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Case-based discussion: Pailin Kongmebhol, M.D. Department of Radiology Faculty of Medicine Chiang Mai University

There are many guidelines for managing thyroid nodules Two important guidelines: 2015 American Thyroid Association (ATA) management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer American College of Radiology (ACR) Thyroid Imaging, Reporting and Data System (TI-RADS)

ATA nodule sonographic pattern From 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. In: Thyroid 2016; 26: 1-133.

High suspicion From 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. In: Thyroid 2016; 26: 1-133.

Intermediate suspicion From 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. In: Thyroid 2016; 26: 1-133.

Low suspicion *Eccentric uniformly solid area From 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. In: Thyroid 2016; 26: 1-133.

Very low suspicion >50% multiple microcysts Cysts that are not meet criteria for high, intermediate or low suspicion From 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. In: Thyroid 2016; 26: 1-133.

Benign From 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. In: Thyroid 2016; 26: 1-133.

From 2015 American Thyroid Association Management Guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. In: Thyroid 2016; 26: 1-133.

From ACR Thyroid Imaging, reporting and data system (TI-RADS): White paper of the ACR TI- RADS Committee. In: J Am Coll Radiol 2017; 14:587-95

Composition* Cystic or almost completely cystic Spongiform#: Composed predominantly (> 50 %) of small cystic spaces. Mixed cystic and solid: predominant solid component Solid or almost completely solid, Composition cannot be determined because of calcification. 0 point 0 point 1 point 2 points #Do not add further points for other categories *From ACR Thyroid Imaging, reporting and data system (TI-RADS): White paper of the ACR TI- RADS Committee. In: J Am Coll Radiol 2017; 14:587-95.

Echogenicity* Anechoic Cystic or almost completely cystic Hyperechoic or isoechoic Compare to thyroid parenchyma Hypoechoic Compare to thyroid parenchyma Very hypoechoic Compare to strap muscles Cannot be determine 0 point 1 point 2 points 3 points 1 point *From ACR Thyroid Imaging, reporting and data system (TI-RADS): White paper of the ACR TI- RADS Committee. In: J Am Coll Radiol 2017; 14:587-95.

Shape* Wider than tall Taller than wide 0 point 3 points -Assessed on transverse image, measurement parallel (height) and parallel (width) to the US beam ***Do not confuse with size measurement*** - Size measurement: 3 axes - Maximum dimension on axial image+ perpendicular dimension - Maximum dimension on sagittal image *From ACR Thyroid Imaging, reporting and data system (TI-RADS): White paper of the ACR TI- RADS Committee. In: J Am Coll Radiol 2017; 14:587-95.

A Taller than wide assessment: A>B B Size measurement: C x D x E C D E

Margin* Smooth Ill-defined Margin cannot be well separated from surrounding parenchyma Lobulated Protusion into adjacent tissue Irregular Jagged, spiculated, sharp angles Extra-thyroid extension Margin cannot be determined 0 point 0 point 2 points 2 points 3 points 0 point *From ACR Thyroid Imaging, reporting and data system (TI-RADS): White paper of the ACR TI- RADS Committee. In: J Am Coll Radiol 2017; 14:587-95.

Echogenic foci* #Choose all that apply# None or large comet tail artifacts V-shaped > 1 mm in cystic components Macrocalcifications Cause acoustic shadowing Peripheral (rim) calcifications Complete or incomplete along margin Peripheral Punctate echogenic foci May have small comet tail artifacts 0 point 1 point 2 points 3 points *From ACR Thyroid Imaging, reporting and data system (TI-RADS): White paper of the ACR TI-RADS Committee. In: J Am Coll Radiol 2017; 14:587-95.

From ACR Thyroid Imaging, reporting and data system (TI-RADS): White paper of the ACR TI- RADS Committee. In: J Am Coll Radiol 2017; 14:587-95

Case 1

Female 54 yrs old History of thyroid nodules for 4 years P.E. : thyroid gland just palpable Request US thyroid for follow up (no prior US available)