the Diagnosis and Management of Thyroid Nodules: - Annexes | EHC

Table 1. Quality and Significance of the four levels of evidence in GRADE

Quality	Current definition	Previous definition
High	We are very confident that the true effect lies close to that of the estimate of the effect	Further research is very unlikely to change our confidence in the estimate of effect
Moderate	We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different	Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate
Low	Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect	Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate
Very low	We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect	Any estimate of effect is very uncertain

Table 2. Factors that determine How to upgrade or downgrade the quality of evidence

Table 3: EU-TIRADS categories with corresponding malignancy risks and indication of FNAC⁽⁸⁾

Table 4: Sonographic Patterns, Estimated Risk of Malignancy, and Fine-Needle Aspiration Guidance for Thyroid Nodules ⁽³⁾.

*Sonographic pattern*	*US features*	*ROM %*	*FNA size cutoff*
High suspicion	Solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule *with* one or more of the following features: irregular margins (infiltrative, micro lobulated), microcalcifications, taller than wide shape, rim calcifications with small extrusive soft tissue component, evidence of ETE	>70–90	Recommend FNA at ≥1 cm
Intermediate suspicion	Hypoechoic solid nodule with smooth margins *without* microcalcifications, ETE, or taller than wide shape	10–20	Recommend FNA at ≥1 cm
Low suspicion	Isoechoic or hyperechoic solid nodule, or partially cystic nodule with eccentric solid areas, *without* microcalcification, irregular margin or ETE, or taller than wide shape.	5–10	Recommend FNA at ≥1.5 cm
Very low suspicion	Spongiform or partially cystic nodules *without* any of the sonographic features described in low, intermediate, or high suspicion patterns	<3	Consider FNA at ≥2 cm Observation without FNA is also a reasonable option
Benign	Purely cystic nodules (no solid component)	<1	No biopsy

Table 5: The Bethesda system for reporting thyroid cytopathology, ROM with clinical management recommendations ⁽⁶⁾.

Diagnostic category	ROM average% (range)	Usual management
Nondiagnostic	13 (5–20)	Repeat with ultrasound guidance
Benign	4 (2–7)	Clinical and sonographic follow-up
Atypia of Undetermined Significance	22 (12–30)	Repeat FNA, molecular testing, diagnostic lobectomy, or surveillance
Follicular neoplasm	30 (23–34)	Molecular testing, diagnostic lobectomy
Suspicious for Malignancy	74 (67–83)	Molecular testing, lobectomy, or near-total thyroidectomy
Malignant	97 (97–100)	Lobectomy or near-total thyroidectomy

the Diagnosis and Management of Thyroid Nodules