ACR-TIRADS Institution and Effect on Thyroid Surgeries in Veterans: A 10-Year Retrospective Study.

Introduction: Thyroid Imaging Reporting and Data System (TI-RADS) was developed to provide a standardized risk-stratification system for patients with thyroid nodules. Single-center studies have demonstrated an acceptable level of interobserver agreement in applying TI-RADS in clinical practice, however data regarding consistency among different centers is limited. In Israel, thyroid nodules are initially evaluated by ultrasound performed by radiologists at the health maintenance organization (HMO) and then patients are referred to tertiary hospitals for ultrasound-guided fine needle aspiration (FNA) biopsy when indicated. Objective: To evaluate the interobserver concordance in TI-RADS classification system reporting between the HMO and a tertiary hospital. Methods: We performed a retrospective analysis of the sonographic features of 370 thyroid nodules TI-RADS category 2 or higher, from 350 patients evaluated by ultrasound at the HMO and at Hadassah Medical Center from January 1, 2018 to December 31, 2019. The primary outcome was concordance between the TI-RADS classification at the HMO compared to the hospital. Additional endpoints included correlation of TI-RADS to the Bethesda category following FNA, and correlation of TI-RADS with malignancy on final pathology. Results: Of 370 nodules, only 73 (19.8%) demonstrated concordance between the HMO and the hospital. The level of agreement was poor, with 277 (74.8%) nodules demonstrating higher TI-RADS at the HMO compared to the hospital, and 20 (5.4%) with lower TI-RADS at the HMO compared to the hospital (p<0.001, weighted Kappa = 0.120). Of the nodules referred to the hospital, 241 (65.1%) were selected for FNA. A strong correlation between the hospital TI-RADS and Bethesda category was demonstrated (p<0.001). Furthermore, 60 (16.2%) nodules were surgically removed. A strong correlation was identified between the hospital TI-RADS and malignancy on final pathology (p<0.001), yet there was no correlation with the TI-RADS of the HMO (p=0.346). Conclusions: There is poor concordance between TI-RADS classification on ultrasound performed in the HMO compared to a tertiary hospital. In patients who underwent FNA and eventually surgery, the hospital TI-RADS strongly correlated with Bethesda category and final risk of malignancy. Standardization of thyroid ultrasound terminology and dedicated training in thyroid imaging are needed to improve the interobserver concordance in clinical practice.

To compare the efficiency of four different ultrasound (US) Thyroid Imaging Reporting and Data Systems (TI-RADS) in malignancy risk stratification in surgically resected thyroid nodules (TNs). The study included 547 benign TNs and 464 malignant TNs. US images of the TNs were retrospectively reviewed and categorized according to the TI-RADSs published by Horvath E et al. (TI-RADS H), Park et al. (TI-RADS P), Kwak et al. (TI-RADS K) and Russ et al. (TI-RADS R). The diagnostic performances for the four TI-RADSs were then compared. At multivariate analysis, among the suspicious US features, marked hypoechogenicity was the most significant independent predictor for malignancy (OR: 15.344, 95% CI: 5.313-44.313) (P < 0.05). Higher sensitivity was seen in TI-RADS H, TI-RADS K, TI-RADS R comparing with TI-RADS P (P < 0.05 for all), whereas the specificity, accuracy and area under the ROC curve (Az) of TI-RADS P were the highest (all P < 0.05). Higher specificity, accuracy and Az were seen in TI-RADS K compared with TI-RADS R (P = 0.003). With its higher sensitivity, TI-RADS K, a simple predictive model, is practical and convenient for the management of TNs in clinical practice. The study indicates that there is a good concordance between TI-RADS categories and histopathology.

Background:In recent times, high-resolution ultrasound thyroid imaging has paved the way for significant transformation in clinical approach to thyroid nodule. There are several risk stratification systems in thyroid imaging, developed with an aim, not only to reduce the inter-observer variability but also to establish effective communication system. Thyroid image reporting and data system (TIRADS) classification system, which is similar to breast imaging reporting and data system for breast lesion, is the most useful of all. To our knowledge, there is just a handful published research articles available based on Indian population in this regard. In this article, we study the thyroid nodules using high-resolution ultrasound in Indian population and we try to correlate the TIRADS and Bethesda system for reporting thyroid cytopathology.Materials and Methods:This prospective study includes 184 patients studied over a period of 2 years (April 2015–April 2017). Patients having thyroid nodule in B-mode ultrasound and are scheduled to get a fine-needle aspiration cytology (FNAC) done. Bethesda classification of these nodules is tabulated in follow-up period simultaneously. By comparing these data, efficacy of TIRADS in differentiating benign from malignant nodules are assessed finally using accuracy, positive predictive value (PPV), cross-tabulation, and Chi-square tests.Results:Out of the 117 TIRADS 2 nodules, none turned out to be Bethesda IV or higher, which means none of these nodules turned out to be malignant. The risk of malignancy for TIRADS 2, TIRADS 3, TIRADS 4, and TIRADS 5 was 0, 2.2, 38.5, and 77.8%, respectively. The risk of malignancy percentage in our study is similar to those values obtained in other prominent studies.Conclusion:The probability of a particular nodule being malignant can be effectively inferred from the ultrasound-based TIRADS system with a certain level of confidence. Considering our results and other literature reviews, it be can be safely assumed that FNAC can be at least deferred in patients having TIRADS 2 nodules, which contribute to majority of newly detected cases. In our experience, there is a remarkable correlation exists between TIRADS ultrasound classification and Bethesda cytology, especially for benign nodules.

Journal of Ultrasound in MedicineEarly View Practice ParameterFull Access AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck First published: 05 May 2023 https://doi.org/10.1002/jum.16251AboutReferencesRelatedInformationPDFSections Introduction Indications Qualifications and Responsibilities of Personnel Request for the Examination Specification of the Examination Documentation Equipment Specification Quality and Safety Acknowledgments Collaborative Subcommittees AIUM Clinical Standards CommitteeReferencesPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessClose modalShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound of the Thyroid and Extracranial Head and Neck was developed (or revised) by the American Institute of Ultrasound in Medicine (AIUM) in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. This Practice Parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but are not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the Parameter with recognition that deviations may occur depending on the clinical situation. Indications Indications for an ultrasound (US) examination of the thyroid and extracranial head and neck include, but are not limited to1: Evaluation of the location and characteristics of palpable neck masses and thyroid nodules. Evaluation of abnormalities detected by other imaging examinations, such as thyroid nodules and/or other neck masses that satisfy criteria for a thyroid ultrasound examination that are detected on computed tomography (CT), positron emission tomography (PET), PET/CT, magnetic resonance imaging (MRI), or other ultrasound examinations (eg, carotid duplex).1 Evaluation of the presence, size, location, and sonographic features of the thyroid gland.2 Evaluation of congenital hypothyroidism, including search for and characterization of orthotopic and/or ectopic thyroid tissue.3, 4 Evaluation of patients at high risk for thyroid malignancy. Imaging of previously detected thyroid nodules that meet criteria for follow-up.5 Evaluation of the thyroid gland for suspicious focal pathology before neck surgery for nonthyroidal disease.6 Evaluation of the thyroid gland for suspicious focal pathology before radioiodine ablation of the gland for hyperthyroidism. Evaluation for regional nodal metastases in patients with proven or suspected thyroid carcinoma before surgical or other management.7 Evaluation for recurrent locoregional metastatic disease and/or nodal metastases after lobectomy, hemi- or total thyroidectomy for thyroid carcinoma.5 Evaluation of known or suspected thyroid cancer (usually papillary microcarcinoma not undergoing surgical resection) that is being monitored periodically with ultrasound active surveillance/active monitoring for disease progression (eg, increase in nodule size, development of nodal metastatic disease, or extrathyroidal extension). Guidance for aspiration biopsy or other interventional procedure performed on thyroid abnormalities or other neck masses.8, 9 Evaluation for causes of relevant laboratory abnormalities, such as abnormalities of parathyroid or thyroid function, elevation of thyroglobulin, hypercalcemia, and so on. Assessment of the location, number, and size of enlarged parathyroid glands in patients with known or suspected hyperparathyroidism, including patients who have undergone previous parathyroid surgery or ablative therapy who have recurrent signs or symptoms of hyperparathyroidism.10, 11 Localization of autologous parathyroid gland implants. Evaluation of masses of the parotid and submandibular glands.12, 13 Evaluation of non-neoplastic conditions of the parotid and submandibular glands, including, but not limited to, sialolithiasis, infection, and autoimmune processes.14-16 Nodal evaluation, including staging, evaluation of response to therapy, and monitoring after therapy, in select patients with head and neck malignancies, including, but not limited to, head and neck primary squamous cell carcinoma, primary salivary malignancy, and melanoma.17-19 Evaluation for supraclavicular nodal metastasis in patients with lung cancer or other infraclavicular primary malignancies at risk for metastasis.20, 21 Nodal evaluation in pediatric patients with cervical lymphadenopathy, including, but not limited to, evaluation for necrosis and abscess formation in the setting of acute lymphadenitis.22, 23 Imaging of ultrasound-detectable vascular abnormalities (such as vascular tumors and vascular malformations) of the head and neck.24 Evaluation of torticollis in neonates and infants25; or Evaluation of adult and pediatric head and neck soft tissue masses including, but not limited to, thyroglossal duct cyst, branchial cleft cyst, lymphatic malformation, thymic ectopia/cyst, hemangioma, primary neck masses, including neurogenic tumors (neuroblastoma, schwannoma, neurofibroma), rhabdomyosarcoma, leukemia/lymphoma, metastatic disease (rhabdomyosarcoma, neuroblastoma, thyroid cancer, etc),26 and phlebectasia.27 Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines28 in accordance with AIUM accreditation policies.29 Sonographers performing the ultrasound examination should be appropriately credentialed30 in the specialty area in accordance with AIUM accreditation policies.29 Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32.31 Request for the Examination The written or electronic request for an ultrasound examination must originate from a physician or other appropriately licensed health care provider or under the provider's direction. The clinical information provided should allow for the performance and interpretation of the appropriate ultrasound examination and should be consistent with relevant legal and local health care facility requirements. Specification of the Examination Sonographic evaluations of the neck may be comprehensive or may be problem-focused, as appropriate for the patient and clinical scenario. Whenever possible, comparison should be made with prior sonograms and/or other appropriate imaging studies. Thyroid Evaluation The examination should be performed with the neck in as much hyperextension as tolerated by the patient, with or without a towel or other support under the neck or shoulders. Upright positioning may be helpful in patients who cannot tolerate neck hyperextension in the supine position. The right and left lobes of the thyroid should be imaged in longitudinal and transverse planes. Recorded images 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 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 Doppler can be used to supplement grayscale evaluation of either diffuse or focal thyroid abnormalities. It is often necessary to extend imaging to include the soft tissues above the isthmus, for example, to evaluate a pyramidal lobe of the thyroid, a thyroglossal duct cyst, or palpable abnormality. Similarly, it is important to visualize components of the gland that extend toward or into the superior mediastinum. In this effort, use of tightly curved array transducers may be helpful. The roles of strain and shear-wave elastography and contrast-enhanced ultrasound (CEUS), although potentially helpful, have not been established definitively. Thyroid abnormalities should be imaged in a way that allows for reporting and documentation of the following: Localized or diffuse parenchymal echotexture (eg, homogeneous vs heterogeneous) and, if relevant, vascularity (hyperemia) of the thyroid parenchyma should be noted.32, 33 There are multiple thyroid nodule risk-stratification systems (RSSs) in existence. Images of thyroid nodules should be acquired such that relevant focal nodules can be classified based on whatever RSS is used by the interpreting physician. For example, the ACR Thyroid Imaging, Reporting and Data System (TI-RADS) RSS employs the following sonographic features: composition (solid and/or cystic components); echogenicity; size (in AP, transverse, and longitudinal dimensions); margins (smooth, ill-defined, irregular, or demonstrating extrathyroidal extension); nodule orientation (eg, taller than wide); and presence and type of echogenic foci and/or calcifications.8, 34, 35 Although the ultrasound features that determine risk in children are the same as those used in adults, to date, none of the RSSs have been specifically endorsed for the pediatric population.9, 36, 37 Examination of relevant neck compartments for adenopathy may be helpful in determining the need for biopsy in the setting of thyroid nodules. Comprehensive evaluation of central and lateral compartment cervical lymph nodes is strongly recommended for patients with known or suspected thyroid cancer.38, 39 This comprehensive evaluation may occur at the time of the initial thyroid ultrasound, the time of an ultrasound-guided biopsy, or as a separate ultrasound evaluation to assist in potential surgical or other management decisions. Institutions are encouraged to have consistent practices to ensure that patients receive a comprehensive nodal evaluation when indicated (see Section 8). In patients who have undergone lobectomy, hemithyroidectomy (lobectomy and isthmectomy), or thyroidectomy, the thyroid bed should be imaged in transverse and longitudinal planes, and abnormal solid or cystic masses should be measured and reported. Again, examination of relevant neck compartments and the adjacent soft tissue is important to look for locoregional metastatic disease in the setting of prior thyroid malignancy. Patients with known or suspected thyroid malignancy who are undergoing active surveillance or active monitoring with ultrasound must be evaluated for progression (eg, interval increase in surveillance nodule size, development of extrathyroidal extension, multifocal disease, or locoregional nodal metastases).40-43 Cervical Lymph Node Evaluation Sonographic examination of cervical lymph nodes may be comprehensive or focused, as appropriate for the patient and clinical scenario. Specific nodes that are imaged and the extent of imaging documentation will vary based on the clinical indication. Please see above for nodal evaluation with respect to thyroid-related indications. The size and location of abnormal lymph nodes should be documented, and suspicious nodal morphology including, but not limited to, calcification, cysts' focal echogenic areas that are unrelated to a fatty hilum, and abnormal blood flow should be documented.44 Round shape and absence of an echogenic hilum, although reported in malignant nodes, are findings with poor specificity in thyroid cancer.45, 46 Location of abnormal lymph node(s) should be documented with annotations and/or enough visual information to be able to describe the location according to the image-based 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.47 Node evaluation should be performed at centers with experienced personnel. Lymph node size varies with nodal compartment (eg, level 2 nodes are often larger than other lateral compartment nodes), and nodal size is often less important in the evaluation of malignancy than nodal morphology. Enlarged cervical nodes can be seen in lymphoma and other malignancies but are often reactive and are seen in acute and chronic infectious and inflammatory disease processes such as postviral syndromes and Hashimoto thyroiditis. In the pediatric population, cervical lymph node size, echotexture, vascularity, and potential nodal suppuration or abscess-formation evaluation are important in the evaluation of acute lymphadenitis.22, 23 Parathyroid Evaluation Parathyroid ultrasound helps guide surgical planning by localizing enlarged parathyroid glands in patients with primary hyperparathyroidism and helping to predict single versus multiple gland enlargement. Examination for suspected parathyroid enlargement due to adenomas, hyperplasia, or, extremely rarely, parathyroid carcinomas should include images posterior to and just inferior to the right and left thyroid lobes, typical parathyroid gland locations. In addition to typical locations, enlarged parathyroid glands and parathyroid adenomas may be ectopic, and the examination may need to be extended to include imaging from the hyoid to the sternum and along the carotid sheath. Abnormalities of the thyroid and cervical nodes should be documented because concomitant thyroid and/or cervical node pathology may be contraindications to minimally invasive parathyroidectomy.10, 11, 48 The examination should be performed with the neck hyperextended and should include longitudinal images from the right and left carotid arteries to the midline, as well as transverse images from the carotid artery bifurcation superiorly to the thoracic inlet inferiorly. Normal parathyroid glands are often not visualized using available sonographic technology; however, enlarged parathyroid glands may be detected. Gentle compression with the ultrasound transducer, asking the patient to swallow during real-time imaging, and the addition of color Doppler imaging (to evaluate for polar rather than central blood flow that is more typical of lymph nodes) are imaging techniques that may make it easier to identify enlarged parathyroid glands. Parathyroid glands may be located below the clavicles or in the mediastinum, and angling smaller footprint, tightly curved array transducers inferiorly from the sternal notch can aid in diagnosis of enlarged inferior parathyroid glands. Approximately 1%–3% of parathyroid adenomas may be retrotracheal; instructing the patient to swallow and/or turn their head to the opposite side may be helpful in identifying these ectopic parathyroid glands. Rarely, parathyroid adenomas may be intrathyroidal. When parathyroid abnormalities are visualized, their number, size, measurements in three dimensions, and location and relationship to the thyroid gland, if applicable, should be documented.6, 49 Parotid and Submandibular Evaluation Sonographic evaluation of the major salivary glands may be comprehensive or focused, as appropriate for the patient and clinical scenario. The parotid and submandibular glands are evaluated in two planes, although anatomic limitations due to the mandible and external ear often require oblique planes. A lower frequency transducer may be helpful to visualize the deep aspects of the parotid gland. Color Doppler may be added, when appropriate, for the evaluation of diffuse or focal abnormalities. Overall echotexture (eg, homogeneous or heterogeneous) and measurements of the parotid and submandibular glands should be performed, when appropriate, such as in the evaluation of autoimmune disease or gland asymmetry. Salivary ductal dilation and calculi should be reported. When possible, a dilated salivary gland duct should be traced to the level of obstruction. Description of focal abnormalities/masses within the salivary glands should include size in three dimensions, margins, echogenicity, composition, and internal blood flow. Intraparotid lymph nodes and their morphologic appearance (normal or abnormal) should be reported.50 Sonographic Guidance of Head and Neck Procedures Sonographic guidance may be used for aspiration and/or biopsy of thyroid/parathyroid/salivary gland abnormalities, lymph nodes, and other masses of the head and neck or for other interventional procedures including, but not limited to, preoperative localization and ultrasound-guided treatment of masses with various ablation methods.51 Documentation Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination.52 Equipment Specification Equipment performance monitoring should be in accordance with the AIUM Routine Quality Assurance of Clinical Ultrasound Equipment.53 Extracranial head and neck ultrasound studies are usually conducted with a 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 10–14 MHz or greater are preferred, although some patients may require a lower-frequency transducer for depth penetration. For evaluation of deep or large structures, a curved transducer may be necessary. For morphologic evaluation of small, superficial lesions, higher frequency transducers, with a small footprint, may be necessary. Additionally, a small-footprint, tightly curved array transducer may be helpful for evaluation of the inferior aspect of the central neck to evaluate for inferior central or upper mediastinal adenopathy and inferior parathyroid glands (Section 5.3). 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. Quality and Safety Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment-performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices.29 ALARA Principle The potential benefits and risks of each examination should be considered. The ALARA (As Low as Reasonably Achievable) principle54 should be observed for factors that affect the acoustical output and by considering transducer dwell time and total scanning time. Further details on ALARA may be found in the current AIUM publication Medical Ultrasound Safety.55 Infection Control Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM's Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel.56 Equipment Performance Monitoring Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practice.29 Acknowledgments This parameter was developed by the AIUM in collaboration with the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU). We are indebted to the many volunteers who contributed their time, knowledge, and energy to developing this document. Collaborative Subcommittees AIUM Mark Lupo, MD ACR Michelle L. Melany, MD, FACR, Chair Javad Azadi, MD Helena Gabriel, MD Safwan Halabi, MD SPR Sosamma Methratta, MD Cicero Silva, MD SRU Malak Itani, MD Kathryn McGillen, MD AIUM Clinical Standards Committee James M. Shwayder, MD, JD, Chair Rachel Bo-ming Liu, MD, Vice Chair Bryann Bromley, MD, FAIUM Rachel Bo-ming Liu, MD, FACEP, FAIUM Juliana Gevaerd Martins, MD Creagh T. Boulger, MD, FAIUM John R. Eisenbrey, PhD, FAIUM Rob Goodman, MB, BChir Margarita V. Revzin, MD, MS, FSRU, FAIUM Oliver Daniel Kripfgans, PhD, FAIUM Jean Lea Spitz, MPH, CAE, RDMS, FAIUM, FSDMS Nirvikar Dahiya, MD, FAIUM John Stephen Pellerito, MD, FACR, FAIUM, FSRU Ethan J. Halpern, MD, FAIUM Original copyright, 1994; revised, 1998, 2003, 2006, 2007, 2013, 2014, 2018, 2022 References 1Hoang JK, Langer JE, Middleton WD, et al. Managing incidental thyroid nodules detected on imaging: white paper of the ACR Incidental Thyroid Thyroid ultrasound and diffuse Ultrasound for primary imaging of congenital J. Thyroid abnormalities by in neonates with congenital et al. American Thyroid management for adult patients with thyroid nodules and thyroid the American Thyroid on thyroid nodules and thyroid Thyroid JD, et al. thyroid ultrasound is indicated in patients undergoing for primary Cancer The of in thyroid Thyroid nodules. JK, et al. Thyroid ultrasound reporting white paper of the ACR thyroid imaging, reporting and system JD, ultrasound be used as the primary for the localization of parathyroid disease prior to surgery for primary A review of Clinical of ultrasound and for preoperative localization of parathyroid in patients with primary Imaging the major salivary glands. Imaging of salivary gland et al. of salivary gland to the diagnosis of toward diagnostic T. diagnostic and of salivary gland using a T. conditions of the salivary glands. Ultrasound evaluation of malignant and cervical lymph Ultrasound et al. between and imaging for squamous cell carcinoma nodes with in the The of ultrasound in the of cervical lymph node metastases in clinically squamous cell carcinoma of the head and Cancer Imaging et al. The of ultrasound in and a diagnosis in patients with lung a two single et al. of external of the neck after and scanning in the preoperative of patients with and color Doppler of cervical in L. and chronic cervical in Imaging of vascular of the head and MD, M. the of the of pediatric neck Ultrasound R. in a diagnostic Training American Institute of Ultrasound in Medicine Standards and Guidelines for the Accreditation of Ultrasound American Institute of Ultrasound in Medicine of American Institute of Ultrasound in Medicine 42 CFR Diagnostic diagnostic laboratory and other diagnostic Middleton WD, et al. Hashimoto sonographic of the of Hashimoto thyroiditis. The review of imaging features and biopsy techniques with et al. of thyroid nodules detected at Society of Radiologists in ultrasound Radiology et al. thyroid are with from and et al. for children with thyroid nodules and thyroid Thyroid Middleton WD, et al. ACR thyroid imaging, reporting and system white paper of the ACR of papillary thyroid comparison of ultrasound imaging and et al. of preoperative in the surgical management of initial and papillary thyroid et al. for papillary thyroid microcarcinoma in is related to the progression of papillary microcarcinoma of the thyroid under Thyroid et al. of in the management of papillary microcarcinoma of the thyroid by active surveillance versus Thyroid of papillary thyroid microcarcinoma should be our treatment and of of malignant neck and Cancer Imaging Langer JE, neck after thyroidectomy for papillary thyroid in the diagnosis of recurrent and metastatic Ultrasound et al. Ultrasound criteria of malignancy for cervical lymph nodes in patients for thyroid nodal classification for evaluation of neck metastatic Imaging of the parathyroid glands. Ultrasound et al. features of parathyroid primary Imaging of the salivary glands. et al. of metastatic lymph nodes in the neck from papillary thyroid carcinoma with practice parameter for documentation of an ultrasound Ultrasound Routine Quality Assurance of Clinical Ultrasound version American Institute of Ultrasound in Medicine Low Reasonably American Institute of Ultrasound in Medicine American Institute of Ultrasound in Medical Ultrasound American Institute of Ultrasound in Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as well as Safe and Use of Ultrasound Coupling American Institute of Ultrasound in Medicine of before in an following and Thyroid ultrasound monitoring for thyroid MD, MD, MD, MD, MD, MD, Pediatric and neck and and Neck after for Head and Neck MD, MD, MD, Mark MD, MD, MD, Stephen MD, MD, MD, MD, MD, The of a primary thyroid carcinoma on patients with head and neck squamous cell M. MD, MD, MS, MD, J. MD, Head Neck

Introduction. Thyroid cancer is the most common endocrine related malignancy in the Philippines. Data showed Filipino patients are at higher risk to develop thyroid malignancy with an increasing incidence annually. Currently, the initial screening test utilized to evaluate thyroid nodules is ultrasonography with studies showing promising results in detecting and evaluating thyroid carcinoma employing the use of the Thyroid Imaging, Reporting and Data System (TIRADS). TIRADS is a standardized classification system to evaluate and characterize thyroid nodules. However, there are studies stating that TIRADS is of limited clinical value for risk stratification of indeterminate cytological results. Objectives. The primary objective of this study is to determine the correlation of the results of TIRADS, Fine Needle Aspiration Cytology (FNAC), and histopathology of thyroid nodules among patients who underwent thyroidectomy at Makati Medical Center from January 2016 to March 2020. Methods. This is a retrospective, analytical, observational, cross-sectional study wherein medical records of patients who were diagnosed with thyroid nodules goiter who underwent thyroid ultrasound with TIRADS scoring, Fine needle Aspiration Biopsy (FNAB) and ultimately thyroidectomy were reviewed. The primary endpoint included diagnostic performance of TIRADS classification and the possible factors that may contribute to discordance to FNAB and Histopathology. Results. One hundred twenty-five patients who underwent thyroidectomy were reviewed. These patients underwent thyroidectomy on the basis of their fine needle aspiration biopsy results. With FNAB as a reference standard, TIRADS had good sensitivity of 100% and low specificity of 27.7% in detecting thyroid malignancy. Patients who had FNAB positive or suspicious for malignancy are 1.37 times more likely to yield a positive TIRADS compared to patients who are FNAB negative (LR+), and 94% less likely to yield a negative TIRADS result (LR-). When TIRADS is positive, the positive predictive value was 31.3% and when TIRADS is negative, the negative predictive value (NPV) was nearly 100%. Overall, the accuracy of TIRADS in thyroid malignancy is 45.6% with ROC area at 0.638, indicating fair discriminative power of TIRADS to differentiate between benign vs malignant thyroid nodules. With histopathology as a reference standard, TIRADS had good sensitivity of 96.3% and low specificity of 33.8%. Patients who are histopathology positive are 1.45 times more likely to yield a positive TIRADS compared to patients who are histopathology negative (LR+), and 89% less likely to yield a negative TIRADS result (LR-). When TIRADS is positive, the positive predictive value was 52.5% and when TIRADS is negative, the negative predictive value (NPV) was 92.3%. Overall, the accuracy of TIRADS in thyroid malignancy is 60.8% with ROC area at 0.65, indicating fair discriminative power to differentiate between benign versus malignant thyroid nodules. Conclusion. TIRADS classification provides high sensitivity value in detecting thyroid malignancies but has fair discriminative power to differentiate between benign versus malignant thyroid nodules. Factors that are associated with discordant classification between TIRADS and FNAB were seen in those who underwent total thyroidectomy with lymph node dissection, and solid composition. There is insufficient evidence to determine whether any of the patient or nodule characteristics were associated with discordance between TIRADS and histopathology. Keywords. TIRADS, Thyroid Nodule, FNAB, Bethesda Score, Histopathology

The thyroid imaging reporting and data system (TI-RADS) was designed to better select patients who had undergone fine-needle aspiration biopsies (FNABs) with high sensitivity and accuracy. However, the combination of TI-RADS scores and Bethesda system categories in indeterminate thyroid nodules has not been examined extensively. This study aimed to stratify indeterminate thyroid nodules (Bethesda categories III, IV and V) according to risk of malignancy as determined by combining TI-RADS score with Bethesda system classification. Retrospective study. Histopathological, cytological and ultrasound (US) data were available for 242 cases after surgery, including 136 indeterminate nodules. All thyroid cytopathological slides and US reports were reviewed and classified according to Bethesda system and TI-RADS categories. The malignancy rate was determined for each Bethesda category, TI-RADS score and both methods combined of indeterminate nodules. The malignancy rates were 8·7%, 51·3% and 67·5% for Bethesda categories III, IV and V, respectively. Based on histopathological comparison, the accuracy was 66·7% for TI-RADS greyscale. TI-RADS 3 and 4A scores were observed in 80% of Bethesda III cases, which led to 80% sensitivity and 90% of negative predictive value (NPV). In contrast, for nodules scored as TI-RADS 4B and 5, the combined cytological results of Bethesda IV and V resulted in a higher risk of malignancy (75% and 76·9%, respectively, P < 0·001). In view of the high NPV of TI-RADS 3/4A only in Bethesda III category, a surgical approach could be considered for lesions defined as Bethesda III, IV and V when TI-RADS 4B and 5 were concomitant.

Introduction: Nodular lesions of the thyroid gland are frequent findings on Ultrasonography (USG). The Thyroid Imaging Reporting and Data System (TI-RADS) scores, based on USG, followed by Fine Needle Aspiration Biopsy (FNAB), are traditionally employed to study these nodules. Different TIRADS systems are available for the risk stratification of Thyroid Nodules (TN). Thyroid Elastography (TE) is a novel method for diagnosing nodules in recent times. Aim: To determine the diagnostic accuracy of conventional USG TI-RADS scoring systems and TE using Acoustic Radiation Force Impulse (ARFI) in diagnosing malignant and benign TNs, taking FNAB as the gold standard. Materials and Methods: This was a cross-sectional study conducted at Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India on a sample of 255 patients (with TNs &gt;1 cm) who underwent thyroid USG (with colour Doppler) followed by TE using ARFI. Virtual Touch imaging (VTi) and VTq quantification (VTq) were performed during TE. TI-RADS scoring, as per the American College of Radiology (ACR) white paper and the Kwak system, along with Shear Wave Velocity (SWV), was recorded along with other qualitative parameters for all the nodules. All the nodules were subjected to either Fine Needle Aspiration Cytology (FNAC) or biopsy for final characterisation into benign or malignant. The Receiver Operating Characteristic (ROC) curve was plotted for the total score as per Kwak, the total number of points as per the ACR committee white paper, and mean SWV, with the best cut-off obtained for each. Sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV) and diagnostic accuracy were calculated as per these cut-offs. Results: Out of the 255 nodules, 204 were benign (80%) and 51 (20%) were malignant, as per FNAC or biopsy. The mean age of the patients was 42.77±13.7 years; 49 (19.2%) were male patients and 206 (80.8%) were female patients. According to ACR TI-RADS, 19 benign and 45 malignant nodules were categorised as TI-RADS 5, while the Kwak TI-RADS system identified 22 malignant nodules as TI-RADS 5. A total of 194 (95.1%) benign nodules had a VTi grade ≤2, while 45 (88.2%) malignant nodules had a VTi grade of 3 or above. There was a significant difference (p-value &lt;0.05) in the VTi grade and SWV of the nodules between groups. Based on the ROC curves, the best cut-off to differentiate benign and malignant nodules was 3.4 m/sec for mean SWV (sensitivity 88.2%, specificity 92.2%, PPV 73.77%, NPV 96.91%). The diagnostic accuracy of SWV was 0.91 (0.85-0.95), ACR TI-RADS was 0.90 (0.78-0.90), and Kwak TI-RADS was 0.95 (0.91-0.97). Conclusion: ACR and Kwak TI-RADS scoring based on conventional thyroid USG, along with TE using ARFI, demonstrated good diagnostic accuracy in detecting malignant TNs. ARFI-based TE should be combined with conventional USG for better diagnostic performance and optimal management of nodules.

New Thyroid Imaging Reporting and Data System (TIRADS) Based on Ultrasonography Features for Follicular Thyroid Neoplasms: A Multicenter Study.

Thyroid nodules are a common and prevalent problem encountered in every day clinical practice. Ultrasound (US) is considered to be the initial imaging modality used in the evaluation of thyroid nodules. The TI-RADS (Thyroid Image Reporting and Data system) is an US-based system used to categorize thyroid nodules and stratify their malignant risk in the aim to standardize reporting and simplify communication among practitioners. The aim of this study is to compare the TI-RADS classification of thyroid nodules on ultrasound with the findings of fine-needle aspiration cytology (FNAC) reported using the Bethesda system. A retrospective study of 59 thyroid nodules that underwent single radiologist bedside neck and thyroid US over a period of one year between January 2020 – January 2021 was performed. The US findings were based on the TI-RADS and all the nodules were eventually subjected to US-guided FNAC. Clinico-pathological retrospective analysis was performed by comparing TI-RADS findings to the Bethesda FNAC classification. Comparing TI-RADS results with the Bethesda system of classification, the risk of malignancy for TI-RADS 2, TI-RADS 3, TI-RADS 4, and TI-RADS 5 were 0%, 10%, 50%, and 100%, respectively. A significant association was noted between the TI-RADS and Bethesda system of classification (P &lt; 0.001). We derived 91.3% sensitivity, 88.9% specificity, 84% positive predictive value, and 94.1% negative predictive value for our study. There is a strong correlation between thyroid sonographic reporting using the TI-RADS and Bethesda cytological classification system for thyroid nodules. The TI-RADS classification is an effective method for risk stratification of thyroid nodules into categories predictive of their malignant potential. This aims to guide further management and facilitate the selection process for fine-needle aspiration biopsy, thus avoiding unnecessary procedures.

Ultrasound is one of the accepted modality for the initial assessment of thyroid nodules. Thyroid image reporting and data system (TIRADS) classification system is the most useful of the risk stratification systems of thyroid imaging in predicting malignancy. The purpose of this study is to assess the clinical usefulness of TIRADS in the evaluation of thyroid nodule and compare it with final histopathological results. This was a prospective observational study conducted in a tertiary care hospital over a period of one year. Preoperative ultrasound was performed in 85 patients admitted for thyroid surgery. Thyroid nodules were classified according to TIRADS into five groups. The TIRADS category was compared with the final histopathological diagnosis following surgery. Sensitivity, specificity, positive as well as negative predictive value and risk of malignancy for each TIRADS category was assessed. The risk of malignancy for TIRADS 2, TIRADS 3, TIRADS 4, and TIRADS 5 was 4.2%, 13.3%, 57.9% and 100%, respectively. The usefulness of TIRADS classification in prediction of malignancy was 77.8% sensitive, 89.6% specific, had a positive predictive value of 66.6% and negative predictive value of 93.8%. The probability of a particular nodule being malignant can be inferred from ultrasound based TIRADS system. Hence ACR TIRADS classification is a valuable tool for diagnosis of thyroid nodule and should be adopted in our routine clinical practice.

Thyroid nodules are a common finding, especially in iodine-deficient regions. Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. Depending on the constellation or number of suspicious ultrasound features, a fine-needle biopsy is recommended. However, none of the previous TIRADS publications considered the functional status of the nodules. Hyperfunctioning thyroid nodules (HTNs) were presumed to exclude malignancy with a very high negative predictive value. Particularly in regions where the iodine supply is low, most HTNs are seen in patients with normal thyroid-stimulating hormone levels. Therefore, thyroid scintigraphy is essential for the detection of HTNs. We investigated whether TIRADS identifies HTNs as nonsuspicious. Methods: We evaluated 615 HTNs (23.2 ± 10.0 mm in maximum diameter in 582 patients ([442 women, 57.7 ± 13.2 y old, and 140 men, 60.1 ± 12.7 y old) detected by 99mTc-pertechnetate or 123I scintigraphy. Before evaluating the scintigraphic appearance, all nodules were analyzed prospectively with sonography, using the TIRADS model referenced in Kwak et al., wherein fine-needle biopsy is recommended for TIRADS 4A or higher. We also investigated 2 subgroups, 42 nodules with available histology and 117 patients with subclinical or overt hyperthyroidism. Results: Whereas 15.9% of the nodules were classified as TIRADS 3 or lower and less than 0.1% as TIRADS 5, most of the nodules were classified as TIRADS 4A (29.3%), 4B (29.3%), or 4C (24.9%). Altogether, more than 80% of the autonomous thyroid nodules were classified as TIRADS 4A or higher, a grade that would result in a recommendation of fine-needle biopsy. Focusing on those 117 HTNs that were already associated with hyperthyroid laboratory values, the rates were similar: 81.2% were categorized as TIRADS 4A or higher (4A, 33.3%; 4B, 29.9%; 4C,17.1%; 5, 0.9%). In the subgroup of patients who underwent thyroid surgery, all nodules were benign, confirming the known negative predictive value of HTNs with regard to malignancy exclusion. Conclusion: Integration of thyroid scintigraphy into the TIRADS model is essential to prevent unnecessary fine-needle biopsy and thyroid surgery.

Consistency of Thyroid Imaging Reporting and Data System Reporting in Community-Based Imaging Centers Versus a Large Tertiary Hospital

Objective To evaluate the diagnostic value of Bethesda system combined with thyroid imaging reporting and data system (TIRADS) in assessing the malignat risk of thyroid nodules. Methods Histopathological, cytological and ultrasound (US) data were studied retrospectively for 243 cases after surgery, including 273 thyroid nodules. All thyroid cytopathological slides and US reports were classified according to Bethesda system and TIRADS. Based on histopathological comparison, the sensitivity and specificity were determined for Bethesda category and Bethesda category combined with TIRADS. Results The sensitivity and specificity of Bethesda category were 91.0% and 90.3%, respectively. In indeterminate nodules, malignancy rate was 38.7% in Bethesda categoriesⅠ and Ⅲ, and 85.4% in Bethesda categories Ⅳ and Ⅴ. In contrast, combined with TIRADS, the sensitivity and specificity of positive results were 82.4%, 100%, and negative results were 99.5%, 83.8%, respectively. The malignancy rate of TIRADS 2/3a in Bethesda categories Ⅰ/Ⅲ, TIRADS 3b/3c/4 in Bethesda categories Ⅰ/Ⅲ, TIRADS 2/3a in Bethesda categories Ⅳ/Ⅴ, and TIRADS 3b/3c/4 in Bethesda categories Ⅳ/Ⅴwere 3.7%, 81.8%, 45.4% and 100%, respectively. Conclusions Bethesda system combined with TIRADS may be helpful to the preoperative diagnosis of thyroid nodules, which may reduce unnecessary repeat fine needle aspiration and excessive surgery. Key words: Ultrasonography; Biopsy, fine-needle; Thyroid diseases; Bethesda system; Thyroid imaging reporting and data system

Due to the widespread use of ultrasound, small thyroid nodules (TNs) ≤ 10 mm are common findings. Standardized approaches for the risk stratification of TNs with Thyroid Imaging Reporting and Data Systems (TIRADS) were evaluated for the clinical routine. With TIRADS, the risk of malignancy in TNs is calculated by scoring the number or combination of suspicious ultrasound features, leading to recommendations for further diagnostic steps. However, there are only scarce data on the performance of TIRADS for small TNs. The aim was to compare three different TIRADS for risk stratification of small TNs in routine clinical practice. We conducted a retrospective cohort analysis of TNs ≤ 10 mm and their available histology. Nodules were classified according to three different TIRADS. In the study, 140 patients (n = 113 female) with 145 thyroid nodules (n = 76 malignant) were included. Most of the malignant nodules were papillary carcinoma (97%), and the remaining 3% were medullary carcinoma. For all tested TIRADS, the prevalence of malignancy rose with increasing category levels. The highest negative predictive value was found for ACR TI-RADS and the highest positive predictive value for Kwak-TIRADS. All tested variants of TIRADS showed comparable diagnostic performance for the risk stratification of small TNs. TIRADS seems to be a promising tool to reliably assess the risk of malignancy of small TNs.

Evaluation of thyroid nodules with coexistent Hashimoto’s thyroiditis according to various ultrasound-based risk stratification systems：A retrospective research