PAPILLON COURSE on THYROID ULTRASOUND
Case of the Month
January 2022 - case 2 - evaluation
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Summary and comments
53 participants have answered the questionnaire.
1. What is the echogenicity of the nodule in the RIGHT lobe?
Distribution of answers
Choice
%
No
Dominantly hypoechoic, heterogeneous
66.0
35
Dominantly iso/hyperechoic, heterogeneous
20.8
11
Minimally/moderately hypoechoic
13.2
7
Iso/hyperechoic
0
0
Deeply hypoechoic
0
0
Expert comment
Although the nodule has parts with different echogenicities, all parts of the lesion are darker than the extranodular thyroid tissue, some or minimally/moderately while others are deeply hypoechoic. It means that the nodule cannot be classified as heterogeneous because by definition a heterogeneous lesion must contain has both iso/hyperechoic and hypoechoic portions.
Minimally/moderately hypoechoic parts prevail over deeply hypoechoic ones, therefore the nodule is minimally/moderately hypoechoic.
2. Which suspicious sign or signs does the nodule in the RIGHT lobe have?
Distribution of answers
Choice
%
No
Microcalcifications
3.8
2
Deep hypoechogenicity
28.3
15
Nonparallel orientation
13.2
7
Irregular borders 20.8
11
None 49.1
26
Expert comment
I did not find any hyperechoic granules which could correspond to microcalcification.
Regarding the echogenicity, see my comment to the previous question.
The dimensions of the nodule were given among patient' data, and both the width and the lenght exceeded the depth, so the nodule did not show nonparallel orientation.
I myself would not consider the nodule' borders irregular, however, I can accept without further ado if anyone has the opposite opinion on this.
3. How to classify the nodule in the RIGHT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
EU-TIRADS 3
20.8
11
EU-TIRADS 4
47.2
25
EU-TIRADS 5
32.1
17
Expert comment
- First, I present those answers who did not find any suspicious characteristics (see question 2).
Echogenicity
Dominantly hypoechoic, heterogeneous
14
Dominantly iso/hyperechoic, heterogeneous
8
Minimally/moderately hypoechoic
4
According to the EU-TIRADS, all dominantly iso/hyperechoic heterogeneous nodule should be classified as EU-TIRADS 4 lesion, so 18 of 26 responders have classified the nodule correctly while 8 of the 26 did wrongly.
- 27 responders have found at least one suspicious feature, which means that all of them should classify the nodule as a TIRADS 5 lesion; 17 of the responders did well while 10 did wrongly.
4. Is FNA indicated from the nodule in the RIGHT lobe according to EU-TIRADS?
Distribution of answers
Choice
%
No
Yes
94.3
50
No
5.7
3
Expert comment
Based on the EU-TIRADS classification, all EU-TIRADS 3 or higher category nodules which maximal diameter exceed 20 mm, should be evaluated cytologically.
5. What suspicious ultrasound characteristic or characteristics has the nodule in the ISTHMUS?
Distribution of answers
Choice
%
No
Marked hypoechogenicity
22.6
12
Microcalcifications
9.4
5
Irregular borders
11.3
6
Irregular shape 9.4
5
None 47.2
25
Expert comment
I consider this nodule as a dominantly solid, minimally/moderately hypoechoic lesion which - based on the coexistence of similarly bright lines and granules - presents back wall figures. On the dimensions of the nodule (see patient' data), the lesion has a regular shape. On the degree of the undulation of the border, I would no consider the borders irregular.
6. What echogenic figure or figures has the nodule in the ISTHMUS?
Distribution of answers
Choice
%
No
Microcalcifications
1.9
1
Back wall cystic figures
66.0
35
Comet tail artifacts
28.3
15
Macrocalcifications 3.8
2
None
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, back wall figures are clearly present. In my opinion, the nodule does not have either of the remaining three figures.
7. How to classify the nodule in the ISTHMUS according to EU-TIRADS?
Distribution of answers
Choice
%
No
EU-TIRADS 3
15
28.3
EU-TIRADS 4
19
35.8
EU-TIRADS 5
19
35.8
Expert comment
Three of those 15 colleagues and 6 of those 19 colleagues who classified the nodule as EU-TIRADS 3 and EU-TIRADS 4, respectively, have found suspicious features, so they gave wrong answer because they had to classify the nodule as EU-TIRADS 5.
All 19 responders who classified th nodule as EU-TIRADS 5, have found suspicious features, so they all gave correct answer to this question.
8. Is FNA indicated from the nodule in the ISTHMUS according to EU-TIRADS?
Distribution of answers
Choice
%
No
Yes
71.2
38
No
28.8
15
Expert comment
An EU-TIRADS 4 or 5 lesion should be evaluated cytologically if the largest diameter exceeds 15 mm while only those EU-TIRADS 3 lesions are candidates of FNA which are larger than 20 mm. The nodule was 17 mm in maximal diameter. So those, who classified the nodule as EU-TIRADS 4 or 5 should suggest FNA while does who consider the lesion as EU-TIRADS 4, should not.
Essentially, 51 responders gave correct while 2 did wrong answer.
