PAPILLON COURSE on THYROID ULTRASOUND

 

Case of the Month

November 2024 - case 1 (263) - evaluation

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Summary and comments

47 colleagues have replied to the questionnaire.

 

1. How would you consider the echogenicity of the nodule?

Distribution of answers

34 Minimally/moderately hypoechoic

13 Very hypoechoic

Expert comment

The echogenicity of the nodule is on the border between moderate and deep hypoechogenicity. So, I think both answers can be accepted.

2. What intranodular echogenic figures does the nodule have?

Distribution of answers

26 Back wall figures

20 Comet tail artifacts

18 Punctate echogenic foci which can be microcalcifications

15 Obvious forms of microcalcifications

Expert comment

The presence of back wall figure is obvious. See, e.g. the long echogenic line dorsal to a small cystic cavity in the upper dorsal part (left in the video at 0:46.
There are some figures which resemble comet-tail artifact. E.g., two figures between 0:54 and 0:56 in the video. These figures are composed of a brighter ventral spot and a less bright dorsal part. The latter mimics the fading tail of a comet-tail, however in the event of comet-tails this fading tail is gradually narrowing. The absence of this gradual narrowing does not exclude that these figures are comet tail but I won't consider these or other echogenic spots as obvious comet tail artifacts.
If we have doubt about the presence of microcalcifications - and I have -, then it is best to avoid the unequivocal wording. The distribution of punctate echogenic spots is regular, many are dorsal to cystic areas. Therefore those, similarly bright spots which seem to be within solid parts, can be also cyst-related figures. In my opinion the last but one answer ('can be microcalcifications') is the acceptable one regarding the presence of microcalcifications.

One more comment. This is a really difficult case and I am fully convinced that many highly experienced ultrasonographer would be on different opinion.

3. What suspicious characteristics does the nodule have?

Distribution of answers

0 Obvious forms of microcalcifications

13 Deep hypoechogenicity

33 Irregular borders

16 Irregular shape

8 None of them

Expert comment

Shape. What seems clear is that the nodule is not irregularly shaped, both the width nd the length exceeds the depth.

Borders. There are two issues. The first is whether the lesion is composed of more nodules or is a single one. In the event of the former, most of the surface' undulations are caused by the presence of multiple nodules next to each other which is not a pathological irregularity.
The second is that in cystic lesions we should be more cautious when judging the nodule borders. The irregularty is frequently caused by the spontaneous decrease in the cystic fluid. For more cases, please click here.

Echogenicity. In my opinion, the solid part of the nodule is minimally/moderately hypoechoic.

Microcalcification. See my previous comment to question 2.

4. How would you classify the nodule according to EU-TIRADS?

Distribution of answers

Out of those 8 colleagues who stated that the nodule does not have any suspicious characteristics

1 classified the nodule as EU-TIRADS 1

1 classified the nodule as EU-TIRADS 2

3 classified the nodule as EU-TIRADS 4

2 classified as EU-TIRADS 5

Expert comment

Taking the answers to the first question into account, all but those colleagues who stated that the nodule is EU-TIRADS 5, classified the nodule correctly. (To regard a nodule as EU-TIRADS 5, it must contain at least one suspicious characteristic.)

Out of those 39 colleagues who stated that the nodule has at least one suspicious characteristic

1 classified the nodule as EU-TIRADS 2

8 classified the nodule as EU-TIRADS 4

38 classified the nodule as EU-TIRADS 4

Expert comment

A nodule which presents any of the suspicious characteristics must be an EU TIRADS 5 one, so 38 colleagues were right, 9 were wrong.

 

5. What is the suggestion of the ETA in this nodule?

Distribution of answers and Expert comment

Essentially, overwhelming majority of colleagues were right: based on their answer to the previous question 38 colleagues gave a correct answer. There were 9 others, who classified the lesion either as EU-TIRADS 4 or 5 and were of the opinion that 'FNA is to be considered'. These answers cannot be accepted, according to the rules of the EU-TIRADS, in the event of a 11 mm large nodule FNA not indicated or clearly indicated, EU-TIRADS 4 or EU-TIRADS 5 nodule, respectively.

 

 

 

 

 

 

 

 

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