Patient handout

Thyroid nodule evaluation (TI-RADS → FNA → Bethesda → management)

PRODUCTION

1. Your condition

This handout is for thyroid nodule evaluation (ti-rads → fna → bethesda → management). Your care team identified this based on: thyroid nodule incidentally seen on neck ct/mri/us/pet (incidentaloma) (durante jama 2018; ata 2015).

Other reasons your team may use this plan: palpable thyroid nodule / anterior neck mass on exam (ata 2015 haugen); suppressed tsh with a thyroid nodule — functional autonomy screen (ata 2016 hyperthyroidism ross); dysphagia / dyspnea / hoarseness / rapid growth — compressive or invasive nodule (ata 2015 haugen).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
serum TSH (TSH-first gate)	—	—	—	ATA 2015 Haugen (26462967) — TSH is the mandatory first test; a suppressed TSH changes the entire pathway
radionuclide (I-123/Tc-99m) thyroid scan	—	—	—	ATA 2016 hyperthyroidism Ross (27521067) — suppressed TSH → scan; an autonomously functioning ("hot") nodule is almost never malignant, FNA generally not indicated → route to endo.hyperthyroidism.core.v1 (toxic adenoma / toxic MNG)

Plan: Thyroid-nodule management ladder — TSH/autonomy gate → TI-RADS size-threshold FNA → Bethesda routing → molecular rule-out → active surveillance (no-drug) → surgery ± RAI → post-thyroidectomy levothyroxine/TSH-suppression (ATA 2015 Haugen; Tessler 2017; Cibas/Ali 2017; Ito 2014; Wells ATA MTC 2015)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Benign / stable on surveillance

If you have:

Benign cytology (Bethesda II) or molecular-negative indeterminate nodule (ATA 2015 Haugen)
Stable size on interval ultrasound
No new neck symptoms

Do this:

Keep your scheduled surveillance ultrasound — most nodules are benign and just need watching (Durante JAMA 2018)
No thyroid hormone is needed to "shrink" a benign nodule (AACE/ACE/AME 2016 Gharib)
Tell your provider if you plan a pregnancy so scans/procedures can be timed safely (ATA 2015 Haugen)

YELLOW — Indeterminate result or on active surveillance for a small cancer

If you have:

Indeterminate cytology (Bethesda III/IV) — molecular testing or repeat biopsy advised (Cibas/Ali 2017)
Low-risk micro-papillary cancer being watched rather than operated (active surveillance) (Ito 2014)
A nodule that is slowly changing on ultrasound

Do this:

Complete the molecular test or repeat biopsy as advised — this often avoids unnecessary surgery (Patel 2018; Steward 2019)
If you are on active surveillance, keep every neck-ultrasound appointment exactly on schedule (Ito 2014; JAES 2020)
Report a new lump, voice change, or trouble swallowing promptly

Call your provider if:

A nodule visibly or palpably enlarges between visits (ATA 2015 Haugen)
New hoarseness or difficulty swallowing/breathing (ATA 2015 Haugen)
You become pregnant while under nodule surveillance (ATA 2015 Haugen)

RED — Aggressive / invasive features

If you have:

A hard, fixed, rapidly enlarging neck mass
New hoarseness with a growing mass (possible vocal-cord involvement)
Difficulty breathing or swallowing from the mass

Do this:

Seek urgent medical care — this needs rapid ENT/oncology evaluation (ATA 2015 Haugen)
A rapidly growing, fixed, hoarse neck mass can be an aggressive thyroid cancer
Bring any prior imaging and pathology results with you

Call your provider if:

Always seek urgent care for a rapidly enlarging fixed neck mass with voice or airway change (ATA 2015 Haugen)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Fixed/hard rapidly enlarging thyroid mass + hoarseness/vocal-cord palsy + fixed cervical adenopathy ± airway compromise — anaplastic/aggressive thyroid malignancy (ATA 2015 Haugen)(life-threatening)
Suspicious nodule + family MEN2/MTC, diarrhoea/flushing, or indeterminate FNA — elevated serum calcitonin (medullary carcinoma) (Wells ATA MTC 2015)
Family history MEN2/MTC or germline RET pathogenic variant — prophylactic-thyroidectomy timing question (Wells ATA MTC 2015)
Thyroid nodule in a child/adolescent — higher malignancy fraction than the same nodule in an adult (ATA pediatric 2015 Francis)
Solid + marked hypoechoic + microcalcification + taller-than-wide + irregular/infiltrative-margin nodule — the composite high-suspicion sonographic pattern (conditional-dependence-corrected composite LR+ ≈20) (Remonti meta-analysis PMID 25747526; Woliński PMID 24473342)
Autonomous (suppressed-TSH/hot) nodule about to receive an iodinated-contrast localisation CT or proceed to thyroid surgery — Jod-Basedow / peri-operative thyroid-storm decompensation risk (ATA 2016 hyperthyroidism Ross)

5. Follow-up

Benign stable: lengthening US intervals, discharge to primary care once stable. Active surveillance: lifelong periodic US with documented intervention triggers and shared decision-making. Treated DTC: long-term thyroglobulin/TSH/US surveillance per ATA recurrence tier, recurrence/return precautions (new neck mass, voice change). Pre-conception/pregnancy timing counselling. Pediatric/MEN2: lifelong specialist follow-up (ATA 2015 Haugen; Ito 2014; ATA pediatric 2015 Francis; ATA MTC 2015 Wells)

6. Sources

Guideline: 2015 ATA Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer (Haugen, Thyroid 2016) + ACR TI-RADS 2017 (Tessler JACR) + 2017 Bethesda System (Cibas/Ali) with NIFTP-adjusted nuance + AACE/ACE/AME 2016 (Gharib); reconciled with ATA 2016 hyperthyroidism (Ross), ATA pediatric 2015 (Francis), ATA MTC 2015 (Wells), and the Kuma/MSK/JAES active-surveillance evidence