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endo.thyroid-nodule.core.v1

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

endocrinologysubacutechronicadult
Hard-required inputs
0 / 10
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

A thyroid nodule is a FINDING, not a diagnosis: ≈65% population prevalence, only ≈7–15% clinically significant cancer. The job is a sequential Bayesian funnel (TSH → US/TI-RADS → FNA/Bethesda → molecular → management) that spares the benign majority biopsy/surgery (Durante JAMA 2018; ATA 2015 Haugen)

Inputs
2
Actions
0
Advance rule
Set
Advance when

Scope set to the subacute/chronic outpatient nodule funnel with the TSH-first / autonomy-gate frame explicit

Patient inputs (14)

Composition / echogenicity / shape / margin / echogenic-foci point components → TR level → size-based FNA threshold

FNA decision is conditional on size AND TI-RADS category (TR5 ≥1.0 cm, TR4 ≥1.5 cm, TR3 ≥2.5 cm)

Malignancy prior rises at age <20 or >60; active-surveillance progression is age-stratified (young > old, Kuma cohort)

Male sex modestly raises the malignancy prior for the same nodule

Pregnancy defers radionuclide scan and surgery (FNA is safe); surgery if required is timed to the second trimester

Prior childhood head/neck irradiation substantially raises the malignancy prior — lower thresholds

Family MEN2/MTC or known germline RET re-frames the engine toward the medullary pathway + prophylactic-thyroidectomy timing

TSH-FIRST gate — a suppressed TSH re-routes to a radionuclide scan (autonomous/hot nodule) before any FNA; normal/high TSH continues the cytology pathway

Dedicated diagnostic neck US is the core risk-stratification tool — feeds the ACR TI-RADS point score and the FNA size decision

Fixed/hard mass + hoarseness/vocal-cord palsy + rapid growth + fixed cervical adenopathy = anaplastic/aggressive — urgent ENT/oncology, not the routine funnel

When TSH suppressed: I-123/Tc-99m scan to identify an autonomously functioning ("hot") nodule — hot nodules rarely malignant, FNA generally not indicated

Bethesda I–VI cytology category carries the implied (post-test) malignancy risk that drives surveillance vs molecular vs surgery

Afirma GSC / ThyroSeq v3 rule-out for indeterminate Bethesda III/IV — high NPV; PPV conditional on category + institutional prevalence

Medullary pivot — calcitonin ± CEA when suspicious nodule + family MEN2/MTC, diarrhoea/flushing, or indeterminate FNA (MTC does not follow the papillary pathway)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement
  • informationallife_threateninganaplastic_invasive_neck_mass
    Fixed/hard rapidly enlarging thyroid mass + hoarseness/vocal-cord palsy + fixed cervical adenopathy ± airway compromise — anaplastic/aggressive thyroid malignancy (ATA 2015 Haugen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremedullary_carcinoma_calcitonin_pivot
    Suspicious nodule + family MEN2/MTC, diarrhoea/flushing, or indeterminate FNA — elevated serum calcitonin (medullary carcinoma) (Wells ATA MTC 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefamily_men2_ret_prophylactic_timing
    Family history MEN2/MTC or germline RET pathogenic variant — prophylactic-thyroidectomy timing question (Wells ATA MTC 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_nodule_higher_malignancy
    Thyroid nodule in a child/adolescent — higher malignancy fraction than the same nodule in an adult (ATA pediatric 2015 Francis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecomposite_high_suspicion_sonographic_pattern
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereautonomous_nodule_iodine_load_storm_risk
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesuppressed_tsh_autonomous_nodule
    Thyroid nodule with a suppressed TSH — autonomously functioning ("hot") nodule on radionuclide scan (ATA 2016 hyperthyroidism Ross)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatechildhood_neck_radiation_elevated_prior
    Thyroid nodule in a patient with prior childhood head/neck irradiation — substantially elevated malignancy prior (ATA 2015 Haugen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_nodule_timing
    Thyroid nodule discovered in a pregnant patient (ATA 2015 Haugen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateactive_surveillance_progression
    Documented progression of a low-risk papillary microcarcinoma under active surveillance (size enlargement or new nodal metastasis) (Ito 2014; Sugitani/JAES 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecoexisting_hashimoto_background
    Thyroid nodule on a Hashimoto (chronic lymphocytic thyroiditis) background — modestly elevated papillary prior and a non-trivial primary thyroid lymphoma consideration (Lai PMID 28977955; Abbasgholizadeh PMID 34861884)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatetsh_suppression_bone_loss_route
    DTC survivor on prolonged levothyroxine TSH-suppression (TSH <0.1) — iatrogenic subclinical thyrotoxicosis accelerating cortical bone loss and fracture risk, especially post-menopausal/elderly (ATA 2015 Haugen)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildindeterminate_cytology_molecular_decision
    Indeterminate FNA cytology (Bethesda III AUS/FLUS or IV follicular neoplasm) — molecular rule-out vs repeat FNA vs diagnostic lobectomy (Cibas/Ali 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildactive_surveillance_candidacy_assessment
    Cytology-proven low-risk papillary microcarcinoma (T1aN0M0) — formal active-surveillance candidacy decision using the Brito/MSK three-domain framework and age-stratified Kuma progression (Ito PMID 24001104; Brito PMID 26414743; Sugitani/JAES PMID 33023426)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

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)
axis: thyroid_nodule_management_ladderstep 1 - Step 1 — TSH-first + autonomy gate (no nodule drug yet)
Selected step "Step 1 — TSH-first + autonomy gate (no nodule drug yet)" — Any thyroid nodule entering the engine
  • serum TSH (TSH-first gate)
    first line
    biochemical_triage
    triggers: any_thyroid_nodule
    ATA 2015 Haugen (26462967) — TSH is the mandatory first test; a suppressed TSH changes the entire pathway
  • radionuclide (I-123/Tc-99m) thyroid scan
    first line
    functional_imaging
    triggers: suppressed_tsh
    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)

outpatient playbook — drug actions (7)

  1. 1. TSH-first + radionuclide scan if suppressed
    n/a (triage) • n/a • once
    trigger: Any thyroid nodule
    Suppressed TSH → scan; hot nodule rarely malignant → route to endo.hyperthyroidism.core.v1 (ATA 2016 hyperthyroidism Ross 27521067)
  2. 2. US + ACR TI-RADS → size-conditional FNA
    FNA if TR5 ≥1.0 / TR4 ≥1.5 / TR3 ≥2.5 cm; else interval US • n/a • once + interval
    trigger: Non-functioning nodule
    Tessler JACR 2017 (28372962); Grani (30299457) defers 53.4% of biopsies NPV 97.8%
  3. 3. Bethesda routing
    I repeat / II observe / III-IV molecular / V-VI surgery • n/a • once
    trigger: FNA returned
    Cibas/Ali 2017 (29091573); Bongiovanni meta NPV 96.3% (22846422)
  4. 4. Molecular rule-out (Afirma GSC / ThyroSeq v3)
    NPV 96–97% rule-out; PPV prevalence-dependent • n/a • once
    trigger: Bethesda III/IV
    Patel (29799911); Steward (30419129); Livhits RCT no significant difference (33300952)
  5. 5. Active surveillance (no-drug) for low-risk PTMC
    serial neck US • n/a • defined cadence
    trigger: Low-risk T1aN0M0 PTMC, appropriate candidate
    Ito Kuma 1235-cohort (24001104); Brito/MSK (26414743); Sugitani/JAES (33023426)
  6. 6. Lobectomy vs total thyroidectomy ± RAI
    risk-stratified surgery; RAI per ATA recurrence risk • surgical / I-131 • once
    trigger: Bethesda V/VI, molecular+, AS progression, medullary
    ATA 2015 Haugen (26462967); Wells ATA MTC 2015 (25810047)
  7. 7. levothyroxine — post-op replacement ± TSH-suppression
    post-total ~1.6 µg/kg/day; suppression depth risk-stratified • PO • once daily
    trigger: Post-thyroidectomy
    ATA 2015 Haugen (26462967); route ongoing care to endo.hypothyroidism.core.v1; rxcui 10582 in-repo

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Thyroid nodule incidentally seen on neck CT/MRI/US/PET (incidentaloma) (Durante JAMA 2018; ATA 2015); Palpable thyroid nodule / anterior neck mass on exam (ATA 2015 Haugen); Suppressed TSH with a thyroid nodule — functional autonomy screen (ATA 2016 hyperthyroidism Ross).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Thyroid nodule evaluation (TI-RADS → FNA → Bethesda → management)** (endo.thyroid-nodule.core.v1).
Phenotype framing: MECE terminal split: benign colloid/hyperplastic nodule vs indeterminate follicular-patterned lesion vs papillary thyroid carcinoma vs MEDULLARY carcinoma (calcitonin/RET pivot — does NOT follow the papillary FNA pathway) vs anaplastic carcinoma vs primary thyroid lymphoma vs metastasis. The TSH→TI-RADS→Bethesda→molecular chain (conditional on age/radiation/family) is the decisive pivot (ATA 2015 Haugen; Cibas/Ali 2017; Wells ATA MTC 2015)
Scope: A thyroid nodule is a FINDING, not a diagnosis: ≈65% population prevalence, only ≈7–15% clinically significant cancer. The job is a sequential Bayesian funnel (TSH → US/TI-RADS → FNA/Bethesda → molecular → management) that spares the benign majority biopsy/surgery (Durante JAMA 2018; ATA 2015 Haugen)

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)** — step "Step 1 — TSH-first + autonomy gate (no nodule drug yet)".
1. serum TSH (TSH-first gate) (biochemical_triage, first line) — ATA 2015 Haugen (26462967) — TSH is the mandatory first test; a suppressed TSH changes the entire pathway
2. radionuclide (I-123/Tc-99m) thyroid scan (functional_imaging, first line) — 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)

Setting playbook (outpatient) — Run the Bayesian funnel — TSH-first/autonomy gate → ACR TI-RADS size-threshold FNA → Bethesda routing → molecular rule-out for indeterminate → active surveillance vs surgery → post-op levothyroxine — sparing the benign majority biopsy/surgery while catching the malignant minority and the medullary pivot (ATA 2015 Haugen; Tessler 2017; Cibas/Ali 2017; Wells ATA MTC 2015)
3. TSH-first + radionuclide scan if suppressed n/a (triage) n/a once — Any thyroid nodule (Suppressed TSH → scan; hot nodule rarely malignant → route to endo.hyperthyroidism.core.v1 (ATA 2016 hyperthyroidism Ross 27521067))
4. US + ACR TI-RADS → size-conditional FNA FNA if TR5 ≥1.0 / TR4 ≥1.5 / TR3 ≥2.5 cm; else interval US n/a once + interval — Non-functioning nodule (Tessler JACR 2017 (28372962); Grani (30299457) defers 53.4% of biopsies NPV 97.8%)
5. Bethesda routing I repeat / II observe / III-IV molecular / V-VI surgery n/a once — FNA returned (Cibas/Ali 2017 (29091573); Bongiovanni meta NPV 96.3% (22846422))
6. Molecular rule-out (Afirma GSC / ThyroSeq v3) NPV 96–97% rule-out; PPV prevalence-dependent n/a once — Bethesda III/IV (Patel (29799911); Steward (30419129); Livhits RCT no significant difference (33300952))
7. Active surveillance (no-drug) for low-risk PTMC serial neck US n/a defined cadence — Low-risk T1aN0M0 PTMC, appropriate candidate (Ito Kuma 1235-cohort (24001104); Brito/MSK (26414743); Sugitani/JAES (33023426))
8. Lobectomy vs total thyroidectomy ± RAI risk-stratified surgery; RAI per ATA recurrence risk surgical / I-131 once — Bethesda V/VI, molecular+, AS progression, medullary (ATA 2015 Haugen (26462967); Wells ATA MTC 2015 (25810047))
9. levothyroxine — post-op replacement ± TSH-suppression post-total ~1.6 µg/kg/day; suppression depth risk-stratified PO once daily — Post-thyroidectomy (ATA 2015 Haugen (26462967); route ongoing care to endo.hypothyroidism.core.v1; rxcui 10582 in-repo)

Non-pharmacologic actions:
- Radionuclide scan for suppressed TSH; route hot nodule to endo.hyperthyroidism.core.v1 (ATA 2016 Ross)
- ACR TI-RADS scoring + size-conditional FNA decision (Tessler JACR 2017)
- Molecular testing for indeterminate Bethesda III/IV (Patel 2018; Steward 2019)
- Active-surveillance enrolment for appropriate low-risk PTMC (Ito 2014; Brito 2016)
- Serum calcitonin/CEA + germline RET for medullary suspicion (Wells ATA MTC 2015)
- Pre-conception / pregnancy timing counselling (defer scan/surgery; FNA safe) (ATA 2015 Haugen)

AVOID / contraindication checks:
- Suppressed_TSH_route_to_radionuclide_scan_before_FNA_hot_nodule_rarely_malignant (ATA 2016 hyperthyroidism Ross 27521067)
- FNA_size_threshold_is_conditional_on_TI RADS_category_TR5_1cm_TR4_1p5cm_TR3_2p5cm (Tessler JACR 2017 28372962)
- Molecular_test_PPV_is_prevalence_dependent_interpret_positive_against_Bethesda_and_institutional_prior (Steward 30419129; Patel 29799911; Livhits 33300952)
- No_LT4_suppressive_therapy_for_benign_nodules (AACE/ACE/AME 2016 Gharib 27167915)
- Medullary_carcinoma_calcitonin_RET_pivot_FNA_may_be_falsely_negative (Wells ATA MTC 2015 25810047)
- Active_surveillance_NOT_appropriate_with_clinical_N1_M1_RLN_paralysis_tracheal_protrusion_aggressive_subtype (Sugitani/JAES 2020 33023426)
- Avoid_TSH_suppression_over_replacement_iatrogenic_thyrotoxicosis_AF_and_fracture_risk (cross ref endo.hypothyroidism.core.v1)
- Pregnancy_defer_radionuclide_scan_and_surgery_FNA_is_safe_surgery_timed_2nd_trimester (ATA 2015 Haugen 26462967)
- RAI_is_risk_stratified_not_routine_for_low_risk_DTC (ATA 2015 Haugen 26462967)
- Sonographic_feature_LRplus_are_NON_independent_do_not_multiply_naively_composite_high_suspicion_LRplus~20_not~78p6 (Remonti 25747526; Woliński 24473342; Moon 25133852)
- Coexisting_Hashimoto_raises_papillary_prior_OR_2p12_and_carries_primary_thyroid_lymphoma_OR_12p92_consider_lymphoma_if_rapidly_enlarging (Lai 28977955; Abbasgholizadeh 34861884)
- Active_surveillance_candidacy_is_a_three_domain_Brito_MSK_decision_not_a_default_immediate_surgery_if_clinical_N1_M1_RLN_palsy_tracheal_protrusion (Brito 26414743; Sugitani/JAES 33023426)
- Autonomous_nodule_iodinated_contrast_or_surgery_can_precipitate_thyroid_storm_pretreat_and_carry_autonomy_iodine_state_forward (ATA 2016 hyperthyroidism Ross 27521067)
- Prolonged_TSH_suppression_drives_cortical_bone_loss_export_to_endo.osteoporosis.core.v1_and_de_escalate_with_excellent_response (ATA 2015 Haugen 26462967)

Monitoring

Regimen monitoring:
- benign nodule: interval neck US by TR level; re-FNA on significant growth or new suspicious features (ATA 2015 Haugen 26462967)
- active surveillance: serial neck US (size + nodal) on a defined cadence; intervene on documented progression (Ito 2014 24001104; Sugitani/JAES 2020 33023426)
- post-thyroidectomy DTC: serum thyroglobulin + anti-Tg-Ab + TSH (risk-stratified target) + neck US (ATA 2015 Haugen 26462967)
- medullary: serial serum calcitonin + CEA (Wells ATA MTC 2015 25810047)
- on TSH-suppression: screen for over-suppression (AF/bone) and de-escalate with excellent response (ATA 2015 Haugen 26462967)
- molecular result: read PPV against the institutional malignancy prevalence prior, not as a fixed probability (Steward 30419129; Patel 29799911)
- composite high-suspicion sonographic pattern: score the conditional-dependence-corrected composite LR+ ≈20, not the naïve feature-product (Remonti 25747526; Woliński 24473342)
- Hashimoto background: track for a rapidly enlarging mass (primary thyroid lymphoma OR 12.92) distinct from a slowly evolving papillary nodule (OR 2.12) (Lai 28977955; Abbasgholizadeh 34861884)
- DTC survivor on TSH-suppression: periodic BMD + bone-turnover surveillance; export suppression depth/duration/menopausal status to endo.osteoporosis.core.v1 (ATA 2015 Haugen 26462967)
- autonomous nodule pre-contrast/pre-surgery: flag thyroid-storm decompensation risk and pre-route to endo.thyroid-storm.core.v1 (ATA 2016 hyperthyroidism Ross 27521067)

Setting (outpatient) monitoring:
- Benign: interval US by TR level; re-FNA on growth/new features (ATA 2015 Haugen)
- Active surveillance: serial neck US, intervene on documented progression (Ito 2014; JAES 2020)
- Post-op DTC: thyroglobulin/anti-Tg-Ab/TSH (risk-stratified) + neck US (ATA 2015 Haugen)
- Medullary: serial calcitonin/CEA (Wells ATA MTC 2015)
- On TSH-suppression: screen for over-suppression (AF/bone) and de-escalate (ATA 2015 Haugen)

Follow-up plan: 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)
- Close-out criterion: Long-term surveillance / discharge / pre-conception plan booked

Monitoring phase: Benign: interval US by TR level (lower-risk longer intervals; re-FNA if significant growth or new suspicious features). Active surveillance: serial neck US (size + nodal) on a defined cadence; intervene on documented progression. Post-thyroidectomy DTC: serum thyroglobulin + anti-Tg antibody + TSH (titrated to a risk-stratified target — suppression for higher recurrence risk) + neck US; on prolonged TSH-suppression add periodic BMD + bone-turnover surveillance and export the suppression depth/duration/menopausal status to endo.osteoporosis.core.v1. Medullary: serial calcitonin/CEA (ATA 2015 Haugen; Ito 2014; Sugitani/JAES 2020; Wells ATA MTC 2015)

Disposition

Current setting: outpatient — Run the Bayesian funnel — TSH-first/autonomy gate → ACR TI-RADS size-threshold FNA → Bethesda routing → molecular rule-out for indeterminate → active surveillance vs surgery → post-op levothyroxine — sparing the benign majority biopsy/surgery while catching the malignant minority and the medullary pivot (ATA 2015 Haugen; Tessler 2017; Cibas/Ali 2017; Wells ATA MTC 2015)

Disposition criteria:
- Continue outpatient endocrinology ± endocrine surgery for the funnel and surveillance (ATA 2015 Haugen)
- Route suppressed-TSH/autonomous nodule → endo.hyperthyroidism.core.v1; post-thyroidectomy hypothyroidism → endo.hypothyroidism.core.v1 (ATA 2015; ATA 2016 Ross)
- Refer pediatric / MEN2-RET / anaplastic to specialist multidisciplinary centre (ATA pediatric 2015 Francis; ATA MTC 2015 Wells)

Escalation triggers (move to higher acuity):
- Fixed/hard rapidly enlarging mass + hoarseness/vocal-cord palsy + fixed adenopathy → urgent ENT/head-neck oncology (anaplastic/invasive) (ATA 2015 Haugen)
- Compressive airway/dysphagia symptoms → expedited surgical evaluation ± airway assessment (ATA 2015 Haugen)
- Documented active-surveillance progression (size growth / new nodal metastasis) → surgery (Sugitani/JAES 2020)
- Elevated serum calcitonin with suspicious nodule → medullary pathway + total thyroidectomy + central neck dissection (Wells ATA MTC 2015)

Patient Action Plan

**Thyroid nodule evaluation & surveillance plan**
Personalised values: ti_rads_level, bethesda_category, molecular_result, management_strategy, tsh_target, pregnancy_plan.

**Benign / stable on surveillance** (green):
Triggers:
- Benign cytology (Bethesda II) or molecular-negative indeterminate nodule (ATA 2015 Haugen)
- Stable size on interval ultrasound
- No new neck symptoms
Actions:
- 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)

**Indeterminate result or on active surveillance for a small cancer** (yellow):
Triggers:
- 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
Actions:
- 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
Contact provider when:
- 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)

**Aggressive / invasive features** (red):
Triggers:
- A hard, fixed, rapidly enlarging neck mass
- New hoarseness with a growing mass (possible vocal-cord involvement)
- Difficulty breathing or swallowing from the mass
Actions:
- 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
Contact provider when:
- Always seek urgent care for a rapidly enlarging fixed neck mass with voice or airway change (ATA 2015 Haugen)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Fixed/hard rapidly enlarging thyroid mass + hoarseness/vocal-cord palsy + fixed cervical adenopathy ± airway compromise — anaplastic/aggressive thyroid malignancy (ATA 2015 Haugen)
- [SEVERE] Suspicious nodule + family MEN2/MTC, diarrhoea/flushing, or indeterminate FNA — elevated serum calcitonin (medullary carcinoma) (Wells ATA MTC 2015)
- [SEVERE] Family history MEN2/MTC or germline RET pathogenic variant — prophylactic-thyroidectomy timing question (Wells ATA MTC 2015)

Citations

- 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 [PMID:26462967](https://pubmed.ncbi.nlm.nih.gov/26462967/)
- Cited evidence (PMID 28372962) [PMID:28372962](https://pubmed.ncbi.nlm.nih.gov/28372962/)
- Cited evidence (PMID 29091573) [PMID:29091573](https://pubmed.ncbi.nlm.nih.gov/29091573/)
- Cited evidence (PMID 22846422) [PMID:22846422](https://pubmed.ncbi.nlm.nih.gov/22846422/)
- Cited evidence (PMID 30419129) [PMID:30419129](https://pubmed.ncbi.nlm.nih.gov/30419129/)

Last reconciled with current guidelines: 2026-05-17.
References
  • 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 — PMID:26462967
  • Cited evidence (PMID 28372962) — PMID:28372962
  • Cited evidence (PMID 29091573) — PMID:29091573
  • Cited evidence (PMID 22846422) — PMID:22846422
  • Cited evidence (PMID 30419129) — PMID:30419129