Author’s ambitions sometimes distort the truth, or once again about the disappearance of pseudonodules in subacute thyroiditis

Thanks to the editorial section of the journal, we can improve our understanding of already published articles. Such assistance was provided to authors and readers in my comment (1) on the article about the disappearance of pseudonodules in subacute thyroiditis (2). Inaccuracies in the concepts of pseudonodules in general, and lack of a clear explanation for the appearance and disappearance of pseudonodules in a particular patient were identified. At the same time, I proposed an evidence-based morphofunctional concept that reveals the pathogenesis of such changes in the thyroid with the appropriate scientific terminology (instead of empirical). Nevertheless, the authors of the article in their response remained true to their subjective position, based on logical distortions (sophisms, from the Greek Σόφισµα), general non-specific phrases and ideas about the structure of the thyroid from a student textbook.

In their article, the authors reported only two nodules in the right lobe of the thyroid gland (2). This article lacked information on the ultrasound condition of the left lobe. The text provided by the authors “multiple nodules in both lobes of the thyroid, some are ill-defined” (3), which I allegedly did not see, is completely absent from the article (2) (I checked it myself several times and with the help of a computer: “command + F”). Scintigraphy data showed a decrease in the uptake of the radioactive preparation in the projection of a large area in the right lobe and almost complete spread of the substance in the left lobe (2). All this together allows us to confirm the presence of a unilateral inflammatory process in large segments of the gland. This large-segment inflammation is its scientific value. The authors did not indicate the condition of the left lobe of the thyroid gland in the article (2), and only after the publication of their article did, they report in a letter (3) some non-nodular heterogeneity in it (the magnitude and characteristics of this change on the left are not disclosed by the authors) and, probably, cited not from the published article, but from their draft.

In Fig. 1A,1C of this article, I see an elongated large segment (a “pseudonodule” from the position of the authors) in the ventral part of the lobe, in which medium-sized segments with lobules are visible (2). In addition, it is clear that the sonologist mistakenly measured the length of this section in Fig. 1C. He did not mark the edge of the caudal pole, where this hypoechoic area extends (the authors write about the location of the node in the “lower pole”). That is, the “pseudonodule” is longer than 2.5 cm, and the authors of the article are inattentive and unreliable in describing the data. For me, this is not important. And I explained in the previous comment that many sonologists can make mistakes due to the lack of knowledge about the levels of segmental organization of the thyroid. It is important that the hypoechoic area visible in Fig. 1 (2) has the shape and location characteristic of large segments of the thyroid (4).

Unfortunately, the authors did not explain what the pseudonodules in their patient are from a morphological and functional standpoint (one of the pseudonodules is visible on ultrasound images as an extended hypoechoic zone in the ventral part of the lobe with a clear border). For thyroidology, it is important to understand how such a pseudonodule 2.5 cm × 1.1 cm × 0.7 cm, which was part of the tissue pathological process of subacute inflammation, appeared pathogenetically. Why did the inflammation proceed separately in a separate area with a clear border and not affect other parts of the lobe? This condition is important, since the authors did not disclose the basis of the morphofunctional processes of the appearance and “resolution of pseudonodules” even in their answer. How exactly did a pseudonodule 2.5 cm long (located along the lobe) and 1.1 cm deep appear and disappear (resolve) over 9 months, given that the length and depth of the lobe changed very little (2,3)? In a scientific article, it is important not only to show but also to fully explain the observed phenomenon.

The authors offered their explanation: “Histopathology of the inflamed thyroid gland can provide direct evidence about nodular formation in subacute thyroiditis” (3). In their response (3), the authors clearly distinguish between the concepts of “nodules” and “pseudonodules”, but offer some knowledge from histopathology as evidence of the formation of “nodules”. This is a substitution of concepts and a refusal to explain. The authors also suggest reading an article by other authors on the surgery of subacute thyroiditis (5), which supposedly reveals the pathogenesis of “pseudonodules”. However, the text of the article does not say anything about the principles of the formation of pseudonodules and their “resolution”, but explains the existence of real nodules in the gland along with inflammatory processes in the rest of the tissue. In the proposed article (5), there are no ultrasound images with nodules or pseudonodules, unlike the article of the authors (2), which also does not allow using someone else’s publication as an explanation.

The authors, without realizing it, use the unscientific concept of “a common term” to justify their idea of the structure of the thyroid gland (3). As can be seen from the text of the response (3), the authors did not read or understand my article on hypoechoic processes in the thyroid gland (4), which clearly and convincingly describes and demonstrates several levels of segments in the parenchyma of the gland (including nervous regulation). The authors rely only on a student textbook in their idea of the histological structure of the thyroid gland and thus demonstrate professional limitations (subjectivity).

The main value of the observed and demonstrated features of the pathology lies in their logical, specific, and objective interpretation. I hope that my two comments will be useful to readers who are determined to improve their research and professional abilities.

With wishes for advanced knowledge to the authors, as well as health to them and their patients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://aot.amegroups.com/article/view/10.21037/aot-2025-3/coif). The author has no conflicts of interest to declare.

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References

1. Ushakov AV. Thyroid nodules, pseudonodules and large segments: from empirics to reality. Ann Thyroid 2024;9:4. [Crossref]
2. Kok CYZ, Liew H, Khoo HW, et al. Thyroid nodules that disappear — a case report on pseudonodules in thyroiditis. Ann Thyroid 2024;9:3. [Crossref]
3. Li H, Khoo H, Liew H, et al. Reply to Letter from Dr. Ushakov on “Thyroid nodules that disappear—a case report on pseudonodules in thyroiditis”. Ann Thyroid 2024;9:8. [Crossref]
4. Ushakov AV. Principles and features of ultrasound hypoechogenicity in diffuse thyroid pathology. Quant Imaging Med Surg 2024;14:2655-70. [Crossref] [PubMed]
5. Ranganath R, Shaha MA, Xu B, et al. de Quervain's thyroiditis: A review of experience with surgery. Am J Otolaryngol 2016 Nov-;37:534-7.