Section 2 The nodular goiter

Part 5 The borders of the nodule


This topic is a quite voluminous one. The main issue is that the interobserver variation regarding irregular margins is the highest or the highest but one among suspicious ultrasound characteristics. Similarly to many other features, thyroiditis frequently leads to deceptive patterns.
The essence of this topic is to learn how to recognize lobulated/spiculated margins which is encountered among the most suspicious signs in every TIRADS.
It's recommended to be aware, that although the irregular borders and the shape of the nodule and the extrathyroidal spread are discussed in three separate subchapters, these three are related topics because all rely on the infiltrative nature of thyroid carcinomas, particularly the papillary subtype.

I emphasize again, that I'm absolutely sure that my interpretation is not the best in many cases. The problem is that even experienced investigators speak similar but not the same language.

This course is composed of several parts. It is advised follow the order of the parts.

  1. Introductory course briefly describes the various forms of the irregular borders, discusses their role in various forms of thyroid cancer and in different TIRADS.

  2. Manual on intranodular echogenic figures serves as a guidance for the reader. The manual can be downloaded in pdf format.

  3. Lectures present the different forms in detail and give an approach to differential diagnostic. This is one of the most time-consuming parts of the topic.

  4. Case study is composed of dozens of cases most of them presents beside 5 to 15 ultrasound images ultrasound videos, as well.

  5. Videolibrary serves the goal of testing the skills by analyzing videos.

  6. If you visit the Exam, you can test your skills. The unspoken purpose of these tests is to get the students to watch and analyze as many videos as possible.

This topic requires more thoughtfulness and attention than almost all other sections of the Course. As had been emphasized several times before, the course is only one leg of the education. You have to perform alone or with guidance as many as possible thyroid ultrasound examination in your workplace.


Case study of the topic

A 39-yr-old woman was referred for evaluation of a nodule described as highly suspicious because of the presence of irregular, partly lobulated, partly spiculated margins and that of microcalcifications. The patient requested the investigation because of complaints suggesting hypothyroidism. There is no doubt that the hypoechogenic mass had both lobulated and spiculated margins, the issue is the origin of this mass. First, the mass was composed of multiple discrete lesions giving the lobulated appearance of the bunch of the grapes. However, the margins should be interpreted not on a mass composed of multiple lesions, but on an individual lesion. The second issue is that the patient had Hashimoto's thyroiditis, and the lesions corresponded not to a pathological nodule but more active foci of the thyroiditis. Thyroiditis is an infiltrative process and therefore it is characterized by infiltrative margins.
In fact, the patient had multiple foci of thyroiditis next to each other and not pathological nodules (for details of the case study, click on the image).

This case study raises several important concerns including the problem of the interpretation of discrete nodules seen on thyroid ultrasound, but here we focus on the actual issue, the importance of the correct interpretation of the nodule' borders.