title: Journal Club: incidental thyroid nodules detected at imaging: can diagnostic workup be reduced by use of the Society of Radiologists in Ultrasound recommendations and the three-tiered system?
abstract: OBJECTIVE
  The purpose of this study was to determine the number of thyroid nodule workups that could be eliminated and the number of malignant tumors that would be missed if the Society of Radiologists in Ultrasound (SRU) recommendations and the three-tiered system were applied to incidental thyroid nodules (ITN) detected at imaging.
  
  
  METHODS
  This retrospective study included ITN in 390 consecutively registered patients who underwent ultrasound-guided fine-needle aspiration of one or more thyroid nodules from July 2010 to June 2011. Images were reviewed, and nodules were categorized according to two workup criteria: ITN seen on ultrasound images were categorized according to SRU recommendations, and those seen on CT, MR, or PET/CT images were classified according to the three-tiered risk-categorization system.
  
  
  RESULTS
  In this study 114 of 390 (29%) patients had nodules first detected incidentally during imaging studies, and 107 patients met the inclusion criteria. These patients had 47 ITN seen at ultrasound and 60 ITN seen at either CT, MRI, or PET/CT. If the SRU recommendations had been applied, 14 of 47 (30%) patients with ITN on ultrasound images would not have received fine-needle aspiration and one of four cases of cancer would have been missed. The missed malignant tumor was a 14-mm localized papillary carcinoma. If the three-tiered system had been applied, 21 of 60 (35%) patients with ITN on CT, MR, or PET/CT images would not have received fine-needle aspiration, but none of the three malignancies would have been missed. Overall, 35 of 107 (33%) of patients with ITN did not meet the SRU recommendations or the three-tiered criteria.
  
  
  CONCLUSIONS
  Use of the SRU recommendations and three-tiered system can reduce the workup of ITN by one third compared with current practice without specific guidelines. One case of localized papillary carcinoma was missed when the SRU recommendations were used.
authors.affiliation: 1 Department of Radiology, Duke University Medical Center, DUMC Box 3808, Durham, NC, 27710.
authors.forename: Hasan A
authors.initials: HA
authors.lastname: Hobbs
authors.forename: Manisha
authors.initials: M
authors.lastname: Bahl
authors.forename: Rendon C
authors.initials: RC
authors.lastname: Nelson
authors.forename: Peter G
authors.initials: PG
authors.lastname: Kranz
authors.forename: Ramon M
authors.initials: RM
authors.lastname: Esclamado
authors.forename: Nathan M
authors.initials: NM
authors.lastname: Wnuk
authors.forename: Jenny K
authors.initials: JK
authors.lastname: Hoang
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D044963:Biopsy, Fine-Needle; D003937:Diagnosis, Differential; D003951:Diagnostic Errors / Q000517:prevention & control; D005260:Female; D006801:Humans; D033162:Incidental Findings; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D049268:Positron-Emission Tomography; D012189:Retrospective Studies; D013964:Thyroid Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology; D016606:Thyroid Nodule / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography