Ultrasonographic Findings in Common Thyroid and Parathyroid Disorders—Advantages of Real Time Observation by the Endocrinologist with their Own Ultrasound Machine

Round 1

Reviewer 1 Report

General comments:

This review manuscript aims at the significance of the main ultrasonography features of common thyroid but also parathyroid conditions, focusing on the advantages of real time /portable US scanner observation. It points to the advantage of the US diagnosis approach by an endocrinologist, rather than by a radiologist. It gives a throughout yet simple show of the possible situations where the aim is relevant and it is worthy for that.

Specific remarks:

The following sentence in L14 and L15 (abstract) should be reviewed as seems to miss sense:

“The thyroid specialist, defined as an endocrinologist with a major interest in thyroid disorders and access to a portable ultrasound machine.”

In the following sentence from L15 to L17 (abstract) who or what can correlate what they see with the thyroid blood test results and clinical findings…? Complete the sentence.

“can correlate what they see with the thyroid blood test results and clinical findings in a way that is not available to the general endocrinologist who relies on the interpretation by the consultant of ultrasound images prepared by a technician.”

L38: Isn´t it a 5MHZ transducer?

L50: should be: “…connecting the two lobes.³”

In L108 (legend of figure 3) authors write “Figure 3. A benign nodule with a series of bright micro-calcifications inside the cell membrane.”. How can the authors affirm those micro-calcifications are intracellular based on the ultrasound imaging?

L152-153: Should be: “The Hürthle cell is larger than a follicular cell, and its cellular material stains pink. These cells…”. The authors should refer the staining method as most of the readers as clinicians and ultrasonography specialists don´t usually do lab work.

L162-163: Should be: “The presence of calcification in association with nodules…”.

L174-175: Legend of figure 8: “In (B) is seen a small calcified nodule 174 (upper arrow)…”. The “upper arrow” is unseen in the figure or difficult to find. Please clarify.

L185: Should be: “…features (fig 9 B) may be…”.

L186-188: Should be (?): “Figure 9. Examples of vascularity around the edge of a benign nodule (A) and associated with blotchy macro-calcifications in a hard, irregular edged, nodule that is suspicious for papillary cancer (B).”.

L191-192: Should be (?): “Figure 10. A small 8 mm benign nodule in the left thyroid lobe shown as an ultrasound image (A) and with surrounding vascularity in (B).”.

L195-196: Should be: “These 195 include taller than…”.

L274-276 In the following sentence it is not clear who developed the 5-stage classification: “As a result of the author’s extensive experience of the ultrasound appearances of Hashimoto thyroiditis has developed a 5-stage classification of the inflammatory changes from early (stages 1, 2) through later (stages 4, 5), as follows;”.

Line 312: When the authors write “Because the author routinely measures…” they should use “…authors…” or at least identify a specific author, if that should be the case.

Line 359-361: In the sentence “These procedures are rarely used in North American and Australia, countries where the author has worked, and it is unlikely that this approach will ever become mainstream outside of Europe.” Should be “…North America…” and once again, it may better be identified the specific author as there are four co-authors.

References 3, 7, 11 and 16 should be standardized in the reference list.

Author Response

"Please see the attachment."

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for your submission. I read it with interest. The manuscript provides an overview of ultrasound findings of thyroid and parathyroid glands.The manuscript makes many claims, but is often lacking in supporting data or references. 

Some examples are as follows:

Claims of 'clear' superiority of a thyroidologist should be avoided unless the authors wish to compare sensitivity, specificity to established values of other clinical specialties from the literature, or perform an actual comparative study.

Please reface the % of time colloid bright spots are labeled microcalcifications. Is there any literature to back this up?

Without any solid data, disputing unreferenced claims such as U/S identification of normal parathyroids is unhelpful.

The Hashimoto's grading system is interesting as a description of ultrasound findings. Do the author's have correlation with disease course, duration or intensity? The author's need to be more specific and concrete regarding data of the clinical utility.

Author Response

"Please see the attachment." 

Author Response File: Author Response.pdf

Reviewer 3 Report

In this paper the authors present a review of the use of ultrasound for thyroid and parathyroid disease focusing on the use of ultrasound as part of clinical endocrinology review and suggest a system for staging inflammation in Hashimotos thyroiditis.

This is an interesting review and of interest to specialists who treat thyroid disease, there is a number of issues with the manuscript which would improve its readability and understanding for readers.

There is a typo in the abstract in the last line – ‘thyroditis.as’ and there are multiple other typos in the text with multiple sentences not having full stops.

The sentence in the introduction ‘All figures are derived’ could be included as an acknowledgement rather than in the introductory text.

A percentage of patients who have a pyramidal lobe (~20%) should be added to the text in the normal thyroid section given this is commonly missed by low volume or inexperienced surgeons in thyroid cancer surgery leading to ineffective RAI ablation and issues with thyroglobulin measurements in intermediate and high risk thyroid cancer patients.

In figure 1 the contrast of the image provided in the PDF makes it difficult to appreciate the edges of the normal thyroid – are the authors able to provide images with an altered contrast to make the images clearer?

For figure 3, the areas should be marked with an arrow or another marker to improve unfamiliar readers understanding of what is being shown – given the authors are suggesting that these are not micro-calfications a better term for description would be colloid ringdown and these could be used in the text in the discussion around colloidoma to make it clearer to the readers.

In figure 8B, the text states there is an arrow markng the finding but I am unable to see this, also these images are difficult to appreciate due to the contrast of the PDF

For figure 11 the same issue is present with the contrast, the microcalficiations demonstrated with a ruler icon would be helpful to show the size.

In the test on page 9, the authors state that on follow up the cervical lymph nodes are examined for abnormal lymph nodes, this should be performed at initial diagnosis of a suspicious thyroid nodule and I would argue for all patients undergoing thyroid ultrasound.

Fig 16, 17 are also difficult to appreciate due to the contrast of the imaging.

For the Hashimotos staging, what do the authors suggest is the clinical use of this system and how does it help in their practice?

In section 14, for the question does the thyroid specialist have advantage over a radiologist, the answer would be more appropriately answered that ‘In the authors experience the answer to this question is yes’ as no evidence comparing the authors to radiologists experience is presented in the paper, further radiologists working with high volume thyroid specialists will likely have a different skill set from radiologists working in general radiology practices.

It could also be of use to discuss the role of clinician practiced ultrasound in either confirming of changing ultrasound/radiology findings of patients presenting with imaging performed before referral.

The section on ultrasound for vocal cord assessment is currently practiced by many surgeons so could be included in the text rather than the future, with this test more useful in female patients.

Author Response

"Please see the attachment." 

Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.