Thyroid nodules are widely prevalent, and often discovered incidentally. Malignancy rates are low for incidental thyroid nodules, and overall outcomes are favorable regardless of diagnosis. Patients with thyroid nodules should be evaluated with TSH levels followed by ultrasound of the thyroid and cervical lymph nodes. It is important to recognize sonographic features suspicious for thyroid malignancy and obtain biopsies when indicated according to major society guidelines. The Bethesda System for Reporting Thyroid Cytopathology along with molecular testing can help guide management decisions regarding thyroid nodules. Surgical resection and other emerging technologies are safe and effective for the treatment of thyroid nodules needing intervention.

Thyroid disorders are common clinical conditions globally. The objective of the present study was to evaluate the physicians\' approach to the diagnosis and treatment of thyroid disorders in Bangladesh.
The present nationally representative cross-sectional study was conducted among 662 physicians of different levels (general practitioners as well as specialists) from different hospitals in Bangladesh from January to June 2023. A self-administered semi-structured questionnaire including information about demographics and practice patterns for the diagnosis and management of thyroid disorders was used for data collection. Descriptive statistics were used to analyze the data.
The American Thyroid Association (ATA) guidelines were the most commonly followed guidelines for the diagnosis and management of thyroid disorders (60%), followed by the American Association of Clinical Endocrinologists (AACE) guidelines (18%) and the European Thyroid Association (ETA) guidelines (9%). Serum TSH, free T3 and free T4 levels were the most frequently used diagnostic tests for the evaluation and follow-ups of both hypothyroid and hyperthyroid states in adults, pregnant women and children, followed by total T3 and total T4 levels. Other tests, such as anti-TPO antibody, anti-TG antibody, anti-TPO, ultrasound scan of the thyroid gland, etc., were rarely used by the participating physicians. Levothyroxine at a dose of 25 to 50 mcg and carbimazole at a dose of 30 to 45 mg were the most frequently used drugs for hypothyroid and hyperthyroid patients, respectively. Almost 65% of the physicians suggested routine thyroid function tests before surgery. In addition, more than 90% of the physicians agreed that thyroid screening for pregnancy, neonates, school children and adults would be mandatory.
The majority of the physicians participating in our study followed relevant guidelines for the diagnosis and management of thyroid disorders in Bangladesh. However, there are still some gaps to be improved, as a good number of physicians did not follow specific guidelines for these disorders.

From low-resolution images in the 1960s to current high-resolution technology, ultrasound has proven to be the initial imaging modality of choice for thyroid application. Point-of-care ultrasound has brought the technology to the thyroid specialist. Combined with physical examination, it provides real-time information regarding goiter, thyroid nodules, and thyroid cancer. Ultrasound-guided fine-needle aspiration biopsy has become the accepted norm, with biopsies rarely performed using palpation alone. Advantages of ultrasound-guided biopsy include precise placement of the needle within the nodule, selective sampling of areas with suspicious features, and accurate direction of the biopsy needle to actively growing viable cells in the periphery of the nodule. Education of endocrinologists in thyroid ultrasound began in the late 1990s and by 2016 more than 6000 clinicians had completed an ultrasound course. Concurrent with this rapid expansion of use of thyroid ultrasound was a rise in the diagnosis of small papillary carcinomas, which might have otherwise remained indolent and undetected. The 2009 American Thyroid Association Guidelines for the Management of Thyroid Nodules and Thyroid Cancer recommended biopsy for all solid hypoechoic nodules measuring larger than 1 cm. Attempting to decrease the frequency of biopsies of low-risk nodules, subsequent guidelines have focused on identifying and selectively biopsying those thyroid nodules at higher risk of clinically significant carcinoma based on ultrasound appearance. A major role for thyroid ultrasound has been in both preoperative staging and mapping to help determine the extent of surgery, as well as postoperative monitoring for locoregional soft tissue or lymph node metastases. With the recognition that the increase in papillary carcinoma was predominantly a result of early diagnosis of small often indolent cancers, active surveillance has become a promising management strategy for papillary thyroid microcarcinomas. Thyroid ultrasound is essential to active surveillance of thyroid cancer. Easy access to high-quality ultrasound studies is a requirement for a successful active surveillance program. Thyroid ultrasound has been used to facilitate interventional procedures, including treatment of thyroid nodules, treatment of recurrent thyroid cancer, and therapy of papillary thyroid microcarcinoma.

BACKGROUND: The management of cytologically indeterminate thyroid nodules is challenging for clinicians. This study aimed to compare the diagnostic performance of the Korean Thyroid Imaging Reporting and Data Systems (K-TIRADS) with that of the American College of Radiology (ACR)-TIRADS for predicting the malignancy risk of indeterminate thyroid nodules.
METHODS: Thyroid nodules diagnosed by fine-needle aspiration (FNA) followed by surgery or core needle biopsy at a single referral hospital were enrolled.
RESULTS: Among 200 thyroid nodules, 78 (39.0%) nodules were classified as indeterminate by FNA (Bethesda category III, IV, and V), and 114 (57.0%) nodules were finally diagnosed as malignancy by surgery or core needle biopsy. The area under the curve (AUC) was higher for FNA than for either TIRADS system in all nodules, while all three methods showed similar AUCs for indeterminate nodules. However, for Bethesda category III nodules, applying K-TIRADS 5 significantly increased the risk of malignancy compared to a cytological examination alone (50.0% vs. 26.5%, P=0.028), whereas applying ACR-TIRADS did not lead to a change.
CONCLUSIONS: K-TIRADS and ACR-TIRADS showed similar diagnostic performance in assessing indeterminate thyroid nodules, and K-TIRADS had beneficial effects for malignancy prediction in Bethesda category III nodules.

OBJECTIVE: To compare diagnostic performance and malignancy risk stratification among guidelines set forth by the American Thyroid Association (ATA) in 2015, the American Association of Clinical Endocrinologists (AACE), the American College of Endocrinology (ACE) and the Association Medici Endocrinologi (AME) in 2016, and the American College of Radiology (ACR) in 2017.
METHODS: The retrospective study was approved by the hospital ethics committee, and the informed consent requirement was waived. From October 2015 to March 2016, a total of 230 patients with 230 consecutive thyroid nodules were enrolled in this study. Each nodule was classified by one junior and one senior radiologist separately according to ACR TI-RADS, AACE/ACE/AME and ATA guidelines. The malignancy diagnostic performance and the number of FNA recommendations were pairwise compared among three guidelines using chi-square tests.
RESULTS: Of the 230 thyroid nodules, 137 were malignant, and 93 were benign. However, 19.6% of the nodules (45 of 230) did not match any pattern using the ATA guidelines but with a high risk of malignancy (68.9%). The ACR TI-RADS derived the highest diagnostic performance, from both junior radiologist (AUC 0.815) and senior radiologist (AUC 0.864). The ACR guidelines also showed the greatest level of sensitivity (junior: 86.1%, senior: 94.9%), compared with AACE/ACE/AME and ATA guidelines. The number of thyroid nodules recommended to fine-needle aspiration (FNA) was the lowest (37.8%, 40.4%) by ACR TI-RADS, and meanwhile, the malignant detection rate within these nodules was highest (64.4%, 68.8%).
CONCLUSIONS: The ACR guidelines present a higher level of diagnostic indicators and may offer a meaningful reduction in FNA recommendations with a higher malignancy detection rate.

Previously, fine-needle aspiration biopsy was recommended for any thyroid nodule >1.0 cm in size. In 2015, the American Thyroid Association (ATA) introduced a pattern-based approach for biopsy recommendations based on size and ultrasound (US) characteristics. In 2016, the American College of Radiology (ACR) published the Thyroid Imaging Reporting and Data System, using a point-based system that assesses risk of US characteristics.
This study aims to compare recommendations for thyroid nodule biopsy between the ATA and ACR systems and identify outcomes of nodules with discordant recommendations (DRs). US characteristics, fine-needle aspiration biopsy, and surgical pathology results were evaluated for all patients with >1.0 cm thyroid nodules treated at a single tertiary-care institution from 2010 to 2018.
Inclusion criteria were met by 1100 nodules from 687 patients; 42.8% (n = 471) had DR between the ATA and ACR guidelines. All (100%) DR nodules were not recommended for biopsy by ACR, though 53% were recommended to have follow-up. A majority (79%) of DR nodules were recommended for biopsy by ATA, with the remaining 21% recommended for follow-up. Among surgically excised DR nodules (n = 292), 10.3% (n = 30) nodules were found to be malignant, with the vast majority (90.3%) being well-differentiated carcinoma. Among malignant nodules, the ACR would not have recommended biopsy or follow-up for 26.7% (n = 8).
The ACR classification system is more restrictive compared with the ATA system for recommending thyroid nodule biopsy. This discrepancy could result in confusion for clinicians and delay in diagnosis or therapy for patients with thyroid cancer.

OBJECTIVE: The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) provides guidelines to practitioners who interpret sonographic examinations of thyroid nodules. The purpose of this study is to compare the ACR TI-RADS system with two other well-established guidelines.
METHODS: The ACR TI-RADS, the Korean Society of Thyroid Radiology (KSThR) Thyroid Imaging Reporting and Data System (TIRADS), and the American Thyroid Association guidelines were compared using 3422 thyroid nodules for which pathologic findings were available. The composition, echogenicity, margins, echogenic foci, and size of the nodules were assessed to determine whether a recommendation would be made for fine-needle aspiration or follow-up sonography when each system was used. The biopsy yield of malignant findings, the yield of follow-up, and the percentage of malignant and benign nodules that would be biopsied were determined for all nodules and for nodules 1 cm or larger.
RESULTS: The percentage of nodules that could not be classified was 0%, 3.9%, and 13.9% for the ACR TI-RADS, KSThR TIRADS, and ATA guidelines, respectively. The biopsy yield of malignancy was 14.2%, 10.2%, and 10.0% for nodules assessed by the ACR TI-RADS, KSThR TIRADS, and ATA guidelines, respectively. The percentage of malignant nodules that were biopsied was 68.2%, 78.7%, and 75.9% for the ACR TI-RADS, the KSThR TIRADS, and the ATA guidelines, respectively, whereas the percentage of malignant nodules that would be either biopsied or followed was 89.2% for the ACR TI-RADS. The percentage of benign nodules that would be biopsied was 47.1%, 79.7%, and 78.1% for the ACR TI-RADS, the KSThR TIRADS, and the ATA guidelines, respectively. The percentage of benign nodules that would be either biopsied or followed was 65.2% for the ACR TI-RADS.
CONCLUSIONS: The ACR TI-RADS performs well when compared with other well-established guidelines.

To minimize potential harm from overuse of fine-needle aspiration, Thyroid Imaging Reporting and Data Systems (TIRADSs) were developed for thyroid nodule risk stratification. The purpose of this study was to perform validation of three scoring risk-stratification models for thyroid nodules using ultrasonography features, a web-based malignancy risk-stratification system, and a model developed by the Korean Society of Thyroid Radiology and the American College of Radiology.
Using ultrasonography images, radiologists assessed thyroid nodules according to the following criteria: internal content, echogenicity of the solid portion, shape, margin, and calcifications. A total of 954 patients (Mage = 50.8 years; range 13-86 years) with 1112 nodules were evaluated at the authors\' institute from January 2013 to December 2014. The discrimination ability of the three models was assessed by estimating the area under the receiver operating characteristic curve. Additionally, Hosmer-Lemeshow goodness-of-fit statistics (calibration ability) were used to evaluate the agreement between the observed and expected number of nodules that were benign or malignant.
Thyroid malignancy was present in 37.2% (414/1112) of nodules. According to the 14-point web-based scoring risk-stratification system, malignancy risk ranged from 4.5% to 100.0% and was positively associated with an increase in risk scores. The areas under the receiver operating characteristic curve of the validation set were 0.884 in the web-based model, 0.891 in the Korean Society of Thyroid Radiology model, and 0.875 in the American College of Radiology model. The Hosmer-Lemeshow goodness-of-fit test indicated that the web-based scoring system showed the best-calibrated result, with a p-value of 0.078.
The three scoring risk-stratification models using the ultrasonography features of thyroid nodules to stratify malignancy risk showed acceptable predictive accuracy and similar areas under the curve. The web-based scoring system demonstrated the strongest agreement in calibration ability analysis. The easily accessible automated web-based scoring risk-stratification system may overcome the complexity of the various Thyroid Imaging Reporting and Data System guidelines and provide simplified guidance on personalized and optimal management in real practice.

OBJECTIVE: Guidelines for managing thyroid nodules are highly dependent on risk stratification based on sonographic findings. The purpose of this study is to evaluate the risk stratification system used by the American College of Radiology Thyroid Imaging Reporting and Data System (TIRADS).
METHODS: Patients with thyroid nodules who underwent sonography and fine-needle aspiration were enrolled in a multiinstitutional study. The sonographic nodule features evaluated in the study were composition, echogenicity, margins, and echogenic foci. Images were reviewed by two radiologists who were blinded to the results of cytologic analysis. Nodules were assigned points for each feature, and the points were totaled to determine the final TIRADS level (TR1-TR5). The risk of cancer associated with each point total and final TIRADS level was determined.
RESULTS: A total of 3422 nodules, 352 of which were malignant, were studied. The risk of malignancy was closely associated with the composition, echogenicity, margins, and echogenic foci of the nodules (p < 0.0001, in all cases). An increased aggregate risk of nodule malignancy was noted as the TIRADS point level increased from 0 to 10 (p < 0.0001) and as the final TIRADS level increased from TR1 to TR5 (p < 0.0001). Of the 3422 nodules, 2948 (86.1%) had risk levels that were within 1% of the TIRADS risk thresholds. Of the 474 nodules that were more than 1% outside these thresholds, 88.0% (417/474) had a risk level that was below the TIRADS threshold.
CONCLUSIONS: The aggregate risk of malignancy for nodules associated with each individual TIRADS point level (0-10) and each final TIRADS level (TR1-TR5) falls within the TIRADS risk stratification thresholds. A total of 85% of all nodules were within 1% of the specified TIRADS risk thresholds.