Re: Cost-effectiveness of immediate biopsy versus surveillance of intermediate-suspicion thyroid nodules

In their recent paper, Kuo et al. found that ultrasound surveillance was more cost-effective than immediate fine needle aspiration for 1.0 cm thyroid nodules classified as intermediate-suspicion based on the 2015 American Thyroid Association (ATA) guidelines. The authors wrote that Thyroid Imaging, Reporting and Data System (TIRADS), which offers an alternative approach to nodule management, is points-based and recommends 2.5 cm and 1.5 cm size cutoffs for aspiration of mildly and moderately suspicious nodules, respectively. They go on to say that their results support the TIRADS threshold for moderately suspicious nodules, which is higher than that from the ATA, citing a 2009 paper by Horvath et al as the source for TIRADS. Although, to the best of our knowledge, that publication was the first to employ the TIRADS acronym, we believe that Kuo et al were actually referring to American College of Radiology Thyroid Imaging, Reporting and Data System (ACR TI-RADS), which was published in 2017. We are pleased that the current study supports our recommendations, which refer fewer thyroid nodules for biopsy and provide a specific ultrasound surveillance plan for suspicious nodules that do not meet criteria for biopsy. We are currently involved in an international effort to harmonize differences in guidelines for thyroid nodule management based on ultrasound, which we believe will benefit practitioners and patients alike. Analysis of costs, such as the study by Kuo et al, will provide valuable guidance for this effort.