TI-RADS System Research Articles

Quality Improvement Methodology to Improve Standardized Reporting of Pediatric Thyroid Ultrasounds Using TI-RADS

Background/purposeThe process of evaluating pediatric thyroid nodules at our institution was inconsistent with a high rate of negative biopsies raising concern of appropriate patient selection for biopsy. Our aim was to institute a standardized risk stratification reporting system for thyroid nodules to increase utilization and agreement of TI-RADS reporting at our institution. MethodsRadiology report data were collected and analyzed as part of a quality improvement project. A standardized TI-RADS dictation template was created, ultrasound technicians were trained, a multi-disciplinary conference initiated, and education provided for radiologists and clinicians. Control charts were used to track utilization and agreement of scoring of TI-RADS reporting based upon review by a radiologist trained in TI-RADS scoring. ResultsFrom January 2019 to January 2021, 218 patients with a thyroid nodule had a thyroid ultrasound performed at our institution. TI-RADS was utilized in 0 % (0 of 57) of children in the four months prior to project initiation. Following creation of the template, utilization increased to 65 % (39 of 60) over 5 months. Utilization further increased after the first training conference and was maintained above 90 % for 13 months. Ultrasound reports were in agreement in 46.7 % (28 of 60) of children initially. Agreement in reporting improved to 71.4 % (10 of 14) in the 3 months following the first training and to 78.4 % (58 of 74) over 12 months. Agreement in reporting was maintained at 80 % in the following 6 months. ConclusionsA quality improvement initiative can improve utilization and agreement of scoring using the TI-RADS system in pediatrics. This may ultimately reduce unnecessary biopsies and sedation in children. Level of evidenceLevel III. Type of studyQuality Improvement.

Comparing ATA guidelines vs TI-RADS for evaluation of pediatric thyroid lesions.

To compare TI-RADS vs ATA guidelines for pediatric thyroid lesions based on ultrasound, in a retrospective study over 10 years. The primary outcome measure was sensitivity of both guidelines in diagnosing a thyroid malignancy on Fine Needle Aspiration (FNA) results. Retrospective data collection of all pediatric patients who had an FNA at the Primary Children's Hospital for thyroid lesions. Both guidelines were compared to determine which set of guidelines is most sensitive based on final outcome of pathology. Seventy-seven patients were included in the study. All 77 underwent FNA as recommended by the ATA guidelines. 54.5% were benign, 22.1% were suspicious, and 23.4% were malignant lesions. Following the TI-RADS guidelines, 40.5% of these patients could have skipped the FNA. Using the ATA guidelines, all malignant lesions would have undergone FNA. However, using the TI-RADS guidelines, some patients with malignant lesions would have been ignored (5.6%) and some followed (22.2%) showing overall less sensitivity (75%). The ATA ultrasound guidelines for evaluation of thyroid nodules in children are more sensitive in screening for well-differentiated thyroid malignancy. Increased sensitivity is due in part to the size constraint within the TIRADS system. All providers who evaluate thyroid nodules in children should use the ATA pediatric guidelines to avoid missing smaller malignancies in children.

Comparison of Fine needle aspiration followed by histopathology and sonographic features of thyroid nodule to formulate a diagnosis: A cross-sectional study

Thyroid nodules are solid lumps filled with fluid that develop inside the thyroid gland. Due to their small size, the majority of them go undetected and are asymptomatic. However, some of them are cancerous. Objectives: To compare the diagnostic accuracy of Fine needle aspiration followed by histopathology and sonographic features of thyroid nodule Methods: In this study, 274 participants were included. All of them were detected with the solitary euthyroid nodule. All the patients considered in the present study had normal values of T4 and TSH as euthyroid nodules were supposed to be studied. All the participants were subjected to undergo a USG as per the TIRADS system and FNAC wherever it was applicable. The biopsy report of the excised sample was considered a gold standard. Result: The classification of FNAC was more specific than the TIRADS system, however, the sensitivity of both the classification was the same. Micro-calcification was most specific and sensitive in the individuals that underwent a USG. Irregular margins had a specificity of 88% and nodules taller-than-wider in shape were 91% specificity. A total of 7 patients had shown benign features on cytology, whereas, they were suspiciously malignant on USG (TIRADES 4 and 5) and showed malignancy in final evaluation after the surgery. Conclusion: The sensitivity of both FNAC and USG in the diagnosis of malignancy of thyroid nodule is equal, however, the specificity of FNA is more (90%). FNAC is a minimally invasive procedure that can be opted for the differentiation of benign and malignant lesions with an accuracy of 86%. Patients showing high-risk features on sonography are subjected to repeat the FNAC and they should also be referred for a surgical biopsy to make a definitive diagnosis.

TIRADS system: what does clinical practice tell us?

TIRADS system: what does clinical practice tell us?

EVALUATION OF PREDICTIVE CAPABILITIES OF TIRADS, EU-TIRADS, TLA_RU SYSTEMS IN THE ULTRASOUND DIAGNOSIS OF THYROID NODULAR PATHOLOGY

The aim of the study was to evaluate the prognostic capabilities of EU-TIRADS, TIRADS, TLA_RU systems in ultrasound diagnostics of thyroid nodular masses. A retrospective independent continuous blind study of ultrasound examination protocols was conducted in 665 patients, 241 patients had benign non-cancerous thyroid diseases, 86 patients had benign tumors (adenomas), 338 patients had thyroid cancer. During the preoperative examination, all patients underwent a multiparametric ultrasound examination of the neck organs according to the standard procedure, with the registration of identified thyroid nodes, with examining the prognostic capabilities of stratification systems – TIRADS, EU-TIRADS, TLA_RU. It was found that the TIRADS system has a sensitivity of 91.04%, specificity – 91.41%. Focusing on the scale of AUC values reflecting the quality of the diagnostic test, it can be stated that TIRADS is a test with excellent quality (AUC =0.972). Basing on the results of the analyzing the data obtained by the EU-TIRADS system, it was revealed that it is a high-quality test (AUC=0.826), but its predictive capabilities are worse than those of TIRADS. The original TLA_RU model has 87.5% sensitivity and 95.7% specificity. During the ROC analysis, it was found that the AUC is equal to 0.954±0.00894, which suggests that the TLA_RU model is an excellent quality test in the differential diagnosis of thyroid nodular masses. Multivariate statistical comparative analysis of thyroid imaging assessment systems (TIRADS, EU-TIRADS and TLA_RU) from the standpoint of evidence-based medicine has shown that thyroid cancer risk stratification systems based on the assessment of multiparametric ultrasound signs have great diagnostic capabilities.

Comparison of Korean vs. American Thyroid Imaging Reporting and Data System in Malignancy Risk Assessment of Indeterminate Thyroid Nodules.

BackgroundThe management of cytologically indeterminate thyroid nodules is challenging for clinicians. This study aimed to compare the diagnostic performance of the Korean Thyroid Imaging Reporting and Data Systems (K-TIRADS) with that of the American College of Radiology (ACR)-TIRADS for predicting the malignancy risk of indeterminate thyroid nodules.MethodsThyroid nodules diagnosed by fine-needle aspiration (FNA) followed by surgery or core needle biopsy at a single referral hospital were enrolled.ResultsAmong 200 thyroid nodules, 78 (39.0%) nodules were classified as indeterminate by FNA (Bethesda category III, IV, and V), and 114 (57.0%) nodules were finally diagnosed as malignancy by surgery or core needle biopsy. The area under the curve (AUC) was higher for FNA than for either TIRADS system in all nodules, while all three methods showed similar AUCs for indeterminate nodules. However, for Bethesda category III nodules, applying K-TIRADS 5 significantly increased the risk of malignancy compared to a cytological examination alone (50.0% vs. 26.5%, P=0.028), whereas applying ACR-TIRADS did not lead to a change.ConclusionK-TIRADS and ACR-TIRADS showed similar diagnostic performance in assessing indeterminate thyroid nodules, and K-TIRADS had beneficial effects for malignancy prediction in Bethesda category III nodules.

The impact of TI-RADS in detecting thyroid malignancies: a prospective study.

Thyroid ultrasonography (US) is the first-step noninvasive and easily accessible diagnostic method widely used in the detection and characterization of nodular thyroid disease. We aimed to develop a TI-RADS, which is easy to apply and only relies on the counting of suspicious criteria. In order to measure the reliability of the system, we investigated its correlation with fine needle aspiration biopsy (FNAB) and post-surgery histological results. In this prospective study, 242 patients who had undergone FNAB with simultaneous cytopathologist in the radiology department between April and August 2016 were analyzed. Before FNAB, the thyroid gland was re-evaluated with US, and TI-RADS classification was made. Demographic characteristics, family thyroid cancer history and radiotherapy history to the neck region were noted. Of the 242 patients, 17.3% were male (42 males/200 females). US-guided FNAB was applied to all patients. Mean age was 50 ± 13years (min: 19, max: 82). Both FNAB and final post-surgery histology results showed that sex and age were not statistically significantly associated with malignancy (p = 0.193) TI-RADS criteria and FNAB results revealed a statistically significant association between irregular contours, the state of anteroposterior diameter being longer than transverse diameter, microcalcifications, marked hypoechogenicity, and malignancy (p < 0,05). Thirty patients were TI-RADS ≥ 4, 206 patients were TI-RADS ≤ 3 and there was a significant correlation between TI-RADS and Bethesda classification (p = 0.001). In addition, statistically significant associations were found between malignancy and family history of thyroid cancer (p = 0.035) and radiotherapy history to the neck region (p = 0.01). TI-RADS system after nodule identification is based only on the counting of suspicious criteria. It will be safe and effective to recommend follow-up with low score TI-RADS, benign characters and insufficient FNAB results, and thus, unnecessary thyroidectomy operations will be prevented. It will be easier for surgeons to recommend surgery and persuade the patients for it when patients have high TI-RADS scores. TI-RADS has high power in detecting malignancy by recommending biopsy of suspicious nodules.

Diagnostic Performances of the ACR-TIRADS System in Thyroid Nodules Triage: A Prospective Single Center Study.

Simple SummaryOn a prospective series of 480 thyroid nodules, the ACR-TIRADS demonstrated a sensitivity and specificity in performing FNA of 58.9% and 59%, respectively. The execution of FNA on nodules with ACR class ≥3 independently from the dimensional criteria would increase the sensitivity to 95% and reduce the false negatives rate (7.3%, 7/96), prompting a re-evaluation of the size criteria. The need for reduction in inappropriate hospital admissions prompts a rigorous triage of patients, and future prospective studies to improve current performances might be considered.Ultrasound scores are used to determine whether thyroid nodules should undergo Fine Needle Aspiration (FNA) or simple clinical follow-up. Different scores have been proposed for this task, with the American College of Radiology (ACR) TIRADS system being one of the most widely used. This study evaluates its ability in triaging thyroid nodules deserving FNA on a large prospective monocentric Italian case series of 493 thyroid nodules from 448 subjects. In ACR 1–2, cytology never prompted a surgical indication. In 59% of cases classified as TIR1c-TIR2, the FNA procedure could be ancillary, according to the ACR-TIRADS score. A subset (37.9%) of cases classified as TIR4-5 would not undergo FNA, according to the dimensional thresholds used by the ACR-TIRADS. Applying the ACR score, a total of 46.5% thyroid nodules should be studied with FNA. The ACR system demonstrated a sensitivity and specificity of 58.9% and 59% in the identification of patients with cytology ≥TIR3A, with a particularly high false negative rate for ACR classes ≥3 (44.8%, 43/96), which would dramatically decrease (7.3%, 7/96) if the dimensional criteria were not taken into account. In ACR 3–4–5, a correspondence with the follow-up occurred in 60.3%, 50.2% and 51.9% of cases. The ACR-TIRADS is a useful risk stratification tool for thyroid nodules, although the current dimensional thresholds could lead to an underestimation of malignant lesions. Their update might be considered in future studies to increase the screening performances of the system.

Risk Stratification in Patients With Follicular Neoplasm on Cytology: Use of Quantitative Characteristics and Sonographic Patterns.

ObjectivesDifferentiating thyroid nodules with a cytological diagnosis of follicular neoplasm remains an issue. The goal of this study was to determine whether ultrasonographic (US) findings obtained preoperatively from the computer-aided detection (CAD) system are sufficient to further stratify the risk of malignancy for this diagnostic cytological category.MethodsFrom September 2016 to September 2018 in our hospital, patients diagnosed with Bethesda category IV (follicular neoplasm or suspicion of follicular neoplasm) thyroid nodules and underwent surgical excisions were include in the study. Quantification and analysis of tumor features were performed using CAD software. The US findings of the region of interest, including index of composition, margin, echogenicity, texture, echogenic dots indicative of calcifications, tall and wide orientation, and margin were calculated into computerized values. The nodules were further classified into American Thyroid Association (ATA) and American College of Radiology Thyroid Imaging Reporting & Data System (TI-RADS) categories.Results92 (10.1%) of 913 patients were diagnosed with Bethesda category IV thyroid nodules. In 65 patients, the histological type of the nodule was identified. The quantitative features between patients with benign and malignant conditions differed significantly. The presence of heterogeneous echotexture, blurred margins, or irregular margins was shown to have the highest diagnostic value. The risks of malignancy for nodules classified as having very low to intermediate suspicion ATA, non-ATA, and high suspicion ATA patterns were 9%, 35.7%, and 51.7%, respectively. Meanwhile, the risks of malignancy were 12.5%, 26.1%, and 53.8% for nodules classified as TIRADS 3, 4, and 5, respectively. When compared to human observers, among whom poor agreement was noticeable, the CAD software has shown a higher average accuracy.ConclusionsFor patients with nodules diagnosed as Bethesda category IV, the software-based characterizations of US features, along with the associated ATA patterns and TIRADS system, were shown helpful in the risk stratification of malignancy.

MON-525 ATA and ACR TIRADS Classification Systems as Additional Predictors of Malignancy in Afirma GSC Suspicious Thyroid Nodules

Objective: Evaluation and management of thyroid nodules with cytologically indeterminate results remain challenging in clinical practice. Despite the implementation of molecular testing in an attempt to avoid surgical intervention, diagnostic thyroidectomy still occurs due to the relatively low positive predictive value of these molecular testing. We conducted a study to analyze whether combining US characteristics and results of molecular testing would better elucidate predicting true positive results. Methods: We retrospectively reviewed thyroid ultrasound images of 172 nodules in 162 patients (mean age, 55 years +/- 14) with indeterminate cytology results (Bethesda III and IV) that underwent Afirma Gene Sequencing Classifier (GSC) testing at a single academic medical center between 2017–2019. All nodules were classified according to 2015 American Thyroid Association (ATA) and 2017 American College of Radiology Thyroid Imaging Reporting and Data System (ACR-TIRADS). Results: A total of 172 with subsequent Afirma GSC molecular testing were included in the study. There were 127 nodules with Bethesda III (AUS/FLUS) (73.8%), and 45 nodules with Bethesda IV (SFN/HCN) (26.2%) results. The mean nodule volume was 5.4 +/- 10 cm3. Afirma GSC identified 129 nodules (75%) as benign and 43 nodules (25%) as suspicious. Per ATA classification, 10.4% (18) of nodules were classified as very low risk, 40.7% (70) as low risk, 36.5% (62) as intermediate and 12.8% (22) as high risk for malignancy. There was a significant association between ATA classification and Afirma benign nodules (P=0.002). All nodules were also classified per TIRADS system with the following distribution: 5 (1.16%) TIRADS 1, 7 (4%) TIRADS 2, 54 (31%) TIRADS 3, 90 (52%) TIRADS 4, and 16 (9.3%) TIRADS 5. We did not observe the similar association between TIRADS system and benign nodules as we did with ATA classification (P=0.4).35 patients (79.5%) with Afirma suspicious results underwent surgery, of which 18 (51.4%) surgical pathology were malignant. 8 patients with Afirma suspicious results decided to proceed with ultrasound surveillance. The malignancy rates of nodules with low, intermediate and high suspicion for malignancy classified by the ATA guidelines were 44% (9 of 18), 33% (56 of 18) and 22% (4 of 18). The malignancy rates of TIRADS category 3, 4 and 5 nodules were 44% (8 of 18 nodules), 44% (8 of 18 nodules) and 11% (2 of 18 nodules). Subset analysis of surgical pathology benign and cancerous nodules did not show significant association between ATA (P=0.5) or TIRADS (P=0.4) classification systems. Conclusion: Our study showed that Afirma benign nodules were associated with a lower risk of malignancy per ATA classification but not with TIRADS system. We did not find a significant association between pathology proven cancer cases and high-risk ATA or TIRADS ultrasound classification systems.

Updated ACR Thyroid Imaging Reporting and Data Systems in risk stratification of thyroid nodules: 1-year experience at a Tertiary Care Hospital in Al-Qassim

BackgroundThyroid imaging reporting and data system (TI-RADS) is assessment of risk stratification of thyroid nodules, using a score. A novel ACR (American College of Radiology) TI-RADS has been recently suggested by American College of Radiology. But, the utility of ACR TI-RADS in risk stratification for thyroid lesion needs further evaluation.AimOf this study was to evaluate ACR TI-RADS classification in discriminating benign and from other thyroid lesions as detected by fine needle aspiration cytology (FNAC).MethodsThis retrospective study included all patients referred to our institute for FNAC of a thyroid nodule over 1 year. Thyroid nodules were categorized according to the 2017 ACR TI-RADS. Ultimately, efficacy of ACR TI-RADS in differentiating benign from non-benign nodules was assessed using ROC curve, cross-tabulation, and Chisquare tests. According to the results of FNAC, nodules were classified into 2 groups; benign lesions (Bethesda II) and malignant lesions (Bethesda IV, V).ResultsThe percentages of Bethesda IV and V lesions defined in our ACR-TIRADS were as follows: ACR TI-RADS 1, 2 (0%), ACR TI-RADS 3 (4%), ACR TI-RADS 4 (6.6%), and ACR TI-RADS 5 (22.6%). ROC curve analysis for ACR TI-RADS to differentiate benign from non-benign pathology showed (AUC 0.60, 95% CI: 0.505–0.713). ACR TI-RADS had sensitivity, specificity, positive predictive value and negative predictive value 75%, 62.35 %, 15.7%, 96.3% respectively.ConclusionDifferentiation between benign and malignant thyroid lesion can be suggested from the ultrasound based ACR TI-RADS system. FNAC might be deferred in patients having ACR TI-RADS 1 and 2.

Correlation of Bethesda cytopathology classification with Ti Rads: When surgery is necessary?

Teaching Points (1) A brief review of Bethesda system;(2) A review of Ti-Rads system;(3) To confront the two systems for recommending surgery. Table of Contents/Outline Bethesda and Ti-Rads improves communication among cytopathologists, radiologists, surgerons and physicians. Bethesda has 6 categories for thyroid FNA. The categories stratify the risk of malignancy and recomend clinical management. The Bethesda classification: I- Nondiagnostic, II- Benign, III- Atypia of Undetermined Significance (not able to be classify as benign, suspicious, or malignant), IV- Follicular Neoplasm (cytologic do not allow diagnosis of carcinoma or adenoma), V- Suspicious for Malignancy (incomplete cellular malign architectural) and VI- malignant. Ti-Rads has 5 categories. 1- normal, 2-certainly benign (simple cyst, septated cyst or isolated macrocalcification), 3- very probably benign (oval shape, regular borders, iso or hyperechoic), 4A– suspicous nodules but low risk of malignancy (oval shape, regular borders and mildly hypoechoic), 4B- suspicious nodules with high risk of malignancy, 1 or 2 high suspicious features (taller-than-wide, spiculated, markdely hypoechoic and microcalcifications), 5-certainly malignant (3 or 5 suspicious features and/or presence of metastatic node). Whenever you have Bethesda III, IV and V with Ti-Rads 4B- and 5, patient should undergo surgery.

The Accuracy of ACR TI-RADS Classification of Neck Ultrasound as a First-Line Diagnostic Approach for Thyroid Neoplasms in Pediatric Patients: A Retrospective Study

Background.Ultrasound (US)-guided fine-needle aspiration biopsy (FNAB) is the gold standard in diagnosing the pathological nature of undetermined thyroid nodules. However, in some instances limitations and shortcomings arise, making it insufficient for determining a specific diagnosis.Objective.Our aim was to evaluate the effectiveness of ACR TI-RADS classification of neck ultrasound as a first-line diagnostic approach for thyroid neoplasms in pediatric patients.Methods.A retrospective analysis was made of FNA and US protocols in 70 patients who underwent the examination and treatment at Dmitry Rogachev National Research Center between January 2012 and August 2017. In the retrospective series 70% (49/70) of patients undergone FNA and 43% (30/70) of them undergone repeated FNA. All US protocols were interpreted according to ACR TI-RADS system by the two independent experts. The clinical judgment was assessed using the concordance test and the reliability of preoperative diagnostic methods was analized.Results.According to histologic examination protocols, benign nodules reported greater multimorbidity 29% (20/70), compared with thyroid cancer 17% (12/70), complicating FNA procedure. A statistically significant predictor of thyroid cancer with a tumor size ACR TI-RADS showed a significant advantage of ACR TI-RADS due to higher sensitivity (97.6 vs 60%), specificity (78.6 vs 53.8%), positive predictive value (87.2 vs 71.4%), and negative predictive value (95.7 vs 41.2%). Concordance on the interpreted US protocols according to ACR TI-RADS classification between two experts was high, excluding accidental coincidence.Conclusion.The data support the feasibility of US corresponding to the ACR TI-RADS classification as a first-line diagnostic approach for thyroid neoplasm reducing the number of unnecessary biopsies for thyroid nodules.

Comments and discussion on the thyroid gland elastography World Recommendations 2015

В статье приведены 28 всемирных рекомендаций по эластографии, опубликованных в 2016 г. группой экспертов Мировой ассоциации специалистов по ультразвуковой диагностике в медицине. Приводятся уровни доказательности каждого из положений и уровень рекомендаций с процентным соотношением голосования экспертов. Обсуждается методика, клиническая интерпретация показателей различных видов эластографии: компрессионной эластографии, точечной эластографии сдвиговых волн, двумерной эластографиисдвиговых волн. Подчеркивается, что эластография – дополнительная методика к ультразвуковому исследованию, состоящему из серошкального и допплеровского режимов. В некоторых положениях указывается, что происходит наложение клинических данных, например, по медуллярному раку щитовидной железы. Приводятся цифровые значения эластографии не только для очаговой патологии, но и для диффузных заболеваний щитовидной железы. Данные положения обсуждаются в свете Общероссийских рекомендаций по узловому зобу Российской ассоциации эндокринологов 2016 г. с поиском путей валидации положений для внедрения в практическое отечественное здравоохранение. Данные рекомендации необходимы для включения в валидированную для России систему TI-RADS с включением ультразвукового критерия “эластография щитовидной железы” в протокол обязательного обследования пациентов с диффузными и очаговыми заболеваниями щитовидной железы.

Use of TI-RADS system in differential diagnosis of thyroid cancer

Aim. To evaluate the effectiveness of ultrasound classification of thyroid palpable abnormalities using TI-RADS system for thyroid cancer detection in the Chuvash Republic. &#x0D; Methods. The study is based on the results of examining of 296 patients (study group) with thyroid palpable abnormalities. All patients from the study group had multi-parametric ultrasound imaging performed using modern methods and techniques (B-mode, color and power Doppler mapping). Based on ultrasound data received, signs of malignancy of thyroid palpable abnormalities by TI-RADS system were identified. Data from ultrasound protocols were compared with cytological and morphological findings. Fine needle biopsy was used as «gold standard» for the diagnosis of thyroid cancer. &#x0D; Results. All patients from study group were divided according to echographic characteristics into 4 subgroups by TI-RADS scale: TI-RADS 3, TI-RADS 4a, TI-RADS 4b, TI-RADS 5. Out of the total number of patients thyroid cancer in TI-RADS 3 subgroup was determined in 14 (4.7%) cases, TI-RADS 4a - in 36 (12.2%), TI-RADS 4b - in 66 (29.1%), TI-RADS 5 - in 160 (54.0%) cases. Among patients from TI-RADS 3 subgroup papillary cancer was detected in 6.7% (11) cases, follicular cancer - in 2.5% (3); in TI-RADS 4a subgroup papillary carcinoma was detected in 61.1% of cases, follicular cancer - in 36.1%, medullary cancer - in 2.8%; in TI-RADS 4b in 76.4% of cases papillary carcinoma was detected, in 31.4% - follicular cancer and in 1.2% - medullary cancer; in TI-RADS 5 subgroup in 46.3% of cases papillary carcinoma was detected, in 46.9% - follicular cancer, in 5.6% - medullary cancer and in 1.3% - anaplastic carcinoma was detected. &#x0D; Conclusion. Suggested TI-RADS classification makes it possible to standardize thyroid ultrasound protocol; introduction of TI-RADS classification into algorithm of early radiological diagnosis of thyroid cancer allows improving thyroid cancer diagnosis.