Diagnostic Ultrasound

The state-of-the-art thyroid ultrasound lab at the Thyroid Center of Santa Monica is equipped with the best technology available to perform ultrasound-guided biopsies of the thyroid, lymph nodes, and parathyroid gland. Dr. Guttler is a sonologist and does all his own ultrasound examinations without a technician.

A dynamic ultrasound done by a thyroid specialist produces the best results in the workup of thyroid nodules. Clear images are a must for accurate thyroid evaluation, an ultrasound-guided needle biopsy, and thyroid nodule follow-up care.

Dr. Richard Guttler offers:

  • Diagnostic ultrasound for thyroid evaluation
  • Ultrasound for pre-op and post-op cancer lymph node mapping
  • Ultrasound-guided needle placement for biopsies
  • Interventional ultrasound-guided injection of ethanol, known as PEI, for non-surgical therapy for thyroid and parathyroid cysts, and for destroying cancer lymph nodes when surgery is not desired or safe

The ultrasound machine is a safe, painless, and non-invasive way to make an image of the thyroid gland without the use of X-rays or injections of radioactive-labeled iodine. A small device like a microphone that sends and receives sound waves is placed over the thyroid gland. The image of the gland is captured by the computer, analyzed, and recorded as a graphic image.

If you’ve had a prior ultrasound that was negative and you are seeking a second opinion, we have a good chance to find the abnormality in your gland because of the experience we have with ultrasound-guided biopsies. Once we find the problem, we can do ultrasound-guided FNA (fine needle aspiration) and washings for PTH.

Ultrasounds are done by Dr. Guttler and read immediately on site. Your diagnosis and treatment can be completed quickly

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Clinical Evaluation

• Male gender.
• Patient’s age 60 years.
• History of head and neck irradiation for thymic and tonsil­lar hypertrophy.acne, etc. or radiotherapy of any kind.
• Family history of thyroid cancer. Papillary thyroid carci­noma (PTC) can be familial in up to 10 % of cases.There is an eightfold increased risk of developing thyroid cancer when there is such a history in a first-degree relative.

Personal history of syndromes or malignancy associated with thyroid cancer in a first-degree relative. i.e., Cowden or Wermer syndrome.familial polyposis, Carney complex and multiple endocrine neoplasia (MEN) types l and 2. PTC can occur in association with acromegaly. papillary renal cell carcinoma, parathyroid tumors, paragangliomas, and ataxia-telangiectasia.

• Rapid nodule growth, firm, and fixed to adjacent tissues.
• Hoarseness, vocal cord paralysis, dysphonia, dysphagia. and dyspnea.
• Enlarged ipsilateral neck lymph nodes.

Ultrasound Characteristics of Thyroid Nodules
The Society of Radiologists in Ultrasound issued a consensus statement in 2004 to determine which thyroid nodules should or should not undergo USG-FNA based on US characteristics.

It was concluded that (1) the various US features studied are not specific in separating benign from malignant thyroid nod­ules due to overlapping characteristics and (2) FNA diagnosis is required before the patient undergoes thyroid surgery for a possible thyroid malignancy.

The US evaluation of a thyroid nodule includes size. echo­genicity (isoechoic, hypoechoic or hyperechoic). composi­tion (cystic, solid, mixed). calcifications
(fine. coarse). halo.

USG-FNA of a given thyroid nodule are determined
mainly by the US characteristics of the nodule
and less by the number of nodules or the
nodule size.

l. Echorexture. A purely cystic nodule
a spongiform­ appearing nodule (multiple
microcystic components in
>50 % (Fig. 3.6), or a complex nodule more
than 50 % cystic (Fig. 3.7) is highly predictive for being benign.

However, malignancy should be considered in cysts
with an irregular/thick wall and microcalcifications or
when a mural nodule has vascularity .
2. Echogenisity
3. Calcifications

4. Margins. The margins of a benign thyroid nodule are usu­
ally regular and well defined, with a smooth, thin surface
5. Halo

6.Doppler

7. Shape. The nodule shape may help to predict malignancy
and prompt one to perform a

USG-FNA. Spherical shape and nodules that are taller
(anteroposterior
diameter) than wide ( transverse diameter) in the
transverse view sta­tistically may be associated with a malignant diagnosis

8. Comet-rail sign. Comet tails are reverberation (“·echo”) artifacts that
result from the reflection of sound waves off of the crystals present
in the desiccated thick
colloid,result­ing in a bright signal:the crystals vibrate under the
sound energy,
producing the comet tail. This sign is reported to be almost
pathognomonic for a benign thyroid nodule, particularly if present
at the periphery of cystic nodules.

Other aggressive malignancies; including lymphoma have lymph node
involve­ment at initial diagnosis.
American
Thyroid Association guidelines, US is the imaging modality of choice
in the evaluation of thyroid nodules.
Preoperative evaluation of patients with known differentiated
thyroid cancer (DTC), (2) the US features of a thyroid nodule are
helpful in predicting malig­nancy or benignity, but they do not
replace the need
to per­form USG-FNA. and (3) US examination is particularly

useful in the selection

of the nodule for USG -FN A in multi­nodular goiter.

Indications for USG-FNA of Thyroid Nodules

The indications arc summarized in Table 3.2.

USG-core needle biopsies arc not recommended for thyroid nodules
due 10
lack of appropriate sampling, particularly in follicular neoplasms or
lesions, and serious complication such as bleeding and pain. nerve
injury, tracheal perforat ion, a nd architectural di tortion that precl ude
accurate histologic interpreta t ion in subsequently excised
specinlens.USG-core needle biopsies may be complementary to FNA
in selected cases
such as diffuse Hashimoto·s thyroiditis and perhaps an advanced
malignant neoplasm.
Thyroid USG-FNA Approach
The superficial location of the thyroid gland facilitates tactile
examination. US evaluation . and FNA. Adequate patient positioning
is crucial for achieving success. Wilh the patient in the supine position
. a pillow shou ld be placed under the shoulders to produce slight
ovcrex1en ion of the neck. Then, US evaluation of both lobes in
the transverse and
TABLE 3.2 Recommendations for USG-FNA: various societies

A.Thyroid nodules that are >1.0 cm
1. All societies except the SRUS recommend USG-FNA of all
nodules 2:1.0 cm
2. Solitary nodule wilh rnicrocalcificalions
3. Solitary nodule with coarse calcificalions or solid nodule
4. Solitary predominantly cystic with a solid mural component
or mixed solid and cystic nodule if 2:2 cm (SRUS). Other
societies recommend USG-FNA of all nodules if 2 cm
5. Solitary nodule having a substanlial growth since prior US
examination. The ATA considers 20 % increase in 2 or the 3
diameters (2:2 mm each) as reasonable nodule growth
6. I f multiple nodules are presen t, select the one() for
USG­ FNA. applying the previous 2-5 criteria for solitary nodules
(in that order)
7. If abnormal cervical lymph node(s) is present. USG-
FNA of the lymph node and or any ipsilateral thyroid
nodule should be done regardless of t he US characteristics
(a) The US features associated with cancer in a lymph
node include loss of fatty hilum, round shape. well-
defined edges. taller than wide. calcifications, cyslic areas.
and increased peripheral vascularity regardless of size
(Fig.3.17)
(b) Thyroid cancer most commonly metastasizes to neck
levels IJ I. I V, and VI. Maligaancy is con(irmed by cytologic
evaluation and/or measurement of thyroglobulin levels in
needle rinses
8. If the nodule is entirely cystic, or stable in size. or none
or the above listed features is seen. then probably
USG-FNA is unnecessary

8. Special considerations for USG-FNA of nodules 90 % diagnostic rate
2. Abnonnal neck lymphadenopathy. US criteria as described
in the prior section
3. History of head and neck irradiation i n childhood or adolescence
4. History of thyroid cancer in one or more first-degree relatives
5. History of prior hernithyroidectomy with incidentally found
thyroid cancer
6. Nodule incidentally found by PET) imaging for other reasons the
risk of malignancy
in these nodules is 15-50 %. and cancers may be more
aggressive. Most are
PTC and others are follicular or H urthlc cell neoplasms
7. Nodule incidentally found by sestamibi scan, a nuclear
medicine scan for parathyroid gland disorders and confirmed
by thyroid US. has a high incidence of malignancy (22-
66 %) and should be sampled

ACT Academy of Clinical Thyroidologists. ATA American
TI1yroid Association,AACE American Academy of
Clinical Endocrinologists.
SRUS Society of Radiologists in Ultrasound

Contact Info
1328 16th Street, Santa Monica, CA 90404
Monday – Friday
9:00 AM to 5:00 PM
(310) 393-8860