Klasifikasi Nodul Tiroid

Adenoma
Adenomas of the thyroid are typically discrete, solitary masses, derived from
follicular epithelium, and hence they are also known as follicular adenomas.
The typical thyroid adenoma is a solitary, spherical, encapsulated lesion that is
well demarcated from the surrounding thyroid parenchyma. adenoma bulges
from the cut surface and compresses the adjacent thyroid. The color ranges from
gray-white to red-brown, depending on the cellularity of the adenoma and its
colloid content. The neoplastic cells are demarcated from the adjacent
parenchyma by a well-defined, intact capsule. Microscopically, the constituent
cells often form uniform-appearing follicles that contain colloid. The epithelial
cells composing the follicular adenoma reveal little variation in cell and nuclear
morphology, and mitotic figures are rare.

There are no specific imaging signs and nodules may be solid or cystic (as
described above) and may be heterogeneous, containing calcification and/or
haemorrhage. Peripheral and coarse calcification is more frequently seen in
benign nodules (Fig. 47.61). Generally, vessels will be seen on colour flow
Doppler around nodules (Fig. 47.62), with some flow being appreciated within
most nodules.



Carcinoma
The major subtypes of thyroid carcinoma and their relative frequencies include
the following:
a. Papillary carcinoma (>85% of cases)
Papillary carcinomas are the most common form of thyroid cancer,
accounting for nearly 85% of primary thyroid malignancies in the United
States. They occur throughout life but most often between the ages of 25 and
50, and account for the majority of thyroid carcinomas associated with
previous exposure to ionizing radiation
Papillary carcinomas are solitary or multifocal lesions. Some tumors may be
well circumscribed and even encapsulated; others may infiltrate the adjacent
parenchyma with ill-defined margins. The lesions may contain areas of
fibrosis and calcification and are often cystic. The cut surface sometimes
reveals papillary foci that may point to the diagnosis.


Nodules are hypoechoic and commonly multiple. Punctate internal
calcification representing psammoma bodies, is common and highly
indicative of malignancy.

Longitudinal image reveals a solid nodule (large arrow) containing
numerous microcalcifications (small arrows). The presence of
microcalcifications in a thyroid nodule is highly indicative of malignancy.
b. Follicular carcinoma (5% to 15% of cases)
Follicular carcinomas account for 5% to 15% of primary thyroid cancers.
They are more common in women (3 : 1) and present at an older age than do
papillary carcinomas, with a peak incidence between 40 and 60 years of age.
Follicular carcinomas are single nodules that may be well circumscribed or
widely infiltrative ( Fig. 24-20A ). Sharply demarcated lesions may be
exceedingly difficult to distinguish from follicular adenomas by gross
examination. Larger lesions may penetrate the capsule and infiltrate well
beyond the thyroid capsule into the adjacent neck. They are gray to tan to
pink on cut section and, on occasion, are somewhat translucent due to the
presence of large, colloid-filled follicles.

Cut surface of a follicular carcinoma with substantial replacement of the
lobe of the thyroid. The tumor has a lighttan appearance and contains small
foci of hemorrhage


Transverse sonogram of the left lobe of the thyroid shows a partially cystic
tumor with solid internal projections (arrows) and thick walls.
c. Anaplastic (undifferentiated) carcinoma (<5% of cases)
Anaplastic carcinomas are undifferentiated tumors of the thyroid follicular
epithelium, accounting for less than 5% of thyroid tumors. They are
aggressive, with a mortality rate approaching 100%. The mass is often
hyoechoic, with areas of calcification seen in over half of patients. It often
has ill-defined margins and areas of necrosis are frequently seen. There may
be evidence of extracapsular spread and adjacent vascular invasion.

Transverse sonogram of the left lobe of the thyroid shows an advanced
tumor with inltrative posterior margins (arrows) and invasion of
prevertebral muscle.
d. Medullary carcinoma (5% of cases)
Medullary carcinomas of the thyroid are neuroendocrine neoplasms derived
from the parafollicular cells, or C cells, of the thyroid, and account for
approximately 5% of thyroid neoplasms. Sporadic medullary thyroid
carcinomas present as a solitary nodule ( Fig. 24-22A ). In contrast,
bilaterality and multicentricity are common in familial cases. Larger
lesions often contain areas of necrosis and hemorrhage and may extend
through the capsule of the thyroid. The tumor tissue is firm, pale gray to tan,
and infiltrative. There may be foci of hemorrhage and necrosis in the larger
lesions.

These tumors typically show a solid pattern of growth and do not have
connective tissue capsules.

The thyroid tumor are usually solid on ultrasound, with echogenic foci due
to the presence of calcification in 80%-90%. Intraturnoral vessels are seen
on ultrasound and have a disorganised pattern. Lymph node involvement
occurs in over 50%. These also frequently demonstrate calcification. There
is a tendency for bony metastatic disease.


Transverse sonogram of the right lobe of the thyroid shows a large nodule with
coarse calcication and posterior acoustic shadowing (arrows)

Perbedaan Gambaran Vaskularisasi Neoplasma Tiroid Dan Proses Inflamasi
Tiroid
The most common pattern of vascularity in thyroid malignancy is marked intrinsic
hypervascularity, which is dened as ow in the central part of the tumor that is
greater than that in the surrounding thyroid parenchyma.


Hashimotos Thyroiditis
Acutely there may either be diffuse involvement of the gland, which
appears of decreased vascularity with multiple small nodules within it, or
there may be focal nodular thyroiditis with small hypoechoic ill-defined
nodules. In the chronic state the thyroid may be enlarged and
hypervascular, with multiple ill-defined hypoechoic areas separated by
echogenic fibrous septa. A small atrophic gland is seen in end-stage
disease.

Longitudinal image through one lobe of the thyroid shows
heterogeneous parenchyma, with a myriad of indistinct tiny nodules.
De Quervain's thyroiditis
In the acute state there is usually a tender ill-defined hypoechoic nodule
and the adjacent thyroid is heterogeneous. There may be diminished
vascularity of the thyroid. In the subacute phase the thyroid is swollen,
tender and hypoechoic.
The Shape of Thyroid Nodule
The shape of a thyroid nodule is a potentially useful US feature that has not been
extensively described in the literature. Kim et al (16) found that a solid thyroid
nodule that is taller than it is wide (ie, greater in its anteroposterior dimension
than its transverse dimension) has a 93% specicity for malignancy.