897

Downloaded from www.ajronline.org by 114.79.32.129 on 08/14/15 from IP address 114.79.32.129. Copyright ARRS. For personal use only; all rights reserved

Computed
Tomography
in
the Evaluation
of Thyroid
Disease

Paul M. Silverman1
Glenn
E. Newman
Melvyn
Korobkin
Joseph
B. Workman
Arl V. Moore
R. Edward
Coleman

Traditionally,

thyroid

has been performed

using radionuclide
scanin 18 patients
to
evaluate
the CT appearance
of various thyroid abnormalities
including
diffuse toxic
goiter, multinodular
goiter, Hashimoto thyroiditis, thyroid adenoma,
and malignant thyroid
tumors. CT images of the thyroid were correlated
with radionuclide
scanning,
surgical

fling.

High-resolution

imaging

computed

tomography

and laboratory

(CT)

results.

primarily

was

performed

findings,

and clinical

evaluation
precisely
structures

of the thyroid by defining the morphology

of the thyroid gland and more
defining the anatomic
extent of thyroid abnormalities
in relation to the normal
of the neck and mediastinum.

CT provided

a complementary

method

for

Radionuclide
imaging
of the thyroid
remains
the primary
radiologic
imaging
procedure
for evaluating
functioning
thyroid
tissue. High-resolution
real-time
sonography
has provided
additional
information
in the evaluation
of patients
with
thyroid disease,
especially
in differentiating
cystic from solid thyroid nodules
[1].
Limited experience
has been obtained
in evaluating
the thyroid gland by computed
tomography
(CT), with the primary emphasis
being the detection
of intrathoracic
thyroid tissue [2-6].
We describe
the morphologic
and anatomic
CT appearance
of the abnormal
thyroid gland and correlate
these results with radionuclide
imaging
and clinical and surgical findings.

Materials

and

Methods

A retrospective
neck

masses

analysis

suspected

was performed on 18 patients

to be of thyroid origin.

who underwent CT scanning of

Fifteen of these patients had a

clinically

radionuclide
examination
of the thyroid. Surgical or autopsy confirmation
was available in 11
of 1 8 patients.
The final diagnosis
in the other seven was based on careful review of the
history, physical examination,
and laboratory
and radiologic
results.
CT examinations
were performed
using a Siemens Somatom
II or GE 8800 CT/T scanner
with the patient in the supine position and the neck extended.
All scans were obtained
using
contiguous
1 cm or 5 mm collimated
sections
through
the neck and thyroid gland tissue
without

the

scans

were

size,

use

of intravenous

continued

homogeneity,

contrast

calcifications,

and

retrotracheal
extension.
The radionuclide
examinations
(eight
Received
September
6, 1 983;
revision December
20, 1983.

accepted

after

All authors: Department

of Radiology.
Duke University
Medical
Center,
Durham,
NC 27710.
Address reprint requests to P. M. Silverman.
AJR

141:897-902,

0361 -803X/84/1

May

1984

425-0897

C American Roentgen

Ray Society

patients)

collimator

and

neck extended.

as indicated
gland

extension.
The CT

location

of

of the thyroid

were

thyroid

were

An anterior

neck view with the patient

by the history or physical examination.

markers
images

of suspected

mediastinal

assessed

tissue,

including

performed

with

thyroid,

for thyroid

gland

substernal

or

seTcpertechnetate

1311

size, homogeneity

radioactive

In cases

The images

(1 0 patients). Three patients had both studies performed. Standard

right anterior oblique, left anterior oblique) were obtained using a pinhole
standard
field gamma
camera
with the patient in the supine position and

or

views (anterior,

material.

into the mediastinum.

on
were

of tracer
the
then

skin

uptake,

location

superimposed

correlated

with

sitting

or lateral

Aadionuclide
of palpable

on

the

radionuclide

image,
images,

views

were

obtained

images were evaluated

nodules
and

substernal
results

for

as demonstrated
or

of physical

by

posterior
exami-

898

SILVERMAN

TABLE

1: Radionuclide
Pathology:

Case

and CT Findings

in Thyroid

AJR:142, May 1984

Disease

Radionuciide(s):

goiter:

ssmTc,

1 (61,F).

Downloaded from www.ajronline.org by 114.79.32.129 on 08/14/15 from IP address 114.79.32.129. Copyright ARRS. For personal use only; all rights reserved

AL.

No.

(age gender)

Multinodular

ET

1311:

Enlarged,

ci

Findings

right-lobe

focal

mass, substernal

2(76,F)

99mTc, 1311: Poor uptake

1311:Enlarged,

3(87,M)

inhomogeneous,

4(47,F)

sternal
ssmTc, 1311: Enlarged,

5(65,M)

substernal
1311: Substemal,

sub-

inhomogeneous,

CT-Radionuclide

Findings

Enlarged, right-lobe focal

mass, substernal
Enlarged, inhomogeneous,

Correlation

Good
NA

cal

Enlarged,
cal
Enlarged,

inhomogeneous,

Good

inhomogeneous,

Good

substemal

inhomogeneous

Cal, substemal,
neous

homoge-

Good

NA

Inhomogeneous

NA

1311:

Homogeneous
Enlarged, inhomogeneous,
cal
Enlarged, inhomogeneous,

Retrotracheal

only by CT

Retrotracheal

only by CT

6(55,M)
7(72,F).
8(73,F).

Homogeneous
seTc: Enlarged, inhomogeneous

9(64,F)

NA

NA

cal, retrotracheal

Tc:
Poor uptake
seTc: Enlarged, inhomogeneous,
sternal

10(53,F)
ii (73,F)
12(71,F)
Graves disease:
13(19,F)
14 (49,F)

sub-

1311: Homogeneous

Tc:

Enlarged, homogeneous
Enlarged, inhomogeneous

Enlarged,

cal, substemal

Substemal

Enlarged,

inhomogeneous,

Good

substernal
Homogeneous

Good

Enlarged,

homogeneous

Good

Enlarged,

inhomogeneous,

substernal
Hashimoto thyroiditis:
15 (56,F)

seTc:

Enlarged,

inhomogeneous,

Enlarged,

17 (33,F)
18 (67,F)
=

Note.-Histoiog
calcifications;

nation,

Mass left lobe

1311:

Enlarged,

homogeneous

NA
NA

conhrmation
was achieved
not applicable.

and surgical

findings

to assess

10, and 13-17.

the significance

Thyroid

of the abnor-

malities detected.

Results

The final diagnosis

based on clinical and pathologic
findings
1 8 patients
included
multinodular
goiter (1 2 patients),
Graves disease (two) Hashimoto
thyroiditis
(one), and focal
thyroid masses (adenoma,
one; thyroid carcinoma,
two). The
results are summarized
in table 1.
in the

Multinodular

Goiter

Six of the 1 2 patients

with multinodular
goiter had histologic
confirmation.
Ten patients had radionuclide
studies (three had
Tc-pertechnetate,
four had 1311 scans, and three had both
studies).
In two patients
the radionuclide
studies
were uninterpretable
because
of poor thyroid accumulation
of tracer.
In all eight patients
with adequate
CT and radionuclide
scans there was good correlation
in homogeneity
of appearance of the thyroid
parenchyma.
In four patients
enlarged

masses

Discrepancy

retrotracheal

trotracheal

Mass left lobe, lymphadenopathy

Mass medial part thyroid

CT identified

Calcified

in cases 2. 4. 6-8,

homogeneous,

substemal,

1311:

only by CT

sub-

sternal
Thyroid masses:
16(35,M)

Substemal

only by CT

mass

were found to be anapiastic

inhomogeneous

carcinoma

glands

were

Focal
NA

re-

only by CT
lymphadenopathy

mass by CT

in case 16 and papillary

found

in homogeneity;

on both

caronoma

in case 17. cal

radionuclide

and

CT scans. Areas of decreased

tracer on radionuclide
imaging
generally corresponded
to areas of decreased
density on CT
images. One patient with a large solitary area of decreased
activity on radionuclide
scanning
had a corresponding
lowdensity
area in the same position
on CT scanning
(fig. 1).
Three patients
had homogeneous-appearing
gland on both
studies.
In two patients
retrotracheal
thyroid tissue was identified
by CT. In one of these patients,
radionuclide
study included
a lateral image that did not identify any retrotracheal
tissue
(fig. 2). In five of six cases with substernal
extension
of thyroid
tissue, the abnormality
was identified
on both CT and radionuclide scanning.
In one patient inadequate
uptake on the
radionuclide
study precluded
identification
of the substernal
component
detected
by CT. In each case CT provided
additional information
regarding
the anatomic
extent of the substernal extension
in relation to the normal mediastinal
structures (fig. 3).
In six cases small punctate
or coarse areas of calcification
were randomly
scattered
throughout
the thyroid
gland and
identified on CT scanning.

AJR:142,

Fig.

rod

CT

May 1984

scan.

-Case

1,

Enlarged

neous
distribution
pofunctioning

multinodular

thyroid

OF

THYROID

DISEASE

899

goiter. A. l thy.
with inhomogeand focal area of hy-

gland

of activity

Downloaded from www.ajronline.org by 114.79.32.129 on 08/14/15 from IP address 114.79.32.129. Copyright ARRS. For personal use only; all rights reserved

tissue in right lobe (arrows). B, CT

scan confirms enlarged. inhomogeneous-appearing
gland with focal area of low density in right lobe
(arrows) corresponding
to area of decreased tracer
uptake

on radionuclide

study.

A
Fig. 2.-Case

7. multinodular
goiter. A, 1311 thy
view. Anterior
marker indicates
sternal notch (5), posterior
marker is placed over
spinous
processes
in back of neck (arrows).
No
abnormal
tissue is noted between
posterior
marker
and normal thyroid tissue (fl to suggest retrotracheal thyroid. B, CT scan. Retrotracheal
component

roid scan, lateral

of thyroid tissue seen on right side (RT). CT attenuation

number

of thyroid

tissue

is 1 00 H. T

/OOH

trachea.

1i ::
:

Graves

Disease

(Diffuse

Goiter)

Of the two patients

with Graves
disease
studied
by CT,
one was studied with mTcpertechnetate
and one with 1311.
One patient had an enlarged
homogeneous
gland identified
on radionuclide
imaging
and CT scanning.
In the second
patient a substernal
component
of thyroid was identified
on
CT; the 99mTC radionuclide
scan revealed
only an enlarged
gland without
an identifiable
substernal
component.

Hashimoto

Thyroiditis

One patient had Hashimoto

thyroiditis.
The Tc-pertechnetate scan revealed an enlarged thyroid gland with inhomogeneous
uptake
and substernal
extension.
The CT scan
demonstrated
an enlarged
but homogeneous
thyroid gland of
a tissue density similar to surrounding
muscle. A retrotracheal
component
was identified
only by CT providing
further anatomic information.

Thyroid

Masses

Two patients
had thyroid
neoplasm,
one with papillary
carcinoma
and a second
with anaplastic
carcinoma.
In the
patient with the anaplastic
carcinoma,
the radionuclide
study
showed
a cold nodule
in the left lobe of the thyroid
that
corresponded
to a low-density
mass displacing
the normal
higher density thyroid gland on CT scanning.
The CT scan
more completely
defined the anatomic
extent of tumor, with
extension
into the neck and metastatic
lymphadenopathy
(fig.
4). At surgery
local lymph node metastases
and extension
into the soft tissues of the neck were confirmed.
In the patient
with papillary carcinoma,
the radionuclide
examination
of the
thyroid gland demonstrated
a slightly enlarged
gland without
areas of decreased
radioactivity.
CT scanning
demonstrated
a focal area of irregular low attenuation
medially in both lobes
and the region
of the thyroid
isthmus.
This area of low
attenuation

corresponded

(fig. 5) identified
One patient

to the patients

at surgery.
had a CT scan

showing

papillary

a densely

carcinoma

calcified

SILVERMAN

900

ET AL.

AJR:142,

May 1984

Downloaded from www.ajronline.org by 114.79.32.129 on 08/14/15 from IP address 114.79.32.129. Copyright ARRS. For personal use only; all rights reserved

Fig. 3.-Case
5, multinodular
goiter. A, l thyreid scan. Normal thyroid tissue (1) and large inhomogeneous
substemal
component
(arrows). B, CT at
level of thyroid. Normal thyroid gland (1). C, 2 cm
below thyroid gland. Thin extension
ofthyroid
tissue
with calcification
(arrows). D, Level of great vessels.
Displacement
laterally of great vessels by substernal thyroid (T). Caudad to this level substernal
thyroid extended
anterior and posterior
to aortic arch.
S = sternum;
lv = innominate
veins:
Ca = carotid
artery; Sa = subclavian
artery.

...

A
Fig. 4.-Case
1 6. A, l thyroid scan. Large hypofunctioning
mass (arrows)
lobe corresponds
to palpable
mass (surgically
proven anaplastic
carciB. CT scan. Normal right thyroid lobe; left lobe is markedly
expanded

in left

noma).

by mass
medially

(M) with faint rim of opacifled

thyroid tissue displaced
(arrows). C. Higher on neck at level of hyoid bone
mass in left neck is consistent
with metastatic
lymphadenopathy.

along periphery
(H). Soft-tissue

AJR:142,

CT

May 1984

OF

THYROID

901

DISEASE

Downloaded from www.ajronline.org by 114.79.32.129 on 08/14/15 from IP address 114.79.32.129. Copyright ARRS. For personal use only; all rights reserved

Fig. 5.-Case
17. A, 1311 scan. Slightly enlarged
thyroid gland without
definite mass. B. CT scan at
level of thyroid isthmus.
Area of relative low attenuation (arrows) compared
with rest of thyroid (papillary carcinoma
of thyroid).

A
mass in the thyroid consistent
with a benign
A radionuclide
study was not performed.

thyroid

adenoma.

thyroidal

vessels,

they

excision.

Large

masses,

significant

Discussion
Thyroid
imaging
using radionuclides
method
for evaluating
the functioning

nuclide
lution

thyroid
and

imaging,

is accurate

however,
only

has

been

the

primary

of thyroid tissue. Radiohas limited anatomic

reso-

in evaluation

of nodules

larger

than

posterior

can

usually

deep

be resected

intrathoracic

mediastinal

component

may

roid,

many

tinal

masses

tion

identification
as thyroid tissue.
CT allowed
the definition
of retrotracheal

between

nuclide
goiters,

the

appearance

of the

gland

studies and CT scanning.

In patients
the multiple
regions of decreased

radionuclide

studies

corresponded

of decreased
density on CT.
CT demonstrated
the relation
mal

thyroid

mediastinal

structures

closely

with multinodular
tracer activity on
to multiple

of substernal

in eight

on radio-

patients

thyroid
in our

regions

to norstudy.

Substernal
thyroid tissue is usually an intrathoracic
extension
of goiterous
thyroid tissue and is most common
in the anterior
mediastinum,
with typical histopathologic
features
of cystic
areas, focal calcifications,
inflammatory
changes,
and fibrosis.
Significant

substernal

goiter

itself

is an indication

for resection

to prevent
potential
complications
of mediastinal
or tracheal
compression
as a result of cystic degeneration
or hernorrhage. Since these lesions are usually an intrathoracic
extension of goiterous
thyroid
and have a vascular
supply from

or a

necessitate

supplementary
median sternotomy
or thoracotomy
[i2, 13j.
CT often aids in the preoperative
assessment
of the location
and extent of intrathoracic
tissue and its relation to the major
vascular
structures
in the mediastinum
(fig. 3D).
Although
radionuclide
scanning
is probably
the preferred
initial method of examination
for suspected
mediastinal
thy-

1 cm [7, 8]. Sonography

has been used primarily
to differentiate cystic and solid cystic masses of the thyroid, but more
recently has been applied to the evaluation
of diffuse thyroid
disease
[9]. The role of CT in evaluating
diseases
of the
thyroid has yet to be fully defined.
Previous
clinical reports
have documented
that CT can
detect the normal morphology
and anatomy
of the neck and
thyroid
gland [1 0, 1 1 These reports
have described
the
increased
density of the normal thyroid gland (70-i 20 H) as
a result of its high iodine content.
Initial studies have described
the characteristic
CT appearance
of diffuse thyroid disease
as an enlarged gland with decreased
density when compared
with the normal thyroid. In our series we found good correla-

1.

by a cervical

extension,

patients

are referred

of uncertain

for CT evaluation

etiology.

In these

of medias-

cases

the

appre-

of the CT appearance
of substernal
thyroid is important
in establishing
the benign
nature of the mass. The often
decreased
density
of the substernal
extension
of thyroid
tissue compared
with normal thyroid tissue may occasionally
create some difficulty
in distinguishing
tissue of thyroid origin
from other mediastinal
masses. In these cases identifying
the
continuity
of the mediastinal
component
with the thyroid gland
ciation

in the

neck

may

be helpful

in confirming

its thyroidal

origin.

Small punctate
or coarse
calcifications
were noted in six
patients with multinodular
goiter. The calcifications
were often
diffusely
distributed
through the thyroid gland in the neck as
well

nents

as within

in three

the

substernal

patients.

This

component,

extension

which

may

aided

thyroid
not

in its

compo-

be detected

radionuclide
imaging
[i 41. The demonstration
of a retrotracheal
component
of the thyroid gland is important
in the
preoperative
assessment
of these patients.
The knowledge
of posterior
tracheal extension
narrowing
the tracheal lumen
may be useful to the anesthesiologist
in selecting
the proper
endotracheal
tube for endotracheal
intubation
[15].
In two patients
with thyroid carcinoma
the areas of abnormality appeared
as poorly defined areas of decreased
density
clearly demarcated
from the rest of the higher-density
thyroid
gland. In one patient CT demonstrated
a thyroid
mass not
visualized
on the radionuclide
study; in the second patient CT
showed
an additional
soft-tissue
mass in the neck that corresponded
to metastatic
lymphadenopathy.
with

Downloaded from www.ajronline.org by 114.79.32.129 on 08/14/15 from IP address 114.79.32.129. Copyright ARRS. For personal use only; all rights reserved

902

SILVERMAN

The identification
of lymphadenopathy
is important
in the
surgical assessment
of patients
with thyroid carcinoma.
The
thyroid
gland lies in the visceral
compartment
of the neck
bounded
posteriorly
by prevertebral
fascia and anteriorly
by
pretracheal
fascia. These fascial layers fuse laterally
at the
carotid sheath. The deep cervical nodes, however,
lie laterally
in a separate
compartment
bounded
by prevertebral
fascia.
Thus, total thyroidectomy
with radical neck dissection
involves surgical manipulation
of two compartments
and is thus
not a single en-bloc dissection
but rather removal of an organ
and an associated
regional node dissection
[1 6]. Whether
or
not to perform a neck dissection
is controversial
and depends
on the histologic
type and extent of tumor. Especially
in well
differentiated
tumors
(papillary,
follicular),
the decision
is
based on the identification
of enlarged lymph nodes on clinical
examination.
In the absence
of palpable lymphadenopathy,
a
cervical
lymph
node dissection
is not performed
[1 7, 1 8]. CT
provides
a potentially
valuable technique
for the detection
of
cervical lymphadenopathy
and may aid surgical
planning.
In
the case of questionable
lymphadenopathy,
a biopsy of cervical lymph
nodes
determines
the need of node dissection.
CT scanning
in thyroid diseases
provides a complementary
technique
to radionuclide
scanning,
which remains the primary
imaging method in the detection
and characterization
of various thyroid
abnormalities.
In patients
with a significant
amount
of substernal
extension
of goiter
by radionuclide
examination,
CT provides
a precise anatomic
display of the
sites of substernal
extension
before surgical intervention.
CT
may be used as a major radiologic
staging
method
in the
evaluation
of the extent
of cervical
and mediastinal
adenopathy
in patients
with thyroid
carcinoma
prior to radical
surgery.
CT scanning
can be used in conjunction
with sonography
as the primary
imaging
study in the evaluation
of
thyroid disease
in patients
in whom recent intravenous
iodinated contrast
material
has made radionuclide
imaging suboptimal.
In our study, the appearance
of the thyroid
parenchyma
showed
good correlation
between
radionuclide
examination
and CT in diffuse thyroid disease.
Areas of decreased
tracer
uptake generally
corresponded
to areas of decreased
attenuation on CT scanning.
CT provided
additional
anatomic
information
not available on radionuclide
imaging by defining
the extent of retrotracheal
and substemal
extension,
its relation to normal
anatomic
structures,
and the presence
of
metastatic
lymphadenopathy
in the neck.

ET

AL.

AJR:142, May 1984

ACKNOWLEDGMENTS
We thank Pamelia Neal, Connie Faison, and Rose Boyd for assistance in manuscript

preparation.

REFERENCES
1.

Scheible

W,

Leopold

real-time

Woo VL, Gosink

GA,

ultrasonography

of

thyroid

BB. High-resolution
nodules.

Radiology

1979;133:413-417
2. Glazer GM, Axel L, Moss AA. CT diagnosis ofmediastinal
thyroid.
MR 1982;1 38:495-498
3. Binder RE, Pugatch AD, Faling U, Kanter RA, Sawin CT. Diagnosis

of posterior

J Comput

4. Moms

mediastinal

Assist

UL, Colletti

intrathoracic

goiter

by computed

tomography.

1980;4:550-552
PM, RaIls PW, et al. CT demonstration

Tomogr

thyroid

J Comput

tissue.

Assist

Tomogr

of
1982;

6:821-824
5.

Bashist

B,

Ellis

K,

Gold

RP.

Computed

tomography

AJR 1983;1 40: 455-460

6. Sekiya T, Tada 5, Kawakami K, Kino M, Fududa
thoracic

of

intra-

goiters.

H. Clinical

application

of computed

tomography

K, Watanabe
to thyroid

dis-

ease. CT 1979;3:185-193
7.

Pinsky,

5, Ryo

UY.

Thyroid

imaging:

a current

status

report.

In:

Freeman LM, Weissmann

HS, eds. Nuclear medicine
annual
1981. New York: Raven, 1981:157-193
8. Ryo UY, Arnold J, Colman M, et al. Thyroid scintigram. Sensitivity
with

sodium

pinhole

pertechnetate
Tc-99m
and gamma
JAMA 1976;235: 1235-1238

camera

with

collimator.

9. Simeone JF, Daniels GH, Mueller PA, et al. High-resolution

realtime sonography
of the thyroid. Radiology
1982;145:431-435
1 0.

Wolf BS, Nakagawa

with

computed

H, Yeh HC. Visualization

tomography.

Radiology

1 1 . Reede DL, Bergeron AT, McCauley

other thoracic inlet disorders. J Otolaryngol
12. Lindskog GE, Goldenberg IS. Differential
and treatment

13. Schwartz
Principles
14. Steinberg

of substernal

SI, Ullehei

goiter.

AC, Shires

of the thyroid

gland

1977;123:368
DI. CT of the thyroid and of

JAMA

1982;1 1:349-357

diagnosis,

pathology,

1957;1 63:527-529

GT, Spencer

FC, Stor

ER.

of surgery. New York: McGraw-Hill,

1974:1573-1577
I. Retrotracheal
goiter: report of three cases in the
age group. Geriatrics
1968;23: 161-166

geriatric
1 5. Gupta 5K, Sashidharan K, Verma DN. Thyroid swellings and
tracheal changes. Indian J Radio! 1976;30:369-370
16. Attie JN, Khafif RA, Steckler AM. Elective neck dissection in
papillary carcinoma of the thyroid. Am J Surg 1971;122:464471
17. Marchetta FC, Sako K. Modified neck dissection for carcinoma
of the thyroid gland. Surg Gynecol Obstet 1964;1 19:551 -558
18. Block MA. Surgery ofthyroid nodules and malignancy. Curr Probl
Surg

1983;20:

139-203