Thyroid Ultrasonography and Fine Needle Aspiration Biopsy: A Practical Guide and Picture Atlas

Clinical Management of Thyroid Nodules

Author(s): Samer El-Kaissi and Jack R Wall

Pp: 58-62 (5)

DOI: 10.2174/9781681086859118010008

* (Excluding Mailing and Handling)

Abstract

The management of thyroid nodules begins with a detailed ultrasound examination to document the size and ultrasound features of the nodule and thereby determine the risk malignancy. In hyperthyroid patients, a thyroid scintigram is important as the great majority of hyperfunctioning thyroid nodules are benign. Depending on the ultrasound pattern and size of the nodule, FNA biopsy may be clinically indicated to exclude malignancy. A benign FNA biopsy completes the diagnostic workup, however ongoing monitoring and repeat FNA biopsy may be warranted in nodules displaying a high suspicion of malignancy on ultrasound. Nondiagnostic nodules should undergo repeat FNA biopsy under ultrasound guidance and if persistently non-diagnostic, management options include observation of very low to low-suspicion nodules and thyroid surgery for nodules with an intermediate or high suspicion pattern on ultrasound. Indeterminate nodules (Bethesda III, IV and V) require further diagnostic workup and/or thyroidectomy. While Bethesda IV and V nodules are primarily treated surgically, our approach is to repeat the FNA biopsy with/without molecular testing for Bethesda III nodules and to consider ongoing observation or thyroid surgery for persistently indeterminate nodules, depending on the sonographic and cytological suspicion of malignancy. Cytologically malignant nodules are also referred for thyroidectomy. The extent of thyroid surgery depends on the size of the thyroid nodule, the patient’s clinical risk factors for thyroid malignancy, the risk of extra-thyroidal extension and patient preference.


Keywords: Atypia of undetermined significance, Benign cytology, Bethesda system for reporting thyroid cytopathology, Core-needle biopsy, FNA biopsy, Follicular lesion of undetermined significance, Follicular neoplasm, Indeterminate cytology, Non-diagnostic cytology, Suspicious for malignancy, Thyroid nodule, Thyroid malignancy, Thyroid nodule molecular testing, Thyroidectomy, Thyroid nodule growth, Thyroid nodule follow-up.

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      • 13. app/Models/UserAccess/UserAccess.php:1266
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      • 16. vendor/laravel/framework/src/Illuminate/Routing/ControllerDispatcher.php:43
      • 17. vendor/laravel/framework/src/Illuminate/Routing/Route.php:260
    • (select j.user_access_id,j.volume_id,j.user_id,j.from_ip,j.to_ip,j.type,j.track,"Trial Access" as access_base_text, CASE j.type WHEN 111 THEN true ELSE false END as terms_popup, "S" as content_download_type, null as restricted_user_access_key, null as restricted_user_access_type, CASE j.track WHEN 0 THEN false ELSE true END as tracksAccessByVolume,"chapter" as access_level, j.chapter_id from `user_access_chapter_trail` as `j` inner join `user_access_info` as `info` on `j`.`user_access_id` = `info`.`user_access_id` where ((j.from_ip <= 59776939 and j.to_ip >=59776939 )) and ((j.from_date <= 1740776237 and j.to_date >= 1740776237 and j.perpetual= 0) or (j.from_date is null and j.to_date is null and j.perpetual= 1)) and j.chapter_id = 12817) union (select j.user_access_id,j.volume_id,j.user_id,j.from_ip,j.to_ip,j.type,j.track,"Subscribed" as access_base_text, false as terms_popup, "S" as content_download_type, null as restricted_user_access_key, null as restricted_user_access_type, CASE j.track WHEN 0 THEN false ELSE true END as tracksAccessByVolume,"chapter" as access_level, j.chapter_id from `user_access_chapter_corporate` as `j` inner join `user_access_info` as `info` on `j`.`user_access_id` = `info`.`user_access_id` where ((j.from_ip <= 59776939 and j.to_ip >=59776939 )) and ((j.from_date <= 1740776237 and j.to_date >= 1740776237 and j.perpetual= 0) or (j.from_date is null and j.to_date is null and j.perpetual= 1)) and j.chapter_id = 12817) union (select j.user_access_id,j.volume_id,j.user_id,j.from_ip,j.to_ip,j.type,j.track,"Token Based Access" as access_base_text, false as terms_popup, "R" as content_download_type, j.uc_id as restricted_user_access_key, "v" as restricted_user_access_type, CASE j.track WHEN 0 THEN false ELSE true END as tracksAccessByVolume,"chapter" as access_level, j.chapter_id from `user_access_chapter_token` as `j` inner join `user_access_info` as `info` on `j`.`user_access_id` = `info`.`user_access_id` where ((j.from_ip <= 59776939 and j.to_ip >=59776939 )) and ((j.from_date <= 1740776237 and j.to_date >= 1740776237 and j.perpetual= 0) or (j.from_date is null and j.to_date is null and j.perpetual= 1)) and j.chapter_id = 12817)
      16.43msalphaeurekaselec_live_10_06_2022UserAccess.php#1266
      Backtrace
      • 13. app/Models/UserAccess/UserAccess.php:1266
      • 14. app/Http/Controllers/ChapterController.php:1549
      • 15. vendor/laravel/framework/src/Illuminate/Routing/Controller.php:54
      • 16. vendor/laravel/framework/src/Illuminate/Routing/ControllerDispatcher.php:43
      • 17. vendor/laravel/framework/src/Illuminate/Routing/Route.php:260
    • select b.banner_link, b.banner_name, b.banner_script, b.banner_remarks, b.banner_file_name, b.banner_placement, bd.content_type, bd.content_id from `tbl_banner` as `b` inner join `tbl_banner_detail` as `bd` on `bd`.`banner_id` = `b`.`banner_id` inner join `users` as `u` on `u`.`id` = `b`.`updated_by` where `b`.`banner_ebook` = 1 and `bd`.`content_type` = 'B' and `bd`.`content_id` = 2636 and `b`.`banner_from_date` <= 1740776237 and `b`.`banner_to_date` >= 1740776237 and `b`.`banner_status` = 'A' order by `b`.`banner_id` desc
      1.51msalphaeurekaselec_live_10_06_2022Banner.php#95
      Bindings
      • 0: 1
      • 1: B
      • 2: 2636
      • 3: 1740776237
      • 4: 1740776237
      • 5: A
      Backtrace
      • 13. app/Models/Banner.php:95
      • 14. app/Http/helpers.php:404
      • 17. vendor/laravel/framework/src/Illuminate/Filesystem/Filesystem.php:124
      • 18. vendor/laravel/framework/src/Illuminate/View/Engines/PhpEngine.php:58
      • 19. vendor/laravel/framework/src/Illuminate/View/Engines/CompilerEngine.php:73
    • select count(*) as aggregate from `uc_cart_products` where cart_id='de8bdf98ad84cb64d0083e025a16f408'
      300μsalphaeurekaselec_live_10_06_2022Cart.php#271
      Backtrace
      • 15. app/Models/Cart.php:271
      • 16. view::layouts._header:291
      • 18. vendor/laravel/framework/src/Illuminate/Filesystem/Filesystem.php:124
      • 19. vendor/laravel/framework/src/Illuminate/View/Engines/PhpEngine.php:58
      • 20. vendor/laravel/framework/src/Illuminate/View/Engines/CompilerEngine.php:73
    App\Models\Keywords
    16Keywords.php#?
    App\Models\Chapter
    1Chapter.php#?
    App\Models\Ebook
    1Ebook.php#?
        _token
        coadAubIrwBbrquX7waxGBmjS0DSpcoKAgcYgVKB
        uc_cart_id
        de8bdf98ad84cb64d0083e025a16f408
        _previous
        array:1 [ "url" => "https://alpha.eurekaselect.com/chapter/12817" ]
        _flash
        array:2 [ "old" => [] "new" => [] ]
        PHPDEBUGBAR_STACK_DATA
        []
        path_info
        /chapter/12817
        status_code
        200
        
        status_text
        OK
        format
        html
        content_type
        text/html; charset=UTF-8
        request_query
        []
        
        request_request
        []
        
        request_headers
        0 of 0
        array:17 [ "x-https" => array:1 [ 0 => "1" ] "host" => array:1 [ 0 => "alpha.eurekaselect.com" ] "priority" => array:1 [ 0 => "u=0, i" ] "cookie" => array:1 [ 0 => "wayfindertarget=eyJpdiI6InBPdVV2VTRDWUt1Zzc4bk9kNFM4UFE9PSIsInZhbHVlIjoiQ1ZnQXAweHNwRnlFTXNDNWlYd0ZSb0JmdjNXTnJ1OTg3YXZHaWtFVG96RT0iLCJtYWMiOiI4M2I4YzlkZGE5YzIwOTc1YTAyMDQ1NzZlMzQ4YTZkM2Q0YzMwODdhNjYwNTZmYzVjOGFhOWVlMzUyMzQxNTJiIiwidGFnIjoiIn0%3Dwayfindertarget=eyJpdiI6InBPdVV2VTRDWUt1Zzc4bk9kNFM4UFE9PSIsInZhbHVlIjoiQ1ZnQXAweHNwRnlFTXNDNWlYd0ZSb0JmdjNXTnJ1OTg3YXZHaWtFVG96RT0iLCJtYWMiOiI4M2I4YzlkZGE5YzIw" ] "accept-encoding" => array:1 [ 0 => "gzip, deflate, br, zstd" ] "sec-fetch-dest" => array:1 [ 0 => "document" ] "sec-fetch-user" => array:1 [ 0 => "?1" ] "sec-fetch-mode" => array:1 [ 0 => "navigate" ] "sec-fetch-site" => array:1 [ 0 => "none" ] "accept" => array:1 [ 0 => "text/html,application/xhtml+xml,application/xml;q=0.9,image/avif,image/webp,image/apng,*/*;q=0.8,application/signed-exchange;v=b3;q=0.7" ] "user-agent" => array:1 [ 0 => "Mozilla/5.0 AppleWebKit/537.36 (KHTML, like Gecko; compatible; ClaudeBot/1.0; +claudebot@anthropic.com)" ] "upgrade-insecure-requests" => array:1 [ 0 => "1" ] "sec-ch-ua-platform" => array:1 [ 0 => ""Windows"" ] "sec-ch-ua-mobile" => array:1 [ 0 => "?0" ] "sec-ch-ua" => array:1 [ 0 => ""HeadlessChrome";v="129", "Not=A?Brand";v="8", "Chromium";v="129"" ] "cache-control" => array:1 [ 0 => "no-cache" ] "pragma" => array:1 [ 0 => "no-cache" ] ]
        request_cookies
        0 of 0
        array:1 [ "wayfindertarget" => null ]
        response_headers
        0 of 0
        array:5 [ "content-type" => array:1 [ 0 => "text/html; charset=UTF-8" ] "cache-control" => array:1 [ 0 => "no-cache, private" ] "date" => array:1 [ 0 => "Fri, 28 Feb 2025 20:57:17 GMT" ] "set-cookie" => array:2 [ 0 => "XSRF-TOKEN=eyJpdiI6IjVoanE0QjNOZmNzQk8xd01IMkJPTnc9PSIsInZhbHVlIjoibjRSRWl5SzVDMmlxZnFWRTU1eVFnL21RNU1YL1dKbE5EdVJXYU9TQ3JwZHRmVGxsUkJVOXBWTUhUNGtQaGNBQ3BXK2djMytDTmRlcTRkdTd0eFhwV1cxQnhtNjByRVdiUlpqZU43bUJZUUpVNTkwc0lqdW5xeTg4VEVYQXFiMmkiLCJtYWMiOiJlYWJiYjAwNjg3NTgxNmUyNDc2OGIxZjAwOWM3NDZmZDgwOTVkMmNlNTAzYjU4NTg3OWE2MGExOTc4M2EyYmYxIiwidGFnIjoiIn0%3D; expires=Mon, 03 Mar 2025 08:57:17 GMT; Max-Age=216000; path=/; secure; samesite=laxXSRF-TOKEN=eyJpdiI6IjVoanE0QjNOZmNzQk8xd01IMkJPTnc9PSIsInZhbHVlIjoibjRSRWl5SzVDMmlxZnFWRTU1eVFnL21RNU1YL1dKbE5EdVJXYU9TQ3JwZHRmVGxsUkJVOXBWTUhUNGtQaGNBQ3BXK2djM" 1 => "alphaeurekaselectnet_session=eyJpdiI6InllVDg0djkyMzk5ZkpZL3ZxRFVkNFE9PSIsInZhbHVlIjoiUkwxNzM2SmZ3WEpndCtaRndDakJmQ1B5S2l5QmNKSmlVcmQwSnI2YzdnY1FPTXF4SXh6K0ZXMVFOSDNoSnM3Ym4wcHRZbFRJQnhDdTV0d294WTVMbjRMbEhnRnNlTUVlaURmTlcyNzZ0WEJzY3ppSWNkdVlFMTcrbWNuRGp1RTQiLCJtYWMiOiI0NmIwNzQxNDY1ZDFhYWMxMTBiNzIxNjE1NDQzNWQxZjVjODQxNWE5NGExODc2YTU4ZTgwMGViY2QwZWY2NTM5IiwidGFnIjoiIn0%3D; path=/; secure; httponly; samesite=laxalphaeurekaselectnet_session=eyJpdiI6InllVDg0djkyMzk5ZkpZL3ZxRFVkNFE9PSIsInZhbHVlIjoiUkwxNzM2SmZ3WEpndCtaRndDakJmQ1B5S2l5QmNKSmlVcmQwSnI2YzdnY1FPTXF4SXh6K0ZXMVF" ] "Set-Cookie" => array:2 [ 0 => "XSRF-TOKEN=eyJpdiI6IjVoanE0QjNOZmNzQk8xd01IMkJPTnc9PSIsInZhbHVlIjoibjRSRWl5SzVDMmlxZnFWRTU1eVFnL21RNU1YL1dKbE5EdVJXYU9TQ3JwZHRmVGxsUkJVOXBWTUhUNGtQaGNBQ3BXK2djMytDTmRlcTRkdTd0eFhwV1cxQnhtNjByRVdiUlpqZU43bUJZUUpVNTkwc0lqdW5xeTg4VEVYQXFiMmkiLCJtYWMiOiJlYWJiYjAwNjg3NTgxNmUyNDc2OGIxZjAwOWM3NDZmZDgwOTVkMmNlNTAzYjU4NTg3OWE2MGExOTc4M2EyYmYxIiwidGFnIjoiIn0%3D; expires=Mon, 03-Mar-2025 08:57:17 GMT; path=/; secureXSRF-TOKEN=eyJpdiI6IjVoanE0QjNOZmNzQk8xd01IMkJPTnc9PSIsInZhbHVlIjoibjRSRWl5SzVDMmlxZnFWRTU1eVFnL21RNU1YL1dKbE5EdVJXYU9TQ3JwZHRmVGxsUkJVOXBWTUhUNGtQaGNBQ3BXK2djM" 1 => "alphaeurekaselectnet_session=eyJpdiI6InllVDg0djkyMzk5ZkpZL3ZxRFVkNFE9PSIsInZhbHVlIjoiUkwxNzM2SmZ3WEpndCtaRndDakJmQ1B5S2l5QmNKSmlVcmQwSnI2YzdnY1FPTXF4SXh6K0ZXMVFOSDNoSnM3Ym4wcHRZbFRJQnhDdTV0d294WTVMbjRMbEhnRnNlTUVlaURmTlcyNzZ0WEJzY3ppSWNkdVlFMTcrbWNuRGp1RTQiLCJtYWMiOiI0NmIwNzQxNDY1ZDFhYWMxMTBiNzIxNjE1NDQzNWQxZjVjODQxNWE5NGExODc2YTU4ZTgwMGViY2QwZWY2NTM5IiwidGFnIjoiIn0%3D; path=/; secure; httponlyalphaeurekaselectnet_session=eyJpdiI6InllVDg0djkyMzk5ZkpZL3ZxRFVkNFE9PSIsInZhbHVlIjoiUkwxNzM2SmZ3WEpndCtaRndDakJmQ1B5S2l5QmNKSmlVcmQwSnI2YzdnY1FPTXF4SXh6K0ZXMVF" ] ]
        session_attributes
        0 of 0
        array:5 [ "_token" => "coadAubIrwBbrquX7waxGBmjS0DSpcoKAgcYgVKB" "uc_cart_id" => "de8bdf98ad84cb64d0083e025a16f408" "_previous" => array:1 [ "url" => "https://alpha.eurekaselect.com/chapter/12817" ] "_flash" => array:2 [ "old" => [] "new" => [] ] "PHPDEBUGBAR_STACK_DATA" => [] ]
        ClearShow all
        Date ↕MethodURLData
        #12025-02-28 20:57:17GET/chapter/128171121918