PAPILLON COURSE on THYROID ULTRASOUND

Choice	No
Dominantly hypoechoic, heterogeneous	28
Dominantly iso/hyperechoic, heterogeneous	7
Minimally/moderately hypoechoic	9
Iso/hyperechoic	1
Deeply hypoechoic	1

Expert comment

Although the nodule has parts with different echogenicities, all parts of the lesion are darker than the extranodular thyroid tissue, some some are minimally/moderately while others are deeply hypoechoic. It means that the nodule cannot be classified as heterogeneous because by definition a heterogeneous lesion must contain has both iso/hyperechoic and hypoechoic portions.
Minimally/moderately hypoechoic parts prevail over deeply hypoechoic ones, therefore the nodule is minimally/moderately hypoechoic.

Distribution of answers

Choice	No
Microcalcifications	3
Deep hypoechogenicity	11
Nonparallel orientation	6
Irregular borders	12
None	28

Expert comment

I did not find any hyperechoic granules which could correspond to microcalcification.
Regarding the echogenicity, see my comment to the previous question.
The dimensions of the nodule were given among patient' data, and both the width and the length exceeded the depth, so the nodule did not show nonparallel orientation.
I myself would not consider the nodule' borders irregular, however, I can accept without further ado if anyone has the opposite opinion on this.

Distribution of answers

Choice	No
EU-TIRADS 3	9
EU-TIRADS 4	20
EU-TIRADS 5	17

Expert comment

Considering the replies to the previous two questions, all but five colleagues have applied the EU TIRADS rules correctly.

Distribution of answers

Choice	No
Yes	36
No	10

Expert comment

Based on the EU-TIRADS classification, all EU-TIRADS 3 or higher category nodules which maximal diameter exceed 20 mm, should be evaluated cytologically.

Distribution of answers

Choice	No
Marked hypoechogenicity	10
Microcalcifications	12
Irregular borders	5
Irregular shape	4
None	25

Expert comment

I consider this nodule as a dominantly solid, minimally/moderately hypoechoic lesion which - based on the coexistence of similarly bright lines and granules - presents back wall figures. On the dimensions of the nodule (see patient's data), the lesion has a regular shape. On the degree of the undulation of the border, I would not consider the borders irregular.

Distribution of answers

Choice	No
Microcalcifications	10
Back wall cystic figures	27
Comet tail artifacts	9
Macrocalcifications	1
None	6

Expert comment

There are similarly bright granules and lines within the nodule and most echogenic figures are dorsal to tiny cystic areas. Therefore, back wall figures are clearly present. In my opinion, the nodule does not have either of the remaining three figures.

Distribution of answers

Choice	No
EU-TIRADS 3	10
EU-TIRADS 4	21
EU-TIRADS 5	15

Expert comment

Considering the replies to the previous two questions, all but four colleagues have applied the EU TIRADS rules correctly.

8. Is FNA indicated from the nodule in the ISTHMUS according to EU-TIRADS?

Distribution of answers

Choice	No
Yes	36
No	10

Expert comment

An EU-TIRADS 4 or 5 lesion should be evaluated cytologically if the largest diameter exceeds 15 mm while only those EU-TIRADS 3 lesions are candidates of FNA which are larger than 20 mm. The nodule was 17 mm in maximal diameter. So those who classified the nodule as EU-TIRADS 4 or 5 should suggest FNA while does who consider the lesion as EU-TIRADS 4, should not.
Essentially, 44 responders gave correct while 2 did wrong answer.