tirads 4 thyroid nodule treatment tirads 4 thyroid nodule treatment

Many studies have not found a clear size/malignancy correlation, and where it has been found, the magnitude of the effect is modest. Bessey LJ, Lai NB, Coorough NE, Chen H, Sippel RS. 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. Until a well-designed validation study is completed, the performance of TIRADS in the real world is unknown. Tessler FN, Middleton WD, Grant EG, et al. The findings that ACR TIRADS has methodological concerns, is not yet truly validated, often performs no better than random selection, and drives significant costs and potential harm, are very unsettling but result from a rational and scientific assessment of the foundational basis of the ACR TIRADS system. Now you can go out and get yourself a thyroid nodule. Save my name, email, and website in this browser for the next time I comment. Thus, the absolute risk of missing important cancer goes from 4.5% to 2.5%, so NNS=100/2=50. The specificity of TIRADS is high (89%) but, perhaps surprisingly, is similar to randomly selecting of 1 in 10 nodules for FNA (90%). We have also estimated the likely costs associated with using the ACR TIRADS guidelines, though for simplicity have not included the costs of molecular testing for indeterminate nodules (which is not readily available in the New Zealand public health system) nor any US follow-up and associated costs. They will want to know what to do with your nodule and what tests to take. 8600 Rockville Pike Once the test is considered to be performing adequately, then it would be tested on a validation data set. Furuya-Kanamori L, Bell KJL, Clark J, Glasziou P, Doi SAR. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. A prospective validation study that determines the true performance of TIRADS in the real-world is needed. It should also be on an intention-to-test basis and include the outcome for all those with indeterminate FNAs. However, many patients undergoing a PET scan will have another malignancy. 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. Clinicians should be using all available data to arrive at an educated estimate of each patients pretest probability of having clinically significant thyroid cancer and use their clinical judgment to help advise each patient of their best options. A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. Differentiation of Thyroid Nodules (C-TIRADS 4) by Combining Contrast-Enhanced Ultrasound Diagnosis Model With Chinese Thyroid Imaging Reporting and Data System Front Oncol. But the test that really lets you see a nodule up close is a CT scan. . 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. Its not something that happens every day, but every day. -. 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). 4b - Suspicious nodules (10-50% risk of malignancy) Score of 2. Disclosure Summary:The authors declare no conflicts of interest. Thyroid nodules are very common and benign in most cases. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. 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 . 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. The ACR TIRADS management flowchart also does not take into account these clinical factors. 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). The health benefit from this is debatable and the financial costs significant. These publications erroneously add weight to the belief that TIRADS is a proven and superior model for the investigation of thyroid nodules. Because the data set prevalence of thyroid cancer was 10%, compared with the generally accepted lower real-world prevalence of 5%, one can reasonably assume that the actual cancer rate in the ACR TIRADS categories in the real world would likely be one-half that quoted from the ACR TIRADS data set, which we illustrate in the following section. Radiology. We have also assumed that all nodules are at least 10 mm and so the TR5 nodule size cutoff of 5 mm does not apply. Using TR1 and TR2 as a rule-out test had excellent sensitivity (97%), but for every additional person that ACR-TIRADS correctly reassures, this requires >100 ultrasound scans, resulting in 6 unnecessary operations and significant financial cost. So, the number needed to scan (NNS) for each additional person correctly reassured is 100 (NNS=100). official website and that any information you provide is encrypted Thyroid nodules are common, affecting around one-half of the population and become increasingly common with advancing age [1, 2]. 4. Second, the proportion of patients in the different ACR TIRADS (TR) categories may, or may not, reflect the real-world population (Table 1). TI-RADS 2: Benign nodules. Your email address will not be published. TI-RADS 1: normal thyroid gland TI-RADS 2: benign nodule TI-RADS 3: highly probable benign nodule TI-RADS 4a: low suspicion for malignancy TI-RADS 4b: high suspicion for malignancy TI-RADS 5: malignant nodule with more than two criteria of high suspicion Imaging features TI-RADS 2 category Constantly benign patterns include simple cyst Such data should be included in guidelines, particularly if clinicians wish to provide evidence-based guidance and to obtain truly informed consent for any action that may have negative consequences. Perhaps surprisingly, the performance ACR-TIRADS may often be no better than random selection. Treatment of patients with the left lobe of the thyroid gland, tirads 3 Cao H, Fan Q, Zhuo S, Qi T, Sun H, Rong X, Xiao X, Zhang W, Zhu L, Wang L. J Ultrasound Med. We aimed to assess the performance and costs of the American College of Radiology Thyroid Image Reporting And Data System (ACR-TIRADS). Alternatively, if random FNAs are performed in 1 in 10 nodules, then 4.5 thyroid cancers (4-5 people per 100) will be missed. Summary Test Performance of Random Selection of 1 in 10 Nodules for FNA, Compared with ACR-TIRADS. Such guidelines do not detail the absolute risk of finding or missing a cancer, nor the often excellent outcome of the treatment of thyroid cancer, nor the potential for unnecessary operations. doi: 10.1111/j.1754-9485.2009.02060.x That particular test is covered by insurance and is relatively cheap. 5. Any additional test has to perform exceptionally well to surpass this clinicians 95% negative predictive performance, without generating false positive results and consequential harm. It is very difficult to know the true prevalence of important, clinically consequential thyroid cancers among patients presenting with thyroid nodules. A re-analysis of thyroid imaging reporting and data system ultrasound scoring after molecular analysis is a cost-effective option to assist with preoperative diagnosis of indeterminate thyroid . Finally, someone has come up with a guide to assist us GPs navigate this difficult but common condition. That particular test is covered by insurance and is relatively cheap. 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. 5 The modified TI-RADS was composed of seven ultrasound features in identifying benign and malignant thyroid nodules, such as the nodular texture, nodular A TR5 cutoff would have NNS of 50 per additional cancer found compared with random FNA of 1 in 10 nodules, and probably a higher NNS if one believes that clinical factors can increase FNA hit rate above the random FNA hit rate. 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]. 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. 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. Clipboard, Search History, and several other advanced features are temporarily unavailable. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. A newer alternative that the doctor can use to treat benign nodules in an office setting is called radiofrequency ablation (RFA). The frequency of different Bethesda categories in each size range . In a patient with normal life expectancy, a biopsy should be performed for nodules >1cm regardless of the ACR TI-RADS risk category. You can then get a more thorough medical evaluation, including a biopsy, which is a small sample of tissue from the nodule to look at under the microscope. It is important to validate this classification in different centres. 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]. They're common, almost always noncancerous (benign) and usually don't cause symptoms. 2022 Jun 7;28:e936368. Radzina M, Ratniece M, Putrins DS, Saule L, Cantisani V. Cancers (Basel). Sometimes a physician may refer you to a specialist (doctor) at a clinic that specializes in thyroid cancer. The optimal investigation and management of the 84% of the population harboring the remaining 50% of cancer remains unresolved. doi: 10.1089/jayao.2019.0098 These figures cannot be known for any population until a real-world validation study has been performed on that population. Whilst our findings have illustrated some of the shortcomings of ACR TIRADS guidelines, we are not able to provide the ideal alternative. ; Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology. View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, American College of Radiology: ACR TI-RADS, Korean Society of Thyroid Radiology: K-TIRADS, iodinated contrast-induced thyrotoxicosis, primary idiopathic hypothyroidism with thyroid atrophy, American Thyroid Association (ATA)guidelines, British Thyroid Association (BTA)U classification, Society of Radiologists in Ultrasound (SRU)guidelines, American College of Radiology:ACR TI-RADS, postoperative assessment after thyroid cancer surgery, ultrasound-guided fine needle aspiration of the thyroid, TIRADS (Thyroid Image Reporing and Data System), colloid type 1:anechoic with hyperechoic spots, nonvascularised, colloid type 2: mixed echogenicity with hyperechoic spots,nonexpansile, nonencapsulated, vascularized, spongiform/"grid" aspect, colloid type 3: mixed echogenicity or isoechoic with hyperechoic spots and solid portion, expansile, nonencapsulated, vascularized, simple neoplastic pattern: solid or mixed hyperechoic, isoechoic, or hypoechoic;encapsulated with a thin capsule, suspicious neoplastic pattern: hyperechoic, isoechoic, or hypoechoic;encapsulated with a thick capsule; hypervascularised; with calcifications (coarse or microcalcifications), malignant pattern A: hypoechoic, nonencapsulated with irregular margins, penetrating vessels, malignant pattern B: isoechoic or hypoechoic, nonencapsulated, hypervascularised, multiple peripheral microcalcifications, malignancy pattern C: mixed echogenicity or isoechoic without hyperechoic spots, nonencapsulated, hypervascularised, hypoechogenicity, especially marked hypoechogenicity, "white knight" pattern in the setting of thyroiditis (numerous hyperechoic round pseudonodules with no halo or central vascularizaton), nodular hyperplasia (isoechoic confluent micronodules located within the inferior and posterior portion of one or two lobes, usually avascular and seen in simple goiters), no sign of high suspicion (regular shape and borders, no microcalcifications), high stiffness with sonoelastography (if available), if >7 mm, biopsy is recommended if TI-RADS 4b and 5 or if patient has risk factors (family history of thyroid cancer or childhood neck irradiation), if >10 mm, biopsy is recommended if TI-RADS 4a or if TI-RADS 3 that has definitely grown (2 mm in two dimensions and >20% in volume). 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]). {"url":"/signup-modal-props.json?lang=us"}, Jha P, Weerakkody Y, Bell D, et al. If a guideline indicates that FNA is recommended, it can be difficult to oppose this based on other factors. We chose a 1 in 10 FNA rate to reflect that roughly 5% of thyroid nodules are palpable and so would likely go forward for FNA, and we considered that a similar number would be selected for FNA based on clinical grounds such as other risk factors or the patient wishes. Full data including 95% confidence intervals are given elsewhere [25]. All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. However, there are ethical issues with this, as well as the problem of overdiagnosis of small clinically inconsequential thyroid cancer. In the TR3 category, there was a gradual difference in cancer rate in those 1-2 cm (6.5%), and those 2-3 cm (8.4%) and those>3 cm (11.3%). Federal government websites often end in .gov or .mil. Please enable it to take advantage of the complete set of features! There are even data showing a negative correlation between size and malignancy [23]. TIRADS 5: probably malignant nodules (malignancy >80%). A negative result with a highly sensitive test is valuable for ruling out the disease. It helps to decide if a thyroid nodule is benign or malignant by combining multiple features on ultrasound. Thyroid nodules come to clinical attention when noted by the patient; by a clinician during routine physical examination; or during a radiologic procedure, such as carotid ultrasonography, neck or chest computed tomography (CT), or positron emission tomography (PET) scanning. If a clinician does no tests and no FNAs, then he or she will miss all thyroid cancers (5 people per 100). A systematic autopsy study, The incidence of thyroid cancer by fine needle aspiration varies by age and gender, Thyroid cancer in the thyroid nodules evaluated by ultrasonography and fine-needle aspiration cytology, Comparison of 5-tiered and 6-tiered diagnostic systems for the reporting of thyroid cytopathology: a multi-institutional study. The process of establishing of CEUS-TIRADS model. It would be unfair to add these clinical factors to only the TIRADS arm or only to the clinical comparator arm, and they would cancel out if added to both arms, hence they were omitted. Cavallo A, Johnson DN, White MG, 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. And because thyroid cancer is often diagnosed in a persons late 30s or 40s, most of us are often diagnosed after the symptoms have already begun. [The diagnostic performance of 2020 Chinese Ultrasound Thyroid Imaging Reporting and Data System in thyroid nodules]. NCI Thyroid FNA State of the Science Conference, The Bethesda System for reporting thyroid cytopathology, ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee, Thyroid nodule size at ultrasound as a predictor of malignancy and final pathologic size, Impact of nodule size on malignancy risk differs according to the ultrasonography pattern of thyroid nodules, TIRADS management guidelines in the investigation of thyroid nodules; an illustration of the concerns, costs and performance, Thyroid nodules with minimal cystic changes have a low risk of malignancy, [The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid], Malignancy risk stratification of thyroid nodules: comparison between the Thyroid Imaging Reporting and Data System and the 2014 American Thyroid Association Management Guidelines, Validation and comparison of three newly-released Thyroid Imaging Reporting and Data Systems for cancer risk determination, Machine learning-assisted system for thyroid nodule diagnosis, Automatic thyroid nodule recognition and diagnosis in ultrasound imaging with the YOLOv2 neural network, Using artificial intelligence to revise ACR TI-RADS risk stratification of thyroid nodules: diagnostic accuracy and utility, A multicentre validation study for the EU-TIRADS using histological diagnosis as a gold standard, Comparison among TIRADS (ACR TI-RADS and KWAK- TI-RADS) and 2015 ATA Guidelines in the diagnostic efficiency of thyroid nodules, Prospective validation of the ultrasound based TIRADS (Thyroid Imaging Reporting And Data System) classification: results in surgically resected thyroid nodules, Diagnostic performance of practice guidelines for thyroid nodules: thyroid nodule size versus biopsy rates, Comparison of performance characteristics of American College of Radiology TI-RADS, Korean Society of Thyroid Radiology TIRADS, and American Thyroid Association Guidelines, Performance of five ultrasound risk stratification systems in selecting thyroid nodules for FNA. It is also relevant to note that the change in nodule appearance over time is poorly predictive of malignancy. Value of Contrast-Enhanced Ultrasound in Adjusting the Classification of Chinese-TIRADS 4 Nodules. Test performance in the TR3 and TR4 categories had an accuracy of less than 60%. We then compare the diagnosis performance of C-TIRADS, CEUS, and CEUS-TIRADS by sensitivity, specificity, and accuracy. Would you like email updates of new search results? These final validation sets must fairly represent the population upon which the test is intended to be applied because the prevalence of the condition in the test population will critically influence the test performance, particularly the positive predictive value (PPV) and negative predictive value (NPV). The difference was statistically significant (P<0.05). To establish a CEUS-TIRADS diagnostic model to differentiate thyroid nodules (C-TIRADS 4) by combining CEUS with Chinese thyroid imaging reporting and data system (C-TIRADS). TIRADS can be welcomed as an objective way to classify thyroid nodules into groups of differing (but as yet unquantifiable) relative risk of thyroid cancer. Following ACR TIRADS management guidelines would likely result in approximately one-half of the TR3 and TR4 patients getting FNAs ((0.537)+(0.323)=25, of total 60), finding up to 1 cancer, and result in 4 diagnostic hemithyroidectomies for benign nodules (250.20.8=4). The results were compared with histology findings. Performance of Contrast-Enhanced Ultrasound in Thyroid Nodules: Review of Current State and Future Perspectives. The cost-effective diagnosis or exclusion of consequential thyroid cancer is an everyday problem faced by all thyroid clinicians. The https:// ensures that you are connecting to the Before Depending on the constellation or number of suspicious ultrasound features, a fine-needle biopsy is . In CEUS analysis, it reflected as equal arrival time, iso-enhancement, homogeneity, and diffuse enhancement, receiving a score of 0 in the CEUS model. 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. sharing sensitive information, make sure youre on a federal Thyroid nodules are a common finding, especially in iodine-deficient regions. Thyroid imaging reporting and data system (TI-RADS)refers to any of several risk stratification systems for thyroid lesions, usually based on ultrasound features, with a structure modelled off BI-RADS. 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. The arrival time, enhancement degree, enhancement homogeneity, enhancement pattern, enhancement ring, and wash-out time were analyzed in CEUS for all of the nodules. An official website of the United States government. Results: Among the 228 C-TIRADS 4 nodules, 69 were determined as C-TIRADS 4a, 114 were C-TIRADS 4b, and 45 were C-TIRADS 4c. National Library of Medicine Friedrich-Rust M, Meyer G, Dauth N et-al. As it turns out, its also very accurate and detailed. In a cost-conscious public health system, one could argue that after selecting out those patients that clearly raise concern for a high risk of cancer (ie, from history including risk factors, examination, existing imaging) the clinician could reasonably inform an asymptomatic patient that they have a 95% chance of their nodule being benign. Unfortunately, the collective enthusiasm for welcoming something that appears to provide certainty has perhaps led to important flaws in the development of the models being overlooked. By CEUS-TIRADS diagnostic model combining CEUS with C-TIRADS, a total of 127 cases were determined as malignancy (111 were malignant and 16 were benign) and 101 were diagnosed as benign ones (5 were malignant and 96 were benign). Your health care provider will examine your neck to feel for changes in your thyroid, such as a lump (nodule) in the thyroid. Department of Endocrinology, Christchurch Hospital. To find 16 TR5 nodules requires 100 people to be scanned (assuming for illustrative purposes 1 nodule per scan). 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 provider may also ask about your risk factors, such as past exposure to radiation and a family history of thyroid cancers. Radiology. A meta-analysis, This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (, Mitoguardin2 is Associated with Hyperandrogenism and Regulates Steroidogenesis in Human Ovarian Granulosa Cells, Factors Associated with Diabetes Distress among Patients with Poorly Controlled Type 2 Diabetes, Serum adiponectin and leptin is not related to skeletal muscle morphology and function in young women, Association Between Metabolic Syndrome Inflammatory Biomarkers and COVID-19 Severity, Long-term outcome of body composition, ectopic lipid and insulin resistance changes with surgical treatment of acromegaly, Volume 7, Issue 4, April 2023 (In Progress), The Journal of Clinical Endocrinology & Metabolism, https://www.uptodate.com/contents/diagnostic-approach-to-and-treatment-of-thyroid-nodules, https://doi.org/10.6084/m9.figshare.11640168.v, http://creativecommons.org/licenses/by-nc-nd/4.0/, Receive exclusive offers and updates from Oxford Academic, 1 in 10 nodules having FNA, assuming pretest probability of cancer of 5%, Negative test being TR1 or TR2; positive test meaning TR3, TR4, or TR5, Positive test meaning TR5; negative test meaning TR1-4, Positive test meaning TR5, TR4 above size cutoff and TR3 above size cutoff; negative test meaning TR1, TR2, TR3 Below Size Cutoff or TR4 below size cutoff, Positive Test Meaning TR5, TR4 Above Size Cutoff and TR3 Above Size Cutoff; negative test meaning TR1, TR2, TR3 below size threshold or TR4 below size cutoff. published a simplified TI-RADS that was prospectively validated 5. The more carefully one looks for incidental asymptomatic thyroid cancers at autopsy, the more are found [4], but these do not cause unwellness during life and so there is likely to be no health benefit in diagnosing them antemortem. If it performs well enough, then the test is applied to a training set of data to better establish performance characteristics. The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 100 nodules in the. Well, there you have it. 2022 Jun 30;12:840819. doi: 10.3389/fonc.2022.840819. 1 Most thyroid nodules are detected incidentally when imaging is performed for another indication. If the nodule got a score of more than 2 in the CEUS schedule, CEUS-TIRADS added 1 category. Thyroid Nodule Characterization: How to Assess the Malignancy Risk. Authors Here at the University of Florida, we are currently recruiting endocrinologists to work with us to help people with thyroid nodules. Required fields are marked *. There are a number of additional issues that should be taken into account when examining the ACR TIRADS data set and resultant management recommendations. 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. Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L. Middleton WD, Teefey SA, Reading CC, et al. It has been retrospectively applied to thyroidectomy specimens, which is clearly not representative of the patient presenting with a thyroid nodule [34-36], and has even been used on the same data set used for TIRADS development, clearly introducing obvious bias [32, 37]. The ACR-TIRADS guidelines also provide easy-to-follow management recommendations that have understandably generated momentum. If the proportions of patients in the different TR groups in the ACR TIRADs data set is similar to the real-world population, then the prevalence of thyroid cancer in the TR3 and TR4 groups is lower than in the overall population of patients with thyroid nodules. 7. The high prevalence of thyroid nodules combined with the generally indolent growth of thyroid cancer present a challenge for optimal patient care. To establish a contrast-enhanced ultrasound (CEUS) diagnostic schedule by CEUS analysis of thyroid nodules of C-TIRADS 4. ", the doctor would like to answer as follows: With the information you provided, you have a homophonic nucleus in the right lobe. Kwak JY, Han KH, Yoon JH et-al. 19 (11): 1257-64. Diag (Basel) (2021) 11(8):137493. The It might even need surge K-TIRADS category was assigned to the thyroid nodules. Disclaimer. To develop a medical test a typical process is to generate a hypothesis from which a prototype is produced. The .gov means its official. These patients are not further considered in the ACR TIRADS guidelines. 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]). But the test that really lets you see a nodule up close is a CT scan. The detection rate of thyroid cancer has increased steeply with widespread utilization of ultrasound (US) and frequent incidental detection of thyroid nodules with other imaging modalities such as computed tomography, magnetic resonance imaging, and, more recently, positron emission tomography-computed tomography, yet the mortality from thyroid cancer has remained static [10, 11].