ACR Thyroid Imaging, Reporting and Data System (TI-RADS ...

1 ORIGINAL ARTICLEHEALTH SERVICES RESEARCH AND POLICYACR Thyroid imaging , Reporting and DataSystem (TI-RADS): White Paper of theACR TI-RADS CommitteeFranklin N. Tessler, MD, CMa, William D. Middleton, MDb, Edward G. Grant, MDc,Jenny K. Hoang, MBBSd, Lincoln L. Berland, MDa, Sharlene A. Teefey, MDb, John J. Cronan, MDe,Michael D. Beland, MDe, Terry S. Desser, MDf, Mary C. Frates, MDg, Lynwood W. Hammers, DOh,i,Ulrike M. Hamper, MDj, Jill E. Langer, MDk, Carl C. Reading, MDl, Leslie M. Scoutt, MDm,A. Thomas Stavros, MDnAbstractThyroid nodules are a frequentfinding on neck sonography. Most nodules are benign; therefore, many nodules are biopsied to identifythe small number that are malignant or require surgery for a definitive diagnosis.

2 Since 2009, many professional societies and in-vestigators have proposed ultrasound-based risk stratification systems to identify nodules that warrant biopsy or sonographic some of these systems were founded on the BI-RADS classification that is widely used in breast imaging , their authors chose toapply the acronym TI-RADS, for Thyroid imaging , Reporting and Data System . In 2012, the ACR convened committees to (1) providerecommendations for Reporting incidental Thyroid nodules, (2) develop a set of standard terms (lexicon) for ultrasound Reporting , and (3)propose a TI-RADS on the basis of the lexicon. The committees published the results of thefirst two efforts in 2015.

3 In this article, theauthors present the ACR TI-RADS Committee s recommendations, which provide guidance regarding management of Thyroid noduleson the basis of their ultrasound appearance. The authors also describe the committee s future Words: Thyroid nodule, Thyroid cancer, management guidelines, ultrasoundJ Am Coll Radiol 2017;-:---. Copyright 2017 American College of RadiologyINTRODUCTIONT hyroid nodules are exceedingly common, with a reportedprevalence of up to 68% in adults on high-resolutionultrasound[1]. Currently,fine-needle aspiration (FNA)is the most effective, practical test to determine whether anodule is malignant or may require surgery to reach adefinitive diagnosis[2].

4 However, most nodules arebenign, and even malignant nodules, particularly onesaDepartment of Radiology, University of Alabama at Birmingham,Birmingham, Institute of Radiology, Washington University School ofMedicine, St Louis, of Radiology, Keck School of Medicine, University ofSouthern California, Los Angeles, of Radiology, Duke University School of Medicine, Durham,North of Diagnostic imaging Brown University, Providence, of Radiology, Stanford University Medical Center, Stanford, of Radiology, Brigham and Women s Hospital, Boston, Healthcare imaging , New Haven, of Internal Medicine, Yale School of Medicine, New Haven, of Radiology and Radiological Science, Johns HopkinsUniversity, School of Medicine, Baltimore, of Radiology, University of Pennsylvania, Philadelphia, of Radiology, Mayo Clinic College of Medicine, Rochester, of Radiology and Biomedical imaging , Yale University, NewHaven, of Radiology, University of Texas Health Sciences Center,San Antonio, author and reprints: Franklin N.

5 Tessler, MD, CM,Department of Radiology, University of Alabama at Birmingham,Birmingham, AL 35249; Berland received personal fees from Nuance Communications duringthe conduct of the study. Dr Beland has received personal fees from HitachiAloka America outside the submitted work. All other authors have noconflicts of interest related to the material discussed in this article. 2017 American College of Radiology1546-1440/17/$ for Anonymous User (n/a) at University of Saskatchewan - Canada Consortium from by Elsevier on April 13, personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights than 1 cm, frequently exhibit indolent ornonaggressive behavior[3-5].

6 Therefore, not all detectednodules require FNA and/or a rapid increase in the reported incidence ofpapillary Thyroid cancer that resulted from screeningthyroid sonography in asymptomatic patients in SouthKorea, mortality has remained extremely low[6]. In theUnited States, overdiagnosis of Thyroid cancer, definedas diagnosis of Thyroid tumors that would not, if leftalone, result in symptoms or death accounted for 70%to 80% of Thyroid cancer cases in women and 45% ofcases in men between 2003 and 2007[7].Therefore, a reliable, noninvasive method to identifywhich nodules warrant FNA on the basis of a reasonablelikelihood of biologically significant malignancy would behighly desirable.

7 In 2015, committees convened by theACR published white papers that presented an approach toincidental Thyroid nodules and proposed standard termi-nology (lexicon) for ultrasound Reporting [8,9].Thepurpose of the present white paper is to present oursystem for risk stratification, which is designed to identifymost clinically significant malignancies while reducing thenumber of biopsies performed on benign RATIONALE AND CONSENSUSPROCESSS everal professional societies and groups of investigatorshave proposed methods to guide ultrasound practitionersin recommending FNA on the basis of ultrasound features[10-18]. Some of these systems were termed TI-RADS( Thyroid imaging , Reporting and Data System ) becausetheywere modeled on the ACR sBI-RADS , which has beenwidely accepted in breast imaging .

8 Other societies, such as theAmerican Thyroid Association (ATA), have taken a slightlydifferent, pattern-oriented approach, but with the sameintent[19]. The plethora, complexity, and lackof congruenceof these systems has limited their adoption by the ultrasoundcommunity and inspired our effort to publish a classificationsystem under the auspices of the ACR. The ACR TI-RADSC ommittee agreed on the following attributes for our riskclassification algorithm. It would be:nfounded on the ultrasound features defined in ourpreviously published lexicon;neasy to apply across a wide gamut of ultrasoundpractices;nable to classify all Thyroid nodules; andnevidence based to the greatest extent proposals presented in this white paper, whichwere developed via conference calls, e-mail, and onlinesurveys, represent the consensus opinion of the ACR TI-RADS Committee.

9 They are based on the literature;analysis of data from the Surveillance, Epidemiology, andEnd Results (SEER) Program of the National CancerInstitute; evaluation of existing risk classification systems;and expert opinion. Our recommendations are intended toserve as guidance for practitioners who incorporate ultra-sound in the management of adult patients with thyroidnodules. They should not be construed as and referring physicians are legally and pro-fessionally responsible for applying their professionaljudgment to every case, regardless of the ACR TI-RADS recommendations. The decision to perform FNA shouldalso account for the referring physician s preference and thepatient s risk factors for Thyroid cancer, anxiety, comor-bidities, life expectancy, and other relevant OF ACR TI-RADSThe ultrasound features in the ACR TI-RADS are cate-gorized as benign, minimally suspicious, moderatelysuspicious, or highly suspicious for malignancy.

10 Points aregiven for all the ultrasound features in a nodule, withmore suspicious features being awarded additional 1presents these features arranged per thefivelexicon categories[8]. When assessing a nodule, thereader selects one feature from each of thefirst fourcategories and all the features that apply from thefinalcategory and sums the points. The point totaldetermines the nodule s ACR TI-RADS level, whichranges from TR1 (benign) to TR5 (high suspicion ofmalignancy). Note that although it is possible for anodule to be awarded zero points and hence be charac-terized as TR1, all other nodules merit at least two pointsbecause a nodule that has a mixed cystic and solidcomposition (one point) will also gain at least one morepoint for the echogenicity of its solid component.