TI-RADS (Thyroid Imaging Reporting and Data System):

Presentation on theme: "TI-RADS (Thyroid Imaging Reporting and Data System):"— Presentation transcript:

1 TI-RADS (Thyroid Imaging Reporting and Data System):
Are We There Yet? Sergiy V. Kushchayev Aliaksei L. Salei Oleg M. Teytelboym Department of Radiology, Mercy Catholic Medical Center, Darby, PA

2 Would you biopsy this nodule?
Nodule # 1 out of 6 Thyroid Nodule: 1.7 cm, mixed solid and cystic, isoechoic, circumscribed, vascular, wider than tall, no microcalcifications Would you biopsy this nodule? What do guidelines say? Stay tuned for answers!

3 Would you biopsy this nodule?
Nodule # 2 out of 6 Thyroid Nodule: 3.5 cm, spongiform, isoechoic, circumscribed, peripheral vascularity, wider than tall, no microcalcifications Would you biopsy this nodule? What do guidelines say? Stay tuned for answers!

4 Would you biopsy this nodule?
Nodule # 3 out of 6 Thyroid Nodule: 2.7 cm, predominantly solid, hypoechoic, circumscribed, marked vascularity, wider than tall, no microcalcifications Would you biopsy this nodule? What do guidelines say? Stay tuned for answers!

5 Would you biopsy this nodule?
Nodule # 4 out of 6 Thyroid Nodule: 2.5 cm, solid, hypoechoic, microlobulated margin, vascular, wider than tall, no microcalcifications Would you biopsy this nodule? What do guidelines say? Stay tuned for answers!

6 Would you biopsy this nodule?
Nodule # 5 out of 6 Thyroid Nodule: 2.2 cm, solid, hypoechoic, irregular margins, vascular, taller than wide, with microcalcifications Would you biopsy this nodule? What do guidelines say? Stay tuned for answers!

7 Would you biopsy this nodule?
Nodule # 6 out of 6 Thyroid Nodule: 1.7 cm solid, hypoechoic, irregular margins, marked vascularity, wider then tall, and microcalcifications Would you biopsy this nodule? What do guidelines say? Stay tuned for answers!

8 Purpose: Thyroid nodule evaluation is a common clinical and imaging challenge. Guidelines from Society of Radiologists in Ultrasound (SRU) in 2005 and American Thyroid Association (ATA) in 2006, revised in 2009, have offered evaluation and management guidance, but left many uncertainties in deciding which nodules to biopsy. Horvath, taking BI-RADS as a model, developed the first TI-RADS concept in Subsequent proposals, particularly by Kwak, have offered improved ability for thyroid nodule risk stratification. This exhibit provides a comprehensive image based review of current TI-RADS proposals, Image Reporting and Characterization System and comparison with SRU and ATA guidelines.

9 Thyroid Cancer: History
1827 – Description of the patient with neck and head tumor of the same texture as thyroid gland. Redfern described types of TC: scirhoid, medullary, and enchondromatous. 1896 – General opinion: TC is rare tumor with average survival 6mo. 60% of operated patients die in 8 weeks. 1901 – Young professor of anatomy Stohr from Wurzburg (Germany) published text-book in histology with microscopic pictures of TC. 1907 – Key paper: Hudson presented 12 cases of TC with histological pictures. He has made revolutionary conclusions for that time. These are actual even now: PTC, metastasis in lymph node by Stohr, 1901 (reevaluation) Invasive TC, FTC vs PTC by Stohr, 1901 (reevaluation) Hudson’s conclusions on thyroid carcinoma, 1907

10 Thyroid Surgery : History
Thyroid surgery has been performed since ancient times. The first documented partial thyroidectomy was carried out by French anatomist and surgeon Pierre Joseph Desault in He removed a 4 cm mass from thyroid through a vertical incision. At that time the prevalence of goiter in Europe was very high due to iodine deficiency. Discovery of iodine in burned ash of seaweed in 1811 led to successful treatment of some goiters. Thyroid surgery mostly was performed for very large goiters and “thyroid masses” with mortality rate about 40%. Thyroid surgery was actually banned by the French Academy of Medicine in 1850. Pierre Joseph Desault

11 Thyroid Cancer: History
Two surgeons who revolutionized thyroid surgery: Theodore Billroth ( ), at the University of Zurich significantly improved surgical technique  on the thyroid gland and reported 8% mortality. Emil Theodor Kocher ( ), Billroth’s student at the University of Bern by 1883 he performed 2,000 thyroidectomies with mortality less than 1%. In 1909 was awarded the Nobel Price for "for his work on the physiology, pathology and surgery of the thyroid gland“.

12 Objectives: Introduction
The Bethesda System For Reporting Thyroid Cytopathology Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) Consensus American Thyroid Association (ATA) guidelines Three Proposed TIRADS systems: TIRADS by Horvath et al (2009) TIRADS by Russ et al (2011) TIRADS by Kwak et al (2011) Image Reporting and Characterization System by Kwak (2013) 6. Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak, Image Reporting and Characterization System by Kwak and their comparison

13 Thyroid Nodules: Palpable thyroid nodules: 5% of general population and up to 30-40% above age 50. Thyroid incidentalomas on autopsy: 8-65%. Thyroid US depicts nodules in up to 67% of the population and % of children Thyroid cancer is present in 5-15% of thyroid nodules.

14 Thyroid Cancers: Overview
PAPILLARY TC (75-80%) Mean age yo Metastases to lymph nodes – 35-50%, almost 90% before 17yo FOLLICULAR TC (10-20%) Mean age 50-55yo Hematogeneous spread of metastases is characteristics FNA cannot differentiate follicular adenoma vs cancer (need to see evidence of capsular invasion) May give very late metastases up to 373 mo MEDULLARY TC (5-8%) Average age yo for sporadic medullary carcinoma and 20-30’s for MEN 25% of medullary carcinoma are familial due to RET proto-oncogene mutation 131-I negative as originates from parafollicular (C cells), producing calcitonin which is marker of medullary carcinoma progression Surgery is the only curative treatment in 35% ANAPLASTIC TC (1-2%) Very aggressive, only 10% present with intrathyroidal tumor, 60% have metastases Surgery is not curative, radiation with chemo may prolong survival. HURTHLE CELL TC (3% ) Still considered as subtype of follicular cancer, however, has different biological features, more aggressive than follicular cancer. Lymph node metastases – 10-25%; rate of distant metastases similar to follicular thyroid canceer (7-25%); trend to multifocality, association with PTC in 20% Only 5-10% of Hurthle Cell Carcinoma uptake 131-I

15 Thyroid Cancer: Epidemiology
Estimated new cases of TC in 2015 – 62,450 with estimated death due to TC in 2015 – 1950. 5 -year survival from thyroid cancer: Incidence per 100,000 persons Deaths per 100,000 persons Type of TC Stage I Stage II Stage III Stage IV PTC Near 100% 93% 51% FTC 71% 50% MTC 98% 81% 28% ATC Always stage IV 7%

16 Objectives: Introduction
The Bethesda System For Reporting Thyroid Cytopathology Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) Consensus American Thyroid Association (ATA) guidelines Three Proposed TIRADS systems: TIRADS by Horvath et al (2009) TIRADS by Russ et al (2011) TIRADS by Kwak et al (2011) Image Reporting and Characterization System by Kwak (2013) 6. Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak, Image Reporting and Characterization System by Kwak and their comparison

17 For Reporting Thyroid Cytopathology
The Bethesda System For Reporting Thyroid Cytopathology The Bethesda System for Reporting Thyroid Cytopathology: Recommended Diagnostic Categories Accordingly, 6 diagnostic categories were introduced. Each diagnostic category is associated with expected risk of malignancy and clinical recommendations for management. The Bethesda System for Reporting Thyroid Cytopathology: Implied Risk of Malignancy and Recommended Clinical Management Cibas ES & Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid –1165.

18 Objectives: Introduction
The Bethesda System For Reporting Thyroid Cytopathology Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) Consensus American Thyroid Association (ATA) guidelines Three Proposed TIRADS systems: TIRADS by Horvath et al (2009) TIRADS by Russ et al (2011) TIRADS by Kwak et al (2011) Image Reporting and Characterization System by Kwak (2013) 6. Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak, Image Reporting and Characterization System by Kwak and their comparison

19 Society of Radiologists in Ultrasound Consensus
In 2005 Society of Radiologists in Ultrasound Consensus published a multidisciplinary agreement on management thyroid nodules involving radiologists, endocrinologists and endocrine surgeons. Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology Dec;237(3):

20 Society of Radiologists in Ultrasound Consensus
Based on literature analysis, US features associated with thyroid carcinoma were identified. US Features Associated with Thyroid Cancer Specific recommendations on management thyroid nodules were proposed. Recommendations for Thyroid Nodules 1 cm or Larger in Maximum Diameter Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology Dec;237(3):

21 Objectives: Introduction
The Bethesda System For Reporting Thyroid Cytopathology Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) Consensus American Thyroid Association (ATA) guidelines Three Proposed TIRADS systems: TIRADS by Horvath et al (2009) TIRADS by Russ et al (2011) TIRADS by Kwak et al (2011) Image Reporting and Characterization System by Kwak (2013) 6. Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak, Image Reporting and Characterization System by Kwak and their comparison

22 ATA guidelines provide comprehensive approach to thyroid nodules.
Algorithm for the evaluation of patients with one or more thyroid nodules: Initially published in 2006 (revised in 2009, new revision expected in 2015) ATA guidelines provide comprehensive approach to thyroid nodules. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer .Thyroid Nov;19(11):

23 ATA guidelines: Sonographic and Clinical Features of Thyroid Nodules and Recommendations for FNA Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer .Thyroid Nov;19(11):

24 Objectives: Introduction
The Bethesda System For Reporting Thyroid Cytopathology Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) Consensus American Thyroid Association (ATA) guidelines Three Proposed TIRADS systems: TIRADS by Horvath et al (2009) TIRADS by Russ et al (2011) TIRADS by Kwak et al (2011) Image Reporting and Characterization System by Kwak (2013) 6. Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak, Image Reporting and Characterization System by Kwak and their comparison

25 TIRADS: OVERVIEW TIRADS system is ultrasonographic classification for thyroid nodules. The terminology “Thyroid Imaging Reporting and Data System” (TIRADS) was first used by Horvath et al in 2009, drawing inspiration from the “Breast Imaging and Reporting Data System” (BIRADS) of the American College of Radiology. The goals: Stratify the risk of malignancy of a lesion based on the US features of the lesion. Standardize and simplify the reports, allowing effective communication between radiologists, cytologists, and clinicians. Improve quality of care and cost-effectiveness, avoiding unnecessary biopsies.

26 TIRADS by Horvath et al. Research group from Chile
Study lasted 8 years, published in 2009 1959 thyroid nodules submitted for fine needle aspiration biopsy (FNAB) Study introduced 6 TIRIADS categories and 10 US patterns Description Risk of malignancy TIRADS 1 Normal thyroid gland TIRADS 2 Benign TIRADS 3 Probably benign <5% TIRADS 4A Suspicion for malignancy 5-10% TIRADS 4B Intermediate suspicion for malignancy 10-80% TIRADS 5 Highly suggestive of malignancy >80% TIRADS 6 Biopsy proven malignancy Horvath E, Majilis S, Rossi R, Franco C, Niedmann J, Castro A & Dominguez M. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. Journal of Clinical Endocrinology and Metabolism –1751

27 Proposed 10 stereotypic US patterns and associated risk of malignancy.
TIRADS by Horvath et al. Proposed 10 stereotypic US patterns and associated risk of malignancy. Horvath E, Majilis S, Rossi R, Franco C, Niedmann J, Castro A & Dominguez M. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. Journal of Clinical Endocrinology and Metabolism –1751

28 TIRADS by Russ et al Thyroid Nodule Suspect pattern Benign pattern
Research group from France Prospective study on 4550 nodules, lasted 2 years (early paper included 500 nodules were published in 2011 in French language). Authors proposed the following flowchart to assign a nodule to one of TIRADS categories Thyroid Nodule Suspect pattern Benign pattern High Suspect: Taller-than-wide Irregular borders Microcalcifications Markedly hypoechoic High stiffness on sonoelastography Very probably Constantly No sign of high suspicion: regular shape and borders, no micro-calcifications and iso/hyperecoic - Simple cyst - Spongiform nodule - “white knight” - isolated macro- calcifications - Nodular hyperplasia 3-5 signs and/or metastatic lymph nodes 1-2 signs, no metastatic lymph nodes No signs of high suspect. Mildly hypoecoic TIRADS 5 TIRADS 4B TIRADS 4A TIRADS 3 TIRADS 2 Russ B, Royer B, Bigorgne C, et al. Prospective evaluation of thyroidimaging reporting and data system on 4550 nodules with and without elastography. Eur J Endocrinol. 2013;168:649–655.

29 Number of suspicious features
TIRADS by Kwak et al Research group from Korea. Prospective study 8 years, published in 2011. 1959 thyroid nodules submitted for FNA. The following features were associated with malignancy: solid component, hypo-echogenicity, marked hypoechogenicity, microlobulated or irregular margins, micro-calcifications, taller-than-wide shape. As the number of suspicious US features increased, the fitted probability and risk of malignancy also increased: Description Number of suspicious features Risk of malignancy TIRADS 1 Negative TIRADS 2 Benign TIRADS 3 Probably benign 1.7% TIRADS 4A Low suspicion for malignancy 1 3.3% TIRADS 4B Intermediate suspicion for malignancy 2 9.2% TIRADS 4C Moderate concern but not classic for malignancy 3-4 % TIRADS 5 Highly suggestive of malignancy 5 87.5% Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, Jung HK, Choi JS, Kim BM & Kim E-K. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology –899

30 Image Reporting and Characterization System for Ultrasound Features of Thyroid Nodules by Kwak et al (2013) Proposed Image Reporting and Characterization System is a modified TIRADS system which does not have usual TIRADS categories. Based on the study of 2000 tumors from 20 different institutions (1796 patients, 1268 were benign and 732 were malignant) authors developed diagnostic prediction model by using ultrasound (US) features of thyroid nodules to stratify the risk of malignancy. Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011;260:892–899.

31 THE SONOGRAPHIC CRITERIA
Image Reporting and Characterization System for Ultrasound Features of Thyroid Nodules by Kwak et al (2013) THE SONOGRAPHIC CRITERIA Size (equal or larger than 5 mm) Composition (according to the ratio of the cystic portion to the solid portion): solid (≤ 10% cystic) predominantly solid (> 10% cystic and ≤ 50% cystic) predominantly cystic (> 50% cystic) spongiform appearance Echogenicity of the solid portion was classified as: Hyper- or isoechogenicity, hypoechogenicity, or marked hypoechogenicity (decreased echogenicity compared to the strap muscles). Orientation Non-parallel (taller than wider) or parallel. Shape Ovoid, round, and irregular (when a nodule was not ovoid to round). Margins Well-defined smooth, microlobulated (spiculated), or ill-defined. Calcifications Microcalcifications (calcifications ≤1 mm in diameter), macrocalcifications, or none. When the nodules had both types of calcifications (macrocalcifications including rim calcifications intermingled with microcalcifications), the nodule was considered to have microcalcifications.

32 MNEUMONICS: Marry SMITH
Image Reporting and Characterization System for Ultrasound Features of Thyroid Nodules by Kwak et al (2013) Six previously described US features (Kwak,2011) associated with thyroid malignancy were used. For each of these features a specific risk score was calculated. Association Between Thyroid Malignancy and Various Sonographic Features at Thyroid Nodules of Training Data Set on Multiple Logistic Regression and Risk Score Analysis MNEUMONICS: Marry SMITH Suspicious US feature Score M Marked hypoechogenicity 6 S Spiculated (microlobulated) margins 5 Microcalcifications 2 I Ill-defined borders 1 T Taller than wider (non-parallel orientation) H Hypoechogenicity Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011;260:892–899.

33 Image Reporting and Characterization System for Ultrasound Features of Thyroid Nodules by Kwak et al (2013) 1. Individual risk score for each suspicious US feature 2. Multiple Logistic Regression Mode 3. Malignancy Rate of Malignancy by Total Score Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011;260:892–899.

34 Malignancy Rate of Malignancy by Total Score
Image Reporting and Characterization System for Ultrasound Features of Thyroid Nodules by Kwak et al (2013) Malignancy Rate of Malignancy by Total Score ANALYSIS OF RESULTS: Thyroid nodule without any malignant features associated with risk of malignancy 6.2%. Steep increase risk malignancy after score >2 (from 13% to 31%) and >6 (from 35% to 61%). Microcalcifications gives 2 points immediately increasing the risk of malignancy at least by 13%. Microlobulated (spiculated) margins: 5 points brining up the risk of malignancy at least by 33%. Marked hypoechogenicity: 6 points increasing the risk of malignancy at least by 34% Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011;260:892–899.

35 Objectives: Introduction.
The Bethesda System For Reporting Thyroid Cytopathology. Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) Consensus. American Thyroid Association (ATA) guidelines. Three Proposed TIRADS systems: TIRADS by Horvath et al (2009) TIRADS by Russ et al (2011) TIRADS by Kwak et al (2011) Image Reporting and Characterization System by Kwak (2013) 6. Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak, Image Reporting and Characterization System by Kwak and their comparison.

36 Thyroid Nodule #1: 1.7 cm, mixed solid and cystic, isoechoic, circumscribed, vascular, wider than tall, no microcalcifications Organization US Feature/TIRADS score Recommendations American Thyroid Association Mixed solid and cystic, hypervascular, ≥ cm Biopsy (Recommendation B) Society of Radiologists in Ultrasound Mixed solid and cystic, < 2 cm No biopsy TIRADS Russ (2013) TIRADS 3 – Very probably benign (isoechoic, no signs of high suspicion) No biopsy (PPV 0.25%) TIRADS Kwak (2011) TIRADS 4A – 1 suspicious feature (solid component) Biopsy (Risk of malignancy 3.3%) Image Reporting and Characterization System by Kwak et al. (2013) Score 0 – no malignant features N/A (Risk of malignancy 6.2%) FNA of the nodule: Bethesda class 2 – benign: nodular hyperplasia with cystic degeneration

37 Thyroid Nodule #2: 3.5 cm, spongiform, isoechoic, circumscribed, peripheral vascularity, wider than tall, no microcalcifications Organization US Feature/TIRADS score Recommendations American Thyroid Association Spongiform, > 2 cm Biopsy (Recommendation C) Society of Radiologists in Ultrasound Mixed solid and cystic, ≥ 2 cm Biopsy TIRADS Russ (2013) TIRADS 2 – Benign pattern (spongiform) No biopsy (PPV 0.25%) TIRADS Kwak (2011) TIRADS 4A – 1 suspicious feature (solid component) Biopsy (Risk of malignancy 3.3%) Image Reporting and Characterization System by Kwak et al. (2013) Score 0 – no malignant features N/A (Risk of malignancy 6.2%) FNA of the nodule: Bethesda class 2 – benign: nodular hyperplasia with cystic degeneration

38 marked vascularity, wider than tall, no microcalcifications
Thyroid Nodule #3: 2.7 cm, predominantly solid, hypoechoic, circumscribed, marked vascularity, wider than tall, no microcalcifications Organization US Feature/TIRADS score Recommendations American Thyroid Association Mixed, hypoechoic, increased vascularity, >1.5 cm Biopsy, Level B Society of Radiologists in Ultrasound Predominantly solid, hypoechoic, >1.5 cm Biopsy TIRADS Russ (2013) TIRADS 4A – mildly suspect (mildly hypoechoic, no sign of high suspicion), >1 cm Biopsy (PPV 6%) TIRADS Kwak (2011) TIRADS 4B – 2 suspicious features (solid component, hypoechoic) Biopsy (Risk of malignancy 9.2%) Image Reporting and Characterization System by Kwak et al. (2013) Score 2 – hypoechoic N/A (Risk of malignancy 8.6%) FNA of the nodule: Bethesda class 4 – suspicious for Hurtle cell neoplasm

39 Thyroid Nodule #4: 2.5 cm, solid, hypoechoic, microlobulated margin, vascular, wider than tall, no microcalcifications Organization US Feature/TIRADS score Recommendations American Thyroid Association Solid, hypoechoic, > 1 cm Biopsy (Recommendation B) Society of Radiologists in Ultrasound Solid, ≥ 1.5 cm Biopsy TIRADS Russ (2013) TIRADS 4B – Highly suspect (irregular margin) Biopsy (PPV 69%) TIRADS Kwak (2011) TIRADS 4C – 3 suspicious features (solid component, hypoechogenicity, microlobulated margin) Biopsy (Risk of malignancy 44.4–72.4%) Image Reporting and Characterization System by Kwak et al. (2013) Score 7 – hypoechoic, microlobulated N/A (Risk of malignancy 60.6%) FNA of the nodule: Bethesda class 5 – suspicious for malignancy: highly suspicious for papillary carcinoma

40 FNA of the nodule: Bethesda class 6 – malignant: papillary carcinoma
Thyroid Nodule #5: 2.2 cm, solid, hypoechoic, irregular margins, vascular, taller than wide, with microcalcifications Organization US Feature/TIRADS score Recommendations American Thyroid Association Solid, hypoechoic, > 1 cm Biopsy (Recommendation B) Society of Radiologists in Ultrasound Microcalcifications, ≥ 1 cm Biopsy TIRADS Russ (2013) TIRADS 5 – Highly suspect (taller than wide, microcalcifications, irregular margins) Biopsy (PPV 100%) TIRADS Kwak (2011) TIRADS 5 – 5 suspicious features (solid, hypoechoic, irregular margins, taller than wide, microcalcifications) Biopsy (Risk of malignancy 87.5%) Image Reporting and Characterization System by Kwak et al. (2013) Score 10 – markedly hypoechoic, irregular margins, taller than wide, microcalcifications N/A (Risk of malignancy 93.8%) FNA of the nodule: Bethesda class 6 – malignant: papillary carcinoma

41 Thyroid Nodule #6: 1.7 cm solid, hypoechoic, irregular margins, marked vascularity, wider then tall, and microcalcifications Organization US Feature/TIRADS score Recommendations American Thyroid Association Solid, hypoechoic >1 cm Biopsy, Level B Society of Radiologists in Ultrasound Solid, microcalcifications >1 cm Biopsy TIRADS Russ (2013) TIRADS 5 (solid, hypoechoic, irregular margin, microcalcification) Biopsy (PPV 100%) TIRADS Kwak (2011) TIRADS 4c (solid, markedly hypoechoic, irregular margin, microcalcification) Biopsy (Risk of malignancy %) Image Reporting and Characterization System by Kwak et al. (2013) Score 9 (solid, markedly hypoechoic, irregular margin, microcalcification) Biopsy (Risk of malignancy 79%) FNA of this nodule:  Bethesda class 6 Malignancy (papillary thyroid carcinoma)

42 Conclusions: Current guidelines from ATA and SRU provide a reliable framework for work-up of thyroid nodules, but do not incorporate most recent literature. Proposed TI-RADS systems by Kwak and Russ, and especially Image Reporting and Characterization System by Kwak appear to be useful tools and may be superior to SRU an ATA in risk stratification of thyroid nodules and recommendations in guiding the biopsy decision. Introducing TI-RADS made first step in standardizing reporting lexicon allowing effective communication between the radiologists, pathologists, and clinicians. Clinical use of TI-RADS may result in improving quality of care and cost-effectiveness, avoiding unnecessary biopsies. Given absence of recent radiology guidelines, consider of incorporation of TI-RADS like system into institutional reporting protocols.

43 References: American College of Radiology. Breast imaging reporting and data system: BI-RADS Atlas, 4th edn. Reston, VA, 2003. Cibas ES & Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid –1165. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Pacini F, Schlumberger M, Sherman SI, Steward DL, Tuttle RM. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer .Thyroid Nov;19(11): Horvath E, Majilis S, Rossi R, Franco C, Niedmann J, Castro A & Dominguez M. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. Journal of Clinical Endocrinology and Metabolism –1751 Fagin JA, Mitsiades N. Molecular pathology of thyroid cancer: diagnostic and clinical im- plications. Best Pract Res Clin Endocrinol Metab 2008;22(6):955–969. Frates MC, Benson CB, Charboneau JW, Cibas ES, Clark OH, Coleman BG, Cronan JJ, Doubilet PM, Evans DB, Goellner JR, Hay ID, Hertzberg BS, Intenzo CM, Jeffrey RB, Langer JE, Larsen PR, Mandel SJ, Middleton WD, Reading CC, Sherman SI, Tessler FN. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology Dec;237(3): Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, et al. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology. 2011;260:892–899. Kwak JY, Han KH, Yoon JH, Moon HJ, Son EJ, Park SH, Jung HK, Choi JS, Kim BM & Kim E-K. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiology –899 Papini E, Guglielmi R, Bianchini A, et al. Risk of malignancy in nonpalpable thyroid nod- ules: predictive value of ultrasound and color- Doppler features. J Clin Endocrinol Metab 2002;87(5):1941–1946. Park JY, Lee HJ, Jang HW, et al. A proposal for a thyroid imaging reporting and data sys- tem for ultrasound features of thyroid carci- noma. Thyroid 2009;19(11):1257–1264. Russ B, Royer B, Bigorgne C, et al. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. Eur J Endocrinol. 2013;168:649–655.