Tirads
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TIRADS thyroid nodule ultrasound classification
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Here is a thorough overview of TIRADS (Thyroid Imaging Reporting and Data System) based on authoritative medical sources:
ACR TI-RADS - Thyroid Imaging Reporting and Data System
TIRADS is a standardized, point-based ultrasound scoring system for thyroid nodules developed by the American College of Radiology (ACR). Its purpose is to risk-stratify nodules and guide decisions about fine-needle aspiration (FNA) biopsy vs. surveillance.
ACR TI-RADS Scoring Chart
The 5 Scoring Categories
Points are assigned across five ultrasound features. The total determines the TR level.
1. Composition (choose one)
| Feature | Points |
|---|---|
| Cystic or almost completely cystic | 0 |
| Spongiform (>50% small cystic spaces) | 0 |
| Mixed cystic and solid | 1 |
| Solid or almost completely solid | 2 |
2. Echogenicity (choose one)
| Feature | Points |
|---|---|
| Anechoic | 0 |
| Hyperechoic or isoechoic | 1 |
| Hypoechoic | 2 |
| Very hypoechoic (more hypoechoic than strap muscles) | 3 |
3. Shape (choose one)
| Feature | Points |
|---|---|
| Wider-than-tall | 0 |
| Taller-than-wide | 3 |
4. Margin (choose one)
| Feature | Points |
|---|---|
| Smooth | 0 |
| Ill-defined | 0 |
| Lobulated or irregular | 2 |
| Extra-thyroidal extension | 3 |
5. Echogenic Foci (choose all that apply)
| Feature | Points |
|---|---|
| None or large comet-tail artifacts | 0 |
| Macrocalcifications | 1 |
| Peripheral (rim) calcifications | 2 |
| Punctate echogenic foci | 3 |
TI-RADS Levels and Management
| Total Points | TR Level | Suspicion | FNA Recommendation |
|---|---|---|---|
| 0 | TR1 | Benign | No FNA |
| 2 | TR2 | Not suspicious | No FNA |
| 3 | TR3 | Mildly suspicious | FNA if ≥ 2.5 cm; Follow if ≥ 1.5 cm |
| 4-6 | TR4 | Moderately suspicious | FNA if ≥ 1.5 cm; Follow if ≥ 1 cm |
| ≥7 | TR5 | Highly suspicious | FNA if ≥ 1 cm; Follow if ≥ 0.5 cm |
Key Clinical Points
- Spongiform nodules (TR1) have <3% malignancy risk; observation is recommended without FNA - Harrison's Principles of Internal Medicine 22E
- TR5 (solid, very hypoechoic, taller-than-wide, irregular margins, punctate foci) carries 10-20% or higher malignancy risk; FNA at ≥1 cm
- All major Risk Stratification Systems (ATA, EU-TIRADS, ACR TI-RADS) agree: no routine FNA for any nodule <1 cm unless metastatic cervical lymph nodes are present
- A suppressed TSH warrants radionuclide scan first - a "hot" (autonomously functioning) nodule is almost never malignant and does not require FNA
- Multiple nodules: malignancy risk is the same as for solitary nodules; each nodule is assessed separately. If multiple nodules share similar features, biopsy the largest
Special Features to Note
- Taller-than-wide shape (3 points) is one of the most worrisome single features
- Punctate echogenic foci (3 points) - may represent psammoma bodies (associated with papillary thyroid carcinoma)
- Extra-thyroidal extension = obvious invasion and is considered malignancy
- Large comet-tail artifacts in cystic areas are benign (0 points)
EU-TIRADS vs. ACR TI-RADS
Both systems use similar ultrasound features but differ slightly in classification:
- ACR TI-RADS uses a point-based additive system (described above)
- EU-TIRADS assigns 5 categories (EU-TIRADS 1-5) based on pattern recognition rather than a strict point tally, but yields consistent malignancy risk estimates - Harrison's 22E
After FNA - Bethesda System
FNA results are reported using the Bethesda Classification (Version 3):
| Category | Risk of Malignancy (mean) |
|---|---|
| I. Nondiagnostic | ~13% |
| II. Benign | ~4% |
| III. AUS (Atypia of Undetermined Significance) | Intermediate |
| IV. Follicular Neoplasm | Intermediate |
| V. Suspicious for Malignancy | High |
| VI. Malignant | ~98% (mostly papillary thyroid carcinoma) |
- Goldman-Cecil Medicine, International Edition | Harrison's Principles of Internal Medicine 22E
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