Discontinuous Peripheral Punctate Echogenic Foci in Thyroid Nodules: A New Sonographic Pattern Suggestive of Papillary Carcinoma

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Background: Ultrasound risk stratification systems for thyroid nodules worldwide describe different types of echogenic foci, including punctate echogenic foci (microcalcifications), coarse internal calcifications, and peripheral (rim) calcifications (complete or incomplete), with different levels of association with malignancy. We identified a previously undescribed pattern of small, discontinuous peripheral punctate echogenic foci (DPEF) associated with papillary thyroid carcinoma (PTC). Methods: This multicenter retrospective case series included thyroid ultrasound images from five countries (Brazil, United States, Italy, France, and Romania) between January 2020 and September 2025. Cases were included solely based on the presence of discontinuous peripheral punctate hyperechoic foci, defined as small echogenic dots arranged along the nodule periphery, regardless of nodule echogenicity or morphology. Each nodule underwent comprehensive evaluation by a multidisciplinary team, including experienced radiologists, endocrinologists, head and neck surgeons, and pathologists. The final diagnosis was confirmed by histopathological examination after surgical resection. Results: Twenty-three thyroid nodules from 22 patients met the inclusion criteria across all participating centers. Patient demographics included 17 women and 5 men, with ages ranging from 17 to 57 years (mean age, 36.1 years; median age, 37.5 years). Nodule size ranged from 0.4 cm to 4.8 cm in maximum diameter. All nodules exhibited the characteristic discontinuous peripheral arrangement of punctate echogenic foci on high-resolution ultrasonography. Histopathological examination confirmed PTC in 100% of the sample ( n = 23), including 16 classical variants, 1 “hobnail” subtype, and 3 cases of papillary carcinoma not otherwise specified. Conclusions: In this hypothesis-generating case series, DPEF was strongly associated with PTC. Further studies are needed to determine the sensitivity and specificity of this new sign. Recognition and reporting of this pattern, which was consistently observed in PTC, are important for raising awareness among thyroid radiologists and sonographers.

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