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Feature Illustration: Thyroid Nodule Margins and Extrathyroidal Extension and Invasion

  • Mira MilasEmail author
  • Dubravka Milas Tollison
  • Zvonimir Luka Milas
Chapter
  • 1.1k Downloads

Abstract

Appreciation of the contour of thyroid nodules is relevant, in the most practical sense, as one feature that contributes to the assessment of risk of malignancy, where those contours may be irregular and infiltrative. All other appearances of the contour, or margin, of a thyroid nodule are useful for overall characterization of the nodule but alone are not sufficient for determination of the need to biopsy and especially not for diagnosis. Physicians and sonographers who perform thyroid ultrasound benefit from keen observation and cultivating knowledge in interpreting margin features accurately. Contour is an essential feature to include in ultrasound reporting. The focus of this chapter is to provide both definitions and ultrasound illustrations related to thyroid nodule margins.

Keywords

Thyroid nodules Thyroid nodule margins Biopsy Ultrasound Sonographers Contour 

Supplementary material

Video 11.1a

(ae) Examples of nodules with smooth margins. Examples (a) through (c) show nodules with a smooth margin. Examples (d) and (e) are nodules that have a halo that has an outer smooth margin although the thickness of the halo varies as it surrounds the nodule. Different observers may classify these nodules as an example of a non-smooth margin. These examples convey the inherent subjective nature variation of ultrasound interpretation, even among experts (MP4 2266 kb)

Video 11.1b

(ae) Examples of nodules with smooth margins. Examples (a) through (c) show nodules with a smooth margin. Examples (d) and (e) are nodules that have a halo that has an outer smooth margin although the thickness of the halo varies as it surrounds the nodule. Different observers may classify these nodules as an example of a non-smooth margin. These examples convey the inherent subjective nature variation of ultrasound interpretation, even among experts (MP4 1724 kb)

Video 11.1c

(ae) Examples of nodules with smooth margins. Examples (a) through (c) show nodules with a smooth margin. Examples (d) and (e) are nodules that have a halo that has an outer smooth margin although the thickness of the halo varies as it surrounds the nodule. Different observers may classify these nodules as an example of a non-smooth margin. These examples convey the inherent subjective nature variation of ultrasound interpretation, even among experts (MP4 9649 kb)

Video 11.1d

(ae) Examples of nodules with smooth margins. Examples (a) through (c) show nodules with a smooth margin. Examples (d) and (e) are nodules that have a halo that has an outer smooth margin although the thickness of the halo varies as it surrounds the nodule. Different observers may classify these nodules as an example of a non-smooth margin. These examples convey the inherent subjective nature variation of ultrasound interpretation, even among experts (MP4 1852 kb)

Video 11.1e

(ae) Examples of nodules with smooth margins. Examples (a) through (c) show nodules with a smooth margin. Examples (d) and (e) are nodules that have a halo that has an outer smooth margin although the thickness of the halo varies as it surrounds the nodule. Different observers may classify these nodules as an example of a non-smooth margin. These examples convey the inherent subjective nature variation of ultrasound interpretation, even among experts (MP4 5935 kb)

Video 11.2a

(ae) Examples of nodules with lobulated margins: invasive papillary thyroid carcinoma in transverse (a) and longitudinal (b) views; (c) represents multiple coalesced smaller nodules, including an area with eggshell calcifications; while this pattern may appear lobulated, it really represents a bundle of smaller nodules and had benign final histology (c); follicular thyroid cancer with lobulated, irregular and in areas indistinct margins perhaps with suggestion of extrathyroidal extension (d); lobulated nodule in longitudinal view also exhibiting irregular margins of a smoother wavy configuration, and consideration of possible extrathyroidal extension at the deep margin (e) (MP4 3408 kb)

Video 11.2b

(ae) Examples of nodules with lobulated margins: invasive papillary thyroid carcinoma in transverse (a) and longitudinal (b) views; (c) represents multiple coalesced smaller nodules, including an area with eggshell calcifications; while this pattern may appear lobulated, it really represents a bundle of smaller nodules and had benign final histology (c); follicular thyroid cancer with lobulated, irregular and in areas indistinct margins perhaps with suggestion of extrathyroidal extension (d); lobulated nodule in longitudinal view also exhibiting irregular margins of a smoother wavy configuration, and consideration of possible extrathyroidal extension at the deep margin (e) (MP4 5381 kb)

Video 11.2c

(ae) Examples of nodules with lobulated margins: invasive papillary thyroid carcinoma in transverse (a) and longitudinal (b) views; (c) represents multiple coalesced smaller nodules, including an area with eggshell calcifications; while this pattern may appear lobulated, it really represents a bundle of smaller nodules and had benign final histology (c); follicular thyroid cancer with lobulated, irregular and in areas indistinct margins perhaps with suggestion of extrathyroidal extension (d); lobulated nodule in longitudinal view also exhibiting irregular margins of a smoother wavy configuration, and consideration of possible extrathyroidal extension at the deep margin (e) (MP4 1888 kb)

Video 11.2d

(ae) Examples of nodules with lobulated margins: invasive papillary thyroid carcinoma in transverse (a) and longitudinal (b) views; (c) represents multiple coalesced smaller nodules, including an area with eggshell calcifications; while this pattern may appear lobulated, it really represents a bundle of smaller nodules and had benign final histology (c); follicular thyroid cancer with lobulated, irregular and in areas indistinct margins perhaps with suggestion of extrathyroidal extension (d); lobulated nodule in longitudinal view also exhibiting irregular margins of a smoother wavy configuration, and consideration of possible extrathyroidal extension at the deep margin (e) (MP4 7339 kb)

Video 11.2e

(ae) Examples of nodules with lobulated margins: invasive papillary thyroid carcinoma in transverse (a) and longitudinal (b) views; (c) represents multiple coalesced smaller nodules, including an area with eggshell calcifications; while this pattern may appear lobulated, it really represents a bundle of smaller nodules and had benign final histology (c); follicular thyroid cancer with lobulated, irregular and in areas indistinct margins perhaps with suggestion of extrathyroidal extension (d); lobulated nodule in longitudinal view also exhibiting irregular margins of a smoother wavy configuration, and consideration of possible extrathyroidal extension at the deep margin (e) (MP4 6107 kb)

Video 11.3

Irregular (jagged) margins in a nodule detectable only along the inferior margin on this longitudinally oriented cine sweep which appears to have smooth contour in other areas (MP4 1702 kb)

Video 11.4a

(af) Examples of nodules with irregular margins: three nodule types are visible (a, left to right: isoechoic solid, hypoechoic small, spongiform large); small papillary thyroid cancer with extrathyroidal extension (b); small papillary thyroid cancer (c); isoechoic nodule with thin halo and irregular margins, final histology showed minimally invasive follicular thyroid cancer (MIFTC, cine clip d); vascularity along thin halo of MIFTC (e); irregular margins of papillary thyroid cancer seen sonographically (f) show direct correlation to the cut section of the same nodule in surgical specimen (Fig. 11.5) (MP4 6159 kb)

Video 11.4b

(af) Examples of nodules with irregular margins: three nodule types are visible (a, left to right: isoechoic solid, hypoechoic small, spongiform large); small papillary thyroid cancer with extrathyroidal extension (b); small papillary thyroid cancer (c); isoechoic nodule with thin halo and irregular margins, final histology showed minimally invasive follicular thyroid cancer (MIFTC, cine clip d); vascularity along thin halo of MIFTC (e); irregular margins of papillary thyroid cancer seen sonographically (f) show direct correlation to the cut section of the same nodule in surgical specimen (Fig. 11.5) (MP4 1547 kb)

Video 11.4c

(af) Examples of nodules with irregular margins: three nodule types are visible (a, left to right: isoechoic solid, hypoechoic small, spongiform large); small papillary thyroid cancer with extrathyroidal extension (b); small papillary thyroid cancer (c); isoechoic nodule with thin halo and irregular margins, final histology showed minimally invasive follicular thyroid cancer (MIFTC, cine clip d); vascularity along thin halo of MIFTC (e); irregular margins of papillary thyroid cancer seen sonographically (f) show direct correlation to the cut section of the same nodule in surgical specimen (Fig. 11.5) (MP4 2795 kb)

Video 11.4d

(af) Examples of nodules with irregular margins: three nodule types are visible (a, left to right: isoechoic solid, hypoechoic small, spongiform large); small papillary thyroid cancer with extrathyroidal extension (b); small papillary thyroid cancer (c); isoechoic nodule with thin halo and irregular margins, final histology showed minimally invasive follicular thyroid cancer (MIFTC, cine clip d); vascularity along thin halo of MIFTC (e); irregular margins of papillary thyroid cancer seen sonographically (f) show direct correlation to the cut section of the same nodule in surgical specimen (Fig. 11.5) (MP4 1278 kb)

Video 11.4e

(af) Examples of nodules with irregular margins: three nodule types are visible (a, left to right: isoechoic solid, hypoechoic small, spongiform large); small papillary thyroid cancer with extrathyroidal extension (b); small papillary thyroid cancer (c); isoechoic nodule with thin halo and irregular margins, final histology showed minimally invasive follicular thyroid cancer (MIFTC, cine clip d); vascularity along thin halo of MIFTC (e); irregular margins of papillary thyroid cancer seen sonographically (f) show direct correlation to the cut section of the same nodule in surgical specimen (Fig. 11.5) (MP4 1851 kb)

Video 11.4f

(af) Examples of nodules with irregular margins: three nodule types are visible (a, left to right: isoechoic solid, hypoechoic small, spongiform large); small papillary thyroid cancer with extrathyroidal extension (b); small papillary thyroid cancer (c); isoechoic nodule with thin halo and irregular margins, final histology showed minimally invasive follicular thyroid cancer (MIFTC, cine clip d); vascularity along thin halo of MIFTC (e); irregular margins of papillary thyroid cancer seen sonographically (f) show direct correlation to the cut section of the same nodule in surgical specimen (Fig. 11.5) (MP4 4927 kb)

Video 11.5a

(ag) Examples of nodules with indistinct margins: papillary thyroid carcinoma in isthmus (a); papillary thyroid carcinoma transverse (b) and longitudinal (c) views; noninvasive follicular variant of papillary thyroid carcinoma (d)—note that around the cystic center, there is a perimeter of solid tissue, and it is the outer border of this solid circumference that is indistinct; right lobe benign thyroid nodule in transverse (e) and longitudinal (f) views, showing that even benign nodules can sometimes have ill-defined and indistinct margins; papillary thyroid carcinoma with microcalcifications and no extrathyroidal extension (g) (MP4 4280 kb)

Video 11.5b

(ag) Examples of nodules with indistinct margins: papillary thyroid carcinoma in isthmus (a); papillary thyroid carcinoma transverse (b) and longitudinal (c) views; noninvasive follicular variant of papillary thyroid carcinoma (d)—note that around the cystic center, there is a perimeter of solid tissue, and it is the outer border of this solid circumference that is indistinct; right lobe benign thyroid nodule in transverse (e) and longitudinal (f) views, showing that even benign nodules can sometimes have ill-defined and indistinct margins; papillary thyroid carcinoma with microcalcifications and no extrathyroidal extension (g) (MP4 4500 kb)

Video 11.5c

(ag) Examples of nodules with indistinct margins: papillary thyroid carcinoma in isthmus (a); papillary thyroid carcinoma transverse (b) and longitudinal (c) views; noninvasive follicular variant of papillary thyroid carcinoma (d)—note that around the cystic center, there is a perimeter of solid tissue, and it is the outer border of this solid circumference that is indistinct; right lobe benign thyroid nodule in transverse (e) and longitudinal (f) views, showing that even benign nodules can sometimes have ill-defined and indistinct margins; papillary thyroid carcinoma with microcalcifications and no extrathyroidal extension (g) (MP4 2000 kb)

Video 11.5d

(ag) Examples of nodules with indistinct margins: papillary thyroid carcinoma in isthmus (a); papillary thyroid carcinoma transverse (b) and longitudinal (c) views; noninvasive follicular variant of papillary thyroid carcinoma (d)—note that around the cystic center, there is a perimeter of solid tissue, and it is the outer border of this solid circumference that is indistinct; right lobe benign thyroid nodule in transverse (e) and longitudinal (f) views, showing that even benign nodules can sometimes have ill-defined and indistinct margins; papillary thyroid carcinoma with microcalcifications and no extrathyroidal extension (g) (MP4 6521 kb)

Video 11.5e

(ag) Examples of nodules with indistinct margins: papillary thyroid carcinoma in isthmus (a); papillary thyroid carcinoma transverse (b) and longitudinal (c) views; noninvasive follicular variant of papillary thyroid carcinoma (d)—note that around the cystic center, there is a perimeter of solid tissue, and it is the outer border of this solid circumference that is indistinct; right lobe benign thyroid nodule in transverse (e) and longitudinal (f) views, showing that even benign nodules can sometimes have ill-defined and indistinct margins; papillary thyroid carcinoma with microcalcifications and no extrathyroidal extension (g) (MP4 5950 kb)

Video 11.5f

(ag) Examples of nodules with indistinct margins: papillary thyroid carcinoma in isthmus (a); papillary thyroid carcinoma transverse (b) and longitudinal (c) views; noninvasive follicular variant of papillary thyroid carcinoma (d)—note that around the cystic center, there is a perimeter of solid tissue, and it is the outer border of this solid circumference that is indistinct; right lobe benign thyroid nodule in transverse (e) and longitudinal (f) views, showing that even benign nodules can sometimes have ill-defined and indistinct margins; papillary thyroid carcinoma with microcalcifications and no extrathyroidal extension (g) (MP4 6160 kb)

Video 11.5g

(ag) Examples of nodules with indistinct margins: papillary thyroid carcinoma in isthmus (a); papillary thyroid carcinoma transverse (b) and longitudinal (c) views; noninvasive follicular variant of papillary thyroid carcinoma (d)—note that around the cystic center, there is a perimeter of solid tissue, and it is the outer border of this solid circumference that is indistinct; right lobe benign thyroid nodule in transverse (e) and longitudinal (f) views, showing that even benign nodules can sometimes have ill-defined and indistinct margins; papillary thyroid carcinoma with microcalcifications and no extrathyroidal extension (2) (MP4 1802 kb)

Video 11.6a

(ac) Examples of nodules with infiltrative margins: medullary thyroid cancer (MTC) in the right thyroid lobe with extrathyroidal extension (ETE) and central and lateral neck lymph node metastases (a); the normal left thyroid lobe of this same MTC case, shown here to illustrate the crisp hyperechoic line between the thyroid capsule and overlying strap muscles in contrast to the ETE in this area on the right lobe (b); nodule with infiltrative features, ETE, calcifications, and indistinct borders (c) (MP4 4784 kb)

Video 11.6b

(ac) Examples of nodules with infiltrative margins: medullary thyroid cancer (MTC) in the right thyroid lobe with extrathyroidal extension (ETE) and central and lateral neck lymph node metastases (a); the normal left thyroid lobe of this same MTC case, shown here to illustrate the crisp hyperechoic line between the thyroid capsule and overlying strap muscles in contrast to the ETE in this area on the right lobe (b); nodule with infiltrative features, ETE, calcifications, and indistinct borders (9) (MP4 3309 kb)

Video 11.6c

(ac) Examples of nodules with infiltrative margins: medullary thyroid cancer (MTC) in the right thyroid lobe with extrathyroidal extension (ETE) and central and lateral neck lymph node metastases (a); the normal left thyroid lobe of this same MTC case, shown here to illustrate the crisp hyperechoic line between the thyroid capsule and overlying strap muscles in contrast to the ETE in this area on the right lobe (b); nodule with infiltrative features, ETE, calcifications, and indistinct borders (c) (MP4 5992 kb)

Video 11.7a

(ae) Examples of nodules with halo margins: nodule with halo showing edge shadowing artifact (a) and vascularity (b) in transverse views and longitudinal view (c); isoechoic nodule with variably thin and thick halo and no extrathyroidal extension (d); nodule with incomplete and less vascular halo (e) (MP4 6134 kb)

Video 11.7b

(ae) Examples of nodules with halo margins: nodule with halo showing edge shadowing artifact (a) and vascularity (b) in transverse views and longitudinal view (c); isoechoic nodule with variably thin and thick halo and no extrathyroidal extension (d); nodule with incomplete and less vascular halo (e) (MP4 5929 kb)

Video 11.7c

(ae) Examples of nodules with halo margins: nodule with halo showing edge shadowing artifact (a) and vascularity (b) in transverse views and longitudinal view (c); isoechoic nodule with variably thin and thick halo and no extrathyroidal extension (d); nodule with incomplete and less vascular halo (e) (MP4 6081 kb)

Video 11.7d

(ae) Examples of nodules with halo margins: nodule with halo showing edge shadowing artifact (a) and vascularity (b) in transverse views and longitudinal view (c); isoechoic nodule with variably thin and thick halo and no extrathyroidal extension (d); nodule with incomplete and less vascular halo (e) (MP4 1851 kb)

Video 11.7e

(ae) Examples of nodules with halo margins: nodule with halo showing edge shadowing artifact (a) and vascularity (b) in transverse views and longitudinal view (c); isoechoic nodule with variably thin and thick halo and no extrathyroidal extension (d); nodule with incomplete and less vascular halo (e) (MP4 6289 kb)

Video 11.8a

(ag) Examples of nodules with extrathyroidal extension (ETE): effacement of overlying strap muscles with suggestion of possible ETE (a); papillary thyroid cancer (PTC) with deep posterior ETE (b); nodule with eggshell calcifications and possible ETE in transverse (c) and longitudinal (d) views; nodule with suggestion of ETE at the posterior deep capsule border (e); infiltrative PTC with indistinct borders and shadow artifact but concerning for ETE (f); longitudinal view of ETE at the posterior deep capsule of the thyroid lobe (g) (MP4 1771 kb)

Video 11.8b

(ag) Examples of nodules with extrathyroidal extension (ETE): effacement of overlying strap muscles with suggestion of possible ETE (a); papillary thyroid cancer (PTC) with deep posterior ETE (b); nodule with eggshell calcifications and possible ETE in transverse (c) and longitudinal (d) views; nodule with suggestion of ETE at the posterior deep capsule border (e); infiltrative PTC with indistinct borders and shadow artifact but concerning for ETE (f); longitudinal view of ETE at the posterior deep capsule of the thyroid lobe (g) (MP4 3548 kb)

Video 11.8c

(ag) Examples of nodules with extrathyroidal extension (ETE): effacement of overlying strap muscles with suggestion of possible ETE (a); papillary thyroid cancer (PTC) with deep posterior ETE (b); nodule with eggshell calcifications and possible ETE in transverse (c) and longitudinal (d) views; nodule with suggestion of ETE at the posterior deep capsule border (e); infiltrative PTC with indistinct borders and shadow artifact but concerning for ETE (f); longitudinal view of ETE at the posterior deep capsule of the thyroid lobe (g) (MP4 5739 kb)

Video 11.8d

(ag) Examples of nodules with extrathyroidal extension (ETE): effacement of overlying strap muscles with suggestion of possible ETE (a); papillary thyroid cancer (PTC) with deep posterior ETE (b); nodule with eggshell calcifications and possible ETE in transverse (c) and longitudinal (d) views; nodule with suggestion of ETE at the posterior deep capsule border (e); infiltrative PTC with indistinct borders and shadow artifact but concerning for ETE (f); longitudinal view of ETE at the posterior deep capsule of the thyroid lobe (g) (MP4 6485 kb)

Video 11.8e

(ag) Examples of nodules with extrathyroidal extension (ETE): effacement of overlying strap muscles with suggestion of possible ETE (a); papillary thyroid cancer (PTC) with deep posterior ETE (b); nodule with eggshell calcifications and possible ETE in transverse (c) and longitudinal (d) views; nodule with suggestion of ETE at the posterior deep capsule border (e); infiltrative PTC with indistinct borders and shadow artifact but concerning for ETE (f); longitudinal view of ETE at the posterior deep capsule of the thyroid lobe (g) (MP4 8730 kb)

Video 11.8f

(ag) Examples of nodules with extrathyroidal extension (ETE): effacement of overlying strap muscles with suggestion of possible ETE (a); papillary thyroid cancer (PTC) with deep posterior ETE (b); nodule with eggshell calcifications and possible ETE in transverse (c) and longitudinal (d) views; nodule with suggestion of ETE at the posterior deep capsule border (e); infiltrative PTC with indistinct borders and shadow artifact but concerning for ETE (f); longitudinal view of ETE at the posterior deep capsule of the thyroid lobe (g) (MP4 6421 kb)

Video 11.8g

(ag) Examples of nodules with extrathyroidal extension (ETE): effacement of overlying strap muscles with suggestion of possible ETE (a); papillary thyroid cancer (PTC) with deep posterior ETE (b); nodule with eggshell calcifications and possible ETE in transverse (c) and longitudinal (d) views; nodule with suggestion of ETE at the posterior deep capsule border (e); infiltrative PTC with indistinct borders and shadow artifact but concerning for ETE (f); longitudinal view of ETE at the posterior deep capsule of the thyroid lobe (g) (MP4 3899 kb)

Video 11.9a

(a, b) Anatomical pathway of the recurrent laryngeal nerve (green) in relation to the thyroid. Top panel shows a thyroid nodule in the right lobe in transverse and longitudinal views, with a closer proximity than the nodule in the left lobe (bottom panels) (MP4 7353 kb)

Video 11.9b

(a, b) Anatomical pathway of the recurrent laryngeal nerve (green) in relation to the thyroid. Top panel shows a thyroid nodule in the right lobe in transverse and longitudinal views, with a closer proximity than the nodule in the left lobe (bottom panels) (MP4 2380 kb)

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Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  • Mira Milas
    • 1
    Email author
  • Dubravka Milas Tollison
    • 2
  • Zvonimir Luka Milas
    • 3
  1. 1.Department of Surgery and the Endocrinology & Metabolism InstituteUniversity of Arizona College of Medicine – Phoenix, Banner - University Medical Center PhoenixPhoenixUSA
  2. 2.Department of Family Medicine, Class of 2001, Banner - University Medical Center PhoenixUniversity of Arizona College of Medicine – PhoenixPhoenixUSA
  3. 3.Department of Surgery, Levine Cancer Center at the Carolinas Medical CenterUniversity of North Carolina Chappell HillCharlotteUSA

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