Your doctor then sends the samples to a laboratory to have them analyzed under a microscope. Endocrinol. We are vaccinating all eligible patients. To illustrate the effect of the size cutoffs we have given 2 examples, 1 where the size cutoffs are not discriminatory and the cancer rate is the same above and below the size cutoff, and the second example where the cancer risk of the nodule doubles once the size goes above the cutoff. Nodules detected this way are usually smaller than those found during a physical exam. Ross DS. We examined the data set upon which ACR-TIRADS was developed, and applied TR1 or TR2 as a rule-out test, TR5 as a rule-in test, or applied ACR-TIRADS across all nodule categories. The gold test standard would need to be applied for comparison. This assumption is obviously not valid and favors TIRADS management guidelines, but we believe it is helpful for clarity and illustrative purposes. Join endocrinologist Paul Ladenson, M.D., as he outlines the signs and symptoms of the various thyroid disorders and discusses the interplay among other diseases and the thyroid. Even a benign growth on your thyroid gland can cause symptoms. Using TR5 as a rule-in test was similar to random selection (specificity 89% vs 90%). The widespread use of ultrasonography during the last decades has resulted in a dramatic increase in the prevalence of clinically inapparent thyroid nodules, which only in 5.0-10.0% harbor thyroid carcinoma. It is very difficult to know the true prevalence of important, clinically consequential thyroid cancers among patients presenting with thyroid nodules. Sometimes, your doctor detects a thyroid nodule when you have an imaging test, such as an ultrasound, CT or MRI scan, to evaluate another condition in your head or neck. The incidental thyroid nodule. Nodules located in the thyroid isthmus are at greater risk of being malignant than those found in the lateral lobes, whereas those in the lower portion of the lobes are at least risk. We aimed to assess the performance and costs of the American College of Radiology Thyroid Image Reporting And Data System (ACR-TIRADS). Perhaps the most relevant positive study is from Korea, which found in a TR4 group the cancer rate was no different between nodules measuring between 1-2 cm (22.3%) and those 2-3 cm (23.5%), but the rate did increase above 3 cm (40%) [24]. This content does not have an Arabic version. 26th ed. If a thyroid nodule isn't cancerous, treatment options include: Watchful waiting. The summary of test performance of random selection, ACR TIRADS as a rule-out test, ACR TIRADS as a rule-in test, and ACR TIRADS applied across all TIRADS categories are detailed in Table 2, and the full data, definitions, and calculations are given elsewhere [25]. The authors suggested, as with BI-RADS, that biopsy candidates were those nodules categorized as TI-RADS category 4 or 5, meaning demonstrating at least one suspicious sonographic feature. If a guideline indicates that FNA is recommended, it can be difficult to oppose this based on other factors. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. 2013;168 (5): 649-55. The category definitions were similar to BI-RADS, based on the risk of malignancy depending on the presence of suspicious ultrasound features: The following features were considered suspicious: The study included only nodules 1 cm in greatest dimension. Its simple: Most people treated with RFA are back to their normal activities the next day with no problems. Hot nodules are almost always noncancerous. In 2017, the Thyroid Imaging Reporting and Data System (TI-RADS) Committee of the American College of Radiology (ACR) published a white paper that presented a new risk-stratification system for classifying thyroid nodules on the basis of their appearance at ultrasonography (US). Such a study should also measure any unintended harm, such as financial costs and unnecessary operations, and compare this to any current or gold standard practice against which it is proposed to add value. Hypothyroidism. In a clinical setting, this would typically be an unselected sample of the test population, for example a consecutive series of all patients with a thyroid nodule presenting to a clinic, ideally across multiple centers. A common treatment for cancerous nodules is surgical removal. 5th ed. Thus, the absolute risk of missing important cancer goes from 5% (with no FNAs) to 2.5% using TIRADS and FNA of all TR5, so NNS=100/2.5=40. This commentary compares and contrasts these two guidelines. The chance of finding cancer is 1 in 20, whereas the chance of testing resulting in an unnecessary operation is around 1 in 7. There are a number of additional issues that should be taken into account when examining the ACR TIRADS data set and resultant management recommendations. These appear to share the same basic flaw as the ACR-TIRADS, in that the data sets of nodules used for their development is not likely to represent the population upon which it is intended for use, at least with regard to pretest probability of malignancy (eg, malignancy rate 12% for Korean TIRADS [26]; 18% and 31% for EU TIRADS categories 4 and 5 [27, 28]). Such data should be included in guidelines, particularly if clinicians wish to provide evidence-based guidance and to obtain truly informed consent for any action that may have negative consequences. Both TI-RADS classifications can safely avert avoidable FNACs in a significant proportion of benign thyroid lesions. If one assumes that they do, then it is important to note that 25% of patients make up TR1 and TR2 and only 16% of patients make up TR5. These patients are not further considered in the ACR TIRADS guidelines. Symptoms and Causes Diagnosis and Tests Management and Treatment Prevention Outlook / Prognosis Living With Frequently Asked Questions Overview American College of Radiology-Thyroid Imaging, Reporting and Data System (ACR-TIRADS) has been promoted as an improvement to existing guidelines such as the 2015 revised American Thyroid Association (ATA) guidelines. Test performance in the TR3 and TR4 categories had an accuracy of less than 60%. We found TI-RADS classification (both ACR and Kwak TI-RADS) to be a reliable, noninvasive, and practical method for assessing thyroid nodules in routine practice. Authors A TR5 cutoff would have NNS of 50 per additional cancer found compared with random FNA of 1 in 10 nodules, and probably a higher NNS if one believes that clinical factors can increase FNA hit rate above the random FNA hit rate. Sensitivity of ACR TIRADS was better than random selection, between 74% to 81% (depending on whether the size cutoffs add value) compared with 1% with random selection. The low pretest probability of important thyroid cancer and the clouding effect of small clinically inconsequential thyroid cancers makes the development of an effective real-world test incredibly difficult. Metab. in 2009 1. So, I am frequently unsure! Accessed Oct. 31, 2019. If a thyroid nodule is producing thyroid hormones, overloading your thyroid gland's normal hormone production levels, your doctor may recommend treating you for hyperthyroidism. See Thyroid cancer. https://www.uptodate.com/contents/search. Methods Ultrasound images of 205 thyroid nodules from 198 patients were analysed in this . For this, we do not take in to account nodule size because size is not a factor in the ACR TIRADS guidelines for initial FNA in the TR1 and TR2 categories (where FNA is not recommended irrespective of size) or in the TR5 category (except in TR5 nodules of0.5 cm to<1.0 cm, in which case US follow-up is recommended rather than FNA). The other one-half of the cancers that are missed by only doing FNA of TR5 nodules will mainly be in the TR3 and TR4 groups (that make up 60% of the population), and these groups will have a 3% to 8% chance of cancer, depending upon whether the population prevalence of thyroid cancer in those being tested is 5% or 10%. Those working in this field would gratefully welcome a diagnostic modality that can improve the current uncertainty. Thyroid nodules can be palpated in 4% to 7% of adults. Given that ACR TIRADS test performance is at its worst in the TR3 and TR4 groups, then the cost-effectiveness of TIRADS will also be at its worst in these groups, in particular because of the false-positive TIRADS results. Unfortunately, the collective enthusiasm for welcoming something that appears to provide certainty has perhaps led to important flaws in the development of the models being overlooked. Therefore, using TIRADS categories TR1 or TR2 as a rule-out test should perform very well, with sensitivity of the rule-out test being 97%. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Mayo Clinic Q and A: Women and thyroid disease, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition. This uses a standardized scoring system for reports providing users with recommendations for when to use fine needle aspiration (FNA) or ultrasound follow-up of suspicious nodules, and when to safely leave alone nodules that are benign/not suspicious. This paper has only examined the ACR TIRADS system, noting that other similar systems exist such as Korean TIRADS [14]and EU TIRADS [15]. What is TIRADS 4 nodule? However, the ACR TIRADS flow chart with its sharp cutoffs conveys a degree of certainty that may not be valid and may be hard for the clinician to resist. Bongiovanni M, Spitale A, Faquin WC, Mazzucchelli L, Baloch ZW. Search for other works by this author on: University of Otago, Christchurch School of Medicine, Department of Endocrinology, St Vincents University Hospital, Department of Radiology, St Vincents University Hospital, Dublin 4 and University College Dublin, Biostatistician, Department of Medical & Womens Business Management, Canterbury District Health Board, Thyroid incidentalomas: management approaches to nonpalpable nodules discovered incidentally on thyroid imaging, The prevalence of thyroid nodules and an analysis of related lifestyle factors in Beijing communities, Prevalence of differentiated thyroid cancer in autopsy studies over six decades: a meta-analysis, Occult papillary carcinoma of the thyroid. Given that a proportion of thyroid cancers are clinically inconsequential, the challenge is finding a test that can effectively rule-in or rule-out important thyroid cancer (ie, those cancers that will go on to cause morbidity or mortality). No focal lesion. For every 100 FNAs performed, about 30 are inconclusive, with most (eg, 20% of the original 100) remaining indeterminate after repeat FNA and requiring diagnostic hemithyroidectomy. The financial cost depends on the health system involved, but as an example, in New Zealand where health care costs are modest by international standards in the developed world, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS would result in approximately NZ$140,000 spent for every additional patient correctly reassured that he or she does not have thyroid cancer [25]. In ACR TI-RADS, points in five feature categories are summed to determine a risk level from TR1 to TR5 . Nervousness or irritability. Once the test is considered to be performing adequately, then it would be tested on a validation data set. After a thyroid surgery, you'll need lifelong treatment with levothyroxine to supply your body with thyroid hormone. The key next step for any of the TIRADS systems, and for any similar proposed test system including artificial intelligence [30-32], is to perform a well-designed prospective validation study to measure the test performance in the population upon which it is intended for use. ; Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology. We found better sensitivity, PPV, and NPV with TIRADS compared with random selection (97% vs 1%, 13% vs 1%, and 99% vs 95%, respectively), whereas specificity and accuracy were worse with TIRADS compared with random selection (27% vs 90%, and 34% vs 85%, respectively (Table 2)[25]. Such guidelines do not detail the absolute risk of finding or missing a cancer, nor the often excellent outcome of the treatment of thyroid cancer, nor the potential for unnecessary operations. The true test performance can only be established once the optimized test has been applied to 1 or more validation data sets and compared with the existing gold standard test. The health benefit from this is debatable and the financial costs significant. We either refer too many thyroid patients unnecessarily or order too many ultrasound or other thyroid scans. Using TIRADS as a rule-out cancer test would be the finding that a nodule is TR1 or TR2 and hence has a low risk of cancer, compared with being TR3-5. The vast majority of nodules followed-up would be benign (>97%), and so the majority of FNAs triggered by US follow-up would either be benign, indeterminate, or false positive, resulting in more potential for harm (16 unnecessary operations for every 100 FNAs). Nodules that produce excess thyroid hormone called hot nodules show up on the scan because they take up more of the isotope than normal thyroid tissue does. The NNS for ACR TIRADS is such that it is hard to justify its use for ruling out thyroid cancer (NNS>100), at least on a cost/benefit basis. Quite where the cutoff should be is debatable, but any cutoff below TR5 will have diminishing returns and increasing harms. 2009;94 (5): 1748-51. Second, the proportion of patients in the different ACR TIRADS (TR) categories may, or may not, reflect the real-world population (Table 1). A recent meta-analysis comparing different risk stratification systems included 13,000 nodules, mainly from retrospective studies, had a prevalence of cancer of 29%, and even in that setting the test performance of TIRADS was disappointing (eg, sensitivity 74%, specificity 64%, PPV 43%, NPV 84%), and similar to our estimated values of TIRADS test performance [38]. Cawood T, Mackay GR, Hunt PJ, OShea D, Skehan S, Ma Y. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M. Yoon JH, Lee HS, Kim EK, Moon HJ, Kwak JY. Horvath E, Majlis S, Rossi R et-al. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. However, in the data set, only 25% of all nodules were categorized as TR1 or TR2 and these nodules harbored only 1% of all thyroid cancers (9 of 343). 5. The more FNAs done in the TR3 and TR4 groups, the more indeterminate FNAs and the more financial costs and unnecessary operations. A newer alternative that the doctor can use to treat benign nodules in an office setting is called radiofrequency ablation (RFA). Cytology result was Bethesda 6. Shin JH, Baek JH, Chung J, et al. Elselvier; 2018. https://www.clinicalkey.com. 1. We refer to ACR-TIRADS where data or comments are specifically related to ACR TIRADS and use the term TIRADS either for brevity or when comments may be applicable to other TIRADS systems. 2020 Mar 10;4 (4):bvaa031. http://www.thyroid.org/thyroid-nodules/. TI-RADS categories Composition Cyst Spongiform Mixed cystic/solid Solid lesions Echogenicity Shape Margin Echogenic foci Healthy thyroid cells absorb and use iodine from the blood. Tessler F, Middleton W, Grant E. Thyroid Imaging Reporting and Data System (TI-RADS): A Users Guide. However, given that TR1 and TR2 make up only 25% of the nodules, then to find 25 nodules that are TR1 or TR2, you would need to do 100 scans. Elsevier; 2020. https://www.clinicalkey.com. 2 In assessing a lump or nodule in your neck, one of your doctor's main goals is to rule out the possibility of cancer. There are inherent problems with studies addressing the issue such as selection bias at referral centers and not all nodules having fine needle aspiration (FNA). In other cases, the nodules can get big enough to cause problems. At best, only a minority of the 3% of cancers would show on follow-up imaging features suspicious for thyroid cancer that correctly predict malignancy. It has not been shown to be effective and is associated with an increased risk of cardiac arrythmia and osteoporosis. American College of Radiology: ACR TI-RADS, Korean Society of Thyroid Radiology: K-TIRADS, iodinated contrast-induced thyrotoxicosis, primary idiopathic hypothyroidism with thyroid atrophy, American Thyroid Association (ATA)guidelines, British Thyroid Association (BTA)U classification, Society of Radiologists in Ultrasound (SRU)guidelines, American College of Radiology:ACR TI-RADS, postoperative assessment after thyroid cancer surgery, ultrasound-guided fine needle aspiration of the thyroid, TIRADS (Thyroid Image Reporing and Data System), colloid type 1:anechoic with hyperechoic spots, nonvascularised, colloid type 2: mixed echogenicity with hyperechoic spots,nonexpansile, nonencapsulated, vascularized, spongiform/"grid" aspect, colloid type 3: mixed echogenicity or isoechoic with hyperechoic spots and solid portion, expansile, nonencapsulated, vascularized, simple neoplastic pattern: solid or mixed hyperechoic, isoechoic, or hypoechoic;encapsulated with a thin capsule, suspicious neoplastic pattern: hyperechoic, isoechoic, or hypoechoic;encapsulated with a thick capsule; hypervascularised; with calcifications (coarse or microcalcifications), malignant pattern A: hypoechoic, nonencapsulated with irregular margins, penetrating vessels, malignant pattern B: isoechoic or hypoechoic, nonencapsulated, hypervascularised, multiple peripheral microcalcifications, malignancy pattern C: mixed echogenicity or isoechoic without hyperechoic spots, nonencapsulated, hypervascularised, hypoechogenicity, especially marked hypoechogenicity, "white knight" pattern in the setting of thyroiditis (numerous hyperechoic round pseudonodules with no halo or central vascularizaton), nodular hyperplasia (isoechoic confluent micronodules located within the inferior and posterior portion of one or two lobes, usually avascular and seen in simple goiters), no sign of high suspicion (regular shape and borders, no microcalcifications), high stiffness with sonoelastography (if available), if >7 mm, biopsy is recommended if TI-RADS 4b and 5 or if patient has risk factors (family history of thyroid cancer or childhood neck irradiation), if >10 mm, biopsy is recommended if TI-RADS 4a or if TI-RADS 3 that has definitely grown (2 mm in two dimensions and >20% in volume). Surgery to remove the gland typically addresses the problem, and recurrences or spread of the cancer cells are both uncommon. A negative result with a highly sensitive test is valuable for ruling out the disease. The ACR-TIRADS guidelines also provide easy-to-follow management recommendations that have understandably generated momentum. Accessed Dec. 6, 2019. Other limitations include the various assumptions we have made and that we applied ACR TIRADS to the same data set upon which is was developed. TIRADS 3 nodule is a thyroid nodule that is mildly suspicious based on ultrasound findings. These final validation sets must fairly represent the population upon which the test is intended to be applied because the prevalence of the condition in the test population will critically influence the test performance, particularly the positive predictive value (PPV) and negative predictive value (NPV). A thyroid fine needle aspiration biopsy can collect samples of cells from the nodule, which, under a microscope, can provide your doctor with more information about the behavior of the nodule. The challenge of appropriately balancing the risks of missing an important cancer versus the chance of causing harm and incurring significant costs from overinvestigation is major. Therefore, the rates of cancer in each ACR TIRADS category in the data set where they used four US characteristics can no longer be assumed to be the case using the 5 US characteristics plus the introduction of size cutoffs. Radiofrequency ablation uses a probe to access the benign nodule under ultrasound guidance, and then treats it with electrical current and heat that shrinks the nodule. Choosing an experienced specialist can mean more options to help personalize your treatment and achieve better results. If . J. Endocrinol. Using ACR-TIRADS as a rule-in test to identify a higher risk group that should have FNA is arguably a more effective application. Thyroid gland. To further enhance the performance of TIRADS, we presume that patients present with only 1 TR category of thyroid nodules. American Thyroid Association. Thus, the absolute risk of missing important cancer goes from 4.5% to 2.5%, so NNS=100/2=50. Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. Very probably benign nodules are those that are both. Permissions beyond the scope of this license may be available here. All rights reserved. Ross DS. TIRADS 3, further investigations are not routinely recommended, but monitor. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. 703-390-9883, Looking for a Specific Department? If a thyroid nodule is causing voice or swallowing problems, your doctor may recommend treating it with surgery to remove all or part of the thyroid gland. 215-574-3150, 1100 Wayne Ave., Suite 1020 Kwak JY, Han KH, Yoon JH et-al. A TI-RADS was first proposed by Horvath et al. Thyroid nodules are exceedingly common, leading to costly interventions for many lesions that ultimately prove benign. Ferri FF. PLoS ONE. The figures that TIRADS provide, such as cancer prevalence in certain groups of patients, or consequent management guidelines, only apply to populations that are similar to their data set. The Thyroid Imaging Reporting and Data System (TI-RADS) of the American College of Radiology (ACR) was designed in 2017 with the intent to decrease biopsies of benign nodules and improve overall diagnostic accuracy. They're common, almost always noncancerous (benign) and usually don't cause symptoms. For TIRADS to add clinical value, it would have to clearly outperform the comparator (random selection), particularly because we have made some assumptions that favor TIRADS performance. Eur. The score for this nodule is 1-2 points. In response, ACR committees were formed to accomplish three goals: License Information The specificity of TIRADS is high (89%) but, perhaps surprisingly, is similar to randomly selecting of 1 in 10 nodules for FNA (90%). 2018;287(1):29-36. The risk of malignancy was derived from thyroid ultrasound (TUS) features. A prospective validation study that determines the true performance of TIRADS in the real-world is needed. Haugen BR, Alexander EK, Bible KC, et al. Current thyroid cancer trends in the United States, Association between screening and the thyroid cancer epidemic in South Korea: evidence from a nationwide study, 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer, Thyroid ultrasound and the increase in diagnosis of low-risk thyroid cancer, Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology, Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations, European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS, Multiinstitutional analysis of thyroid nodule risk stratification using the American College of Radiology Thyroid Imaging Reporting and Data System, The Bethesda System for reporting thyroid cytopathology: a meta-analysis, The role of repeat fine needle aspiration in managing indeterminate thyroid nodules, The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. This may include: Radioactive iodine. However, the left lobe of the thyroid gland, tirads 3, is usually benign, with a low malignancy rate of about 1.7%. Castellana M, Castellana C, Treglia G, Giorgino F, Giovanella L, Russ G, Trimboli P. Oxford University Press is a department of the University of Oxford. If a thyroid nodule is causing voice or swallowing problems, your doctor may recommend treating it with surgery to remove all or part of the thyroid gland. Nodules that are TIRADS 3 have a low risk of important thyroid cancer, probably 1 to 5%. To get the most from your appointment, try these suggestions: Mayo Clinic does not endorse companies or products. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Of note, we have not taken into account any of the benefits, costs, or harms associated with the proposed US follow-up of nodules, as recommended by ACR-TIRADS. Feeling tired more easily. Perhaps surprisingly, the performance ACR-TIRADS may often be no better than random selection. Reference article, Radiopaedia.org (Accessed on 01 Mar 2023) https://doi.org/10.53347/rID-21448. Any test will struggle to outperform educated guessing to rule out clinically important thyroid cancer. Rumack CM, et al., eds. In 2013, Russ et al. If it performs well enough, then the test is applied to a training set of data to better establish performance characteristics. You're also likely to have another biopsy if the nodule grows larger. At Another Johns Hopkins Member Hospital: The Johns Hopkins Thyroid and Parathyroid Center, Webinar: Thyroid Disease, an Often Surprising Diagnosis, Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov, Radiofrequency Ablation for Thyroid Nodules. Data Set Used for Development of ACR TIRADS [16] and Used for This Paper The possible cancer rate column is a crude, unvalidated estimate, calculated by proportionately reducing the cancer rates by 10.3%: 5% to reflect the likely difference in the cancer rate in the data set used (10.3%) and in the population presenting with a thyroid nodule (5%). This allows patients with a TR1 or TR2 nodule to be reassured that they have a low risk of thyroid cancer, rather than a mixture of nodules (not just TR1 or TR2) not being able to be reassured. Russ G, Royer B, Bigorgne C et-al. Once your doctor detects a thyroid nodule, you're likely to be referred to a doctor trained in endocrine disorders (endocrinologist). Overview of thyroid nodule formation. Thyroid. This is likely an underestimate of the number of scans needed, given that not all nodules that are TR1 or TR2 will have purely TR1 or TR2 nodules on their scan. They are found . Lin JD, Chao TC, Huang BY, Chen ST, Chang HY, Hsueh C. Bongiovanni M, Crippa S, Baloch Z, et al. The US follow-up is mainly recommended for the smaller TR3 and TR4 nodules, and the prevalence of thyroid cancer in these groups in a real-world population with overall cancer risk of 5% is low, likely<3%. Radiographic features Ultrasound 2018; doi:10.1097/CAD.0000000000000617. Accessed Oct. 31, 2019. In: Rosai and Ackerman's Surgical Pathology. Treating nodules that cause hyperthyroidism If a thyroid nodule is producing thyroid hormones, overloading your thyroid gland's normal hormone production levels, your doctor may recommend treating you for hyperthyroidism. For the calculations, we assume an approximate size distribution where one-third of TR3 nodules are25 mm and half of TR4 nodules are15 mm. NCI Thyroid FNA State of the Science Conference, The Bethesda System for reporting thyroid cytopathology, ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee, Thyroid nodule size at ultrasound as a predictor of malignancy and final pathologic size, Impact of nodule size on malignancy risk differs according to the ultrasonography pattern of thyroid nodules, TIRADS management guidelines in the investigation of thyroid nodules; an illustration of the concerns, costs and performance, Thyroid nodules with minimal cystic changes have a low risk of malignancy, [The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid], Malignancy risk stratification of thyroid nodules: comparison between the Thyroid Imaging Reporting and Data System and the 2014 American Thyroid Association Management Guidelines, Validation and comparison of three newly-released Thyroid Imaging Reporting and Data Systems for cancer risk determination, Machine learning-assisted system for thyroid nodule diagnosis, Automatic thyroid nodule recognition and diagnosis in ultrasound imaging with the YOLOv2 neural network, Using artificial intelligence to revise ACR TI-RADS risk stratification of thyroid nodules: diagnostic accuracy and utility, A multicentre validation study for the EU-TIRADS using histological diagnosis as a gold standard, Comparison among TIRADS (ACR TI-RADS and KWAK- TI-RADS) and 2015 ATA Guidelines in the diagnostic efficiency of thyroid nodules, Prospective validation of the ultrasound based TIRADS (Thyroid Imaging Reporting And Data System) classification: results in surgically resected thyroid nodules, Diagnostic performance of practice guidelines for thyroid nodules: thyroid nodule size versus biopsy rates, Comparison of performance characteristics of American College of Radiology TI-RADS, Korean Society of Thyroid Radiology TIRADS, and American Thyroid Association Guidelines, Performance of five ultrasound risk stratification systems in selecting thyroid nodules for FNA.
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