Management of Thyroid Nodules with TI-RADS 3 Classification

Assessment and Diagnosis

For a patient with thyroid nodules classified as TI-RADS 3, fine-needle aspiration (FNA) biopsy should be performed for nodules ≥1.5 cm in size, as recommended by the American College of Radiology (ACR) 1
The ultrasound shows heterogeneous echotexture with bilateral nodules, including a mixed nodule in the upper left lobe (1.34 × 1.01 cm), which is approaching the size threshold for FNA biopsy 2
The nodules show solid isoechoic patterns with smooth borders, intra-nodular flow on Doppler, and no micro or macro calcifications, which are characteristics that can be used to evaluate the risk of malignancy 2

Thyroid function tests should be performed as the first laboratory assessment to evaluate thyroid function, according to the American Thyroid Association 1
Fine-needle aspiration (FNA) biopsy is indicated for nodules that meet the size threshold of 1.5 cm for TI-RADS 3 nodules, as recommended by the ACR 1
For nodules not meeting FNA criteria, ultrasound follow-up in 12 months is appropriate to assess for stability, as suggested by the American College of Radiology (ACR) 1
If FNA results are benign, continued ultrasound surveillance is recommended at 12-24 month intervals, according to the American Thyroid Association 1
If FNA results are indeterminate or suspicious for malignancy, further management would include possible molecular testing or surgical consultation, as recommended by the National Comprehensive Cancer Network (NCCN) 1

While most thyroid nodules are benign, proper evaluation is essential to identify the minority that are malignant, as emphasized by the American Cancer Society 1
False-negative results can occur in 5-10% of FNA biopsies, so clinical suspicion should remain if other concerning features develop during follow-up, as noted by the American Thyroid Association 3