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Ultrasound is the primary imaging modality for case selection. While researchers have put forward selection criteria for PTCs based on size, absence of suspicious lymph nodes and tumor location, there are limited reported data highlighting inherent ultrasound limitations and guidelines for case selection and follow-up. We report our experience including imaging limitations encountered in the ongoing AS prospective observational study for PTCs measuring\u2009&lt;\u20092\u00a0cm at our institute. We define disease progression as an increase in size of\u2009&gt;\u20093\u00a0mm in the largest dimension of nodule or evidence of metastatic disease or extrathyroidal extension. Accurate, consistent and reproducible measurements of PTCs are essential in risk stratifying patients for the option of AS or disease progression. Interobserver discrepancy, shadowing from coarse calcification and background parenchyma heterogeneity or thyroiditis can limit accurate PTC size assessment and therefore hinder patient eligibility evaluation or AS follow-up. Following the ACR Thyroid Imaging, Reporting and Data System (TI-RADS) protocol of three-axes technique to measure a thyroid nodule enables reproducibility of measurements. In patients with multi-nodular goiter, accurate identification and labeling of the PTC is important to avoid mistaking with adjacent benign nodules at follow-up. Ultrasound assessment for extrathyroid extension of PTC, and relationship of PTC to trachea and the anatomic course of the recurrent laryngeal nerve are important considerations in evaluation for AS eligibility.<\/jats:p>","DOI":"10.1186\/s13244-021-01072-9","type":"journal-article","created":{"date-parts":[[2021,9,16]],"date-time":"2021-09-16T12:02:53Z","timestamp":1631793773000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":20,"title":["Ultrasound in active surveillance for low-risk papillary thyroid cancer: imaging considerations in case selection and disease 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All participants provided informed consent to participate in the prospective study as per institutional research ethics board stipulations (Clinicaltrials.gov: NCT03271892).","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"There are no patient identifiers in the manuscript text or the images provided and therefore does not require consent of patients for publication.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Dr. Sawka and Dr. Goldstein are Co-PIs in the ongoing prospective observation study \u2018Deciding on Active Surveillance or Surgery for Primary Management of Low Risk Papillary Thyroid Cancer (AS-PTC).\u2019 The authors otherwise have no competing interest.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"130"}}