What is the treatment for a Thyroid Imaging Reporting and Data System (TI-RADS) 3 thyroid nodule?

Management of TI-RADS 3 Thyroid Nodules

For TI-RADS 3 thyroid nodules, fine-needle aspiration biopsy (FNAB) should be performed to confirm the pathological diagnosis before determining appropriate management. 1

Diagnostic Approach

• TI-RADS 3 nodules are classified as mildly suspicious with a malignancy risk of less than 5% 2
• Initial evaluation should include:
  • Ultrasound characterization to confirm TI-RADS 3 classification 3
  • Fine-needle aspiration biopsy (FNAB) to establish pathological diagnosis 1
  • Assessment of thyroid function tests 1

Management Algorithm Based on FNAB Results

For Benign Nodules (Bethesda II)

• Observation is appropriate for:

  • Asymptomatic nodules with maximal diameter <2 cm 1
  • Nodules without growth over time 1

• Thermal ablation is indicated for benign nodules that:

  • Cause clinical symptoms such as compression 1
  • Create cosmetic concerns or anxiety 1
  • Have maximal diameter ≥2 cm and are increasing gradually 1
  • Are autonomously functioning thyroid nodules 1

For Indeterminate or Suspicious Nodules (Bethesda III-V)

• Further evaluation with:
  • Core needle biopsy (CNB) for FNAB-undiagnosed thyroid nodules 1
  • Molecular testing (BRAF/RAS, TERT, PIK3CA, TP53) to assist in diagnosis 1
  • Surgical consultation for definitive management 3

Thermal Ablation Technique

When thermal ablation is indicated:

• Pre-procedure requirements:

  • Discontinue anticoagulant medications 1
  • Complete necessary laboratory tests (blood count, coagulation function, etc.) 1
  • Obtain informed consent after explaining risks and benefits 1

• Procedure details:

  • Local anesthesia with 1-2% lidocaine 1
  • Needle insertion approach via either isthmus or lateral neck region 1
  • Post-procedure monitoring for complications 1

Follow-up Protocol

• For nodules under observation:

  • Regular ultrasound follow-up at 6-12 month intervals 3
  • Reassessment of nodule size, characteristics, and symptoms 3

• For nodules treated with thermal ablation:

  • Contrast-enhanced ultrasound (CEUS) to evaluate treatment effectiveness 1
  • Assessment of volume reduction rate (VRR) 1

Important Considerations and Caveats

• The ACR TI-RADS scoring system shows 98.8% specificity for identification of benign nodules, but a small proportion of thyroid cancers may be missed 4
• No TI-RADS 3 nodules were associated with Bethesda category V or VI (suspicious or malignant) diagnoses in a large study, supporting conservative management 5
• Family history of thyroid cancer and prior radiotherapy to the neck region are significant risk factors that may warrant more aggressive management 6
• Cervical lymph nodes should always be evaluated by ultrasound when thyroid nodules are found 1

Contraindications to Thermal Ablation

• Severe bleeding tendency 1
• Severe cardiopulmonary insufficiency 1
• Contralateral vocal cord paralysis on the treatment side 1
• Pregnancy and lactation (should be approached with caution) 1

By following this evidence-based approach to TI-RADS 3 nodules, clinicians can minimize unnecessary procedures while ensuring appropriate management of potentially concerning thyroid lesions.