Kompetensi K-EMD

(Konsultan Endokrin Metabolik dan Diabetes)

Dr. Ardianto Tamin, SpPD, KEMD

PENDAHULUAN
• K-EMD di Indonesia 144 orang, Palembang 3 orang
• Sp2 Endokrin seluruh Indonesia 35 Orang
• FK UNSRI, FK UI, FK UNPAD, FK UGM, FK UB, FK UNAIR, UNHAS
(Center Pendidikan)
• FK UNSYIAH ACEH, FK UNDIP, FK USU Medan  Peralihan Hospital
Base  University Base
KEAHLIAN KHUSUS
• Endokrin Metabolik dan Diabetes
• Kelenjar Tiroid Advance
• Kelenjar Adrenal
• Metabolisme Lipid dan Obesitas
• Nutrisi Medis
• Kelainan Metabolisme Tulang dan Mineral
• Gangguan Pertumbuhan
• Aspek Hormon dan Infertilitas
• Endokrin Dasar: hipothalamus dan Hipofisis
Layanan Untuk RS
1. Tindakan non Invasive Tiroid
• Aspirasi Kista Tiroid
• PEI (Percutaneus Ethanol Injection)
Ablation
• RFA (Radio Frekuensi Ablasi)
• FNAB dan CNB (Core Needle Biopsy)
2. Bidang Diabetes
• Poliklinik Terpadu Diabetes
• Kaki Diabetic
• Poliklinik Dislipidemia
3. Klinik Obesitas dan Prediabetes
4. Klinik Gangguan Pertumbuhan
5. Poliklinik Hormonal dan Terapi
Aspirasi Kista Tiroid by Guide US
Indikasi : Alat dan Bahan
• Simple Cyst • Needle 22-25
• Kiste Campuran  Histopatologi • Kapas Alkohol
• Kiste Hemoragic yang kecil histopatologi • Spuit 5-20 cc
• Three Way
Kelemahan:
• Recurency/ kambuh
Tarif dan Biaya
• RSMH 500.000-1jt, RSCM 650-800.000-2,5jt
PEI (percutaneus Ethanol Injection)
Indikasi : Alat dan Bahan
• Simple Cyst • Needle 22-25
• Kiste Hemoragic yang kecil< 5-6 cm • Kapas Alkohol
• Spuit 5-20 cc
• Three Way
• Cairan Ethanol 96%
Kelemahan:
• Recurency/ kambuh <<
• Nyeri
Tarif dan Biaya
• RSMH 500/1,5jt, RSCM 850/6,5 jt
FNAB dan CNB (Core Needle Biopsy)
Indikasi : Alat dan Bahan
• Nodul Tiroid • Needle 22-25
• Nodul Campuran • Kapas Alkohol
• Spuit 3-5 cc
• Alkohol 96%
• Objek Glass
• Alat CNB
Kelemahan:
• Nyeri <<
Tarif dan Biaya
• RSMH 450/3jt, RSCM 735/5jt
 RFA
(Radio Frequency Ablation
Background
• Thyroid nodules are common in the general population and occur in 20–70% .
• Thyroid lobectomy or nodule resection is the standard treatment according to the
size of nodules.
• Thyroid nodule with symptomatic or asymptomatic, cosmetic problems and/or
mechanical pressure
• 2002  The first use RFA  thyroid nodule: Prof Jung Hwan Baek, PhD
(Radiologist, Asan Medical Center, Korea)
• 2008  RFA in 33rd European Thyroid Association (ETA) Annual Meeting,
Thessaloniki, Yunani
• 2008 – 2021  >> Guideline Associations.
• Recent studies: RFA to be excellent from both safety and efficacy standpoints, with
patients achieving between 70% - 90% volume reduction rates (VRR)
Development Benign Thyroid Nodules

11,1 % • Large nodules can cause compressive

75,8 %
symptoms
• Some require treatment for cosmetic
13,1 reasons
%
• Surgery and levothyroxine have been
used to treat
• Surgery has several drawbacks and
OR, 3.0 complications
OR, 2.0 • Cost effetiveness

OR, 8.9
C. Durante et.al JAMA 2015:313(9):926-935
Lee GM et.al. Endocrine. 2018
Modalities, technical characteristics, and estimated costs of thermoablation
treatment: RFA

Papini E.et.al, ETA 2020,Eur Thyroid J 2020;9:172–185

RFA has the advantages of minimal invasion
• Simple Operation
Nervus Thyroid
1

• Controllability in
Myoma Total RF
Ablation Breast 2 ablation range
System
Bone
Kidney • Stability
Lung
3 • Reliabilty
Liver
Basic Principles of RFA
Alternating electric current
oscillating between 200 and
1200 kHz
• High Frequency Ablation
Creating frictional heat around the
electrode
• Rapid Vibration and Frictional heat
Near immediate tissue coagulation is
induced at tempeartures between 60-
100oC
• High Temperature
Ablative heating leads to tissue
dehydration and water
vaporization

Heat creates immediate damage to Fibrosis or calcifications after

tumour tissue only in regions very
close to the electrode thermal conductance

• Conductive heat • Joule effect

Wong KP, et.al, International of Endocrinology, 2013

Basic Principles of RF Ablation
RF Generator

Water pump
Cooling

Electrode

Ground Pads
Publish Indication & Guideline for RFA of Thyroid Nodule

2012 Korean 2018 Korean

Korean Society of
Italian AACE (American (KSthR) (KSThR)
Thyroid Radiology
Expert Clinical
(KSthR):
Opinion Endocrinologist)
2009, 2011, and Statement 2016 Guideline
2017 Guideline 2015
2015 Italian 2019 Italian
Opinion MITT Group 2020 ETA
NICE
Austrian (National
ACE AME Statement
(American (American
Thyroid Institute
College of Medicine
Association and Care
Excellence Endocrinology Endocrino
2016 Official
Statement 2016 2016 logy 2016 2019
Guideline Guideline
Guideline 2016 NICE Austria
Statement
MITT-Multidiciplinary Team

Endocrinologist

Oncology Surgeons

Radiologists

Pathologists
11 Statement form MITT Group

Etanol Ablation Indication for Cystic or

1
Predominant Cystic 7 Routinely follow-up with Clinical and US

Thermal Ablation as an option for

2
Predominant cystic 8 Re-Treatment if relapse or Regrowth

Double Cytological confirmation before

3 Thermal Ablation For Nodule Regrowth Need a new
9
Cytological

4 Single Cytological for Low Risk Malignancy

10 Thermal Ablation as an Option for AFTN
Thermal Ablation as a first line Treatment
5 for Benign Thyroid Nodule Small size AFTN can be Treat with Thermal
11 Ablation
Thermal Ablation as a second option for
6 MNNT
MNNT=Multi Nodule Nontoxic, AFTN= Autonomously Functioning Thyroid Nodule
Patient Selection
• In 2012, the Korean Society of Thyroid Radiology made a consensus statement
regarding the treatment of thyroid nodules with RFA.
• Essentially, RFA is indicated either for patients with nodule-related symptoms or
with hyperfunctioning nodule(s) which is causing thyrotoxicosis.
• It is important that, before the ablation, the nodule should be confirmed to be
benign in nature with at least two separate US-guided fine-needle aspiration
cytologies and/or core biopsies.
• In general, RFA is a safe procedure.
• However, we should be cautious in application of RFA in patients who are either
pregnant or having history of serious heart problems

Wong KP, et.al, International of Endocrinology, 2013

Indication of Thermal RF Ablation
Korean thyroid Society of
Radiology 2017
1. Benign thyroid nodule
with symptoms
2. Benign thyroid with
cosmetic complaint
3. AFTNs
4. Recurrent thyroid cancers
in OP Bed, Lymph Nodes
in High Surgical Risk
AFTNs: Autonomously functioning Thyroid Nodules. OP: operation
Symptoms Score using VAS
( Grade 0-10)
Cosmetic score using :
1. No Palpable mass
2. No cosmetic Problem but
palpable mass
3. Cosmetic problems during
swallowing
4. Readily detected cosmetic
problems
Italy Experts Meeting, 2015
1.Large ( > 20 ml) Benign
thyroid nodule with symtoms
& cosmetic complaints
2.AFTNs
3.Recurrent thyroid cancers in
OP Bed, Lymph Nodes when
surgery in contraindicated
and radiolodine is in effective.
4.Nonfuctioning, benign thyroid
(volume < 20 ml) with early
discomport & growth over
time
Roberto G, J. Ultrasound 2015 (18): 421-30
Kim JH, Korean J radiol 2018:19(4):632-55
Pre‑ablation assessment

• Laboratory tests included: CBC, coagulation tests and thyroid function tests.
• Thyroid function tests: fT3, normal range 2.76–6.30 pmol/l, free thyroxine (fT4,
normal range 10.42–24.32 pmol/l) and TSH, normal range 0.23–5.50 mU/l
• US to assess the size, location, component, margin, shape, echogenicity, calcifcation
and vascularity.
• Volume of thyroid nodules: =πabc/6 (V is the volume, while a is the largest
diameter, b and c are the other two perpendicular diameters)
• Nodules were further categorized into three subgroups according to volume as the
small (<10 ml), medium (10–30 ml), and large (>30 ml)
• Before RFA, symptom score was self-measured by patients using a 10-cm visual
analogue scale (grade 0–10).
• The cosmetic score was assessed by a physician (1, no palpable mass; 2, no cosmetic
problem but palpable mass; 3, a cosmetic problem on swallowing only; and 4, a
readily detected cosmetic problem).
Wong KP, et.al, International of Endocrinology, 2013
 RC Pathology Bethesda Italian Australian Japanese
Thy 1 Non-diagnosis for I. Non-diagnostic or TIR 1. Non-diagnostic 1. Non-diagnostic 1. Inadequate
cytological diagnosis. unsatisfactory TIR 1c. Non-diagnostic-
Thy 1c.Non-diagnostic for cystic
cytological diagnosis-Cystic
lesion

Thy2. Non-neoplactic II. Benign TiR 2. Non-malignant 2. Benign 2. Normal or benign

Thy2c. Non-neoplastic-
Cystic lesion

Thy3a. Neoplasma possible AUS/FLUS TIR 3A. LRIL 3. Indeterminate or 3. Indeterminate

atypia/non diagnostic. TIR 3B. HRIL folicular lesion of B. Others
Thy3f. Neoplasma possible, underestimated 3. Indeterminate
suggesting folicular significance A. Follicular neoplasma
neoplasma B. A-1 Favor benign
C. A.2 Borderline
D. A-3 Favor malignant

Thy4. Suspicious for IV. Follicular Neoplasma or TIR 4. Suspicious for 4. Sugestive of folicular 4. Malignancysuspected
malignancy suspicious for follicular malignancy neoplasma
neoplasma

Thy5. Malignant V. Suspiciuos for TIR 5. Malignant 5. Suspicious malignancy 5. Malignant

malignancy
VI. Malignant 6. Malignant

AUS: atypia of undeterminated significancy, FLUS: Follicular lesion of underterminated significance, HIRL: high
risk indeterminated lesion, RC path: Royal college of pathologist
Setting Procedure of Thyroid RFA

Out Patients Clinic Operating Theater

• Korean • >> US
• Local anesthetic • General anesthetic
• Cost effectiveness • Patiens is most relaxed
• Fewer teams • More Teams
RFA Room Facilities
RF
Generator

Saline
Water
Dextrose
PUMP
Spuit

US

Ground
Electrode
Pads

Anestesion
drug
Procedural Steps

• The patient should be positioned in supine with neck slightly extended.

• Local anesthetic with lignocaine or xilocaine is then injected underneath the skin
near the cervical-surrounding soft tissue and thyroid capsule
• Some would also administer premedication of fentanyl and midazolam to
minimize discomfort
• Ground adhesive pads are adhered to both thighs and are connected to RF
generator, and the generator was connected to RF electrode.
• There are two types of RF device and technique for thyroid nodules: Fixed
Ablation and Shot Moving Ablation technique

Wong KP, et.al, International of Endocrinology, 2013

Two type RF Ablation Technique
Fixed Ablation Technique
• Italian Group
• Electrode is a 14-gauge, 10 cm long, four-hook expandable
needle.
• The electrode is a 14-gauge, 10 cm long, four-hook expandable
needle.
• Under US guidance, the electrode is inserted along the greatest
dimension of the nodule.
• The hook is then opened to a maximum of 3.5 cm and placed
with caution so as to avoid injury to vital structures.
• Each hook is recommended to be 10 mm away from thyroid
capsule, 5∼6 mm from pseudocapsule of the outer edge of
nodule, and 15 mm from heat-sensitive cervical structures.
• Lidocaine is injected into superficial cervical tissue and on the
thyroid gland capsule under US guidance.
• Correct position of electrode tips and hook is assessed by US.
• With this technique, a spherical ablative zone is usually
achieved.
• After the ablation, the hooks are retracted and the electrode is
slowly withdrawn after the RF energy has been switched off.
Moving shot technique
• Korean: Prof. Baek
• Electrode is usually 15 cm in length and 17 gauge in size with
1 cm active tip
• Recent modifications have allowed even shorter (7 cm shaft
length) and smaller (18-19 gauge) electrode with active tips
around 0.5, 0.7, 1, 1.5, and 2 cm.
• With these shorter and smaller electrode, it allows better
control and variation of ablation option in treating small or
vital structure closed thyroid nodule.
• The target thyroid nodule is divided into multiple small
conceptual ablation units and during the procedure, each
conceptual unit is being ablated by the moving ablation
electrode tip.
• The electrode is inserted through the isthmus under the US
guidance.
• As a result, the whole course of electrode could be seen and
that greatly reduces the risk of injury of the nearby structures.
• The ablation first starts from the deepest layer up and so the
electrode is slowly withdrawn to the surface.
Wong KP, et.al, International of Endocrinology, 2013
RFA Procedure of a benign thyroid nodule

Li J, et.al, Scientific Report , 2021 (11)

 RFA Procedure:
1. The needle is inserted through the isthmus in
order to visualize the entire length of the
electrode and the target nodule.
2. Ablation starts from the deepest portion of the
nodule to the superficial area according to the
order of the numbering of each small conceptual
ablation unit, by moving the electrode tip.
3. The ablation area is small near the peripheral
danger triangle (black triangle), while it is large
in the central, safe area.
4. Recurrent laryngeal nerve (black circle) is within
the danger triangle.
5. The carotid artery (red color), internal jugular
vein (blue color), and vagus nerve (gray color)
are lateral to each thyroid lobe.

Schema of the transisthmic approach and the moving shot technique

IS A SAFE PROCEDURE
Initial Experience of RFA for Benign Thyroid Nodules:
(from 2012-2017 & Several Countries)
Author Hendra,et.al Wang CY Aysan.E Hojat.E Hamidi
Country Indonesia Taiwan Turkey Iran USA
Period 2013-2014 2012 2013-2015 2016-2017 2013-2016
VRR at 1 month 40.1 48.7 - 40 36.8
(%)
VRR at 3 month - 55.3 51.16 67 43.9
(%)
VRR at 6 month 70 51.4 69.21 - 44.2
(%)
VRR at 12 month 80 49.2 - - 54.3
(%)

Hendra Z, et.al, J ASEAN Endocrine Society 2015;30:2

Lee MT, J of Medical Ultrasound 2016;e24:32-8
Aysan E, et.al. Langenbecks Arch Surg 2016;401:357-63
Hojat E,et.al. Iran J radiol2017;5:e48418
Hamidi,et.al. Mayo Clin Proc, XXX, 2018
Initial Experience of RFA for Benign Thyroid Nodules:
(from 2012-2017 & Several Countries)
Author Hendra,et.al Wang CY Aysan.E Hojat.E Hamidi
Diameter > 2cm > 3 cm > 1 cm Subjective > 3 cm
Symptoms
Setting Outpatiens clinic Outpatiens clinic Outpatiens Outpatiens Operation
Operation Clinic Theater
Theather
Anesthesia Local Local Local General Local General
Approach Trans-Isthmic Trans-Isthmic Trans-Isthmic Trans-Isthmic Trans-Isthmic
Direct Nodule
Tchnique Moving Shot Moving Shot Moving Shot Moving Shot Moving Shot
Complications Mild Neck Pain NA Mild Pain NA Mild Neck Pain
Auricular Pain

Hendra Z, et.al, J ASEAN Endocrine Society 2015;30:2

Lee MT, J of Medical Ultrasound 2016;e24:32-8
Aysan E, et.al. Langenbecks Arch Surg 2016;401:357-63
Hojat E,et.al. Iran J radiol2017;5:e48418
Hamidi,et.al. Mayo Clin Proc, XXX, 2018
Result of patients who underwent radiofrequency
ablation for hyperfunctioning thyroid nodule

Wong KP, et.al, International of Endocrinology, 2013

Predective of the efficacy of RF ablation of benign Thyroid nodules

Variable Coefficient (β) Standard error* P value

Age 0.005 0.099 0.959
Gender -3.093 3.492 0.378
Number of treatment sessions 1.640 0.864 0.060
Delivered energy ** 0.140 0.879 0.810
Initial volume -0.587 0.141 <0.001
Initial solidity -0.084 0.032 0.010
Initial vascularity 2.174 1.427 0.130

*Standard error of the estimated coefficient

** Mean energy delivered per millitre of pre-treatment nodule volume

Lim HK, et.al, Eur RadiologyI 2012

Predective of the efficacy of RF ablation of benign Thyroid nodules
Complications RFA
• Various complications during RFA: pain, voice changes, skin burn, hematoma,
nodule rupture, and thyroid function disturbance.
• Most of the patients recover well with proper treatment with very few
complications.
• Korean multicenter study involving 1459 patients, there were 3.3% patients with
complications and, of these, 1.4% had major complications.
• Pain is the most common reported complication during the procedure  It
occasionally radiates to ear, shoulder, jaw, and chest.
• However, it is usually self-limiting and resolved soon when the power of RFA has
been switched off.
• It is controlled with simple oral analgesic and only 5.5% of patients require
analgesic for more than 2 days.
Complications RFA

• Voice change after RFA is uncommon (about 1%) but, nevertheless, it is the most
fearful and serious complication.
• It is likely caused by thermal injury to recurrent laryngeal nerve or sometime
vagal nerve in case of large thyroid nodule.
• Most of the patients recover within 3 months.
• To reduce this, underablation near tracheoesophageal groove is recommended.
Complications following RFA of benign thyroid nodules
(from a systematic review of 3409 patients by Wang et al)
No Complications N cases % Other Research
1 Pain and sensation of heat 281 8,24 2,6-17,5
2 Voice change 32 0,93 0,94
3 Hematoma/hemorrhage 31 0,90
4 Vasovagal reactions 19 0,55
5 Nodule Rupture 14 0.41
6 Horner syndrome 14 0,41
7 Increase in blood pressure 12 0,35
8 Nausea/vomiting 11 0,32
9 Fever 11 0,32
10 Cough 10 0,29
11 Skin burn 6 0,17
12 Reccurrent nerve injury 4 0,11
13 Hypothyroidism 3 0,08
14 Needle track seeding 2 0,05
15 Thyroiditis and thyrotoxicosis 1 0,02
16 Brachial plexus injury 1 0,01
17 Pseudocystic transformation 1 0,01
Side effects and complications RFA

Deandrea M.et al, European J of Endocrinology,2019: 180: 79-87

Complication and side effect RFA of Thyroid Nodules
Intra- Procedure Immediate After Procedure After Procedural ( within 30 days )
Pain ( VAS > 5 ) Swelling Bruise
Bleeding Skin Burn Fever
Intranodule Pseudocystic transformation
Pericapsule Nodule rupture
Vasovagal reaction
Cough

Hendra Z, et.al, RS Zainal Abidin, Banda Aceh

Conclusion: Thyroid nodule rupture after RFA can be classified into three types based on its localization: anterior,
posterolateral, and medial types. Because majority of thyroid nodule ruptures after RFA can be managed
conservatively, familiarity with these imaging features is essential in avoiding unnecessary imaging workup or invasive
procedures.
Short and Long-Term Clinical Efficacy of RFA

Result of volume reduction in patients who underwent radiofrequency ablation for cold thyroid nodule
Wong KP, et.al, International of Endocrinology, 2013
Main findings of studies on RFA long-term outcomes in
patients with benign thyroid nodules
Study Main findings
(N)
Mean VRR 1st Years 5st Years Regrowth Rate

Lim 2013 93,4% 5,6%

Ha 2013 87,2%
Sim 2017 97,7% 24,1%
Jung 2018 (n=276) 80,3% 95,3%
Deandrea 2019 (n=215) 63% 67% 4,1%
Aldea Martinez 2019 76,8% (3 years)
Hong 2019 92,1%
Bernadi 2020 66% vs 82% 79% 17% vs 34%
Bernadi 2021 >49% (IAR)
 Compressive and
cosmetic score
before and at
12 months after
RFA

Deandrea M.et al, European J of Endocrinology,2019: 180: 79-87

Main characteristics of studies on RFA long-term outcomes in
patients with benign thyroid nodules
Comparative Efficacy of RFA with Other Ablative Treatment

Ha EJ, J Clin Endocrinol Metab 100: 1903-11,2015

Efficacy and tolerability of RFA to surgery
Outcomes RFA (n=37) Surgey (n=74) Outcomes RFA (n=37) Surgey (n=74)
Efficay Tolerability
Patients with symptoms 13 43 Patients without 31 68
Resolution of nodule 11 43* levothyroxine prior to
related symptoms treatment
Patients with 12 20
hyperfunctioning Hypothyroidism 0 17*
nodules
Total number of 38 74
ATD withdrawal/thyroid 4 20* procedures
function normalization
Patients with cosmetic 37 74 Postoperative pain 2 74
results
Exellent cosmetic result 35 65* Complication rate 2 10*

*
P<0.05 versus RFA, ATD: antithyroid drugs, RFA: radiofrequency ablation

Bernadi S.et.al, International J of Endorinology, 2014

 Costs of
RFA and
surgery

Bernadi S.et.al, International J of Endorinology, 2014

Overall comparison of surgery versus RFA
Variable Surgery (n=200) RFA (n=200) P value
Residua 11.9% 2.9% .004
Reccurrentb 2.5% 0.05% .100
Complication 6% 1% .002
Postoperative medication 71.5% 0 .002
Mean hospitalization (days) 6.6±1.6 2.1±0.9 .000
Cost (yuan China/dollars US) ɣ15,962± 1073 ɣ15,535±2309 .99
$2556.95±171.88 $2648.74± 369.88

a
Residue is defined as no complicated treatment in single or multiple nodule
b
Recurance is defined as the appearance of a new goiter after treatement

Che Y.et.al, Am J Neuroendocrine 2015

Radiofrequency ablation of thyroid nodules: prospective cost-
effectiveness analysis in comparison to conventional thyroidectomy

Marcelo SS.et al.Arch Endocrinol Metab. 2021;65/6

Follow up: issue?
Conclusions
• Current scientifific literature indicates that RFA is an effective treatment of
benign thyroid nodules.
• The ideal target appears to be: a single, cold, benign, and
symptomatic thyroid nodule, with a baseline volume below
20 mL
• In this nodule, RFA should deliver more than 1300 J/mL, in order to achieve a
satisfactory volume reduction and avoid retreatments in the following 5
years.
RFA di Indonesia
Pelayanan RFA Tiroid: Tarif
• Aceh • RSCM 12,5 jt pasien UMUM
• Jakarta • ACEH: BPJS, Malang BPJS
• Malang
• Banten Harga Alat RFA
• Sumsel? • 450 juta
Algorithm for evaluation and management of patients with thyroid nodules based on US pattern and FNA cytology

Haugen BR E.et.al, ATA 2015, Thyroid J; 26(1): 1–133

ATA nodule sonographic patterns and risk of malignancy
Haugen BR E.et.al, ATA 2015, Thyroid J; 26(1): 1–133
Algorithm of K-TIRADS for malignancy risk stratification based on solidity and echogenicity of thyroid
nodules

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

Recommended US Terminology and Definition for Thyroid Nodules

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

Malignancy Risk Stratification According to Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and FNA Indications

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

Korean Thyroid Imaging Reporting and Data System 5 (high suspicion)

A. Solid hypoechoic nodule with

microcalcifications.
B. Solid hypoechoic nodule with
multiple microcalcifications and
macrocalcifications.
C. Solid hypoechoic nodule with
non-parallel orientation.
D. Solid hypoechoic nodule with
spiculated/microlobulated
margin.
Diagnosis: papillary carcinoma (A-D).

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

Korean Thyroid Imaging Reporting and Data System 4 (intermediate suspicion)

A. Solid hypoechoic nodule without

suspicious US features. Diagnosis:
benign follicular nodule.
B. Solid isoechoic (predominantly
isoechoic) nodule with
microcalcification. Diagnosis: benign
follicular nodule.
C. Predominantly solid hypoechoic
nodule with multiple
microcalcifications. Diagnosis:
papillary carcinoma.
D. Predominantly cystic hypoechoic
nodule with microcalcification
(arrow). Diagnosis: papillary
carcinoma.

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

Korean Thyroid Imaging Reporting and Data System 3 (low suspicion)

None of nodules have any suspicious US

features such as microcalcification, non-
parallel orientation, and spiculated/
microlobulated margins.
A. Solid isoechoic nodule. Diagnosis:
follicular variant papillary carcinoma.
B. Predominantly solid and isoechoic
nodule. Diagnosis: benign follicular
nodule.
C. Predominantly solid and hypoechoic
nodule. Diagnosis: benign follicular
nodule.
D. Predominantly cystic and isoechoic
nodule. Diagnosis: benign follicular
nodule

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

Korean Thyroid Imaging Reporting and Data System 2 (benign)

A. Spongiform nodule. Diagnosis:

benign (FNA not performed).
B. Spongiform nodule with tiny
microcystic changes. Diagnosis:
benign follicular nodule.
C. Predominantly cystic nodule with
multiple comet tail artifacts.
Diagnosis: benign follicular nodule
with colloid.
D. Cyst with comet-tail artifact.
Diagnosis: benign (colloid cyst, FNA
not performed)

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

Recommended Management Based on FNA Results and US Patterns in Thyroid Nodules

AUS = atypia undetermined significance, CNB = core needle biopsy, FLUS = follicular lesions of undetermined
significance, FN = follicular neoplasm, FNA = fine-needle aspiration, K-TIRADS = Korean Thyroid Imaging Reporting
and Data System, SFN = suspicious for a follicular neoplasm, US = ultrasonography

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

Imaging-Based Risk Stratification of Cervical Lymph Nodes for Nodal Metastasis

US Diagnosis and Management of Thyroid Nodules, Korean J Radiol 2016;17(3):370-395

POLIKLINIK KAKI DIABETES
ALAT RFA DAN CNB
PELATIHAN DAN MAGANG DI RSCM
BARAKALLAHU FIIK