Good afternoon, I'm Jennifer Sipas and I'm an endocrinologist. So I guess that's my only real disclosure today is I'm not a radiologist But I do play one on TV So we're gonna talk about some cases It's gonna be hopefully pretty interactive at least on your apps And if you feel like jumping up and screaming at me and telling me I'm wrong, that's fine and acceptable But I want us to really kind of just challenge each other to sort of think about these things a little bit So we're gonna talk about some cases and some classification of thyroid nodules So if you haven't scanned the QR code go ahead and do that There's a couple more on the next few slides because what I learned on Friday is that we never left it up long enough and people kept saying go back go back So I'm gonna go forward. There we go. No disclosures Okay, and then one more just for a good measure So we're gonna as I mentioned we're gonna talk about some of the sonographic features of thyroid nodules on ultrasound and categorizing them with the two main ultrasound risk stratification systems ACR tirads and ATA and I apologize if there are Europeans and Koreans in here I'm not being exclusionary But with the size of this talk, it was just too much to try to add in multiple stratification systems And we're going to talk about some of the strengths limitations of these two systems and then some of some of the similarities and differences as well So you're probably familiar with this risk stratification system from the ATA this pattern based system is meant to Categorize nodules with the escalating risk of malignancy and with that increasing risk There is a decreasing threshold for FNA now This is the system that I use but I also kind of modify it a little bit to my purposes by way of a disclosure but But the nice thing about this this System that I find to be very useful is that once you learn these patterns, it's very very quick to stratify nodules and classify them Especially when patients have multiple nodules and when patients have a lot of nodules it can take quite a long time to categorize each of those nodules and the reason this was a pattern based was that the authors of the 2016 guidelines felt like that pattern based recognition we had better inter observer agreement than individual feature recognition And one of the other things that I really like about this system is that it's really it includes inclusive as well of patient factors so if the patient has a family history of radiation exposure or if the patient has a family history of Thyroid cancer those things are taken into account and we may even lower our threshold for FNA Sorry, I have a little voice issue today So and then the other side of is that the ACR thyroid so for those that you aren't familiar with us This is point based system. The first four categories here on the left side of the screen you pick one of the features for each of those main categories and then in the last column here echogenic foci Any and all of those that are applicable in that given nodule are also added up to come up with a total score which then translates to size threshold for FNA and size thresholds for Follow-up if they don't meet criteria for FNA So this is really nice because it's very clear-cut as to what we should be doing with these nodules It gives you a pretty explicit Instruction on on what's the next step for this patient particularly if you're not someone that's doing ultrasound on your own And so when I give these lectures to primary care providers, I think this is truly probably the better system For those folks because it's just giving them All right, here's your next step and and then the provider can can guide the patient along the way But there of course are limitations to each of those systems So, how do they perform? well there have been a number of studies looking at these tests both side-by-side and Individually and how to how well do they Identify malignancy how sensitive and specific are they and what you can see is that ATA? Is very sensitive and that's because the thresholds for FNA are a lot lower So there we perform FNAs at a smaller size with the ATA and that translates Of course to a higher rate of unnecessary FNAs but with the ACR tirads The specificity is higher with this because it's more stringent as to what gets aspirated And that's what the got the authors of the ACR tirads was they were seeking to do that they wanted to minimize the number of Unnecessary FNAs because they recognize that thyroid cancer is on the rise and we're being too aggressive Trying to find all cancers so they weren't seeking to identify all thyroid cancers. They were seeking to identify meaningful thyroid cancers So when we're looking at a test that has diff You know, it's at odds for sensitivity versus specificity one's better than the other than which one really performs better Well the diagnostic odds ratio Helps to combine those two factors into one feature That will allow us to sort of compare head-to-head how these two perform and you can see that these two systems perform fairly similarly Now One of the big things that folks have sort of pointed out as being a big difference between these two systems is the size Thresholds for FNA and I alluded to that earlier when I said the sensitivity of ATA is higher because the thresholds for FNA are lower so what happens if we take the thresholds for FNA of the ACR tirads and apply them to ATA and what we see is that the Sensitivity of the ATA system then declines to a similar value of what we see with ACR tirads and similarly the specificity becomes almost equivalent to what we see with ACR tirads when we use those thresholds and in Stratifying nodules with the ATA criteria So to me what this means is that these two systems perform very similarly and essentially what they're doing is they're identifying nodules that pretty much overlap with one another using one system or the other so This up here I superimpose the ATA system over what the ACR tirads Classification system is and you can see here what the differing thresholds are for FNA So the main differences are these in low and intermediate risk nodules. Where's that cut point for FNA? And then if we superimpose EU tirads on there again, you can see this is more in line with what the ACR tirads is using and K tirads pretty much mimics or is very similar to what To ATA and and their sensitivity and specificity are quite similar to the ATA systems So really they're describing the same thing. It's just their size thresholds for FNA are going to be a little bit different Okay, so we're gonna talk about some cases So this first case is a 24 year old patient It was incidentally detected on CT to have a thyroid nodule. No prior history No, no awareness of this nodule. No compressive symptoms. TSH is normal. No family history and no radiation So on the radiology report It's described as a 1.6 centimeter nodule in the isthmus and it's described as an ACR tirads 5 and so I've got the classification there of The nodule and an FNA is recommended So here is our nodule so Here's the nodule in the isthmus, these are our static images and our I Don't can I do the video with this? Ah, I don't have a mouse to do the video Do we have do we have the ability to play those? Or or do I how do we do that? Ah, thank you. Oh Oh Look at that Okay, so our nodule here and just kind of scrolling a little fast. Sorry about that And then this one here am I doing that or are you doing it? Okay so So we're gonna have an ARS question. So for those of you if you came in late, that was your little code Mm-hmm. All right, so you got your everybody still got a few phones in the air Okay You said tirads 5 on that's what that's what the radiology report was. Okay. All right. Thanks. I Like it. I like the way you're thinking. Okay. So what's the next step in the evaluation of this patient? Should we do an FNA? Should we do elastography radio iodine uptake and scan? dance to the funky music or reassure our patient Okay, so here's your voting All right, yeah, so Cool all right, so not many elastography Representatives in the audience, but we got one. All right Yeah, so So there's not gonna be in this one. I I did give a sort of a right answer here But for most of my questions, I'm not gonna have a right answer This is really just I want to know what people are thinking But in this situation you're alluding to it with the question of is this really a tirads 5 nodule so with tirads in the in the sort of print of that article That it says specifically that we should not score a spongiform nodule. So this nodule is clearly spongiform That's a hard stop there You identify it as being spongiform and assign no further points to that nodule because of course they're gonna have some echogenic foci These are colloid containing nodules so they can really easily get upscored and that's one of the main Sort of criticisms of ACR tirads It was written in there properly But folks aren't paying attention to the fact that you're not supposed to score and I get consults for these all the time And so it sometimes can be challenging to convince the patient that you don't really have cancer when I'm essentially telling them the exact opposite of what the what the radiology report would imply And then some of the other Issues and along the same lines we're going to talk a little bit about micro calcifications and punctate echogenic foci But those can get potentially Can upscore a nodule inappropriately and even the authors of that guideline have recognized that and have made some recommendations about how to maybe potentially alter that in future iterations of tirads And then we still have the issue of inter observer variability I mean, this is individual features and there's not great agreement. They'll really the only things that are agreed upon pretty well are the shape of the nodule And the presence of macro calcifications everything else, especially punctate echogenic foci I have really either fair or poor agreement So so there can be some real limitations to this and then the big thing for me the reason I don't use it I can't remember all the scores that are associated with each of the individual points And you know I say that shamelessly that I just can't remember all those little numbers that are associated with the features and it takes a really long Time to score up each one of the nodules when our patients have multiple modules So I tend not to use it, but I do like their thresholds for FNA a lot better Because it means I'm not having a biopsy as many things. So So with that patient I necessarily Would not agree with the assessment I'm not saying that we should be scoring these spongiform nodules But it's important to recognize that spongiform nodules will frequently have these linear Hyperlucency's these are not calcifications. I frequently see these being over called as calcifications This is an artifact of the physics of ultrasound as the ultrasound wave Travels through one medium and hits another medium with a different acoustic impedance. It sends a bright Reflection back to the probe. So when the ultrasound goes between this cystic area and hits this solid Septation within that nodule it sends a flash back to the probe and then that shows up as bright This is also called posterior acoustic enhancement. So these are not calcifications. These are just an artifact of physics Okay. So our next case is a 68 year old woman Who presented for evaluation of a thyroid nodule this was just noted on routine exam On ultrasound it was described as a largely cystic nodule with a small Solid mural component and it measured about 1.8 centimeters in largest dimension So get your little phones out here. What's the classification of this nodule? Is it very low suspicion low suspicion? Intermediate high or non classifiable Okay, so I'm gonna let you vote Take a drink This is fun to see all the varying results here Okay, so a fair number of you are voting low and intermediate suspicion I actually think this is maybe non-classifiable But I can see why you would say lower intermediate suspicion. So one of the main limitations of the ATA Classification system is there are a number of nodules that aren't classifiable and whether this one is or isn't we can debate that but in that that's one of the main sort of hits on ATA and The nodules that are generally kind of non classifiable are those nodules that have heterogeneous heterogeneous echogenicity If they have coarse calcifications with them or if they have micro calcifications or slash punctate echogenic foci That are not associated with a hypoechoic nodule So if it's isoechoic with punctate echogenic foci or it's a cyst with punctate echogenic foci It's not classifiable with the ATA So how often are we seeing these? Well, it's variably reported in the literature. This is a number of studies that have shown a varying rate between three and 18%. But the real question is, what's the risk of cancer in these nodules? And generally, that's around 10 to 20%. So these look similar to what we would classify as intermediate risk nodules with the ATA system. So if you see a nodule that's non-classifiable, you could potentially use the thresholds for FNA that you would use with the intermediate suspicion nodules and feel fairly confident that that risk of malignancy is kind of on that lower end of the spectrum there. All right, so back to our case, let's just look at this nodule a little more carefully since we all kind of had differing opinions on what it was. So first of all, it's got this mural component. So that by itself is a little bit concerning. And then it has some little punctate echogenic foci in there but sometimes cystic nodules can have debris in there and that can be really challenging to tell if it's actually solid or if it's just debris. So if we're classifying this thing by tirads, we would say, okay, it's mixed in composition, it's isoechoic, it's got a normal looking shape, but the margins maybe are lobulated. It's not real clear how we are supposed to qualify these margins with a cystic nodule like this. So you could either include those two points or not. But the echogenic foci would potentially upscore this nodule. So I would say this is at least a higher risk nodule using ACR tirads. Can I get the play? Can you play these? Thanks. So you can see the lobulation within there. That's a little concerning to me. And then you can see a fair number of echogenic foci. They both have video. Thanks. Okay. And if we look at the vascularity, that's how you can tell if this thing is debris or if it's actually a solid component. So this is a concerning nodule to me. And that's certainly not all debris. Maybe some of it is up here, but this is all sort of that mural component. So when we're seeing that, that's concerning for potential malignancy there. And so she had an FNA which was read as atypia of undetermined significance. And with the expression classifier of BRAF mutation was detected in this nodule. So when we talk about papillary thyroid cancer, we're thinking primarily about solid nodules. But we all worry about that potential for a cystic papillary thyroid cancer. Fortunately, they're rare, but up to a third of cancers can have some cystic change. So we need to be able to sort through which ones are concerning cysts and which ones aren't. So this study out of the Mayo Clinic looked at a series of patients and they found that most thyroid cancers are solid, which we knew. And those thyroid cancers that were greater than 50% cystic had some other suspicious sonographic feature within the solid component. So this is important for us to pay attention to the solid component of that nodule and then score the nodule from there. Certainly the cyst can modify the risk of the nodule, but when you're seeing this lobulation, and in this case increased vascularity, microcalcifications, those nodules are more concerning and should be considered for FNA. And another study looking at a bigger cohort of patients, 22 malignant nodules, comparing them to 80 benign nodules. These were all partially cystic nodules. What they found that were predictive features for malignancy in looking at the entire nodule was the shape. So if the entire nodule was taller than wide, that was predictive of malignancy. And if it had a speculated margin, that was also predictive. And then when we look at the solid component, if it was eccentrically configured, like in the nodule I showed you in our case, if the margins within that solid portion were not smooth, and then the presence of microcalcifications, those conferred an increased risk of malignancy. And so just to go over the eccentric versus concentric difference, here on the left side of the screen, these are eccentric little lobulations of nodules that are kind of jutting into the cystic portion, so that's a little more concerning. We used to talk about the acute versus the obtuse angle. That's been a little bit more unclear if that is holding up in multiple different studies, but certainly the presence of that eccentric component is concerning versus a concentric cystic area within the solid nodule. Okay. So our next case is a 76-year-old female with thyroid nodules who presents for a second opinion. On initial screening exam in 2019, she was found to have a mildly low TSH with normal T4 and T3, and those were consistently demonstrated over a few years of follow-up. So she had an uptake and scan, and it was read as having bilateral photopenic defects in the upper poles. And so she was sent for an ultrasound of the neck, and she was started on methimazole. She's older. She has some bone disease. They were concerned about leaving her TSH low, so she was started on some methimazole. And so here's her ultrasound. In the right lobe, you can see this hypoechoic nodule with sort of a coarse calcification in it, and then maybe some punctate foci in there, and this is the sagittal view. That's that coarse calcification. On the radiology report, this nodule was read as predominantly solid, hypoechoic with ill-defined margins. Now again, ill-defined is not the same, and it's not bad compared to irregular or lobulated, so I wanna emphasize that. So ill-defined just means it's probably the same color as the surrounding thyroid parenchyma, but that does not confer an increased risk. So this is zero points for that. She has these punctate echogenic foci, and this is the transverse view, so this is wider than tall on the, I'm sorry, this is the sagittal view, so this is wider than tall. And it kinda looks like maybe she has a couple of nodules here, like this is one and this is one. So these were read as TYRADS5 nodules, again. Nope. So, sorry, so the next series of questions are, are these punctate echogenic foci, or are they comet tails, okay? All right, so you should have some images on your phone that should tell you what the nodule looks like. It's kinda what I expected. And I wanted to sort of illustrate this point. So these can be tough to discern, all right? So this is the nodule, if you didn't do your phone thing. This is the area that we're looking at. Are those echogenic foci, are those comet tails? What are we looking at? And if we look at the images, can you do the movies on both of those, please? It's really hard to tell, even with cine clips. It can be really challenging to discern these. And even with expert radiologists looking at these images, you're gonna get some disagreement about whether these are comet tails, and maybe reassuring, because they're associated with little cystic spaces, or are they punctate echogenic foci, or are they comet tails in a solid? So here, yeah. I guess we're having technical difficulties. So here's another one. Are these punctate echogenic foci, or are they comet tails? Or both? Yeah, so that's pretty interesting to see. We definitely don't agree. And then the last one. Now, obviously, this big guy over here, that's a large comet tail artifact, and we'll talk about those in a little bit. I'm interested in the one that's solid-ish with the blue arrow. All right, so vote away. All right, good. You guys are playing well with my plan. So, and I'll tell you, I struggle with this in my practice a lot. So there's not a right answer here. Just using you as a ploy here. So the patient was sent to radiology for an FNA of bilateral thyroid nodules, and both of the nodules in both poles, both sides of the thyroid, were read as follicular lesions of undetermined significance. So she's sent in now for further recommendations because she doesn't want anything else done to her. So I think I have a movie in here somewhere. Yeah, on the left side. Yeah, there we go. So this is the left side going from inferior to superior. That's superior, and now we're going inferiorly. And you can see here in the sagittal view the inferior pole is where the nodule is, and this is the one on the right. This is obviously the left. So the question is, what would you do next? Would you observe her, repeat the FNA? Again, these were read as flus. Would you repeat the FNA, perform molecular testing, or send her straight to total thyroidectomy because you're worried about these calcifications, if they're calcifications, okay? Okay. Dr. Klopper is happy to see this result. Okay. Great. Yeah. Yeah. Oh, okay. It, you pick. The question is, repeat FNA right away, or repeat in three to six months? Yes, either one. So most folks are really interested in what the molecular testing will show, and I think that's fair. So let's talk about echogenic foci more specifically. So we know that there are a number of different types of echogenic foci within nodules. So most of them are associated with an increased risk of malignancy. Even the ones we talk about, comatales, we tend to be reassured by those, but maybe we shouldn't. But the large comatales, the one that I showed you in that cystic nodule, and they're larger than a millimeter, those are genuinely associated with a low risk of malignancy, and those are reassuring findings in a cystic nodule. But all of these other small comatales, punctate echogenic foci, you can see the risk of malignancy with those is pretty high. And then peripheral calcifications and clump calcifications. Now this is a little bit of an older study, and our colleagues at Penn have done some really nice studies looking at coarse calcifications. But generally, the point I wanna make here is that large comatale signs are reassuring, and the risk of malignancy associated with these various types of calcifications is not quite as high as is advertised in the ATA system when we say a nodule has a 70% risk of malignancy. Okay, so it's around probably 15 to 20%. But the important part is that these calcifications, these echogenic foci, it matters with what company they keep. And what I mean by that is if they are solid and associated with these echogenic foci, that's higher risk. But the nodules that are partially cystic have a lower malignancy risk with the punctate foci and then the small comatale signs. And when you plop them into a solid nodule, that's when we're concerned. So if we look back at our patient who has these minute cystic spaces, that risk of malignancy with those echogenic foci is probably a little bit lower. And it can be really challenging to discern which of these little foci are associated with those microcystic spaces and which are potentially somatitis calcifications. And what another study has shown is that those somatitis calcifications that we're so worried about being a harbinger of papillary thyroid cancer, they have a positive predictive value. Those punctate echogenic foci have a positive predictive value of identifying somatitis calcifications of about 48%. So it's really hard to discern the difference between these little comatales with the microcystic spaces versus something that's a harbinger of something worse. But if we look at the overall composition of the nodule, those are probably associated with a lower risk of malignancy. And the authors of ACR-TIRADS have come out with another paper more recently suggesting that perhaps we should downgrade the points associated with punctate echogenic foci when they're in the setting of a nodule with cystic change. So potentially seeing a future iteration of TIRADS that'll alter that risk that goes along with this. Yes. If you look carefully, all the punctate foci are around the cystic areas. There is a small area that is all solid in the middle and there is not a single punctate area there. Yep. So I wouldn't even biopsy this one. I agree with you. So if folks online couldn't hear that, essentially he's arguing that all of the echogenic foci were associated with cystic areas and in that solid area there were no echogenic foci. And I completely agree. And so with our patient, if we look carefully at where this area of increased activity, I'm not looking at the photopenic areas, I'm looking at the areas of increased activity, that's exactly where all these nodules were located. So it's important to kind of take a step back and look at the overall picture. Our patient has hyperthyroidism or subclinical hyperthyroidism. She has hot nodules in the inferior poles and they correlate, the nodules correlate with those hot areas. So based on a long conversation I had with her, we didn't do anything. We sat on her, we titrated her methimazole. She didn't want to have anything done. She didn't even really want to take the methimazole. I had to sort of strong arm her into that one. But we really lowered her dose significantly and hopefully will just follow her long term. Okay, so next case is a 40 year old male with a history of Hashimoto's thyroiditis that was diagnosed when he was 16 years old. He presents to the endocrine clinic for evaluation of subjective enlargement of his thyroid. He initially when presented to me in 2011 had an FNA that was benign on the left side. He came back for a repeat ultrasound in 2012 and then the nodule didn't change and I lost him. So he came back, this was 10 years later after his last follow up. So this was his nodule in 2011. So it's isoechoic, well defined nodule. So what is our sonographic class for this nodule with ATA? Okay, so low suspicion and intermediate suspicion for most folks. I would say this is probably a low suspicion nodule just because of the echogenicity being isoechoic or maybe a little hyperechoic but he has Hashimoto's disease so his gland is a little dark, you can appreciate. This was the ultrasound in 2011. This was the ultrasound now and there's a very significant increase in size of this nodule. And in the sagittal view you can see this hyperechoic enlarged nodule with a bit of a halo around it. There is my, but not completely visible. These are movies if you would, both of them. I'm gonna share my tips with our AV guy. So make sure you guys are generous with the tips after this. Next. All right. How does the Cine help me? It doesn't, I just was really excited that I could actually do it so I wanted to share it. I'm torturing you. Because I can, because I have the mic. All right, so what's the rate of a false negative FNA? We generally teach that it's about less than 3%, 2% depending on the institution. And what's the rate of missed malignancy with a nodule that's growing? And we use this all the time, we talk about it. Oh, it's growing, it's growing, but how predictive is that for identifying missed malignancies? This is a single study, single center study out of Brazil looking at nodules that had an initial benign FNA and then stratifying them based on their followup ultrasound. So if the ultrasound was initially suspicious and the initial FNA was benign, those nodules had a false negative rate of almost 20%. If the nodule was, had a reassuring ultrasound but was growing, the rate of missed malignancy was around 2.4%. If the size was unchanged but the nodule developed suspicious features, then the risk of malignancy was around 11%. And if it's stable and a reassuring ultrasound, they missed no malignancy. So, and that was actually the biggest group of patients. So size change doesn't really predict missed malignancy, but we use it anyway. So we know this for two from the Italian group, groups that showed us in the five-year followup of benign FNAs, 15% of nodules grew. What predicted growth of nodules was multinodularity and younger patient age, which they also showed here in a different group. Younger patients had a higher likelihood of developing a growth of their nodule. And if the nodule was solid, it had a higher likelihood of growth. So we repeated the FNA, and this time there was some atypia. And I specifically called the pathologist to ask him, you know, what are you seeing? This guy has Hashi. So if there's atypical cells in there, I want you to know that he has Hashi. This isn't just hurtful cells that you would expect with Hashimoto's. And he said, no, I'm seeing nuclear clearing. And I even saw a few micro follicular patterns in there. So he was genuinely concerned about this nodule, as was I. So the question is, what do you do next? This will be fun to see. So do we do a repeat FNA? Do we watch this guy? Do we do a Hemi? Do we do a total based on the size of the nodule? Or do we do molecular testing? Fingers crossed, Rick. Okay. Okay, so you guys are reading your guidelines and doing the Hemi. That's good. And molecular testing as well. So I think both of those are very reasonable options. And those were the discussion points that we had. I wanna talk a little bit about some of the subtypes of atypia and flus first though. So the new Bethesda guidelines recommend further clarification about the subtype of AUS flus that is seen on cytology to help us further direct our patients. So architectural atypia implies that a few micro follicles are seen, but not enough to call it a follicular neoplasm. These specimens may be post-cellular. And the cytologic atypia is, you're seeing a few of the features of potentially papillary thyroid cancer, but not all of them, and not enough to call suspicious for malignancy or PTC outright. And these also may be post-cellular. And then oncocytic atypia may be seen in a patient who has Hashimoto's disease, but we're not seeing the other findings that we would expect to see with Hashimoto's disease, but just an abundance of Hertzel cells. So if we look at the various, basically if we look at nuclear versus architectural atypia that's maybe seen on these, what we see is that nuclear atypia is associated with a two to three-fold increased risk of malignancy compared to architectural atypia. So that may alter the malignancy risk in our patient's nodule because he had nuclear atypia. And if we look at the potential for doing a repeat FNA, and I think that's a reasonable option, although most folks didn't choose that option, there are, this meta-analysis did demonstrate that a repeat FNA can reclassify up to half of nodules with an initial AUS flus diagnosis into a benign cytology. But the question you then ask is, well, how do we know which one to believe? Well, in these studies, they found that this group of nodules had just under 4% risk of malignancy when they had a repeat FNA that was benign. And then the nodules that had Bethesda 3 diagnosis on repeat FNA had perhaps a slightly higher risk of malignancy than what we expect with this diagnosis. And then Bethesda 4 has a higher risk as well. So if we look at the two molecular tests that are available, we know that their negative predictive value is what we're most interested in in terms of trying to keep this guy out of the OR. And we know that the negative predictive value is dependent upon the pretest probability of malignancy, the prevalence of malignancy in our population study. So if we're looking at the GSC test, that was in that validation study, the risk of malignancy, or the prevalence of malignancy in that cohort was 24%. And that gave us that negative predictive value that was so nice at 94%. But if we look at a higher risk of malignancy in this patient potentially, I don't know what his risk of malignancy is in him individually. And I told him that. I don't know if the test would rule out malignancy as well as safely if his risk of cancer is higher than 24%. And I told him I don't know what his risk of malignancy is. And so we talked about it at length and he opted to go with total thyroidectomy. He's 40 years old, this thing's already shown that it could grow. And we talked about the potential of continued growth and ultimately needing a thyroidectomy at some point. He's already having compressive symptoms. And we know that the patients who ultimately end up having a thyroidectomy after a benign molecular test are usually folks that have compressive symptoms. So we opted to take his thyroid out. He's already on levothyroxine substitution therapy. He didn't like the idea of having a two-step thyroidectomy if this turned out to be malignant. So he opted for total thyroidectomy up front. Unfortunately it was benign, or fortunately it was benign, but his symptoms are improved. All right, how am I doing on time? Running tight, all right. So next case is a 45-year-old physician. He noted a new mass in his left neck. And he started about a week ago. It's mildly tender to palpation. This is the right lobe, Hashimoto's kind of look to it. And then this is the left lobe. So what's the ATA sonographic classification of this nodule? All right. As Lee Corso would say, not so fast. Can you play it for me? So a little snowy sky appearance there. And play the other one for me. Thanks. So this was actually a cyst, and that's just all debris within that nodule. So it's important for us to look at the live clips in this patient. I just wanted to see if I could trick you. I did. All right, and this is the vascular flow, or lack thereof, in the nodule. So this was all just debris. Okay, so I think I'm essentially out of time. I don't know if we're allowed to go over, or if we want to ask some questions. Okay. Good. No one's moving, so I'll go on. All right, so next case is a 75-year-old female who's incidentally noted to have increased activity on her PET scan that was done for staging of her breast cancer. So she was referred for further evaluation. No medical history. She has AFib, and she takes warfarin. No radiation history. No family history. Her TSH is a little low, and her INR is at target. So here's her PET scan. And I'm just giving you some of the slices so you can appreciate sort of the up and down part. So it kind of looks focal in areas, but then it looks kind of diffuse in other areas. And it's not a huge amount of uptake. So that's my non-radiologist radiologist assessment. So this is her nodules on ultrasound static imaging. And you can appreciate kind of a nodular, diffusely nodular appearance. And if you can play that for me, they're both clips. Just innumerable nodules, all kind of coalescent there. Isoechoic, some hyperechoic. Okay. Cool. Thank you. So, would you guys do an FNA on this thing, first of all? I mean, raise of hands. I don't have a question on this. Somebody would stick it? Nobody wants to stick their neck out? Okay. I think it's fine to poke it. The next question is, would you stop their anticoagulation? No. I see a few nods of no. Okay. All right. So, not a lot of data on this, but the data that is out there suggests that it's safe to do an FNA. The rates of hematoma formation in patients who are on anticoagulation are not different from the patients who are not taking anticoagulation. What I would say is to use a 27-gauge needle as opposed to a 25. This study, I think they were using 25s, but they still had a really nice low rate. Minimize the number of sticks you do, and if you have trainees, maybe take that one away from the trainee and do it yourself. That's usually my practice. Not that my trainees aren't outstanding. They are, but I just want to make sure that we're not moving around too much in there, kind of in and out, and then I put ice on it right away. So, I think it is safe to do an FNA in a patient who's on anticoagulation. So, additional history in this woman. She's from Iran. She moved to the US just a couple of months ago. Her antibodies are negative, and this is her iodine scan. So, just kind of toxic multinodular goiter, and I think that this is probably due to her iodine deficiency that she had when she was in Iran. So, kind of an interesting case, at least to me, and we did not aspirate her thyroid. We just kind of followed her. If anything is changing or developing suspicious features, our plan is to do an FNA, but so far she's been doing really well and doing well with her breast cancer therapy. I think that's another piece that really needs to be thought about when we're seeing these patients. If they're getting a PET scan for some other malignancy, we need to be sort of mindful of where the thyroid cancer potentially would fit into sort of the overall cancer plan, and if the patient's got a much more aggressive malignancy, I'm not as much worried about a small thyroid cancer that may or may not have any clinical significance for her, but certainly with very careful follow-up with the plan to change our minds if the thyroid starts to change in a meaningful way. And I think that's it for the interesting cases. I threw another one in there that's not very interesting. So. Thank you.

thyroid nodules

sonographic risk stratification

malignancy

patient factors

echogenic foci

calcifications

molecular testing

atypical cells