In a patient with normal life expectancy, a biopsy should be performed for nodules >1cm regardless of the ACR TI-RADS risk category. Doctors use radioactive iodine to treat hyperthyroidism. -, Takano T. Overdiagnosis of Juvenile Thyroid Cancer: Time to Consider Self-Limiting Cancer. There are inherent problems with studies addressing the issue such as selection bias at referral centers and not all nodules having fine needle aspiration (FNA). HHS Vulnerability Disclosure, Help We assessed a hypothetical clinical comparator where 1 in 10 nodules are randomly selected for fine needle aspiration (FNA), assuming a pretest probability of clinically important thyroid cancer of 5%. So, the number needed to scan (NNS) for each additional person correctly reassured is 100 (NNS=100). Until a well-designed validation study is completed, the performance of TIRADS in the real world is unknown. Therefore, 60% of patients are in the middle groups (TR3 and TR4), where the US features are less discriminatory. TIRADS 4: suspicious nodules (5-80% malignancy rate). The NNS for ACR TIRADS is such that it is hard to justify its use for ruling out thyroid cancer (NNS>100), at least on a cost/benefit basis. Based on the 2017 ACR TIRADS classification, the doctor will continue to specify whether the patient needs a biopsy of thyroid cells or not: Thyroid nodule size > 2.5cm: Indication for cytology biopsy. A 35-year-old woman with a nodule in the left-lobe of her thyroid gland. Thyroid Nodule Characterization: How to Assess the Malignancy Risk. Friedrich-Rust M, Meyer G, Dauth N et-al. A 38-year-old woman with a nodule in the right-lobe of her thyroid gland. In addition, changes in nomenclature such as the recent classification change to noninvasive follicular thyroid neoplasm with papillary-like nuclear features would result in a lower rate of thyroid cancer if previous studies were reported using todays pathological criteria. Those wishing to continue down the investigative route could then have US, using TIRADS or ATA guidelines or other measures to offer some relative risk-stratification. Keywords: At best, only a minority of the 3% of cancers would show on follow-up imaging features suspicious for thyroid cancer that correctly predict malignancy. It is very difficult to know the true prevalence of important, clinically consequential thyroid cancers among patients presenting with thyroid nodules. The CEUS-TIRADS category was 4c. There are even data showing a negative correlation between size and malignancy [23]. If it performs well enough, then the test is applied to a training set of data to better establish performance characteristics. Radiology. -, Zhou J, Yin L, Wei X, Zhang S, Song Y, Luo B, et al. Methodologically, the change in the ACR-TIRADS model should now undergo a new study using a new training data set (to avoid replicating any bias), before then undergoing a validation study. If a patient presented with symptoms (eg, concerns about a palpable nodule) and/or was not happy accepting a 5% pretest probability of thyroid cancer, then further investigations could be offered, noting that US cannot reliably rule in or rule out thyroid cancer for the majority of patients, and that doing any testing comes with unintended risks. If one decides to FNA every TR5 nodule, from the original ACR TIRADS data set, 34% were found to be cancerous, but note that this data set likely has double the prevalence of thyroid cancer compared with the real-world population. Write for us: What are investigative articles. View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, American College of Radiology: ACR TI-RADS, Korean Society of Thyroid Radiology: K-TIRADS, iodinated contrast-induced thyrotoxicosis, primary idiopathic hypothyroidism with thyroid atrophy, American Thyroid Association (ATA)guidelines, British Thyroid Association (BTA)U classification, Society of Radiologists in Ultrasound (SRU)guidelines, American College of Radiology:ACR TI-RADS, postoperative assessment after thyroid cancer surgery, ultrasound-guided fine needle aspiration of the thyroid, TIRADS (Thyroid Image Reporing and Data System), colloid type 1:anechoic with hyperechoic spots, nonvascularised, colloid type 2: mixed echogenicity with hyperechoic spots,nonexpansile, nonencapsulated, vascularized, spongiform/"grid" aspect, colloid type 3: mixed echogenicity or isoechoic with hyperechoic spots and solid portion, expansile, nonencapsulated, vascularized, simple neoplastic pattern: solid or mixed hyperechoic, isoechoic, or hypoechoic;encapsulated with a thin capsule, suspicious neoplastic pattern: hyperechoic, isoechoic, or hypoechoic;encapsulated with a thick capsule; hypervascularised; with calcifications (coarse or microcalcifications), malignant pattern A: hypoechoic, nonencapsulated with irregular margins, penetrating vessels, malignant pattern B: isoechoic or hypoechoic, nonencapsulated, hypervascularised, multiple peripheral microcalcifications, malignancy pattern C: mixed echogenicity or isoechoic without hyperechoic spots, nonencapsulated, hypervascularised, hypoechogenicity, especially marked hypoechogenicity, "white knight" pattern in the setting of thyroiditis (numerous hyperechoic round pseudonodules with no halo or central vascularizaton), nodular hyperplasia (isoechoic confluent micronodules located within the inferior and posterior portion of one or two lobes, usually avascular and seen in simple goiters), no sign of high suspicion (regular shape and borders, no microcalcifications), high stiffness with sonoelastography (if available), if >7 mm, biopsy is recommended if TI-RADS 4b and 5 or if patient has risk factors (family history of thyroid cancer or childhood neck irradiation), if >10 mm, biopsy is recommended if TI-RADS 4a or if TI-RADS 3 that has definitely grown (2 mm in two dimensions and >20% in volume). The figures that TIRADS provide, such as cancer prevalence in certain groups of patients, or consequent management guidelines, only apply to populations that are similar to their data set. Other limitations include the various assumptions we have made and that we applied ACR TIRADS to the same data set upon which is was developed. Clinical Application of C-TIRADS Category and Contrast-Enhanced Ultrasound in Differential Diagnosis of Solid Thyroid Nodules Measuring 1 cm. 2018;287(1):29-36. 8600 Rockville Pike These patients are not further considered in the ACR TIRADS guidelines. 2020 Mar 10;4 (4):bvaa031. The sensitivity, specificity, and accuracy of CEUS were 78.7%, 87.5%, and 83.3% respectively. Thyroid Nodules: Causes, Symptoms & Treatment - Cleveland Clinic (2017) Radiology. Most thyroid nodules aren't serious and don't cause symptoms. Your email address will not be published. Whilst the details of the design of the final validation study can be debated, the need for a well-designed validation study to determine the test characteristics in the real-world setting is a basic requirement of any new test. We found better sensitivity, PPV, and NPV with TIRADS compared with random selection (97% vs 1%, 13% vs 1%, and 99% vs 95%, respectively), whereas specificity and accuracy were worse with TIRADS compared with random selection (27% vs 90%, and 34% vs 85%, respectively (Table 2)[25]. Ultrasound (US) risk-stratification systems for investigation of thyroid nodules may not be as useful as anticipated. The more carefully one looks for incidental asymptomatic thyroid cancers at autopsy, the more are found [4], but these do not cause unwellness during life and so there is likely to be no health benefit in diagnosing them antemortem. The diagnosis or exclusion of thyroid cancer is hugely challenging. What is thyroid disease tirads 3? | Vinmec It is important to validate this classification in different centres. 283 (2): 560-569. Save my name, email, and website in this browser for the next time I comment. It is this proportion of patients that often go on to diagnostic hemithyroidectomies, from which approximately 20% are cancers [12, 17, 21], meaning the majority (80%) end up with ultimately unnecessary operations. Russ G, Royer B, Bigorgne C et-al. Ultimately, most of these turn out to be benign (80%), so for every 100 FNAs, you end up with 16 (1000.20.8) unnecessary operations being performed. Refer to separate articles for the latest systems supported by various professional societies: A TI-RADS was first proposed by Horvath et al. This is a specialist doctor who specializes in the treatment and diagnosis of thyroid cancer. It would be unfair to add these clinical factors to only the TIRADS arm or only to the clinical comparator arm, and they would cancel out if added to both arms, hence they were omitted. The sensitivity, specificity, and accuracy of CEUS-TIRADS were 95.7%, 85.7%, and 92.1% respectively. The authors suggested, as with BI-RADS, that biopsy candidates were those nodules categorized as TI-RADS category 4 or 5, meaning demonstrating at least one suspicious sonographic feature. Thyroid nodules are a common finding, especially in iodine-deficient regions. Thyroid Nodules: Advances in Evaluation and Management | AAFP Jin Z, Zhu Y, Lei Y, Yu X, Jiang N, Gao Y, Cao J. Med Sci Monit. Now, the first step in T3N treatment is usually a blood test. government site. Because we have a lot of people who have been put in a position where they dont have the proper education to be able to learn what were going through, we have to take this time and go through it as normal. The consequences of these proportions are highly impactful when considering the real-world performance of ACR-TIRADS. If a guideline indicates that FNA is recommended, it can be difficult to oppose this based on other factors. Authors Tiantong Zhu 1 , Jiahui Chen 1 , Zimo Zhou 2 , Xiaofen Ma 1 , Ying Huang 1 Affiliations 4. Data sets with a thyroid cancer prevalence higher than 5% are likely to either include a higher proportion of small clinically inconsequential thyroid cancers or be otherwise biased and not accurately reflect the true population prevalence. In the TR3 category, there was a gradual difference in cancer rate in those 1-2 cm (6.5%), and those 2-3 cm (8.4%) and those>3 cm (11.3%). . tirads 4 thyroid nodule treatment - Investigative Signal TIRADS Management Guidelines in the Investigation of Thyroid Nodules Its not something that happens every day, but every day. Tests and procedures used to diagnose thyroid cancer include: Physical exam. Thyroid Cancer: Diagnosis, Treatment and Follow-Up | IntechOpen The 2 examples provide a range of performance within which the real test performance is likely to be, with the second example likely to provide TIRADS with a more favorable test performance than in the real world. TI-RADS 1: normal thyroid gland TI-RADS 2: benign nodule TI-RADS 3: highly probable benign nodule TI-RADS 4a: low suspicion for malignancy TI-RADS 4b: high suspicion for malignancy TI-RADS 5: malignant nodule with more than two criteria of high suspicion Imaging features TI-RADS 2 category Constantly benign patterns include simple cyst spiker54. To establish a contrast-enhanced ultrasound (CEUS) diagnostic schedule by CEUS analysis of thyroid nodules of C-TIRADS 4. no financial relationships to ineligible companies to disclose. Given the need to do more than 100 US scans to find 25 patients with just TR1 or TR2 nodules, this would result in at least 50 FNAs being done. In a clinical setting, this would typically be an unselected sample of the test population, for example a consecutive series of all patients with a thyroid nodule presenting to a clinic, ideally across multiple centers. TI-RADS score - Ultrasound Assessment of Thyroid Nodules - GP Voice The high prevalence of thyroid nodules combined with the generally indolent growth of thyroid cancer present a challenge for optimal patient care. Given that ACR TIRADS test performance is at its worst in the TR3 and TR4 groups, then the cost-effectiveness of TIRADS will also be at its worst in these groups, in particular because of the false-positive TIRADS results. Chinese thyroid imaging reporting and data system(C-TIRADS); contrast-enhanced ultrasound (CEUS); differentiation; thyroid nodules; ultrasound (US). Attempts to compare the different TIRADS systems on data sets that are also not reflective of the intended test population are similarly flawed (eg, malignancy rates of 41% [29]). The system has fair interobserver agreement 4. Please enable it to take advantage of the complete set of features! If a clinician does no tests and no FNAs, then he or she will miss all thyroid cancers (5 people per 100). Thyroid Imaging Reporting and Data System (TI-RADS): A User's Guide When it reflected an absent enhancement in CEUS, the nodule was judged as CEUS-TIRADS 3. Cheng H, Zhuo SS, Rong X, Qi TY, Sun HG, Xiao X, Zhang W, Cao HY, Zhu LH, Wang L. Int J Endocrinol. We realize that such factors may increase an individuals pretest probability of cancer and clinical decision-making would change accordingly (eg, proceeding directly to FNA), but we here ascribe no additional diagnostic value to avoid overestimating the performance of the clinical comparator. proposed a system with five categories, which, like BI-RADS, each carried a management recommendation 2. Objectives: The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) has achieved high accuracy in categorizing the malignancy status of nearly 950 thyroid nodules detected on thyroid ultrasonography. PLoS ONE. In which, divided into groups such as: Malignant 3.3%; malignancy 9.2%; malignant 44.4 - 72.4%, malignant. It is interesting to see the wealth of data used to support TIRADS as being an effective and validated tool. However, the consequent management guidelines are difficult to justify at least on a cost basis for a rule-out test, though ACR TIRADS may provide more value as a rule-in test for a group of patients with higher cancer risk. National Library of Medicine The https:// ensures that you are connecting to the However, in the data set, only 25% of all nodules were categorized as TR1 or TR2 and these nodules harbored only 1% of all thyroid cancers (9 of 343). Unable to load your collection due to an error, Unable to load your delegates due to an error. Cavallo A, Johnson DN, White MG, et al. The management guidelines may be difficult to justify from a cost/benefit perspective. For TIRADS to add clinical value, it would have to clearly outperform the comparator (random selection), particularly because we have made some assumptions that favor TIRADS performance. Cawood T, Mackay GR, Hunt PJ, OShea D, Skehan S, Ma Y. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M. Yoon JH, Lee HS, Kim EK, Moon HJ, Kwak JY. The common first step when you have a thyroid nodule is to go to your health care provider and get a referral. And because thyroid cancer is often diagnosed in a persons late 30s or 40s, most of us are often diagnosed after the symptoms have already begun. Methods: Hypoechoic Nodule on Thyroid: Cancer Risk, Next Steps, Outlook - Healthline Become a Gold Supporter and see no third-party ads. The gold test standard would need to be applied for comparison. Among the 228 C-TIRADS 4 nodules, 69 were determined as C-TIRADS 4a, 114 were C-TIRADS 4b, and 45 were C-TIRADS 4c. Using TR5 as a rule-in test was similar to random selection (specificity 89% vs 90%). Yoon JH, Han K, Kim EK, Moon HJ, Kwak JY. Keywords: This approach likely performs better than randomly selecting 1 in 10 nodules for FNA, but we intentionally made assumptions that would favor the performance of ACR TIRADS to illustrate that if a poor clinical comparator cannot clearly be beaten, then the clinical value that such new systems bring is correspondingly poor. The specificity of TIRADS is high (89%) but, perhaps surprisingly, is similar to randomly selecting of 1 in 10 nodules for FNA (90%). The process of validation of CEUS-TIRADS model. Anderson TJ, Atalay MK, Grand DJ, Baird GL, Cronan JJ, Beland MD. The chance of finding a consequential thyroid cancer during follow-up is correspondingly low. EU-TIRADS 2 category comprises benign nodules with a risk of malignancy close to 0%, presented on sonography as pure/anechoic cysts ( Figure 1A) or entirely spongiform nodules ( Figure 1B ). In view of their critical role in thyroid nodule management, more improved TI-RADSs have emerged. Of note, we have not taken into account any of the benefits, costs, or harms associated with the proposed US follow-up of nodules, as recommended by ACR-TIRADS. Findings of a large, prospective multicenter study from Egypt, published in the August 2019 issue of the European Journal . Thyroid nodules are lumps that can develop on the thyroid gland. 'Returning to TI-RADS' may assist with triage of indeterminate thyroid The optimal investigation and management of the 84% of the population harboring the remaining 50% of cancer remains unresolved. The implication is that US has enabled increased detection of thyroid cancers that are less clinically important [11-13]. . However, if the concern is that this might miss too many thyroid cancers, then this could be compared with the range of alternatives (ie, doing no tests or doing many more FNAs). to propose a simpler TI-RADS in 2011 2. ectomy, Parotid gland surgery, Transoral laser microsurgery, Transoral robotic surgery, Oral surgery, Parotid gland tumor, Skin cancer, Tonsil cancer, Throat cancer, Salivary gland tumor, Salivary gland cancer, Thyroid nodule, Head and neck cancer, Laryngeal cancer, Tongue . As it turns out, its also very accurate and detailed. Before This allows patients with a TR1 or TR2 nodule to be reassured that they have a low risk of thyroid cancer, rather than a mixture of nodules (not just TR1 or TR2) not being able to be reassured. Unauthorized use of these marks is strictly prohibited. Therefore, using TIRADS categories TR1 or TR2 as a rule-out test should perform very well, with sensitivity of the rule-out test being 97%. Would you like email updates of new search results? Risk of Malignancy in Thyroid Nodules Using the American - PubMed eCollection 2022. Thyroid nodules come to clinical attention when noted by the patient; by a clinician during routine physical examination; or during a radiologic procedure, such as carotid ultrasonography, neck or chest computed tomography (CT), or positron emission tomography (PET) scanning. J. Endocrinol. These figures cannot be known for any population until a real-world validation study has been performed on that population. Ultrasound classification of thyroid nodules: does size matter? The other thing that matters in the deathloops story is that the world is already in an age of war. The. 1 Most thyroid nodules are detected incidentally when imaging is performed for another indication. The low pretest probability of important thyroid cancer and the clouding effect of small clinically inconsequential thyroid cancers makes the development of an effective real-world test incredibly difficult. In the case of thyroid nodules, there are further challenges. A meta-analysis, This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (, Mitoguardin2 is Associated with Hyperandrogenism and Regulates Steroidogenesis in Human Ovarian Granulosa Cells, Factors Associated with Diabetes Distress among Patients with Poorly Controlled Type 2 Diabetes, Serum adiponectin and leptin is not related to skeletal muscle morphology and function in young women, Association Between Metabolic Syndrome Inflammatory Biomarkers and COVID-19 Severity, Long-term outcome of body composition, ectopic lipid and insulin resistance changes with surgical treatment of acromegaly, Volume 7, Issue 4, April 2023 (In Progress), The Journal of Clinical Endocrinology & Metabolism, https://www.uptodate.com/contents/diagnostic-approach-to-and-treatment-of-thyroid-nodules, https://doi.org/10.6084/m9.figshare.11640168.v, http://creativecommons.org/licenses/by-nc-nd/4.0/, Receive exclusive offers and updates from Oxford Academic, 1 in 10 nodules having FNA, assuming pretest probability of cancer of 5%, Negative test being TR1 or TR2; positive test meaning TR3, TR4, or TR5, Positive test meaning TR5; negative test meaning TR1-4, Positive test meaning TR5, TR4 above size cutoff and TR3 above size cutoff; negative test meaning TR1, TR2, TR3 Below Size Cutoff or TR4 below size cutoff, Positive Test Meaning TR5, TR4 Above Size Cutoff and TR3 Above Size Cutoff; negative test meaning TR1, TR2, TR3 below size threshold or TR4 below size cutoff. After repeat US-guided FNA, some patients achieve a cytological diagnosis, but typically two-thirds remain indeterminate [18], accounting for approximately 20% of initial FNAs (eg, 10%-30% [12], 31% [19], 22% [20]). I have some serious news about my thyroid nodules today. The financial cost depends on the health system involved, but as an example, in New Zealand where health care costs are modest by international standards in the developed world, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS would result in approximately NZ$140,000 spent for every additional patient correctly reassured that he or she does not have thyroid cancer [25]. The TIRADS reporting algorithm is a significant advance with clearly defined objective sonographic features that are simple to apply in practice. We have also estimated the likely costs associated with using the ACR TIRADS guidelines, though for simplicity have not included the costs of molecular testing for indeterminate nodules (which is not readily available in the New Zealand public health system) nor any US follow-up and associated costs. EU-TIRADS 1 category refers to a US examination where no thyroid nodule is found; there is no need for FNAB. The process of establishing of CEUS-TIRADS model. The equation was as follows: z = -2.862 + 0.581X1- 0.481X2- 1.435X3+ 1.178X4+ 1.405X5+ 0.700X6+ 0.460X7+ 0.648X8- 1.715X9+ 0.463X10+ 1.964X11+ 1.739X12. ; Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology. In a cost-conscious public health system, one could argue that after selecting out those patients that clearly raise concern for a high risk of cancer (ie, from history including risk factors, examination, existing imaging) the clinician could reasonably inform an asymptomatic patient that they have a 95% chance of their nodule being benign. Objective: To determine whether the size of thyroid nodules in ACR-TIRADS ultrasound categories 3 and 4 is correlated with the Bethesda cytopathology classification. Thyroid nodules - Symptoms and causes - Mayo Clinic These cutoffs are somewhat arbitrary, with conflicting data as to what degree, if any, size is a discriminatory factor. Unable to process the form. Mao S, Zhao LP, Li XH, Sun YF, Su H, Zhang Y, Li KL, Fan DC, Zhang MY, Sun ZG, Wang SC. Only a small percentage of thyroid nodules are cancerous. First, 10% of FNA or histology results were excluded because of nondiagnostic findings [16]. [The diagnostic performance of 2020 Chinese Ultrasound Thyroid Imaging Reporting and Data System in thyroid nodules]. Cao H, Fan Q, Zhuo S, Qi T, Sun H, Rong X, Xiao X, Zhang W, Zhu L, Wang L. J Ultrasound Med. Diagnostic approach to and treatment of thyroid nodules. The ACR TIRADS white paper [22] very appropriately notes that the recommendations are intended to serve as guidance and that professional judgment should be applied to every case including taking into account factors such as a patients cancer risk, anxiety, comorbidities, and life expectancy. ", the doctor would like to answer as follows: With the information you provided, you have a homophonic nucleus in the right lobe. To find 16 TR5 nodules requires 100 people to be scanned (assuming for illustrative purposes 1 nodule per scan). Thyroid Nodules. Bastin S, Bolland MJ, Croxson MS. Role of Ultrasound in the Assessment of Nodular Thyroid Disease. TI-RADS - Thyroid Imaging Reporting and Data System 2020 Chinese Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: The. The problem is that many people dont know that they have a thyroid nodule, so they dont know how to treat it. In CEUS analysis, it reflected as later arrival time, hypo-enhancement, heterogeneous and centripetal enhancement, getting a score of 4 in the CEUS model. 1. This site needs JavaScript to work properly. Tessler FN, Middleton WD, Grant EG, et al. For this, we do not take in to account nodule size because size is not a factor in the ACR TIRADS guidelines for initial FNA in the TR1 and TR2 categories (where FNA is not recommended irrespective of size) or in the TR5 category (except in TR5 nodules of0.5 cm to<1.0 cm, in which case US follow-up is recommended rather than FNA). Your health care provider will examine your neck to feel for changes in your thyroid, such as a lump (nodule) in the thyroid. TIRADS 6: category included biopsy proven malignant nodules. The ACR-TIRADS guidelines also provide easy-to-follow management recommendations that have understandably generated momentum. But the test that really lets you see a nodule up close is a CT scan. Conclusions: Recently, the American College of Radiology (ACR) proposed a Thyroid Imaging Reporting and Data System (TI-RADS) for thyroid nodules based on ultrasonographic features. The test that really lets you see a nodule up close is a CT scan. Given that a proportion of thyroid cancers are clinically inconsequential, the challenge is finding a test that can effectively rule-in or rule-out important thyroid cancer (ie, those cancers that will go on to cause morbidity or mortality). PMC The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 100 nodules in the validation cohort. The truth is, most of us arent so lucky as to be diagnosed with all forms of thyroid cancer, but we do live with the results of it. Copyright 2022 Zhu, Chen, Zhou, Ma and Huang. Tom James Cawood, Georgia Rose Mackay, Penny Jane Hunt, Donal OShea, Stephen Skehan, Yi Ma, TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance, Journal of the Endocrine Society, Volume 4, Issue 4, April 2020, bvaa031, https://doi.org/10.1210/jendso/bvaa031. If a patient was happy taking this small risk (and particularly if the patient has significant comorbidities), then it would be reasonable to do no further tests, including no US, and instead do some safety netting by advising the patient to return if symptoms changed (eg, subsequent clinically apparent nodule enlargement). Clipboard, Search History, and several other advanced features are temporarily unavailable. Whilst our findings have illustrated some of the shortcomings of ACR TIRADS guidelines, we are not able to provide the ideal alternative. Thyroid imaging reporting and data system (TI-RADS)refers to any of several risk stratification systems for thyroid lesions, usually based on ultrasound features, with a structure modelled off BI-RADS. For every 100 FNAs performed, about 30 are inconclusive, with most (eg, 20% of the original 100) remaining indeterminate after repeat FNA and requiring diagnostic hemithyroidectomy. A minority of these nodules are cancers. A systematic autopsy study, The incidence of thyroid cancer by fine needle aspiration varies by age and gender, Thyroid cancer in the thyroid nodules evaluated by ultrasonography and fine-needle aspiration cytology, Comparison of 5-tiered and 6-tiered diagnostic systems for the reporting of thyroid cytopathology: a multi-institutional study.
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