Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Ultrasound-guided thyroid biopsy

Manfred Blum, MD, FACP
Section Editor
Douglas S Ross, MD
Deputy Editor
Jean E Mulder, MD


High-resolution ultrasonography provides a detailed map of thyroid nodules and helps to characterize the nodules and adjacent structures in the neck. Thyroid ultrasound, in conjunction with fine-needle aspiration (FNA) biopsy, plays an important role in the evaluation of a patient with a suspected thyroid nodule. The use of ultrasound-guided thyroid biopsy is reviewed here. Other clinical uses of thyroid ultrasonography and an overview of thyroid biopsy, including palpation-guided techniques, limitations, and complications, are discussed separately. (See "Overview of the clinical utility of ultrasonography in thyroid disease" and "Thyroid biopsy".)


Thyroid ultrasound should be performed in all patients with a suspected thyroid nodule or nodular goiter on physical examination or with nodules incidentally noted on other imaging studies (carotid ultrasound, computed tomography [CT], magnetic resonance imaging [MRI], or fludeoxyglucose-positron emission tomography [FDG-PET] scan). There is increasing evidence that the presence of suspicious ultrasound features is more predictive of malignancy than nodule size alone. The decision to biopsy a thyroid nodule should be based upon a combination of ultrasonographic features, a history of factors that increase the risk of thyroid cancer (such as radiation exposure during youth), recent enlargement sustained by the nodule, nodule size, and/or associated painless lymphadenopathy. This topic is reviewed in detail separately. (See "Diagnostic approach to and treatment of thyroid nodules", section on 'Evaluation'.)


Fine-needle aspiration (FNA) biopsy is the procedure of choice for evaluating thyroid nodules and selecting candidates for surgery. If the presence of a thyroid nodule and indication for FNA is confirmed by diagnostic ultrasound and the nodule corresponds to what is palpated on physical examination, FNA can be performed directly without ultrasound guidance. However, ultrasound guidance is often preferred [1,2]. Compared with palpation-guided FNA, the use of ultrasound improves the cytologic diagnostic accuracy rate and reduces the nondiagnostic rate [3-7]. In a retrospective evaluation of 9683 patients with thyroid nodules, 4986 and 4697 patients were evaluated by palpation and ultrasound-guided FNA, respectively [3]. The nondiagnostic rate was significantly higher after palpation-guided FNA (14.1 versus 8.5 percent). Over a 15-year period, over 1000 nodules were resected because of suspicious or malignant cytology on palpation or ultrasound-guided FNA. The false-negative rate was higher in nodules that were biopsied via palpation rather than ultrasound (2.3 versus 1 percent).

When available, we suggest ultrasound-guided FNA for the majority of nodules. Ultrasound-guided FNA is essential for those nodules that are:

Nonpalpable or difficult to palpate

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 30, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Tollin SR, Mery GM, Jelveh N, et al. The use of fine-needle aspiration biopsy under ultrasound guidance to assess the risk of malignancy in patients with a multinodular goiter. Thyroid 2000; 10:235.
  2. Leenhardt L, Hejblum G, Franc B, et al. Indications and limits of ultrasound-guided cytology in the management of nonpalpable thyroid nodules. J Clin Endocrinol Metab 1999; 84:24.
  3. Danese D, Sciacchitano S, Farsetti A, et al. Diagnostic accuracy of conventional versus sonography-guided fine-needle aspiration biopsy of thyroid nodules. Thyroid 1998; 8:15.
  4. Deandrea M, Mormile A, Veglio M, et al. Fine-needle aspiration biopsy of the thyroid: comparison between thyroid palpation and ultrasonography. Endocr Pract 2002; 8:282.
  5. Izquierdo R, Arekat MR, Knudson PE, et al. Comparison of palpation-guided versus ultrasound-guided fine-needle aspiration biopsies of thyroid nodules in an outpatient endocrinology practice. Endocr Pract 2006; 12:609.
  6. Cesur M, Corapcioglu D, Bulut S, et al. Comparison of palpation-guided fine-needle aspiration biopsy to ultrasound-guided fine-needle aspiration biopsy in the evaluation of thyroid nodules. Thyroid 2006; 16:555.
  7. Carmeci C, Jeffrey RB, McDougall IR, et al. Ultrasound-guided fine-needle aspiration biopsy of thyroid masses. Thyroid 1998; 8:283.
  8. Hagag P, Strauss S, Weiss M. Role of ultrasound-guided fine-needle aspiration biopsy in evaluation of nonpalpable thyroid nodules. Thyroid 1998; 8:989.
  9. Steele SR, Martin MJ, Mullenix PS, et al. The significance of incidental thyroid abnormalities identified during carotid duplex ultrasonography. Arch Surg 2005; 140:981.
  10. Carpi A, Nicolini A, Casara D, et al. Nonpalpable thyroid carcinoma: clinical controversies on preoperative selection. Am J Clin Oncol 2003; 26:232.
  11. Moon HJ, Son E, Kim EK, et al. The diagnostic values of ultrasound and ultrasound-guided fine needle aspiration in subcentimeter-sized thyroid nodules. Ann Surg Oncol 2012; 19:52.
  12. Nam-Goong IS, Kim HY, Gong G, et al. Ultrasonography-guided fine-needle aspiration of thyroid incidentaloma: correlation with pathological findings. Clin Endocrinol (Oxf) 2004; 60:21.
  13. Accurso A, Rocco N, Palumbo A, Leone F. Usefulness of ultrasound-guided fine-needle aspiration cytology in the diagnosis of non-palpable small thyroid nodules. Tumori 2005; 91:355.
  14. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009; 19:1167.
  15. Brito JP, Singh-Ospina N, Gionfriddo MR, et al. Restricting ultrasound thyroid fine needle aspiration biopsy by nodule size: which tumors are we missing? A population-based study. Endocrine 2016; 51:499.
  16. Alexander EK, Heering JP, Benson CB, et al. Assessment of nondiagnostic ultrasound-guided fine needle aspirations of thyroid nodules. J Clin Endocrinol Metab 2002; 87:4924.
  17. Redman R, Zalaznick H, Mazzaferri EL, Massoll NA. The impact of assessing specimen adequacy and number of needle passes for fine-needle aspiration biopsy of thyroid nodules. Thyroid 2006; 16:55.
  18. Henrichsen TL, Reading CC, Charboneau JW, et al. Cystic change in thyroid carcinoma: Prevalence and estimated volume in 360 carcinomas. J Clin Ultrasound 2010; 38:361.
  19. Mittendorf EA, Tamarkin SW, McHenry CR. The results of ultrasound-guided fine-needle aspiration biopsy for evaluation of nodular thyroid disease. Surgery 2002; 132:648.
  20. Leung VA, Kirpalani A, Mnatzakanian G, et al. Effect of a Biopsy Center on Adequacy Rates of Thyroid Nodule Fine-Needle Aspiration. AJR Am J Roentgenol 2017; 209:358.
  21. Medina Chamorro FM, Calle JA, Stein JE, et al. Experience of the Implementation of Rapid On-Site Evaluation in Ultrasound-Guided Fine-Needle Aspiration Biopsy of Thyroid Nodules. Curr Probl Diagn Radiol 2017.
  22. Pisani T, Vecchione A, Sinopoli NT, et al. Cytological and immunocytochemical analysis of laterocervical lymph nodes in patients with previous thyroid carcinoma. Anticancer Res 1999; 19:3527.
  23. Boi F, Baghino G, Atzeni F, et al. The diagnostic value for differentiated thyroid carcinoma metastases of thyroglobulin (Tg) measurement in washout fluid from fine-needle aspiration biopsy of neck lymph nodes is maintained in the presence of circulating anti-Tg antibodies. J Clin Endocrinol Metab 2006; 91:1364.
  24. Breslin M, Lawrance JA, Desai M, et al. The role of ultrasound-guided fine-needle aspiration biopsy in the previously treated patient with thyroid cancer. Clin Otolaryngol Allied Sci 2004; 29:146.
  25. Krishnamurthy S, Bedi DG, Caraway NP. Ultrasound-guided fine-needle aspiration biopsy of the thyroid bed. Cancer 2001; 93:199.
  26. Pisani T, Vecchione A, Giovagnolii MR. Galectin-3 immunodetection may improve cytological diagnosis of occult papillary thyroid carcinoma. Anticancer Res 2004; 24:1111.
  27. Nikiforov YE. Molecular diagnostics of thyroid tumors. Arch Pathol Lab Med 2011; 135:569.
  28. Nikiforov YE, Carty SE, Chiosea SI, et al. Highly accurate diagnosis of cancer in thyroid nodules with follicular neoplasm/suspicious for a follicular neoplasm cytology by ThyroSeq v2 next-generation sequencing assay. Cancer 2014; 120:3627.
  29. Chung SY, Oh KK, Chang HS. Sonographic findings of tuberculous thyroiditis in a patient with Behçet's syndrome. J Clin Ultrasound 2002; 30:184.
  30. Basaria S, Ayala AR, Westra WH, Cooper DS. Amyloidosis: role of fine-needle aspiration. Thyroid 2003; 13:313.
  31. Uruno T, Miyauchi A, Shimizu K, et al. Usefulness of thyroglobulin measurement in fine-needle aspiration biopsy specimens for diagnosing cervical lymph node metastasis in patients with papillary thyroid cancer. World J Surg 2005; 29:483.
  32. Kakiuchi Y, Idota N, Nakamura M, Ikegaya H. A Fatal Case of Cervical Hemorrhage After Fine Needle Aspiration and Core Needle Biopsy of the Thyroid Gland. Am J Forensic Med Pathol 2015; 36:207.
  33. Harvey JN, Parker D, De P, et al. Sonographically guided core biopsy in the assessment of thyroid nodules. J Clin Ultrasound 2005; 33:57.
  34. Brenta G, Schnitman M, Bonnahon L, et al. Evaluation of innovative skin-marking technique performed before thyroid ultrasound-guided fine-needle aspiration biopsies. Endocr Pract 2002; 8:5.
  35. Rausch P, Nowels K, Jeffrey RB Jr. Ultrasonographically guided thyroid biopsy: a review with emphasis on technique. J Ultrasound Med 2001; 20:79.
  36. Lyle MA, Dean DS. Ultrasound-guided fine-needle aspiration biopsy of thyroid nodules in patients taking novel oral anticoagulants. Thyroid 2015; 25:373.
  37. Tublin ME, Martin JA, Rollin LJ, et al. Ultrasound-guided fine-needle aspiration versus fine-needle capillary sampling biopsy of thyroid nodules: does technique matter? J Ultrasound Med 2007; 26:1697.
  38. Baloch ZW, Tam D, Langer J, et al. Ultrasound-guided fine-needle aspiration biopsy of the thyroid: role of on-site assessment and multiple cytologic preparations. Diagn Cytopathol 2000; 23:425.