An Ultrasonogram Reporting System for Thyroid Nodules Stratifying Cancer Risk for Clinical Management

Thyroid Board, Clinica Alemana de Santiago, Av. Vitacura 5951 Santiago, Chile.
The Journal of Clinical Endocrinology and Metabolism (Impact Factor: 6.21). 04/2009; 94(5):1748-51. DOI: 10.1210/jc.2008-1724
Source: PubMed


There is a high prevalence of thyroid nodules on ultrasonographic (US) examination. However, most of them are benign. US criteria may help to decide cost-effective management.
Our objective was to develop a standardized US characterization and reporting data system of thyroid lesions for clinical management: the Thyroid Imaging Reporting and Data System (TIRADS).
This was a prospective study using the TIRADS, which is based on the concepts of the Breast Imaging Reporting Data System of the American College of Radiology.
A correlation of the US findings and fine needle aspiration biopsy (FNAB) results in 1959 lesions biopsied under US guidance and studied histologically during an 8-yr period was divided into three stages. In the first stage, 10 US patterns were defined. In the second stage, four TIRADS groups were defined according to risk. The percentages of malignancy defined in the Breast Imaging Reporting and Data System were followed: TIRADS 2 (0% malignancy), TIRADS 3 (<5% malignancy), TIRADS 4 (5-80% malignancy), and TIRADS 5 (>80% malignancy).
The TIRADS classification was evaluated at the third stage of the study in a sample of 1097 nodules (benign: 703; follicular lesions: 238; and carcinoma: 156). Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 88, 49, 49, 88, and 94%, respectively. The ratio of benign to malignant or follicular FNAB results currently is 1.8.
The TIRADS has allowed us to improve patient management and cost-effectiveness, avoiding unnecessary FNAB. In addition, we have established standard codes to be used both for radiologists and endocrinologists.

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    • "Based on these findings, mixed nodules should be biopsied at the same size thresholds as solid nodules, as opposed to what the current ATA guidelines suggest. US is a helpful tool in the detection of thyroid cancer, and several scores have been recently proposed to select the nodule which should be biopsied [15] [16]. Papini et al. reported that the combination of solid echostructure with hypoechogenic pattern has 87% sensitivity for thyroid cancer, albeit with low specificity and low positive predictive value [17]. "
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    ABSTRACT: Objective. Ultrasonographic characteristics are associated with thyroid malignancy. Our aim was to compare the diagnostic value of ultrasound features in the detection of thyroid malignancy in both solid and mixed nodules. Methods. We prospectively studied female patients (≥50 years) referred to ultrasound-guided fine needle aspiration biopsy. Ultrasound features considered suspicious were hypoechogenicity, microcalcifications, irregular margins, high anteroposterior (AP)/axial-ratio, and absent halo. Associations were separately assessed in mixed and solid nodules. Results. In a group of 504 elderly female patients (age = 69 ± 8 years), the frequency of malignant cytology was 6%. Thirty-one percent of nodules were mixed and 60% were solid. The rate of malignant cytology was similar for mixed and solid nodules (7.4 versus 5.8%, P: 0.56). While in mixed nodules none of the ultrasound characteristics were associated with malignant cytology, in solid nodules irregular margins and microcalcifications were significant (all P < 0.05). The combination of irregular margins and/or microcalcifications significantly increased the association with malignant cytology only in solid nodules (OR: 2.76 (95% CI: 1.25-6.10), P: 0.012). Conclusions. Ultrasound features were of poor diagnostic value in mixed nodules, which harbored malignant lesions as often as solid nodules. Our findings challenge the recommended minimal size for ultrasound-guided fine needle aspiration biopsy in mixed nodules.
    Full-text · Article · Jun 2014 · Journal of Thyroid Research
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    • ". This was in a bid to standardize the reporting of results of thyroid US that can be understood by clinicians and also stratify the risk of malignancy of a lesion based on the US features of the lesion . Horvath et al. described 10 US patterns of thyroid nodules and related the rate of malignancy according to the pattern [9]. However, these US patterns were not applicable to all thyroid nodules and appeared difficult to use in routine clinical practice. "
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    ABSTRACT: Background: Ultrasonography (US) is the best diagnostic tool in the initial assessment of thyroid nodule. Giving its appropriateness and accessibility, ultrasound-based thyroid imaging reporting and data systems (TIRADS) classifica- tions have been developed with main goal to standardize reporting and facilitate communication between practitioners, and to indicate when fine-needle aspiration biopsy (FNAB) should be performed. Objective: To determine the reliabil- ity of Russ’ modified TIRADS classification in predicting thyroid malignancy. Materials and Methods: It was a cross sectional study carried out at Centre Hospitalier de Lagny, Marne La Vallée (France). Consecutive records of patients with focal thyroid nodules on ultrasound (US) for which US-guided FNAB was performed and pathology results were available, from January 2007 to August 2012, were selected for review. The risk of malignancy of each TIRADS cate- gory was determined and correlation with pathology assessed. Statistical performances of some US features were also assessed. The threshold for statistical significance was set at 0.05. Results: A total of 430 records of patients were eligi- ble. Twenty-three out of 430 (5.3%) nodules were malignant. The risk of malignancy of the TIRADS categories were as follows: TIRADS2 0%, TIRADS3 2.2%, TIRADS4A 5.9%, TIRADS4B 57.9%, TIRADS5 100% (Gamma statistic = 0.85; Spearman correlation = 0.30, Pearson’s R = 0.37, p < 0.001). Some US features were associated with a higher risk of malignancy: irregular contours (OR = 22.4), taller-than-wide shape (OR = 19.5), microcalcifications (OR = 15.2), and marked hypoechogenicity (OR = 12.7). Conclusion: Russ’ modified TIRADS classification is reliable in predicting thyroid malignancy. More evidence is nevertheless necessary for widespread adoption and use
    Full-text · Article · Aug 2013 · Open Journal of Radiology
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    • "While follow up, the most frequent way to proceed are the repeated US examination and a fine needle aspiration biopsy (FNAB). Even though the biopsy is considered by many doctors as a basis for further monitoring, performing FNAB of any identified lesions may not be prudent [4,5]. It happens that FNAB confirms the benign nature of the lesion and, nevertheless, it is quite frequently repeated (often many times) in spite of the fact that US image pattern does not change during a long-term observation. "
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    ABSTRACT: The standard management in patients with thyroid nodules is to assess the risk of malignancy, based on cytological examination. On the other hand, there are thyroid patterns of ultrasound (US) image, associated with an increased risk of malignancy. The aim of our study was to create a diagnostic algorithm that would employ both data from US examination (expressed by a total score, according to our scoring system) and FNAB results, classified according to Bethesda system (The Bethesda System for Reporting Thyroid Cytopathology - TBSRTC categories). Material and methods 100 thyroid cancer foci (94 papillary carcinomas, 4 medullary carcinomas, 2 undifferentiated carcinomas) and 100 benign focal lesions were selected during postoperative histopathological examination of thyroid glands excised during surgery from 111 patients. The corresponding US images of each lesion – performed in the course of preoperative diagnostics – were evaluated for the presence of seven (7) different features in US image, suggesting a malignant character of lesion, viz. vascularity, i.e., the increased central intranodular blood flows, microcalcifications, “taller-than-wide” orientation, solid composition, hypoechogenicity, irregular margin and either absence of peripheral halo or the presence of outer shell of uneven thickness, surrounding the lesion. The sensitivity, specificity, positive predictive values, negative predictive values and odds ratios for each US feature were calculated. In US image of the analyzed cancer foci, we obtained the following values of odds ratio for each of the above mentioned features suggesting malignancy: “taller-than-wide” orientation - odds ratio - 301.0, microcalcifications - 24.67, increased intranodular vascularity - 20.44, hypoechogenicity - 18.61, irregular margins - 7.81, absence of halo - 5.88, and solid composition - 4.16. Taking into account our own experience and the present data, in juxtaposition with the opinions of other authors, we propose a division of US features into 3 groups of different prognostic importance, expressed by a total score calculated based on our scoring system. Accordingly, microcalcifications, “taller-than-wide” orientation, the increased intranodular vascularity, and hypoechogenicity constitute one group - each of the features in this group is awarded 1 point. In turn, the characteristics of minor prognostic importance, such as irregular margin, absence of halo, solid composition, and large size (a diameter longer than 3.0 cm) - are associated with the granting 0.5 points each. The most important prognostic features – a rapid growth (enlargement) of nodules/focal lesions and a presence of pathologically altered lymph nodes are associated with the granting 3 points for each. Our scoring system can be applied in order to better assessment of thyroid US patterns in whole. In patients with a total score ranging from 0 < 4 points there is US pattern of a low risk of malignancy, with ≥ 4 < 7 points - intermediate risk, and in patients with a score ≥ 7 points – a high risk in question. Complementary use of our scoring system and FNAB TBSRTC categories can help to make optimal clinical decisions as regards the selection of treatment strategy.
    Full-text · Article · Apr 2013 · Thyroid Research
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