Thyroid cancer - Radiofrequency - Puncture - Diagnosis - Treatment
Thyroiditis and Graves' disease
In descending order of frequency:
-
Lymphocytic thyroiditis (former name: chronic thyroiditis);
-
Subacute thyroiditis;
-
Acute thyroiditis;
-
Fibrous thyroiditis.
Lymphocytic thyroiditis (Hashimoto)
These thyroiditis, related to immune disturbances, present either in a chronic form (Hashimoto's disease) or in a subacute form.
In addition to the immune origin, they have in common hormonal disturbances in a deliberately biphasic mode.
It is an autoimmune syndrome that mainly affects women with early hyperthyroidism followed by late hypothyroidism.
Biologically, there is an increase in anti-TPO antibodies in chronic thyroiditis
Ultrasound appearance
The ultrasound appearance changes according to the phases of the disease.
Initial phase: moderate goiter, usually painless.
The contours are generally bumpy.
The echostructure is heterogeneous hypoechoic with hyperechoic trabeculae originating from the thyroid capsule, giving a pseudo nodular appearance.
Some thyroiditis have an overall nodular appearance with hyperechoic echostructure corresponding to regeneration nodules (White Knight). During the initial phase there is an increase in the vascularization of the parenchyma and then a gradual normalization. And in the late stage, a decrease in the overall vascularization of the parenchyma.
Globally hypoechoic appearance with hyperechoic spans originating from the thyroid capsule giving a pseudo-nodular "leopard" appearance.
The edges are bumpy.
Some thyroiditis the parenchyma is globally nodular compatible with "White Knight" regeneration nodules.
Document from Dr. Haitham Sharara CHU of Nîmes.
Often thyroiditis is associated with the presence of inflammatory adenopathies in lymph node territories VI.
The Doppler shows hypervascularization during the initial phase.
Document from Dr. Haitham Sharara CHU of Nîmes.
Hashimoto's disease and the nodule.
Thyroiditis in general slightly increases the risk of cancer in the event of a nodule.
Each nodule must benefit from a cytopuncture
The evolution of thyroiditis.
The evolution of chronic thyroiditis is very slow > 10 years and in the terminal phase there is avascular atrophy of the thyroid.
More rarely, progression to lymphoma remains exceptional.
De Quervain's subacute thyroiditis or granulomatous thyroiditis
De Quervain's subacute thyroiditis is rarer than chronic thyroiditis and more common in women between the ages of 20 and 30.
It is a viral disease (mumps, influenza, trivial nasopharyngeal episode, etc.), and more recently I have noticed the appearance in certain patients with COVID, of a clinical and ultrasound picture compatible with subacute thyroiditis of De Quervain.
The virus is not always identified during which the thyroid follicles are damaged, and release thyroglobulin (Tg), T4 and T3 into the circulation.
Histologically, there is infiltration by mono- and polynuclear cells, break-ins of colloid outside the more or less disorganized follicles, surrounded by multi-nucleated giant cells.
Clinical picture
Pain dominates the clinical picture of variable intensity, radiating from the thyroid region to the ears.
It is associated with: an increase in the thyroid volume of the entire thyroid, rarely on one side only, with dysphagia in an influenza-like context, and with signs of hyperthyroidism: asthenia, tachycardia, tremor, thermophobia, nervousness, etc.
In an asthenic, feverish context.
Evolution towards healing without thyroid function abnormality.
Biological report
-
A very accelerated VS; and marked elevation of CRP;
-
Normal or slightly altered leukocytosis;
-
Usually low TSH with mild elevation of free T4 and T3 and Tg;
-
Antithyroid antibodies (antiTg and antithyroperoxidase [TPO]) are absent or low.
The ultrasound aspect
Focal and extensive hypoechoic pseudo-nodular areas, asymmetrical associated with the presence of inflammatory adenopathies.
The pain when passing the probe is constant.
Ultrasound shows a global hypoechoic aspect or by zones.
Sonographic evolution of subacute thyroiditis towards almost complete disappearance of the pseudo-nodular inflammatory aspect.
Examination carried out 2 years later: a complete regression of the inflammatory aspect is noted.
Documents of Dr Haitham Sharara University Hospital of Nîmes.
Clinical case :
43-year-old female patient with right-sided cervical pain and fever.
Ultrasound shows the presence of a pseudo-nodular inflammatory area (False EU TIRADS 5).
Examination carried out during the painful phase of the disease
Lack of knowledge of the inflammatory aspect can lead to the description of nodules.
The evolution of the Doppler:
The Doppler shows an increase in vascularization during the painful phase
Normalization of vascularization after healing.
Documents of Dr. Haitham Sharara CHU of Nîmes.
Typical appearance with pseudo-nodular areas in the superficial area of the left lobe.
Documents of Dr. Haitham Sharara CHU of Nîmes.
Acute thyroiditis
Very rare, it occurs especially in a young person in a septicemic context or carrier of a fistula of the piriform sinus.
Clinically, she realizes a mass in the thyroid region, most often unilateral, painful and feverish.
When the context is not evocative, the risk is to confuse it with subacute thyroiditis, which is more frequent, and to prescribe an unfortunate corticosteroid therapy which accelerates the evolution towards abscess.
Ultrasound shows a large hypoechoic, heterogeneous and poorly limited area, the puncture of which collects the germ and sometimes allows pus to be evacuated.
Antibiotics are needed, and sometimes surgical drainage. Tuberculosis is rarely involved, but possible.
This is a thyroid abscess whose suppurative form has become exceptional since the advent of antibiotics.
The clinical picture is dominated by local pain, signs of infection and deterioration in general condition.
The passage of the probe is extremely painful.
Presuppurative phase The ultrasound appearance is that of subacute thyroiditis.
Collection phase The abscessed area is very hypoechoic, heterogeneous with blurred boundaries.
Riedel's fibrous thyroiditis
It is a very rare condition, preferentially affecting middle-aged women and presenting as an extensive inflammatory zone, sheathing the carotid axis and the trachea.
She is sensitive to corticosteroid therapy.
Ultrasound reveals very hypoechoic and heterogeneous zones with the presence of adenopathies. They are poorly vascularized.
The sheathing character for neighborhood structures is quite evocative.
This aspect can point to anaplastic cancer, but the age of onset of the two conditions is very different.
The cytological aspect is not specific, and does not always make it possible to eliminate cancer.
Literature pictures.
Graves' disease
Graves' disease is an autoimmune disease of the thyroid manifested by hyperthyroidism, homogeneous goiter and sometimes ophthalmopathy.
The frequency of the disease is less than 1% with a female predominance of 5-10/1 men.
Biological diagnosis is based on the presence of anti-TSH receptor antibodies with biological hyperthyroidism.
Ultrasound.
Hypoechoic heterogeneous lobulated honeycomb goiter associated on Doppler with strong diffuse vascularization and increased systolic velocity in the lower thyroid arteries.
Hypoechoic goiter.
Diffuse hypervascularization with increased systolic velocity of the inferior thyroid artery.
Documents of Dr. Haitham Sharara CHU of Nîmes.
Documents of Dr. Haitham Sharara CHU of Nîmes.
The presence of a thyroid nodule with Graves' disease increases the risk of cancer.
Here is a thyroid nodule in the context of Graves' disease.
It is a hyperechoic nodule in an oblique position without microcalcifications or lobulated or spiculated contours.
The cytology of this nodule is in favor of an indeterminate BETHESDA 3 vesicular lesion.
The definitive ana-pathology is in favor of papillary carcinoma with an atypical aspect.
Another case of Graves' disease with a highly suspicious nodule on ultrasound (EU TIRADS 5) and cytology in favor of papillary carcinoma (Bethesda VI).
It is recommended to perform a cytopuncture systematically in case of association of a nodule with Graves' disease, regardless of the appearance of the nodule.