Clinical presentation: A 49-yr-old woman was referred for follow-up evaluation of a nodular goiter, which has been diagnosed for 7 years. Cytology resulted in benign lesion at the time of the recognition of the nodule.

Palpation: no abnormality.

Laboratory test: TSH 2.51 mIU/L.

Ultrasound. The thyroid was echonormal. There were two hypoechoic nodules in the right lobe. The middle had macrocalcification and was suspicious containing microcalcifications, as well. The lower presented hyperechoic granules, which were more probably back wall cystic figures caused by posterior enhancement than punctate echogenic foci (microcalcifications).

Aspiration cytology was performed from both nodules and resulted in benign and non-diagnostic report, middle and lower lesions, respectively.

Comments.

1. This is an example of non-pathological blur caused by the dorsal acoustic shadow of a macrocalcification.

2. The smaller nodule in the right lobe should be regarded as an EU-TIRADS 5 lesion while the classification of the other, larger nodule is more difficult. Although the hyperechogenic figures are very likely not microcalcifications, the echogenicity matters: if it is held deeply hypoechoic then the nodule should be regarded as an EU-TIRADS 5 nodule, if the echogenicity is regarded as minimally-moderately hypoechoic, then the nodule is an EU-TIRADS 4 lesion. In my opinion, the nodule is deeply hypoechoic, so I would consider this lesion as an EU-TIRADS 5 nodule.