TI-RADS (Thyroid Imaging Reporting and Data System): Are We There Yet? Sergiy V. Kushchayev Aliaksei L. Salei Oleg M. Teytelboym Department of Radiology,

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, PA

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 6

Thyroid Nodule: 3.5 cm, spongiform, isoechoic, circumscribed, peripheral vascularity, wider than tall, no microcalcifications

Nodule # 2 out of 6



Thyroid Nodule: 2.7 cm, predominantly solid, hypoechoic, circumscribed, marked vascularity, wider than tall, no

microcalcifications



Nodule # 3 out of 6

Thyroid Nodule: 2.5 cm, solid, hypoechoic, microlobulated margin, vascular, wider than tall, no microcalcifications



Nodule # 4 out of 6

Thyroid Nodule: 2.2 cm, solid, hypoechoic, irregular margins, vascular, taller than wide, with microcalcifications



Nodule # 5 out of 6

Thyroid Nodule: 1.7 cm solid, hypoechoic, irregular margins, marked vascularity, wider then tall, and microcalcifications



Nodule # 6 out of 6

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.

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, 1907

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

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“.

1. Introduction

2. The Bethesda System For Reporting Thyroid Cytopathology

3. Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) Consensus

4. American Thyroid Association (ATA) guidelines

5. 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:

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:

Thyroid Cancers: Overview

PAPILLARY TC (75-80%)

Mean age 40-45yo Metastases to lymph nodes – 35-50%, almost 90% before 17yo

FOLLICULAR 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-I

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.html

Objectives:

1. Introduction







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 Management

Objectives:

1. Introduction







Society of Radiologists in Ultrasound Consensus

In 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.

Society of Radiologists in Ultrasound Consensus

Based 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 Diameter

Objectives:

1. Introduction







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:

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 FNA

Objectives:

1. Introduction







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.

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 malignancy

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 1748–1751

TIRADS by Russ et al

Research group from France Prospective 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-wideIrregular borders

MicrocalcificationsMarkedly hypoechoic

High stiffness on sonoelastography

Very probably

No signs of high suspect.

Mildly hypoecoic

1-2 signs,no metastatic lymph nodes

3-5 signs and/or metastatic

lymph nodes

TIRADS 4ATIRADS 4BTIRADS 5

Constantly

No sign of high suspicion:

regular shape and borders, no

micro-calcifications and

iso/hyperecoic

- Simple cyst- Spongiform nodule- “white knight”- isolated macrocalcifications- Nodular hyperplasia

TIRADS 2TIRADS 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.

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:

DescriptionNumber of

suspicious featuresRisk 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%

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.

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), macrocalcifications, 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


Kwak et al (2013)

MNEUMONICS: Marry SMITH

Suspicious US feature Score

M 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.


Association Between Thyroid Malignancy and Various Sonographic Features at Thyroid Nodules of Training Data

Set on Multiple Logistic Regression and Risk Score Analysis


Kwak et al (2013)

3. Malignancy Rate of Malignancy

by Total Score

2. Multiple Logistic Regression Mode

1. Individual risk score for each suspicious US feature



Kwak et al (2013)

ANALYSIS OF RESULTS:

1. Thyroid nodule without any malignant features associated with risk of malignancy 6.2%.

2. Steep increase risk malignancy after score >2 (from 13% to 31%) and >6 (from 35% to 61%).

3. Microcalcifications gives 2 points immediately increasing the risk of malignancy at least by 13%.

4. Microlobulated (spiculated) margins: 5 points brining up the risk of malignancy at least by 33%.

5. Marked hypoechogenicity: 6 points increasing the risk of malignancy at least by 34%


Malignancy Rate of Malignancy by

Total Score


Kwak et al (2013)

Objectives:

1. Introduction.

2. The Bethesda System For Reporting Thyroid Cytopathology.

3. Management of Thyroid Nodules Detected at US: Society of Radiologists in Ultrasound (SRU) Consensus.

4. American Thyroid Association (ATA) guidelines.

5. Three Proposed TIRADS systems: TIRADS by Horvath et al (2009)

TIRADS by Russ et al (2011)TIRADS by Kwak et al (2011)


6. Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak, Image Reporting and Characterization System by Kwak and their comparison.

Thyroid Nodule #1: 1.7 cm, mixed solid and cystic, isoechoic, circumscribed, vascular, wider than tall, no microcalcifications

Organization US Feature/TIRADS score Recommendations

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 degeneration

Thyroid Nodule #2: 3.5 cm, spongiform, isoechoic, circumscribed, peripheral vascularity, wider than tall, no microcalcifications


American Thyroid Association Spongiform, > 2 cm Biopsy (Recommendation C)


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%)


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

Thyroid Nodule #3: 2.7 cm, predominantly solid, hypoechoic, circumscribed, marked vascularity, wider than tall, no microcalcifications


American Thyroid Association Mixed, hypoechoic, increased vascularity, >1.5 cm

Biopsy, Level B


Predominantly solid, 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%)


Score 2 – hypoechoic N/A (Risk of malignancy 8.6%)

FNA of the nodule: Bethesda class 4 – suspicious for Hurtle cell neoplasm

Thyroid Nodule #4: 2.5 cm, solid, hypoechoic, microlobulated margin, vascular, wider than tall, no microcalcifications


American Thyroid Association Solid, hypoechoic, > 1 cm Biopsy (Recommendation B)


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%)


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

Thyroid Nodule #5: 2.2 cm, solid, hypoechoic, irregular margins, vascular, taller than wide, with microcalcifications


American Thyroid Association Solid, hypoechoic, > 1 cm Biopsy (Recommendation B)


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%)


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 carcinoma

Thyroid Nodule #6: 1.7 cm solid, hypoechoic, irregular margins, marked vascularity, wider then tall, and microcalcifications


American Thyroid Association Solid, hypoechoic >1 cm Biopsy, Level B


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%)


Score 9 (solid, markedly hypoechoic, irregular margin, microcalcification)

Biopsy (Risk of malignancy 79%)

FNA of this nodule: Bethesda class 6 Malignancy (papillary thyroid carcinoma)

Conclusions:

1. Current guidelines from ATA and SRU provide a reliable framework for work-up of thyroid nodules, but do not incorporate most recent literature.

2. 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.

3. Introducing TI-RADS made first step in standardizing reporting lexicon allowing effective communication between the radiologists, pathologists, and clinicians.

4. Clinical use of TI-RADS may result in improving quality of care and cost-effectiveness, avoiding unnecessary biopsies.

5. Given absence of recent radiology guidelines, consider of incorporation of TI-RADS like system into institutional reporting protocols.

1. American College of Radiology. Breast imaging reporting and data system: BI-RADS Atlas, 4th edn. Reston, VA, 2003.

2. Cibas ES & Ali SZ. The Bethesda system for reporting thyroid cytopathology. Thyroid 2009 19 1159–1165. 3. 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.4. 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.

5. 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

6. 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.

7. 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.

8. 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.

9. 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

10. Papini E, Guglielmi R, Bianchini A, et al. Risk of malignancy in nonpalpable thyroid nodules: predictive value of ultrasound and color- Doppler features. J Clin Endocrinol Metab 2002;87(5):1941–1946.

11. Park JY, Lee HJ, Jang HW, et al. A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. Thyroid 2009;19(11):1257–1264.

12. 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.

13. http://seer.cancer.gov/csr/1975_2011/browse_csr.php?sectionSEL=26&pageSEL=sect_26_table.16.html

References:

Documents

TI-RADS (Thyroid Imaging Reporting and Data System): Are We There Yet? Sergiy V. Kushchayev Aliaksei L. Salei Oleg M. Teytelboym Department of Radiology,