What are the guidelines on the initial evaluation of thyroid nodules?

Updated: Jun 24, 2020
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All the guidelines advocate ultrasound evaluation of thyroid nodules; ATA and NCCN guidelines also recommend measurement of serum thyroid-stimulating hormone (TSH) levels to determine whether a fine needle aspiration biopsy (FNAB) is indicated. A routine measurement of serum thyroglobulin (Tg) for the initial evaluation of thyroid nodules is not recommended because Tg levels are elevated in most benign thyroid conditions. [1, 5, 7, 6]

Although all the guidelines recommend FNAB as the procedure of choice in the evaluation of solid thyroid nodules, there is variance in the size of the nodule as an indication for FNAB. [1, 5, 6]  AACE/AME/ETA indications for FNAB according to size are as follows [7] :

  • Lesions ≥10 mm with high-risk US features
  • Lesions ≥20 mm with intermediate-risk US features
  • Lesions >20 mm with low-risk US features, but that are increasing in size or associated with a risk history and before thyroid surgery or minimally invasive ablation therapy

Other guidelines provide the following recommendations:

  • >0.5 cm in diameter (ATA) [1]
  • >1 cm in diameter (ESMO) [6]
  • NCCN guidelines use the ACR TI-RADS thresholds of ≥1 cm for highly suspicious nodules, ≥1.5 cm for moderately suspicious nodules and ≥2.5 cm for mildly suspicious nodules. [8, 5]

NCCN, ATA AACE/AME/ETA guidelines recommend radionuclide imaging in patients with a low TSH level. [1, 5, 7]

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