PAPILLON COURSE on THYROID ULTRASOUND
Case of the Month
October 2021 - case 2 - evaluation
 |
 |
 |
 |
Summary and comments
46 participants have answered the questions.
For watching the full case study, click here.
1. Does the right lobe have pathological nodule?
Distribution of answers
Yes 6
No 41
Expert comment
The question points to the lack of clear cut definition on nodules. If we were to accept the ATA proposal, all discrete lesions would have to be called nodule. Fortunately, most respondents think otherwise. The pattern of the right lobe shows the most common pattern of chronic thyroiditis. Hypoechogenic discrete areas correspond to more active thyroid foci and not to a nodule in a pathological sense.
2. What is the echogenicity of the largest lesion in the left lobe?
Distribution of answers
This is an iso/hyperechoic nodule 38
This is minimally/moderately hypoechoic nodule 3
Spongiform cyst 5
Expert comment
If we compared the nodule' echogenicity to that of the extranodular tissue (or as the EU-TIRADS suggest in hypoechoic thyroids, to the salivary gland), then the lesion should be classified as iso/hyperechoic. However, if the reference tissue would be a normal healthy thyroid than the nodule should be regarded as minimally/moderately hypoechoic.
I would describe the nodule as iso/hyperechogenic because it is close to normal echogenicity even when compared to a healthy thyroid. Nevertheless, I can fully accept the 'minimally/moderately hypoechogenic response. The nodule cannot be classified as spongiform. The latter has to conditions, first it refers to cystic nodules, and spongiform pattern means the presence of tiny cystic areas separated by fibrous vessels. Secondly, these spongiform areas have to reach at least 50% of the nodule.
3. How to classify the largest lesion in the LEFT lobe according to the EU-TIRADS??
Distribution of answers
43 respondents classified the nodule as iso/hyperechoic.
41 were told that the lesion is EU-TIRADS 3 (low risk)
2 were told that the lesion is EU-TIRADS 4 (intermediate risk)
3 respondents classified the nodule as minimally/moderately hypoechoic and all of them told that the lesion is EU-TIRADS 3 (intermediate risk).
Expert comment
If we consider the nodule as iso/hyperechoic, then the nodule is an Eu-TIRADS 3 lesion. If we judge the nodule as minimally/moderately hypoechoic, then the nodule should be regarded as an EU-TIRADS 4 lesion. So, except for two, the responses were correct.
4. According to the EU-TIRADS, should this nodule be evaluated by cytology?
Distribution of answers
41 respondents classified the nodule as EU-TIRADS 3 (low risk)
28 of them stated that the nodule should be evaluated by cytology according to EU-TIRADS.
13 of them stated that the nodule should NOT be evaluated by cytology according to EU-TIRADS.
5 respondents classified the nodule as EU-TIRADS 4 (intermediate risk) and all of them stated that the nodule should be evaluated by cytology according to EU-TIRADS.
Expert comment
FNA is not indicated or is indicated depending on the EU-TIRADS classification, EU-TIRADS 3 lesion or EU-TIRADS 4 lesion, respectively. According to the EU-TIRADS rules, 33 answers were correct while 13 were not correct.
5. Did you personally indicate FNA in this lesion?
Distribution of answers
Yes 25
No 18
Uncertain 3
Expert comment
This is not an obvious situation and naturally, all three answers can be accepted. Taking the reality into account, I personally would perform FNA. Although the risk of cancer is very low in this nodule, but a follicular tumor should be considered in a solitary lesion presenting halo. There is no other chance of recognizing follicular cancers at the stage when they do not yet have a distant metastasis than to perform a cytological examination in echonormal nodules smaller than 2 cm that show a sheath mark. The approach of TIRADS is the opposite. (A detailed explanation of the problem can be found in the TIRADS chapter.)
