Thyroid Nodule Imaging. Status and Limitations.

Document Type : Review article


Multan Institute of Nuclear Medicine and Radiotherapy, Multan, Pakistan


Thyroid nodules are common, occurring in almost two-thirds of some populations; among these only about 7% are malignant. The most important question with any new discovered thyroid nodule is, “is this malignant?” The main arbiter of malignancy or benignity remains fine needle aspiration and the mainstay of treatment surgery. But given the resources involved, doing an FNAC or surgery in every discovered nodule would be prohibitive to impossible. The clinician must decide which nodule to investigate and which to watch in the hope that this will never turn out to be malignant. FNACs are used basically to decide which nodule to operate upon (or more importantly which to not operate upon) and clinical and imaging features are used to decide which nodule to investigate by FNAC and which to leave alone. This paper describes the various imaging options for looking at thyroid nodules and briefly discusses the advantages and disadvantages with each.


Main Subjects

1. Welker MJ, Orlov D. Thyroid nodules. Am Fam Physician. 2003;67(3):559-66.
2. Tuttle RM, Lemar H, Burch HB. Clinical features associated with an increased risk of thyroid malignancy in patients with follicular neoplasia by fine-needle aspiration. Thyroid. 1998;8(5):377-83.
3. Zuberi LM, Yawar A, Islam N, Jabbar A. Clinical presentation of thyroid cancer patients in Pakistan- AKUH experience. JPMA The Journal of the Pakistan Medical Association. 2004;54(10):526-8.
4. McCall A, Jarosz H, Lawrence AM, Paloyan E. The incidence of thyroid carcinoma in solitary cold nodules and in multinodular goiters. Surgery. 1986;100(6):1128-32.
5. Sachmechi I, Miller E, Varatharajah R, Chernys A, Carroll Z, Kissin E, et al. Thyroid carcinoma in single cold nodules and in cold nodules of multinodular goiters. Endocr Pract. 2000; 6(1):5-7.
6. Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, et al. Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab. 2002;87(5):1941-6.
7. Hoang JK, Lee WK, Lee M, Johnson D, Farrell S. US Features of thyroid malignancy: pearls and pitfalls. Radiographics. 2007;27(3):847-60.
8. Mancuso AA. Oh #*$%#! Another pesky incidental thyroid nodule! AJNR Am J Neuroradiol. 2005;26(10):2444-5.
9. Daumerie C, Ayoubi S, Rahier J, Buysschaert M, Squifflet JP. Prevalence of thyroid cancer in hot nodules. Ann Chir. 1998;52(5):444-8.
10. Mirfakhraee S, Mathews D, Peng L, Woodruff S, Zigman JM. A solitary hyperfunctioning thyroid nodule harboring thyroid carcinoma: review of the literature. Thyroid Res. 2013;6(1):7.
11. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1167-214.
12. Sathekge MM, Mageza RB, Muthuphei MN, Modiba MC, Clauss RC. Evaluation of thyroid nodules with technetium-99m MIBI and technetium-99m pertechnetate. Head Neck. 2001;23(4):305-10.
13. Nakahara H, Noguchi S, Murakami N, Hoshi H, Jinnouchi S, Nagamachi S, et al. Technetium-99msestamibi scintigraphy compared with thallium-201 in evaluation of thyroid tumors. J Nucl Med. 1996;37(6):901-4.
14. Bertagna F, Treglia G, Piccardo A, Giubbini R. Diagnostic and clinical significance of F-18-FDG-PET/ CT thyroid incidentalomas. J Clin Endocrinol Metab. 2012;97(11):3866-75.
15. Mosci C, Iagaru A. PET/CT imaging of thyroid cancer. Clin Nucl Med. 2011;36(12):e180-5.
16. Hoang JK, Raduazo P, Yousem DM, Eastwood JD. What to do with incidental thyroid nodules on imaging? An approach for the radiologist. Semin Ultrasound CT MR. 2012;33(2):150-7.
17. Hobbs HA, Bahl M, Nelson RC, Kranz PG, Esclamado RM, Wnuk NM, et al. Journal Club: incidental thyroid nodules detected at imaging: can diagnostic workup be reduced by use of the Society of Radiologists in Ultrasound recommendations and the three-tiered system? AJR Am J Roentgenol. 2014;202(1):18-24.
18. Chaudhary V, Bano S. Thyroid ultrasound. Indian J Endocrinol Metab. 2013;17(2):219-27.
19. Kotecha S, Bhatia P, Rout PG. Diagnostic ultrasound in the head and neck region. Dent Update. 2008; 35(8): 529-30, 33-4.
20. Koischwitz D, Gritzmann N. Ultrasound of the neck. Radiol Clin North Am. 2000; 38(5):1029-45.
21. Sohn YM, Kwak JY, Kim EK, Moon HJ, Kim SJ, Kim MJ. Diagnostic approach for evaluation of lymph node metastasis from thyroid cancer using ultrasound and fine-needle aspiration biopsy. AJR Am J Roentgenol. 2010;194(1):38-43.
22. Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011; 260(3): 892-9.
23. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M. The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid. J Radiol. 2011;92(7-8):701-13.
24. Horvath E, Majlis S, Rossi R, Franco C, Niedmann JP, Castro A, et al. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab. 2009; 94(5): 1748-51.
25. Kim DW, Jung SJ, Ha TK, Park HK, Kang T. Comparative Study of Ultrasound and Computed Tomography for Incidentally Detecting Diffuse Thyroid Disease. Ultrasound Med Biol. 2014.
26. Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, et al. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2005;237(3):794-800.
27. Park JY, Lee HJ, Jang HW, Kim HK, Yi JH, Lee W, et al. A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. Thyroid. 2009; 19(11):1257-64.
28. Anuradha C, Abhishek K, Pushpa B, Deepak A, MJ P. Positive predictive value and inter-observer agreement of TIRADS for ultrasound features of thyroid nodules. ECR 20142014.
29. Ko SY, Lee HS, Kim EK, Kwak JY. Application of the Thyroid Imaging Reporting and Data System in thyroid ultrasonography interpretation by less experienced physicians. Ultrasonography. 2014; 33(1): 49-57.
30. Ko SY, Lee HS, Kim EK, Kwak JY. Application of the Thyroid Imaging Reporting and Data System in thyroid ultrasonography interpretation by less experienced physicians. Ultrasonography. 2013; 33(1): 49-57.
31. Smith-Bindman R, Lebda P, Feldstein VA, Sellami D, Goldstein RB, Brasic N, et al. Risk of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a population-based study. JAMA Intern Med. 2013;173(19):1788-96.
32. Alexander EK, Cooper D. The importance, and important limitations, of ultrasound imaging for evaluating thyroid nodules. JAMA Intern Med. 2013; 173(19): 1796-7.
33. Tay SY, Chen CY, Chan WP. Sonographic criteria predictive of benign thyroid nodules useful in avoiding unnecessary ultrasound-guided fine needle aspiration. J Formos Med Assoc. 2014; pii: S0929- 6646(14)00109-0.
34. Vinayak S, Sande JA. Avoiding unnecessary fine-needle aspiration cytology by accuractely predicting the benign nature of thyroid nodules using ultrasound. J Clin Imaging Sci. 2012;2:23.
35. Brito JP, Gionfriddo MR, Al Nofal A, Boehmer KR, Leppin AL, Reading C, et al. The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab. 2014;99(4):1253-63.
36. Kim JY, Kim SY, Yang KR. Ultrasonographic criteria for fine needle aspiration of nonpalpable thyroid nodules 1-2 cm in diameter. Eur J Radiol. 2013;82:321-6.
37. McCarthy M. US thyroid cancer rates are epidemic of diagnosis not disease, study says. BMJ. 2014; 348: g1743.
38. Howlader N, Krapcho M, Garshell J, Miller D, Altekruse SF, Kosary CL, et al. SEER Cancer Statistics Review. 2013; 1975-2011.
39. Harach HR, Franssila KO, Wasenius VM. Occult papillary carcinoma of the thyroid. A "normal" finding in Finland. A systematic autopsy study. Cancer. 1985;56(3):531-8.
40. Lee YS, Lim H, Chang HS, Park CS. Papillary thyroid microcarcinomas are different from latent papillary thyroid carcinomas at autopsy. J Korean Med Sci. 2014;29(5):676-9.
41. Ahn SS, Kim EK, Kang DR, Lim SK, Kwak JY, Kim MJ. Biopsy of thyroid nodules: comparison of three sets of guidelines. AJR Am J Roentgenol. 2010;194:31-7.
42. Moon HJ, Kim EK, Kwak JY. Malignancy risk stratification in thyroid nodules with benign results on cytology: combination of thyroid imaging reporting and data system and bethesda system. Ann Surg Oncol. 2014;21(6):1898-903.
43. Kim EK, Park CS, Chung WY, Oh KK, Kim DI, Lee JT, et al. New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR Am J Roentgenol. 2002;178(3):687-91.