Pitfalls in Sonographic Evaluation of Thyroid Abnormalities

Ultrasound of the thyroid has become increasingly common, with evaluation of thyroid nodules representing the main indication for its use. While detection of thyroid nodules with modern high-resolution sonographic equipment is generally not a challenge, pitfalls may occur by which normal structures or pathology in neighboring organs are mistaken for thyroid nodules. Numerous reports in the literature describe various sonographic features of nodules in an attempt to stratify lesions into benign or malignant categories. While neither nodule size nor number is reliable, echogenicity, microcalcifcation, shape, and composition have been reported to be helpful in classifying thyroid nodules. No single feature should be used in isolation, and consensus guidelines have been established as to when fine-needle aspiration is indicated. Pitfalls remain in the evaluation of thyroid nodules demonstrating atypical features, such as cystic papillary carcinomas. Focal presentation of typically diffuse processes, such as Graves' disease and Hashimoto thyroiditis, may mimic malignant nodules, but carcinomas occur in these settings as well as in a background of normal thyroid parenchyma. Finally, because ultrasound is commonly used for surveillance of patients with thyroid carcinoma after thyroidectomy, sonographers should be familiar with the ultrasound appearance of disease recurrence and its mimics.