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Thyroid Nodules 10 22. A low or low-normal serum TSH concentration in patients with multiple nodules may suggest that some nodule(s) may be autonomous. In such cases, a radionuclide (preferably 123 I) thyroid scan should be considered and directly compared to the US images to determine functionality of each nodule >1 cm. FNA should then be considered only for those isofunctioning or nonfunctioning nodules, among which those with high suspicion sonographic pattern should be aspirated preferentially. (WR-L) 23. Given the low false negative rate of US-guided FNA cytology and the higher yield of missed malignancies based upon nodule sonographic pattern rather than growth, the follow up of thyroid nodules with benign cytology diagnoses should be determined by risk stratification based upon ultrasound pattern. A) Nodules with high suspicion US pattern: repeat US and US-guided FNA within 12 months. (SR-M) B) Nodules with low to intermediate suspicion US pattern: repeat US at 12–24 months. If sonographic evidence of growth (20% increase in at least two nodule dimensions with a minimal increase of 2 mm or more than a 50% change in volume) or development of new suspicious sonographic features, the FNA could be repeated or observation continued with repeat US, with repeat FNA in case of continued growth. (WR-L). C) Nodules with very low suspicion US pattern (including spongiform nodules): The utility of surveillance US and assessment of nodule growth as an indicator for repeat FNA to detect a missed malignancy is limited. If US is repeated, it should be done at >24 months. (WR-L) 24. Nodules may be detected on US that do not meet criteria for FNA at initial imaging (Recommendation 8). The strategy for sonographic follow-up of these nodules should be based upon the nodule's sonographic pattern. A) Nodules with high suspicion US pattern: repeat US in 6–12 months (WR-L) B) Nodules with sonographic features of low to intermediate suspicion US pattern: consider repeat US at 12–24 months. (WR-L). C) Nodules >1 cm with very low suspicion US pattern (including spongiform nodules) and pure cyst: the utility and time interval of surveillance US for risk of malignancy is not known. If US is repeated, it should be at >24 months (NR-I). D) Nodules <1 cm with very low suspicion US pattern (including spongiform nodules) and pure cysts do not require routine sonographic follow-up (WR-L). E) Nodules <5 mm without high suspicion US pattern do not require routine sonographic FU and if repeated, the US should be performed at ≥24 months (WR-L). 25. Routine TSH suppression therapy for benign thyroid nodules in iodine sufficient populations is not recommended. Though modest responses to therapy can be detected, the potential harm outweighs benefit for most patients. (SR-H)

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