Clinical Application of C-TIRADS Category and Contrast-Enhanced Ultrasound in Differential Diagnosis of Solid Thyroid Nodules Measuring 1 cm. The process of validation of CEUS-TIRADS model. The diagnosis or exclusion of thyroid cancer is hugely challenging. A total of 228 thyroid nodules (C-TIRADS 4) were estimated by CEUS. 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]). The CEUS-TIRADS combining CEUS analysis with C-TIRADS could make up for the deficient sensibility of C-TIRADS, showing a better diagnostic performance than US and CEUS. {"url":"/signup-modal-props.json?lang=us"}, Jha P, Weerakkody Y, Bell D, et al. 24;8 (10): e77927. In a patient with normal life expectancy, a biopsy should be performed for nodules >1cm regardless of the ACR TI-RADS risk category. 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. All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. If a guideline indicates that FNA is recommended, it can be difficult to oppose this based on other factors. Radiology. The actual number of inconclusive FNA results in the real-world validation set has not been established (because that study has not been done), but the typical rate is 30% (by this we mean nondiagnostic [ie, insufficient cells], or indeterminate [ie, atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS)/follicular neoplasm/suspicious for follicular neoplasm [Bethesda I, III, IV]). The Thyroid Imaging Reporting and Data System (TI-RADS) of the American College of Radiology (ACR) was designed in 2017 with the intent to decrease biopsies of benign nodules and improve overall . 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). MeSH The performance of any diagnostic test in this group has to be truly exceptional to outperform random selection and accurately rule in or rule out thyroid cancer in the TR3 or TR4 groups. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. 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 ). Zhang B, Tian J, Pei S, Chen Y, He X, Dong Y, Zhang L, Mo X, Huang W, Cong S, Zhang S. Wildman-Tobriner B, Buda M, Hoang JK, Middleton WD, Thayer D, Short RG, Tessler FN, Mazurowski MA. The Thyroid Imaging Reporting And Data System (TI-RADS) was developed by the American College of Radiology and used by many radiologist in Australia. The CEUS-TIRADS category was 4a. So, the number needed to scan (NNS) for each additional person correctly reassured is 100 (NNS=100). 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 high prevalence of thyroid nodules combined with the generally indolent growth of thyroid cancer present a challenge for optimal patient care. Thus, the absolute risk of missing important cancer goes from 4.5% to 2.5%, so NNS=100/2=50. Alternatively, if random FNAs are performed in 1 in 10 nodules, then 4.5 thyroid cancers (4-5 people per 100) will be missed. Your email address will not be published. To show the best possible performance of ACR TIRADS, we are comparing it to clinical practice in the absence of TIRADS or other US thyroid nodule stratification tools, and based on a pretest probability of thyroid cancer in a nodule being 5%, where 1 in 10 nodules are randomly selected for FNA. However, many patients undergoing a PET scan will have another malignancy. 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. In ACR TI-RADS, points in five feature categories are summed to determine a risk level from TR1 to TR5 . doi: 10.1016/S0140-6736(14)62242-X Endocrine (2020) 70(2):25679. 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]. doi: 10.1007/s12020-020-02441-y doi: 10.12659/MSM.936368. Tests and procedures used to diagnose thyroid cancer include: Physical exam. Anderson TJ, Atalay MK, Grand DJ, Baird GL, Cronan JJ, Beland MD. Using ACR-TIRADS as a rule-in test to identify a higher risk group that should have FNA is arguably a more effective application. Therefore, taking results from this data set and assuming they would apply to the real-world population raises concerns. The problem is that many people dont know that they have a thyroid nodule, so they dont know how to treat it. The It might even need surge Cao H, Fan Q, Zhuo S, Qi T, Sun H, Rong X, Xiao X, Zhang W, Zhu L, Wang L. J Ultrasound Med. Federal government websites often end in .gov or .mil. The system is sometimes referred to as TI-RADS French 6. Keywords: Sensitivity of ACR TIRADS was better than random selection, between 74% to 81% (depending on whether the size cutoffs add value) compared with 1% with random selection. A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. Would you like email updates of new search results? However, given that TR1 and TR2 make up only 25% of the nodules, then to find 25 nodules that are TR1 or TR2, you would need to do 100 scans. These cutoffs are somewhat arbitrary, with conflicting data as to what degree, if any, size is a discriminatory factor. Thyroid radiology practice has an important clinical role in the diagnosis and non-surgical treatment of patients with thyroid nodules, and should be performed according to standard practice guidelines for proper and effective clinical care. TIRADS 5: probably malignant nodules (malignancy >80%). Using TR5 as a rule-in test was similar to random selection (specificity 89% vs 90%). Radiology. 2. As it turns out, its also very accurate and detailed. Im on a treatment plan with my oncologist, my doctor, and Im about to start my next round of treatments. ; Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology. Disclosure Summary:The authors declare no conflicts of interest. Well, there you have it. An official website of the United States government. The flow chart of the study. PPV was poor (20%), NPV was no better than random selection, and accuracy was worse than random selection (65% vs 85%). Bookshelf Authors Some cancers would not show suspicious changes thus US features would be falsely reassuring. ACR TIRADS performed poorly when applied across all 5 TR categories, with specificity lower than with random selection (63% vs 90%). Therefore, 60% of patients are in the middle groups (TR3 and TR4), where the US features are less discriminatory. The nodules were scored, measured and assigned to one of five TI-RADS levels (TR): TR1 - benign, TR2 - not suspicious, TR3 - mildly suspicious, TR4 - moderately suspicious, TR5 - highly suspicious. Current thyroid cancer trends in the United States, Association between screening and the thyroid cancer epidemic in South Korea: evidence from a nationwide study, 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer, Thyroid ultrasound and the increase in diagnosis of low-risk thyroid cancer, Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology, Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations, European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS, Multiinstitutional analysis of thyroid nodule risk stratification using the American College of Radiology Thyroid Imaging Reporting and Data System, The Bethesda System for reporting thyroid cytopathology: a meta-analysis, The role of repeat fine needle aspiration in managing indeterminate thyroid nodules, The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. A key factor is the low pretest probability of important thyroid cancer but a higher chance of finding thyroid cancers that are very unlikely to cause ill health during a persons lifetime. 1. Data Availability: All data generated or analyzed during this study are included in this published article or in the data repositories listed in References. Epub 2021 Oct 28. The prevalence of incidental thyroid cancer at autopsy is around 10% [3]. Noticeably benign pattern (0% risk of malignancy) TI-RADS 3: Probably benign nodules (<5% risk of malignancy) TI-RADS 4: 4a - Undetermined nodules (5-10% risk of malignancy) Score of 1. Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L. Middleton WD, Teefey SA, Reading CC, et al. Now you can go out and get yourself a thyroid nodule. To establish a contrast-enhanced ultrasound (CEUS) diagnostic schedule by CEUS analysis of thyroid nodules of C-TIRADS 4. Instead, it has been applied on retrospective data sets, with cancer rates far above 5%, rather than on consecutive unselected patients presenting with a thyroid nodule [33]. 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. If the nodule got a score of 2 in the CEUS schedule, the CEUS-TIRADS category remained the same as before. Careers. Castellana M, Castellana C, Treglia G, Giorgino F, Giovanella L, Russ G, Trimboli P. Oxford University Press is a department of the University of Oxford. The current ACR TIRADS system changed from that assessed during training, with the addition of the taller-than-wide and size criteria, which further questions the assumption that the test should perform in the real world as it did on a the initial training data set. Therefore, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS to correctly rule out thyroid cancer in 1 additional patient would require more than 100 US scans (NNS>100) to find 25 TR1 and TR2 patients, triggering at least 40 additional FNAs and resulting in approximately 6 additional unnecessary diagnostic hemithyroidectomies at significant economic and personal costs. doi: 10.1210/jendso/bvaa031. Whilst we somewhat provocatively used random selection as a clinical comparator, we do not mean to suggest that clinicians work in this way. Thyroid Tirads 4: Thyroid lesions with suspicious signs of malignancy. Those working in this field would gratefully welcome a diagnostic modality that can improve the current uncertainty. -, Fresilli D, David E, Pacini P, Del Gaudio G, Dolcetti V, Lucarelli GT, et al. Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. Russ G, Royer B, Bigorgne C et-al. Its not something that happens every day, but every day. Outlook. See this image and copyright information in PMC. Update of the Literature. Perhaps the most relevant positive study is from Korea, which found in a TR4 group the cancer rate was no different between nodules measuring between 1-2 cm (22.3%) and those 2-3 cm (23.5%), but the rate did increase above 3 cm (40%) [24]. 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. 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. 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. 19 (11): 1257-64. TI-RADS 4b applies to the lesion with one or two of the above signs and no metastatic lymph node is present. The TIRADS reporting algorithm is a significant advance with clearly defined objective sonographic features that are simple to apply in practice. Thyroid nodules are solid or fluid-filled lumps that form within your thyroid, a small gland located at the base of your neck, just above your breastbone. 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. Results: 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. 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. FNA, fine-needle aspiration; US, ultrasound; CEUS, contrast-enhanced ultrasound; C-TIRADS, Chinese imaging reporting and data system. Now, the first step in T3N treatment is usually a blood test. 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 . eCollection 2022. 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). EU-TIRADS 1 category refers to a US examination where no thyroid nodule is found; there is no need for FNAB. Data Set Used for Development of ACR TIRADS [16] and Used for This Paper The possible cancer rate column is a crude, unvalidated estimate, calculated by proportionately reducing the cancer rates by 10.3%: 5% to reflect the likely difference in the cancer rate in the data set used (10.3%) and in the population presenting with a thyroid nodule (5%). A thyroid nodule is an unusual lump (growth) of cells on your thyroid gland. Putting aside any potential methodological concerns with ACR TIRADS, it may be helpful to illustrate how TIRADS might work if one assumed that the data set used was a fair approximation to the real-world population. 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 methodology used to acquire the data set, the gender bias, and cancer rate in the data set, it is unlikely to be a fair reflection of the population upon which the test is intended to be applied, and so cannot be considered a true validation set. The proportion of malignancy in Bethesda III nodules confirmed by surgery were significantly increased in proportion relative to K-TIRADS with 60.0% low suspicion, 88.2% intermediate suspicion, and 100% high suspicion nodules (p < 0.001). But the test that really lets you see a nodule up close is a CT scan. Your health care provider will examine your neck to feel for changes in your thyroid, such as a lump (nodule) in the thyroid. 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). The difference was statistically significant (P<0.05). 3. Until TIRADS is subjected to a true validation study, we do not feel that a clinician can currently accurately predict what a TIRADS classification actually means, nor what the most appropriate management thereafter should be. The pathological result was papillary thyroid carcinoma. Multivariate factors logistic analysis was performed and a CEUS diagnostic schedule was established. Thyroid nodules could be classified into one of 10 ultrasound patterns, which had a corresponding TI-RADS category. The cost-effective diagnosis or exclusion of consequential thyroid cancer is an everyday problem faced by all thyroid clinicians. It is limited by only being an illustrative example that does not take clinical factors into account such as prior radiation exposure and clinical features. spiker54. If it performs well enough, then the test is applied to a training set of data to better establish performance characteristics. However, the ACR TIRADS flow chart with its sharp cutoffs conveys a degree of certainty that may not be valid and may be hard for the clinician to resist. Furuya-Kanamori L, Bell KJL, Clark J, Glasziou P, Doi SAR. These appear to share the same basic flaw as the ACR-TIRADS, in that the data sets of nodules used for their development is not likely to represent the population upon which it is intended for use, at least with regard to pretest probability of malignancy (eg, malignancy rate 12% for Korean TIRADS [26]; 18% and 31% for EU TIRADS categories 4 and 5 [27, 28]). In 2013, Russ et al. In CEUS analysis, it reflected as equal arrival time, iso-enhancement, homogeneity, and diffuse enhancement, receiving a score of 0 in the CEUS model. PET-positive thyroid nodules have a relatively high malignancy rate of 35%. This comes at the cost of missing as many cancers as you find, spread amongst 84% of the population, and doing 1 additional unnecessary operation (160.20.8=2.6, minus the 1.6 unnecessary operations resulting from random selection of 1 in 10 patients for FNA [25]), plus the financial costs involved. 2022 Jun 7;28:e936368. 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). The following article describes the initial iterations proposed by individual research groups, none of which gained widespread use. The consequences of these proportions are highly impactful when considering the real-world performance of ACR-TIRADS. Tirads 5 thyroid gland: is a thyroid gland with 5 or more lesions, the rate of malignancy accounts for 87.5%. We refer to ACR-TIRADS where data or comments are specifically related to ACR TIRADS and use the term TIRADS either for brevity or when comments may be applicable to other TIRADS systems. ACR TIRADS has not been applied to a true validation set upon which it is intended to be used, and therefore needs to be considered with caution when applying it to the real-world situation. The other one-half of the cancers that are missed by only doing FNA of TR5 nodules will mainly be in the TR3 and TR4 groups (that make up 60% of the population), and these groups will have a 3% to 8% chance of cancer, depending upon whether the population prevalence of thyroid cancer in those being tested is 5% or 10%. TI-RADS 1: Normal thyroid gland. Advances in knowledge: The study suggests TIRADS and thyroid nodule size as sensitive predictors of malignancy. 2021 Dec 7;101(45):3748-3753. doi: 10.3760/cma.j.cn112137-20210401-00799. The specificity of TIRADS is high (89%) but, perhaps surprisingly, is similar to randomly selecting of 1 in 10 nodules for FNA (90%). K-TIRADS category was assigned to the thyroid nodules. 4b - Suspicious nodules (10-50% risk of malignancy) Score of 2. 2022 Jun 30;12:840819. doi: 10.3389/fonc.2022.840819. So, for 100 scans, if FNA is done on all TR5 nodules, this will find one-half of the cancers and so will miss one-half of the cancers. 2009;94 (5): 1748-51. The vast majority of nodules followed-up would be benign (>97%), and so the majority of FNAs triggered by US follow-up would either be benign, indeterminate, or false positive, resulting in more potential for harm (16 unnecessary operations for every 100 FNAs). If the nodule had a regular hyper-enhancement ring or got a score of less than 2 in CEUS analysis, CEUS-TIRADS subtracted 1 category. In rare cases, they're cancerous. I have some serious news about my thyroid nodules today. For a rule-out test, sensitivity is the more important test metric. We have detailed the data set used for the development of ACR TIRADS [16] in Table 1, plus noted the likely cancer rates in the real world if one assumes that the data set cancer prevalence (10.3%) is double that in the population upon which the test is intended to be used (pretest probability of 5%). There remains the need for a highly performing diagnostic modality for clinically important thyroid cancers. These patients are not further considered in the ACR TIRADS guidelines. 5. 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. The ACR TIRADS management flowchart also does not take into account these clinical factors. TI-RADS 2: Benign nodules. Whilst our findings have illustrated some of the shortcomings of ACR TIRADS guidelines, we are not able to provide the ideal alternative. Bethesda, MD 20894, Web Policies 6. Mao S, Zhao LP, Li XH, Sun YF, Su H, Zhang Y, Li KL, Fan DC, Zhang MY, Sun ZG, Wang SC. As a result, were left looking like a complete idiot with the results. Haugen BR, Alexander EK, Bible KC, et al. The system has fair interobserver agreement 4. 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. -, Takano T. Overdiagnosis of Juvenile Thyroid Cancer: Time to Consider Self-Limiting Cancer. Later arrival time, hypo-enhancement, heterogeneous enhancement, centripetal enhancement, and rapid washout were risk factors of malignancy in multivariate analysis. Now, the first step in T3N treatment is usually a blood test. Once the test is considered to be performing adequately, then it would be tested on a validation data set. It is very difficult to know the true prevalence of important, clinically consequential thyroid cancers among patients presenting with thyroid nodules. J Adolesc Young Adult Oncol (2020) 9(2):2868. FNA, fine-needle aspiration; US, ultrasound; CEUS, contrast-enhanced, A 38-year-old woman with a nodule in the right-lobe of her thyroid gland., A 35-year-old woman with a nodule in the left-lobe of her thyroid gland., The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 228 nodules in the. Performing FNA on TR5 nodules is a relatively effective way of finding thyroid cancers. Furthermore, we are presuming other clinical factors (ie, palpability, size, number, symptoms, age, gender, prior radiation exposure, family history) add no diagnostic value above random selection. 1 Most thyroid nodules are detected incidentally when imaging is performed for another indication. 2018;287(1):29-36. Jin Z, Zhu Y, Lei Y, Yu X, Jiang N, Gao Y, Cao J. Med Sci Monit. The flow chart of the study. Each variable is valued at 1 for the presence of the following and 0 otherwise: The above systems were difficult to apply clinically due to their complexity, leading Kwak et al. So just using ACR TIRADS as a rule-out test could be expected to leave 99% of undiagnosed cancers amongst the remaining 75% of the population, in whom the investigation and management remains unresolved. The gender bias (92% female) and cancer prevalence (10%) of the data set suggests it may not accurately reflect the intended test population. 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. Performance of Contrast-Enhanced Ultrasound in Thyroid Nodules: Review of Current State and Future Perspectives. . [The diagnostic performance of 2020 Chinese Ultrasound Thyroid Imaging Reporting and Data System in thyroid nodules]. A subdivision into 4a (malignancy between 5 and 10%) and 4b (malignancy between 10 and 80%) was optional. The implication is that US has enabled increased detection of thyroid cancers that are less clinically important [11-13]. Differentiation of Thyroid Nodules (C-TIRADS 4) by Combining Contrast-Enhanced Ultrasound Diagnosis Model With Chinese Thyroid Imaging Reporting and Data System Front Oncol. TIRADS ( T hyroid I maging R eporting and D ata S ystem) is a 5-point scoring system for thyroid nodules on ultrasound, developed by the American College of Radiology ( hence also termed as ACR- TIRADS). The sensitivity, specificity, and accuracy of CEUS were 78.7%, 87.5%, and 83.3% respectively. Radiofrequency ablation uses a probe to access the benign nodule under ultrasound guidance, and then treats it with electrical current and heat that shrinks the nodule. 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. At the time the article was last revised Yuranga Weerakkody had Whereas using TIRADS as a rule-in cancer test would be the finding that a nodule is TR5, with a sufficiently high chance of cancer that further investigations are required, compared with being TR1-4. Among thyroid nodules detected during life, the often quoted figure for malignancy prevalence is 5% [5-8], with UptoDate quoting 4% to 6.5% in nonsurgical series [9], and it is likely that only a proportion of these cancers will be clinically significant (ie, go on to cause ill-health). doi: 10.1089/jayao.2019.0098 The first time Tirads 3 after cytology is benign, but you do not say how many mm and after 3 months of re-examination, it was . The true test performance can only be established once the optimized test has been applied to 1 or more validation data sets and compared with the existing gold standard test. A study that looked at all nodules in consecutive patients (eg, perhaps FNA of every nodule>10 mm) would be required to get an accurate measure of the cancer prevalence in those nodules that might not typically get FNA. Value of Contrast-Enhanced Ultrasound in Adjusting the Classification of Chinese-TIRADS 4 Nodules. The management guidelines may be difficult to justify from a cost/benefit perspective. -. (2009) Thyroid : official journal of the American Thyroid Association. With the right blood tests, you can see if you have a thyroid nodule, and if so, you can treat it with radioactive iodine.

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