SONOWORLD : Papillary carcinoma of the thyroid with cervical nodal metastases
 
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Thyroid/parathyroid » General
Papillary carcinoma of the thyroid with cervical nodal metastases
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Presentation A 25 year old woman presented with firm right lateral neck swelling. She also had a six pound weight loss over a period of one month. An ultrasound of the neck was performed.
 
 
 
Caption: Transverse scan at the site of neck swelling.
Description: Transverse view reveals a rounded hypoechoic mass lateral to the jugular and the common carotid vessels. The mass shows a few areas of fine punctate calcification. This is suspicious for an abnormal node.
 
 
 
Caption: Transverse thyroid scan.
Description: The right thyroid gland demonstrates a well-defined hypoechoic mass in the superior part of the gland. The mass shows areas of punctate calcification [similar to the kind seen in the right nodal mass] and also a few areas of heterogeneity.
 
 
 
Caption: Sagittal scan of the right thyroid gland.
Description: Sagittal view demonstrating the mass in the thyroid gland with the non-shadowing calcific areas. An anechoic area is also noted within the mass, suggestive of cystic change.
 
 
 
Caption: Color Doppler scan of the right thyroid gland.
Description: Color Doppler view showing areas of vascularity surrounding the mass, with some internal vascularity.
 
 
 
Caption: Color Doppler view of the right lateral neck mass.
Description: The right nodal mass also shows increased internal vascularity.
 
 
 
Caption: Power Doppler view of the node.
Description: Increased vascularity is noted throughout the node.
 
Differential Diagnosis Malignant nodule in the thyroid gland with lymph node metastases.
 
Final Diagnosis Papillary carcinoma of the right thyroid gland with cervical lymph node metastases.
 
Discussion Papillary carcinoma is the most common thyroid malignancy, followed by follicular, anaplastic and medulary carcinoma. Papillary carcinoma is commonly seen in the younger age group, and is usually occult. The young adult often presents with nodal metastases as the primary complaint, with ultrasound of the neck revealing the occult nodule in the thyroid. Papillary carcinoma has a good prognosis, and hence it should be treated aggressively.

Ultrasound is an effective imaging modality for thyroid malignancies because of the inherent high echogenicity of the gland and superficial location rendering high resolution scanning possible. Since many of these thyroid malignancies are occult, ultrasound provides easy detection of these masses which are usually hypoechoic contrasted against the relatively echogenic thyroid gland. At the same time ultrasound can also detect the involved cervical nodes which, if metastatic, become rounded and lose their central hilar echo complex.

Papillary carcinoma has a broad spectrum of sonographic appearances. Chan, et al reviewed the common features of papillary carcinoma. These include:
1. A hypoechoic mass with well-defined margins
2. Microcalcifications or no calcifications
3. Hypervascularity
4. Heterogeneity is also a common finding
The uncommon features of this malignancy include:
1. A hyperechoic appearance
2. Irregular margins of the mass [may predict tumor invasion]
3. Coarse calcifications [click here to view] 
4. Cystic areas within the mass
If the mass is completely encapsulated, then the halo sign is usually seen.

There have been conflicting views regarding the reliability of microcalcifications as indicators for malignancy. However, most studies agree that small echogenic particles without acoustic shadowing mainly constitute microcalcifications which have a high specificity as a marker for malignancy. Accordingly, any thyroid mass detected with ultrasound should be carefully inspected for the presence of microcalcifications. Hatabu, et al described a new sonographic sign of ‘a calcified nodule in a cyst’, that should raise suspicion for a cystic papillary carcinoma. However, it should be noted that these echogenic areas may sometimes represent fibrous bands and condensed colloids.

Since many thyroid carcinomas present as occult masses, ultrasound guidance for FNA of these clinically non-palpable thyroid nodules is often necessary. Current literature recommends high resolution ultrasound imaging of the neck combined with fine needle aspiration as an initial diagnostic test in suspect thyroid malignancies.

Most thyroid nodules are benign, but for those that are not absolutely benign in ultrasound characteristics FNA biopsy is currently the best method to diagnose malignancy. Ultrasound also provides a convenient and reliable means for following benign lesions over time.

 
Case References 1. RS. Role of ultrasonography in the diagnosis and management of thyroid cancer. Endocr Pract. 2000 Sep-Oct;6(5):396-400.
2. Chan BK, Desser TS, et al. Common and uncommon sonographic features of papillary thyroid carcinoma. J Ultrasound Med. 2003 Oct; 22(10):1083-90.
3. Lu C, Chang TC, et al. Ultrasonographic findings of papillary thyroid carcinoma and their relation to pathologic changes. J Formos Med Assoc. 1994 Nov-Dec; 93(11-12):933-8.
4. Lin JD, Huang BY, et al. Diagnosis of occult thyroid carcinoma by thyroid ultrasonography with fine needle aspiration cytology. Acta Cytol. 1997 Nov-Dec; 41(6):1751-6.
5. Consorti F, et al. Clinical significance of thyroid nodule calcification. G Chir. 2003 Mar; 24(3):78-81.
6. Hatabu H, et al. Cystic papillary carcinoma of the thyroid gland: a new sonographic sign. Clin Radiol. 1991 Feb; 43(2):121-4.
7. Takashima S, et al. Thyroid nodules: re-evaluation with ultrasound. J Clin Ultrasound. 1995 Mar-Apr; 23(3):179-84.
 
Follow Up Papillary carcinoma of the thyroid was diagnosed histologically and confirmed at surgery.
 
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