MANAGEMENT OF

THYROID NODULES
DETECTED AT US: SOCIETY
OF RADIOLOGISTS IN
ULTRASOUND CONSENSUS
CONFERENCE STATEMENT
Frates M, Benson C, et al. Radiology 2005; 237:794-800

S SCHEEPERS

Introduction

Panel met in Washington in 2004

Determine which thyroid nodules should
undergo US-guided FNA

Introduction

Widespread use of FNA

Improved detection of thyroid cancer
Decreased frequency of thyroid surgery
Increased cancer rates at thyroidectomy

However: importance of early diagnosis

of thyroid cancer in low risk patients
uncertain
Slow growing
Low morbidity and mortality

Background

Epidemiology
Thyroid nodules are very common
4-8% of adults by palpation
10-41% by US
50% by autopsy
Prevalence increases with age
Malignancy most common <20 or >60

Background

Factors associated with increased

likelihood of malignancy
Physical exam
Firmess of nodule
Rapid growth
Fixation to adjacent structures
Vocal cord paralysis
Enlarged regional lymph nodes
Hx of neck irradiation
Family hx of thyroid cancer

Background

Facts about thyroid cancer

Incidence in patients with nodules 9.2-13.0%
Irrespective of number of nodules
Multiple nodules
Cancer rate per nodule decreases
Overall rate of cancer per patient remains the

same
1/3 of patients cancer is found in non-dominant
nodule
Incidence in incidental or non-palpable nodules

same as palpable nodules

Background

Histology
Papillary = majority (75-80%)
30-year survival rate of 95%
Follicular (10-20%)
Medullary (3-5%)
Anaplastic (1-2%)

Ultrasound

Definition
Nodule is discrete lesion, within thyroid, sonographically

distinguishable from adjacent parenchyma

Features to evaluate
Size
Echogenicity
Composition (cystic, solid, mixed)
Calcification (presence and type)
Halo
Margins
Internal blood flow

Ultrasound

Nodule size NOT predictive of malignancy

Suspicious findings
Calcifications (highest PPV, low sens)
Hypoechogenicity
Iregular margins
Abscence of halo
Predominantly solid composition (highest

sens, low PPV)

Intranodule vascularity

Consensus statement

Should only be applied to lesions >1cm

Ucertainty whether diagnosis of smaller

cancers would improve life expectancy

Lead to an excessive number of biopsies

Consensus statement

Solitary nodule, strongly consider FNA if:

>1cm and microcalcifications
>1.5cm and
Solid or almost entirely solid
Coarse calcifications

>2cm
Mixed solid and cystic
Almost entirely cystic with solid mural

component
Substantial growth since prior US

Consensus statement

Multiple nodules
Assess each nodule as above

Non-diagnostic FNA
Second FNA for lesions as above

Abnormal LN overrides US features

criteria
Biopsy of LN and/or ipsilateral thyroid

nodule

Explanations

Measurements
Calipers placed outside halo
Use maximum diameter

Explanations

Calcification
Any Ca2+ raises suspicion
Microcalcs 3X increase in

risk
Coarse calcs 2X increase
in risk

Explanations

Composition
Quantify percentage

solid vs cystic
Solid
Pred solid
Mixed (50/50)
Pred cystic
Cystic

Explanations

Colour Doppler US
Marked internal flow

increase in risk
More flow in nodule

than surrounding
thyroid tissue
More flow in central
nodule than
peripherally

Explanations

Interval growth
Rapid growth indicates increased risk

Multiple nodules
Selection based on US characteristics of

each nodule

Explanations

Abnormal cervical
lymph nodes
Should prompt Bx
US features of

pathologic LN
Heterogeneous

echotexture
Calcifications
Cystic areas within LN
Rounded LN
LN causing mass
effect

Research topics

How should substantial growth be

defined?
If Px with multiple nodules, which and
how many nodules should undergo
FNA?
What is cost-effectiveness of various
approaches?

THANK YOU!