PAPILLON COURSE on THYROID ULTRASOUND
Case of the Month
October 2024 - case 2 (973) - evaluation
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Summary and comments
50 colleagues have sent a reply.
1. How would you consider the echogenicity of the nodule?
Distribution of answers
3 Iso/hyperechoic.
46 Minimally/moderately hypoechoic.
1 Very hypoechoic.
Expert comment
The nodule is clearly darker than the extranodular, healthy thyroid and lighter than the strap muscle running ventral to thyroid: this must be a minimally/moderately hypoechoic nodule.
2. What intranodular echogenic figures does the nodule have?
Distribution of answers
4 Back wall figures.
1 Back wall figures.|Obvious forms of microcalcifications.
1 Back wall figures.|Obvious forms of microcalcifications.|Punctate echogenic foci which can be microcalcifications.
4 Comet tail artifacts.
4 Comet tail artifacts.|Back wall figures.
2 Comet tail artifacts.|Back wall figures.|Punctate echogenic foci which can be microcalcifications.
1 Comet tail artifacts.|Obvious forms of microcalcifications.
2 Comet tail artifacts.|Obvious forms of microcalcifications.|Punctate echogenic foci which can be microcalcifications.
4 Comet tail artifacts.|Punctate echogenic foci which can be microcalcifications.
24 Punctate echogenic foci which can be microcalcifications.
2 Obvious forms of microcalcifications.
1 Obvious forms of microcalcifications.|Punctate echogenic foci which can be microcalcifications.
Expert comment
The nodule clearly has back wall figures - only 12 colleagues revealed these optical artifacts.
The presence of comet-tail artifacts cannot be excluded nor surely confirmed. Nevertheless, typical forms with the dorsal fading tail in cystic portions are not present. I would consider some of the spots as comet-tails (e.g. in the ventral part at 0:54 in the video).
More important is the presence or absence of microcalcifications. This case proved to be later an autonomously functioning adenoma. (FNA resulted in follicular tumor without any significant atypia, and I sent the patient to scintigraphy.) So, this is a benign nodule, which cannot have true microcalcifications. I agree with those 34 colleagues who believed that some punctate echogenic foci can be microcalcifications. Eight colleagues stated that obvious forms of microcalcifications are present. I think they were wrong. Diagnosis of microcalcifications is the matter of exclusion of other forms. In this nodule the echogenic granules occur with echogenic lines, mostly dorsal to cystic spaces.
3. What suspicious characteristics does the nodule have?
Distribution of answers
3 Irregular borders.
2 Irregular shape.
11 Obvious forms of microcalcifications.
2 Obvious forms of microcalcifications.|Deep hypoechogenicity.|Irregular borders.|Irregular shape.
1 Obvious forms of microcalcifications.|Deep hypoechogenicity.|Irregular shape.
2 Obvious forms of microcalcifications.|Irregular borders.
3 Obvious forms of microcalcifications.|Irregular borders.|Irregular shape.
1 Obvious forms of microcalcifications.|Irregular shape.
25 None of them.
Expert comment
Regarding the echogenicity and microcalcification see Comments to the 1st and 2nd questions.
We can find sections where the depth exceeds the width (see 0:36 in video). Strictly speaking the largest depth measured here is a bit larger than the largest depth measured at 0:34 in the video. Therefore, if someone is of the opinion that the nodule presents taller-than-wide shape, it cannot be debated. However, if we accept the suggestions of some experts, i.e. the use of a 1.2 ratio as a cut-off value, then the shape can be considered as regular.
I did not find any parts of the nodule where the surface irregularity reached the pathological level, therefore I won't consider the borders as irregular.
4. How would you classify the nodule according to EU-TIRADS?
Distribution of answers
2 This is an EU-TIRADS 3 lesion.
24 This is an EU-TIRADS 4 lesion.
24 This is an EU-TIRADS 5 lesion.
Expert comment
Personally, I would consider this nodule as an EU-TIRADS 4 one because I accept the view that due to the low specificity of irregular shape, it is better to use the 1.2 ratio as a cut-off value (see previous comment).
More important is the question of the correct application of the rules. In this respect all colleagues categorized the nodule correctly, if the answers to the 3rd question are considered. The situation is a bit worse if the answers to the 2nd question are considered. The explanation for this contradiction is that some colleagues gave different answers to the 2nd and 3rd question regarding the presence of obvious forms of microcalcifications.
