Short answer: If you have Hashimoto's and an ultrasound found a nodule in your thyroid, the American Thyroid Association (ATA) says "the vast majority of thyroid nodules are benign (noncancerous)", that a small proportion do contain cancer, and that most nodules need some type of evaluation. It also says Hashimoto's thyroiditis "is associated with an increased risk of thyroid nodules." A radiologist writes the report, which may carry a TI-RADS line from the American College of Radiology (ACR), whose system is built to tell practitioners which nodules warrant a biopsy. What your own report means, and what happens next, is your doctor's call.
The report may have landed in your portal before anyone explained it. Hypoechoic, spongiform, TR3. You're allowed to want those words in plain English before the appointment.
Your blood tests and your ultrasound answer different questions. The ATA says most thyroid nodules are non-functioning, meaning the nodule itself usually leaves tests like TSH unchanged. RadiologyInfo.org, a patient site whose pages are reviewed by committees that include the Radiological Society of North America and the ACR, says an ultrasound can't tell whether your thyroid is underactive, overactive or normal. Osmi's lab album is for the blood side: every blood result on its own card, shown against the range your own lab printed. Keep the ultrasound report itself with your papers.
What a nodule is, and where Hashimoto's comes in
The ATA's thyroid nodules page describes a nodule as "an abnormal growth of thyroid cells that forms a lump within the thyroid gland." The National Cancer Institute (NCI) puts it plainly: "Thyroid nodules are common but usually are not cancer." The ATA adds that most don't cause symptoms and are often found by chance on a scan or exam done for something else.
On Hashimoto's, each body uses its own verb. The ATA says Hashimoto's "is associated with an increased risk of thyroid nodules." MedlinePlus says nodules "are sometimes found in people who have Hashimoto disease." Cedars-Sinai says doctors don't know what causes thyroid nodules, but that scientists have found a link between Hashimoto's thyroiditis and their development. Whether that link explains your nodule is a question for your doctor.
If cancer is the word on your mind: in 2019 the ATA summarized a large study of patients seen at Brigham and Women’s Hospital Thyroid Nodule Clinic, all with nodules larger than 1 cm. Those who also had Hashimoto's "were at increased risk of having indeterminate biopsy results and thyroid cancer", and "The aggressiveness of the cancer was similar in the two groups." The summary's takeaway: "But when someone has both conditions, thyroid nodules may need to be more carefully examined and followed in patients who have Hashimoto’s thyroiditis." That study describes a group of patients. For your own risk, Cleveland Clinic says: "If you have any questions about your risk of developing thyroid cancer or thyroid disease, talk to your provider."
If your whole gland is enlarged rather than one lump, goiter and Hashimoto's covers that.
Who writes the report
RadiologyInfo sets out the route: "A radiologist, a doctor trained to supervise and interpret radiology exams, will analyze the images. The radiologist will send a signed report to the doctor who requested the exam. Your doctor will then share the results with you." MedlinePlus adds that "Many thyroid ultrasound reports will now give each nodule a score and discuss the characteristics of the nodule that caused the score."
The parts of the report, and who names them
The ACR publishes a reporting template for its system, using an ACR lexicon built "to describe all thyroid nodules on sonography." Your report may not match it line for line.
| Report line | What it records | Who names it |
|---|---|---|
| Thyroid size and texture | The gland as a whole | ACR reporting template |
| Nodule size and location | Maximum size; right, left or isthmus; upper, mid or lower | ACR reporting template |
| Composition | Cystic, spongiform, mixed cystic and solid, or solid | ACR lexicon |
| Echogenicity | Anechoic, hyperechoic, isoechoic, hypoechoic or very hypoechoic | ACR lexicon |
| Shape | Taller-than-wide, or not | ACR lexicon |
| Margins | Smooth, ill-defined, lobulated or irregular, or extra-thyroidal extension | ACR lexicon |
| Echogenic foci | None, large comet-tail artifacts, macrocalcifications, peripheral calcifications, or punctate echogenic foci | ACR lexicon |
| TI-RADS category | TR1 to TR5 | ACR TI-RADS |
| Recommendation | Fine needle aspiration, a follow-up ultrasound, or no further follow-up | ACR TI-RADS |
The ATA says ultrasound "can easily determine if a nodule is solid or fluid filled (cystic), and it can determine the precise size of the nodule," and that "some ultrasound characteristics of thyroid nodules are more frequent in thyroid cancer than in noncancerous nodules." Which ones matter for your nodule is for the radiologist and your doctor to read. With Hashimoto's, the ATA adds, an ultrasound, if done, can also show signs of inflammation, even in early stages when thyroid hormone levels are still normal.
The TI-RADS line
Cleveland Clinic: "You might see a TI-RADS score in your test results. This helps doctors classify thyroid nodules and determine what to do next." The ACR's TI-RADS page says the system exists "to inform practitioners about which nodules warrant biopsy." Composition, echogenicity, shape, margins and echogenic foci each get points, and the points add up to the level.
The ACR's assessment chart names the five levels: TR1 Benign, TR2 Not Suspicious, TR3 Mildly Suspicious, TR4 Moderately Suspicious and TR5 Highly Suspicious. In the ACR's system, the level and the nodule's size together decide whether the recommendation is a biopsy, a follow-up ultrasound, or nothing further.
The ACR's TI-RADS FAQ for radiologists notes that patients are increasingly able to view reports through portals, and may be concerned when a small TR4 nodule described as moderately suspicious isn't biopsied or even followed up. For this reason, it says, "radiologists may elect not to mention the risk descriptors in reports." So your report may carry the words, only the TR number, or neither. What your category means for you is a question for the doctor who ordered the scan.
What the ATA says happens next
Because it's usually not possible to tell whether a nodule is cancerous from an exam and blood tests alone, the ATA says evaluation "often includes specialized tests such as thyroid ultrasonography and fine needle biopsy."
Not every nodule goes to a needle. RadiologyInfo says that when the radiologist can't tell a benign lump from a malignant one with complete certainty, a biopsy may be recommended, "but in some cases surveillance and a repeat sonogram after a few months looking for stability may suffice." The ATA says nodules that are benign on biopsy or too small to biopsy "should still be watched closely with ultrasound examination."
If you're having a repeat ultrasound, ask what interval your doctor wants. And Cleveland Clinic says: "Call your provider if you notice any pain or changes in your neck."
Questions to ask about your ultrasound
MedlinePlus says to "Talk to your provider about the results of any thyroid ultrasound." Write these down before you go:
- What did the radiologist call my nodule, and which TI-RADS category is it?
- Is that category the reason for the recommendation on my report?
- Do you want a biopsy, a repeat ultrasound, or neither, and why?
- If it's a repeat ultrasound, when?
- Does my Hashimoto's change how you want to follow this nodule?
- Is a full copy of the report mine to keep?
- Who do I call if I notice a change in my neck before then?
The appointment sheet is one page, built from the record you already keep, that you share with your practitioner in one tap. It carries your recent labs against the range your own lab printed, and it doesn't diagnose anything or read your results for you. Your questions stay yours to bring, so take this list and the report in with it.
Please see your doctor about any thyroid nodule, and call before your next appointment if something in your neck changes. What your report means, and what to do next, is their call.
One small thing for today: find the full ultrasound report and put it with your list of questions.
Questions women ask about thyroid nodules
Can Hashimoto's cause thyroid nodules? The ATA says Hashimoto's thyroiditis is associated with an increased risk of thyroid nodules, and MedlinePlus lists Hashimoto disease among the possible causes. The ATA also says it doesn't know what causes most nodules. Ask your doctor whether your Hashimoto's is part of the picture.
Does having Hashimoto's change how a nodule is checked? An ATA summary of one large 2019 study, which looked at nodules larger than 1 cm at one hospital clinic, says that with both conditions, nodules may need to be more carefully examined and followed. Ask your doctor whether it changes your plan.
What is a TR3 or TR4 thyroid nodule? They're two of the five levels in the ACR's TI-RADS system: the ACR's chart labels TR3 Mildly Suspicious and TR4 Moderately Suspicious. The level and the nodule's size together decide what the ACR recommends. Talk to your provider about your own result.
Will my thyroid blood tests show a nodule? The ATA says most thyroid nodules are non-functioning, meaning the nodule itself usually leaves tests like TSH unchanged. RadiologyInfo says an ultrasound can't tell whether your thyroid is underactive, overactive or normal. So the blood test and the scan answer different questions, and Cleveland Clinic says your provider will help you understand your test results.
Why doesn't my report use the TI-RADS risk words? The ACR's TI-RADS FAQ for radiologists notes that patients are increasingly able to view reports through portals, and may be concerned when a small TR4 nodule described as moderately suspicious isn't biopsied or even followed up. For this reason, it says, "radiologists may elect not to mention the risk descriptors in reports." If yours doesn't name a category, ask your doctor which one it is.
How long does a thyroid ultrasound take? Cleveland Clinic says a thyroid ultrasound usually takes around 30 minutes from start to finish. RadiologyInfo says a radiologist analyzes the images and sends a signed report to the doctor who requested the exam, who then shares the results with you. Cleveland Clinic adds that your provider will help you understand your test results.
Educational, not medical advice.
