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Call
(630) 938-6161
to Schedule a Consultation

25 N Winfield Rd Ste 505
Winfield IL 60190-1295

Thyroid Nodules

When Should a Nodule be Biopsied?

When Should a Thyroid Nodule be Biopsied?

Guidelines have been published based on extensive research comparing surgical pathology results of thyroid nodules to their pre-operative appearance on ultrasound.

  • Helps to guide decision making on:
    • Which nodules should be biopsied (aka FNA – fine needle aspiration)?
    • Which nodules do not need a biopsy but need ultrasound surveillance? And for how long?
    • Which nodules can be safely followed with physical exams alone?
Central Neck Dissection

American College of Radiology – Thyroid Imaging Reporting & Data System (TI-RADS) Guidelines

Uses a combination of size and a cumulative score based on ultrasound features:

Composition (solid or cystic; 0 – 2 points)

  • Completely cystic (fluid filled) – 0.
  • Spongiform (numerous tiny pockets of fluid resembling air pockets in a sponge) – 0.
  • Mixed cystic and solid – 1.
  • Solid or almost completely solid – 2.

Echogenicity (shade of gray relative to normal thyroid tissue; 0 – 3 points)

  • Anechoic (completely black, cystic) – 0.
  • Hyperechoic (brighter than normal thyroid) or isoechoic (same color as normal thyroid) – 1.
  • Hypoechoic (darker than normal thyroid) – 2.
  • Very hypoechoic (much darker than normal thyroid) – 3.

Shape (when looking at cross-sectional images; 0 – 3 points)

  • Wider than tall (oval laying on its long side) – 0.
  • Taller than wide (oval standing upright on its short side) – 3.

Margin (edge / perimeter of the nodule; 0 – 3 points)

  • Smooth – 0.
  • Lobulated / irregular – 2.
  • Extrathyroidal extension (breaking through the capsule of the thyroid) – 3.

Echogenic Foci (bright white areas; 0 – 3 points)

  • None or comet-tail artifacts (white spots, typically in cystic / fluid filled spaces of nodules, with an extending tail) – 0.
  • Macrocalcifications (large white spots) – 1.
  • Peripheral / rim calcifications (bright white capsule or eggshell appearance) – 2.
  • Punctate echogenic foci / Microcalcifications – 3.
content-image

Cited Source: Liebertpub, Inc.

Examples of thyroid nodule appearance on ultrasound, ranging from benign (bottom) to high risk for cancer (top).

Central Neck Dissection

Cumulative score

  • 0 points; TR 1 – Benign.
    • No FNA needed, no ultrasound surveillance required, safe to follow with physical exams alone.
  • 2 points; TR 2 – Not Suspicious.
    • No FNA needed, no ultrasound surveillance required, safe to follow with physical exams alone.
  • 3 points; TR 3 – Mildly Suspicious / Low Risk.
    • FNA if ≥ 2.5 cm.
    • ≥ 1.5 cm ultrasound surveillance for 5 years (1, 3, and 5 years after discovery).
    • < 1.5 cm safe to follow with physical exams alone.
  • 4 – 6 points; TR 4 – Moderately Suspicious / Medium Risk
    • FNA if ≥ 1.5 cm.
    • ≥ 1.0 cm ultrasound surveillance for 5 years (1, 2, 3, and 5 years after discovery).
    • < 1.0 cm safe to follow with physical exams alone.
  • ≥ 7 points; TR 5 – Highly Suspicious / High Risk
    • FNA if ≥ 1.0 cm.
    • ≥ 0.5 cm ultrasound surveillance for 5 years (yearly for 5 years after discovery).
    • < 0.5 cm safe to follow with physical exams alone.
  • Consider lowering the threshold for biopsy based on patient preference and/or high-risk history (e.g., 1st degree relative with thyroid cancer, significant radiation exposure history, hereditary syndromes, etc.).
  • *No more than 4 nodules with the highest TR point totals should be followed with surveillance ultrasounds.
  • Generally speaking, nodules < 1.0 cm should not be biopsied unless it may affect the decision on the extent of surgery for a known thyroid cancer diagnosis.

ACR TI RADS

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Cited Source: JACR

Thyroid Cancer Risk Factors

Recommended for 5 years.

Frequency of repeat ultrasounds varies based on TR level.

  • Assessing for chance in appearance (TR score) and size.
    • TR 3 – 1, 3, and 5 years after benign FNA.
    • TR 4 – 1, 2, 3, and 5 years after benign FNA.
    • TR 5 – yearly for 5 years after benign FNA.

If a nodule’s TR level ever increases on follow-up imaging, the next ultrasound should be performed in 1 year regardless of previous plan.

Follow-up ultrasounds can stop at 5 years for TR 3, 4, & 5 if there is no significant change in size or increased TR score.

  • Stability over 5 years reliably indicates that a nodule is benign and unlikely to grow in the future.

After 5 years, the nodules can safely be monitored with physical exams alone.

  • Repeat ultrasound only if change is noted on exam or new compressive symptoms are experienced.
  • If patient is young, has a + high-risk history, or chooses to, repeat ultrasounds can be obtained every ~ 5 years thereafter.

When to repeat an FNA that was previously benign:

  • For TR 5 / high risk nodules:
    • Any substantial growth in at least two dimensions beyond measuring error (1–3 mm).
  • For TR 3 & 4 nodules:
    • Any new increase in point totals to highly suspicious (≥ 7 points).
    • 20% increase in at least 2 nodule dimensions (minimum >2 mm) or increase by >50% in volume.
  • About 15% of benign nodules will continue to grow over a patient’s lifetime.

Same as if the nodule had a benign FNA (see above).

Quality of the ultrasound being used.

Varying skill level of the technician obtaining images for the radiologist to interpret.

Difference in subjective interpretation from one radiologist to the next can result in varying TR scores.

Measuring error from 1 – 3 mm, greater for larger nodules.

Challenge when thyroiditis is present.

  • Scarring from thyroiditis can change the appearance of the thyroid over time making it difficult to keep track of some nodules.
    • Nodules can sometimes disappear / reappear over time due to this.
  • Scarring can sometimes cause the appearance of a ‘pseudo nodule.’
    • Pseudo nodules have no risk for thyroid cancer.

Comparing reports from different institutions can be tricky due to differences in protocols, image capturing, and interpretation.

Biopsy is usually not indicated in a thyroid gland or multinodular goiter that is replaced by multiple, confluent (touching) nodules of similar appearance.

This type of multinodular thyroid gland or goiter has an extremely low risk for being cancer.

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