PAPILLON COURSE on THYROID ULTRASOUND
Case of the Month
January 2025 - case 1 (129) - evaluation
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Summary and comments
49 participants have answered the questions.
1. The patient is very afraid of sampling and agrees to only a single puncture. Which nodule would you sample?
Distribution of answers
Choice
No
The right one
8
The left one
41
Expert comment
The case was discussed on the January 30 webinar where the experts agreed that the left lobe is more likely malignant than the right one.
2. What echogenic figure or figures has the nodule in the RIGHT lobe? (Multiple answers were possible.)
Distribution of answers
Choice
No
Microcalcifications
13
Back wall cystic figures
35
Comet tail artifacts
9
Macrocalcifications 3
None
1
Expert comment
The nodule clearly had back wall figures. Regarding the judgement on the presence of microcalcifications, see the next comment.
One echogenic figure is suspicious being comet tail artifact (see the upper-dorsal part of the nodule, left and lower in the image at 0:10 sec).
I could not find any macrocalcifications within the nodule.
3. What suspicious ultrasound characteristic or characteristics has the nodule in the RIGHT lobe? (Multiple answers were possible.)
Distribution of answers
Choice
No
Marked hypoechogenicity
3
Microcalcifications
16
Irregular borders
6
Irregular shape 6
None of them 29
Expert comment
Although the nodule has parts which are darker than the strap muscle, minimally/moderately hypoechoic areas predominate, it means that the nodule is minimally/moderately hypoechoic.
While there are several hyperechoic spots suspicious of microcalcification, in my opinion, there are no unequivocal microcalcifications.
The nodule is not perfectly regular geometrical, however such degree of undulations is a frequent finding in thyroid nodules. I would not consider the borders irregular. On the other hand, the definition is not very exact, it does not specify the degree which an undulation should exceed to be classified as irregular.
We should compare the largest diameters and not the diameters in a certain section. Although the diameters were almost the same, both the largest width and the largest length exceeded the largest depth, therefore the nodule did not present nonparallel orientation.
4. How to classify the nodule in the RIGHT lobe according to EU-TIRADS?
Distribution of answers
Choice
No
EU-TIRADS 2
2
EU-TIRADS 3
7
EU-TIRADS 4
25
EU-TIRADS 5
15
Expert comment
Twenty colleagues have found suspicious characteristics, all but two colleagues have classified the nodule correctly as a TIRADS 5 lesion.
The remaining 29 did not find suspicious findings. Two of them were of the opinion that the nodule is a TIRADS 2 one. It cannot be because this is neither a simple nor a spongiform cyst. The other 18 colleagues classified the nodule as a TIRADS 3 or one which can be the correct answer in the absence of suspicious features.
5. Is FNA indicated from the nodule in the RIGHT lobe according to EU-TIRADS?
Distribution of answers
Choice
No
Yes
40
No
9
Expert comment
If we rely on the answer to the 5th question, then 2 but the 49 colleagues applied the EU-TIRADS rules correctly. In the event of a 16-mm large nodule, FNA should be performed if the nodule is EU-TIRADS 4 or 5, but not if this is EU-TIRADS 2 or 3.
6. What echogenic figure or figures have the nodule in the LEFT lobe? (Multiple answers were possible.)
Distribution of answers
Choice
No
Microcalcifications
24
Back wall cystic figures
17
Comet tail artifacts
0
Macrocalcifications 0
None
15
Expert comment
First, it is a strange situation that in this question, 24 responders thought that the nodule contained microcalcifications, while in the next question only 10 did similarly. Although there are some suspicious granules within the lesion, I would consider them rather back wall figures because similarly bright lines are present in equal proportion.
Similarly to the colleagues, I wasn't able to find either comet tail artifact or macrocalcifications.
7. What suspicious ultrasound characteristic or characteristics has the nodule in the LEFT lobe? (Multiple answers were possible.)
Distribution of answers
Choice
No
Marked hypoechogenicity
30
Microcalcifications
14
Irregular borders
39
Irregular shape 21
None of them 4
Expert comment
The echogenicity of the nodule is better to judge in this case in the longitudinal section. I mean that this is deeply hypoechoic (see in the video from 0:30 sec).
Although there are some suspicious granules within the lesion, I would consider them rather back wall figures because similarly bright lines are present in equal proportion.
I agree with the majority of responders, the nodule has clearly irregular borders (e.g., see in the video at 0:32 and at 0:36 sec).
Among the patient' data I have given the dimensions of the nodule, which shows that the depth of the nodule is greater than its length, so the nodule has irregular shape.
8. How to classify the nodule in the LEFT lobe according to EU-TIRADS?
Distribution of answers
Choice
No
EU-TIRADS 2 EU-TIRADS 3
3
EU-TIRADS 4
2
EU-TIRADS 5
43
Expert comment
All but four of the 49 responders who have found at least one suspicious characteristic, classified the nodule correctly as TIRADS 5. All but one of the remaining four responders were of the opinion that the nodule is a TIRADS 3 lesion - they are right.
9. Is FNA indicated from the nodule in the LEFT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
Yes
96.7
57
No
3.3
2
Expert comment
If we rely on the answer to the 5th question, then all responders who considered the nodule as EU-TIRADS 5, gave correct answer, and would perform FNA.
Both colleagues who considered the lesion as TIRADS 4 wrongly suggested FNA. According to the rules of the EU-TIRADS, a category 4 lesion should be aspirated if the largest diameter exceeds 15 mm. This nodule was only 11 mm, so based on the EU-TIRADS, no cytology should have been performed from the lesion.
None of those four colleagues who classified the nodule as TIRADS 2 or 3 suggested FNA - they all applied the EU rules correctly.
