PAPILLON COURSE on THYROID ULTRASOUND

 

 

Summary and comments

52 colleagues replied to the survey.

 

1. How would you consider the echogenicity of the cystic nodule in the RIGHT lobe?

Distribution of answers

13 Iso/hyperechoic

32 Minimally/moderately hypoechoic

7 Very hypoechoic

Expert comment

In my opinion the nodule is minimally/moderately hypoechoic - darker than the extranodular healthy parenchyma but lighter than the strap muscle. The case was discussed on the December 19 webinar, when Gilles Russ was of the opinion that the solid-looking dorsal area can be even a clot.

2. What suspicious characteristics does the cystic nodule in the RIGHT lobe have? Multiple answers possible!

Distribution of answers

5 Deep hypoechogenicity

9 Irregular borders

2 Irregular shape

6 Obvious forms of microcalcifications

37 None of them

Expert comment

The shape can be regarded both as regular and irregular because the width and the depth are very close. The borders of a cyst should be judged before aspiration and at that time it was regular. Regarding the echogenicity and microcalcification see the previous and next question. All in all, I agree with the majority of colleagues, the nodule does not present any suspicious findings.

3. What intranodular hyperechoic figure or figures does the cystic nodule in the RIGHT lobe have? Multiple answers possible

Distribution of answers

44 Back wall figures

10 Comet tail artifact

11 MICROcalcifications

1 MACROcalcification

2 None of them

Expert comment

The presence of back wall figures is evident that of comet tails is conceivable. I believe that the echogenic punctate spots are presentations of back wall figures and are by no way obvious microcalcifications. I was not able to find any figure which can be regarded as macrocalcification.

4. How would you classify the cystic nodule in the RIGHT lobe according to EU-TIRADS?

Distribution of answers

2 EU TIRADS 1

3 EU TIRADS 2

17 EU TIRADS 3

17 EU TIRADS 4

13 EU TIRADS 5

Expert comment

Considering the answers to Question 1 and 2, all but 7 colleagues applied the EU-TIRADS rule correctly. The issue was that 5 colleagues believed the nodule is minimally hypoechoic and is TIRADS 3 while 2 have found suspicious characteristics but considered the nodule as TIRADS 4.

5. What is the suggestion of the ETA in the event of the largest lesion in the RIGHT lobe?

Distribution of answers

25 FNA should be performed.

2 FNA is not indicated.

25 FNA is to be considered.

Expert comment

If we take the nodule's size into account (the largest diameter was 18 mm), the nodule is target of aspiration if considered EU TIRADS 4 but not if considered EU TIRADS 3. The other issue is that the size of the possible solid part is much smaller. According to the rules the largest size of a nodule should be taken into account, but from a practical point-of-view, mostly the largest diameter of the solid portion matters.
So, colleagues who judged the nodule as EU TIRADS 3 were right if they would not indicate FNA. Both the 'should be considered' and 'is considered' answers are acceptable if somebody believed that the nodule is EU TIRADS 4 - see first paragraph.

6. What suspicious characteristics does the smaller, solid nodule in the RIGHT lobe have? Multiple answers possible!

Distribution of answers

3 Deep hypoechogenicity

15 Irregular borders

3 Irregular shape

3 Microcalcifications

34 None of them

Expert comment

The nodule is best seen between 0:25 and 0:31 in the clip. I agree with most colleagues, the nodule does not show any suspicious features.

7. How would you consider the echogenicity of the larger nodule in the LEFT lobe?

Distribution of answers

3 Homogeneous, iso/hyperechoic

11 Homogeneous, minimally/moderately hypoechoic

1 Homogeneous, very hypoechoic

19 Heterogeneous, dominantly iso/hyperechoic

18 Heterogeneous, dominantly hypoechoic

Expert comment

The nodule clearly has minimally hypoechoic and isoechoic parts, too. The ratio of them is close to 1, so I think that the last two answers can be accepted.

8. What intranodular hyperechoic figure or figures does the largest lesion in the LEFT lobe have? Multiple answers possible!

Distribution of answers

47 Back wall figures

5 Comet tail artifact

9 MICROcalcifications

0 MACROcalcification

3 None of them.

Expert comment

Back wall figures are clearly present. Some figures can be regarded as comet tails (e.g., at 0:53 both the uppermost and lowermost figures). None of the figures can be considered as microcalcifications.

9. What suspicious characteristics does the larger lesion in the LEFT lobe have? Multiple answers possible!

Distribution of answers

1 Deep hypoechogenicity

35 Irregular borders

13 Irregular shape

8 Microcalcifications

8 None of them

Expert comment

Strictly speaking, the nodule presents irregular borders (see at 0:44 in the video). I am not able to find any other suspicious features.

10. How would you classify the largest lesion in the LEFT lobe according to EU-TIRADS?

Distribution of answers

1 EU TIRADS 1

1 EU TIRADS 2

4 EU TIRADS 3

6 EU TIRADS 4

40 EU TIRADS 5

Expert comment

There were 3 colleagues who found suspicious findings but classified the nodule as TIRADS 5.

11. FNA of two above discussed nodules resulted in benign lesion. How does the elevated calcitonin level influence your decision?

Distribution of answers

8 Considering the benign cytology and the ultrasound pattern, the calcitonin level does not change the decision.

8 I suggest performing FNA also from the smaller nodules

14 I would suggest repeat FNA and calcitonin measurement in 6 to 12 months

18 I would discuss the situation with the patient with the intention of accepting surgery rather than follow-up

1 I would discuss the situation with the patient with the intention of accepting follow-up rather than surgery.

3 There is nothing to talk about, the patient must be operated on.

Expert comment

This is a difficult problem. In my opinion, except for the first answer, all others can be accepted. Considering the quite great chance of false positive calcitonin results between the upper normal limit and 5-times level of this, the last opportunity can be questioned. I would choose the 2nd, the 3rd and the 5th options.