Puneet Bhargava MD 1 Adeel Seyal MD 2 Chandana Lall MD 3 Sadhna Verma MD 4 Nicholas Bodmer MD 5 Sarah Bastawrous

1. Management of Thyroid Nodules and Thyroid Cancer: A Curriculum Based on American Thyroid Association Guidelines with Bethesda System of Reporting Thyroid Cytopathology Correlation Puneet Bhargava MD1 Adeel Seyal MD2 Chandana Lall MD3 SadhnaVerma MD4 Nicholas BodmerMD5 Sarah BastawrousMD1 Mariam Moshiri MD5 ManjiriDigheMD5 bhargp@uw.edu 1 Department of Radiology, University of Washington School of Medicine & VA Puget Sound HCS, Seattle WA 2 Department of Internal Medicine, Harrison Medical Center, Bremerton WA 3 Department of Radiology, University of California, Irvine CA 4 Department of Radiology, University of Cincinnati, OH 5 Department of Radiology, University of Washington School of Medicine

2. Disclosure None of the authors have a financial relationship with a commercial organization that may have a direct or indirect interest in the content

3. Pre-requisites • We suggest reading the following review articles before viewing the teaching file for better understanding of the recommendations discussed in this presentation • American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and DifferentiatedThyroidCancer. Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009 Nov;19(11):1167-214. doi: 10.1089/thy.2009.0110. [Link] • Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. The Bethesda System For ReportingThyroidCytopathology. Am J ClinPathol. 2009 Nov;132(5):658-65. doi: 10.1309/AJCPPHLWMI3JV4LA. [Link]

4. Goals and objectives • The aim of this presentation is to help radiologists, radiologists in training and endocrinologists learn appropriate recommendations based on revised American Thyroid Association (ATA) guidelines on thyroid nodules and differentiated thyroid cancer • Criteria for fine needle aspiration (FNA) of thyroid nodules in a quiz format according to ATA guidelines are reviewed • We discuss the interpretation of FNA results and briefly review the management of differentiated thyroid cancer

5. US and Clinical Features of Thyroid Nodules and Recommendations for FNA cytology The American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009 Nov;19(11):1167-214. Reproduced with permission.

6. The Bethesda System for Reporting Thyroid Cytopathology: Recommended Diagnostic Categories Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. The Bethesda System For Reporting Thyroid Cytopathology. Am J ClinPathol. 2009 Nov;132(5):658-65. Reproduced with permission.

7. The Bethesda System for Reporting Thyroid Cytopathology: Implied Risk of Malignancy and Recommended Clinical Management Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. The Bethesda System For Reporting Thyroid Cytopathology. Am J ClinPathol. 2009 Nov;132(5):658-65. Reproduced with permission.

8. High-risk category nodules • History of thyroid cancer in one or more first degree relatives • History of external beam radiation as a child • Exposure to ionizing radiation in childhood or adolescence • Prior hemithyroidectomy with discovery of thyroid cancer • 18FDG avidity on PET scanning • Multiple endocrine neoplasia (MEN) 2/Familial medullary thyroid cancer (FMTC)-associated RET protooncogene mutation • Calcitonin >100 pg/ml

9. Suspicious US features • Microcalcifications • Hypoechoic nodule • Increased nodular vascularity • Infiltrative margins • Taller than wide • Suspicious cervical lymphadenopathy

10. Suspicious US features – Microcalcifications Microcalcifications– highly specific for papillary thyroid cancer

11. Suspicious US features – Hypoechoic nodule Hypoechogenicity – raises the suspicion for malignancy

12. Suspicious US features – Increased vascularity Intranodular vascularity – suspicious for malignancy (neovascularity)

13. Suspicious US features – Irregular infiltrative margins Irregular infiltrative margin – feature of aggressiveness

14. Suspicious US features – Taller than wide morphology Taller than wide morphology (in the transverse dimension)

15. Suspicious US features – Suspicious cervical lymphadenopathy • Suspicious cervical lymphadenopathy (excluding submandibular lymph nodes) • - Specific but insensitive finding to help identify malignant nodules • Heterogeneous echotexture, loss of fatty hilum, calcifications, cystic change, and peripheral vascularity. • Rounded lymph node or one causing mass effect • Size is less reliable but lymph nodes >7 mm in short axis are suspicious

16. Management of Differentiated Thyroid Cancer (DTC) • DTC (papillary and follicular cancers) comprise of about 90% of thyroid cancers • If the biopsy is diagnostic of malignancy then initial surgical procedure should be near-total or total thyroidectomy for thyroid cancers >1 cm unless there are contraindications (Recommendation A) • For patients with clinically involved central or lateral neck lymph nodes therapeutic central-compartment neck dissection should be performed with total thyroidectomy to clear the disease from the neck (Recommendation B)

17. DTC – Role of TSH suppression therapy • DTC expresses TSH receptors on the cell membranes and therefore increases the expression of several proteins and cellular growth in response to TSH stimulation • For high-risk and intermediate-risk thyroid cancer patients initial TSH suppression should be below 0.1 mU/L. For low-risk patients, it is recommended to maintain TSH at or slightly below the normal limits (0.1-0.5 mU/L) (Recommendation B) • Low-risk patients who have not had remnant ablation, TSH should be maintained at or slightly below the normal limits (0.1-0.5 mU/L) (Recommendation B)

18. DTC – Role of radioactive iodine (RAI) remnant ablation • RAI remnant ablation is recommended for patients with known distant metastases, gross extrathyroidal extension of the tumor regardless of tumor size, or primary tumor size >4 cm even in the absence of other higher risk features • It is not recommended to perform RAI ablation in patients with unifocal cancer <1 cm in the absence of other higher risk features (Recommendation E) • It is not recommended to perform RAI ablation in patients with multifocal cancer when all foci are <1 cm in the absence of other higher risk features (Recommendation E)

19. Major factors impacting decision making in Radioiodine Remnant Ablation a Because of either conflicting or inadequate data, ATA cannot recommend either for or against RAI ablation for this entire subgroup The American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009 Nov;19(11):1167-214. Reproduced with permission.

20. Quiz: Nodule 1 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 1 Recommendation: Perform FNA cytology Explanation • US shows mixed cystic-solid nodule • ATA guidelines recommend FNA for thyroid nodule ≥2.0 cm if there are no sonographic features suspicious for malignancy (Recommendation C) Pathology Follicular lesion, low to intermediate probability of neoplasm. Also called Follicular Lesion of Undetermined Significance (FLUS). Mixed solid-cystic 3.5 cm thyroid nodule Management • Check TSH in the initial evaluation of a patient with thyroid nodule (Recommendation A) • A low or low-normal TSH may suggest the presence of autonomous nodule. A 99mTc Pertechnetate or 123I scan should be performed and correlated with US findings to determine nodule functionality of nodule >1-1.5 cm. FNA should be considered for iso- to nonfunctioning nodules, especially those with suspicious US features. (Recommendation B) • If the cytology reports a follicular neoplasm then consider 123I thyroid scan, especially if the serum TSH is in the low-normal range. If no concordant autonomously functioning nodule is seen, lobectomy or total thyroidectomy is considered (Recommendation C) • Bethesda system recommends repeat FNA for FLUS lesions. In most cases a more definitive interpretation results; only 20% of nodules are reclassified FLUS.

21. Quiz: Nodule 2 Evaluate the features of this lymph node and comment if FNA is needed or not? Answer: Nodule 2 Recommendation: Perform FNA cytology Explanation • US neck is highly sensitive in detecting cervical metastases in patients with DTC • Suspicious lymph nodes greater than 5-8 mm in the short axis diameter should be biopsied for cytology with thyroglobulin measurement in the needle washout fluid (Recommendation A) Cervical lymph node measuring 0.9 x 1.9 cm in a patient with DTC after surgery

22. Quiz: Nodule 3 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 3 Recommendation: DO NOT perform FNA cytology Explanation • US shows spongiform appearance • This appearance is 99.7% specific for identification of a benign thyroid nodule • According to ATA guidelines FNA cytology is recommended for a spongiform nodule ≥2.0 cm (Recommendation C) Thyroid nodule measuring 1.7 cm in the greatest diameter Comparison with Society of Radiologists in Ultrasound (SRU) guidelines • SRU does not consider spongiform nodule as a separate entity and considers it as mixed cystic-solid nodules recommending FNA cytology for nodules ≥2.0 cm

23. Quiz: Nodule 4 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 4 Recommendation: Perform FNA cytology Explanation • US shows punctate hyperechoic foci consistent with microcalcifications • ATA guidelines recommend FNA in a thyroid nodule ≥1 cm if microcalcifications are present (Recommendation B) Pathology Papillary Thyroid Cancer (PTC) Thyroid nodule measuring 3.4 cm in the greatest diameter Management • If cytology result is diagnostic of or suspicious for PTC, surgery is recommended(Recommendation A) Note: Microcalcifications, if present, are highly specific for PTC, but may be difficult to distinguish from colloid. Although most micropapillary carcinomas may be incidental findings, a subset may be more clinically relevant, especially those >5mm in diameter. These nodules in high-risk populations and abnormal lymph nodes associated with these nodules should undergo FNA.

24. Quiz: Nodule 5 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 5 Recommendation: Perform FNA cytology Explanation • US shows a cystic-solid nodule with punctate hyperechoic foci consistent with microcalcifications • ATA recommends FNA in a cystic-solid thyroid nodule ≥1.5-2 cm if suspicious ultrasound features are present (Recommendation B) Pathology Follicular lesion; low probability of neoplasm. Also called Follicular Lesion of Undetermined Significance (FLUS). Thyroid nodule measuring 2cm in the greatest dimension Management • Check TSH in the initial evaluation of a patient with thyroid nodule (Recommendation A) • A low or low-normal TSH may suggest the presence of autonomous nodule. A 99mTc Pertechnetate or 123I scan should be performed and correlated with US findings to determine nodule functionality of nodule >1-1.5 cm. FNA should be considered for iso- to nonfunctioning nodules, especially those with suspicious US features. (Recommendation B) • If the cytology reports a follicular neoplasm then consider 123I thyroid scan, especially if the serum TSH is in the low-normal range. If no concordant autonomously functioning nodule is seen, lobectomy or total thyroidectomy is considered (Recommendation C) • Bethesda system recommends repeat FNA for FLUS lesions. In most cases a more definitive interpretation results; only 20% of nodules are reclassified FLUS. Note: Microcalcifications, if present, are highly specific for PTC, but may be difficult to distinguish from colloid. Although most micropapillary carcinomas may be incidental findings, a subset may be more clinically relevant, especially those >5mm in diameter. These nodules in high-risk populations and abnormal lymph nodes associated with these nodules should undergo FNA.

25. Quiz: Nodule 6 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 6 Recommendation: DO NOT perform FNA cytology unless patient is high-risk or these are abnormal neck lymph nodes Explanation • US shows a subcentimeter thyroid nodule with multiple microcalcifications • ATA guidelines recommend FNA for nodules with microcalcifications if their size is ≥1 cm (Recommendation B) Pathology Papillary Thyroid Cancer (PTC) Thyroid nodule measuring 0.8 cm in the greatest dimension Role of FNA in subcentimeter thyroid nodules • After imaging a subcentimeter nodule with a suspicious appearance, US examination for lateral and central neck lymph nodes should be performed • Detection of an abnormal lymph node should lead to FNA of the lymph node

26. Quiz: Nodule 7 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 7 Recommendation: Perform FNA cytology Explanation • US shows a solid nodule with a single macrocalcification and multiple microcalcifications. • ATA guidelines recommend to perform FNA in nodules with microcalcifications if size is ≥1 cm (Recommendation B) Pathology Follicular neoplasm Thyroid nodule measuring 1.4 cm in the greatest dimension Management • If cytology result is diagnostic of or suspicious for follicular neoplasm, surgery is recommended(Recommendation A) Note: Microcalcifications, if present, are highly specific for PTC, but may be difficult to distinguish from colloid. Although most micropapillary carcinomas may be incidental findings, a subset may be more clinically relevant, especially those >5mm in diameter. These nodules in high-risk populations and abnormal lymph nodes associated with these nodules should undergo FNA.

27. Quiz: Nodule 8 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 8 Recommendation: Perform FNA cytology Explanation • US shows a solid nodule with multiple macrocalcifications • ATA guidelines recommend FNA for solid nodules which are iso- or hyperechoic if the size is ≥1-1.5 cm (Recommendation C) Pathology Benign Thyroid nodule measuring 2.1 cm in the greatest dimension Management • If the nodule is benign on cytology, further immediate diagnostic studies or treatment are not routinely required (Recommendation A)

28. Quiz: Nodule 9 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 9 Recommendation: Perform FNA cytology Explanation • US shows a solid nodule without any calcifications • ATA guidelines recommend FNA for iso- or hyperechoic nodule if the size is ≥1-1.5 cm (Recommendation C) Pathology Follicular lesion, low to intermediate probability of neoplasm. Also called Follicular Lesion of Undetermined Significance (FLUS). Thyroid nodule measuring 1.2 cm in the greatest dimension Management • Check TSH in the initial evaluation of a patient with thyroid nodule (Recommendation A) • A low or low-normal TSH may suggest the presence of autonomous nodule. A 99mTc Pertechnetate or 123I scan should be performed and correlated with US findings to determine nodule functionality of nodule >1-1.5 cm. FNA should be considered for iso- to nonfunctioning nodules, especially those with suspicious US features. (Recommendation B) • If the cytology reports a follicular neoplasm then consider 123I thyroid scan, especially if the serum TSH is in the low-normal range. If no concordant autonomously functioning nodule is seen, lobectomy or total thyroidectomy is considered (Recommendation C) • Bethesda system recommends repeat FNA for FLUS lesions. In most cases a more definitive interpretation results; only 20% of nodules are reclassified FLUS.

29. Quiz: Nodule 10 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 10 Recommendation: Perform FNA cytology Explanation • US shows a solid nodule without any calcifications • ATA guidelines recommend FNA in solid hypoechoic nodules if their size is >1 cm (Recommendation B) Pathology Follicular lesion, low to intermediate probability of neoplasm. Also called Follicular Lesion of Undetermined Significance (FLUS). Thyroid nodule measuring 1.4 cm in the greatest dimension Management • Check TSH in the initial evaluation of a patient with thyroid nodule (Recommendation A) • A low or low-normal TSH may suggest the presence of autonomous nodule. A 99mTc Pertechnetate or 123I scan should be performed and correlated with US findings to determine nodule functionality of nodule >1-1.5 cm. FNA should be considered for iso- to nonfunctioning nodules, especially those with suspicious US features. (Recommendation B) • If the cytology reports a follicular neoplasm then consider 123I thyroid scan, especially if the serum TSH is in the low-normal range. If no concordant autonomously functioning nodule is seen, lobectomy or total thyroidectomy is considered (Recommendation C) • Bethesda system recommends repeat FNA for FLUS lesions. In most cases a more definitive interpretation results; only 20% of nodules are reclassified FLUS.

30. Quiz: Nodule 11 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 11 Recommendation: Perform FNA cytology Explanation • US shows a solid nodule without any calcifications. Color Doppler US shows predominantly peripheral vascularity and very little internal vascularity • Peripheral vascularity is not a suspicious feature ATA guidelines use internal vascularity as a suspicious feature in evaluating cystic-solid nodules and in patients with high-risk findings in their history • ATA guidelines recommend FNA in solid hypoechoic nodules if their size is >1 cm (Recommendation B) Thyroid nodule measuring 1.4 cm in the greatest dimension Pathology Follicular neoplasm Management • If cytology result is diagnostic of or suspicious for follicular neoplasm, surgery is recommended(Recommendation A)

31. Quiz: Nodule 12 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 12 Recommendation: DO NOT perform FNA cytology Explanation • US shows a mixed solid cystic nodule • ATA guidelines recommend FNA for mixed solid-cystic nodule without any suspicious sonographic features if the size is ≥2 cm (Recommendation C) Pathology Papillary thyroid carcinoma (PTC) Thyroid nodule measuring 1.8 cm in the greatest dimension Management • If cytology result is diagnostic of or suspicious for PTC, surgery is recommended(Recommendation A)

32. Quiz: Nodule 13 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 13 Recommendation: Perform FNA cytology Explanation • US shows a mixed solid cystic nodule with internal vascularity. Internal nodular vascularity is considered as a suspicious feature • ATA guidelines recommend FNA for mixed solid-cystic nodule with suspicious sonographic features like internal nodular vascularity if the size is ≥1.5-2 cm (Recommendation B) Pathology Thyroid nodule measuring 1.8 cm in the greatest dimension Papillary thyroid carcinoma (PTC) Management • If cytology result is diagnostic of or suspicious for PTC, surgery is recommended(Recommendation A)

33. Quiz: Nodule 14 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 14 Recommendation: Perform FNA cytology Explanation • US shows a mixed solid-cystic nodule which is predominantly cystic with a solid mural nodule • ATA guidelines recommend FNA for mixed solid-cystic nodule without any suspicious sonographic features if the size is ≥2 cm (Recommendation C) Pathology Follicular lesion with cystic degeneration. Also categorized as Follicular Lesion of Undetermined Significance (FLUS). Thyroid nodule measuring 2cm in the greatest dimension Management • Check TSH in the initial evaluation of a patient with thyroid nodule (Recommendation A) • A low or low-normal TSH may suggest the presence of autonomous nodule. A 99mTc Pertechnetate or 123I scan should be performed and correlated with US findings to determine nodule functionality of nodule >1-1.5 cm. FNA should be considered for iso- to nonfunctioning nodules, especially those with suspicious US features. (Recommendation B) • If the cytology reports a follicular neoplasm then consider 123I thyroid scan, especially if the serum TSH is in the low-normal range. If no concordant autonomously functioning nodule is seen, lobectomy or total thyroidectomy is considered (Recommendation C) • Bethesda system recommends repeat FNA for FLUS lesions. In most cases a more definitive interpretation results; only 20% of nodules are reclassified FLUS.

34. Quiz: Nodule 15 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 15 Recommendation: DO NOT perform FNA cytology Explanation • US shows an almost entirely cystic nodule without any solid areas • ATA guidelines recommend not to perform FNA in purely cystic nodule (Recommendation E) Thyroid nodule measuring 3.2 cm in the greatest dimension

35. Quiz: Nodule 16 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 16 Recommendation: DO NOT perform FNA cytology Explanation • US shows two purely cystic nodules • ATA guidelines recommend not to perform FNA in purely cystic nodule regardless of the size (Recommendation E) Two thyroid nodules measuring 0.4 cm and 0.3 cm in the greatest dimension

36. Quiz: Nodule 17 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 17 Recommendation: DO NOT perform FNA cytology Explanation • US shows two purely cystic nodules. Color Doppler ultrasound shows no internal vascularity • ATA guidelines recommend not to perform FNA in purely cystic nodule regardless of the size (Recommendation E) Two thyroid nodules measuring 0.4 cm and 0.3 cm in the greatest dimension There is a potential pitfall of misdiagnosing small hypoechoic solid nodules as cystic. Demonstrating lack of internal vascularity can prevent this.

37. Quiz: Nodule 18 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 18 Recommendation: DO NOT perform FNA cytology Explanation • US shows purely cystic nodule with small layering debris • ATA guidelines recommend not to perform FNA in purely cystic nodule regardless of the size (Recommendation E) Thyroid nodule measuring 4.1 cm in the greatest dimension Do not mistake layering debris for solid component. Lack of internal vascularity on Color Doppler can confirm cystic nature of the nodule.

38. Quiz: Nodule 19 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 19 Recommendation: DO NOT perform FNA cytology Explanation • US shows a solid nodule • ATA guidelines recommend FNA in solid hypoechoic nodules if their size is >1 cm (Recommendation B) and for solid iso- or hyperechoic nodules if their size is ≥1-1.5 cm (Recommendation C) Thyroid nodule measuring 0.8 cm in the greatest dimension

39. Quiz: Nodule 20 Evaluate the features of this nodule and comment if FNA is needed or not? Answer: Nodule 20 Recommendation: Perform FNA cytology Explanation • US shows growth in a solid nodule that was previously measured at 0.8 cm • ATA guidelines recommend FNA if there is evidence for nodule growth either by palpation or sonographically (Recommendation B) • Growth is defined by ATA as more than a 50% change in volume or a 20% increase in at least two nodule dimensions with a minimal increase of 2 mm in solid nodules or in the solid portion of mixed cystic-solid nodules • Benign thyroid nodules should be followed by serial ultrasound examinations 6-18 months after the initial FNA. If the nodule size is stable, the interval before the next follow-up clinical examination or US may be longer (Recommendation C) Thyroid nodule measuring 1.3 cm in the greatest dimension. One year ago it was 0.8 cm in the greatest dimension as shown in the previous slide (Nodule 19)

40. Summary • Thyroid nodules are common clinical problem • ATA recommendations assist radiologists and endocrinologists to appropriately manage thyroid nodules encountered in clinical practice • Our curriculum of carefully selected 20 scenarios will help us make prompt and appropriate management recommendations

41. Suggested reading • American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and DifferentiatedThyroid Cancer, Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM.Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009 Nov;19(11):1167-214. doi: 10.1089/thy.2009.0110. [Link] • Kim MJ, Kim EK, Park SI, Kim BM, Kwak JY, Kim SJ, Youk JH, Park SH. US-guided fine-needle aspiration of thyroid nodules: indications, techniques, results. Radiographics. 2008 Nov-Dec;28(7):1869-86; discussion 1887. doi: 10.1148/rg.287085033. [Link] • Hoang JK, Lee WK, Lee M, Johnson D, Farrell S. US Features of thyroid malignancy: pearls and pitfalls. Radiographics. 2007 May-Jun;27(3):847-60; discussion 861-5. [Link] • Kim EK, Park CS, Chung WY, Oh KK, Kim DI, Lee JT, Yoo HS. New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR Am J Roentgenol. 2002 Mar;178(3):687-91. [Link] • Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN; Society of Radiologists in Ultrasound. Management of thyroidnodulesdetected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2005 Dec;237(3):794-800. [Link] • Frates MC. Update on guidelines for management of thyroid nodules. Society of Radiologists in Ultrasound 2010; 20:4–5. • Bhargava P, Bodmer N, Dighe M. Management of thyroid nodules: A curriculum in a quiz format based on Society of Radiologists in Ultrasound guidelines. MedEDPORTAL; 2011. Available from: www.mededportal.org/publication/8467

42. References • American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and DifferentiatedThyroid Cancer, Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM.Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009 Nov;19(11):1167-214. doi: 10.1089/thy.2009.0110. [Link]

43. Comments and suggestions: bhargp@uw.edu