PAPILLON COURSE on THYROID ULTRASOUND
Case of the Month
December 2021 - case 1 - evaluation
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Summary and comments
56 participants have answered the questions. I apologize for the obvious nonsense option in Questions 2 because of a misspelling.
1. What is the echogenicity of the nodule in the RIGHT lobe?
Distribution of answers
Choice
%
No
Iso/hyperechoic
7.1
4
Minimally/moderately hypoechoic
26.8
15
Deeply hypoechoic
5.4
3
Dominantly deeply hypoechoic, heterogeneous
1.8
1
Dominantly minimally/moderately hypoechoic, heterogeneous
57.1
32
Dominantly iso/hyperechoic, heterogeneous
1.8
1
Expert comment
I would consider the nodule as a homogeneously minimally/moderately hypoechoic lesion. The less hypoechoic parts are also a bit darker than the extranodular tissue.
2. Which echogenic figures has the nodule in the RIGHT lobe?
Distribution of answers
Choice
%
No
Microcalcifications
12.5
7
Back wall cystic figures
75.0
40
Comet tail artifacts
12.5
7
Macrocalcifications
0
0
Expert comment
There are similarly bright granules and lines within the nodule and most echogenic figures are dorsal to tiny cystic areas. Therefore, these are back wall figures.
3. How to classify the nodule in the RIGHT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
EU-TIRADS 3
25.0
14
EU-TIRADS 4
60.7
34
EU-TIRADS 5
14.3
8
Expert comment
Essentially, majority of responders gave a correct answer. Those who stated that the nodule is either deeply hypoechoic or has microcalcifications, correctly categorized the lesion as TIRADS 5, similarly to those who stated that the nodule does not present microcalcification and is minimally-moderately hypoechoic and regarded the nodule as TIRADS 5. Those failed who regarded the nodule as minimally-moderately hypoechoic and put it into TIRADS 3 category instead of TIRADS 4.
4. What is the echogenicity of the LARGEST nodule in the LEFT lobe?
Distribution of answers
Choice
%
No
Iso/hyperechoic
21.4
12
Dominantly iso/hyperechoic, heterogeneous
62.5
35
Minimally/moderately hypoechoic
8.9
5
Minimally/moderately hypoechoic, heterogeneous
7.1
4
Deeply hypoechoic
0
0
Deeply hypoechoic, heterogeneous
0
0
Expert comment
Most parts of the nodule is clearly iso/hyperechoic. There is no definition in the literature of what proportion a minority part must exceed in order to call a nodule heterogeneous. The largest, contiguous minimally/moderately hypoechoic part is around 1 cm (e.g., at 0:28 in the video). Based on this, I tend to consider the nodule to be heterogeneous. However, the first answer is also clearly acceptable.
5. How to classify the LARGEST nodule in the LEFT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
EU-TIRADS 3
78.6
44
EU-TIRADS 4
19.6
11
EU-TIRADS 5
1.8
1
Expert comment
Based on the answer to the previous question, a maximum of 12 could have been considered the nodule EU-TIRADS 3. According to the definition of the EU-TIRADS, a not only minimally/moderately but also dominantly iso/hyperechoic nodules should be considered as EU-TIRADS 4 lesion.
6. What is the echogenicity of the nodule in the LEFT lobe which is presented also in enlarged view?
Distribution of answers
Choice
%
No
Iso/hyperechoic
5.4
3
Minimally/moderately hypoechoic
10.7
6
Deeply hypoechoic
25.0
14
Dominantly deeply hypoechoic, heterogeneous
30.4
17
Dominantly minimally/moderately hypoechoic, heterogeneous
28.6
16
Dominantly iso/hyperechoic, heterogeneous
0
0
Expert comment
In my opinion, the echogenicity of this nodule is best judged between 0:17 and 0:20 seconds of video when all parts of the nodule are darker than the extranodular tissue, the majority parts of the nodule are minimally/moderately hypoechoic and a small proportion is deeply hypoechoic. We can also stop the video from making the nodule look decidedly deeply hypoechogenic. (E.g., at 0:21 seconds.) But during or immediately after the movement, the assessment of echogenicity is much less reliable. Therefore, I would judge the nodule as minimally/moderately hypoechoic.
7. Which suspicious characteristics has the nodule in the LEFT lobe which is presented also in enlarged view?
Distribution of answers
Choice
%
No
Microcalcifications
19.6
11
Pathological form of nonparallel orientation
23.2
13
Both of them
46.4
26
None of them
10.7
6
Expert comment
In my opinion, the nodules shows neither nonparallel orientation nor microcalcifications. This is sandwiched between two other nodules, which hinder the normal sideway growth, therefore the irregular shape is of non-pathological origin. (OK, no one TIRADS makes distinction between pathological and non-pathological forms of nonparallel orientation.)
For those who think the nodule contains microcalcification, please look at the nodule several times at 0.5x magnification. Here one can see that the same echogenic figure that appears to be point-like appears to be linear later. This is against microcalcification. Nevertheless, I'm quite sure that great proportion of experienced investigators would not agree with me.
8. How to classify the nodule in the LEFT lobe which is presented also in enlarged view?
Distribution of answers
Choice
%
No
EU-TIRADS 3
3.6
2
EU-TIRADS 4
14.3
8
EU-TIRADS 5
82.1
46
Expert comment
50 respondents thought that the nodule has either microcalcification or pathological form of nonparallel orientation. One of the remaining 6, judge the nod nodule as deeply hypoechoic. 46 out of these 51 responders correctly regarded the nodule as TIRADS 5 while the remaining 5 colleagues gave bad answer. There were 5 other colleagues who thought that the nodule presents no suspicious sign, except for one, all grouped the lesion correctly into either EU-TIRADS 3 or EU-TIRADS 5 group. Only one colleague gave wrong answer who regarded a minimally-moderately hypoechoic nodule as E-TIRADS 3 lesion.
