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Guidelines

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European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: The EU-TIRADS

Russ G.a · Bonnema S.J.b · Erdogan M.F.c · Durante C.d · Ngu R.e · Leenhardt L.a

Author affiliations

aThyroid and Endocrine Tumors, Institute of Endocrinology, Pitié Salpêtrière Hospital, Pierre and Marie Curie University, Paris, France
bDepartment of Endocrinology, Odense University Hospital, Odense, Denmark
cDepartment of Endocrinology and Metabolism, University of Ankara School of Medicine, İbni Sina Hastanesi, Ankara, Turkey
dDepartment of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
eHead Neck and Thyroid Imaging, Department of Radiology, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, United Kingdom

Corresponding Author

Laurence Leenhardt, MD, PhD

Thyroid and Endocrine Tumors Institute of Endocrinology, Pitié Salpêtrière Hospital

Pierre and Marie Curie University, 83 Bd de l’Hôpital

FR–75651 Paris Cedex 13 (France)

E-Mail laurence.leenhardt@aphp.fr

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Eur Thyroid J 2017;6:225–237

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Abstract

Thyroid ultrasound (US) is a key examination for the management of thyroid nodules. Thyroid US is easily accessible, noninvasive, and cost-effective, and is a mandatory step in the workup of thyroid nodules. The main disadvantage of the method is that it is operator dependent. Thyroid US assessment of the risk of malignancy is crucial in patients with nodules, in order to select those who should have a fine needle aspiration (FNA) biopsy performed. Due to the pivotal role of thyroid US in the management of patients with nodules, the European Thyroid Association convened a panel of international experts to set up European guidelines on US risk stratification of thyroid nodules. Based on a review of the literature and on the American Association of Clinical Endocrinologists, American Thyroid Association, and Korean guidelines, the panel created the novel European Thyroid Imaging and Reporting Data System, called EU-TIRADS. This comprises a thyroid US lexicon; a standardized report; definitions of benign and low-, intermediate-, and high-risk nodules, with the estimated risks of malignancy in each category; and indications for FNA. Illustrated by numerous US images, the EU-TIRADS aims to serve physicians in their clinical practice, to enhance the interobserver reproducibility of descriptions, and to simplify communication of the results.

© 2017 European Thyroid Association. Published by S. Karger AG, Basel


References

  1. Russ G, Leboulleux S, Leenhardt L, Hegedüs L: Thyroid incidentalomas: epidemiology, risk stratification with ultrasound and workup. Eur Thyroid J 2014; 3:154–163.
  2. Ross DS: Nonpalpable thyroid nodules – managing an epidemic. J Clin Endocrinol Metab 2002; 87:1938–1940.
  3. Burman KD, Wartofsky L: Thyroid nodules. N Engl J Med 2015; 373:2347–2356.
  4. Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, Panunzi C, Rinaldi R, Toscano V, Pacella CM: Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab 2002; 7:1941–1946.
  5. Bonavita JA, Mayo J, Babb J, Bennett G, Oweity T, Macari M, Yee J: Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules can be left alone? AJR Am J Roentgenol 2009; 193:207–213.
  6. Kim EK, Park CS, Chung WY, Oh KK, Kim DI, Lee JT, Yoo HS: New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR Am J Roentgenol 2002; 178:687–691.
  7. Rago T, Vitti P, Chiovato L, Mazzeo S, De Liperi A, Miccoli P, Viacava P, Bogazzi F, Martino E, Pinchera A: Role of conventional ultrasonography and color flow-Doppler sonography in predicting malignancy in “cold” thyroid nodules. Eur J Endocrinol 1998; 138:41–46.
  8. Brito JP, Gionfriddo MR, Al Nofal A, Boehmer KR, Leppin AL, Reading C, Callstrom M, Elraiyah TA, Prokop LJ, Stan MN, Murad MH, Morris JC, Montori VM: The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab 2014; 99:1253–1263.
  9. Remonti LR, Kramer CK, Leitão CB, Pinto LC, Gross JL: Thyroid ultrasound features and risk of carcinoma: a systematic review and meta-analysis of observational studies. Thyroid 2015; 25:538–550.
  10. Campanella P, Ianni F, Rota CA, Corsello SM, Pontecorvi A: Quantification of cancer risk of each clinical and ultrasonographic suspicious feature of thyroid nodules: a systematic review and meta-analysis. Eur J Endocrinol 2014; 170:R203–R211.
  11. Choi SH, Kim EK, Kwak JY, Kim MJ, Son EJ: Interobserver and intraobserver variations in ultrasound assessment of thyroid nodules. Thyroid 2010; 20:167–172.
  12. Reading CC, Charboneau JW, Hay JD, Sebo TJ: Sonography of thyroid nodules: a “classic pattern” diagnostic approach. Ultrasound Q 2005; 21:157–165.
  13. Russ G: Risk stratification of thyroid nodules on ultrasonography with the French TI-RADS: description and reflections. Ultrasonography 2016; 35:25–38.
  14. Horvath E, Majlis S, Rossi R, Franco C, Niedmann JP, Castro A, Dominguez M: An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab 2009; 94:1748–1751.
  15. Russ G, Royer B, Bigorgne C, Rouxel A, Bienvenu-Perrard M, Leenhardt L: Prospective evaluation of thyroid imaging reporting and data system on 4,550 nodules with and without elastography. Eur J Endocrinol 2013; 168:649–655.
  16. Na DG, Baek JH, Sung JY, Kim JH, Kim JK, Choi YJ, Seo H: Thyroid imaging reporting and data system risk stratification of thyroid nodules: categorization based on solidity and echogenicity. Thyroid 2016; 26:562–572.
  17. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L: 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2016; 26:1–133.
  18. Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegedüs L, Paschke R, Valcavi R, Vitti P; AACE/ACE/AME Task Force on Thyroid Nodules: American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules – 2016 update. Endocr Pract 2016; 22:622–639.
  19. Wei X, Li Y, Zhang S, Gao M: Meta-analysis of thyroid imaging reporting and data system in the ultrasonographic diagnosis of 10,437 thyroid nodules. Head Neck 2016; 38:309–315.
  20. Yoon JH, Lee HS, Kim EK, Moon HJ, Kwak JY: Malignancy risk stratification of thyroid nodules: comparison between the Thyroid Imaging Reporting and Data System and the 2014 American Thyroid Association management guidelines. Radiology 2016; 278:917–924.
  21. Su HK, Dos Reis LL, Lupo MA, Milas M, Orloff LA, Langer JE, Brett EM, Kazam E, Lee SL, Minkowitz G, Alpert EH, Dewey EH, Urken ML: Striving toward standardization of reporting of ultrasound features of thyroid nodules and lymph nodes: a multidisciplinary consensus statement. Thyroid 2014; 24:1341–1349.
  22. Andrioli M, Carzaniga C, Persani L: Standardized ultrasound report for thyroid nodules: the endocrinologist’s viewpoint. Eur Thyroid J 2013; 2:37–48.
  23. Grant EG, Tessler FN, Hoang JK, Langer JE, Beland MD, Berland LL, Cronan JJ, Desser TS, Frates MC, Hamper UM, Middleton WD, Reading CC, Scoutt LM, Stavros AT, Teefey SA: Thyroid ultrasound reporting lexicon: white paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee. J Am Coll Radiol 2015; 12(pt A):1272–1279.
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  25. Virmani V, Hammond I: Sonographic patterns of benign thyroid nodules: verification at our institution. AJR Am J Roentgenol 2011; 196:891–895.
  26. Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, Jung HK, Choi JS, Kim BM, Kim EK: Thyroid Imaging Reporting and Data System for US features of nodules: a step in establishing better stratification of cancer risk. Radiology 2011; 260:892–899.
  27. Machens A, Holzhausen HJ, Dralle H: The prognostic value of primary tumor size in papillary and follicular thyroid carcinoma. Cancer 2005; 103:2269–2273.
  28. Yoon JH, Kim EK, Hong SW, Kwak JY, Kim MJ: Sonographic features of the follicular variant of papillary thyroid carcinoma. J Ultrasound Med 2008; 27:1431–1437.
  29. Kim DS, Kim JH, Na DG, Park SH, Kim E, Chang KH, Sohn CH, Choi YH: Sonographic features of follicular variant papillary thyroid carcinomas in comparison with conventional papillary thyroid carcinomas. J Ultrasound Med 2009; 28:1685–1692.
  30. Yoon JH, Kwon HJ, Kim EK, Moon HJ, Kwak JY: The follicular variant of papillary thyroid carcinoma: characteristics of preoperative ultrasonography and cytology. Ultrasonography 2016; 35:47–54.
  31. Sillery JC, Reading CC, Charboneau JW, Henrichsen TL, Hay ID, Mandrekar JN: Thyroid follicular carcinoma: sonographic features of 50 cases. AJR Am J Roentgenol 2010; 194:44–54.
  32. Na DG, Kim JH, Kim DS, Kim SJ: Thyroid nodules with minimal cystic changes have a low risk of malignancy. Ultrasonography 2016; 35:153–158.
  33. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M: The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid. J Radiol 2011; 92:701–713.
  34. Kim SS, Kim MR, Mok JY, Huh JE, Jeon YK, Kim BH, Kim SJ, Kim YK, Kim IJ: Benign cystic nodules may have ultrasonographic features mimicking papillary thyroid carcinoma during interval changes. Endocr J 2011; 58: 633–638.
  35. Brito JP, Ito Y, Miyauchi A, Tuttle RM: A clinical framework to facilitate risk stratification when considering an active surveillance alternative to immediate biopsy and surgery in papillary microcarcinoma. Thyroid 2016; 26: 144–149.
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  37. Lee CY, Kim SJ, Ko KR, Chung KW, Lee JH: Predictive factors for extrathyroidal extension of papillary thyroid carcinoma based on preoperative sonography. J Ultrasound Med 2014; 33:231–238.
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  39. Moon SJ, Kim DW, Kim SJ, Ha TK, Park HK, Jung SJ: Ultrasound assessment of degrees of extrathyroidal extension in papillary thyroid microcarcinoma. Endocr Pract 2014; 20:1037–1043.
  40. Rim JH, Chong S, Ryu HS, Chung BM, Ahn HS: Feasibility study of ultrasonographic criteria for microscopic and macroscopic extra-thyroidal extension based on thyroid capsular continuity and tumour contour in patients with papillary thyroid carcinomas. Ultrasound Med and Biol 2016; 42:2391–2400.
  41. Chammas MC, de Araujo Filho VJ, Moysés RA, Brescia MD, Mulatti GC, Brandão LG, Cerri GG, Ferraz AR: Predictive value for malignancy in the finding of microcalcifications on ultrasonography of thyroid nodules. Head Neck 2008; 30:1206–1210.
  42. Beland MD, Kwon L, Delellis RA, Cronan JJ, Grant EG: Nonshadowing echogenic foci in thyroid nodules: are certain appearances enough to avoid thyroid biopsy? J Ultrasound Med 2011; 30:753–760.
  43. Malhi H, Beland MD, Cen SY, Allgood E, Daley K, Martin SE, Cronan JJ, Grant EG: Echogenic foci in thyroid nodules: significance of posterior acoustic artifacts. AJR Am J Roentgenol 2014; 203:1310–1316.
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  46. Zhang JZ, Hu B: Sonographic features of thyroid follicular carcinoma in comparison with thyroid follicular adenoma. J Ultrasound Med 2014; 33:221–227.
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Article / Publication Details

First-Page Preview
Abstract of Guidelines

Received: May 04, 2017
Accepted: June 17, 2017
Published online: August 08, 2017
Issue release date: September 2017

Number of Print Pages: 13
Number of Figures: 12
Number of Tables: 2

ISSN: 2235-0640 (Print)
eISSN: 2235-0802 (Online)

For additional information: https://www.karger.com/ETJ

References

  1. Russ G, Leboulleux S, Leenhardt L, Hegedüs L: Thyroid incidentalomas: epidemiology, risk stratification with ultrasound and workup. Eur Thyroid J 2014; 3:154–163.
  2. Ross DS: Nonpalpable thyroid nodules – managing an epidemic. J Clin Endocrinol Metab 2002; 87:1938–1940.
  3. Burman KD, Wartofsky L: Thyroid nodules. N Engl J Med 2015; 373:2347–2356.
  4. Papini E, Guglielmi R, Bianchini A, Crescenzi A, Taccogna S, Nardi F, Panunzi C, Rinaldi R, Toscano V, Pacella CM: Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color-Doppler features. J Clin Endocrinol Metab 2002; 7:1941–1946.
  5. Bonavita JA, Mayo J, Babb J, Bennett G, Oweity T, Macari M, Yee J: Pattern recognition of benign nodules at ultrasound of the thyroid: which nodules can be left alone? AJR Am J Roentgenol 2009; 193:207–213.
  6. Kim EK, Park CS, Chung WY, Oh KK, Kim DI, Lee JT, Yoo HS: New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR Am J Roentgenol 2002; 178:687–691.
  7. Rago T, Vitti P, Chiovato L, Mazzeo S, De Liperi A, Miccoli P, Viacava P, Bogazzi F, Martino E, Pinchera A: Role of conventional ultrasonography and color flow-Doppler sonography in predicting malignancy in “cold” thyroid nodules. Eur J Endocrinol 1998; 138:41–46.
  8. Brito JP, Gionfriddo MR, Al Nofal A, Boehmer KR, Leppin AL, Reading C, Callstrom M, Elraiyah TA, Prokop LJ, Stan MN, Murad MH, Morris JC, Montori VM: The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab 2014; 99:1253–1263.
  9. Remonti LR, Kramer CK, Leitão CB, Pinto LC, Gross JL: Thyroid ultrasound features and risk of carcinoma: a systematic review and meta-analysis of observational studies. Thyroid 2015; 25:538–550.
  10. Campanella P, Ianni F, Rota CA, Corsello SM, Pontecorvi A: Quantification of cancer risk of each clinical and ultrasonographic suspicious feature of thyroid nodules: a systematic review and meta-analysis. Eur J Endocrinol 2014; 170:R203–R211.
  11. Choi SH, Kim EK, Kwak JY, Kim MJ, Son EJ: Interobserver and intraobserver variations in ultrasound assessment of thyroid nodules. Thyroid 2010; 20:167–172.
  12. Reading CC, Charboneau JW, Hay JD, Sebo TJ: Sonography of thyroid nodules: a “classic pattern” diagnostic approach. Ultrasound Q 2005; 21:157–165.
  13. Russ G: Risk stratification of thyroid nodules on ultrasonography with the French TI-RADS: description and reflections. Ultrasonography 2016; 35:25–38.
  14. Horvath E, Majlis S, Rossi R, Franco C, Niedmann JP, Castro A, Dominguez M: An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab 2009; 94:1748–1751.
  15. Russ G, Royer B, Bigorgne C, Rouxel A, Bienvenu-Perrard M, Leenhardt L: Prospective evaluation of thyroid imaging reporting and data system on 4,550 nodules with and without elastography. Eur J Endocrinol 2013; 168:649–655.
  16. Na DG, Baek JH, Sung JY, Kim JH, Kim JK, Choi YJ, Seo H: Thyroid imaging reporting and data system risk stratification of thyroid nodules: categorization based on solidity and echogenicity. Thyroid 2016; 26:562–572.
  17. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, Pacini F, Randolph GW, Sawka AM, Schlumberger M, Schuff KG, Sherman SI, Sosa JA, Steward DL, Tuttle RM, Wartofsky L: 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 2016; 26:1–133.
  18. Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegedüs L, Paschke R, Valcavi R, Vitti P; AACE/ACE/AME Task Force on Thyroid Nodules: American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules – 2016 update. Endocr Pract 2016; 22:622–639.
  19. Wei X, Li Y, Zhang S, Gao M: Meta-analysis of thyroid imaging reporting and data system in the ultrasonographic diagnosis of 10,437 thyroid nodules. Head Neck 2016; 38:309–315.
  20. Yoon JH, Lee HS, Kim EK, Moon HJ, Kwak JY: Malignancy risk stratification of thyroid nodules: comparison between the Thyroid Imaging Reporting and Data System and the 2014 American Thyroid Association management guidelines. Radiology 2016; 278:917–924.
  21. Su HK, Dos Reis LL, Lupo MA, Milas M, Orloff LA, Langer JE, Brett EM, Kazam E, Lee SL, Minkowitz G, Alpert EH, Dewey EH, Urken ML: Striving toward standardization of reporting of ultrasound features of thyroid nodules and lymph nodes: a multidisciplinary consensus statement. Thyroid 2014; 24:1341–1349.
  22. Andrioli M, Carzaniga C, Persani L: Standardized ultrasound report for thyroid nodules: the endocrinologist’s viewpoint. Eur Thyroid J 2013; 2:37–48.
  23. Grant EG, Tessler FN, Hoang JK, Langer JE, Beland MD, Berland LL, Cronan JJ, Desser TS, Frates MC, Hamper UM, Middleton WD, Reading CC, Scoutt LM, Stavros AT, Teefey SA: Thyroid ultrasound reporting lexicon: white paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee. J Am Coll Radiol 2015; 12(pt A):1272–1279.
  24. Tramalloni J, Monpeyssen H, Correas JM, Hélénon O: Thyroid nodule management: ultrasonography, fine-needle cytology (in French). J Radiol 2009; 90(pt 2):362–370.
  25. Virmani V, Hammond I: Sonographic patterns of benign thyroid nodules: verification at our institution. AJR Am J Roentgenol 2011; 196:891–895.
  26. Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, Jung HK, Choi JS, Kim BM, Kim EK: Thyroid Imaging Reporting and Data System for US features of nodules: a step in establishing better stratification of cancer risk. Radiology 2011; 260:892–899.
  27. Machens A, Holzhausen HJ, Dralle H: The prognostic value of primary tumor size in papillary and follicular thyroid carcinoma. Cancer 2005; 103:2269–2273.
  28. Yoon JH, Kim EK, Hong SW, Kwak JY, Kim MJ: Sonographic features of the follicular variant of papillary thyroid carcinoma. J Ultrasound Med 2008; 27:1431–1437.
  29. Kim DS, Kim JH, Na DG, Park SH, Kim E, Chang KH, Sohn CH, Choi YH: Sonographic features of follicular variant papillary thyroid carcinomas in comparison with conventional papillary thyroid carcinomas. J Ultrasound Med 2009; 28:1685–1692.
  30. Yoon JH, Kwon HJ, Kim EK, Moon HJ, Kwak JY: The follicular variant of papillary thyroid carcinoma: characteristics of preoperative ultrasonography and cytology. Ultrasonography 2016; 35:47–54.
  31. Sillery JC, Reading CC, Charboneau JW, Henrichsen TL, Hay ID, Mandrekar JN: Thyroid follicular carcinoma: sonographic features of 50 cases. AJR Am J Roentgenol 2010; 194:44–54.
  32. Na DG, Kim JH, Kim DS, Kim SJ: Thyroid nodules with minimal cystic changes have a low risk of malignancy. Ultrasonography 2016; 35:153–158.
  33. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M: The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid. J Radiol 2011; 92:701–713.
  34. Kim SS, Kim MR, Mok JY, Huh JE, Jeon YK, Kim BH, Kim SJ, Kim YK, Kim IJ: Benign cystic nodules may have ultrasonographic features mimicking papillary thyroid carcinoma during interval changes. Endocr J 2011; 58: 633–638.
  35. Brito JP, Ito Y, Miyauchi A, Tuttle RM: A clinical framework to facilitate risk stratification when considering an active surveillance alternative to immediate biopsy and surgery in papillary microcarcinoma. Thyroid 2016; 26: 144–149.
  36. Leenhardt L, Erdogan MF, Hegedüs L, Mandel SJ, Paschke R, Rago T, Russ G: 2013 European Thyroid Association guidelines for cervical ultrasound scan and ultrasound-guided techniques in the postoperative management of patients with thyroid cancer. Eur Thyroid J 2013; 2:147–159.
  37. Lee CY, Kim SJ, Ko KR, Chung KW, Lee JH: Predictive factors for extrathyroidal extension of papillary thyroid carcinoma based on preoperative sonography. J Ultrasound Med 2014; 33:231–238.
  38. Kwak JY, Kim EK, Youk JH, Kim MJ, Son EJ, Choi SH: Extrathyroid extension of well-differentiated papillary thyroid microcarcinoma on US. Thyroid 2008; 18:609–614.
  39. Moon SJ, Kim DW, Kim SJ, Ha TK, Park HK, Jung SJ: Ultrasound assessment of degrees of extrathyroidal extension in papillary thyroid microcarcinoma. Endocr Pract 2014; 20:1037–1043.
  40. Rim JH, Chong S, Ryu HS, Chung BM, Ahn HS: Feasibility study of ultrasonographic criteria for microscopic and macroscopic extra-thyroidal extension based on thyroid capsular continuity and tumour contour in patients with papillary thyroid carcinomas. Ultrasound Med and Biol 2016; 42:2391–2400.
  41. Chammas MC, de Araujo Filho VJ, Moysés RA, Brescia MD, Mulatti GC, Brandão LG, Cerri GG, Ferraz AR: Predictive value for malignancy in the finding of microcalcifications on ultrasonography of thyroid nodules. Head Neck 2008; 30:1206–1210.
  42. Beland MD, Kwon L, Delellis RA, Cronan JJ, Grant EG: Nonshadowing echogenic foci in thyroid nodules: are certain appearances enough to avoid thyroid biopsy? J Ultrasound Med 2011; 30:753–760.
  43. Malhi H, Beland MD, Cen SY, Allgood E, Daley K, Martin SE, Cronan JJ, Grant EG: Echogenic foci in thyroid nodules: significance of posterior acoustic artifacts. AJR Am J Roentgenol 2014; 203:1310–1316.
  44. Na DG, Kim DS, Kim SJ, Ryoo JW, Jung SL: Thyroid nodules with isolated macrocalcification: malignancy risk and diagnostic efficacy of fine-needle aspiration and core needle biopsy. Ultrasonography 2016; 35:216–219.
  45. Kim BM, Kim MJ, Kim EK, Kwak JY, Hong SW, Son EJ, Kim KH: Sonographic differentiation of thyroid nodules with eggshell calcifications. J Ultrasound Med 2008; 27:1425–1430.
  46. Zhang JZ, Hu B: Sonographic features of thyroid follicular carcinoma in comparison with thyroid follicular adenoma. J Ultrasound Med 2014; 33:221–227.
  47. Moon HJ, Kwak JY, Kim MJ, Son EJ, Kim EK: Can vascularity at power Doppler US help predict thyroid malignancy? Radiology 2010; 255:260–269.
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