Ultrasound Thyroid Cancer Features

Hi there,
I'm a sonographer and i do thyroid scans as well as assist radiologists in doing thyroid FNA's quite frequently. I don't have as much knowledge as a radiologist or endo by any means but can give you my insight.
There is absolutely no way other than by doing an FNA to determine malignancy. Thyroid nodules vary drastically. Cystic, solid, complex, etc as you know. The most worrisome features (for our radiologists) are MICROcalcifications and agressive growth. Generally our radiologists do not biopsy any lesion under 1cm unless punctate microcalcs are noted. Cystic nodules (colloid nodules) are generally not worrisome (if they have the true appearance of a colloid) and are not generally biopsied unless grow aggressively. As for vascularity, shape, hypo halo, these things are non specific when it comes to thyroid lesions. The thyroid is a very vascular organ. Malignant nodules can be either hyper or hypo vascular, unlike other tumours in the body which tend to have a certain blood supply. The taller than wide characteristic you describe i have never heard with thyroid nodules. We generally only use this with breast lesions. Perhaps there is some new literature on that but i am not familiar with it at all.

As for mixing samples.
The radiologists NEVER mix samples from different lesions with eachother. Each lesion gets 3 needle passes, atleast one of those samples going on a slide, and the other 2 in a cyto jar. Otherwise the cells from each nodule get mixed and if a malignancy is found, there would be no way to tell which one it came from. Perhaps your endo mixed the samples because the lesions were fairly similar in appearance, close together, were very small or just looked like benign colloids. In that case they probably werent really concerned for malignancy.

If you are very concerned you should have a follow up in 6 months time, and if any of the nodules have grown repeat the biopsy at that time.
Hope this helps

Thanks for your response. But if you look up online taller than wide shape of thyroid nodules you will find *a lot* of information about this as a common thyroid cancer ultrasound feature and I'm really surprised you have never heard of it!

Please look up online the ezxcellent extensive report, The American Association of Clinical Endocriniologists Task Force on Thyroid Nodules and academic papers online by a top University of Penn thyroid cancer doctor, Dr.Susan Mandel and Dr.Jack Baskin who is now retired but he was the past president and founder of The American Association of Clinical Endocrinologists and the director of a thyroid endocrine clinic and they and manyothers have all written about the taller than wide shape of thyroid cancers!

Last year I spoke with a university of Maryland radiologist who co-wrote an excellent article with another university of Maryland radiologist for the online journal, Applied Radiology Journal in March 2007, called, Thyroid Nodules:When to Biopsy, and I told her that my former endo at University of Penn kept dismissing the taller than wide feature as outdated,and she said Oh I think it still holds and that there was a recent study in the online journal Radiology by a Dr.Moon that found this too.

I asked her if it was from Korea and she said yes and after I hung up with her I looked up the study again online and sure enough it was the same exact study I had found recently!

Dr.Mark Lupo said to me last year on The excellent medical forum, Medhelp that taller than wide shape is debated as a suspicious feature but that it's still useful when looking at thyroid nodules.

The American Association of Clinical Endocrinologists Task Force Ojn Thyroid Nodules says to make an exception and biopsy thyroid nodules under 1cm if they have any suspicious ultrasound features which includes, taller than wide shape,hypoechoic,and absent halo all of which I have.

Also in a special online report on the increase in thyroid cancer from The National Cancer Institute last February and March, Dr.Michael Tuttle from the Sloan kettering Cancer Center said that when he was a fellow many years ago they could only biopsy nodules over 1cm, but he said technology has advanced so much that they can now successfully biopsy nodules smaller than 5 and 6mm!

I don't regret that I had my very small thyroid nodules biopsied and they couldn't ever see that I had any Hurthle cells from looking at my nodules on an ultrasound and I will be 45 next year and The National Cancer Institute and others says that after age 45 the prognoses is not as good and by the time my nodules if they are cancer grow large enough to be considered for biopsy, since recent studies found that many small papillary cancers didn't grow in 8 years, I could be 50 or older by the time I'm diagnosed!

Also, my endo couldn't really tell just by looking at my nodules and guessing that they were the same type of nodules are that they were colloid nodules by comning the cells from 2 nodules into one container. He said it cost less to do it this way and that if any were cancer my whole thyroid would have to come out anyway.

He said that he has even heard that the top thyroid cancer doctor Dr.Susan Mandel has done it this way.And Dr.Mark Lupo said to me on Medhelp that it's not an unusual thing to do.

Also there is an excellent online article for the Journal Thyroid from March 2006 written by Dr.Jack Baskin and Dr.Daniel Duick called,The Endocrinologist's View of Ultrasound Guidelines For Fine Needle Aspiration.

In it they criticize the 2004 Society of Radiologists in Ultrasound Conference because it's too narrow and limited because it only uses size and calification as features of when to do a thyroid FNA even though the SRU admits that size is not a determing factor with thyroid cancers and that many are very small.

They give examples of how reseachers found that good % of people with thyroid cancers smaller than 1.5cm were already stage 3 and that it had already spread outside the thyroid.

They explain that many of these people didn't just have solid nodules with calification but many likely had other and additional ultrasound features that are also common with thyroid cancer such as, taller than wide shape, hypoechoic,and absent halo.

Absent halo is found in 80% of thyroid cancers and I have no halo around all 3 nodules! In the online article,Thyroid Nodules:When To Biopsy? the 2 university of Maryland radiologists also report this but they also say that a halo may be absent in over 50% of benign nodules as well.

My daugther was recently dx with multinodulargoiter, she has 3 nodules, 2 of then more the 1cm of size, her tsh/ft4 are normal and she is positive for antithyroid antibodies, the u/s also showed multiples lymphatic nodules arround, at this point I dont know if she needs biopsy, and if this lymphatic nodules are related or symply is a normal finding in childrel. Should this nodules (solids) biopsied??

My daughter too was found to have one nodule on her thyroid during a new patient endocrinology visit to follow up on a prolactinoma. Against her wishes, I went with her to the visit and told the new doctor that she seemed very tired for being 23 years old. He asked if her thyroid had been checked to which I repplied, no. When he felt her neck, he noticed a lump. She had an ultrasound then a biopsy and both showed that it was negative for cancer. However, when she return in 9 months to have a follow up of the nodule, it was found during a second ultrasound that she had 2-3 newer nodules on the left side. The endocrinologist told her to return in 6 months. Instead, I immediately met with two surgeons and requested her thyroid be removed. As a result, cancer was found on one of the smaller and newer nodules! According to the pathology report at the time of her surgery, we were reasured by the surgeon and the endocrinologist that she had papillary carcinoma and the cancer was found inside the nodule and it had not spread. Therefore no other treatment was required other then follow ups. Keep in mind, that in this country, you can consider yourself lucky if you have medical insurance. She didn't. Her employer did not offer insurance. Thanks to the Obamacare, I since have been able to add her to my insurance and she has been able to continue follow ups. Two years after the fact, I insisted that she go to Moffit Cancer Center in Tampa Florida to meet with a different endocrinologist who I felt may have a better background in Oncology. After her visit, one of the Moffit pathologists reviewed all of the records and slides that she had brought with her to the visit. He found that cancer cells were not only inside the nodule but also outside the nodule in the adipose tissue. The only reason that I found this out was because I again insisted that she obtain a copy of that pathology report and when I reviewed it, I found the discrepancy. I then called Moffit to ask them why had they not informed us there was a discrepancy and they could not give me an explanation because they did not have one. So, 1) the pathologist where she had her surgery made a mistake in his findings and 2) the endocrinologist and/or pathologist at Moffit also made a mistake by not communicating with each other and us regarding the discrepancy. This is cancer we are talking about. She just had another ultrasound and was told that she was ok. Since she now knows that I want to see every report, she had a copy of the ultrasound report mailed to me. Findings indicate bilateral hypoechoic foci which to me does not sound good. From what I understand this is a term used when sound bounces back faster then it should if there was normal tissue. So, if is not bouncing back fast enough, to me that means there is abnormal or dense tissue. The fix, just keep coming back for follow ups. It is no wonder that people are dying of cancer because it is found too late. Doctors keep telling patients to come back for follow ups. If I would have waited, it would have been much worse. What I have learned...do not trust any doctor and if your daugher is over 18 and thinks she is an adult and can meet with the doctor herself, go to the doctor's visits with her anyway and ask questions. Best of luck.

My daughter too was found to have one nodule on her thyroid during a new patient endocrinology visit to follow up on a prolactinoma. Against her wishes, I went with her to the visit and told the new doctor that she seemed very tired for being 23 years old. He asked if her thyroid had been checked to which I repplied, no. When he felt her neck, he noticed a lump. She had an ultrasound then a biopsy and both showed that it was negative for cancer. However, when she return in 9 months to have a follow up of the nodule, it was found during a second ultrasound that she had 2-3 newer nodules on the left side. The endocrinologist told her to return in 6 months. Instead, I immediately met with two surgeons and requested her thyroid be removed. As a result, cancer was found on one of the smaller and newer nodules! According to the pathology report at the time of her surgery, we were reasured by the surgeon and the endocrinologist that she had papillary carcinoma and the cancer was found inside the nodule and it had not spread. Therefore no other treatment was required other then follow ups. Keep in mind, that in this country, you can consider yourself lucky if you have medical insurance. She didn't. Her employer did not offer insurance. Thanks to Obamacare, I since have been able to add her to my insurance and she has been able to continue follow ups. Two years after the fact, I insisted that she go to Moffit Cancer Center in Tampa Florida to meet with a different endocrinologist who I felt may have a better background in Oncology. After her visit, one of the Moffit pathologists reviewed all of the records and slides that she had brought with her to the visit. He found that cancer cells were not only inside the nodule but also outside the nodule in the adipose tissue. The only reason that I found this out was because I again insisted that she obtain a copy of that pathology report and when I reviewed it, I found the discrepancy. I then called Moffit to ask them why had they not informed us there was a discrepancy and they could not give me an explanation because they did not have one. So, 1) the pathologist where she had her surgery made a mistake in his findings and 2) the endocrinologist and/or pathologist at Moffit also made a mistake by not communicating with each other and us regarding the discrepancy. This is cancer we are talking about. She just had another ultrasound and was told that she was ok. Since she now knows that I want to see every report, she had a copy of the ultrasound report mailed to me. Findings indicate bilateral hypoechoic foci which to me does not sound good. From what I understand this is a term used when sound bounces back faster then it should if there was normal tissue. So, if is not bouncing back fast enough, to me that means there is abnormal or dense tissue. The fix, just keep coming back for follow ups. It is no wonder that people are dying of cancer because it is found too late. Doctors keep telling patients to come back for follow ups. If I would have waited, it would have been much worse. What I have learned...do not trust any doctor and if your daugher is over 18 and thinks she is an adult and can meet with the doctor herself, go to the doctor's visits with her anyway and ask questions. Best of luck.

So glad that your daughter's condition was caught and that she will be okay. Luckily, Papillary thyroid cancer is easy to treat and has a *very* high cure rate. But like you said, not everyone is as lucky. Had she had something worse and a less insistent parent, things could have turned out differently.

As someone who was also diagnosed with thyroid cancer at a young age (24--I'm 30 now), I know how important it is to follow up and be your own advocate, to ask questions and do research. Just make sure you are telling her all the information and that the final decision is hers, after all, she is an adult, even if you are her parent. One day, she will have to be in charge of her own care and will have to be secure in herself to know that she can handle things without you. Just some friendly advice from someone who has been where your daughter is.

Best of luck to both of you.

These past 9 mos. I have been experiencing throat/neck pain. At first I thought it was from not drinking enough water with my night meds. I went through a few lidocaine cocktails at work to get me by, but they didn't work,lol. The pain has gotten to be quite bothersome lately, which prompted me to get it checked. My wonderful ARNP found a lump ... See morethat she felt needed to be examined by an ultrasound. I had the test on October 9,2009. I recieved results and the report read of a hypoechoic noncystic nodule with vascular character 1.2cm maximum dia. in the lower pole right lobe of my thyroid gland. There is also a 4mm vascular nodule hypoechoic focus centrally observed in the left lobe. The gland is otherwise homogeneous in echotexture and normal in vascularity and normal in size. I was told by my Doctor that I would need to find an oncologist. I was scheduled for the next step which was a thyriod scan. It was fine. Thyroid Peroxidase Antibodies <10 ref. range <35 IU/mL Thyroglobulin Antibodies <20 ref. range <20 IU/mL Thyroglobulin 9.8 ref range 2.0-35.0 ng/mL Path Report is so hard to understand though Clinical Data: RIGHT THYROID NODULE DIAGNOSIS: FNA, RIGHT THYROID NODULE: MICROFOLLICULAR PREDOMINANT PATTERN WITH ABUNDANT COLLOID. MICROSCOPIC DESCRIPTION: It appears mostly microfollicular with nuclear overriding. Classification: Indeterminate. Due to the predominance of the microfollicular pattern a follicular neoplasm cannot be totally excluded. I drove 6 hours to Moffitt to be seen to sch. surgery like edno said but the surgeon didn't act concerned and told me to repeat all tests in 6 months... it has been almost 3 and I have had no relief from the dull ache in there. I am having night sweats on and off too, can anyone help? Since all tests except FNA came back fine do I really need to have a TT?




I went to work this morning, knowing I had to leave early to take my daughter to the ENT today for preop for tonsillectomy,andenoidectomy, and turbinate (sp?) reduction. My office refers to this particular ENT all the time since he is top notch. I have not heard anything negative about him. So, I phoned over to see if they could get me in to get established at the same time we had to pick up my daughter's paperwork to take to the surgery center. To my surprise they could! I knew I needed to get a second opinion about the follicular adenoma/neoplasm since it has been three months since going to Moffitt Cancer Center Endocrine Tumor Program. I brought all of my test results and he looked everything over. He asked how it all started last April... I said with pain (dull constant ache). He agreed with endogrinologist that the lobe should be removed. He spent quite a bit of time listening to me and noted the growth in the nodule when he palpated. He validated my pain by saying that it was a way to let me know my body was responding to something that should not be there. He has all records except my slides and films, which are at Moffitt, but I do not think he needs them since he has the reports. I simply asked him what would he suggest I do and he said it definately needed to come out and I agreed to let him be my surgeon. I asked him how he planned to do the surgery and he told me he does the traditional cut. He explained that way may be best so he could place a drain to control a possible hematoma since I have developed them after every surgery so far. He walked me to the surgery scheduler's office and chatted with her while I waited and she asked me to come in and told me he wanted the first available date. I did not expect to be scheduled so quickly, I guess, since I just went in for a second opinion and to discuss my case. At first I kinda freaked that there was an opening on the 26th (my anniversary) so I asked her if we might be able to PENCIL it in for the following month, because I needed to talk to my family and my job, and she did. We decided on March 2nd and that was the latest she wanted me to go out. I was able to sit and discuss all the details with my husband. He had a lot of questions of course and he said to go ahead with Feb. 26th. He dosen't want to wait. I called the Scheduler with him and she said that would be fine but she would be at my chosen hospital on the 16th (Feb.) with Dr. for surgeries that morning. They perform surgery at two hospitals in the area and he also works at a free standing surgery center where he is part owner. She told me he may be able to cancel his office visits, or clinic to be able to do it that afternoon. I was shocked that he would do that! I told her that I would wait until the 26th and she said the 16th would be fine and to give her 10 minutes so she could text him! Wow, I felt odd, lol. She called me back in five and told me he said it was a go and to be back there on Monday for preop at 1pm AND told me she was going to book me to see him, which is not heard of! He is cancelling his clinic for that afternoon! She said to gather all the questions and bring them in and he will patiently answer all of them. So! Surgery is set for Feb 16th 2010. I am comfortable with this as I am very tired of dealing with the achiness in my throas and the other symptoms. I am not ready for the healing time and the wait for pathology to come back, even though I KNOW God is performing miracles and all WILL come back fine! I have had to deal with surgical menopause and hate the idea of another hormone shift. However this has been going on since last April-May and this too shall pass, right?