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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5794_Библиотеки_им_академика_М_И_Перельмана.pdf
4.1 Nodular Hyperplasia (Adenomatous Goiter)
Fig. 4.53 Shear wave
elastogram showed
scattered traversing
patterns of high
elasticity and E
Max
was
54.9 kPa
33
Fig. 4.54 CNB showed
dilated involutional
follicles suggesting
nodular hyperplasia
34
Fig. 4.55 B-mode
ultrasonogram showed
solid 2.25 cm round
isoechoic nodule with
halo in the left upper
lobe
Fig. 4.56 B-mode
ultrasonogram showed
solid 2.25 cm round
isoechoic nodule with
halo in the left upper
lobe
4 Dierential Diagnosis ofThyroid Nodules
4.2 Chronic Lymphocytic
(Hashimoto’s) Thyroiditis
Chronic lymphocytic thyroiditis is the most common cause of hypothyroidism and is usually
associated with the high titers of autoantibodies
to thyroid peroxidase (TPO) and thyroglobulin.
Progressive autoimmune destructions of thyroid
epithelial cells are associated with inltration of
polymorphic lymphoid cells including small
lymphocytes, larger reactive lymphocytes and
plasma cells to the thyroid parenchyma with the
formation of germinal centers. Thyroid follicles
are lined by Hürthle cells (oncocytes) with
abundant eosinophilic granular cytoplasm and a
large nuclei, and interstitial connective tissue is
increased with brosis [1]. The inammatory
process causes a diffused enlargement of thyroid
but sometimes localized enlargement may be
seen as focal thyroid nodules.
4.2 Chronic Lymphocytic (Hashimoto’s) Thyroiditis
Fig. 4.57 Color
Doppler showed
moderately increased
internal blood ow
within the nodule
Fig. 4.58 SWE showed
diffuse increased
elasticity and E
141.2 kPa
Max
was
35
On B-mode ultrasound of chronic lymphocytic thyroiditis, the parenchyma is heterogeneous and coarse with multiple hypoechoic solid
nodules, sometimes surrounded by brosis. SWE
showed increased elasticity depending the degree
of brosis [11].
4.2.1 Case 1
A 54-year-old woman was found to have a nodule on routine check and was referred for the
evaluation. Ultrasonogram showed a 1.77 cm
isoechoic round nodule in the left lobe (Figs.4.60
36
Fig. 4.59 Core needle
biopsy showed
involutional follicles
with interstitial brosis
(arrow) suggesting
nodular hyperplasia
Fig. 4.60
Ultrasonogram showed
1.77 cm isoechoic round
nodule in the left lower
lobe
4 Dierential Diagnosis ofThyroid Nodules
and 4.61) with moderate internal blood ow on
color Doppler (Fig.4.62). Shear wave elastogram
showed scattered increased elasticity within the
nodule (E
50.3kPa, Fig.4.63). FNA showed
Max
many oxyphilic cells (Fig. 4.64), and the CNB
result was chronic lymphocytic thyroiditis showing lymphocytic inltration (arrow, Fig. 4.65)
and interstitial brosis (thin arrow, Fig. 4.65)
causing increased elasticity on SWE (Fig.4.63).
4.2.2 Case 2
A 68-year-old woman presented with right
neck mass. On ultrasonogram, an isoechoic
solid 4.09 cm nodule was found in the right
lower lobe (Figs. 4.66 and 4.67) with markedly increased blood flow on color Doppler
(Fig. 4.68). Shear wave elastogram showed
diffusely increased elasticity with E
Max
4.2 Chronic Lymphocytic (Hashimoto’s) Thyroiditis
Fig. 4.61 Ultrasonogram
showed 1.77 cm isoechoic
round nodule in the left
lower lobe
Fig. 4.62 Color
Doppler showed
moderately increased
internal blood ow
within the nodule
37
Fig. 4.63 Shear wave
elastogram showed
scattered increased
elasticity within the
nodule and E
Max
was
50.3 kPa
38
Fig. 4.64 FNA showed
many oxyphilic cells
(arrow)
Fig. 4.65 CNB result
was chronic lymphocytic
thyroiditis showing
lymphocytic inltration
(arrows), and interstitial
brosis (thin arrows)
4 Dierential Diagnosis ofThyroid Nodules
Fig. 4.66 On
ultrasonogram,
isoechoic solid 4.09 cm
nodule was found in the
right lower lobe
4.2 Chronic Lymphocytic (Hashimoto’s) Thyroiditis
Fig. 4.67 On
ultrasonogram,
isoechoic solid 4.09 cm
nodule was found in the
right lower lobe
Fig. 4.68 Markedly
increased internal
vascularity was observed
on color Doppler
39
Fig. 4.69 Shear wave
elastogram showed
diffusely increased
elasticity with E
Max
161.4 kPa
40
Fig. 4.70 CNB
revealed chronic
lymphocytic thyroiditis
showing lymphocytic
inltration (arrows)
accompanied by dense
brosis (thin arrow)
Fig. 4.71 CNB
revealed. chronic
lymphocytic thyroiditis
showing lymphocytic
inltration (arrow)
4 Dierential Diagnosis ofThyroid Nodules
161.4kPa (Fig. 4.69). CNB revealed chronic
lymphocytic thyroiditis showing lymphocytic
infiltration (arrow, Figs. 4.70 and 4.71),
accompanied by dense fibrosis (thin arrow,
Fig. 4.70) explaining the high elasticity on
SWE (Fig.4.69).
4.2.3 Case 3
A 71-year-old woman was found to have a nodule on routine check and was referred for evaluation. Ultrasonogram showed a 3.22cm isoechoic
nodule with moderate internal vascularity in the
left middle lobe (Figs. 4.72, 4.73, and 4.74).
Shear wave elastogram showed diffusely
increased elasticity within the nodule with E
145.7 kPa (Fig. 4.75). The CNB result was
chronic lymphocytic thyroiditis (Fig.4.76) showing oxyphilic follicular cells (arrow, Fig. 4.77)
and lymphocytic inltration.
Max
4.2.4 Case 4
A 62-year-old woman was referred for the evaluation of thyroid nodule. She had been treated
with thyroid hormone for 10 years under the
diagnosis of hypothyroidism. On B-mode ultrasonogram, a hypoechoic 1cm nodule was found
in the right middle lobe (Figs. 4.78 and 4.79).
Shear wave elastogram showed diffusely high
elasticity and E
was 132.7 kPa (Fig. 4.80).
Max
CNB revealed chronic lymphocytic thyroiditis
showing inltration of lymphocytic cells (thin
arrow, Fig.4.81) and oxyphilic change of follicular epithelial cells (arrow Fig.4.82).
4.2.5 Case 5
A 60-year-old woman presented with left thyroid
nodule. On B-mode USG, a 1.43 cm predominantly solid nodule with central cystic change
4.2 Chronic Lymphocytic (Hashimoto’s) Thyroiditis
Fig. 4.72
Ultrasonogram showed
3.22 cm isoechoic
nodule in the left lobe
Fig. 4.73
Ultrasonogram showed
3.22 cm isoechoic
nodule in the left lobe
41
Fig. 4.74 Moderately
increased internal
vascularity was observed
on color doppler
42
Fig. 4.75 Shear wave
elastogram showed
diffusely increased
elasticity within the
nodule with E
kPa
Max
145.7
4 Dierential Diagnosis ofThyroid Nodules
Fig. 4.76 CNB result
was chronic lymphocytic
thyroiditis showing
lymphocytic inltration
and moderate internal vascularity was observed
in the left lobe (Figs.4.83, 4.84 and 4.85). SWE
showed low elasticity (E
32.2kPa, Fig.4.86).
Max
CNB showed chronic lymphocytic thyroiditis
with heavy inltration of lymphoid cells (thin
arrow, Fig. 4.87) and oxyphilic cells (arrow,
Fig.4.87).
4.2.6 Case 6
A 71-year-old woman was found to have a nodule on routine check and was referred for evaluation. Ultrasonogram showed a 1.54cm isoechoic
round nodule in the right lower lobe (Figs.4.88
and 4.89) with little internal blood ow on color