Contrast-Enhanced Ultrasound in the Management of Thyroid Nodules

  • Enrico Papini
  • Giancarlo Bizzarri
  • Antonio Bianchini
  • Rinaldo Guglielmi
  • Filomena Graziano
  • Francesco Lonero
  • Sara Pacella
  • Claudio M. Pacella

Thyroid nodules are discovered by palpation in 3–7% of subjects in the general population, but an epidemic of clinically unapparent thyroid lesions is detected by high-resolution ultrasonography (US) of the cervical region. The clinical importance of thyroid nodules, besides the infrequent local compressive symptoms or thyroid dysfunction, is the possibility of thyroid cancer, which occurs in about 5% of all thyroid nodules. Thus it is essential to improve our diagnostic tools to avoid the use of unnecessary diagnostic surgery.

Brightness-mode US is currently the most accurate imaging test to evaluate solitary thyroid nodules or multinodular goiters. Thyroid US results in improved management for patients, with clinical findings suggestive of thyroid nodules. Many patients either have a palpable but not suspicious nodule, or have incidentally revealed but sonographically relevant nodules that warrant fine needle aspiration biopsy. Unfortunately, in most cases US characteristics cannot unequivocally distinguish benign and malignant lesions. Color Doppler US was proposed to evaluate nodule vascularity, since hypervascularity with an intranodular chaotic arrangement of blood vessels is supposed to be associated with malignancy. However, several reports have failed to consistently identify cancer on color Doppler alone


Thyroid Nodule Benign Nodule Thyroid Lesion Benign Thyroid Nodule Solitary Thyroid Nodule 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Tan GH, Gharib H (1997) Thyroid incidentalomas: management approaches to nonpalpable nodules discovered incidentally on thyroid imaging. Ann Intern Med 126:226–31PubMedGoogle Scholar
  2. 2.
    Ezzat S, Sarti DA, Cain DR, et al (1994) Thyroid incidentalomas: prevalence by palpation and ultrasonography. Arch Intern Med 154:1838–40PubMedCrossRefGoogle Scholar
  3. 3.
    Hegedus L, Bonnema SJ, Bennedbaek FN (2003) Management of simple nodular goiter: current status and future perspectives. Endocrine Rev 24:102–132CrossRefGoogle Scholar
  4. 4.
    Filetti S, Durante C, Torlontano M (2006) Nonsurgical approaches to the management of thyroid nodules. Nat Clin Pract Endocrinol Metab 2:384–94PubMedCrossRefGoogle Scholar
  5. 5.
    Belfiore A, Giuffrida D, La Rosa GL, et al (1989) High frequency of cancer in cold thyroid nodules occurring at young age. Acta Endocrinol (Copenh) 121:197–202Google Scholar
  6. 6.
    AACE/AME Task Force on Thyroid Nodules, American Association of Clinical Endocrinologists, and Associazione Medici Endocrinologi (2006) Medical guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract 12:63–102Google Scholar
  7. 7.
    Cooper DS, Doherty GM, Haugen BR, et al (2006) The American Thyroid Association Guidelines Taskforce. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 16:109–142PubMedCrossRefGoogle Scholar
  8. 8.
    Pacini F, Schlumberger M, Dralle H et al (2006) European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium. Eur J Endocrinol 154: 787–803PubMedCrossRefGoogle Scholar
  9. 9.
    Marqusee E, Benson CB, Frates MC, et al (2000) Usefulness of ultrasonography in the management of nodular thyroid disease. Ann Intern Med 133:696–700PubMedGoogle Scholar
  10. 10.
    Papini E, Guglielmi R, Bianchini A, et al (2002) Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab 87:1941–6PubMedCrossRefGoogle Scholar
  11. 11.
    Mandel SJ (2004) Diagnostic use of ultrasonography in patients with nodular thyroid disease. Endocr Pract 10:246–52PubMedGoogle Scholar
  12. 12.
    Frates MC, Benson CB, Charboneau JW, et al (2005) Society of Radiologists in Ultrasound. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 237:794–800PubMedCrossRefGoogle Scholar
  13. 13.
    Hamberger B, Gharib H, Melton LJ III, et al (1982) Fine-needle aspiration biopsy of thyroid nodules: impact on thyroid practice and cost of care. Am J Med 73:381–4PubMedCrossRefGoogle Scholar
  14. 14.
    Goellner JR, Gharib H, Grant CS, et al (1987) Fine needle aspiration cytology of the thyroid, 1980 to 1986. Acta Cytol 31:587–90PubMedGoogle Scholar
  15. 15.
    Gharib H, Goellner JR (1993) Fine-needle aspiration biopsy of the thyroid: an appraisal. Ann Intern Med 118:282–9PubMedGoogle Scholar
  16. 16.
    Schlinkert RT, van Heerden JA, Goellner JR, et al (1997) Factors that predict malignant thyroid lesions when fine-needle aspiration is “suspicious for follicular neoplasm.” Mayo Clin Proc 72:913–6PubMedCrossRefGoogle Scholar
  17. 17.
    Rago T, Di Coscio G, Basolo F et al (2007) Combined clinical, thyroid ultrasound and cytological features help to predict thyroid malignancy in follicular and Hurthle cell thyroid lesions: results from a series of 505 consecutive patients. Clin Endocrinol (Oxf) 66:13–20Google Scholar
  18. 18.
    MacDonald L, Yazdi HM (1996) Nondiagnostic fine needle aspiration biopsy of the thyroid gland: a diagnostic dilemma. Acta Cytol 40:423–8PubMedGoogle Scholar
  19. 19.
    McHenry CR, Walfish PG, Rosen IB (1993) Non-diagnostic fine needle aspiration biopsy: a dilemma in management of nodular thyroid disease. Am Surg 59:415–9PubMedGoogle Scholar
  20. 20.
    Foster FS, Burns PN, Simpson DH, Wilson SR, Christopher DA, Goertz DE (2000) Ultrasound for the visualization and quantification of tumor microcirculation. Cancer Metastasis Rev. 19:131–8PubMedCrossRefGoogle Scholar
  21. 21.
    Wilson SR, Burns PN (2006) Microbubble contrast for radiological imaging: 2. Applications. Ultrasound Q 22:15–8PubMedGoogle Scholar
  22. 22.
    Burns PN, Wilson SR (2000) Simpson DH et al. Pulse inversion imaging of liver blood flow: improved method for characterizing focal masses with microbubble contrast. Invest Radiol 35:58–71PubMedCrossRefGoogle Scholar
  23. 23.
    Burns PN, Wilson SR (2007) Focal liver masses: enhancement patterns on contrast-enhanced images: concordance of US scans with CT scans and MR images. Radiology 242:162–74PubMedCrossRefGoogle Scholar
  24. 24.
    Huang Wei C, Bleuzen A, Bourlier P, et al (2006) Differential diagnosis of focal nodular hyperplasia with quantitative parametric analysis in contrast-enhanced sonography. Invest Radiol 41:353–368CrossRefGoogle Scholar
  25. 25.
    Spiezia S, Farina R, Cerbone G et al (2001) Analysis of color Doppler signal intensity variation after levovist injection: a new approach to the diagnosis of thyroid nodules. J Ultrasound Med 20:223–231PubMedGoogle Scholar
  26. 26.
    Appetecchia M. Bacaro D, Brigida R, Milardi D, Bianchi A, Solivetti F (2006) Second generation ultrasonographic contrast agents in the diagnosis of neoplastic thyroid nodules. J Exp Clin Cancer Res 25:325–30PubMedGoogle Scholar
  27. 27.
    Argalia G, De Bernardis S, Mariani D et al (2002) Ultrasonographic contrast agent: evaluation of time intensity curves in the characterisation of solitary thyroid nodules. Radiol Med 103: 407–413PubMedGoogle Scholar
  28. 28.
    Bartolotta TV, Midiri M, Galia M, et al (2006) Qualitative and quantitative evaluation of solitary thyroid nodules with contrast-enhanced ultrasound: initial results. Eur Radiol 16:2234–2241PubMedCrossRefGoogle Scholar
  29. 29.
    Pacella CM, Rossi Z, Bizzarri G, et al (1993) Ultrasound-guided percutaneous laser ablation of liver tissue in a rabbit model. Eur Radiol 3:26–32CrossRefGoogle Scholar
  30. 30.
    Pacella CM, Bizzarri G, Guglielmi R, et al (2000) Thyroid tissue: US-guided percutaneous interstitial laser ablation–A feasibility study. Radiology 217:673–677PubMedGoogle Scholar
  31. 31.
    Dossing H, Bennedbaek FN, Karstrup S, Hegedus L (2002) Benign solitary solid cold thyroid nodules: US-guided interstitial laser photocoagulation–Initial experience. Radiology 225:53–57PubMedCrossRefGoogle Scholar
  32. 32.
    Pacella CM, Bizzarri G, Spiezia S, et al (2004) Thyroid tissue: US-guided percutaneous laser thermal ablation. Radiology 232:272–80PubMedCrossRefGoogle Scholar
  33. 33.
    Dossing H, Bennedbaek FN, Hegedus L (2005) Effect of ultrasound guided interstitial laser photocoagulation on benign solitary cold thyroid nodules–a randomised study. Eur J Endocrinol 152:341–5PubMedCrossRefGoogle Scholar
  34. 34.
    Papini E, Guglielmi R, Bizzarri G et al (2007) Treatment of benign cold thyroid nodules: a randomized clinical trial of percutaneous laser ablation versus levothyroxine therapy or follow-up. Thyroid 17:229–35PubMedCrossRefGoogle Scholar
  35. 35.
    Guglielmi R, Pacella CM, Dottorini ME, et al (1999) Severe thyrotoxicosis due to hyperfunctioning liver metastasis from follicular carcinoma: treatment with 131I and Interstitial laser ablation. Thyroid 9:173–177PubMedCrossRefGoogle Scholar
  36. 36.
    Pacella CM, Stasi R, Bizzarri G, et al (2007) Percutaneous laser ablation of unresectable primary and metastatic adrenocortical carcinoma. Eur J Radiol. May 9; [Epub ahead of print]Google Scholar
  37. 37.
    Wood BJ, Abraham J, Hvizda JL, Alexander HR, Fojo T (2003) Radiofrequency ablation of adrenal tumors and adrenocortical carcinoma metastases. Cancer 97:554–60PubMedCrossRefGoogle Scholar
  38. 38.
    Kim YS, Rhim H, Tae K, Park DW, Kim ST (2006) Radiofrequency ablation of benign cold thyroid nodules: initial clinical experience. Thyroid 16:361–7PubMedCrossRefGoogle Scholar
  39. 39.
    Taylor KJW, Burns PN, Wells PNT (1987) Clinical Applications of Doppler Ultrasound. New York: Raven PressGoogle Scholar
  40. 40.
    Wachsberg HR (2007) B-Flow imaging of the hepatic vasculature: correlation with color Doppler sonography. AJR 188:522–533CrossRefGoogle Scholar
  41. 41.
    Terrier F, Grossholz M, Becker CD (1999) Spiral CT of the abdomen. New York: SpringerGoogle Scholar
  42. 42.
    Matsuda Y, Yabuuchi I (1986) Hepatic tumors: US contrast enhancement with CO2 microbubbles. Radiology 161, 701–705PubMedGoogle Scholar
  43. 43.
    Chin CT, Burns PN (2000) Predicting the acoustic response of a microbubble population for contrast imaging in medical ultrasound. Ultrasound Med Biol 26:1293–300PubMedCrossRefGoogle Scholar
  44. 44.
    Mazzaglia PJ, Berber E, Milas M, Siperstein AE (2007) Laparoscopic radiofrequency ablation of neuroendocrine liver metastases: a 10-year experience evaluating predictors of survival. Surgery 142:10–9PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Enrico Papini
    • 1
  • Giancarlo Bizzarri
    • 2
  • Antonio Bianchini
    • 2
  • Rinaldo Guglielmi
    • 1
  • Filomena Graziano
    • 1
  • Francesco Lonero
    • 2
  • Sara Pacella
    • 2
  • Claudio M. Pacella
    • 3
  1. 1.Department of Diagnostic Imaging AlbanoItaly
  2. 2.Italy
  3. 3.Department of Radiology and Diagnostics ImagingOspedale Regina ApostolorumItaly

Personalised recommendations