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Tips for improving consistency of thyroid nodule interpretation with ACR TI-RADS

Gavin Low
Gavin Low
, 
Meredith Bara
Meredith Bara
, 
Yang Du
Yang Du
, 
Prayash Katlariwala
Prayash Katlariwala
, 
Roger Croutze
Roger Croutze
, 
Katrin Resch
Katrin Resch
, 
Jonathan Porter
Jonathan Porter
, 
Sam Medica
Sam Medica
 and 
Mitchell Wilson
Mitchell Wilson
   | Feb 08, 2022
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Article Category: Pictorial essay
Published Online: Feb 08, 2022
Page range: 51 - 56
Received: Oct 07, 2021
Accepted: Dec 07, 2021
DOI: https://doi.org/10.15557/JoU.2022.0009
Keywords
© 2022 Gavin Low, Meredith Bara, Yang Du , Prayash Katlariwala, Roger Croutze, Katrin Resch, Jonathan Porter, Medica Sam, Mitchell Wilson, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1

Greyscale sonographic images of: A. a thyroid nodule with round punctate echogenic foci (white thin arrow); B. a thyroid nodule with linear echogenic interfaces (black arrow); and C. a thyroid nodule with echogenic foci demonstrating a comet-tail artifact, in keeping with a colloid (white thick arrow)
Greyscale sonographic images of: A. a thyroid nodule with round punctate echogenic foci (white thin arrow); B. a thyroid nodule with linear echogenic interfaces (black arrow); and C. a thyroid nodule with echogenic foci demonstrating a comet-tail artifact, in keeping with a colloid (white thick arrow)

Fig. 2

Greyscale sonographic images of: A. a hyperechoic nodule (white arrow) with higher echogenicity compared to the adjacent thyroid parenchyma; B. an isoechoic nodule with similar echogenicity to the adjacent thyroid parenchyma; C. a hypoechoic nodule with lower echogenicity compared to the adjacent thyroid parenchyma; and D. a very hypoechoic nodule with lower echogenicity compared to the neck musculature
Greyscale sonographic images of: A. a hyperechoic nodule (white arrow) with higher echogenicity compared to the adjacent thyroid parenchyma; B. an isoechoic nodule with similar echogenicity to the adjacent thyroid parenchyma; C. a hypoechoic nodule with lower echogenicity compared to the adjacent thyroid parenchyma; and D. a very hypoechoic nodule with lower echogenicity compared to the neck musculature

Fig. 3

Greyscale sonographic image of a mixed cystic and solid nodule scored as ‘hypoechoic’ based on the echogenicity of the solid component
Greyscale sonographic image of a mixed cystic and solid nodule scored as ‘hypoechoic’ based on the echogenicity of the solid component

Fig. 4

Greyscale sonographic images of thyroid nodules with heterogeneous echogenicity: A. a mixed isoechoic and hypoechoic thyroid nodule (since >50% of the nodule is hypoechoic, this will be the descriptor selected for scoring); and B. a 50% isoechoic and 50% hypoechoic thyroid nodule (in this case, the more conservative ‘isoechoic’ descriptor will be selected for scoring)
Greyscale sonographic images of thyroid nodules with heterogeneous echogenicity: A. a mixed isoechoic and hypoechoic thyroid nodule (since >50% of the nodule is hypoechoic, this will be the descriptor selected for scoring); and B. a 50% isoechoic and 50% hypoechoic thyroid nodule (in this case, the more conservative ‘isoechoic’ descriptor will be selected for scoring)

Fig. 5

Greyscale image of a thyroid nodule which would be classified as ‘solid’ based on >80% solid volume
Greyscale image of a thyroid nodule which would be classified as ‘solid’ based on >80% solid volume

Fig. 6

Greyscale sonographic image of a thyroid nodule with circumferential rim calcification. The acoustic shadow from the calcification obscures the composition and echogenicity of the nodule. In this scenario, the descriptors ‘solid’ and ‘iso– or–hyperechoic’ are selected for scoring
Greyscale sonographic image of a thyroid nodule with circumferential rim calcification. The acoustic shadow from the calcification obscures the composition and echogenicity of the nodule. In this scenario, the descriptors ‘solid’ and ‘iso– or–hyperechoic’ are selected for scoring

Fig. 7

Greyscale sonographic images of: A. spongiform nodule and B. a mixed cystic and solid nodule. Compared to (B), the cystic spaces are smaller and more evenly distributed (A)
Greyscale sonographic images of: A. spongiform nodule and B. a mixed cystic and solid nodule. Compared to (B), the cystic spaces are smaller and more evenly distributed (A)

Fig. 8

Transverse greyscale sonographic image of a completely round thyroid nodule (anteroposterior measurement equals transverse measurement). The more conservative ‘wider-than-tall’ description should be selected for scoring
Transverse greyscale sonographic image of a completely round thyroid nodule (anteroposterior measurement equals transverse measurement). The more conservative ‘wider-than-tall’ description should be selected for scoring

Fig. 9

Greyscale sonographic images of a thyroid nodule, demonstrating how to measure nodule size, (a) × (b) × (c)
Greyscale sonographic images of a thyroid nodule, demonstrating how to measure nodule size, (a) × (b) × (c)

Criteria for FNA or follow-up ultrasound according to ACR TI-RADS(3)

Add points from all categories to determine TI-RADS level
0 Points2 Points3 Points4 to 6 Points7 Points or more
TR1TR2TR3TR4TR5
BenignNot suspiciousMildly suspiciousModerately suspiciousHighly suspicious
No FNANo FNAif ≥FNA 2.5 cmif ≥FNA 1.5 cmif FNA ≥1 cm
Follow-up if ≥1.5 cmFollow-up if ≥1 cmFollow-up if ≥0.5 cm

Five sonographic categories and their corresponding points for ACR TI-RADS(3)

Composition (choose 1)Echogenicity (choose 1)Shape (choose 1)Margins (choose 1)Echogenic Foci (choose all that apply)
Cystic or almost completely cystic0Anechoic0Wider than tall0Smooth0None or large comettail artifacts0
Spongiform0Hyperechoic isoechoic or1Taller than wide3Ill-defined0Macrocalcifications1
Mixed cystic and solid1Hypoechoic2Lobulated or irregular2Peripheral (rim) calcifications2
Solid or almost completely solid2Very hypoechoic3Extra thyroidal extension3Punctate echogenic foci3
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