SUMMARY
1. How to judge the right lobe regarding the presence of pathological nodule?
The right lobe has pathological nodule. 2
The right lobe does not have pathological nodule. 3
The presence of pathological nodule is doubtful. 4In my opinion the correct answer is either the seond or the third. I would answer that we cannot decide whehter the right lobe has or has not a true nodule. The discrete, iso/hyperechoic lesion in the lower part is the lesion in question. This can be only the largest of those parts of the lobe which were not or less influenced by the underlying thyroiditis. However, the possibility of a true nodele cannot be excluded.
2. How to describe the echogenicity of the thyroid?
The thyroid is echonormal and has hypoechoic areas. The echogenicity index is around 50%. 4
The thyroid is composed of minimally/moderately and deeply hypoechoic areas. 5
The thyroid is deeply hypoechoic. 0
The thyroid is iso/hyperechoic. 0In my opinion, the second answer is the correct one because even the brighter areas of the gland are hypoechoic if we compare to a healthy thyroid.
3. How to classify the echogenic lines and granules in the thyroid?
These are back wall figures caused by posterior enhancement. 3
These are presentations of connective tissue. 6
Some of them are microcalcifications. 0These echogenic figures are presentations of fibrosis. In Hashimoto's thyroiditis the very hypoechoic areas are not cystic. Theoretically, we can consider that the deeply hypoechoic areas correspond to fluid, however, a cystic area has almost always sharp borders and regular shape. The deeply hypoechoic small areas of this thyroid has irregular shape and indistinctive borders.
4. How to describe the largest lesion in the lower pole of the left lobe?
This is an iso/hyperechoic nodule. 2
This is a minimally/moderately hypoechoic nodule? 0
Compared to the extralesional tissue, the nodule is iso/hyperechoic while compared to a healthy thyroid, the lesion should be regarded as minimally/moderately hypoechoic. 4
Irrespectively of the reference tissue, this is a dominantly iso/hyperechoic, heterogeneous nodule. 3
Irrespectively of the reference tissue, this is a dominantly minimally/moderately hypoechoic, heterogeneous nodule. 0The third answer is the correct. See the 2nd comment here.
5. Is FNA indicated based on EU-TIRADS?
Yes. 4
No. 5
Uncertain. 0
FNA indicated FNA not indicated Either iso/hyperechoic or min./moderately hypoechoic Iso/hyperechoic The cells highlighted with yellow are the correct answers. The nodule was 20 mm in maximal diameter. According to the EU-TIRADS, a category 3 (iso/hyperechoic) nodule requires FNA if the largest diameter exceeds >20 mm. Naturally, in this case the 2, theroretically false answers can be accepted, too.
6.Would you personally indicate FNA?
Yes. 5
No. 4The risk of malignancy was very low in this case. Therefore, the negligence of FNA is acceptable. In my opinion, several other conditions can be considered; these are the access to FNA and the psyhological aspects. I would perform FNA because a reassuring cytological result weighs differently than a reassuring oral opinion.
The complete case study is presented here.
