Should I order a thyroid ultrasound-guided biopsy for a patient with a history of thyroid nodules and a TI-RADS (Thyroid Imaging, Reporting and Data System) 4 classification?

Thyroid Ultrasound-Guided Biopsy for TI-RADS 4 Thyroid Nodules

Yes, you should order an ultrasound-guided biopsy for this patient with TI-RADS 4 thyroid nodules, as these nodules have a significant risk of malignancy and require further evaluation according to established guidelines. 1

Assessment of Current Thyroid Findings

• The patient has a history of hyperthyroidism and thyroid nodules previously identified as TI-RADS 4 (high suspicion) on ultrasound performed on 03/31/2025 1
• The ultrasound showed an enlarged heterogeneous thyroid with bilateral confluent and calcified nodules 1
• TI-RADS 4 classification indicates moderate to high suspicion for malignancy, with recommended follow-up including biopsy 2
• The patient reports persistent cough which could potentially be related to thyroid pathology 1

Indications for Thyroid Nodule Biopsy

• TI-RADS 4 nodules have a significantly higher risk of malignancy compared to lower TI-RADS categories (1-3) 3
• Studies show that high TI-RADS scores (4-5) are associated with papillary thyroid carcinoma in up to 29.4% of cases 2
• The ACR guidelines recommend fine-needle aspiration (FNA) for TI-RADS 4 nodules, especially when they are of significant size 1
• The patient's nodules were described as "calcified," which is one of the suspicious sonographic features that increases malignancy risk 4

Diagnostic Algorithm for This Patient

1. Confirm TI-RADS 4 classification: Review previous ultrasound findings to verify the TI-RADS 4 classification 1
2. Assess nodule size: For TI-RADS 4 nodules, biopsy is generally recommended for nodules ≥1 cm 5
3. Evaluate suspicious features: Calcifications, irregular margins, and heterogeneity all increase suspicion for malignancy 4
4. Consider patient's risk factors: The patient is a smoker, which may increase risk 1

Biopsy Procedure Considerations

• Ultrasound-guided FNA is more accurate, economical, and safer than palpation-guided approaches 5
• The biopsy results should be categorized according to the Bethesda System for Reporting Thyroid Cytopathology 5
• Local anesthesia (1-2% lidocaine) should be used during the procedure 1
• The needle approach can be either via the isthmus or lateral neck region 1

Potential Pitfalls and Caveats

• False-negative results can occur in 5-10% of FNA biopsies, so clinical suspicion should remain if other concerning features are present 5
• The patient's uncontrolled diabetes (A1C >15%) should be addressed before the procedure to reduce infection risk 1
• Anticoagulant medications, if any, should be discontinued prior to the biopsy procedure 1
• While the biopsy is important, the patient's severely uncontrolled diabetes (glucose 328 mg/dL, A1C >15%) represents an urgent medical issue that should be addressed concurrently 1

Expected Outcomes and Follow-up

• Biopsy results will guide further management decisions, including potential surgical intervention if malignancy is confirmed 1
• If the biopsy confirms benign pathology, continued surveillance with ultrasound would be appropriate 1
• For malignant or suspicious findings, referral to an endocrinologist and thyroid surgeon would be indicated 5
• The diagnostic accuracy of combining ultrasound features with FNA cytology significantly improves management decisions 6, 7