Thyroid nodules are commonly detected in daily clinical practice, and their diagnosis and therapy usually involve different specialists and various diagnostic and therapeutic methods. Thyroid nodule management requires the integration of laboratory, imaging, and pathology examinations to achieve a proper diagnosis. It enables the elimination of unnecessary therapeutic procedures in many individuals and the timely identification of patients who require specific therapies. Furthermore, bioinformatics may change the current management of clinical data, enabling more personalized diagnostic approaches for patients with thyroid nodules.
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Category | US Features | Malignancy Risk, % | Recommendations |
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Sonographic Pattern | US Features | Estimated Risk of Malignancy, % | FNA Size Cutoff (Largest Dimension) |
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(a) | |||
∼10–30 | |||
Repeat FNA, molecular testing, or lobectomy | |||
IV. Follicular neoplasm or suspicious for a follicular neoplasm | 10–40 | 25–40 | Molecular testing, lobectomy |
V. Suspicious for malignancy | 45–60 | 50–75 | Near-total thyroidectomy or lobectomy |
VI. Malignant | 94–96 | 97–99 | Near-total thyroidectomy or lobectomy |
RCPath | Bethesda | Italian SIAPEC-AIT | |
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Category | Malignancy Risk, % | Recommendations | |
EU-TIRADS 1: Normal | None | ||
Thy1 Non-diagnostic for cytological diagnosis Thy1c Non-diagnostic for cytological diagnosis—cystic lesion |
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TIR1 Non-diagnostic TIR1c Non-diagnostic cystic |
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Thy2 Non-neoplastic Thy2c Non-neoplastic, cystic lesion |
2014 Italian SIAPEC-AIT | 2017 Bethesda | 2016 RCPath Classification |
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History |
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Clinical examination |
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Clinical investigations |
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EU-TIRADS 1: Normal | No nodules | None | None | |||||
High suspicion | Solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with one or more of the following features: irregular margins (infiltrative, micro-lobulated), microcalcifications, taller-than-wide shape, rim calcifications with small extrusive soft tissue component, evidence of extrathyroidal extension | >70–90 | Recommend FNA at ≥1 cm | |||||
EU-TIRADS 2: benign | Pure cyst, Entirely spongiform |
No FNA required (unless for therapeutic purposes/to relieve compression) | ||||||
Intermediate suspicion | Hypoechoic solid nodule with smooth margins without microcalcifications, ETE, or taller-than-wide shape | 0 | 10–20 | Recommend FNA at ≥1 cm | EU-TIRADS 3: low risk | Ovoid, smooth isoechoic/hyperechoic No features of high suspicion |
2–4 | >20 mm FNA |
Low suspicion | Isoechoic or hyperechoic solid nodule, or partially cystic nodule with eccentric solid areas, without microcalcification, irregular margin or ETE, or taller-than-wide shape | 5–10 | Recommend FNA at ≥1.5 cm | EU-TIRADS 4: intermediate risk | Ovoid, smooth, mildly hypoechoic No features of high suspicion |
6–17 | >15 mm FNA | |
Very low suspicion | Spongiform or partially cystic nodules without any of the sonographic features described in low-, intermediate-, or high-suspicion patterns | <3 | Consider FNA at ≥2 cm Observation without FNA is also a reasonable option |
EU-TIRADS 5: high risk | At least 1 of the following features of high suspicion:
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26–87 | >10 mm FNA, <10 mm: consider FNA or active surveillance |
Benign | |
Purely cystic nodules (no solid component) | |
<1 | No biopsy |
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None | |||||
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EU-TIRADS 2 | benign, malignancy risk 0%; | No FNA required (unless for therapeutic purposes/to relieve compression) | ||
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EU-TIRADS 3 | low risk, malignancy risk 2–4% | >20 mm FNA | |
EU-TIRADS 4 | intermediate risk, malignancy risk 6–17% | >15 mm FNA | |||
EU-TIRADS 5 | high risk, malignancy risk 26–87% | >10 mm FNA, <10 mm: consider FNA or active surveillance | |||
(b) | |||||
Category | Points | Malignancy Risk, % | Recommendations | ||
TR1: | 0 points | benign (aggregate risk level 0.3%); | No FNA required | ||
TR2: | 2 points | not suspicious (aggregate risk level 1.5%); | No FNA required | ||
TR3: | 3 points | mildly suspicious (aggregate risk level 4.8%); | ≥25 mm FNA | ||
TR4: | 4–6 points | moderately suspicious (aggregate risk level 5.9–12.8%); | ≥15 mm FNA | ||
TR5: | 7 points or more | highly suspicious (aggregate risk level 20.8–68.4% for 10 points). | ≥10 mm FNA, | ||
(c) | |||||
Category | Malignancy Risk, % | Recommendations | |||
Benign | Risk level < 1% | No FNA required | |||
Very low suspicion | Risk level < 3% | Consider FNA at ≥2 cm Observation without FNA is also a reasonable option |
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Low suspicion | Risk level 5–10% | Recommend FNA at ≥1.5 cm | |||
Intermediate suspicion | Risk level 10–20% | Recommend FNA at ≥1 cm | |||
High suspicion | Risk level > 70–90% | Recommend FNA at ≥1 cm |
Diagnostic Category | Risk of Malignancy if NIFTP ≠ CA (%) | Risk of Malignancy if NIFTP = CA (%) | Usual Management | |||||
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I. Non-diagnostic or unsatisfactory | 5–10 | 5–10 | Repeat FNA with ultrasound guidance | |||||
II. Benign | ||||||||
Diagnostic category (ROM %) | Management | Diagnostic category (ROM %) | Management | Diagnostic category (ROM %) | Management | |||
TIR 3A Low-risk indeterminate lesion | 0–3 | 0–3 | Clinical and sonographic follow-up | |||||
(12–22%) | Consistent with a benign follicular nodule (includes adenomatoid nodule, colloid nodule, etc.). Consistent with lymphocytic (Hashimoto) thyroiditis in the proper clinical context Consistent with granulomatous (subacute) thyroiditis |
TIR2 Non-malignant | ||||||
Clinical follow | up/Repeat FNA |
III. AUS/FLUS (10–30%) |
Repeat FNA/Molecular testing or lobectomy |
Thy 3a Neoplasm possible – atypia/non-diagnostic (25%) |
Multidisciplinary assessment | III. Atypia of undetermined significance or follicular lesion of undetermined significance | Thy3a Neoplasm possible—atypia/non-diagnostic | |
TIR 3B High-risk indeterminate lesion | 6–18III. Atypia of undetermined significance or follicular lesion of undetermined significance | TIR3A Low-risk indeterminate lesion (LRIL) | ||||||
(30–55%) |
Surgery | IV. Follicular neoplasm/suspicious follicular neoplasm (25–40%) |
Molecular testing, lobectomy |
Thy3f Neoplasm possible, suggesting follicular neoplasm | IV. Follicular neoplasm or suspicious for a follicular neoplasm Specify if Hürthle cell (oncocytic) type |
TIR3B High-risk indeterminate lesion (HRIL) | ||
Thy 3f | Thy4 Suspicious of malignancy | V. Suspicious for malignancy | TIR4 Suspicious of malignancy | |||||
Neoplasm possible, | suggesting follicular | neoplasm (31%) |
Multidisciplinary assessment | Thy5 Malignant | VI. Malignant | TIR5 Malignant |