PAPILLON COURSE on THYROID ULTRASOUND

1. What is the echogenicity of the nodule in the RIGHT lobe?

Distribution of answers

Choice	Percentage	No
Iso/hyperechoic	6.98 %	3
Minimally/moderately hypoechoic	88.37 %	38
Deeply hypoechoic	4.65 %	2

Expert comment

The nodule is minimally/moderately hypoechoic because this is darker than the extranodular tissue and brighter than the strap muscle running just ventral to the thyroid.

2. What is the dominant kind of intranodular echogenic figures in the nodule in the RIGHT lobe?

Distribution of answers

Choice	Percentage	No
Microcalcifications	30.23 %	13
Back wall cystic figures	23.26 %	10
Comet tail artifacts	4.65 %	2
Macrocalcifications	41.86 %	18

Expert comment

The pale echogenic lines and granules correspond to the normal architecture of the nodule and the thyroid. These can be found even outside the nodule. These resemble back wall figures but are not dorsal to cystic areas. So, the real question is the origin or the bright echogenic figures. Some of the are located dorsal to tiny cystic areas, e.g., the echogenic lines in the dorsal third of the nodule at 0:32 to 0:34 in the video. On the other hand, there are 3 or four bright granules in the lower-medial part of the nodule. There is no cystic area ventral to most of them. These are probably microcalcifications. Therefore, I would choose the first answer.

3. Does the nodule in the RIGHT lobe have microcalcifications?

Distribution of answers

Choice	Percentage	No
Yes.	53.49 %	23
No.	18.6 %	8
Doubtful.	27.91 %	12

Expert comment

See my answer to the previous question. I think that the 'Yes' answer is the more correct one but the 'Doubtful' answer cannot be rejected.

4. How to judge the borders of the nodule in the RIGHT lobe?

Distribution of answers

Choice	Percentage	No
The borders are blurred.	2.33 %	1
The borders are irregular, lobulated and blurred.	95.35 %	41
The borders are blurred.	2.33 %	1
The borders are sharp and regular.	2.33 %	1

Expert comment

First of all, I have to apologize because none of the answers listed contain a really good answer.
The nodule has irregular lobulated margins. We should consider that the hypoechoic mass is composed of multiple nodules next to each other and the relatively large undulations are caused not by pathological lobulation. However, there are some protrusions which cannot be explained by the former possibility. E.g., see the undulation at the dorso-lateral part of the mass (0:23) and the upper dorsal part of the nodule (0:33), these parts of the margins are lobulated. The border is indistinctive in some parts of the nodule, mainly at the ventral portion. Nevertheless, most of the borders are not blurred. S, the degree of blur should not be regarded as pathological. In my opinion, the good answer would be that the nodule has lobulated but not blurred borders. The third answer is closest to this opinion.

5. How to classify the nodule in the RIGHT lobe according to EU-TIRADS?

Distribution of answers

Choice	Percentage	No
EU-TIRADS 1	0 %	0
EU-TIRADS 2	0 %	0
EU-TIRADS 3	2.33 %	1
EU-TIRADS 4	11.63 %	5
EU-TIRADS 5	86.05 %	37

Expert comment

Those who thought that the nodule has either microcalcifications or blurred borders should put the lesion into EU-TIRADS 5 category. Those who stated that the nodule has neither microcalcifications nor irregular borders, should choose the EU-TIRADS 4 option. Taking these considerations into account all but two of the answers were correct.

6. Based on the suggestions of the EU-TIRADS system, is FNA indicated?

Distribution of answers

Choice	Percentage	No
Yes.	97.67 %	42
No.	2.33 %	1
Uncertain.	0 %	0

Expert comment

In a nodule with 11 mm maximal diameter, FNA is indicated only in EU-TIRADS 5 lesions. If the nodule is regarded as an EU-TIRADS 5 lesion, then FNA is mandatory according to EU-TIRADS. In other cases, FNA is not indicated. 35 out of 43 answers were correct.