Radiological semiotics of diffuse and nodular goiter

Normal adult thyroid gland:

- Weight: ∼ 20–30 g
- Volume: ∼ 7–10 mL
- Location: caudal to larynx surrounding the anterolateral part of the trachea
Consists of two lateral lobes of unequal size: the right and left lobes, and the
unpaired isthmus of the thyroid gland connecting both lobes. The isthmus may be absent,
and then both lobes are loosely attached to each other. The thyroid gland is covered on the
outside by a fibrous capsule.
The lower parts of both the right and left lobes reach the 5th-6th ring of the trachea.
The isthmus of the gland is located at the level of the 1st-3rd or 2nd-4th ring of the
trachea.
In adults, the longitudinal size reaches 6 cm, the transverse size is 4 cm, and
thickness is up to 2 cm.

Basic methods of diagnosing thyroid disease:

Ultrasound:
- 7.5-13 MHz probes are used to examine the thyroid
- Thyroid volume is calculated using the formula:
Fraction Volume = Length x Width x Thickness x 0.479 (0.479 is the ellipsoid
correction factor).
- The volume of the thyroid gland is equal to the sum of the volumes of both
lobes. The volume of the isthmus (up to 10 mm thick) is not taken into
account.
- Normally, the width of the thyroid lobe of an adult is 13–18 mm, the thickness
is 16–18 mm, the thickness of the isthmus is 2–6 mm. The volume of the
thyroid gland in adult men varies from 7 to 25 cm3, in women – from 4 to 18
cm3.
- According to the WHO recommendation, goiter in adults is diagnosed with
thyroid volume in men is more than 25 cm3, in women - more than 18 cm3

CT and MRI:
- indicated in retrosternal localization of the thyroid gland, as well as in case of
insufficient information content of ultrasound results

Radioisotope research:
- method of functional visualization of the thyroid gland.
- Of the radioisotopes of iodine
123I is less radiotoxic due to its short half-life (13 hours) and optimal energy
spectrum (photon energy – 159 keV).
131I (half-life – 8 days, photon energy 18 – 364 keV) is more often used
before radioiodine therapy for diffuse toxic goiter to determine the ability of the
thyroid gland to accumulate iodine.
The 99mTc-MIBI (half-life 6 hours, photon energy 140 keV) is designed for
 myocardial scintigraphy. In thyroidology, it is used as a marker of malignant
neoplasms of the thyroid gland, due to its ability to actively accumulate in
mitochondria-rich tissues.

X-ray:
- is performed with barium contrast to the esophagus, which makes it possible
to assess the condition of the trachea and esophagus if their narrowing or
displacement is suspected

Fine needle aspiration biopsy:

- is used for the differential diagnosis of benign and malignant thyroid tumors.

Goiter is any abnormal enlargement of the thyroid gland.

Classification:
By epidemiology:
- Endemic goiter - Thyroid enlargement observed in a significant number of
population in a particular locality.
- Sporadic goiter - Goiter occurring sporadically.

By morphology:
- Diffuse goiter - diffusely enlarged thyroid
- Nodular goiter - irregular enlarged thyroid due to nodule formation
- Mixed goiter

By localization:
- Usually located.
- Partially sternal.
- Annular.
- Distilled goiter from embryonic bookmarks (goiter of the tongue root,
additional lobe of the thyroid gland).

Diffuse toxic goiter:

Triad of symptoms:
- goiter (an increase in the volume of the thyroid gland more than 18 ml in
women and 23 ml in men),
- tachycardia (rapid heartbeat) and endocrine
- ophthalmopathy (exophthalmos, "bulging eyes").
Examples:
- Graves disease
- Inflammation (e.g., Hashimoto thyroiditis)
- TSH-secreting pituitary adenoma
- Iodine deficiency
 Epidemiology:
- affects about 1% of the population, and its prevalence is higher in
iodine-deficient areas.
- Women get sick 10 times more often, the highest risk of developing DTZ is in
young and middle age, at 20-40 years, which is generally characteristic of
autoimmune pathology

Pathophysiology:
- is caused by a violation of the functioning of the immune system under the
influence of provoking factors against the background of a hereditary
predisposition

Classification of thyrotoxicosis:
- Subclinical thyrotoxicosis - a decrease in TSH levels with normal thyroxine
and triiodothyronine values.
- Clinical (manifest) thyrotoxicosis - a decrease in TSH in combination with
elevated levels of thyroxine and triiodothyronine

Diagnosis:
- Ultrasound
- Thyroid scintigraphy

Nodular goiter:
- presence of one or more nodular neoplasms
Examples:
- Uninodular goiter (e.g., cysts, adenoma, cancer)
- Toxic and nontoxic multinodular goiter
Epidemiology:
- at least 2–5% of the general population;
- With age, the prevalence of nodular goiter increases.
- In women, nodular goiter occurs in 5-10 times more often

Pathophysiology:
- There is an active proliferation of a pool of tumor cells that gradually form a
nodule.
- Follicular adenoma is a benign tumor from the follicular epithelium, more often
originating from A-cells.
macrofollicular (simple)
microfollicular (fetal)
trabecular (embryonic)
- Less commonly, adenoma originates from B cells (oncocytoma).

Classification:
Depending on the number of foci, the following are distinguished:
- solitary nodule (single thyroid nodule);
 - multinodular goiter (two or more thyroid nodules);
- conglomerate nodular goiter (a conglomerate of soldered nodes).
Depending on the thyroid function, the following are distinguished:
- nodular toxic goiter (hyperthyroidism);
- nodular nontoxic goiter (euthyroidism or hypothyroidism)
Degrees of nodular goiter:
- Grade 1 nodular goiter– the goiter is not visible, but is well palpable;
- Grade 2 nodular goiter – the goiter is palpable and visible on
examination.
Structure of diseases:
- nodular colloidal goiter with varying degrees of proliferation (90%)
- follicular adenoma of the thyroid gland (7–8%);
- thyroid cancer (1–2%)
- other diseases (less than 1%).

Diagnosis:
- palpation
- fine needle aspiration biopsy
- thyroid scintigraphy
- ultrasound

Signs of goiter on mediastinal radiographs:

- Widening of the mediastinal shadow to one or both sides.
- Displacement of the tracheal lumen and esophagus on an X-ray
- Calcification in the structure of the goiter can be a sign of its malignancy.
- In mediastinal fluoroscopy, the shadow shifts during swallowing movements –
if this does not happen, it means that the desired mass is in the lungs or in
the pleura (chest wall)
- Pulsation of the mass in the mediastinum may be characteristic of a goiter.
- Asymmetrical, irregularly shaped formation
- The structure is homogeneous, limescale inclusions are often visible
- External contours are smooth, convex
- Closely connected to the trachea, deflects and narrows it
- When swallowing and coughing, it shifts upwards
- Malignancy is reported in 1-17% of cases
- Contours become fuzzy during malignancy
- Radionuclide examination shows accumulation of radiopharmaceuticals
(I-131)