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A case report on multimodal ultrasound imaging of a suspicious solid thyroid nodule
Authors: Dr. Jorge Pinares [1], Prof. Dr. med. Julian Künzel [2], Prof. Dr. med. Ernst-Michael Jung [3]
[1] Dr. Jorge Pinares, Maxillofacial Radiologist, University of Chile and Pontifical Catholic University, Chile.
[2] Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital of Regensburg, Germany
[3] Institute of Diagnostic Radiology and Interdisciplinary Ultrasound Department, University Hospital of Regensburg, Germany
1Clinical History
A 49-year-old woman with an asymptomatic, palpable thyroid nodule was referred for an ultrasonography examination on 23 January 2025, after completing laboratory tests and scintigraphy. The laboratory results showed a normal TSH level, indicating proper thyroid function (0.542 mlU/l). Additionally, TGAb and TPOAb were < 15 IU/ml, and TSH receptor antibodies were < 1.1 IU/l. Scintigraphy revealed a hypofunctional lesion on the left thyroid lobe, prompting further investigation. Based on these findings, a multimodal ultrasound examination was performed at the Institute of Diagnostic Radiology and Interdisciplinary Ultrasound Department, University Hospital of Regensburg, which included B-mode imaging with automated AI-based documentation (Smart Thyroid), color-coded duplex, elastography, and contrast-enhanced ultrasound (CEUS).
2Image Findings
An experienced examiner performed the ultrasound examination using a high-end ultrasound machine (Mindray Resona R9; L15-3WU linear array probe). Real-time B-mode ultrasound imaging revealed a solid, isoechoic nodule with lobulated margins in the lower pole of the left thyroid lobe. The nodule appeared heterogeneous, and with cystic changes. The detected nodule was also analyzed and measured automatically using an AI program for thyroid nodules (Smart Thyroid) in three planes. The size was determined in the longitudinal and transverse axes, including length, depth, and width, and the volume was calculated (Figure 1).
The nodule was classified as ACR – TIRADS 4 with an indication for fine needle aspiration (FNAC) or core needle biopsy (CNB).
Color coded duplex sonography (CCDS) and Ultra Microangiography (including its three modes: UMA, CUMA, PUMA) were used to assess the vascularization of the lesion (Figure 2). The lesion exhibited rich and regular vascular pattern, with marginal vascularization.
Ultrasound elastography, available in parallel mode as strain and shear wave elastography, was used to assess the stiffness of the nodule tissue compared to the normal thyroid parenchyma. Image quality was automatically evaluated and rated as optimal. Measurements were recorded over individually adjusted regions of interest (ROI), with values of up to 2.33 m/s at the lesion margins (Figure 3).
CEUS was performed via intravenous injection of 2 ml of sulfur-hexafluoride microbubbles (SonoVue®/BRACCO) with 10ml of saline solution via a cubital approach (Figure 4). The period from the early arterial phase (after 10-15 s) to the venous phase (after 60-70 s) was digitally stored as cine loop. After recording, the CEUS loop was evaluated for the perfusion analysis of the dynamic nodule vascularization using time intensity curve (TIC) analysis with the internal perfusion program of the high-end ultrasound device. Regions of interest (ROI) were individually placed at the center and the margins of the lesion for assessment and comparison with the surrounding thyroid tissue (Figure 5). Parametric color maps were fitted to the corresponding perfusion parameters such as time to peak (TTP), peak, mean transit time (mTT), and wash in area under the curve (Figure 6).
The lesion showed a regular and homogeneous perfusion pattern from the margins to the center, with faster enhancement compared to the surrounding normal parenchyma, resulting in a hyper-enhanced appearance. Additionally, the lesion exhibited a slow wash-out during the delayed phase.
Color coded duplex sonography (CCDS) and Ultra Microangiography (including its three modes: UMA, CUMA, PUMA) were used to assess the vascularization of the lesion (Figure 2). The lesion exhibited rich and regular vascular pattern, with marginal vascularization.
Ultrasound elastography, available in parallel mode as strain and shear wave elastography, was used to assess the stiffness of the nodule tissue compared to the normal thyroid parenchyma. Image quality was automatically evaluated and rated as optimal. Measurements were recorded over individually adjusted regions of interest (ROI), with values of up to 2.33 m/s at the lesion margins (Figure 3).
CEUS was performed via intravenous injection of 2 ml of sulfur-hexafluoride microbubbles (SonoVue®/BRACCO) with 10ml of saline solution via a cubital approach (Figure 4). The period from the early arterial phase (after 10-15 s) to the venous phase (after 60-70 s) was digitally stored as cine loop. After recording, the CEUS loop was evaluated for the perfusion analysis of the dynamic nodule vascularization using time intensity curve (TIC) analysis with the internal perfusion program of the high-end ultrasound device. Regions of interest (ROI) were individually placed at the center and the margins of the lesion for assessment and comparison with the surrounding thyroid tissue (Figure 5). Parametric color maps were fitted to the corresponding perfusion parameters such as time to peak (TTP), peak, mean transit time (mTT), and wash in area under the curve (Figure 6).
The lesion showed a regular and homogeneous perfusion pattern from the margins to the center, with faster enhancement compared to the surrounding normal parenchyma, resulting in a hyper-enhanced appearance. Additionally, the lesion exhibited a slow wash-out during the delayed phase.
3Diagnosis
Benign lesion, possibly an adenoma.
4Discussion
BACKGROUND:
Thyroid nodules are common in clinical practice, and most of them are benign. However, according to various studies, the risk of malignancy in these nodules ranges from 7% to 15%, depending on several factors. Clinical evaluation includes a thorough history and physical examination, laboratory tests, neck ultrasound, and a FNAC. FNAC is a fast, minimally invasive, and well-established technique that plays a critical role in the preoperative evaluation of patients with thyroid nodules. However, it is not cost-effective to submit all lesions to FNAC according to TIRADS. Additionally, although rare, this technique could carry some risks, including hematomas and tumor seeding. Several B-mode ultrasound criteria contribute to suggesting malignancy according to TIRADS classification systems. However, they are not sufficiently specific to definitively classify a lesion as malignant (1). The emergence of modern ultrasound technology, which combines detailed B-scan imaging, high resolution color-coded duplex procedures, ultrasound elastography techniques, and CEUS with perfusion analysis, provides a more precise characterization of thyroid lesions before biopsy. It can potentially redefine the TIRADS category of a thyroid nodule (2), particularly through CEUS analysis. This technique provides clearer visualization of the microvascular distribution, contrast agent perfusion intensity, entry and exit patterns, and detailed vascular morphology within nodules, offering valuable insights into lesions specially in a transitional state between benign and malignant (3). We report a 49-year-old woman, who was admitted to our hospital with a cold TIRADS 4 thyroid nodule. Multimodal ultrasound imaging was employed to improve the characterization of the thyroid nodule, refining its risk of malignancy.
CLINICAL PERSPECTIVE:
The ultrasound examination revealed an echogenic nodule with cystic changes and no signs of induration. CEUS demonstrated a ring enhancement with a regular and homogeneous perfusion pattern, progressing from the margins to the center and also exhibiting a slow wash-out during the delayed phase, unlike malignant lesions, which are typically associated with a faster marginal wash-in, unclear enhancement margins, non-homogeneous wash-in, and fast partial or complete wash-out.
Therefore, considering that various studies have suggested that CEUS can contribute to redefining the TIRADS classification of a suspicious lesion based on its benign or malignant enhancement pattern, and given that the present case exhibited CEUS imaging characteristics of a benign nodule, these findings support a potential TIRADS downgrade for this lesion.
THERAPY PLANNING:
It was recommended to perform periodic follow-ups of the patient every 6 months, reassessing the need for FNAC. But in March 2025 a hemithyroidectomy was performed, as the patient was worried about potential risk of malignancy. Histology revealed a nodule measuring a maximum of 2.5 cm in size with a colloidally shiny cut surface without encapsulation. The final diagnosis was goiter nodule with no evidence of malignancy.
Thyroid nodules are common in clinical practice, and most of them are benign. However, according to various studies, the risk of malignancy in these nodules ranges from 7% to 15%, depending on several factors. Clinical evaluation includes a thorough history and physical examination, laboratory tests, neck ultrasound, and a FNAC. FNAC is a fast, minimally invasive, and well-established technique that plays a critical role in the preoperative evaluation of patients with thyroid nodules. However, it is not cost-effective to submit all lesions to FNAC according to TIRADS. Additionally, although rare, this technique could carry some risks, including hematomas and tumor seeding. Several B-mode ultrasound criteria contribute to suggesting malignancy according to TIRADS classification systems. However, they are not sufficiently specific to definitively classify a lesion as malignant (1). The emergence of modern ultrasound technology, which combines detailed B-scan imaging, high resolution color-coded duplex procedures, ultrasound elastography techniques, and CEUS with perfusion analysis, provides a more precise characterization of thyroid lesions before biopsy. It can potentially redefine the TIRADS category of a thyroid nodule (2), particularly through CEUS analysis. This technique provides clearer visualization of the microvascular distribution, contrast agent perfusion intensity, entry and exit patterns, and detailed vascular morphology within nodules, offering valuable insights into lesions specially in a transitional state between benign and malignant (3). We report a 49-year-old woman, who was admitted to our hospital with a cold TIRADS 4 thyroid nodule. Multimodal ultrasound imaging was employed to improve the characterization of the thyroid nodule, refining its risk of malignancy.
CLINICAL PERSPECTIVE:
The ultrasound examination revealed an echogenic nodule with cystic changes and no signs of induration. CEUS demonstrated a ring enhancement with a regular and homogeneous perfusion pattern, progressing from the margins to the center and also exhibiting a slow wash-out during the delayed phase, unlike malignant lesions, which are typically associated with a faster marginal wash-in, unclear enhancement margins, non-homogeneous wash-in, and fast partial or complete wash-out.
Therefore, considering that various studies have suggested that CEUS can contribute to redefining the TIRADS classification of a suspicious lesion based on its benign or malignant enhancement pattern, and given that the present case exhibited CEUS imaging characteristics of a benign nodule, these findings support a potential TIRADS downgrade for this lesion.
THERAPY PLANNING:
It was recommended to perform periodic follow-ups of the patient every 6 months, reassessing the need for FNAC. But in March 2025 a hemithyroidectomy was performed, as the patient was worried about potential risk of malignancy. Histology revealed a nodule measuring a maximum of 2.5 cm in size with a colloidally shiny cut surface without encapsulation. The final diagnosis was goiter nodule with no evidence of malignancy.
5Teaching Points
This case highlights the role of multimodal ultrasonography, especially CEUS, in the evaluation of thyroid nodules. This technique plays an important role in refining the diagnostic assessment of thyroid nodules categorized by TIRADS. By providing a detailed visualization of enhancement patterns and perfusion dynamics, CEUS enables a more accurate distinction between benign and potentially malignant features. This was demonstrated in the present case by identifying key characteristics, including hyper-enhancement with a regular and homogeneous perfusion pattern, as well as a slow wash-out, allowing for the establishment of the most probable diagnosis of a benign thyroid lesion. This approach underscores CEUS's potential to downstage nodules and reduce the need for invasive procedures in the treatment of thyroid disorders.
6References
[1.] Brandenstein M, Wiesinger I, Künzel J, Hornung M, Stroszczynski C, Jung EM. Multiparametric Sonographic Imaging of Thyroid Lesions: Chances of B-Mode, Elastography and CEUS in Relation to Preoperative Histopathology. Cancers (Basel). 2022; 29;14(19):4745. doi: 10.3390/cancers14194745.
[2.] Jung EM, Stroszczynski C, Jung F. Advanced multimodal imaging of solid thyroid lesions with artificial intelligence-optimized B-mode, elastography, and contrast-enhanced ultrasonography parametric and with perfusion imaging: Initial results. Clin Hemorheol Microcirc. 2023;84(2):227-236. doi: 10.3233/CH-239102.
[3.] Xu Y, Qi X, Zhao X, Ren W, Ding W. Clinical diagnostic value of contrast-enhanced ultrasound and TI-RADS classification for benign and malignant thyroid tumors: One comparative cohort study. Medicine. 2019;98(4):e14051. doi: 10.1097/MD.0000000000014051.
[2.] Jung EM, Stroszczynski C, Jung F. Advanced multimodal imaging of solid thyroid lesions with artificial intelligence-optimized B-mode, elastography, and contrast-enhanced ultrasonography parametric and with perfusion imaging: Initial results. Clin Hemorheol Microcirc. 2023;84(2):227-236. doi: 10.3233/CH-239102.
[3.] Xu Y, Qi X, Zhao X, Ren W, Ding W. Clinical diagnostic value of contrast-enhanced ultrasound and TI-RADS classification for benign and malignant thyroid tumors: One comparative cohort study. Medicine. 2019;98(4):e14051. doi: 10.1097/MD.0000000000014051.
