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NOT FOR PUBLICATION, QUOTATION, OR CITATION
RESOLUTION NO. 16
BE IT RESOLVED,
that the American College of Radiology adopt the ACR–AIUM–
SPR–SRU Practice Guideline for the Performance of a Thyroid and
Parathyroid Ultrasound Examination
Sponsored By:
ACR Council Steering Committee
The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation
oncologists, and clinical medical physicists in the United States. The College is a nonprofit professional society whose primary
purposes are to advance the science of radiology, improve radiologic services to the patient, study the socioeconomic aspects of the
practice of radiology, and encourage continuing education for radiologists, radiation oncologists, medical physicists, and persons
practicing in allied professional fields.
The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic
practice to help advance the science of radiology and to improve the quality of service to patients throughout the United States.
Existing practice guidelines and technical standards will be reviewed for revision or renewal, as appropriate, on their fifth anniversary
or sooner, if indicated.
Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough
consensus process in which it has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety
as well as the ACR Board of Chancellors, the ACR Council Steering Committee, and the ACR Council. The practice guidelines and
technical standards recognize that the safe and effective use of diagnostic and therapeutic radiology requires specific training, skills,
and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical
standard by those entities not providing these services is not authorized .
ACR–AIUM–SPR–SRU PRACTICE GUIDELINE FOR THE
PERFORMANCE OF A THYROID AND PARATHYROID
ULTRASOUND EXAMINATION
PREAMBLE
These guidelines are an educational tool designed to assist practitioners in providing appropriate
radiologic care for patients. They are not inflexible rules or requirements of practice and are not
intended, nor should they be used, to establish a legal standard of care. For these reasons and
those set forth below, the American College of Radiology cautions against the use of these
guidelines in litigation in which the clinical decisions of a practitioner are called into question.
The ultimate judgment regarding the propriety of any specific procedure or course of action must
be made by the physician or medical physicist in light of all the circumstances presented. Thus,
an approach that differs from the guidelines, standing alone, does not necessarily imply that the
approach was below the standard of care. To the contrary, a conscientious practitioner may
responsibly adopt a course of action different from that set forth in the guidelines when, in the
reasonable judgment of the practitioner, such course of action is indicated by the condition of the
patient, limitations of available resources, or advances in knowledge or technology subsequent to
publication of the guidelines. However, a practitioner who employs an approach substantially
different from these guidelines is advised to document in the patient record information sufficient
to explain the approach taken.
Thyroid/Parathyroid Ultrasound
PRACTICE GUIDELINE
2013 Resolution No. 16
NOT FOR PUBLICATION, QUOTATION, OR CITATION
The practice of medicine involves not only the science, but also the art of dealing with the
prevention, diagnosis, alleviation, and treatment of disease. The variety and complexity of human
conditions make it impossible to always reach the most appropriate diagnosis or to predict with
certainty a particular response to treatment. Therefore, it should be recognized that adherence to
these guidelines will not assure an accurate diagnosis or a successful outcome. All that should be
expected is that the practitioner will follow a reasonable course of action based on current
knowledge, available resources, and the needs of the patient to deliver effective and safe medical
care. The sole purpose of these guidelines is to assist practitioners in achieving this objective.
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I.
INTRODUCTION
The clinical aspects contained in specific sections of this guideline (Introduction, Indications,
Specifications of the Examination, and Equipment Specifications) were revised collaboratively by
the American College of Radiology (ACR), and the American Institute of Ultrasound in Medicine
(AIUM), the Society of Pediatric Radiology (SPR), and the Society of Radiologists in
Ultrasound (SRU). Recommendations for physician requirements, written request for the
examination, procedure documentation, and quality control vary between the two among the
organizations and are addressed by each separately.
This guideline has been developed is intended to assist practitioners performing sonographic
evaluations of the thyroid gland, and parathyroid glands, and adjacent soft tissues.
Occasionally, an additional and/or specialized examination with another modality may be
necessary. While it is not possible to detect every abnormality, adherence to the following
guidelines will maximize the probability of detecting most abnormalities that occur in the thyroid
and parathyroid glands.
II.
INDICATIONS
Indications for a thyroid and parathyroid ultrasound (US) examination include, but are not limited
to [1]:
1. Evaluation of the location and characteristics of palpable neck masses, including an
enlarged thyroid.
2. Evaluation of abnormalities detected by other imaging examinations or laboratory studies
e.g., a thyroid nodule detected on computed tomography (CT), positron emission
tomography (PET)-CT, magnetic resonance imaging (MRI), or seen on other
ultrasound examination of the neck (e.g., carotid ultrasound).
3. Evaluation of laboratory abnormalities. areas of abnormal uptake seen on radioisotope
thyroid examinations
4. Evaluation of the presence, size, and location of the thyroid gland.
5. Evaluation of high-risk patients at high risk for occult thyroid malignancy.
6. Follow-up imaging of previously detected thyroid nodules, when indicated.
7. Evaluation for recurrent disease or regional nodal metastases in patients with proven or
suspected thyroid carcinoma prior to thyroidectomy.
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8. Evaluation for recurrent disease or regional nodal metastases after total or partial
thyroidectomy for thyroid carcinoma.
9. Evaluation of the thyroid gland for suspicious nodules prior to neck surgery for
nonthyroid disease [2].
10. Evaluation of the thyroid gland for suspicious nodules prior to radioiodine ablation
of the gland.
11. Identification and localization of parathyroid abnormalities in patients with known
or suspected hyperparathyroidism [3,4].
12. Assessment of the number and size of enlarged parathyroid glands in patients who have
undergone previous parathyroid surgery or ablative therapy with recurrent symptoms of
hyperparathyroidism.
13. Localization of thyroid/parathyroid abnormalities or adjacent cervical lymph nodes
for biopsy, ablation, or other interventional procedures.
14. Localization of autologous parathyroid gland implants.
8. Localization of parathyroid abnormalities in patients with suspected primary or secondary
hyperparathyroidism
III.
QUALIFICATIONS AND RESPONSIBILITIES OF PERSONNEL
Each organization addresses this requirement individually. ACR language is as follows:
See the ACR–SPR–SRU Practice Guideline for Performing and Interpreting Diagnostic
Ultrasound Examinations.
IV.
WRITTEN REQUEST FOR THE EXAMINATION
Each organization addresses this requirement individually. ACR language is as follows:
The written or electronic request for a thyroid and parathyroid ultrasound
examination should provide sufficient information to demonstrate the medical
necessity of the examination and allow for its proper performance and
interpretation.
Documentation that satisfies medical necessity includes 1) signs and symptoms
and/or 2) relevant history (including known diagnoses). Additional information
regarding the specific reason for the examination or a provisional diagnosis
would be helpful and may at times be needed to allow for the proper performance
and interpretation of the examination.
The request for the examination must be originated by a physician or other
appropriately licensed health care provider. The accompanying clinical
information should be provided by a physician or other appropriately licensed
health care provider familiar with the patient’s clinical problem or question and
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consistent with the state’s scope of practice requirements. (ACR Resolution 35,
adopted in 2006)
V.
SPECIFICATIONS OF THE EXAMINATIONS
A. The Thyroid Examination
The examination should be performed with the neck in hyperextension. The right and left lobes of
the thyroid gland should be imaged in at least two projections, in the longitudinal and transverse
planes. Recorded images views of the thyroid should include transverse images of the superior,
mid, and inferior portions of the right and left thyroid lobes; longitudinal images of the medial,
mid, and lateral portions of both lobes; and at least a transverse image of the isthmus. The size of
each thyroid lobe should be recorded in three dimensions, anteroposterior (AP), transverse, and
longitudinal. The thickness (AP measurement) of the isthmus on the transverse view should be
recorded. Color or power Doppler examination can be used to supplement the grayscale
evaluation of either diffuse or focal abnormalities of the thyroid. It is often necessary to
extend imaging to include the soft tissue above the isthmus – for example, to evaluate a
possible pyramidal lobe of the thyroid – or congenital abnormalities such as a thyroglossal
duct cyst, or if any superior palpable abnormality is noted. The examination should also
include a brief evaluation of the lateral neck compartments.
Thyroid abnormalities should be imaged in a way that allows for reporting and
documentation of the following:
Visualized thyroid abnormalities should be documented
1. The location, size, number, and character of significant abnormalities, including
measurements of nodules and focal abnormalities should be documented and
measurements should be made in at least two and preferably in three dimensions.
2. The localized or diffuse nature of any thyroid abnormality, including assessment of
overall gland vascularity [5,6].
3. The sonographic features of any thyroid abnormality with respect to echogenicity,
composition (degree of cystic change), margins (smooth or irregular), presence and
type of calcification (if present), and other relevant sonographic patterns [7-19].
4. The presence and size of any abnormal lymph node in the lateral compartment of
the neck (see section B below).
In patients who have undergone complete or partial thyroidectomy, the thyroid bed should
be imaged in transverse and longitudinal planes. Any masses or cysts in the region of the
bed should be measured and reported. Additionally, the lateral neck should be evaluated as
described in section B.
Whenever possible, comparison should be made with other appropriate imaging studies.
Abnormalities of the adjacent soft tissues, when encountered, such as abnormal lymph nodes or
thrombosed veins, should be documented
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Whenever possible, comparison should be made with other appropriate imaging studies. Spectral,
color, and/or power Doppler ultrasound may be useful to evaluate the vascularity of the thyroid
gland and of localized masses
Sonographic guidance may be used for aspiration or biopsy of thyroid abnormalities or other
masses of the neck, or for other interventional procedures [20-22].
B. Cervical Lymph Node Evaluation
High resolution ultrasound examination of the neck is used for the staging of patients with
thyroid cancer and other head and neck cancers, and in the surveillance of patients after
treatment of such cancers [23-29]. In these patients, the size and location of abnormal
lymph nodes should be documented. Suspicious features such as calcification, cystic areas,
absence of central hilum, round shape and abnormal blood flow should be documented. The
location of abnormal lymph node should be described according to the image based nodal
classification system developed by Som et al which corresponds to the clinical nodal
classification system developed by the American Joint Committee on Cancer and the
American Academy of Otolaryngology – Head and Neck Surgery, or in a fashion that allows
the referring clinician to convert the location of abnormal nodes to that system [30].
C. The Parathyroid Examination
Examination for suspected parathyroid enlargement should include images in the region of the
anticipated parathyroid gland location. One of the important uses of parathyroid ultrasound is
to try to localize parathyroid adenomas in patients with primary hyperparathyroidism to
help with surgical planning [3,4].
The examination should be performed with the neck hyperextended and should include
longitudinal and transverse images from the carotid arteries to the midline bilaterally, and
extending from the carotid artery bifurcation superiorly to the thoracic inlet inferiorly. As
parathyroid glands may be hidden below the clavicles in the lower neck and upper mediastinum,
it may also be helpful to have the patient swallow during the examination with constant real-time
observation. Color and/or power or spectral Doppler ultrasound may be helpful. The upper
mediastinum may be imaged with an appropriate probe by angling under the sternum from the
sternal notch. Rarely, parathyroid adenomas may also be intrathyroidal. Although the normal
parathyroid glands are usually not visualized using available sonographic technology, enlarged
parathyroid glands may be visualized. When visualized, their location, size, and number should
be documented and measurements should be made in three dimensions. The relationship of any
visualized parathyroid gland(s) to the thyroid gland should be documented, if applicable
[2,31,32].
Whenever possible, comparison should be made with other appropriate imaging studies. Spectral,
color, and/or power Doppler ultrasound may be helpful
Sonographic guidance may be used for aspiration or biopsy of parathyroid abnormalities or other
masses of the neck, or for other interventional procedures.
VI.
DOCUMENTATION
Each organization addresses this requirement individually. ACR language is as follows:
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Adequate documentation is essential for high-quality patient care. There should be a permanent
record of the ultrasound examination and its interpretation. Comparison with prior relevant
imaging studies may prove helpful. Images of all appropriate areas, both normal and abnormal,
should be recorded. Variations from normal size should generally be accompanied by
measurements. Images should be labeled with the patient identification, facility identification,
examination date, and image orientation. An official interpretation (final report) of the ultrasound
examination should be included in the patient’s medical record. Retention of the ultrasound
examination images should be consistent both with clinical need and with relevant legal and local
health care facility requirements.
Reporting should be in accordance with the ACR Practice Guideline for Communication of
Diagnostic Imaging Findings.
VII.
EQUIPMENT SPECIFICATIONS
Thyroid and parathyroid studies should be conducted with a linear or curved linear transducer.
The equipment should be adjusted to operate at the highest clinically appropriate frequency,
realizing that there is a trade-off between resolution and beam penetration. For most patients,
mean frequencies of 10 to 14 MHz or greater are preferred, though some patients may require a
lower frequency transducer for depth penetration. If the gland is deep or extremely enlarged, a
curved linear transducer may be necessary. Resolution should be of sufficient quality to
evaluate the internal morphology of visible lesions. Doppler frequencies should be set to optimize
flow detection. Diagnostic information should be optimized, while keeping total sonographic
exposure as low as reasonably achievable.
VIII.
QUALITY CONTROL IMPROVEMENT, SAFETY, INFECTION CONTROL,
AND PATIENT EDUCATION
Each organization addresses this requirement individually. ACR language is as follows:
Policies and procedures related to quality, patient education, infection control, and safety should
be developed and implemented in accordance with the ACR Policy on Quality Control and
Improvement, Safety, Infection Control, and Patient Education appearing under the heading
Position Statement on QC & Improvement, Safety, Infection Control, and Patient Education on
the ACR web site (http://www.acr.org/guidelines).
Equipment performance monitoring should be in accordance with the ACR Technical Standard
for Diagnostic Medical Physics Performance Monitoring of Real Time Ultrasound Equipment.
ACKNOWLEDGEMENTS
This guideline was revised according to the process described under the heading The Process for
Developing ACR Practice Guidelines and Technical Standards on the ACR web site
(http://www.acr.org/guidelines) by the Guidelines and Standards Committee of the ACR
Commission on Ultrasound in collaboration with the AIUM, the SPR, and the SRU.
Collaborative Committee - members represent their societies in the initial and final revision of
this guideline
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ACR
Sheila Sheth, MD, FACR, Chair
Sara J. Abramson, MD, FACR
Helena Gabriel, MD
Maitray D. Patel, MD
AIUM
Robert D. Harris, MD, MPH, FACR
Jill E. Langer, MD
Robert A. Levine, MD, FACE
SPR
Judith A. Craychee, MD
Cindy R. Miller, MD
Henrietta Kotlus Rosenberg, MD, FACR, FAAP
Dayna M. Weinert, MD
SRU
William D. Middleton, MD, FACR
Carl C. Reading, MD, FACR
Mitchell E. Tublin, MD
ACR Guidelines and Standards Committee - Ultrasound – ACR Committee responsible for
sponsoring the draft through the process
Beverly E. Hashimoto, MD, FACR, Chair
Sandra O. DeJesus Allison, MD
Marcela Bohm-Velez, MD, FACR
Helena Gabriel, MD
Ruth B. Goldstein, MD
Leann E. Linam, MD
Maitray D. Patel, MD
Henrietta Kotlus Rosenberg, MD, FACR, FAAP
Sheila Sheth, MD, FACR
Robert M. Sinow, MD
Maryellen R.M. Sun, MD
Sharlene A. Teefey, MD, FACR
Jason M. Wagner, MD
ACR Guidelines and Standards Committee – Pediatric – ACR Committee responsible for
sponsoring the draft through the process
Eric N. Faerber, MD, FACR, Chair
Sara J. Abramson, MD, FACR
Richard M. Benator, MD, FACR
Brian D. Coley, MD
Kristin L. Crisci, MD
Kate A. Feinstein, MD, FACR
Lynn A. Fordham, MD, FACR
S. Bruce Greenberg, MD
J. Herman Kan, MD
Beverley Newman, MD, MB, BCh, BSC, FACR
Marguerite T. Parisi, MD, MS
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Sumit Pruthi, MBBS
Nancy K. Rollins, MD
Manrita K. Sidhu, MD
Deborah Levine, MD, FACR, Chair, Ultrasound Commission
Marta Hernanz-Schulman, MD, FACR, Chair, Pediatric Commission
Debra L. Monticciolo, MD, FACR, Chair, Quality and Safety Commission
Julie K. Timins, MD, FACR, Chair, Committee on Guidelines
Comments Reconciliation Committee
Christopher G. Ullrich, MD, FACR, Chair
Sanjay K. Shetty, MD, MBA, Co-Chair
Sara J. Abramson, MD, FACR
Kimberly E. Applegate, MD, MS, FACR
Judith A. Craychee, MD
Eric N. Faerber, MD, FACR
Howard B. Fleishon, MD, MMM, FACR
Helena Gabriel, MD
Robert D. Harris, MD, MPH, FACR
Beverly E. Hashimoto, MD, FACR
Denzil J. Hawes-Davis, DO
Marta Hernanz-Schulman, MD, FACR
Jill E. Langer, MD
Deborah Levine, MD, FACR
Robert A. Levine, MD, FACE
William D. Middleton, MD, FACR
Cindy R. Miller, MD
Debra L. Monticciolo, MD, FACR
Maitray D. Patel, MD
Carl C. Reading, MD, FACR
Henrietta Kotlus Rosenberg, MD, FACR, FAAP
Leslie M. Scoutt, MD, FACR
Sheila Sheth, MD, FACR
Julie K. Timins, MD, FACR
Mitchell E. Tublin, MD
Dayna M. Weinert, MD
REFERENCES
1. Solbiati L, Osti V, Cova L, Tonolini M. Ultrasound of thyroid, parathyroid glands and neck
lymph nodes. Eur Radiol 2001;11:2411-2424.
2. Arciero CA, Shiue ZS, Gates JD, et al. Preoperative thyroid ultrasound is indicated in
patients undergoing parathyroidectomy for primary hyperparathyroidism. J Cancer
2012;3:1-6.
3. Levy JM, Kandil E, Yau LC, Cuda JD, Sheth SN, Tufano RP. Can ultrasound be used
as the primary screening modality for the localization of parathyroid disease prior to
surgery for primary hyperparathyroidism? A review of 440 cases. ORL J
Otorhinolaryngol Relat Spec 2011;73:116-120.
4. Patel CN, Salahudeen HM, Lansdown M, Scarsbrook AF. Clinical utility of ultrasound
and 99mTc sestamibi SPECT/CT for preoperative localization of parathyroid adenoma
in patients with primary hyperparathyroidism. Clin Radiol 2010;65:278-287.
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382
383
384
385
386
387
388
389
390
391
392
393
394
395
5. Anderson L, Middleton WD, Teefey SA, et al. Hashimoto thyroiditis: Part 1,
sonographic analysis of the nodular form of Hashimoto thyroiditis. AJR Am J
Roentgenol 2010;195:208-215.
6. Frates MC, Benson CB, Doubilet PM, et al. Prevalence and distribution of carcinoma in
patients with solitary and multiple thyroid nodules on sonography. J Clin Endocrinol Metab
2006;91:3411-3417.
7. Bonavita JA, Mayo J, Babb J, et al. Pattern recognition of benign nodules at ultrasound
of the thyroid: which nodules can be left alone? AJR 2009;193:207-213.
8. Chan BK, Desser TS, McDougall IR, Weigel RJ, Jeffrey RB, Jr. Common and uncommon
sonographic features of papillary thyroid carcinoma. J Ultrasound Med 2003;22:1083-1090.
9. Cooper DS, Doherty GM, Haugen BR, et al. Revised American Thyroid Association
management guidelines for patients with thyroid nodules and differentiated thyroid
cancer. Thyroid 2009;19:1167-1214.
10. Frates MC, Benson CB, Charboneau JW, et al. Management of thyroid nodules detected at
US: Society of Radiologists in Ultrasound consensus conference statement. Radiology
2005;237:794-800.
11. Henrichsen TL, Reading CC. Thyroid ultrasonography. Part 2: nodules. Radiol Clin
North Am 2011;49:417-424, v.
12. Hoang JK, Lee WK, Lee M, Johnson D, Farrell S. US Features of thyroid malignancy: pearls
and pitfalls. Radiographics 2007;27:847-860; discussion 861-845.
13. Iannuccilli JD, Cronan JJ, Monchik JM. Risk for malignancy of thyroid nodules as assessed
by sonographic criteria: the need for biopsy. J Ultrasound Med 2004;23:1455-1464.
14. Kim EK, Park CS, Chung WY, et al. New sonographic criteria for recommending fine-needle
aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR 2002;178:687-691.
15. Layfield LJ, Cibas ES, Gharib H, Mandel SJ. Thyroid aspiration cytology: current
status. CA Cancer J Clin 2009;59:99-110.
16. Moon WJ, Jung SL, Lee JH, et al. Benign and malignant thyroid nodules: US
differentiation--multicenter retrospective study. Radiology 2008;247:762-770.
17. Morris LF, Ragavendra N, Yeh MW. Evidence-based assessment of the role of
ultrasonography in the management of benign thyroid nodules. World J Surg
2008;32:1253-1263.
18. Reading CC, Charboneau JW, Hay ID, Sebo TJ. Sonography of thyroid nodules: a "classic
pattern" diagnostic approach. Ultrasound Q 2005;21:157-165.
19. Tae HJ, Lim DJ, Baek KH, et al. Diagnostic value of ultrasonography to distinguish between
benign and malignant lesions in the management of thyroid nodules. Thyroid 2007;17:461466.
20. Lewis BD, Hay ID, Charboneau JW, McIver B, Reading CC, Goellner JR. Percutaneous
ethanol injection for treatment of cervical lymph node metastases in patients with papillary
thyroid carcinoma. AJR 2002;178:699-704.
21. 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;60:21-28.
22. O'Malley ME, Weir MM, Hahn PF, Misdraji J, Wood BJ, Mueller PR. US-guided fine-needle
aspiration biopsy of thyroid nodules: adequacy of cytologic material and procedure time with
and without immediate cytologic analysis. Radiology 2002;222:383-387.
23. Ahuja AT, Ying M. Sonographic evaluation of cervical lymph nodes. AJR 2005;184:16911699.
24. Ahuja AT, Ying M, Yuen HY, Metreweli C. Power Doppler sonography of metastatic nodes
from papillary carcinoma of the thyroid. Clin Radiol 2001;56:284-288.
25. Gor DM, Langer JE, Loevner LA. Imaging of cervical lymph nodes in head and neck cancer:
the basics. Radiol Clin North Am 2006;44:101-110, viii.
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26. Leboulleux S, Girard E, Rose M, et al. Ultrasound criteria of malignancy for cervical lymph
nodes in patients followed up for differentiated thyroid cancer. J Clin Endocrinol Metab
2007;92:3590-3594.
27. Sheth S, Hamper UM. Role of sonography after total thyroidectomy for thyroid cancer.
Ultrasound Q 2008;24:147-154.
28. Shin JH, Han BK, Ko EY, Kang SS. Sonographic findings in the surgical bed after
thyroidectomy: comparison of recurrent tumors and nonrecurrent lesions. J Ultrasound Med
2007;26:1359-1366.
29. Stulak JM, Grant CS, Farley DR, et al. Value of preoperative ultrasonography in the surgical
management of initial and reoperative papillary thyroid cancer. Arch Surg 2006;141:489-494;
discussion 494-486.
30. Som PM, Curtin HD, Mancuso AA. Imaging-based nodal classification for evaluation of neck
metastatic adenopathy. AJR Am J Roentgenol 2000;174:837-844.
31. Reeder SB, Desser TS, Weigel RJ, Jeffrey RB. Sonography in primary hyperparathyroidism:
review with emphasis on scanning technique. J Ultrasound Med 2002;21:539-552; quiz 553534.
32. Yabuta T, Tsushima Y, Masuoka H, et al. Ultrasonographic features of intrathyroidal
parathyroid adenoma causing primary hyperparathyroidism. Endocr J 2011;58:989994.
Suggested Reading (Additional articles that are not cited in the document but that the committee
recommends for further reading on this topic)
1. Ahuja AT, Metreweli C. Ultrasound of thyroid nodules. Ultrasound Quarterly 2000;16:111122.
5. do Rosario PW, Fagundes TA, Maia FF, Franco AC, Figueireo MB, Purisch S. Sonography
in the diagnosis of cervical recurrence in patients with differentiated thyroid carcinoma. J
Ultrasound Med 2004;23:915-920.
10. Lewis BD, Charboneau JW, Reading CC. Ultrasound-guided biopsy and ablation in the neck.
Ultrasound Quarterly 2002;18:3-12.
12. Marqusee E, Benson CB, Frates MC, et al. Usefulness of ultrasonography in the management
of nodular thyroid disease. Ann Intern Med 2000;133:696-700.
16. Peccin S, de Castsro JA, Furlanetto TW, Furtado AP, Brasil BA, Czepielewski MA.
Ultrasonography: is it useful in the diagnosis of cancer in thyroid nodules? J Endocrinol
Invest 2002;25:39-43.
17. Rausch P, Nowels K, Jeffrey RB Jr. Ultrasonographically guided thyroid biopsy: a review
with emphasis on technique. J Ultrasound Med 2001;20:79-85.
19. Rosario PW, de Faria S, Bicalho L, et al. Ultrasonographic differentiation between metastatic
and benign lymph nodes in patients with papillary thyroid carcinoma. J Ultrasound Med
2005;24:1385-1389.
21. Tessler FN, Tublin ME. Thyroid sonography: current applications and future directions. AJR
1999;173:437-443.
22. van den Brekel MW, Castelijns JA. Imaging of lymph nodes in the neck. Semin Roentgenol
2000;35:42-53.
23. Wunderbaldinger P, Harisinghani MG, Hahn PF, et al. Cystic lymph node metastasis in
papillary thyroid carcinoma. AJR 2002;178:693-697.
24. Yeh HC, Futterweit W, Gilbert P. Micronodulation: ultrasonographic sign of Hashimoto
thyroiditis. J Ultrasound Med 1996;15:813-819.
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PRACTICE GUIDELINE
2013 Resolution No. 16
Thyroid/Parathyroid Ultrasound
NOT FOR PUBLICATION, QUOTATION, OR CITATION
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*Guidelines and standards are published annually with an effective date of October 1 in the year
in which amended, revised or approved by the ACR Council. For guidelines and standards
published before 1999, the effective date was January 1 following the year in which the guideline
or standard was amended, revised, or approved by the ACR Council.
Development Chronology for this Guideline
1994 (Resolution 23)
Revised 1998 (Resolution 34)
Revised 2003 (Resolution 18)
Amended 2006 (Resolution 35)
Revised 2007 (Resolution 31)
Thyroid/Parathyroid Ultrasound
PRACTICE GUIDELINE
2013 Resolution No. 16