Guideline:
Management of thyroid nodules on US
Guideline:
Management of incidental thyroid nodules on CT, MR and non-thyroid US
References:
1. NCCN
Guidelines: Thyroid Carcinoma, version 2.2014. Published online at NCCN.org.
2. Managing
Incidental Thyroid Nodules Detected on Imaging: White Paper of the ACR
Incidental Thyroid Findings Committee. Jenny K. Hoang, et al. JACR 2015; 12:
143-150.
3. Revised
American Thyroid Association Management Guidelines for Patients with Thyroid
Nodules and Differentiated Thyroid Cancer. Cooper, DS et al. Thyroid 2009;
19:1167-1214.
4. Management
of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound Consensus
Conference Statement. Mary C. Frates, et al. Radiology 2005; 237:794-800.
Macro name: Guideline thyroid nodule
Macro last updated: 2/4/15
US simple cyst
According
to consensus guidelines, a thyroid lesion with sonographic features of a simple
cyst should be correlated with the patient’s TSH level. If the TSH level is
low, an I-123 thyroid uptake and scan is recommended. Otherwise, follow-up US
in 6-12 months is recommended. If stable for 1 – 2 years, subsequent ultrasound
can be considered at 3 – 5 year intervals. (Hoang JK et al. J Amer Coll Radiol
2015 12 (2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014;
Cooper DS et al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology
(2005) 237:794-800)
US solid, not suspicious <1.5cm or suspicious
<1cm
According
to consensus guidelines, solid thyroid nodules with suspicious features
(hypoechoic, microcalcifications, increased central vascularity, infiltrative
margins, taller than wide in the transverse plane) and <1cm or without
suspicious features and <1.5cm, should be correlated with the patient’s TSH
level. If the TSH level is low, an I-123 thyroid uptake and scan is
recommended. Otherwise, follow-up US in 6-12 months is recommended. If stable
for 1 – 2 years, subsequent ultrasound can be considered at 3 – 5 year
intervals. (Hoang JK et al. J Amer Coll Radiol 2015 12 (2):142-150; NCCN
Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et al. Thyroid
(2009) 19(11):1167-1214; Frates MC et al. Radiology (2005) 237:794-800)
US solid suspicious >= 1cm
According
to consensus guidelines, solid thyroid nodules, >1cm, with suspicious
features (hypoechoic, microcalcifications, increased central vascularity,
infiltrative margins, taller than wide in the transverse plane), should be
correlated with the patient’s TSH level. If the TSH level is low, an I-123
thyroid uptake and scan is recommended. Otherwise, US-guided FNA of the nodule
is recommended. Should the nodule be benign on FNA, follow-up US in 6-12 months
is recommended. If stable for 1 – 2 years, subsequent ultrasound can be
considered at 3 – 5 year intervals. (Hoang JK et al. J Amer Coll Radiol 2015 12
(2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et
al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology (2005)
237:794-800)
US solid not suspicious >=1.5cm
According
to consensus guidelines, solid thyroid nodules, >1.5cm, without suspicious
features (hypoechoic, microcalcifications, increased central vascularity,
infiltrative margins, taller than wide in the transverse plane), should be
correlated with the patient’s TSH level. If the TSH level is low, an I-123
thyroid uptake and scan is recommended. Otherwise, US-guided FNA of the nodule
is recommended. Should the nodule be benign on FNA, follow-up US in 6-12 months
is recommended. If stable for 1 – 2 years, subsequent ultrasound can be
considered at 3 – 5 year intervals. (Hoang JK et al. J Amer Coll Radiol 2015 12
(2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et
al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology (2005)
237:794-800)
US cystic-solid suspicious < 1.5cm or not
suspicious <2cm
According
to consensus guidelines, mixed cystic-solid thyroid nodules, <1.5cm with
suspicious features (hypoechoic, microcalcifications, increased central
vascularity, infiltrative margins, taller than wide in the transverse plane) or
<2cm without suspicious features
should be correlated with the patient’s TSH level. If the TSH level is low, an
I-123 thyroid uptake and scan is recommended.
Otherwise, follow-up US in 6-12 months is recommended. If stable for 1 –
2 years, subsequent ultrasound can be considered at 3 – 5 year intervals.
(Hoang JK et al. J Amer Coll Radiol 2015 12 (2):142-150; NCCN Practice
Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et al. Thyroid (2009)
19(11):1167-1214; Frates MC et al. Radiology (2005) 237:794-800)
US cystic-solid suspicious >=1.5cm
According
to consensus guidelines, mixed cystic-solid thyroid nodules, >1.5cm, with
suspicious features (hypoechoic, microcalcifications, increased central
vascularity, infiltrative margins, taller than wide in the transverse plane),
should be correlated with the patient’s TSH level. If the TSH level is low, an
I-123 thyroid uptake and scan is recommended. Otherwise, US-guided FNA of the nodule
is recommended. Should the nodule be benign on FNA, follow-up US in 6-12 months
is recommended. If stable for 1 – 2 years, subsequent ultrasound can be
considered at 3 – 5 year intervals. (Hoang JK et al. J Amer Coll Radiol 2015 12
(2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et
al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology (2005)
237:794-800)
US cystic-solid not suspicious >=2cm
According
to consensus guidelines, mixed cystic-solid thyroid nodules, >2cm, without
suspicious features (hypoechoic, microcalcifications, increased central
vascularity, infiltrative margins, taller than wide in the transverse plane),
should be correlated with the patient’s TSH level. If the TSH level is low, an
I-123 thyroid uptake and scan is recommended. Otherwise, US-guided FNA of the
nodule is recommended. Should the nodule be benign on FNA, follow-up US in 6-12
months is recommended. If stable for 1 – 2 years, subsequent ultrasound can be
considered at 3 – 5 year intervals. (Hoang JK et al. J Amer Coll Radiol 2015 12
(2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et
al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology (2005)
237:794-800)
US spongiform <2cm
According
to consensus guidelines, spongiform thyroid nodules (i.e. nodules with an
aggregation of multiple multicystic components in more than 50% of the volume
of the nodule) <2cm should be correlated with the patient’s TSH level. If
the TSH level is low, an I-123 thyroid uptake and scan is recommended. Otherwise, follow-up US in 6-12 months is
recommended. If stable for 1 – 2 years, subsequent ultrasound can be considered
at 3 – 5 year intervals. (Hoang JK et al. J Amer Coll Radiol 2015 12
(2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et
al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology (2005)
237:794-800)
US spongiform >2cm
According
to consensus guidelines, spongiform thyroid nodules (i.e. nodules with an
aggregation of multiple multicystic components in more than 50% of the volume
of the nodule) >2cm should be correlated with the patient’s TSH level. If
the TSH level is low, an I-123 thyroid uptake and scan is recommended.
Otherwise, US-guided FNA of the nodule is recommended. Should the nodule be
benign on FNA, follow-up US in 6-12 months is recommended. If stable for 1 – 2
years, subsequent ultrasound can be considered at 3 – 5 year intervals. (Hoang
JK et al. J Amer Coll Radiol 2015 12 (2):142-150; NCCN Practice Guideline – Thyroid
Carcinoma v 2.2014; Cooper DS et al. Thyroid (2009) 19(11):1167-1214; Frates MC
et al. Radiology (2005) 237:794-800)
US c cervical lymphadenopathy
According
to consensus guidelines, thyroid nodules with cervical lymphadenopathy should
be correlated with the patient’s TSH level. If the TSH level is low, an I-123
thyroid uptake and scan is recommended. Furthermore, US-guided FNA of the
nodule and the adenopathy are recommended. Should the FNAs be benign, follow-up
US in 6-12 months is recommended. If stable for 1 – 2 years, subsequent
ultrasound can be considered at 3 – 5 year intervals. (Hoang JK et al. J Amer
Coll Radiol 2015 12 (2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v
2.2014; Cooper DS et al. Thyroid (2009) 19(11):1167-1214; Frates MC et al.
Radiology (2005) 237:794-800)
high risk patient
According
to consensus guidelines, thyroid nodules in patients at higher than normal risk
for thyroid cancer (including radiation therapy as a child or adolescent, first
degree relative with thyroid cancer or MEN2, FDG-avid on PET, a personal
history of thyroid cancer or thyroid cancer-associated conditions, such as
familial adenomatous polyposis, Carney complex, Cowden syndrome) may warrant
evaluation when smaller than the above criteria, depending on clinical concern.
(Hoang JK et al. J Amer Coll Radiol 2015 12 (2):142-150; NCCN Practice
Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et al. Thyroid (2009)
19(11):1167-1214; Frates MC et al. Radiology (2005) 237:794-800)
CT/MR <35 y/o and < 1 cm or >35 y/o and <
1.5cm
According
to consensus guidelines, thyroid nodules found incidentally on CT, MR, or
extrathyroidal US that are smaller than 1cm in patients less than 35 years old,
or smaller than 1.5cm in patients 35 years or older, require no further
evaluation. (Hoang JK et al. J Amer Coll Radiol 2015 12 (2):142-150; NCCN
Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et al. Thyroid
(2009) 19(11):1167-1214; Frates MC et al. Radiology (2005) 237:794-800)
CT/MR <35 y/o,
>1 cm
According
to consensus guidelines, in patients less than 35 years old, thyroid nodules
> 1cm found incidentally on CT, MR, or extrathyroidal US should be evaluated
with a dedicated thyroid ultrasound. (Hoang JK et al. J Amer Coll Radiol 2015
12 (2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS
et al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology (2005)
237:794-800)
CT/MR , >35 y/o,
>1.5 cm
According
to consensus guidelines, in patients 35 years or older, thyroid nodules >
1.5 cm found incidentally on CT, MR, or extrathyroidal US should be evaluated
with a dedicated thyroid ultrasound. (Hoang JK et al. J Amer Coll Radiol 2015
12 (2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS
et al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology (2005)
237:794-800)
CT/MR local invasion or suspicious LNs
According
to consensus guidelines, thyroid nodules with signs of local invasion or in the
presence of suspicious lymph nodes (lymph nodes with cystic change,
calcification, or increased enhancement) should be evaluated with a dedicated
thyroid ultrasound. (Hoang JK et al. J Amer Coll Radiol 2015 12 (2):142-150;
NCCN Practice Guideline – Thyroid Carcinoma v 2.2014; Cooper DS et al. Thyroid
(2009) 19(11):1167-1214; Frates MC et al. Radiology (2005) 237:794-800)
FDG-PET (+)
According
to consensus guidelines, focal metabolic activity in the thyroid on FDG-PET,
should be evaluated with both dedicated thyroid ultrasound and FUS-guided FNA
of the PET-avid lesion if the patient has normal life expectancy. (Hoang JK et
al. J Amer Coll Radiol 2015 12 (2):142-150; NCCN Practice Guideline – Thyroid
Carcinoma v 2.2014; Cooper DS et al. Thyroid (2009) 19(11):1167-1214; Frates MC
et al. Radiology (2005) 237:794-800)
Other NM (+)
According
to consensus guidelines, focal activity in the thyroid on sestamibi or
octreotide scintigraphy should be evaluated with dedicated thyroid ultrasound
if the patient has normal life expectancy. (Hoang JK et al. J Amer Coll Radiol
2015 12 (2):142-150; NCCN Practice Guideline – Thyroid Carcinoma v 2.2014;
Cooper DS et al. Thyroid (2009) 19(11):1167-1214; Frates MC et al. Radiology
(2005) 237:794-800)