Guidelines for Primary Imaging Test and Biopsy Methods in the Diagnosis of Thyroid Nodules: Joint Report by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency

Hyun Kyung Lim; Eun Ju Ha; In Young Youn; Jung Hyun Yoon; Jung Hwan Baek; Kyung Hyun Do; Miyoung Choi; Jin A Choi; Min Lee; Dong Gyu Na

doi:10.3348/jksr.2018.79.1.1

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This article has been corrected. See "Erratum: Guidelines for Primary Imaging Test and Biopsy Methods in the Diagnosis of Thyroid Nodules: Joint Report by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency" in Volume 79 on page 110.

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Lim, Ha, Youn, Yoon, Baek, Do, Choi, Choi, Lee, and Na: Guidelines for Primary Imaging Test and Biopsy Methods in the Diagnosis of Thyroid Nodules: Joint Report by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency

Review Article

J Korean Soc Radiol 2018;79(1):1-10.

Published online: 19 January 2018

DOI: https://doi.org/10.3348/jksr.2018.79.1.1

Guidelines for Primary Imaging Test and Biopsy Methods in the Diagnosis of Thyroid Nodules: Joint Report by the Korean Society of Radiology and National Evidence-Based Healthcare Collaborating Agency

Hyun Kyung Lim, MD¹, Eun Ju Ha, MD^2,, In Young Youn, MD³, Jung Hyun Yoon, MD⁴, Jung Hwan Baek, MD⁵, Kyung Hyun Do, MD⁵, Miyoung Choi, RN⁶, Jin A Choi, MPH⁵, Min Lee, MPH⁵, Dong Gyu Na, MD⁷

¹Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, Korea

²Department of Radiology, Ajou University School of Medicine, Suwon, Korea

³Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea

⁴Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea

⁵Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

⁶Division for Healthcare Technology Assessment Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea

⁷Department of Radiology, Gangneung Asan Hospital, Gangneung, Korea

^∗Corresponding author: Eun Ju Ha, MD Department of Radiology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Korea. Tel. 82-31-219-4057 Fax. 82-31-219-5852 E-mail:radhej@naver.com

Received 8 November 2017 Revised 5 December 2017 Accepted 7 December 2017

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

The Korean Society of Radiology and the National Evidence-based Healthcare Collaborating Agency developed the guideline for primary imaging and biopsy methods in the diagnosis of thyroid nodules. The development committee, the working committee, and the advisory committee were formed to develop the recommendation. The development committee mainly plays a role of methodological consulting and overall planning and management of the advisory development stage. The working committee was composed of experts recommended by the Korean Society of Thyroid Radiology and conducted a practical adaptation process from the selection of core questions to the final recommendation. The Advisory Committee consisted of clinical experts recommended by the Korean Thyroid Association and reviewed core questions and draft recommendations and participated in the Expert Panel Survey. This guideline recommends cervical ultrasound as the first imaging modality for diagnosis of suspected thyroid nodules and recommends ultrasound-guided fine needle aspiration for histologic diagnosis of thyroid nodules. This guideline is expected to be of significant benefit to clinicians treating thyroid nodules.

Keywords: Thyroid Nodule, Thyroid Neoplasm, Ultrasonography, Biopsy, Fine-Needle

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Fig. 1

Flow diagram of guideline selection (Key Question 1).

Fig. 2

Flow diagram of guideline selection (Key Question 2).

Table 1.

Recommendations Matrix of Existing Guidelines (Key Question 1)

Source Guidelines (Publication Year)	AACE/AME/ETA Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules (2010)	Ultrasonography and the US-Based Management of Thyroid Nodules: Consensus Statement and Recommendations (2011)	British Thyroid Association Guidelines for the Management of Thyroid Cancer (2014)	Thyroid Carcinoma, Version 2. 2015 (NCCN Guideline) (2015)	2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer (2016)
AGREE II (domain 3. rigour of development)	69	41	84	74	63
Recommendation	US evaluation is recommended for • Patients at risk for thyroid malignancy • Patients with palpable thyroid nodules or MNGs • Patients with lymphadenopathy suggestive of a malignant lesion	Among the modern imaging modalities, high-resolution US is the most sensitive diagnostic modality for the detection of the thyroid nodules and it is necessary to perform US for the nodules found after palpation	US is an extremely sensitive examination for thyroid nodules. It can be specific for the diagnosis of thyroid carcinoma (particularly papillary carcinoma), and aids decision making about which nodules to perform FNAC 1) All patients being investigated for possible thyroid cancer should undergo an US of the neck in secondary care by an appropriate, competent practitioner	For thyroid nodules known or suspected on clinical or imaging findings, US recommended	Thyroid sonography with survey of the cervical lymph nodes should be performed in all patients with known or suspected thyroid nodules
Grading of recommendation	Grade B, BEL 3	Not available	Good practice point	Category 2A	Strong recommendation, High-quality evidence

AACE = American Association of Clinical Endocrinologists, AGREE = Appraisal of Guidelines for Research & Evaluation, AME = Associazione Medici Endocrinologi, BEL = best evidence level, ETA = European Thyroid Association, FNAC = fine needle aspiration cytology, MNG = multinodular goiter, NCCN = National Comprehensive Cancer Network, US = ultrasound

Table 2.

Recommendations Matrix of Existing Guidelines (Key Question 2)

Source Guidelines (publication year)	AACE/AME/ETA Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules (2010)	Ultrasonography and the US-Based Management of Thyroid Nodules: Consensus Statement and Recommendations (2011)	British Thyroid Association Guidelines for the Management of Thyroid Cancer (2014)	Thyroid Carcinoma, Version 2. 2015 (NCCN guideline) (2015)	2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer (2016)
AGREE II (domain 3. rigour of development)	69	41	84	74	63
Recommendation	3.7.2.1. How to select nodule(s) for FNA biopsy (Grade B, BEL 3): • FNA biopsy is recommended for nodule(s): - Of diameter larger than 1.0 cm that is solid and hypoechoic on US - Of any size with US findings suggestive of extracapsular growth or metastatic cervical lymph nodes - Of any size with patient history of neck irradiation in childhood or adolescence; PTC, MTC, or MEN 2 in first-degree relatives; previous thyroid surgery for cancer; increased calcitonin levels in the absence of interfering factors - Of diameter smaller than 10 mm along with US findings associated with malignancy (see section 3.7.1.2.); the coexistence of 2 or more suspicious US criteria greatly increases the risk of thyroid cancer • Nodules that are hot on scintigraphy should be excluded from FNA biopsy (see difference in recommendations for children; section 8.4.) 3.7.2.2. FNA Biopsy of Multinodular Glands • It is rarely necessary to biopsy more than 2 nodules when they are selected on the basis of previously described criteria (Grade D) • If a radioisotope scan is available, do not biopsy hot areas (Grade B, BEL 4)	Figure 8	1) US appearances that are indicative of a benign nodule (U1–2) should be regarded as reassuring not requiring FNAC, unless the patient has a statistically high risk of malignancy (Chapter 3.7) 2) If the US appearances are equivocal, indeterminate or suspicious of malignancy (U3–5), an US guided FNAC should follow	THYR-1: Consider FNA based on clinical and sonographic features	(a) FNA is the procedure of choice in the evaluation of thyroid nodules, when clinically indicated
Grading of recommendation	3.7.2.1. Grade B, BEL 3 3.7.2.2. Grade D, Grade B, BEL 4; Grade B, BEL 4	Not available	2++, B	Category 2A	Strong recommendation, High-quality evidence

AACE = American Association of Clinical Endocrinologists, AGREE = Appraisal of Guidelines for Research & Evaluation, AME = Associazione Medici Endocrinologi, BEL = best evidence level, ETA = European Thyroid Association, FNA = fine-needle aspiration, FNAC = fine needle aspiration cytology, MEN = multiple endocrine neoplasia, MTC = medullary thyroid carcinoma, NCCN = National Comprehensive Cancer Network, PTC = papillary thyroid carcinoma, US = ultrasound

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