type the systick with few solid areas so here we see cyst with thin internal septa the scepter do not show internal vascularity on the right top we see cysts with a mural nodule with a few mural nodules however the noodles do not show internal vascularity and thereby they could be just clumped blood clots lying at that place and hence it is also a benign um it is the scoring is only zero so it is a benign nodule then uh the third category wherein there is a predominant this is still the second predominantly cystic with peripheral small solid area however the difference is the solid area shows some internal vascularity which does not mean that it is a sign of malignancy it's just to differentiate it from the blood clot as we notice the on the previous slide the the blood clots will not show any vascularity within whereas if there is some solid area with vascularity then uh you know it is different from a blood clot however the scoring would still remain the same it will be given a score of zero this is how a spongy form or a reticulate pattern would look like there are multiple internal microcystic appearances this is again a sign of benign and classical of colloid nodules this is the solid nodules to the left is a solid nodule with few internal cystic areas which has a score of one and uh the to the right is a completely purely solid nodule with a lot of vascularity moving on to the next uh feature echogenicity uh there'll be four different types one is anechoic which means completely cystic then isoecoid oh how do we measure the echogenicity it is compared to the adjacent thyroid parenchyma so if it is completely dark as compared to that it is anechoic if it is hyperechoic means it is brighter the nodule appears brighter than the surrounding thyroid parenchyma then it's called hyperechoic iso means it is it is similar in appearance to the adjacent parenchyma the hypoechoic means it is uh high it is darker than the adjacent parenchyma however how do we differentiate hypo and very high co equal if we compare it with the we compare the equation of the nodule with the strap muscles so the thyroid strap muscles will be seen on the images and if the nodule is darker than the thyroid but brighter than the strap muscles then it is called hypo and if it is even darker than the strap muscles then it is labeled as a very hypoechoic nodule and which is a sure sign of it being a malignant lesion so this is how a homogeneously uh hyper a hyperechoic nodule looks like uh that or to the right is a heterogeneously hyperechoic however hyperechoic overall it means a sign of benign thyroid nodule this is the iso echoic nodule if you see uh compare it to compare the nodule with the adjacent thyroid parenchyma they almost look similar that's why isoicoid hypoechoic you see the asterisk mark here it shows the strap muscles so the the the nodule is darker than the adjacent thyroid parenchyma but similar in appearance to the asterisk that is the strap muscles hence it is a hypoechoic nodule and this is how a very hypoechoic nodule would look like it is sorry it is almost so dark that it is appearing even darker than the strap muscles ah so this is the strap muscle uh i have not put in a mark but uh the c the n the and the c is the common carotid the n is the thyroid nodule and to its you know top left we see the strap muscles so the nodule is even darker than that and it's a very hypoechoic motion then moving on to the next ultrasound feature is the shape so wider than taller and taller than wider there are only two a wider than taller nodule is a benign nodule and a taller and wider nodule is a sign of malignancy then the next the margin of the thyroid nodule so again there will be a well-defined regular margin there'll be a lobular margin there'll be irregular margin and there'll be extra thyroid extensions so this is how a lobular margin would look like it has lobulations along its side the irregular margins wherein the margins are so not well defined and they are speculated or showing irregular shape which is a sign of you know infiltrations in the adjacent thyroid parenchyma micro infiltrations and this is how a extra thyroid extension would look like let me show you this image the this is an uh the whole thyroid nodule when there is a dotted line that shows an intact thyroid capsule there is no extension outside but the uh the other two arrows they show a loss of the thyroid capsule at that spot which means there is an extension extra thyroid extension similarly over here the red arrow demarcates the extra thyroid extension peripheral halo so this is not considered in the aci there is reporting system however the it is important it would be it would it has an additional value uh to help us so i normally report it in the reports this is how a thin regular and vascular halo looks like now this is not a true hello remember this is just a compressed thyroid tissue and vessels lying in the periphery of the nodule and uh that is why the rheum of vascularity appears so this is a sign of benign nodules then thick irregular and incomplete halo is a sign of malignancy seen in herself it can also be seen in a lot of other thyroid malignancies and this is classical of malignancy you see there is a thick avascular peripheral halo hypoechoic and this indicates a true fibrous capsule surrounding the malignant nodule echogenic foci or calcifications there will be comet tail artifacts or the ring down artifact as we call it there will be macro calcification micro calcifications and we'll see we'll see as we go through it so yeah ring down artifact macro calcification is classically greater than one millimeter in size showing posterior acoustic shadowing uh it is it it is also seen in uh medullary thyroid cancers the dystrophic micro calcifications are characteristic of medullary thyroid malignancy this is how a macro calcification again looks like greater than one millimeter ah oh yeah sorry i forgot this egg shell or the rim calcification you know so there are two types again there's a complete extra calcification as we see in this image it's a complete rim of calcification and there'll be a interrupted or disrupted rim which makes uh uh maybe suspicious of malignancy and the fourth one is punctate calcification function echogenic foci or the micro calcifications less than one millimeter in size and not showing any posterior acoustic shadowing they are classical of uh papillary thyroid malignancies vascularity although it is not included in the acr tyres i find it important and i just document it in my reports the peripheral vascularity suggests benign nodule having both peripheral and intranodular it's an equivocal nodule and the intra nodular vascularity is suspicious of malignancy and hence requires an fmac so this is how a peripheral vascularity looks like as i said that's this is not a true capsule it's a pseudo capsule this is peripheral and intra nodular vascularity both and this is just an intranodular but it is more significant and more suspicious of malignancy a word about hashimoto's thyroiditis there are hashimoto's thyroiditis does not have true nodules it's a pseudonodular appearance there may be white type noodle a giraffe height pattern and papillary thyroid cancers and thyroid lymphomas are more common they have an increased risk in patients with hashimoto's thyroiditis i'll just show you a few images this is how the pseudonodular appearance looks like it is because of thin and thick fibrous septa in a hypoechoic thyroid this is a classical appearance of hashimoto thyroiditis this is a white knight nodule as you can see the background thyroid parenchyma is hypoechoic with micro nodularity and there is one well defined homogeneously hyperechoic nodule at the you know inferior pole and this is called a white night nodule and when there are multiple such white night noodles in a background hypoechoic micro nodular hashimoto's parenchyma it gives the appearance of a jiraphide uh a word about thyroid malignancies overall thyroid malignancies are not that common among uh it's it's just the incidence is just one percent of all malignancies uh among them the papillary thyroid carcinomas are more common then followed by follicular medullary anaplastic lymphomas and metastases this is how a papillary thyroid carcinoma classically looks like it is a homogeneous it is a hypoechoic ill-defined irregular marginated nodule um taller than wider showing multiple tiny painted echogenic foci and intra nodular vascular the classic feature is the punctuated echogenic foci it is seen in papillary thyroid malignancy again another example showing tiny tiny tiny micro calcifications within the nodule classical of ptc uh follicular adenoma and carcinomas are difficult to differentiate on imaging so you if on fna there is a reporting of the follicular adenoma or follicular cells then by default whether whatever is the size of the lesion whatever is the tyres scoring that lesion should be excised and the nodule should be sent for the histopathological evaluation because it could very well turn out to be a carcinoma medullary thyroid carcinoma it is secreted from by it is arising from the para follicular c cells secreting hydrocalcetonin it is associated with men's syndrome it has these characteristic dystrophic macro calcifications within the nodule which are you know classical of the medullary thyroid carcinoma and a plastic it shows irregular ill-defined margins and uh extra thyroid extension in this image we are seeing the thyroid rings thyroid catalytic rings in the center and the nodule to the you know right and anterior to it showing loss of the margins along with the trachea so they might be tracheal invasion at that point thyroid lymphoma it is more common in patient with hashimoto's thyroiditis a few features of thyroid lymphoma being they are hypovascular they are homogeneously hypoechoic they appear as hyper metabolic muscles on pet scan and they show increased through transmission thyroid metastasis may be seen in patients with malignant melanoma breast and renal malignancy there is no specific feature about metastasis they just appear as a malignant thyroid nodule on ultrasound or any other modality so this is how the basic you know we discuss i'm not going through it again just a summary of the benign and suspicious features in a thyroid nodule a word about shear wave elastography elastography is being used uh everywhere these days i personally at my center use it for the breast thyroid breast and thyroid as well as liver and spleen uh so uh this is a grayscale mapping that the leisure that the image indicates as you can see there is color coding so uh from blue so dark blue light blue green yellow and red these are the spectrum so from bottom up it it increases the risk of malignancy so the nodule which has if you see the first nodule it has predominantly bluish picture bluish tint which indicates it is a benign nodule the second one and the third one show a mixed picture which may be indeterminate or suspicious ones however the last one is classical of malignant it is highly suspicious because it shows a predominantly red color uh now i would just like a word of caution that do not stick to the colors it depends on the uh the scaling the way it has been put in here the way it has been you know adjusted or preset in your machine here the blue indicates benign and red indicates malignant but it may be the reverse in some other machines basically shear wave elastography gives you an idea about the tissue stiffness considering that malignant lesions are most different malignant nodules are more stiffer than the benign nodules uh although it is not inclu included in the acr thyroid scoring system we have now started giving you know this information as well in our report uh we just we don't just see the thyroid then when a patient comes to me for thyroid ultrasound i don't see only the thyroid and leave the rest of the neck now we also see the rest of the neck structures the glands and more importantly the cervical lymph nodes ah we all know that there are these six zones in this cervical lymph nodes the zone one is the submental submandibular zone two three and four are the upper mid and lower jugular the zone five the posterior triangle of the neck and zone six uh being the deep vascular nodes um again uh the there is a classical you know just as in the thyroid nodules you should report it systematically so also in the lymph nodes there should be a systematic pattern that you follow you describe the size the shape of the nodule the location based on these six zones don't randomly right just just right you know level one level two level three that would be of aid then the margins of the nodule the vascularity and the hilum whether the hilum is preserved or it's lost and few features if there is a cystic area within the nodule or if there is a calcification then mention that this is how a normal cervical lymph node would look like it would appear flat it shows ah sorry it shows a peripheral hyalum and the hilar vessels hylovascularity so there are a lot of times we see lot of lymph nodes in the neck but not all of them are pathological or worth worrying about most of them could be reactive or you know normal nodes in the neck so you need to differentiate so then what are the features in a lymph node that are suspicious of malignancy round shape loss of echogenic highland presence of cystic areas or micro calcification within the node non-hydrovascularity and extra capsular spread just a few images to help you understand a round shape is suspicious lot of intra nodular vascularity non high non high low vascularity presence of a cystic area within the nodule lymph node and extra capsular spread and punctate calcification this uh there's a very interesting uh kind of lymph node that i once saw it was a metastatic node from a papillary thyroid carcinoma and there's a deposition of thyroglobulin within the lymph node and that is why the internal hyperechoic area so just a few features now fnac the after once this ultrasound is the first step the in imaging then we next what we do we decide whether this patient needs an fnac or not so based on your acr tyres reporting system and your score and your report the uh consultant will you know go through the report and will decide whether this patient is a candidate for fnac or not uh we have already gone through the criteria of fnac based on the asia thailand reporting i am not repeating that now what is an fnac it is a fine needle aspiration cytology wherein we i use a 25 gauge needle such a thin bone needle 25 the patient even does not feel any pain or you know it just he just feels the needle going through it it's just a sensation but there is no pain associated with it so that and under ultrasound again the importance of ultrasound lies here under ultrasound guidance why because this is an example where there is a common carotid artery and an ijv and i have targeted a level four right level four lymph node if you can see two two of the nodes ah now you can't be this precise by a blind defense you know even though there may be a large palpable thyroid nodule or a neck mass you cannot blindly do an fnc or biopsy through it because even within the lymph node or the thyroid nodule there may be specific areas that you want to target like a cluster of micro calcification or a microcystic area you know like for example also if there's a multi-nodule or goiter not all the nodules may be suspicious there may be only few of only one or two of the nodules which may have the suspicious features it is during all these things you know this precision can be achieved only by the use of ultrasound in uh doing the fnes and also to avoid the major next structures while you are uh doing the fnac uh the key point that i realized in an fns is quick in quick out that is the formula that i follow why because we want a non hemorrhagic material we want the cells to come in but not the bleeding or the blood cells or the hemorrhage to come in because that will spoil the quality of the slide and the histopathologist would not like to report on such a slide it's very complex for them so a good quality fna slide for to give a good quality fna slide you need to follow the right technique quick in quick out no aspiration required you just sorry there is just a movement of the needle i'll show you in the video in just half a second the just with this movement you do it once or twice or thrice you just go in and out of the nodule and you take your needle out can you run the video here rocha yes you see so uh there is there are these pulsating vessels to on the you know extreme right uh we need to run this video one more time and there is a lymph node which i have targeted you see this is where the precision of ultrasound comes into role and along with it you know the specific targeting of the specific size and quick in quick out this is how we do it yeah back to the presentation okay yeah uh there are very rarely any complications of fnac sometimes if you have stayed within the nodule too long or if you have had to manipulate a lot then to reach the nodule sometimes if it's a deeper nodule and you've had to manipulate a lot then there may be some subcapsular or interfacial hematoma which may happen which normally disappears within two to five days uh it also helps if you compress uh that side for about five to ten minutes after the procedure give a deep compression then there will be no ongoing bleed and whatever hematoma has formed that will also resolve over time so you should put the patient to rest you know reassure them that don't worry this will go away in a while and if it increases or if there is more pain or discomfort because of it tell them to come and see you again so you can immediately put your probe and see if the hematoma is expanding or not but it rarely happens in my in my you know experience till now i have not had a single case that has come back to me saying that the hematoma is enlarging or there is an ongoing bleed so it's very rare if you are correct in the technique then you can't go wrong sometimes really there may be injury to the carotid or the ijv or the adjacent nose or trachea and esophagus but these are very rare complications so just a last summary of how we can you know characterize the thyroid nodule or how we can go about it first measure the so this this part half of it will be the consultant will be doing it the rest is the radiologist so it's a team basically as a team this is how we look at a thyroid nodule we may measure the serum tsh levels if it is low or suppressed then we go for centigraphy the centigraphy if it shows a hot noodle then we directly refer for radio you know therapy or surgery and if it is not a hot noodle then we go for an fnac of that module again if the tsa levels are normal or elevated we go for an ultrasound based on the ultrasound features and the thyroid scoring system and the size of the nodule we go for an fnac now in the fn ac there will be a clear-cut benign diagnosis sometimes there may be an insufficient material wherein you may need to repeat the fnac and give the representative sample to the pathologist they may be a suspicious or indeterminate nodule and a malignant audio both of which require surgical excision so so thyroid is not that complicated as it looks like and um you know it is a gland where just by minor corrections just by the right diagnosis the patient's life can come to nearly normal all of the symptoms that the patient has the lifestyle issues the weight gain the mood swings all of them can be corrected so as a team we should you know work together and um and focus on the early diagnosis precise imaging and effinaces for these patients i'd like to welcome any questions that you have from the crowd [Music] thank you ma'am it was a wonderful presentation and uh though uh even if uh we some of ours are not radiologists yes uh the guidelines and the navigation we went through now like how to diagnose the warning signs and then go to the you know uh how to distinguish between precise takes is take uh in between then solid and then really solid and also the ultrasound that was really wonderful you know hyper echoic how and i'm telling you very honestly ma'am there are so many clinicians and we are not radiologists always so we really have to depend on the final impression sometimes you know yeah so but you uh nicely explained uh that you know fine hyper quick means uh where are we heading are we heading towards malignancy and if we are heading towards malignancy when it is confirmed malignancy and definitely the ecp right that your grades the guidelines uh that is definitely a valuable asset and uh in fact you gave us some valuable uh practical tips how to do a proper clean cut definitely because if the fnac is not good as you said the histopathologist will not be able to diagnose immediately and we have to repeat and that's really a problem for everyone so it was a wonderful presentation ma'am i learned a lot of things because i'm not a radiologist i'm a clinician and i'm sure uh seeing the you know the comments they're really happy the audience is really i saw one question in the comments somebody is asking me about elastography yes elastography surely has a role in uh thyroid imaging but it is not yet that established that we can uh replace it with an fnac so the uh acr thyroid scoring and fnac comes first elastography is an additional tool uh you know giving us a more confident idea that this is a malignant nodule this is a shear short benign nodule so it's just an add-on right now but it cannot replace the fnac and you showed some color codings color codings in the elastograph where we grew from a light blue to green to dark blue yeah so this was all a very valuable information yeah uh somebody's also asking me my take on trucker biopsy uh true current biopsies are not done for the thyroid i don't know a lot of people feel uh we also get requests from consultants for trucker biopsy considering that trucker biopsy would be more informative than an fnac but because thyroid is a very vascular organ there is no role of true current biopsy and fnac if it's correctly done it gives you the diagnosis it does not give you repeats it does not give you inconclusive results it's just about learning the right technique to get the fnac done no biopsy for thyroid if at all the fns is not giving you the answer then excision of the nodule is the only answer and then do the you biopsy and it and then send it for the histopathological evaluation but no biopsy ever in the thyroid gland then that's a very important take yeah is activates preferred over ai thyroids yes for now it is the key thing and this is what is followed worldwide for now times may change the protocols may change over time but right now this is the thing ac are tired and these are all downloadable ma'am from yes right yes yes yes so we initially like now we remember the scoring system and all but earlier we were not so provided we were also new in our practice we always had this sheet attached to our you know computer or our pc somewhere above on top of it so we can just refer to it whenever we are reporting the thyroid report yeah yeah to be always on the same clinical pathway and the correct way we are going you know even when you suppose you are not there the other doctors are there and we all follow the same standardized protocol yes yes that is the purpose actually because for the patient that is going to help yeah yeah and we don't make mistakes and we don't uh do by our preference and our tastes yeah we have a standardized product yes then we don't give a random report in our own language that's not how we do it we follow protocol we follow guidelines and the exact terminology because it's about saving a life yes ma'am and because it's all about saving a life as you said the correct timely diagnosis under correct protocol and the correct clinical pathway and a clinician's decision and family decision and patient education that can save a life and especially because just you know few medication or few small tips may be able to change a patient's quality of life i have seen a few of my friends having hypothyroid being sluggish and low energy and not feeling good about life for a couple of years because they were undiagnosed as being hypothyroid so yeah and just because that's what men when they come with the warning signs or remember they come with the warning signs to us you know we often do the routine thyroid tests yeah yeah and we keep on uh following them up uh with the medicine and we adjust the dose of ultroxime thyronorm or thyroxine or whatever and we see okay the patient also sometimes says i'm good i'm good i'm better i lost weight i'm more active now i don't feel sleepy but uh actually this radio imaging can pick up all those you know missing legs and save uh many more years to come in a patient's life yeah definitely how often should we advise the thyroid test do you mean a thyroid ultrasound uh so if it is a no so if it's a new case you can send a patient so just as you order a serum tsh and the thyroid hormone test at the same time you should get a baseline thyroid study done that is the first thyroid ultrasound and you can follow up the patient for so if there is no nodule in that ultrasound if it's just a normal thyroid gland or if it's a clear cut benign nodule then you can for you know request a thyroid ultrasound after six months but if it is between tr three four and five and maybe an immediate um fnac as per the protocol precise protocol or a follow-up thyroid ultrasound in three months time uh there's one more question from dr uh particularly differentiation lymph node or cystic change and lymph node in malignancy from tuberculosis no all we can say is it is a pathological lymph node ah there are telltale signs though there are other supporting features uh so okay to answer your question a necrosis or the cystic change in a malignant in a metastatic node will be the same appearing as that in a tubercular necrotic node but if there is presence of micro calcification if there are lymph nodes elsewhere in the body you know they are the supporting features there is an ic junction thickening suggestive of abdominal as well if there is a pleural effusion so then it's a complete picture but if you ask me only from the lymph node uh having a cystic area can i say that it is a tubercular node or a metastatic node no we should not and it is not required out of us as a radiologist what we need to tell the clinician is that it is a pathological lymph node wherein a biopsy or an fnac or an excision i mean ultrasound guided biopsy excision biopsy or an f is required that's it this patient should undergo one of the three for further diagnosis that is what is required out of us loss of fatty hyaluronin lymph node what does it mean yes so i showed you an image wherein the lymph node can we can we have the presentation ah it's difficult now yeah so uh cervical lymph node and the loss of hyaluron okay so normally this is how a normal cervical lymph node would look like it has a high lump if your xylem means the echogenic part in one of the very you know peripheral area of the lesion like this this is a hypoechoic uh dark appearing rounded lymph node wherein in the periphery there is a hyperechoic or a brighter ah area which is called the hilum of the lymph node now when that hilum is lost for example in this there is no such highland scene then it is indicative of loss of phylum and suggestive of malignancy in all of these five lymph node images there is no high lump seen so there is a loss of hyaluron and normally there will be other high levels yeah normally there'll be a highland like this and i would like to thank the audience for joining us in such large numbers on a sunday morning it's wonderful i myself am never keen to join any session on a sunday morning and i love you all you have been a wonderful audience yes it has been a wonderful audience and it has been very kind and uh and great gesture on your part to give time on a sunday morning and give us so much of education

BEING ATTENDED BY

Dr. Murtuza Zozwala & 473 others

SPEAKERS

dr. Megha Sanghvi

Dr. Megha Sanghvi

Consultant Radiologist, Zydus Hospital

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dr. Megha Sanghvi

Dr. Megha Sanghvi

Consultant Radiologist, Zydus Hospital

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