PAPILLON COURSE on THYROID ULTRASOUND
Case of the Month
January 2022 - case 1 - evaluation
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Summary and comments
59 participants have answered the questions. I apologize for the obvious nonsense option in Questions 2 because of a misspelling.
1. The patient is very afraid of sampling and agrees to only a single puncture. Which nodule would you sample?
Distribution of answers
Choice
%
No
The right one
12.1
7
The left one
87.9
52
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. What echogenic figure or figures has the nodule in the RIGHT lobe?
Distribution of answers
Choice
%
No
Microcalcifications
40.7
24
Back wall cystic figures
71.2
42
Comet tail artifacts
20.3
12
Macrocalcifications 18.6
11
None
0
0
Expert comment
The nodule clearly had back wall figures. Regarding the judgement on the presence of microcalcifications, see the next comment.
One echogenic figure is suspicious being comet tail artifact (see the upper-dorsal part of the nodule, left and lower in the image at 0:10 sec).
I could not find any macrocalcifications within the nodule.
3. What suspicious ultrasound characteristic or characteristics has the nodule in the RIGHT lobe?
Distribution of answers
Choice
%
No
Marked hypoechogenicity
32.2
19
Microcalcifications
44.1
26
Irregular borders
28.9
17
Irregular shape 23.7
14
Expert comment
Although the nodule has parts which are darker than the strap muscle, minimally/moderately hypoechoic areas predominate, it means that the nodule is minimally/moderately hypoechoic.
While there are several hyperechoic spots suspicious of microcalcification, in my opinion, there are no unequivocal microcalcifications.
The nodule is not perfectly regular geometrical, however such degree of undulations is a frequent finding in thyroid nodules. I would not consider the borders irregular. On the other hand, the definition is not very exact, it does not specify the degree which an undulation should exceed to be classified as irregular.
We should compare the largest diameters and not the diameters in a certain section. Although the diameters were almost the same, both the largest width and the largest length exceeded the largest depth, therefore the nodule did not present nonparallel orientation.
4. How to classify the nodule in the RIGHT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
EU-TIRADS 3
3.4
2
EU-TIRADS 4
22.0
13
EU-TIRADS 5
74.6
44
Expert comment
All responders have found at least one suspicious characteristic. It means that everybody had to put the nodule into EU-TIRADS 5 subgroup. So, 44 responders gave correct while 15 did incorrect answer to this question.
5. Is FNA indicated from the nodule in the RIGHT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
Yes
96.7
57
No
3.3
2
Expert comment
If we rely on the answer to the 5th question, then all responders gave correct answer.
6. What echogenic figure or figures has the nodule in the LEFT lobe?
Distribution of answers
Choice
%
No
Microcalcifications
55.9
33
Back wall cystic figures
49.2
29
Comet tail artifacts
6.8
4
Macrocalcifications 1.7
1
None
5.1
3
Expert comment
First, it is a strange situation that in this question, 33 responders thought that the nodule contained microcalcifications, while in the next question only 15 did similarly. Although there are some suspicious granules within the lesion, I would consider them rather back wall figures because similarly bright lines are present in equal proportion.
Similarly to the majority of the colleagues, I wasn't able to find either comet tail artifact or macrocalcifications.
7. What suspicious ultrasound characteristic or characteristics has the nodule in the LEFT lobe?
Distribution of answers
Choice
%
No
Marked hypoechogenicity
64.4
38
Microcalcifications
25.4
15
Irregular borders
89.8
53
Irregular shape 53.5
31
Expert comment
The echogenicity of the nodule is better to judge in this case in the longitudinal section. I mean that this is deeply hypoechoic (see in the video from 0:30 sec).
Although there are some suspicious granules within the lesion, I would consider them rather back wall figures because similarly bright lines are present in equal proportion.
I agree with the majority of responders, the nodule has clearly irregular borders (e.g., see in the video at 0:32 and at 0:36 sec).
Among the patient' data I have given the dimensions of the nodule, which shows that the depth of the nodule is greater than its length, so the nodule has irregular shape.
8. How to classify the nodule in the LEFT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
EU-TIRADS 3
0
0
EU-TIRADS 4
10.2
6
EU-TIRADS 5
89.8
53
Expert comment
All responders have found at least one suspicious characteristic. It means that everybody had to put the nodule into EU-TIRADS 5 subgroup. So, 53 responders gave correct while 6 did incorrect answer to this question.
9. Is FNA indicated from the nodule in the LEFT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
Yes
96.7
57
No
3.3
2
Expert comment
If we rely on the answer to the 5th question, then all responders who considered the nodule as EU-TIRADS 5, gave correct answer, and would perform FNA. According to the rules of the EU-TIRADS, a category 4 lesion should be aspirated if the largest diameter exceeds 15 mm. This nodule was only 11 mm, so based on the EU-TIRADS, no cytology should have been performed from the lesion. So 2 of those 6 responders who classified the nodule as Eu-TIRADS 4 gave correct while the remaining 4 wrong answer.
