Are We There Yet Sergiy V Kushchayev Aliaksei L Salei Oleg M Teytelboym Department of Radiology Mercy Catholic Medical Center Darby PA Thyroid Nodule 17 cm mixed solid and cystic ID: 351325
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Slide1
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, PASlide2
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! Nodule # 1 out of 6Slide3
Thyroid Nodule: 3
.5 cm, spongiform, isoechoic, circumscribed, peripheral vascularity, wider than tall, no microcalcifications
Nodule # 2 out of 6
Would you biopsy this nodule?
What do guidelines say?
Stay tuned for answers! Slide4
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!
Nodule # 3 out of 6Slide5
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!
Nodule # 4 out of 6Slide6
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! Nodule # 5 out of 6Slide7
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!
Nodule # 6 out of 6Slide8
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 2009. 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.Slide9
Thyroid Cancer: History
1827 – Description of the patient with neck and head tumor of the same texture as thyroid gland.1850 -
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, 1907Slide10
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 1791. 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
Slide11
Thyroid Cancer: History
Two surgeons who revolutionized thyroid surgery:
Theodore Billroth (
1829-1894
), at the University of Zurich significantly improved surgical technique
on the thyroid gland and reported
8% mortality.
Emil Theodor
Kocher
(
1841-1917),
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“.Slide12
Introduction
The Bethesda System For Reporting Thyroid CytopathologyManagement 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
Objectives:Slide13
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 0.2-5.1% of children
Thyroid cancer is present in 5-15% of thyroid nodules. Thyroid Nodules:Slide14
Thyroid Cancers: Overview
PAPILLARY TC (75-80%) Mean age 40-45yo
Metastases to lymph nodes – 35-50%, almost 90% before 17yoFOLLICULAR 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 50-60
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-ISlide15
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
Type of TC
Stage I
Stage II
Stage III
Stage IV
PTC
Near 100%
Near 100%
93%
51%
FTC
Near 100%
Near 100%
71%
50%
MTC
Near 100%
98%
81%
28%
ATC
Always
stage IV
7%
Deaths per
100,000 persons
http://
seer.cancer.gov
/
csr
/1975_2011/
browse_csr.php?sectionSEL
=26&pageSEL=sect_26_table.16.htmlSlide16
Objectives:
IntroductionThe Bethesda System For Reporting Thyroid Cytopathology
Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) ConsensusAmerican Thyroid
A
ssociation (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
comparisonSlide17
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
Cibas
ES & Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid 2009 19 1159–1165.
The Bethesda System for Reporting Thyroid Cytopathology: Recommended Diagnostic Categories
The Bethesda System for Reporting Thyroid Cytopathology: Implied Risk of Malignancy and Recommended Clinical ManagementSlide18
Objectives:
IntroductionThe Bethesda System For Reporting Thyroid Cytopathology
Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) ConsensusAmerican 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
comparisonSlide19
Society of Radiologists in Ultrasound
ConsensusIn 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. 2005 Dec;237(3):794-800. Slide20
Society of Radiologists in Ultrasound
ConsensusBased on literature analysis, US features associated with thyroid carcinoma were identified. Specific recommendations on management thyroid nodules were proposed.
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. 2005 Dec;237(3):794-800.
US Features Associated with Thyroid Cancer
Recommendations for Thyroid Nodules 1 cm or Larger in Maximum DiameterSlide21
Objectives:
IntroductionThe Bethesda System For Reporting Thyroid Cytopathology
Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) ConsensusAmerican Thyroid
A
ssociation (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
comparisonSlide22
ATA guidelines:
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
. 2009 Nov;19(11):1167-214.
Algorithm for the evaluation of patients with one or more thyroid
nodules:Slide23
ATA guidelines:
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. 2009 Nov;19(11):1167-214.
Sonographic and Clinical Features of Thyroid Nodules and Recommendations for FNASlide24
Objectives:
IntroductionThe Bethesda System For Reporting Thyroid Cytopathology
Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) ConsensusAmerican Thyroid
A
ssociation (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
comparisonSlide25
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
.Slide26
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
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 2009 90 1748–1751
Description
Risk of
malignancy
TIRADS
1
Normal thyroid gland
0
TIRADS 2
Benign
0
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 malignancySlide27
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 2009 90 1748–1751Slide28
TIRADS by Russ
et al
Research group from FranceProspective 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
Suspect pattern
Benign pattern
Thyroid Nodule
High Suspect:
Taller-than-wide
Irregular borders
Microcalcifications
Markedly
hypoechoic
High stiffness on
sonoelastography
Very probably
No signs of high suspect.
Mildly
hypoecoic
1-2 signs,
n
o
metastatic lymph
nodes
3-5 signs and/or metastatic lymph nodes
TIRADS 4A
TIRADS 4B
TIRADS 5
Constantly
No sign of high suspicion: regular shape and borders, no micro-calcifications and
i
so
/
hyperecoic
- Simple cyst
- Spongiform nodule
- “white knight”
- isolated macro-
calcifications
- Nodular hyperplasia
TIRADS 2
TIRADS 3
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.Slide29
TIRADS by
Kwak et al Research group from Korea.
Prospective study 8 years, published in 2011.1959 thyroid nodules submitted for FNA.
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 2011 260 892–899
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
0
0
TIRADS 2
Benign
0
0
TIRADS 3
Probably benign
0
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
44.4-72.4%
TIRADS 5
Highly suggestive
of malignancy
5
87.5%Slide30
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.
Image
Reporting and Characterization System for
Ultrasound
Features of Thyroid Nodules
by
Kwak
et al (2013)
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.Slide31
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),
m
acrocalcifications
, or
none
. When
the nodules had both types of calcifications (
macrocalcifications
including rim calcifications intermingled with
microcalcifications
), the nodule was considered to have
microcalcifications
.
THE SONOGRAPHIC CRITERIA
Image
Reporting and Characterization System for
Ultrasound
Features of Thyroid Nodules
by
Kwak
et al (2013)Slide32
MNEUMONICS:
Marry SMITH
Suspicious US featureScoreM
Marked
hypoechogenicity
6
S
Spiculated
(
microlobulated
)
margins
5
M
Microcalcifications
2
I
Ill-defined borders
1
T
Taller than wider (non-parallel orientation)
1
H
Hypoechogenicity
2
Six previously described US features (Kwak,2011)
associated
with thyroid malignancy were
used. For
each of these features
a specific
risk score was calculated.
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.
Association Between Thyroid Malignancy and Various
Sonographic
Features at Thyroid Nodules of Training Data Set on Multiple Logistic Regression and Risk Score Analysis
Image
Reporting and Characterization System for
Ultrasound
Features of Thyroid Nodules
by
Kwak
et al (2013)Slide33
3. Malignancy
Rate of Malignancy
by
Total
Score
2. Multiple
Logistic
Regression Mode
1. Individual risk score for
each suspicious US feature
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.
Image
Reporting and Characterization System for
Ultrasound
Features of Thyroid Nodules
by
Kwak
et al (2013)Slide34
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.
Malignancy
Rate of Malignancy by Total
Score
Image
Reporting and Characterization System for
Ultrasound
Features of Thyroid Nodules
by
Kwak
et al (2013)Slide35
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
A
ssociation (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.Slide36
Thyroid Nodule #1: 1.7 cm, mixed solid and cystic,
isoechoic, circumscribed, vascular, wider than tall, no microcalcificationsOrganization
US Feature/TIRADS scoreRecommendations
American Thyroid Association
Mixed solid and cystic,
hypervascular
, ≥ 1.5-2 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 degenerationSlide37
Thyroid Nodule #2:
3.5 cm, spongiform, isoechoic, circumscribed, peripheral vascularity, wider than tall, no microcalcifications
OrganizationUS 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 Slide38
Thyroid Nodule #3: 2.7 cm, predominantly solid,
hypoechoic, circumscribed, marked vascularity, wider than tall, no microcalcificationsOrganization
US Feature/TIRADS scoreRecommendations
American Thyroid Association
Mixed,
hypoechoic
, increased
vascularity,
>1.5 cm
Biopsy,
Level B
Society of Radiologists in Ultrasound
Predominantly
s
olid,
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 –
h
ypoechoic
N/A (Risk of malignancy 8.6%)
FNA of the nodule
: Bethesda
class 4
– suspicious for Hurtle cell neoplasmSlide39
Thyroid Nodule #4:
2.5 cm, solid, hypoechoic, microlobulated margin, vascular, wider than tall, no microcalcifications
OrganizationUS 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 Slide40
Thyroid Nodule #5: 2.2 cm, solid,
hypoechoic, irregular margins, vascular, taller than wide, with microcalcificationsOrganization
US Feature/TIRADS scoreRecommendations
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 carcinomaSlide41
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
44-72
%)
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)Slide42
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.Slide43
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 2009 19 1159–1165. 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. 2009 Nov;19(11):1167-214. 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 2009 90 1748–1751
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. 2005 Dec;237(3):794-800.
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 2011 260 892–899
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
.
http://
seer.cancer.gov
/
csr
/1975_2011/
browse_csr.php?sectionSEL
=26&pageSEL=sect_26_table.16.html
References: