Current Guidelines for the Management of Thyroid Nodules

Robert A. Levine, MD, FACE, ECNU


Endocr Pract. 2012;18(4):596-599. 

In This Article

KSTR Guidelines

In 2011, the KSTR published guidelines for management of thyroid nodules using a different approach. They divided nodules into 3 categories: probably benign, suspicious for malignancy, and indeterminate. Nodules considered probably benign include spongiform nodules and completely cystic or predominantly cystic nodules. Nodules are considered suspicious for malignancy if they have a taller than wide shape, irregular margins, marked hypoechoic echotexture, macrocalcifications or microcalcifications, extracapsular extension, or a spiculated margin. Nodules that cannot be classified in the probably benign or suspicious for malignancy category are considered indeterminate.

The recommendation for biopsy is based on both the category and the size of the nodule. For those nodules considered probably benign, the KSTR guidelines recommend that no follow-up ultrasonography is needed if the nodule is smaller than 1 cm in diameter. For nodules larger than 1 cm and probably benign, they recommend a follow-up ultrasound study at 2 years and at 3 to 5 years. Finally, they recommend "selective use of biopsy" for those nodules thought to be probably benign but larger than 2 cm. The KSTR guidelines recommend biopsy of all nodules exhibiting any feature suspicious for malignancy. They acknowledge, however, that nodules smaller than 5 mm are difficult to biopsy and thus recommend selective fine-needle aspiration biopsy based on the risk factors of the patient and the experience of the clinician. The guidelines recommend biopsy of all nodules larger than 5 mm with a suspicious feature, "if feasible." The KSTR guidelines also recommend a repeated biopsy of any suspicious nodule with benign initial cytologic findings.

For nodules considered indeterminate, with neither benign nor suspicious features, the KSTR guidelines recommend follow-up ultrasonography if the nodule is smaller than 1 cm and biopsy for all such nodules larger than 1 cm. Finally, they recommend that any nodule showing growth (defined as a 20% increase in diameter or a 50% increase in volume) should undergo biopsy.