PAPILLON COURSE on THYROID ULTRASOUND
Case of the Month
October 2021 - case 1 - evaluation
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Summary and comments
49 participants have answered the questions.
For watching the full case study, click here.
1. What is the subtype of the larger nodule?
There was a complete agreement that the nodule is dominantly cystic.
Expert comment. No comment... It is obvious that the lesion is a dominantly cystic nodule.
2. What is the subtype of the larger nodule in relation to the solid component?
Distribution of answers
Central type cyst 17
Peripheral type cyst 27
Spongiform cyst 5
Expert comment
In my opinion, it is most likely a central cyst. Even before aspiration, a thin band of solid tissue could be seen on much of the inner surface of the nodule. At that time, however, the situation was not yet clear. After aspiration, however, I think the previously compressed narrow solid band is depicted all the way to the inner surface.
3. Does the larger nodule have microcalcifications?
Distribution of answers
Yes 13
No 26
Doubtful 10
Expert comment
In three cases, the possibility of microcalcification arises. Firstly, in the event of the solid-cystic structure floating in the nodule showed for the first 10 seconds in video. Here I think the possibility of microcalcification can be clearly ruled out, the hyperechoic lines and granules are located dorsal to tiny cystic areas, therefore these are back wall figures caused by posterior enhancement.
Secondly, in the medial wall of the cyst, we can see hyperechoic granules (from 0:07 to 0:12 seconds in the video). In my opinion, these are also more back wall figures. On the one hand, they are seen in a cystically degenerated area and are located behind cystic areas in several places. On the other hand, the appearance of this elongated hyperechoic structure is very similar to the floating one described earlier.
Thirdly, there are hyperechoic granules best seen during ultrasound-guided aspiration (from 0:45 to 0:52 seconds in the video). These 5 or six punctate echogenic foci can correspond to microcalcification. However, it is much more likely that these are back wall figures also seen in the floating structure before the aspiration.
In summary, I think the 'No' or 'Doubtful' answers can be correct. With this degree of uncertainty, by no means do I advise that we clearly state on the medical report that the nodule contains microcalcification.
4. Does the larger nodule have back wall cystic figures?
Distribution of answers
Yes 33
No 10
Uncertain 6
Expert comment
The nodule clearly contains back wall figures. The hyperchoic lines and granules behind tiny cystic areas seen in the floating mass cannot be interpreted differently. See the first 10 seconds of the video.
5. Does the larger nodule have comet tail artifacts?
Distribution of answers
Yes 23
No 22
Uncertain 4
Expert comment
The cystic part of the nodule clearly has hyperechoic figures which lack the characteristic dorsal tail. (E.g., at the 7th and 9th and 16th second in the lower part (right in the video) of the cystic area.) On the one hand, a hyperechoic spot within a cystic area can be interpreted as comet tail artifact even in the absence of the dorsal tail. On the other hand, it would be unusual in such a large cyst to find only one or two colloidal crystals. There may be other explanations for the hyperechoic figures in the cystic part, torn cell debris and small pieces of tissue may appear in this way.
In summary, I do not consider these to be colloidal crystals (comet-tail artifacts), my answer would 'no' to the question.
However, I can accept the other two answers.
6. How to judge the borders of the larger nodule?
Distribution of answers
I prefer judging the borders before the aspiration, therefore the nodule borders should be regarded as normal. 23
The borders are irregular, lobulated because we should judge the borders after the aspiration of the cystic content. 11
The borders are regular both before and after the aspiration. 15
Expert comment
The borders of the nodule were regular before aspiration while they became irregular, lobulated after the aspiration. See e.g., at the 0:56 and at 1:07 seconds in the video. So, theoretically, the good answer could be the either the 1st or the 2nd one.
We have no rules when to judge the borders of a cystic nodule, before or after aspiration. Nevertheless, I clearly think that the situation before the aspiration is worth considering. Many benign cysts become irregularly bordered after aspiration. And this cannot be considered pathological lobulation. Of the latter, we speak of the infiltrative growth of the nodule in the background of the irregular borders.
In summary, I think that the correct answer is the first one, i.e., the nodule borders should be regarded as normal because the borders should be judged before aspiration.
