PAPILLON COURSE on THYROID ULTRASOUND

Section 2 The nodular goiter

Part 4 Intranodular echogenic figures

This topic is the most voluminous one of the entire Course. It requires 10 to 20 hours from the learner to handle this issue. The problem is that the presentation of intranodular figures are very close to each other, e.g. the distinction between a microcalcification and a comet-tail artifact might depend not on the appearance of the echogenic granule itself but also on the environment surrounding the figure. Here we face again with the usual problem of ultrasound characteristics: except for macrocalcifications we lack a clear-cut biological reference and the interobserver variation is high even among highly experienced examiners. Not infrequently the differentiation among the various forms is not possible. I'm absolutely sure that my interpretation is not the best in many cases. I have to confess that although I had been performed more than 130,000 thyroid ultrasound examinations before preparing this topic, my approach - even my every-day clinical practice - has been changed after this topic had been prepared.

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 intranodular figures and demonstrates the role of these characteristics 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. 10 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 55 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 substantially 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 46-year-old woman was referred for evaluation of a suspected multifocal papillary carcinoma detected in an ultrasound examination. Indeed, the patient had several cystic areas without any clinical and oncological significance. Most of these cystic lesions contained one or more typical comet tail artifacts. Although I performed aspiration cytology which resulted in benign lesion and tried to convince the patient that she did not have even a carcinoma and the lesions were normal findings, I failed to fully convince her. She requested a second opinion from another endocrinologist who did not perform ultrasound. Considering the great anxiety of the patient, he offered surgical exploration. Histopathology resulted in intact thyroid containing several cystically dilated follicles. (For details, click on the image.)

This story raises several important concerns including the role of thyroid ultrasound screening and the responsibility of the radiologist but let's focus on the actual issue, the importance of the correct interpretation of an intranodular hyperechogenic figure.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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