What are the guideline sources, guidelines and references for Thyroid nodules ?
Guideline sources The following summarized guidelines for the evaluation and management of thyroid nodules are prepared by our editorial team based on guidelines from the European Thyroid Association (ETA 2022; 2020), the American Association of Family Physicians (AAFP 2020), the American Thyroid Association (ATA 2017; 2016), the American College of Endocrinology (ACE/AME/AACE 2016), and the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2013). 1 2 3 4 5 6 7 Guidelines 1. Screening and diagnosis https://web.pathway.md/diseases/recMV0SAiK8dimU45 1/14 6/24/23, 4:07 PM Thyroid nodules Pathway Indications for screening: do not obtain screening ultrasound in the general population or patients with a normal thyroid on palpation and a low clinical risk of thyroid disease. D 2. Classification and risk stratification Risk of malignancy: Recognize that most thyroid nodules are asymptomatic and benign but do not exclude malignancy based on the absence of symptoms. B Recognize that the risk of cancer is not substantially different in the case of a solitary nodule versus a multinodular goiter. B 3. Diagnostic investigations History and physical examination: as per AACE 2016 guidelines, elicit and record the following data: age personal or family history of thyroid disease or cancer previous head or neck irradiation rate of neck mass growth anterior neck pain dysphonia, dysphagia, or dyspnea symptoms of hyperthyroidism or hypothyroidism use of iodine-containing drugs or supplements. B Show 2 more Diagnostic imaging, ultrasound: As per AAFP 2020 guidelines, obtain thyroid ultrasound involving the cervical lymph nodes in all patients with thyroid nodules. B As per AME/ACE/AACE 2016 guidelines, obtain ultrasound in patients at risk for thyroid malignancy having palpable thyroid nodules or goiter or neck lymphadenopathy suggestive of a malignant lesion. B Show 3 more As per ATA 2016 guidelines, obtain thyroid ultrasound, including an assessment of the cervical lymph nodes, in all patients with known or suspected thyroid nodules. A Diagnostic imaging (elastography): consider obtaining elastography to acquire information about nodule stiffness as a complementary tool to grayscale ultrasound for nodules with indeterminate ultrasound or cytologic findings. C Diagnostic imaging (CT/MRI): Do not obtain MRI or CT in the routine evaluation of thyroid nodules. D https://web.pathway.md/diseases/recMV0SAiK8dimU45 2/14 6/24/23, 4:07 PM Thyroid nodules Pathway Consider obtaining MRI and CT for the assessment of the size, airway compression, substernal extension of nodular goiter, or the presence of pathologic lymph nodes in the cervical region not visualized by ultrasound. C Diagnostic imaging, PET: As per AME/ACE/AACE 2016 guidelines: Avoid obtaining positron emission tomography/CT in the routine evaluation of thyroid nodules because of insufficient diagnostic accuracy, high cost, and limited accessibility. D Consider obtaining positron emission tomography/CT for additional information about the risk of malignancy in thyroid nodules with indeterminate cytologic results. C As per ATA 2016 guidelines, do not obtain 18F-FDG-positron emission tomography routinely in the evaluation of thyroid nodules with indeterminate cytology. D Show 2 more Diagnostic imaging, radionuclide scan: As per AAFP 2020 guidelines, obtain a radionuclide thyroid uptake scan if the TSH level is low in patients with a thyroid nodule. B As per AME/ACE/AACE 2016 guidelines, obtain thyroid scintigraphy in patients with a thyroid nodule or multinodular goiter when the TSH level is below the lower limit of the reference range or when ectopic thyroid tissue or a retrosternal goiter is suspected. B Show 4 more As per ATA 2016 guidelines: Obtain a radionuclide (preferably 123-iodine) thyroid scan if the serum TSH is subnormal in patients with thyroid nodules. Do not obtain a radionuclide scan as the initial imaging evaluation if the serum TSH is normal or elevated. B Consider obtaining a radionuclide (preferably iodine-123) thyroid scan in patients with multiple nodules and low or low-normal serum TSH levels, and compare to ultrasound images to determine the functionality of each nodule 1 cm. C Laboratory tests, thyroid hormones and antibodies: As per AAFP 2020 guidelines, obtain serum TSH level measurement in the initial evaluation of patients with a thyroid nodule. B As per AME/ACE/AACE 2016 guidelines, obtain serum TSH level measurement in patients with thyroid nodules. A Show 4 more As per ATA 2016 guidelines: Obtain serum TSH level measurement in the initial evaluation of patients with thyroid nodules. B Do not obtain serum thyroglobulin routinely in the initial evaluation of thyroid nodules. D Laboratory tests, calcitonin: As per AME/ACE/AACE 2016 guidelines, insufficient evidence to recommend for or against the routine measurement of serum calcitonin level in the evaluation of thyroid nodules. I https://web.pathway.md/diseases/recMV0SAiK8dimU45 3/14 6/24/23, 4:07 PM Thyroid nodules Pathway Show 2 more As per ATA 2016 guidelines, insufficient evidence to recommend for or against the routine measurement of serum calcitonin in patients with thyroid nodules. I Laboratory tests (parathyroid tests): obtain serum calcium and PTH testing in patients with a nodular lesion suggestive of parathyroid adenoma. B 4. Diagnostic procedures Core-needle biopsy: consider performing an US-guided core-needle biopsy of solid thyroid nodules with persistently inadequate FNA cytologic findings. C Show 2 more Fine-needle aspiration, indications based on nodule zise: As per AAFP 2020 guidelines, perform FNA of thyroid nodules 1 cm having a suspicious pattern on ultrasound. B As per AME/ACE/AACE 2016 guidelines, balance between the risk of a potentially delayed diagnosis and superfluous diagnostic procedures or surgery when selecting nodules for US- guided FNA. B Show 3 more As per ATA 2016 guidelines, perform FNA of thyroid nodules meeting the following criteria: 1 cm in greatest dimension with high suspicion ultrasound pattern (Strong recommendation, Moderate-quality evidence) 1 cm in greatest dimension with intermediate suspicion ultrasound pattern (Strong recommendation, Low-quality evidence) 1.5 cm in greatest dimension with low suspicion ultrasound pattern. B Show 2 more Fine-needle aspiration, indications based on other characteristics: As per AME/ACE/AACE 2016 guidelines: Do not perform FNA of nodules functional on scintigraphy. D Perform FNA of nodules with increased stiffness. B As per ATA 2016 guidelines: Perform FNA of thyroid nodules 1 cm in size with focal 18F-FDG-positron emission tomography uptake. B Do not perform FNA in patients with diffuse 18F-FDG-positron emission tomography uptake in conjunction with ultrasound and clinical evidence of chronic lymphocytic thyroiditis. D Fine-needle aspiration (complex nodules): sample the solid component of the lesion through FNA biopsy. B Show 2 more Fine-needle aspiration (cystic nodules): do not perform FNA of purely cystic thyroid nodules. D https://web.pathway.md/diseases/recMV0SAiK8dimU45 4/14 6/24/23, 4:07 PM Thyroid nodules Pathway Fine-needle aspiration, multiple nodules: As per AME/ACE/AACE 2016 guidelines: Do not perform a biopsy of more than 2 nodules in the same patient when the nodules are selected based on the previously described criteria. D Do not perform a biopsy in hot areas if a radioisotope scan is available. D As per ATA 2016 guidelines, evaluate patients with multiple thyroid nodules 1 cm in the same fashion as patients with a solitary nodule 1 cm. Consider performing FNA of multiple nodules if each nodule (> 1 cm) carries an independent risk of malignancy. B Show 3 more Fine-needle aspiration (lymph nodes): perform FNA for cytologic assessment of the lymph node and the suspicious nodule in the presence of suspicious cervical lymphadenopathy. B Fine-needle aspiration, aspirate washout: As per AME/ACE/AACE 2016 guidelines: Measure thyroglobulin, calcitonin, or PTH levels on FNA washout of suspicious thyroid lesions or lymph nodes when clinically appropriate. (BEL GRADE A). B Measure thyroglobulin or calcitonin levels, according to clinical indications, on FNA washout of suspicious lymph nodes. B As per ATA 2016 guidelines, measure thyroglobulin levels on FNA washout for suspicious cervical lymph nodes in selected patients, recognizing that interpretation may be difficult in patients with an intact thyroid gland. B Fine-needle aspiration, reporting: As per AME/ACE/AACE 2016 guidelines, include all relevant clinical and ultrasound information in the requisition form for FNA. B Include a rating of the ultrasound risk of malignancy based on an acknowledged ultrasound classification system. B Use the following ultrasound rating categories: high risk, intermediate risk, and low risk. B Show 6 more As per ATA 2016 guidelines, use the Bethesda System for Reporting Thyroid Cytopathology for reporting thyroid nodule FNA cytology. B Molecular testing: As per AACE 2016 guidelines, consider obtaining molecular testing as a complement to cytologic evaluation and when the results are expected to influence clinical management. B Show 6 more As per ATA 2016 guidelines, counsel patients before obtaining molecular testing regarding the potential benefits and limitations of testing and the possible uncertainties in the therapeutic and long-term clinical implications of results. B Show 2 more 5. Medical management https://web.pathway.md/diseases/recMV0SAiK8dimU45 5/14 6/24/23, 4:07 PM Thyroid nodules Pathway Levothyroxine: As per AACE 2016 guidelines, do not initiate levothyroxine suppressive therapy in patients with benign thyroid nodules. D Show 3 more As per ATA 2016 guidelines: Do not initiate TSH suppression therapy routinely in patients with benign thyroid nodules in iodine-sufficient populations. D Insufficient evidence to support the use of thyroid hormone therapy in patients with growing benign thyroid nodules. I Iodine supplementation: As per AACE 2016 guidelines, consider initiating iodine supplementation in young patients with small nodular goiter and high-normal TSH levels in geographic areas with mild iodine deficiency. C As per ATA 2016 guidelines, ensure adequate iodine intake in patients with benign, solid, or mostly solid nodules. Initiate daily iodine supplementation (containing 150 g of iodine) in patients with suspected or confirmed inadequate dietary intake. B Radioactive iodine therapy (indications): consider offering radioactive iodine therapy for hyperfunctioning and/or symptomatic goiter, especially in patients with previous thyroid surgery or at surgical risk and in patients declining surgery. B Radioactive iodine therapy (pretreatment counseling): obtain a screening evaluation to confirm the absence of pregnancy in female patients of childbearing age before initiating radioactive iodine therapy, and advise avoiding pregnancy for 6-12 months after receiving radioactive iodine. B Show 2 more Radioactive iodine therapy, pretreatment evaluation: As per AME/ACE/AACE 2016 guidelines, recognize that radioactive iodine is contraindicated in pregnant and breastfeeding patients. Obtain a pregnancy test before initiating radioactive iodine therapy in female patients of childbearing potential. B Show 3 more As per ATA 2016 guidelines, obtain baseline CBC and renal function tests in patients receiving therapeutic doses of radioactive iodine therapy. B Radioactive iodine therapy (treatment monitoring): Obtain regular thyroid function monitoring in patients receiving radioactive iodine therapy. B Consider repeating the treatment after 3-6 months in patients with persistent or recurrent hyperthyroidism or inadequate size reduction. C 6. Therapeutic procedures Percutaneous ethanol injection: https://web.pathway.md/diseases/recMV0SAiK8dimU45 6/14 6/24/23, 4:07 PM Thyroid nodules Pathway As per AACE 2016 guidelines, consider performing percutaneous ethanol injection as outpatient therapy in patients with cysts and complex nodules with a large fluid component. B Sample the solid component of complex lesions carefully before performing percutaneous ethanol injection. C Show 2 more As per ATA 2016 guidelines, consider performing percutaneous ethanol injection or surgical removal, depending on compressive symptoms and cosmetic concerns, in patients with recurrent cystic thyroid nodules with benign cytology. C Thermal ablation (indications): do not perform thermal ablation in patients with asymptomatic lesions. D Show 6 more Thermal ablation (preprocedural counseling): counsel patients before thermal ablation, PO and in writing, about the thermal ablation treatment options, their potential efficacy and side effects, the therapeutic alternatives, and the necessity of being compliant. B Thermal ablation, preprocedural evaluation: As per ETA 2020 guidelines, consider repeating FNA to confirm the benign diagnosis of cytologically benign nodules before thermal ablation, except for spongiform nodules and pure cystic lesions (EU TI-RADS Class 2). B Show 2 more As per AME/ACE/AACE 2016 guidelines, repeat FNA for cytologic confirmation before thermal ablation treatment. B Thermal ablation (anesthesia): administer local SC and pericapsular anesthesia before thermal ablation procedures. Consider administering mild conscious sedation, especially in case of high- intensity focused ultrasound treatment. B Thermal ablation, modalities: As per ETA 2020 guidelines, perform laser thermal ablation or radiofrequency ablation as first- line thermal ablation procedures. B Show 4 more As per AME/ACE/AACE 2016 guidelines, consider performing laser thermal ablation or radiofrequency ablation in patients with solid or complex thyroid nodules that progressively enlarge, are symptomatic, or cause cosmetic concern. C Thermal ablation (postprocedural care): Obtain clinical and ultrasound evaluation at the end of the procedure to rule out potential early adverse effects and define the extent of the ablated area. Instruct patients to present for clinical and ultrasound assessment if severe pain, local swelling, or fever occurs within the first week after thermal ablation. B Obtain early-term (3 months) and intermediate-term (6 and 12 months) clinical, biochemical, and ultrasound evaluations. Consider obtaining long-term follow-up monitoring in the absence of symptoms every 1-2 years to reveal regrowth. B https://web.pathway.md/diseases/recMV0SAiK8dimU45 7/14 6/24/23, 4:07 PM Thyroid nodules Pathway 7. Perioperative care Preoperative imaging: As per AACE 2016 guidelines: Consider obtaining positron emission tomography/CT for the preoperative staging of malignant nodules with aggressive features. C Consider obtaining MRI, CT, and/or 18F-FDG-positron emission tomography/CT for more accurate preoperative staging in selected patients with aggressive features. C As per ATA 2016 guidelines, obtain preoperative neck ultrasound for cervical (central and especially lateral neck compartments) lymph nodes in all patients undergoing thyroidectomy for malignant/suspicious for malignancy cytologic or molecular findings. B Show 2 more Preoperative laboratory tests: As per AACE 2016 guidelines, consider obtaining preoperative serum thyroglobulin measurement in patients undergoing surgery for cancer. C As per ATA 2016 guidelines, do not obtain routine preoperative serum thyroglobulin and anti- thyroglobulin antibody level measurements. D Preoperative fine-needle aspiration: As per AACE 2016 guidelines: Perform FNA biopsy of any concomitant suspicious nodule or lymph node before surgery for malignant nodules. B Confirm the metastatic nature of a lymph node with measurement of thyroglobulin or calcitonin on FNA washout in patients with suspicious ultrasound features. B As per ATA 2016 guidelines: Perform US-guided FNA of ultrasound suspicious lymph nodes 8-10 mm in the smallest diameter to confirm malignancy if this would change management. B Measure thyroglobulin levels on FNA washout for suspicious cervical lymph nodes in selected patients, recognizing that interpretation may be difficult in patients with an intact thyroid gland. B Preoperative voice assessment: As per ATA 2016 guidelines: Obtain preoperative voice assessment (including the patient's description of vocal changes and the physician's assessment of voice) in all patients undergoing thyroid surgery. B Perform preoperative laryngeal examination in all patients with any of the following: preoperative voice abnormalities B history of cervical or upper chest surgery placing the recurrent laryngeal nerve or vagus nerve at risk B known thyroid cancer with posterior extrathyroidal extension or extensive central nodal metastases. B https://web.pathway.md/diseases/recMV0SAiK8dimU45 8/14 6/24/23, 4:07 PM Thyroid nodules Pathway As per AAO-HNSF 2013 guidelines, obtain assessment and document the patient's voice once a decision has been made to proceed with thyroid surgery. B Show 4 more Postoperative voice assessment: As per ATA 2016 guidelines: Obtain postoperative voice assessment after thyroid surgery. Perform a formal laryngeal examination if the voice is abnormal. B Communicate important intraoperative findings and details of postoperative care to the patient and other physicians involved in the patient's postoperative care. B As per AAO-HNSF 2013 guidelines, document whether there has been a change in voice between 2 weeks and 2 months following thyroid surgery. B Show 3 more 8. Surgical interventions Diagnostic surgical excision: As per AACE 2016 guidelines, consider performing surgery on persistently nondiagnostic solid nodules. Consider obtaining follow-up in a minority of solid nodules with clearly favorable clinical and ultrasound features. C As per ATA 2016 guidelines, consider performing surgical excision for removal and definitive diagnosis of a thyroid nodule with follicular neoplasm/suspicious for follicular neoplasm cytology if molecular testing is either not obtained or inconclusive. B Show 2 more Indications for surgery, benign nodule: As per AME/ACE/AACE 2016 guidelines: Consider performing surgery in patients with benign thyroid nodules with clearly associated local pressure symptoms or in patients with suspicious ultrasound features despite benign FNA findings. C Perform lobectomy plus isthmectomy as the preferred extent of resection in patients with benign uninodular goiter. Consider performing (near) total thyroidectomy in patients with multinodular goiter. B As per ATA 2016 guidelines: Consider performing surgery in patients with growing benign nodules after a repeat FNA if there are large (> 4 cm), causing compressive or structural symptoms, or based upon clinical concern. C Consider performing surgical removal or percutaneous ethanol injection, depending on compressive symptoms and cosmetic concerns, in patients with recurrent cystic thyroid nodules with benign cytology. C Indications for surgery, intermediate nodule: As per AME/ACE/AACE 2016 guidelines: https://web.pathway.md/diseases/recMV0SAiK8dimU45 9/14 6/24/23, 4:07 PM Thyroid nodules Pathway Perform surgery in most patients with high-risk intermediate thyroid nodules. B Perform thyroid lobectomy plus isthmectomy. Consider performing total thyroidectomy depending on the clinical setting, the coexistence of contralateral lobe thyroid nodules, and patient preference. A Avoid performing frozen sections as they are usually not useful. D As per ATA 2016 guidelines, perform diagnostic surgical excision or offer surveillance in patients with nodules with atypia of undetermined significance/follicular lesion of undetermined significance, depending on clinical risk factors, ultrasound pattern, and patient preference, if repeat FNA cytology, molecular testing, or both are not obtained or inconclusive. B Show 3 more Indications for surgery (suspicious nodule): Perform surgery in patients with FNA suspicious nodules. A Consider performing intraoperative frozen sections. C Indications for surgery, malignant nodule: As per AME/ACE/AACE 2016 guidelines: Review ultrasound and cytologic results with the patient, discuss treatment options, and obtain a consultation with a surgeon experienced in endocrine surgery. B Perform surgery in patients with differentiated thyroid carcinoma. A As per ATA 2016 guidelines, perform surgery in patients with cytology results diagnostic for primary thyroid malignancy B or suspicious for papillary carcinoma. B Technical considerations for surgery, recurrent laryngeal nerve preservation: As per ATA 2016 guidelines, ensure visual identification of the recurrent laryngeal nerve during dissection. B Show 2 more As per AAO-HNSF 2013 guidelines, identify the recurrent laryngeal nerves during thyroid surgery. B Show 3 more Technical considerations for surgery (parathyroid gland preservation): preserve parathyroid glands and their blood supply during thyroid surgery. B 9. Specific circumstances Pediatric patients, evaluation: As per ETA 2022 guidelines: Obtain thyroid ultrasound to assess the risk of malignancy in a thyroid nodule based on multiple ultrasound characteristics. Do not use ultrasound alone to definitively distinguish a benign thyroid nodule from thyroid cancer. Perform FNA in patients with suspected nodules. B https://web.pathway.md/diseases/recMV0SAiK8dimU45 10/14 6/24/23, 4:07 PM Thyroid nodules Pathway Obtain complete neck ultrasound to evaluate all cervical levels for the presence of lymph node enlargement in pediatric patients with thyroid nodules. B As per AME/ACE/AACE 2016 guidelines, evaluate and manage nodular disease in pediatric patients in the same fashion as in adult patients. B Pediatric patients (monitoring): obtain serial ultrasound to monitor benign nodules and perform repeat fine needle biopsy if suspicious features develop. B Pediatric patients, surgery: As per ETA 2022 guidelines, consider performing hemithyroidectomy or total thyroidectomy by an experienced high-volume pediatric thyroid cancer surgeon in pediatric patients with benign nodules with compressive symptoms, cosmetic concerns, or according to patient/parent preference after counseling of the possible benefits and risks of thyroid surgery. C Show 2 more As per AME/ACE/AACE 2016 guidelines, consider performing surgery on "cold" and "hot" nodules because of a greater prevalence of malignancy in pediatric patients with thyroid nodules. C Pregnant patients, radionuclide scan: As per ATA 2017 guidelines: Do not obtain radionuclide scintigraphy or radioiodine uptake determination during pregnancy. D Consider obtaining a radionuclide scan to evaluate nodule function in patients with persistently suppressed serum TSH after pregnancy if the patient is not breastfeeding. B As per AME/ACE/AACE 2016 guidelines, postpone radionuclide thyroid scan until after delivery and cessation of breastfeeding in patients with subnormal TSH levels during the second half of pregnancy. B Pregnant patients, fine-needle aspiration: As per ATA 2017 guidelines: Consider deferring FNA of a clinically relevant thyroid nodule until after pregnancy in patients with suppressed serum TSH levels persisting beyond 16 weeks gestation. B Perform FNA for newly detected nodules in pregnant patients with nonsuppressed TSH levels. Determine which nodules require FNA based on the nodule's ultrasound patterns. Consider deciding on the timing of FNA, whether during gestation or early postpartum, based on the clinical assessment of cancer risk or by patient preference. B As per AME/ACE/AACE 2016 guidelines, perform FNA in patients with suspicious clinical or ultrasound findings since cytologic diagnostic criteria are not substantially influenced by pregnancy. B As per ATA 2016 guidelines, perform FNA of clinically relevant thyroid nodules in euthyroid and hypothyroid pregnant patients. B Pregnant patients (serum calcitonin): insufficient evidence to recommend for or against the routine measurement of serum calcitonin in pregnant patients with thyroid nodules. I https://web.pathway.md/diseases/recMV0SAiK8dimU45 11/14 6/24/23, 4:07 PM Thyroid nodules Pathway Pregnant patients, management of benign nodules: As per ATA 2017 guidelines, do not obtain special surveillance strategies during pregnancy in patients with cytologically benign thyroid nodules. D As per AME/ACE/AACE 2016 guidelines, manage thyroid nodules in pregnant patients in the same fashion as non-pregnant patients. B Show 5 more Pregnant patients (management of intermediate nodules): do not perform routine surgery during pregnancy in patients with cytologically indeterminate nodules without cytologically malignant lymph nodes or other signs of metastatic disease. D Show 2 more Pregnant patients, management of malignant nodules: As per ATA 2017 guidelines, obtain ultrasound monitoring in patients with papillary thyroid cancer discovered by cytology in early pregnancy. B Show 3 more As per AME/ACE/AACE 2016 guidelines, perform thyroidectomy during the second trimester in patients with thyroid malignancy diagnosed during the first or second trimester. B Show 4 more 10. Patient education Pretreatment counseling (radioiodine therapy): Counsel female patients to avoid pregnancy for 6-12 months after receiving radioactive iodine. B Counsel male patients receiving cumulative radioactive iodine activities 400 mCi on potential risks of infertility. B Pretreatment counseling (thermal ablation): counsel patients before thermal ablation, PO and in writing, about the thermal ablation treatment options, their potential efficacy and side effects, the therapeutic alternatives, and the necessity of being compliant. B Pretreatment counseling (surgery): counsel patients before surgery regarding surgical risks, including nerve and parathyroid injury, through the informed consent process and communicate with associated physicians, including anesthesia personnel, regarding important findings elicited during the preoperative workup. B 11. Follow-up and surveillance Management of treatment-related complications: insufficient evidence to recommend for or against the routine use of measures to prevent salivary gland damage after radioactive iodine therapy. I Show 2 more https://web.pathway.md/diseases/recMV0SAiK8dimU45 12/14 6/24/23, 4:07 PM Thyroid nodules Pathway Follow-up evaluation (incidentalomas): manage thyroid incidentalomas according to thyroid nodule diagnostic criteria. B Show 2 more Follow-up evaluation (asymptomatic cysts): consider offering expectant management in patients with asymptomatic cystic nodules. C Follow-up evaluation, nondiagnostic by FNA: As per AME/ACE/AACE 2016 guidelines, repeat US-guided FNA if initial FNA is nondiagnostic and the nodule is solid on ultrasound. B Show 2 more As per ATA 2016 guidelines, repeat US-guided FNA and, if available, on-site cytologic evaluation in patients with a nodule with an initial nondiagnostic cytology result. B Follow-up evaluation, benign by FNA: As per AME/ACE/AACE 2016 guidelines, obtain clinical follow-up of FNA benign nodules unless symptomatic. B Show 4 more As per ATA 2016 guidelines, do not obtain further immediate diagnostic evaluations in patients with thyroid nodules benign on cytology. D Show 5 more Follow-up evaluation, intermediate by FNA: As per AME/ACE/AACE 2016 guidelines, manage indeterminate thyroid nodules based on their cytologic subclassification, clinical data, and ultrasound features. B taking into consideration the available technical resources and patient preferences. B Show 2 more As per ATA 2016 guidelines, repeat ultrasound at 12-24 months in patients with thyroid nodules with low-to-intermediate suspicion ultrasound pattern. Consider repeating FNA or obtain observation continued with repeat ultrasound, with repeat FNA in case of continued growth, in case of ultrasound evidence of growth (20% increase in at least 2 nodule dimensions with a minimal increase of 2 mm or > 50% change in volume) or development of new suspicious ultrasound features. B Show 2 more Follow-up evaluation, suspicious by FNA: As per AME/ACE/AACE 2016 guidelines, repeat FNA in patients with inadequate cellularity or requiring additional techniques for better characterization. B As per ATA 2016 guidelines, repeat ultrasound and US-guided FNA within 12 months in patients with nodules with high suspicion ultrasound pattern. B References https://web.pathway.md/diseases/recMV0SAiK8dimU45 13/14 6/24/23, 4:07 PM Thyroid nodules Pathway 1. 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Open 5. Enrico Papini, Herv Monpeyssen, Andrea Frasoldati et al. 2020 European Thyroid Association Clinical Practice Guideline for the Use of Image-Guided Ablation in Benign Thyroid Nodules. Eur Thyroid J. 2020 Jul;9 4 172 185. Open 6. Chantal A Lebbink, Thera P Links, Agnieszka Czarniecka et al. 2022 European Thyroid Association Guidelines for the management of pediatric thyroid nodules and differentiated thyroid carcinoma. Eur Thyroid J. 2022 Nov 29;11 6):e220146. Open 7. Erik K Alexander, Elizabeth N Pearce, Gregory A Brent et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid. 2017 Mar;27 3 315 389. Open 8. Simone De Leo, Sun Y Lee, Lewis E Braverman. Hyperthyroidism. Lancet. 2016 Aug 27;388 10047 906 918. Open https://web.pathway.md/diseases/recMV0SAiK8dimU45 14/14