Thyroid nodules: risk stratification for malignancy with ultrasound and guided biopsy

Replacing palpating fingers with an ultrasound (US) probe has resulted in an epidemic of thyroid nodules. Despite the high prevalence of thyroid nodules in the general population, thyroid malignancy is rare. Although no imaging modality can accurately predict the nature of every nodule, high-resolution US is the most sensitive, easily available and cost-effective diagnostic test available to detect thyroid nodules, measure their dimensions and identify their structure. The presence of calcifications, irregular spiculated outline, hypoechogenicity in a solid nodule, chaotic intranodular vascularity and an elongated shape are well-known US features of malignancy in thyroid nodules. Cervical lymph node metastasis and extrathyroidal extension of a thyroid nodule are highly specific for malignancy but seen infrequently. Spongiform nodules, purely or predominantly cystic nodules, nodules with well-defined hypoechoic halo and echogenic as well as isoechoic nodules are usually benign. None of the US characteristics have 100% accuracy in detecting or excluding malignancy. Fine-needle biopsy is currently the best triage test for pre-operative evaluation of a thyroid nodule. There is no significant difference in the risk for malignancy between palpable and non-palpable nodules and size is not a reliable indicator for their malignant potential. The best tool for risk stratification for malignancy in thyroid nodules is US and guided biopsy of nodules with suspicious imaging features. This is especially relevant in patients with multinodular goitre.