Correct Answer: C

Explanation: The Thyroid Imaging Reporting and Data System (TIRADS) is a risk stratification system used to categorize thyroid nodules based on their ultrasound features. It helps to standardize reporting and provides guidance for managing thyroid nodules based on their likelihood of malignancy.

TIRADS classifies thyroid nodules into different categories, ranging from TIRADS 1 (benign) to TIRADS 5 (highly suspicious for malignancy). The categories are determined by evaluating specific ultrasound features of the nodule, such as echogenicity, shape, margins, presence of calcifications, and other characteristics. See table below.

Based on the ultrasound findings provided, the patient's thyroid nodule would likely be classified as TIRADS 5.

TIRADS 5 refers to a category of thyroid nodules with highly suspicious ultrasound features, which are associated with a high risk of malignancy. In this case, the presence of multiple suspicious features such as being hypoechoic, having microcalcifications, irregular margins, and a taller-than-wide shape would lead to the nodule being categorized as TIRADS 5.

As mentioned earlier, a TIRADS 5 classification indicates a high likelihood of malignancy, which is why a thyroid fine-needle aspiration (FNA) biopsy is the most appropriate next step in the work-up to further evaluate the nature of the nodule and determine if it is benign or malignant.

References:

Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, Teefey SA, Cronan JJ, Beland MD, Desser TS, Frates MC, Hammers LW, Hamper UM, Langer JE, Reading CC, Scoutt LM, Stavros AT. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017 May;14(5):587-595. doi: 10.1016/j.jacr.2017.01.046. Epub 2017 Apr 2. PMID: 28372962. [Article Link]

Correct Answer: B

Explanation: Advances in imaging techniques have led to an increased detection of incidental thyroid nodules (ITNs). While extrathyroidal ultrasound remains the most common method of identifying ITNs, they can also be detected using CT, MRI, or FDG-PET. Consequently, the American College of Radiology has issued recommendations on when further investigation is necessary. According to these guidelines, ITNs measuring ≥1 cm in patients below 35 years of age or ≥1.5 cm in patients aged 35 or older, those exhibiting local tissue invasion, or suspicious lymph nodes should undergo further evaluation. In cases where multiple ITNs are present, the criteria apply to the largest nodule. Given that our patient meets these criteria, further workup is warranted.Following a thorough patient history collection and physical examination, the next step in evaluating a thyroid nodule involves conducting an ultrasound and assessing thyroid-stimulating hormone (TSH) levels. Ultrasound is the preferred imaging modality for assessing thyroid nodules as it can identify suspicious features and provide accurate information regarding their size and number. If the ultrasound and TSH findings raise concerns regarding malignancy, the subsequent step in the evaluation process is fine needle aspiration.

References:

Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Findings Committee. J Am Coll Radiol. 2015;12(2):143-150. [Article Link]Tamhane S, Gharib H. Thyroid nodule update on diagnosis and management. Clin Diabetes Endocrinol. 2016;2:17. Published 2016 Oct 3. [Article Link]

Correct Answer: D (ultrasound of the neck)

Explanation:
The imaging modality of choice for a neck lump is ultrasound though CT scan with contrast of the neck (not the thorax) is strongly recommended per clinical practice guidelines. During examination, if the lump looks suspicious, an ultrasound guided biopsy (fine needle aspiration preferred over core biopsy) may be performed to obtain a tissue sample for analysis. Most neck masses in adults are neoplastic or malignant. Neck masses that are noninfectious, have been present for ≥2 weeks and are fixed, firm, >1.5 cm in size, and with ulceration of overlying skin are at increased risk of being malignant. Risk factors for head and neck malignancy include age, smoking and alcohol history, and male gender, in addition to poor oral and dental hygiene, environmental and occupational factors, exposure to EBV & HPV, and previous history of head and neck cancer. MRI or PET-CT scanning may be indicated during follow-up evaluation, not initial presentation.

References:
Pynnonen MA, Gillespie MB, Roman B, et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngol Head Neck Surg. 2017;157(2_suppl):S1-S30. doi:10.1177/0194599817722550

C (Bethesda Criteria IV)

According to Bethesda System for Reporting Thyroid Cytopathology, the recommended management of a patient with a diagnosis of follicular nodule or suspicious for follicular nodule (FN/SFN) is surgical excision of the lesion, most often a hemithyroidectomy or lobectomy, but molecular testing may be used to supplement risk assessment rather than proceeding directly to surgery.

SUPER high-yield for sub-I rotations!