PAPILLON COURSE on THYROID ULTRASOUND
Case of the Month
November 2024 - case 2 (783) - evaluation
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Summary and comments
42 colleagues have replied to the survey.
1. How would you consider the echogenicity of the largest lesion in the RIGHT lobe?
Distribution of answers
3 Iso/hyperechoic
30 Minimally/moderately hypoechoic
9 Very hypoechoic
Expert comment
I agree with most colleagues, the nodule is minimally/moderately hypoechoic.
2. What suspicious characteristics does the largest lesion in the RIGHT lobe have? Multiple answers possible!
Distribution of answers
8 Deep hypoechogenicity
2 Irregular borders
2 Irregular shape
30 None of them
Expert comment
Again, I agree with most colleagues, the nodule has no suspicious signs. The degree of undulations is not pathological. As I described in the introduction, the dimensions of the nodule were 6x5x9 mm, width, depth, length, respectively; it means that both the width and the length were larger than the depth - so the nodule presents regular shape.
3. How would you classify the largest lesion in the RIGHT lobe according to EU-TIRADS?
Distribution of answers
Out of those 30 colleagues who stated that the nodule does not have any suspicious characteristics
1 classified the nodule as EU-TIRADS 1
2 classified the nodule as EU-TIRADS 2
5 classified the nodule as EU-TIRADS 3
22 classified as EU-TIRADS 4
Expert comment
Taking the answers to the first question into account 24 colleagues classified the nodule correctly while 6 failed.
Out of those 11 colleagues who stated that the nodule does have at least one suspicious characteristic
1 classified the nodule as EU-TIRADS 3
5 classified the nodule as EU-TIRADS 4
5 classified the nodule as EU-TIRADS 5
Expert comment
Only those who considered the nodule as EU-TIRADS 5 were right because the presence of even a single suspicious finding classifies the nodule as EU-TIRADS 5.
4. What is the suggestion of the ETA in the event of the largest lesion in the RIGHT lobe?
Distribution of answers and Expert comment
This was a 9 mm large nodule. 36 colleagues classified the nodule as EU-TIRADS 1 or 2 or 3 or 4. In such subcentimeter nodule FNA is not indicated. Seven colleagues were wrong because they stated that FNA is indicated or is to be considered, while 29 were right.
Five colleagues classified the nodule as EU-TIRADS 5. Two were on the opinion that FNA should be performed, 2 were on the opinion that FNA is to be considered while one colleague stated the FNA is not indicated. In my opinion the answer 'FNA should be performed' is not acceptable. In subcentimeter TIRADS nodules, FNA is only mandatory if the nodule presents extrathyroidal extension or in the event of pathological lymph node.
5. How would you consider the echogenicity of the nodule in the LEFT lobe?
Distribution of answers
21 Heterogeneous, dominantly hypoechoic
19 Heterogeneous, dominantly iso/hyperechoic
2 Homogeneous, minimally/moderately hypoechoic
Expert comment
In my opinion, this is a dominantly iso/hyperpechoic nodule with minority deeply hypoechoic parts.
6. What suspicious characteristics does the nodule in the LEFT lobe have? Multiple answers possible!
Distribution of answers
10 Deep hypoechogenicity
28 Irregular borders
18 Irregular shape
7 Obvious forms of microcalcifications
9 None of them
Expert comment
The nodule is wider and longer than deeper, so it has NOT irregular shape. The borders can be regarded as irregular but it is very difficult to judge where the nodule starts and where it ends. I don't think that obvious forms of microcalcifications are present. Regarding the echogenicity, see my reply to the previous question.
One more consideration. Despite the lack of most (or even all) suspicious findings, the ultrasound presentation is very suspicious. If FNA were benign in nodule with such a presentation, I would consider surgery even if the lesion would be much smaller.
7. How would you classify the nodule in the LEFT lobe according to EU-TIRADS?
Distribution of answers and Expert comment
9 colleagues found no suspicious characteristics. Considering their answer to question 5, six of them classified the nodule correctly while 3 of them incorrectly. A nodule without suspicious findings is either TIRADS 3 or TIRADS 4, entirely iso/hyperechoic or at least partly minimally/moderately hypoechoic, respectively.
33 colleagues have found at least one suspicious characteristic. 28 classified the nodule correctly as TIRADS 5 while five did not because they incorrectly stated that the nodule is either TIRADS 3 or 4.
8. What is your opinion about extrathyroidal spread in the event of the nodule in the LEFT lobe?
Distribution of answers
16 The nodule does not extend extrathyroidal.
16 Minimal extrathyroidal extension is to be considered.
4 Minimal extrathyroidal extension is present.
5 Gross extrathyroidal extension is to be considered.
1 Gross extrathyroidal extension is present.
Expert comment
One issue is the judgement on the extrathyroidal spread. Indeed, the nodule presented with gross extrathyroidal extension into the strap muscle and adipose tissue. So, it would be ridiculous if I won't accept the last two answers. On the other hand, I am not able to find any signs of gross extrathyroidal spread.
The other issue is whether the nodule show any ultrasound signs of extrathyroidal spread. The nodule shows all three, this has abutting and bulging contours and the pseudocapsule of the thyroid is broken where the nodule is on the surface of the lobe. So, the presence of extrathyroidal spread cannot be excluded. Personally, my answer would be the second: minimal extrathyroidal spread is to be considered.
