Chinese thyroid imaging reporting and data system(C-TIRADS); contrast-enhanced ultrasound (CEUS); differentiation; thyroid nodules; ultrasound (US). This comes at the cost of missing as many cancers as you find, spread amongst 84% of the population, and doing 1 additional unnecessary operation (160.20.8=2.6, minus the 1.6 unnecessary operations resulting from random selection of 1 in 10 patients for FNA [25]), plus the financial costs involved. Data Availability: All data generated or analyzed during this study are included in this published article or in the data repositories listed in References. Update of the Literature. EU-TIRADS 1 category refers to a US examination where no thyroid nodule is found; there is no need for FNAB. The system has fair interobserver agreement 4. Many of these papers share the same fundamental problem of not applying the test prospectively to the population upon which it is intended for use. J. Clin. Therefore, for every 25 patients scanned (100/4=25) and found to be either TR1 or TR2, 1 additional person would be correctly reassured that they do not have thyroid cancer. However, there are ethical issues with this, as well as the problem of overdiagnosis of small clinically inconsequential thyroid cancer. Reference article, Radiopaedia.org (Accessed on 05 Mar 2023) https://doi.org/10.53347/rID-21448. Thyroid nodules are detected by ultrasonography in up to 68% of healthy patients. In CEUS analysis, it reflected as later arrival time, hypo-enhancement, heterogeneous and centripetal enhancement, getting a score of 4 in the CEUS model. doi: 10.1016/S0140-6736(14)62242-X -. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. A thyroid nodule is an unusual lump (growth) of cells on your thyroid gland. Performance of Contrast-Enhanced Ultrasound in Thyroid Nodules: Review of Current State and Future Perspectives. Kwak JY, Han KH, Yoon JH et-al. -, Lee JH, Shin SW. Overdiagnosis and Screening for Thyroid Cancer in Korea. Value of Contrast-Enhanced Ultrasound in Adjusting the Classification of Chinese-TIRADS 4 Nodules. 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. Alternatively, if random FNAs are performed in 1 in 10 nodules, then 4.5 thyroid cancers (4-5 people per 100) will be missed. Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L. Middleton WD, Teefey SA, Reading CC, et al. These publications erroneously add weight to the belief that TIRADS is a proven and superior model for the investigation of thyroid nodules. Thyroid radiology practice has an important clinical role in the diagnosis and non-surgical treatment of patients with thyroid nodules, and should be performed according to standard practice guidelines for proper and effective clinical care. Disclosure Summary:The authors declare no conflicts of interest. The high prevalence of thyroid nodules combined with the generally indolent growth of thyroid cancer present a challenge for optimal patient care. A normal finding in Finland. Tessler FN, Middleton WD, Grant EG, et al. A meta-analysis, This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (, Mitoguardin2 is Associated with Hyperandrogenism and Regulates Steroidogenesis in Human Ovarian Granulosa Cells, Factors Associated with Diabetes Distress among Patients with Poorly Controlled Type 2 Diabetes, Serum adiponectin and leptin is not related to skeletal muscle morphology and function in young women, Association Between Metabolic Syndrome Inflammatory Biomarkers and COVID-19 Severity, Long-term outcome of body composition, ectopic lipid and insulin resistance changes with surgical treatment of acromegaly, Volume 7, Issue 4, April 2023 (In Progress), The Journal of Clinical Endocrinology & Metabolism, https://www.uptodate.com/contents/diagnostic-approach-to-and-treatment-of-thyroid-nodules, https://doi.org/10.6084/m9.figshare.11640168.v, http://creativecommons.org/licenses/by-nc-nd/4.0/, Receive exclusive offers and updates from Oxford Academic, 1 in 10 nodules having FNA, assuming pretest probability of cancer of 5%, Negative test being TR1 or TR2; positive test meaning TR3, TR4, or TR5, Positive test meaning TR5; negative test meaning TR1-4, Positive test meaning TR5, TR4 above size cutoff and TR3 above size cutoff; negative test meaning TR1, TR2, TR3 Below Size Cutoff or TR4 below size cutoff, Positive Test Meaning TR5, TR4 Above Size Cutoff and TR3 Above Size Cutoff; negative test meaning TR1, TR2, TR3 below size threshold or TR4 below size cutoff. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Russ G, Royer B, Bigorgne C et-al. They are found . The cost of seeing 100 patients and only doing FNA on TR5 is at least NZ$100,000 (compared with $60,000 for seeing all patients and randomly doing FNA on 1 in 10 patients), so being at least NZ$20,000 per cancer found if the prevalence of thyroid cancer in the population is 5% [25]. 6. 2009;94 (5): 1748-51. What does highly suspicious thyroid nodule mean? For this, we do take into account the nodule size cutoffs but note that for the TR3 and TR4 categories, ACR TIRADS does not detail how it chose the size cutoffs of 2.5 cm and 1.5 cm, respectively. ACR TIRADS performed poorly when applied across all 5 TR categories, with specificity lower than with random selection (63% vs 90%). Any test will struggle to outperform educated guessing to rule out clinically important thyroid cancer. 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. The test that really lets you see a nodule up close is a CT scan. K-TIRADS category was assigned to the thyroid nodules. The difference was statistically significant (P<0.05). Among thyroid nodules detected during life, the often quoted figure for malignancy prevalence is 5% [5-8], with UptoDate quoting 4% to 6.5% in nonsurgical series [9], and it is likely that only a proportion of these cancers will be clinically significant (ie, go on to cause ill-health). The probability of malignancy was based on an equation derived from 12 features 2. Tests and procedures used to diagnose thyroid cancer include: Physical exam. The findings that ACR TIRADS has methodological concerns, is not yet truly validated, often performs no better than random selection, and drives significant costs and potential harm, are very unsettling but result from a rational and scientific assessment of the foundational basis of the ACR TIRADS system. Furuya-Kanamori L, Bell KJL, Clark J, Glasziou P, Doi SAR. If one assumes that in the real world, 25% of the patients have a TR1 or TR2 nodule, applying TIRADS changes the pretest 5% probability of cancer to a posttest risk of 1%, so the absolute risk reduction is 4%. A robust validation study is required before the performance and cost-benefit outcomes of any of the TIRADS systems can be known. In 2013, Russ et al. J. Endocrinol. So just using ACR TIRADS as a rule-out test could be expected to leave 99% of undiagnosed cancers amongst the remaining 75% of the population, in whom the investigation and management remains unresolved. Disclaimer. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. This data set was a subset of data obtained for a previous study and there are no clear details of the inclusion and exclusion criteria, including criteria for FNA. The gold test standard would need to be applied for comparison. The process of validation of CEUS-TIRADS model. If one decides to FNA every TR5 nodule, from the original ACR TIRADS data set, 34% were found to be cancerous, but note that this data set likely has double the prevalence of thyroid cancer compared with the real-world population. Lin JD, Chao TC, Huang BY, Chen ST, Chang HY, Hsueh C. Bongiovanni M, Crippa S, Baloch Z, et al. The common first step when you have a thyroid nodule is to go to your health care provider and get a referral. All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. Given the need to do more than 100 US scans to find 25 patients with just TR1 or TR2 nodules, this would result in at least 50 FNAs being done. Unable to process the form. The 2 examples provide a range of performance within which the real test performance is likely to be, with the second example likely to provide TIRADS with a more favorable test performance than in the real world. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. 3. 2013;168 (5): 649-55. to propose a simpler TI-RADS in 2011 2. The nodules were scored, measured and assigned to one of five TI-RADS levels (TR): TR1 - benign, TR2 - not suspicious, TR3 - mildly suspicious, TR4 - moderately suspicious, TR5 - highly suspicious. Cheng H, Zhuo SS, Rong X, Qi TY, Sun HG, Xiao X, Zhang W, Cao HY, Zhu LH, Wang L. Int J Endocrinol. National Library of Medicine PLoS ONE. 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). Refer to separate articles for the latest systems supported by various professional societies: A TI-RADS was first proposed by Horvath et al. These cutoffs are somewhat arbitrary, with conflicting data as to what degree, if any, size is a discriminatory factor. 4b - Suspicious nodules (10-50% risk of malignancy) Score of 2. 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%. In 2009, Park et al. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Taken as a capsule or in liquid form, radioactive iodine is absorbed by your thyroid gland. Methodologically, the change in the ACR-TIRADS model should now undergo a new study using a new training data set (to avoid replicating any bias), before then undergoing a validation study. Recently, the American College of Radiology (ACR) proposed a Thyroid Imaging Reporting and Data System (TI-RADS) for thyroid nodules based on ultrasonographic features. At the time the article was created Praveen Jha had no recorded disclosures. Bongiovanni M, Spitale A, Faquin WC, Mazzucchelli L, Baloch ZW. The TIRADS reporting algorithm is a significant advance with clearly defined objective sonographic features that are simple to apply in practice. and transmitted securely. For the calculations, we assume an approximate size distribution where one-third of TR3 nodules are25 mm and half of TR4 nodules are15 mm. But the test that really lets you see a nodule up close is a CT scan. Radiology. doi: 10.3390/diagnostics11081374 If your doctor is not sure what to do with your nodule, lets say its just a very small, non-cancerous, nodule, you may need to go to an endocrinologist. For example, a previous meta-analysis of more than 25,000 FNAs showed 33% were in these groups [17]. If a guideline indicates that FNA is recommended, it can be difficult to oppose this based on other factors. government site. official website and that any information you provide is encrypted 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. 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]. (2017) Radiology. These figures cannot be known for any population until a real-world validation study has been performed on that population. MeSH 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. Attempts to compare the different TIRADS systems on data sets that are also not reflective of the intended test population are similarly flawed (eg, malignancy rates of 41% [29]). Noticeably benign pattern (0% risk of malignancy) TI-RADS 3: Probably benign nodules (<5% risk of malignancy) TI-RADS 4: 4a - Undetermined nodules (5-10% risk of malignancy) Score of 1. 4. 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. 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. Horvath E, Majlis S, Rossi R et-al. 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. The authors proposed the following criteria, based on French Endocrine Society guidelines, for when to proceed with fine needle aspiration biopsy: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 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. 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. Objectives: Your health care provider will examine your neck to feel for changes in your thyroid, such as a lump (nodule) in the thyroid. Now, the first step in T3N treatment is usually a blood test. The CEUS-TIRADS combining CEUS analysis with C-TIRADS could make up for the deficient sensibility of C-TIRADS, showing a better diagnostic performance than US and CEUS. To establish a CEUS-TIRADS diagnostic model to differentiate thyroid nodules (C-TIRADS 4) by combining CEUS with Chinese thyroid imaging reporting and data system (C-TIRADS). Thyroid nodules are common, affecting around one-half of the population and become increasingly common with advancing age [1, 2]. 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 .