New ultrasound scoring system for thyroid nodules to reduce unnecessary biopsies

June 19, 2017 by Jeff Hansen, University of Alabama at Birmingham
Franklin Tessler. Credit: UAB

Nodules—a type of abnormality detected by ultrasound—are extremely common in the thyroid gland. Up to two-thirds of adults have nodules in this gland, and most are benign or only cause a slow-growing cancer that is no threat to life.

A minority are aggressive cancer that requires treatment, leaving physicians and patients with a problem—which nodules need to be biopsied for malignancy tests, which nodules show a small risk and merit observation without a biopsy, and which need no follow-up at all?

"If you have a cancer that is not going to harm you, and you are not aware of it, is it useful to do a fine-needle aspiration?" said Franklin Tessler, M.D., C.M, a professor in the University of Alabama at Birmingham Department of Radiology. "People are asking, what are we doing? Are we using scarce resources wisely?"

Thyroid cancers are greatly over-diagnosed in the United States. About three-quarters of thyroid cancers in women and nearly one-half in men would not—if the nodules had been left alone and not biopsied with a needle—resulted in symptoms or death.

Tessler and a national committee of experts have now published American College of Radiology for an ultrasound-based risk stratification system to identify nodules that warrant biopsy or sonographic follow-up. The guidelines, they write, are "designed to identify most clinically significant malignancies while reducing the number of biopsies performed on ."

"This potentially will have a big public health effect," said Tessler, who is also the Radiology executive vice chair and medical director, vice chair for Radiology Informatics, and division director of Diagnostic Radiology. The 15 co-authors on the blue-ribbon committee with Tessler are at Washington University School of Medicine; Keck School of Medicine, University of Southern California; Duke University School of Medicine; the University of Alabama at Birmingham; Brown University; Stanford University Medical Center; Brigham and Women's Hospital; Hammers Healthcare Imaging, New Haven, Connecticut; Yale School of Medicine; Johns Hopkins University, School of Medicine; the University of Pennsylvania; Mayo Clinic College of Medicine; and the University of Texas Health Sciences Center.

Their Thyroid Imaging, Reporting and Data System, or TI-RADS, is modeled after the American College of Radiology's BI-RADS, a widely accepted risk stratification system for breast lesions.

The experts sought guidelines that are 1) founded on ultrasound features defined in their previously published lexicon; 2) easy to apply across a wide gamut of ultrasound practices; 3) able to classify all ; and 4) evidence-based, to the greatest extent possible, with the aid of underlying data on 3,800 nodules and more than 100,000 cancers.

Their new guidelines follow many attempts over the past 15 years to create guidelines for whether to do a fine-needle aspiration biopsy. Most are based on details of the appearance and size of nodules that are visualized with high-resolution ultrasound.

But "the plethora, complexity and lack of congruence of these systems has limited their adoption by the ultrasound community and inspired our effort to publish a classification system under the auspices of the American College of Radiology," Tessler and colleagues write.

The American College of Radiology TI-RADS has five different categories for nodule appearance—composition, echogenicity, shape, margin and echogenic foci. The shape category has two choices—wider-than-tall vs. taller-than-wide. The other four categories have four choices each, such as "hypoechoic" under the category echogenicity or "lobulated or irregular" under margin. Each choice as a point value, ranging from 0 to 3 points. "Wider-than-tall," for example, is 0 points, and "taller-than-wide" is 3 points.

As the authors explain, "Points are given for all the ultrasound features in a nodule, with more suspicious features being awarded additional points. ... When assessing a nodule, the reader selects one feature from each of the first four categories and all the features that apply from the final category and sums the points. The point total determines the nodule's ACR TI-RADS level, which ranges from TR1, benign, to TR5, high suspicion of malignancy."

If the sum is 0 points, the nodule is TR1 and the guidelines recommend no fine-needle aspiration or follow-up. If the sum is 2 points, the nodule is TR2, or "not suspicious," and the guidelines recommend no fine-needle aspiration or follow-up.

A sum of 3 points is TR3, or "mildly suspicious." For these nodules, the guidelines recommend fine-needle aspiration if the nodule is 2.5 centimeters or greater, or about 1 inch or more, and they recommend follow-ups with subsequent ultrasounds if it is 1.5 centimeters or greater.

TR4 nodules, or "moderately suspicious," are 4 to 6 points, and TR5 nodules, or "highly suspicious," are 7 points or more. For TR4 nodules, the guidelines recommend fine-needle aspiration if the nodule is 1.5 centimeters or greater and follow-ups if it is 1 centimeter or greater. For TR5 nodules, the guidelines recommend fine-needle aspiration if the nodule is 1 centimeter or greater and follow-ups if it is 0.5 centimeters or greater.

The guidelines recommend limiting fine-needle aspiration to two nodules per patient because biopsy of three or more nodules is poorly tolerated by patients, and the third biopsy increases cost with little added benefit and some additional risk. The guidelines also suggest appropriate timing for follow-up sonograms.

"The ACR TI-RADS is designed to balance the benefit of identifying clinically important cancers against the risk and cost of subjecting patients with benign nodules or indolent cancers to biopsy and treatment," the authors write. "Our recommendations for follow-up ultrasound substantially mitigate the possibility that significant malignancies will remain undetected over time and are concordant with the increasing trend toward active surveillance, or 'watchful waiting,' for low-risk thyroid cancer."

Their white paper, "ACR thyroid imaging, reporting and data system (TI-RADS): White paper of the ACR TI-RADS committee," was published in the Journal of the American College of Radiology.

Explore further: Only select incidental thyroid nodules need further evaluation

More information: Franklin N. Tessler et al, ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee, Journal of the American College of Radiology (2017). DOI: 10.1016/j.jacr.2017.01.046

Related Stories

Only select incidental thyroid nodules need further evaluation

April 24, 2017
(HealthDay)—Only a few select incidental thyroid nodules require further evaluation, according to a review published online April 20 in JAMA Otolaryngology-Head & Neck Surgery.

Long-term follow-up of benign thyroid nodules shows favorable prognosis

March 3, 2015
After five years of follow-up, a majority of asymptomatic, benign thyroid nodules exhibited no significant change in size, or actually decreased in size, and diagnoses of thyroid cancer were rare, according to a study in ...

Fewer uncertain thyroid results with core needle vs repeat FNA

October 24, 2016
(HealthDay)—To reduce inconclusive results for thyroid nodules, core-needle biopsy (CNB) is more effective than repeat fine-needle aspiration (FNA), according to a study published online Oct. 5 in Head & Neck.

Gene expression test identifies low-risk thyroid nodules

June 25, 2012
A new test can be used to identify low-risk thyroid nodules, reducing unnecessary surgeries for people with thyroid nodules that have indeterminate results after biopsy. The results of the multi-center trial, which includes ...

Thyroid cancer biopsy guidelines should be simplified, researchers say

August 26, 2013
A team led by UC San Francisco researchers has called for simplified guidelines on when to biopsy thyroid nodules for cancer, which they say would result in fewer unnecessary biopsies.

Recommended for you

Single-cell study in a childhood brain tumor affirms the importance of context

April 20, 2018
In defining the cellular context of diffuse midline gliomas, researchers find the cells fueling their growth and suggest a potential approach to treating them: forcing their cells to be more mature.

Aggressive breast cancer already has resistant tumour cells prior to chemotherapy

April 20, 2018
Difficult to treat and aggressive "triple-negative" breast cancer is chemoresistant even before chemotherapy begins, a new study by researchers from Karolinska Institutet and the University of Texas MD Anderson Cancer Center ...

Mechanism that drives development of liver cancer brought on by non-alcoholic fatty liver disease discovered

April 19, 2018
A team of researchers from several institutions in China has found a mechanism that appears to drive the development of a type of liver cancer not caused by alcohol consumption. In their paper published in the journal Science ...

Discovery adds to evidence that some children are predisposed to develop leukemia

April 19, 2018
St. Jude Children's Research Hospital researchers have made a discovery that expands the list of genes to include when screening individuals for possible increased susceptibility to childhood leukemia. The finding is reported ...

Scientists identify 170 potential lung cancer drug targets using unique cellular library

April 19, 2018
After testing more than 200,000 chemical compounds, UT Southwestern's Simmons Cancer Center researchers have identified 170 chemicals that are potential candidates for development into drug therapies for lung cancer.

Chip-based blood test for multiple myeloma could make bone biopsies a relic of the past

April 19, 2018
The diagnosis and treatment of multiple myeloma, a cancer affecting plasma cells, traditionally forces patients to suffer through a painful bone biopsy. During that procedure, doctors insert a bone-biopsy needle through an ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.