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Advanced Thyroid and Parathyroid Ultrasound pp 95–103Cite as

Feature Illustration: Thyroid Nodule Margins and Extrathyroidal Extension and Invasion

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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.

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Authors and Affiliations

  1. Department of Surgery and the Endocrinology & Metabolism Institute, University of Arizona College of Medicine – Phoenix, Banner - University Medical Center Phoenix, 1441 North 12th Street, 2nd floor, Phoenix, AZ, 85006, USA

    Mira Milas M.D., F.A.C.S.

  2. Department of Family Medicine, Class of 2001, Banner - University Medical Center Phoenix, University of Arizona College of Medicine – Phoenix, 1300 North 12th Street, Phoenix, AZ, 85006, USA

    Dubravka Milas Tollison M.D.

  3. Department of Surgery, Levine Cancer Center at the Carolinas Medical Center, University of North Carolina Chappell Hill, 1021 Morehead Medical Dr. #3259, Charlotte, NC, 28204, USA

    Zvonimir Luka Milas M.D.

Authors
  1. Mira Milas M.D., F.A.C.S.
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  2. Dubravka Milas Tollison M.D.
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  3. Zvonimir Luka Milas M.D.
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Correspondence to Mira Milas M.D., F.A.C.S. .

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Editors and Affiliations

  1. Department of Surgery and the Endocrinology & Metabolism Institute, University of Arizona College of Medicine - Phoenix, Banner - University Medical Center Phoenix, Phoenix, Arizona, USA

    Mira Milas

  2. Department of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Susan J. Mandel

  3. Department of Radiology, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Jill E. Langer

1 Electronic Supplementary Material

Below is the link to the electronic supplementary material.

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

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)

(a–f) 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)

(a–f) 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)

(a–f) 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)

(a–f) 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)

(a–f) 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)

(a–f) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–c) 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)

(a–c) 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)

(a–c) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–e) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(a–g) 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)

(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)

(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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Milas, M., Tollison, D.M., Milas, Z.L. (2017). Feature Illustration: Thyroid Nodule Margins and Extrathyroidal Extension and Invasion. In: Milas, M., Mandel, S.J., Langer, J.E. (eds) Advanced Thyroid and Parathyroid Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-319-44100-9_11

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  • DOI: https://doi.org/10.1007/978-3-319-44100-9_11

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