TIRADS 4: suspicious nodules (5-80% malignancy rate). It is important to validate this classification in different centres. The site is secure. Second, the proportion of patients in the different ACR TIRADS (TR) categories may, or may not, reflect the real-world population (Table 1). There are two suspicious signs with the nodule (solid and irregular margin) and it was defined as C-TIRADS 4b. Yoon JH, Han K, Kim EK, Moon HJ, Kwak JY. 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. So, the number needed to scan (NNS) for each additional person correctly reassured is 100 (NNS=100). -, Zhou J, Yin L, Wei X, Zhang S, Song Y, Luo B, et al. Thyroid nodules are very common and benign in most cases. Clinicians should be using all available data to arrive at an educated estimate of each patients pretest probability of having clinically significant thyroid cancer and use their clinical judgment to help advise each patient of their best options. PLoS ONE. But the test that really lets you see a nodule up close is a CT scan. doi: 10.1089/jayao.2019.0098 Radiology. Federal government websites often end in .gov or .mil. When it reflected an absent enhancement in CEUS, the nodule was judged as CEUS-TIRADS 3. I have some serious news about my thyroid nodules today. Friedrich-Rust M, Meyer G, Dauth N et-al. Bethesda, MD 20894, Web Policies It is very difficult to know the true prevalence of important, clinically consequential thyroid cancers among patients presenting with thyroid nodules. J. Endocrinol. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. They're common, almost always noncancerous (benign) and usually don't cause symptoms. Symptoms and Causes Diagnosis and Tests Management and Treatment Prevention Outlook / Prognosis Living With Frequently Asked Questions Overview Tessler F, Middleton W, Grant E. Thyroid Imaging Reporting and Data System (TI-RADS): A Users Guide. 3. If a clinician does no tests and no FNAs, then he or she will miss all thyroid cancers (5 people per 100). J. Clin. Clinical Application of C-TIRADS Category and Contrast-Enhanced Ultrasound in Differential Diagnosis of Solid Thyroid Nodules Measuring 1 cm. The diagnostic schedule of CEUS could get better diagnostic performance than US in the differentiation of thyroid nodules. The arrival time, enhancement degree, enhancement homogeneity, enhancement pattern, enhancement ring, and wash-out time were analyzed in CEUS for all of the nodules. Shin JH, Baek JH, Chung J, et al. K-TIRADS category was assigned to the thyroid nodules. Instead, it has been applied on retrospective data sets, with cancer rates far above 5%, rather than on consecutive unselected patients presenting with a thyroid nodule [33]. 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. Using TR5 as a rule-in test was similar to random selection (specificity 89% vs 90%). Advances in knowledge: The study suggests TIRADS and thyroid nodule size as sensitive predictors of malignancy. Later arrival time, hypo-enhancement, heterogeneous enhancement, centripetal enhancement, and rapid washout were risk factors of malignancy in multivariate analysis. In ACR TI-RADS, points in five feature categories are summed to determine a risk level from TR1 to TR5 . The sensitivity, specificity, and accuracy of CEUS were 78.7%, 87.5%, and 83.3% respectively. 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. It helps to decide if a thyroid nodule is benign or malignant by combining multiple features on ultrasound. The truth is, most of us arent so lucky as to be diagnosed with all forms of thyroid cancer, but we do live with the results of it. This study aimed to assess the performance and costs of the American College of Radiology (ACR) Thyroid Image Reporting And Data System (TIRADS), by first looking for any important issues in the methodology of its development, and then illustrating the performance of TIRADS for the initial decision for or against FNA, compared with an imagined clinical comparator of a group in which 1 in 10 nodules were randomly selected for FNA. Until a well-designed validation study is completed, the performance of TIRADS in the real world is unknown. The difference was statistically significant (P<0.05). TI-RADS 2: Benign nodules. 3, 4 The modified TI-RADS based on the ACR TI-RADS scoring system was sponsored by Wang et al. Any additional test has to perform exceptionally well to surpass this clinicians 95% negative predictive performance, without generating false positive results and consequential harm. 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. The area under the curve was 0.753. Hong MJ, Na DG, Baek JH, Sung JY, Kim JH. Bastin S, Bolland MJ, Croxson MS. Role of Ultrasound in the Assessment of Nodular Thyroid Disease. 8600 Rockville Pike 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). -, Lee JH, Shin SW. Overdiagnosis and Screening for Thyroid Cancer in Korea. A 35-year-old woman with a nodule in the left-lobe of her thyroid gland. The management guidelines may be difficult to justify from a cost/benefit perspective. Thyroid Tirads 4: Thyroid lesions with suspicious signs of malignancy. Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: can we avoid repeat biopsy? 2018;287(1):29-36. Based on the 2017 ACR TIRADS classification, the doctor will continue to specify whether the patient needs a biopsy of thyroid cells or not: Thyroid nodule size > 2.5cm: Indication for cytology biopsy. Its not something that happens every day, but every day. doi: 10.12659/MSM.936368. It is this proportion of patients that often go on to diagnostic hemithyroidectomies, from which approximately 20% are cancers [12, 17, 21], meaning the majority (80%) end up with ultimately unnecessary operations. . TI-RADS 4b applies to the lesion with one or two of the above signs and no metastatic lymph node is present. 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). 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. 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. Value of Contrast-Enhanced Ultrasound in Adjusting the Classification of Chinese-TIRADS 4 Nodules. These nodules are relatively common and are usually harmless, but there is a very low risk of thyroid cancer. Such validation data sets need to be unbiased. 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 . 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. The area under the curve was 0.803. 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). Jin Z, Zhu Y, Lei Y, Yu X, Jiang N, Gao Y, Cao J. Med Sci Monit. The diagnostic performance of CEUS-TIRADS was significantly better than CEUS and C-TIRADS. 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%). Eur. The Thyroid Imaging Reporting And Data System (TI-RADS) was developed by the American College of Radiology and used by many radiologist in Australia. The more carefully one looks for incidental asymptomatic thyroid cancers at autopsy, the more are found [4], but these do not cause unwellness during life and so there is likely to be no health benefit in diagnosing them antemortem. The. Thyroid nodules are a common finding, especially in iodine-deficient regions. Perhaps surprisingly, the performance ACR-TIRADS may often be no better than random selection. 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. TI-RADS 4c applies to the lesion with three to five of the above signs and/or a metastatic lymph node is present. The consequences of these proportions are highly impactful when considering the real-world performance of ACR-TIRADS. National Library of Medicine ACR TIRADS has not been applied to a true validation set upon which it is intended to be used, and therefore needs to be considered with caution when applying it to the real-world situation. Careers. Write for us: What are investigative articles. However, most of the sensitivity benefit is due to the performance in the TR1 and TR2 categories, with sensitivity in just the TR3 and TR4 categories being only 46% to 62%, depending on whether the size cutoffs add value (data not shown). Anderson TJ, Atalay MK, Grand DJ, Baird GL, Cronan JJ, Beland MD. Bongiovanni M, Spitale A, Faquin WC, Mazzucchelli L, Baloch ZW. eCollection 2020 Apr 1. After repeat US-guided FNA, some patients achieve a cytological diagnosis, but typically two-thirds remain indeterminate [18], accounting for approximately 20% of initial FNAs (eg, 10%-30% [12], 31% [19], 22% [20]). 5 The modified TI-RADS was composed of seven ultrasound features in identifying benign and malignant thyroid nodules, such as the nodular texture, nodular Whereas using TIRADS as a rule-in cancer test would be the finding that a nodule is TR5, with a sufficiently high chance of cancer that further investigations are required, compared with being TR1-4. 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. Endocrine (2020) 70(2):25679. 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. With the right blood tests, you can see if you have a thyroid nodule, and if so, you can treat it with radioactive iodine. Now, the first step in T3N treatment is usually a blood test. The following article describes the initial iterations proposed by individual research groups, none of which gained widespread use. This site needs JavaScript to work properly. The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 100 nodules in the validation cohort. Conclusions: 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. Anti-thyroid medications. The actual number of inconclusive FNA results in the real-world validation set has not been established (because that study has not been done), but the typical rate is 30% (by this we mean nondiagnostic [ie, insufficient cells], or indeterminate [ie, atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS)/follicular neoplasm/suspicious for follicular neoplasm [Bethesda I, III, IV]). It has been retrospectively applied to thyroidectomy specimens, which is clearly not representative of the patient presenting with a thyroid nodule [34-36], and has even been used on the same data set used for TIRADS development, clearly introducing obvious bias [32, 37]. 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. In which, divided into groups such as: Malignant 3.3%; malignancy 9.2%; malignant 44.4 - 72.4%, malignant. Whilst our findings have illustrated some of the shortcomings of ACR TIRADS guidelines, we are not able to provide the ideal alternative. Applying ACR-TIRADS across all nodule categories did not perform well, with sensitivity and specificity between 60% and 80% and overall accuracy worse than random selection (65% vs 85%). FOIA That particular test is covered by insurance and is relatively cheap. 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. Save my name, email, and website in this browser for the next time I comment. However, many patients undergoing a PET scan will have another malignancy. The flow chart of the study. An official website of the United States government. Putting aside any potential methodological concerns with ACR TIRADS, it may be helpful to illustrate how TIRADS might work if one assumed that the data set used was a fair approximation to the real-world population. Russ G, Royer B, Bigorgne C et-al. spiker54. Disclaimer. In a cost-conscious public health system, one could argue that after selecting out those patients that clearly raise concern for a high risk of cancer (ie, from history including risk factors, examination, existing imaging) the clinician could reasonably inform an asymptomatic patient that they have a 95% chance of their nodule being benign. eCollection 2022. Tirads 5 thyroid gland: is a thyroid gland with 5 or more lesions, the rate of malignancy accounts for 87.5%. If the nodule got a score of more than 2 in the CEUS schedule, CEUS-TIRADS added 1 category. Therefore, 60% of patients are in the middle groups (TR3 and TR4), where the US features are less discriminatory. A prospective validation study that determines the true performance of TIRADS in the real-world is needed. 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. We then compare the diagnosis performance of C-TIRADS, CEUS, and CEUS-TIRADS by sensitivity, specificity, and accuracy. Therefore, taking results from this data set and assuming they would apply to the real-world population raises concerns. The sensitivity, specificity, and accuracy of C-TIRADS were 93.1%, 55.3%, and 74.6% respectively. 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. 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. Findings of a large, prospective multicenter study from Egypt, published in the August 2019 issue of the European Journal . The optimal investigation and management of the 84% of the population harboring the remaining 50% of cancer remains unresolved. Tom James Cawood, Georgia Rose Mackay, Penny Jane Hunt, Donal OShea, Stephen Skehan, Yi Ma, TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance, Journal of the Endocrine Society, Volume 4, Issue 4, April 2020, bvaa031, https://doi.org/10.1210/jendso/bvaa031. 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]. Quite where the cutoff should be is debatable, but any cutoff below TR5 will have diminishing returns and increasing harms. Metab. doi: 10.1007/s12020-020-02441-y These cutoffs are somewhat arbitrary, with conflicting data as to what degree, if any, size is a discriminatory factor. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. official website and that any information you provide is encrypted 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. In CEUS analysis, it reflected as equal arrival time, iso-enhancement, homogeneity, and diffuse enhancement, receiving a score of 0 in the CEUS model. HHS Vulnerability Disclosure, Help For the calculations, we assume an approximate size distribution where one-third of TR3 nodules are25 mm and half of TR4 nodules are15 mm. Radzina M, Ratniece M, Putrins DS, Saule L, Cantisani V. Cancers (Basel). Here at the University of Florida, we are currently recruiting endocrinologists to work with us to help people with thyroid nodules. The first time Tirads 3 after cytology is benign, but you do not say how many mm and after 3 months of re-examination, it was . 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. Third, when moving on from the main study in which ACR TIRADS was developed [16] to the ACR TIRADS white paper recommendations [22], the TIRADS model changed by the addition of a fifth US characteristic (taller than wide), plus the addition of size cutoffs. 2022 Jun 7;28:e936368. The results were compared with histology findings. A newer alternative that the doctor can use to treat benign nodules in an office setting is called radiofrequency ablation (RFA). 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. 7. Before To develop a medical test a typical process is to generate a hypothesis from which a prototype is produced. The problem is that many people dont know that they have a thyroid nodule, so they dont know how to treat it. The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 100 nodules in the. The financial costs and surgical morbidity in this group must be taken into account when considering the cost/benefit repercussions of a test that includes US imaging for thyroid cancer. As a result, were left looking like a complete idiot with the results. 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. A subdivision into 4a (malignancy between 5 and 10%) and 4b (malignancy between 10 and 80%) was optional. 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. 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. Im on a treatment plan with my oncologist, my doctor, and Im about to start my next round of treatments. We found sensitivity and PPV with TIRADS was poor, but was better than random selection (sensitivity 53% vs 1%, and PPV 34% vs 1%) whereas specificity, NPV, and accuracy was no better with TIRADS compared with random selection (specificity 89% vs 90%, NPV 94% vs 95%, and accuracy 85% vs 85%), Table 2 [25]. Performing FNA on TR5 nodules is a relatively effective way of finding thyroid cancers. Zhang B, Tian J, Pei S, Chen Y, He X, Dong Y, Zhang L, Mo X, Huang W, Cong S, Zhang S. Wildman-Tobriner B, Buda M, Hoang JK, Middleton WD, Thayer D, Short RG, Tessler FN, Mazurowski MA. Keywords: Epub 2021 Oct 28. In patients with thyroid nodules, ultrasonography (US) has been established as a primary diagnostic imaging method and is essential for treatment decision. Some cancers would not show suspicious changes thus US features would be falsely reassuring. With the right blood tests, you can see if you have a thyroid nodule, and if so, you can treat it with radioactive iodine. MeSH Kwak JY, Han KH, Yoon JH et-al. 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]). Outlook. Based on the methodology used to acquire the data set, the gender bias, and cancer rate in the data set, it is unlikely to be a fair reflection of the population upon which the test is intended to be applied, and so cannot be considered a true validation set. Thus, the absolute risk of missing important cancer goes from 4.5% to 2.5%, so NNS=100/2=50. Only a small percentage of thyroid nodules are cancerous. Chinese thyroid imaging reporting and data system(C-TIRADS); contrast-enhanced ultrasound (CEUS); differentiation; thyroid nodules; ultrasound (US). 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]. The CEUS-TIRADS category was 4a. -, Takano T. Overdiagnosis of Juvenile Thyroid Cancer: Time to Consider Self-Limiting Cancer. The chance of finding a consequential thyroid cancer during follow-up is correspondingly low. A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. The gender bias (92% female) and cancer prevalence (10%) of the data set suggests it may not accurately reflect the intended test population. . In view of their critical role in thyroid nodule management, more improved TI-RADSs have emerged. Haugen BR, Alexander EK, Bible KC, et al. Become a Gold Supporter and see no third-party ads. If the nodule had a regular hyper-enhancement ring or got a score of less than 2 in CEUS analysis, CEUS-TIRADS subtracted 1 category. 4. As it turns out, its also very accurate and detailed. Performance of Contrast-Enhanced Ultrasound in Thyroid Nodules: Review of Current State and Future Perspectives. 2022 Jan 6;2022:5623919. doi: 10.1155/2022/5623919. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. They will want to know what to do with your nodule and what tests to take. The pathological result was Hashimotos thyroiditis. FNA, fine-needle aspiration; US, ultrasound; CEUS, contrast-enhanced ultrasound; C-TIRADS, Chinese imaging reporting and data system. 2011;260 (3): 892-9. Department of Endocrinology, Christchurch Hospital. 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.