TI-RADS (Thyroid nodule Imaging
Reporting and Data System)
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr Ahmed Esawy
Objectives:
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) Practical application of SRU consensus, ATA guidelines, TIRADS by Russ, TIRADS by Kwak, Image Reporting and Characterization System by Kwak and their comparison
Dr Ahmed Esawy
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.
Dr Ahmed Esawy
Thyroid Ultrasound Reporting Lexicon
Dr Ahmed Esawy
The thyroid lobes are normally 4–6 cm in craniocaudal length and 1.3–1.8 cm in their anteroposterior and transverse dimensions; the isthmus normally has an anteroposterior thickness of up to 3 mm
Dr Ahmed Esawy
Composition. (A) Solid nodule: 46-year-old man with 3.5-cm solid, hypoechoic nodule. Margins are smooth. Macrocalcifications were identified on other sections. Diagnosis: medullary carcinoma.
Solid: Composed entirely or nearly entirely of soft tissue, with only a few tiny cystic spaces
Category 1: Composition Definition ■Composition describes the internal components of a nodule, that is, the presence of soft tissue or fluid, and the proportion of each
Dr Ahmed Esawy
Predominately solid nodule: 63 year old female with a 1.6 cm predominately solid, hyperechoic nodule. Margins are smooth. Note presence of punctate echogenic foci and foci with small comet tail artifacts. Diagnosis: colloid nodule (Bethesda 2).
Predominately solid: Composed of soft tissue components occupying 50% or more of the volume of the nodule
Dr Ahmed Esawy
Predominately cystic: Composed of soft tissue components occupying less than 50% of the volume of the nodule
Predominately cystic nodule: 26 year old male with a 4.5 cm predominately cystic nodule. Note solid components along superior/posterior wall (arrow). Diagnosis: Cystic nodule, non-diagnostic (Bethesda 1). Appearance of aspirate was consistent with old blood. Nodule recurred but no change over two year follow up. Dr Ahmed Esawy
Spongiform: Composed predominately of tiny cystic spaces
Dr Ahmed Esawy
Category 2: Echogenicity Definition ■Level of echogenicity of the solid, noncalcified component of a nodule, relative to surrounding thyroid tissue
Dr Ahmed Esawy
Hyperechoic nodule: 63 year old female with 1.6 cm hyperechoic predominately solid, smooth nodule. Note punctate echogenic foci. Diagnosis: colloid nodule (Bethesda 2).
Hyperechoic: Increased echogenicity relative to thyroid tissue
Dr Ahmed Esawy
Hypoechoic nodule: 62 year old male with 1.6 cm hypoechoic, solid nodule with smooth margins. Note large comet tail artifact along inferior border. Diagnosis: papillary carcinoma.
Hypoechoic: Decreased echogenicity relative to thyroid tissue
Dr Ahmed Esawy
Echogenicity. Very hypoechoic nodule: 55-year-old woman with 1.0-cm very hypoechoic left lobe nodule (N). Margins are smooth. Note that nodule is less echogenic than adjacent strap muscles (S) and essentially isoechoic to the common carotid artery (C). Diagnosis: papillary carcinoma.
○Very hypoechoic: Decreased echogenicity relative to adjacent neck musculature
Dr Ahmed Esawy
Isoechoic: Similar echogenicity relative to thyroid tissue.
Dr Ahmed Esawy
Shape: 56-year-old woman with taller-than-wide nodule in left lobe of thyroid . Dimensions measured in the transverse plane are 1.4 cm transverse 1.8 cm anteroposterior.Diagnosis : follicular variant, papillary carcinoma.
Category 3: Shape Term: taller-than-wide. Definition ■A taller-than-wide shape is defined as a ratio of >1 in the anteroposterior diameter to the horizontal diameter when measured in the transverse plane
Dr Ahmed Esawy
Category 4: Size How the nodule should be measured: ■ Use maximal diameter on the basis of longitudinal, anteroposterior, and transverse measurements in centimeters per millimeter.
Dr Ahmed Esawy
Poorly differentiated carcinoma in an 81-year-old
Ill-defined: Border of the nodule is difficult to distinguish from thyroid parenchyma; the nodule lacks irregular or lobulated margins.
Category 5: Margins Definition ■Refers to the border or interface between the nodule and the adjacent thyroid parenchyma or adjacent extrathyroidal structures.
Dr Ahmed Esawy
Follicular adenoma in a 30-year-old woman. Transverse sonogram of the left lobe of the thyroid shows a follicular adenoma with a hypoechoic halo (arrows).
Halo: Border consists of a dark rim around the periphery of the nodule. The halo can be described as completely or partially encircling the nodule. In the literature, halos have been further characterized as uniformly thin, uniformly thick, or irregular in thickness
Dr Ahmed Esawy
Smooth margin: 49 year old female with 2.2 cm hypoechoic nodule with a smooth margin. Diagnosis: Benign follicular nodule (Bethesda 2).
Smooth: Uninterrupted, well-defined, curvilinear edge typically forming a spherical or elliptical shape
Dr Ahmed Esawy
Irregular margin: 47-year-old woman with heterogeneously hyperechoic 16-mm nodule with irregular margins.Note angulated borders anteriorly. Diagnosis: papillary carcinoma..
○Irregular margin: The outer border of the nodule is spiculated, jagged, or with sharp angles with or without clear soft tissue protrusions into the parenchyma. The protrusions may vary in size and conspicuity and may be present in only one portion of the nodule
Dr Ahmed Esawy
lobulated margin: 56 year old man with 3.4 cm lobulated, hyperechoic nodule. Macrocalcifications were present in other sections. Diagnosis: Papillary carcinoma.
Lobulated: Border has focal rounded soft tissue protrusions that extend into the adjacent parenchyma. The lobulations may be single or multiple and may vary in conspicuity and size (small lobulations are referred to as microlobulated)
Dr Ahmed Esawy
Extra-thyroidal extension: 73 year old male with a large, lobulated hypoechoic mass involving isthmus and left lobe. Note loss of definition of tissue planes anteriorly suggesting extra-thyroidal invasion. Diagnosis: Anaplastic carcinoma.
Extrathyroidal extension: Nodule extends through the thyroid capsule
Dr Ahmed Esawy
Category 6: Echogenic Foci
Definition ■Refers to focal regions of markedly increased echogenicity within a nodule relative to the surrounding tissue. Echogenic foci vary in size and shape and may be encountered alone or in association with several well-known posterior acoustic artifacts.
Dr Ahmed Esawy
Echogenic foci. Punctate echogenic foci: 44-year-old woman with 3.2-cm isoechoic smoothly marginated nodule.Note numerous punctate echogenic foci with no posterior acoustic artifacts. Diagnosis: colloid nodule (Bethesda 2).
Punctate echogenic foci: “Dot-like” foci having no posterior acoustic posterior artifacts. Kwak et al defined punctate foci/microcalcifications as being <1 mm. Most authors define this feature on the basis of appearance alone
Dr Ahmed Esawy
Macrocalcifications: 49 year old female with a 1.7 cm hypoechoic, ill-defined nodule at the junction of the right lobe and isthmus. Large shadowing echogenic structure (macrocalcification) is present in posterior portion of the nodule. Diagnosis: Colloid nodule (Bethesda 2).
Macrocalcifications: When calcifications become large enough to result in posterior acoustic shadowing, they should be considered macrocalcifications. Macrocalcifications may be irregular in shape
Dr Ahmed Esawy
Punctate echogenicities in thyroid nodules. (a) Sagittal US image of nodule (arrowheads) containing multiple fine echogenicities (arrow) with no comet-tail artifact. These are highly suggestive of malignancy. FNA and surgery confirmed papillary carcinoma. (b) Transverse US image of nodule (arrowheads) containing cystic areas with punctate echogenicities and comet-tail artifact (arrow) consistent with colloid crystals in a benign nodule.
Dr Ahmed Esawy
Peripheral calcifications: 43 year old female with 3.1 cm solid, hyperechoic nodule with peripheral calcifications. Diagnosis: Follicular carcinoma.
Peripheral calcifications: These calcifications occupy the periphery of the nodule. The calcification may not be completely continuous but generally involves the majority of the margin. Peripheral calcifications are often dense enough to obscure the central components of the nodule
Dr Ahmed Esawy
Echogenic foci with large comet tail artifacts: 41 year old male with 2.7 cm cystic nodule containing multiple, mobile, echogenic foci with large comet tail artifacts. Note tapering of comet tails posteriorly. Diagnosis: Colloid nodule (Bethesda 2).
Comet-tail artifacts: A comet-tail artifact is a type of reverberation artifact. The deeper echoes become attenuated and are displayed as decreased width, resulting in a triangular shape. If an echogenic focus does not have this feature, a comet-tail artifact should not be described
Dr Ahmed Esawy
US scans show features indicative of malignancy, including (a) hypoechogenicity ( star = strap muscle, arrows = nodule); (b) microcalcifi cations (arrows); (c) marked hypoechogenicity ( star = strap muscle,arrows = nodule), microlobulated margin, and taller-than-wide shape; and (d) irregular margin (arrows = nodule). Dr Ahmed Esawy
THYPES OF THYRIOD NODULES
Dr Ahmed Esawy
Colloid nodules, also known as adenomatous nodules] or colloid nodular goiter Colloid nodules (CN) are non-neoplastic non-inflammatory benign nodules occurring within the thyriod gland . They form the vast majority of nodular thyriod disease may be single or multiple
thyroid-stimulating hormone test, can help differentiate a thyrotoxic nodule from an euthyroid nodule
PATHOLOGY A colloid nodular goiter occurs when the thyroid gland is unable to meet the metabolic demands of the body with sufficient hormone production. The thyroid gland compensates by enlarging, which usually overcomes mild deficiencies of thyroid hormone. If the thyroid gland is then re-exposed to iodine, the nodules may produce thyroid hormone independently. Occasionally, the nodules may produce too much thyroid hormone, causing thyrotoxicosis. This is called a toxic nodular goiter.
ULTRASOUND iso to hypoechoic May be cystic (cystic nodular giotre) may have internal cystic or heterogeneous change may have calcification multiple echogenic foci (of inspissated colloid) with comet tail artifact
Colloid nodules
Dr Ahmed Esawy
TIRADS by Horvath et al.
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
Dr Ahmed Esawy
C, US image of a colloid type 3 pattern: a mixed, nonencapsulated, expansile, isoechoic nodule with hyperechoic spots and broad septa
A, US image of multiple typical colloid cysts: anechoic areas with hyperechogenic spots (type 1 colloid pattern). B, US image of a type 2 colloid nodule: a mixed, nonexpansile, nonencapsulated structure with a “grid” appearance given by isoechoic solid areas and hyperechoic spots. The gland is not enlarged.
TIRADS 2
Dr Ahmed Esawy
D, US aspect of Hashimoto thyroiditis with a pseudo-nodule: normal size heterogeneous gland with lobulated borders and a hyperechoic pseudo-nodule (arrow), partially surrounded by a halo
TIRADS 3
Dr Ahmed Esawy
E, US image of a simple neoplastic pattern (4A): a solid hyperechoic nodule without calcifications, surrounded by a thin capsule. F, A hypoechoic area with ill-defined borders, without calcifications. This pattern may be found in both subacute thyroiditis and carcinomas
G, US image of a suspicious neoplastic pattern (4B): an encapsulated heterogeneous nodule with coarse calcifications, surrounded by a thick capsule. H, US image of malignant pattern A: solid hypoechoic, irregular nodules with ill-defined margins, with calcifications (thin arrow) or without calcifications (thick arrow).
TIRADS 4A
TIRADS 4B
Dr Ahmed Esawy
I, US image of malignant pattern B: solid, nonencapsulated, isoechoic, ill-defined nodule with a “salt and pepper” aspect, due to peripheral microcalcifications. J, US image of malignant pattern C: a mixed, isoechoic, vascularized, nonencapsulated nodule with calcifications and no hyperechoic spots. -
TIRADS 5 B TIRADS 5 C
Dr Ahmed Esawy
Dr Ahmed Esawy
TIRADS by Kwak et al
Description
Number of suspicious features
Risk 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%
TIRADS 6 biopsy proven malignancy
Dr Ahmed Esawy
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
Image Reporting and Characterization System for Ultrasound Features of Thyroid Nodules by Kwak et al (2013)
Dr Ahmed Esawy
TIRADS by Russ et al
Suspect pattern Benign pattern
Thyroid Nodule
High Suspect:
Taller-than-wide Irregular borders
Microcalcifications Markedly 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 4A
TIRADS 4B
TIRADS 5
Constantly
No sign of high suspicion: regular
shape and borders, no micro-
calcifications and iso/hyperecoic
- Simple cyst - Spongiform nodule - “white knight” - isolated macro- calcifications - Nodular hyperplasia
TIRADS 2
TIRADS 3
Dr Ahmed Esawy
by Russ et al
by Kwak et al
Horvath et al.
normal thyroid gland normal thyroid gland
normal thyroid gland TIRADS 1
CONSTATNLY - Simple cyst - Spongiform nodule - “white knight” - isolated macro- calcifications - Nodular hyperplasia
T2 =benign Same as Horvath (colloid type I)
Anechoic with hyperechoic spots, nonvascularized lesion. (colloid type I)
TIRADS 2
Same as Horvath with peripheral halo
(colloid type II)
Nonencapsulated, mixed, nonexpansile, with hyperechoic spots, vascularized lesion, ″grid″ aspect (spongiform nodule). (colloid type II)
Same as Horvath (colloid type III) These conditions have 0% risk of malignancy
Nonencapsulated, mixed with solid portion, isoechogenic, expansile, vascularized nodule with hyperechoic spots. (colloid type III)
THREE TIRADS
Dr Ahmed Esawy
by Russ et al
by Kwak et al
Horvath et al.
Very probably No sign of high suspicion: regular shape and borders, no micro-calcifications and iso/hyperecoic
probably benign lesions Same as Horvath
probably benign lesions Hyper, iso, or hypoechoic, partially encapsulated nodule with peripheral vascularization, in Hashimoto’s thyroiditis. Hashimoto pseudo- nodule
TIRADS 3
T4A=Mildly suspect No signs of high
suspect. Mildly hypoecoich
T4A low suspicion one suspicious feature
suspicion 5-10% Hyper, iso, or hypoechoic, hypervascularized, encapsulated nodule with a thick capsule, containing calcifications (coarse or microcalcifications). Suspicious neoplastic pattern
TIRADS 4 A
T4B moderate suspicion two suspicious features
Intermediate suspicion 10-80 % Hypoechoic, nonencapsulated nodule, with irregular shape and margins, penetrating. vessels, with or without calcifications
TIRADS 4 B T4B=highly suspect 1-2 signs, no metastatic lymph nodes
THREE TIRADS
Dr Ahmed Esawy
by Russ et al
by Kwak et al
Horvath et al.
NO TIRAD C Moderate concern but not classic for malignancy 3-4 suspicious features
NO TIRAD C TIRADS 4 C
T5=highly suspect 3-5 signs and/or metastatic lymph nodes
High Suspect:
Taller-than-wide
Irregular borders
Microcalcifications
Markedly hypoechoic High stiffness on sonoelastograph
Highly suggestive of malignancy
all five suspicious features
SMITHarry M
Marked hypoechogenicity Spiculated (microlobulated) margins Microcalcifications Ill-defined borders Taller than wider (non- parallel orientation) Hypoechogenicity
highly suspicion <80 % Iso or hypoechoic, nonencapsulated nodule with multiple peripheral microcalcifications and hypervascularization. Malignant pattern B Nonencapsulated, isoechoic mixed hypervascularized nodule with or without calcifications, without hyperechoic spots. Malignant pattern C
TIRADS 5
THREE TIRADS
Dr Ahmed Esawy
TI-RADS 1 : normal thyroid gland Dr Ahmed Esawy
TI-RADS 2 : simple thyroid cyst Dr Ahmed Esawy
Thyroid Cyst TIRADS 2 Dr Ahmed Esawy
TI-RADS 2: solid nodule with central cyst not eccentric Dr Ahmed Esawy
TI-RADS 2: nodule with homogeneous peripheral calcification.
Dr Ahmed Esawy
TI-RADS 2: spongiform nodule. Dr Ahmed Esawy
Spongiform nodule TIRADS 2 Dr Ahmed Esawy
White Knight TIRADS 2 Dr Ahmed Esawy
Isolated macro calcification TIRADS 2 Dr Ahmed Esawy
Regular-shaped, round, isoechoic solid nodule with regular borders and shape and no calcifications: TI-RADS 3. This nodule was classified as benign by cytopathological analysis
Dr Ahmed Esawy
TI-RADS 3: hyperechoic nodule
Dr Ahmed Esawy
TI-RADS 3: slightly hyperechoic nodule with small cysts and peripheral vascularity
Dr Ahmed Esawy
The nodule on Figure before corresponds to a toxic adenoma on thyroid scintigraphy with 99mTC-sodium pertechnetate.
Dr Ahmed Esawy
TI-RADS 3: several nodules in the same gland with a similar ultrasound pattern: hyper or isoechoic nodules, with small cystic changes and small hypoechoic spots, as well as microcalcifications (arrow) and peripheral perfusion. In the thyroid scintigraphy (lower row on the right) TNs appear as toxic adenomas in a patient with hyperthyroidism Dr Ahmed Esawy
Patient with nodular goiter. In a hyperechoic nodule with small cysts, consistent with TI-RADS 3, a small papillary thyroid carcinoma (pT1b) was histologically detected after surgery Dr Ahmed Esawy
Isoechogenic TIRADS 3 Dr Ahmed Esawy
Moderately heterogenous nodule with isoechoic and mildly hypoechoic regions, regular shape and borders: TI-RADS 4A. Mildly hypoechoic is defined as more hypoechoic than the surrounding gland but less than strap muscles. This nodule was classified as a microvesicular adenoma by histopathological analysis Dr Ahmed Esawy
TI-RADS4a: markedly hypoechoic nodule, of normal shape and abnormal vascularity. Score of 1. Dr Ahmed Esawy
Hypoechogenic nodule TIRADS 4A
Dr Ahmed Esawy
TI-RADS 4b: nodule with microcalcifications and poorly defined irregular margins. . Dr Ahmed Esawy
TI-RADS 4b: nodule with two sonographically suspicious criteria for malignancy: hypoechogenicity and internal vascularity.
Dr Ahmed Esawy
Solid isoechoic nodules with ill-defined borders and microcalcifications: several round, sometimes linear, tiny punctuations. At the opposite of granular deposits, no US absorption below the punctuations and no hypoechoic microcavities above them are seen, as well as no comet-tail artifacts. TI-RADS 4B. This nodule was cytologically suspicious for malignancy and classified as a papillary carcinoma by histopathological analysis.
Dr Ahmed Esawy
Taller-than-wide nodule TIRADS 4B
Dr Ahmed Esawy
Irregular margins TIRADS 4B Dr Ahmed Esawy
Marked hypoechogenicity TIRADS 4B Dr Ahmed Esawy
Microcalcifications TIRADS 4B Dr Ahmed Esawy
TI-RADS 4c: nodule with microcalcifications, irregular borders and taller than wide shape (greater in its anteroposterior diameter than in its transverse diameter).
Dr Ahmed Esawy
TI-RADS 4c: hypoechoic nodule of irregular margins with a taller than wide shape.
Dr Ahmed Esawy
TI-RADS 5: hypoechogenic nodule with microcalcifications and poorly defined margins, with perinodular tissue invasion (arrow). Taller than wide shape. Presence of a cervical lymph node suspicious for malignancy Dr Ahmed Esawy
TI-RADS 5: suspicious hypoechoic lymph node, with round shape and abnormal vascularity. Dr Ahmed Esawy
Thyroid Nodule : 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 Dr Ahmed Esawy
Thyroid Nodule : 3.5 cm, spongiform, isoechoic, circumscribed,
peripheral vascularity, wider than tall, no microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Spongiform, > 2 cm Biopsy (Recommendation C)
Society of Radiologists in
Ultrasound
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%)
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 Dr Ahmed Esawy
Thyroid Nodule 2.7 cm, predominantly solid, hypoechoic, circumscribed,
marked vascularity, wider than tall, no microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Mixed, hypoechoic, increased vascularity, >1.5
cm
Biopsy, Level B
Society of Radiologists in
Ultrasound
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%)
Image Reporting and
Characterization System by
Kwak et al. (2013)
Score 2 – hypoechoic N/A (Risk of malignancy
8.6%)
FNA of the nodule: Bethesda class 4 – suspicious for Hurtle cell neoplasm
Dr Ahmed Esawy
Thyroid Nodule : 2.5 cm, solid, hypoechoic, microlobulated
margin, vascular, wider than tall, no microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Solid, hypoechoic, > 1 cm Biopsy (Recommendation B)
Society of Radiologists in
Ultrasound
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%)
Image Reporting and
Characterization System by Kwak
et al. (2013)
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
Dr Ahmed Esawy
Thyroid Nodule : 2.2 cm, solid, hypoechoic, irregular margins,
vascular, taller than wide, with microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Solid, hypoechoic, > 1 cm Biopsy (Recommendation B)
Society of Radiologists in
Ultrasound
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%)
Image Reporting and
Characterization System by Kwak
et al. (2013)
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 Dr Ahmed Esawy
Thyroid Nodule : 1.7 cm solid, hypoechoic, irregular margins,
marked vascularity, wider then tall, and microcalcifications
Organization US Feature/TIRADS score Recommendations
American Thyroid Association Solid, hypoechoic >1 cm Biopsy, Level B
Society of Radiologists in
Ultrasound
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%)
Image Reporting and
Characterization System by
Kwak et al. (2013)
Score 9 (solid, markedly hypoechoic, irregular
margin, microcalcification)
Biopsy (Risk of malignancy
79%)
FNA of this nodule: Bethesda class 6 Malignancy (papillary thyroid carcinoma)
Dr Ahmed Esawy
Selected Benign and Malignant Thyroid Lesions Benign lesions
Benign follicular nodule Adenomatoid nodule Colloid nodule Follicular adenoma Hürthle cell adenoma Thyroiditis Chronic lymphocytic (Hashimoto) thyroiditis
Malignant lesions
Papillary carcinoma Follicular carcinoma Hürthle cell carcinoma Poorly differentiated carcinoma Anaplastic/undifferentiated carcinoma Medullary carcinoma Lymphoma Metastasis
Dr Ahmed Esawy
US Features of benign Thyroid Nodules Features suggesting benignity
Uniform halo around nodule Predominantly cystic Avascular Enlarged thyroid with multiple nodules
Dr Ahmed Esawy
Transverse US images of mostly cystic thyroid nodule with a mural component containing flow. (a) Gray-scale image shows predominantly cystic nodule (calipers) with small solid-appearing mural component (arrowheads). (b) Addition of color Doppler mode demonstrates flow within mural component (arrowheads), confirming that it is tissue and not debris. US-guided FNA can be directed into this area. The lesion was benign at cytologic examination.
Dr Ahmed Esawy
Sagittal image of predominantly solid nodule (arrowheads), which proved to be benign at cytologic examination
Dr Ahmed Esawy
Transverse image of mixed solid and cystic nodule (calipers), which proved to be benign at cytologic examination
Dr Ahmed Esawy
Sagittal image of predominantly cystic nodule (calipers), which proved to be benign at cytologic examination. (e) Sagittal image of cystic nodule (arrowheads). FNA of this presumed benign lesion was not performed because the nodule appears entirely cystic.
Dr Ahmed Esawy
Adenomatous nodule in a 66-year-old man with a low thyroid-stimulating hormone level of 0.1 mIU/mL. (a) Transverse US image shows a predominantly solid 2.4-cm nodule with well-circumscribed margins and a surrounding halo (benign US features). (b) Scintigraphic image obtained with 123I shows increased uptake in a hot nodule and relative photopenia of the adjacent normal thyroid tissue. The outline of the neck is not well visualized.
Dr Ahmed Esawy
Incidentally detected left-sided colloid nodule of the thyroid in a 74-year-old woman. (a) Axial T2-weighted MR image shows a well-circumscribed, hyperintense 2.2-cm nodule (arrow). Colliod nodule Dr Ahmed Esawy
Colloid nodule. Transverse US image shows a predominantly anechoic cystic lesion (*) with a thin wall, well-circumscribed margins, and mild posterior acoustic enhancement. Note the linear echogenic colloid crystals suspended within the fluid (arrow). These are all benign US features. Dr Ahmed Esawy
Chronic lymphocytic (Hashimoto) thyroiditis in a 53-year-old woman with a “swollen thyroid.” (a) Longitudinal duplex US image shows diffusely heterogeneous thyroid parenchyma with abnormal diffusely increased vascular flow.
Dr Ahmed Esawy
Follicular adenoma in a 36-year-old woman. Longitudinal color Doppler sonogram of the right lobe of the thyroid shows perinodular flow around a follicular adenoma.
Dr Ahmed Esawy
Large toxic follicular adenoma in a 45-yearold woman. (a) Transverse sonogram of the left lobe of the thyroid shows a 4.5-cm nodule (arrows) that was benign despite its size. (b) Coronal scintigram obtained with technetium 99m pertechnetate shows a hyperfunctioning adenoma (arrow).
Dr Ahmed Esawy
Follicular adenoma in a 30-year-old woman. Transverse sonogram of the left lobe of the thyroid shows a follicular adenoma with a hypoechoic halo (arrows).
Dr Ahmed Esawy
Benign thyroid nodule in a 51-year-old woman. Transverse sonogram of the right lobe of the thyroid shows a colloid nodule with a ring-down artifact (arrow), a finding indicative of inspissated colloid calcification
Dr Ahmed Esawy
US Features of malignant Thyroid Nodules
Features suspicious for malignancy Specific features
Microcalcifications Extension beyond thyroid margin Cervical lymph node metastasis Taller than wide in transverse plane Markedly hypoechoic
Less specific features
No halo around nodule (Per nodular thyroid parenchyma invasion) Ill-defined or irregular margin
Solid (Partially cystic nodule with eccentric location of the fluid portion and lobulation of the solid component
Increased central vascularity ( Intranodular vascularity)
Dr Ahmed Esawy
Hürthle cell neoplasm in a 53-year-old man with a palpable thyroid nodule at physical examination. (a) Transverse US image shows a predominantly hypoechoic 1.5-cm solid nodule (arrow) that meets the criteria for biopsy
Dr Ahmed Esawy
Papillary carcinoma in a 60-year-old woman with nontoxic multinodular goiter. (a) Longitudinal US image of the left lobe of the thyroid shows a 2.4-cm solid nodule in the lower pole with ill-defined margins and microcalcifications (arrow), both of which are suspicious US features. A shadowing macrocalcification is also noted (arrowhead). (b) Longitudinal US image of the right lobe shows three additional nodules: a 1.1-cm solid nodule (left), a 1.2-cm solid nodule (middle), and a 2.3-cm mixed cystic and solid nodule (right). In the right lobe, only the 2.3-cm nodule meets the US criteria for FNAB
Dr Ahmed Esawy
Poorly differentiated carcinoma in an 81-year-old man with a right-sided thyroid mass that was discovered at neck CT. (a) Transverse US image shows a predominantly hypoechoic 5.4-cm solid nodule with ill-defined margins (a suspicious US feature) and no normal adjacent thyroid parenchyma. Dr Ahmed Esawy
Medullary carcinoma in a 36-year-old woman with a right-sided thyroid nodule. (a) Transverse duplex US image shows a 2.6-cm solid nodule with an ill-defined lateral margin and extracapsular extension beyond the thyroid margin (arrow). The nodule has a taller-than-wide appearance and is markedly hypoechoic. All of these are suspicious US features.
Dr Ahmed Esawy
Primary thyroid lymphoma in a 54-year-old woman with long-standing goiter and a 1-month history of progressive neck swelling. (a) Longitudinal US image shows a diffusely enlarged and abnormally heterogeneous thyroid without normal intervening parenchyma. Note the infiltrative appearance and evidence of extracapsular extension (arrow), a suspicious US feature. (b) Axial CT image shows diffuse replacement of the thyroid parenchyma. Note the associated narrowing of the trachea and lateral displacement of the adjacent vascular structures. Mildly enlarged abnormal left cervical lymph nodes (*) are also evident
Dr Ahmed Esawy
Metastatic lung carcinoma in a 63-year-old man with known lung carcinoma in whom a new thyroid nodule was discovered at staging CT. Longitudinal duplex US image shows a mildly heterogeneous, hypoechoic 3-cm solid nodule with increased peripheral and central vascularity. Increased central vascularity is a suspicious US feature.
Dr Ahmed Esawy
Thyroid microcalcifications are psammoma bodies, which are 10–100-m round aminar crystalline calcific deposits . They are one of the most specific features of thyroid malignancy, with a specificity of 85.8%–95% (2,15–17) and a positive predictive value of 41.8%–94.2%
Papillary thyroid carcinoma in a 42-year-old man. (a) Photomicrograph (original magnification, 400; hematoxylin-eosin stain) shows a psammoma body (arrow), a round laminar crystalline calcification
Dr Ahmed Esawy
Medullary thyroid carcinoma in a 32-year-old man. (a) Transverse sonogram of the right lobe of the thyroid shows a large nodule with coarse calcification and posterior acoustic shadowing (arrows). (b) Axial computed tomographic (CT) image shows the nodule with an internal focus of coarse calcification (arrows).
Dr Ahmed Esawy
Anaplastic thyroid carcinoma in an 84-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows an advanced tumor with infiltrative posterior margins (arrows) and invasion of prevertebral muscle. (b) Axial contrast-enhanced CT image shows a large tumor that has invaded the prevertebral muscle (arrows).
Dr Ahmed Esawy
Infiltrative primary leiomyosarcoma of the thyroid in a 90-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a tumor (between calipers) with infiltration from the posterior tumor margin into the prevertebral space (arrows).
Dr Ahmed Esawy
Papillary carcinoma in an 87-year-old man. Transverse sonogram of the thyroid isthmus shows a poorly defined tumor with marked hypoechogenicity and irregular margins (arrows) and without a hypoechoic halo. Dr Ahmed Esawy
Renal cell carcinoma metastases to the thyroid in a 69-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows a round hypoechoic nodule (arrows) and an irregular-shaped hypoechoic nodule (arrowheads). (b) Color Doppler sonogram of the round nodule shows increased internal vascularity
Dr Ahmed Esawy
B cell lymphoma of the thyroid in a 73-yearold woman with Hashimoto thyroiditis. Transverse sonogram of the left lobe of the thyroid shows a large heterogeneous mass (between calipers) with marked hypoechogenicity when compared with the strap muscles (SM). A normal isthmus (arrow) also is visible. IJV internal jugular vein.
Marked hypoechogenicity is very suggestive of malignancy
Dr Ahmed Esawy
Sagittal image of solid nodule (arrowheads), which proved to be papillary carcinoma
Dr Ahmed Esawy
Role of color Doppler US. (a) Transverse gray-scale image of predominantly solid thyroid nodule (calipers). (b) Addition of color Doppler mode shows marked internal vascularity, indicating increased likelihood that nodule is malignant. This was a papillary carcinoma.
Dr Ahmed Esawy
US features that should arouse suspicion about lymph node metastases include a rounded bulging shape, increased size, replaced fatty hilum, irregular margins, heterogeneous echotexture, calcifications, cystic areas vascularity throughout the lymph node instead of normal central hilar vessels at Doppler imaging
A completely uniform halo around a nodule is highly suggestive of benignity, with a specificity of 95%
Dr Ahmed Esawy
(7) Papillary carcinoma and cystic lymph node metastasis in a 28-year-old woman. (a) Longitudinal sonogram of the right lobe of the thyroid shows an irregular hypoechoic tumor with microcalcifications. (b) Longitudinal sonogram of the right neck shows a cystic level 5 nodal metastasis with internal septation and foci of calcification (arrows). (c) Axial contrast-enhanced CT image shows the metastasis (arrow). Dr Ahmed Esawy
(8) Papillary carcinoma and vascular lymph node metastasis in a 27-year-old woman. (a) Transverse sonogram shows a tumor that has infiltrated the entire right lobe of the thyroid (arrows). (b) Transverse sonogram of the right neck shows a level 3 lymph node metastasis with increased vascularity (arrow). (c) Axial contrast-enhanced CT image shows a vascular lymph node with a targetlike appearance (arrow). Dr Ahmed Esawy
Papillary carcinoma and cystic lymph node metastasis in a 44-year-old woman with a multinodular thyroid. Transverse sonogram of the right lobe of the thyroid shows a hypoechoic carcinoma in the isthmus, with microcalcifications and absence of a halo (arrowheads). The right lobe of the thyroid is displaced anteriorly by a large, partially cystic, level 6 (paratracheal) nodal metastasis (arrows), which appears to be within the thyroid and which was mistaken for a benign thyroid nodule. Because several solid benign nodules were present, the initial diagnosis was benign multinodular thyroid. The cystic nodal metastasis was confirmed at surgery. CCA common carotid artery. Dr Ahmed Esawy
Pitfalls in the Diagnosis of Malignancy
Dr Ahmed Esawy
Cystic or Calcified Lymph Node Metastases
Medullary thyroid carcinoma and calcified nodal metastases in a 57-year-old man. (a) Transverse sonogram shows a lymph node metastasis with coarse calcifications (arrows) immediately inferior to the left lobe of the thyroid. The metastasis was mistaken for a benign calcified hyperplastic thyroid nodule. Several truly benign thyroid nodules also were found at US, and these findings led to an incorrect diagnosis of multinodular thyroid. CCA common carotid artery. (b) Sagittal sonogram obtained at follow-up US shows two other calcified lymph node metastases (arrows) on the left side, at level 2. (c) Coronal unenhanced CT image shows the calcified nodal metastases in both locations (arrows). Dr Ahmed Esawy
Cystic Variant of Papillary Carcinoma
Hu¨ rthle cell (follicular) carcinoma in a 60-year-old woman. (a) Transverse sonogram of the left lobe of the thyroid shows a partially cystic tumor with solid internal projections (arrows) and thick walls. (b) Color Doppler sonogram (shown in black and white) depicts increased vascularity in the solid parts of the tumor (arrow)
Dr Ahmed Esawy
Rare cystic papillary thyroid carcinoma in a 55-year-old woman. (a) Transverse sonogram of the right lobe of the thyroid shows a complex cystic lesion with thick walls and solid components (arrows). (b) Color Doppler sonogram shows vascularity in a small part of the lesion margin (arrow). (c) Axial contrastenhanced CT image shows the tumor (arrows) but does not clearly depict its complexity. A cystic component occurs in 13%–26% of all
thyroid malignancies Dr Ahmed Esawy
Diffusely Infiltrative Hypervascular Tumor
Diffuse follicular variant of papillary thyroid carcinoma in a 37-year-old woman with thyrotoxicosis mistaken for Graves disease. (a) Transverse sonogram of the left lobe of the thyroid shows a heterogeneously hypoechoic enlarged thyroid (arrows) with no residual normal thyroid tissue. (b) Color Doppler image shows diffuse increased parenchymal vascularity. (c) Transverse sonogram of the right neck shows a lymph node metastasis inferior to the right lobe of the thyroid (arrow) with coarse calcification. This finding aroused suspicion about the possible presence of a primary thyroid carcinoma. Histopathologic analysis of the surgical specimen showed replacement of the thyroid gland by a diffuse follicular variant of papillary thyroid carcinoma. CCA common carotid artery. Dr Ahmed Esawy
Abnormal cervical lymph nodes. (a) Sagittal US image of enlarged node (calipers) with central punctate echogenicities, consistent with microcalcifications, shows mass effect on internal jugular vein (V). Node was proved to be metastatic papillary carcinoma. (b) Sagittal US image of enlarged node (calipers) with cystic component. Node was proved to be metastatic papillary carcinoma.
Dr Ahmed Esawy
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:
Dr Ahmed Esawy
ATA nodule sonographic patterns and risk of malignancy Dr Ahmed Esawy
Recommendations for Thyroid Nodules 1 cm or Larger in Maximum Diameter US Feature Socity of radiologists in ultrasound consensus
—FNA is likely unnecessary in diffusively enlarged gland with multiple nodules of similar US appearance without intervening parenchyma. Presence of abnormal lymph nodes overrides US features of thyroid nodule(s) and should prompt US-guided FNA or biopsy of lymph node and/or ipsilateral nodule
Dr Ahmed Esawy
FNAB
Dr Ahmed Esawy
Dr Ahmed Esawy
US/Clinical Features Indication/Threshold for FNAB Solitary nodule Solid nodule with suspicious US features, particularly ≥1 cm microcalcifications Solid nodule without suspicious US features ≥1.5 cm Mixed cystic-solid nodule with suspicious US features ≥1.5 cm Mixed cystic-solid nodule without suspicious US features ≥2 cm Spongiform nodule ≥2 cm Simple cyst with none of the aforementioned characteristics FNAB not necessary Substantial growth (>50%) since previous US examination FNAB indicated Suspicious cervical lymph node FNAB lymph node with or without a nodule Multiple nodules Normal intervening parenchyma FNAB of up to four suspicious nodules, with selection based on criteria for a solitary nodule; if no suspicious nodule is present, biopsy of the largest nodule may be considered No normal intervening parenchyma FNAB not necessary Diffuse rapid enlargement of thyroid FNAB indicated to exclude anaplastic carcinoma, lymphoma, or metastasis Clinically high risk of thyroid cancer Threshold for FNAB is lower due to high risk of thyroid cancer (eg, threshold >0.5 cm for a suspicious solid nodule) History of radiation exposure in childhood or adolescence FDG-avid nodule at PET Age <15 y or >45 y, particularly in males First-degree relative with thyroid cancer or type 2 MEN Personal history of thyroid cancer at lobectomy Personal history of thyroid cancer–associated conditions (familial adenomatous polyposis, Carney complex, Cowden syndrome, or type 2 MEN)
Guidelines for FNAB Indications Based on US and Clinical Features
Dr Ahmed Esawy
Drawing illustrates FNAB technique, with parallel positioning of the needle relative to the US transducer and the thyroid
Dr Ahmed Esawy
Capillary technique for FNAB. (a) Photograph shows proper positioning of the biopsy needle, which is oriented parallel to the US transducer. Note that no syringe is attached to the 27-gauge biopsy needle (Movie 1 [online]). (b) Transverse US image demonstrates the hyperechoic needle along its length. The needle tip is positioned within the superficial portion of the hypoechoic left-sided thyroid nodule
Dr Ahmed Esawy
In general, for an FNAB to be considered diagnostic (adequate), a minimum of six groups of ten follicular cells must be present upon totaling all slides
If there are multiple suspicious nodules, up to four such nodules should be considered for FNAB
We suggest that core biopsy be performed in addition to FNAB for the sampling of nodules with a prior nondiagnostic or indeterminate FNAB
follicular adenoma and follicular carcinoma cannot usually be distinguished with FNAB alone and are reported as a follicular neoplasm . The histologic distinction between follicular adenoma and follicular carcinoma can be made only upon surgical excision, by assessing for the absence (adenoma) or presence (carcinoma) of capsular-vascular invasion.
Dr Ahmed Esawy
Aspiration technique for FNAB. (a) Photograph shows proper positioning of the biopsy needle, which is oriented perpendicular to the US transducer. Aspiration is achieved by means of gentle suction with a 10-mL syringe (Movie 3 [online]). (b) Transverse US image depicts the needle tip, which is identified as a hyperechoic focus (arrow) within the center of the nodule
Dr Ahmed Esawy
THYPES OF THYRIOD NODULES
Adenoma neoplastic Carcinoma Colloid nodule
Macro follicular
adenoma (simple
colloid)
Papillary (75 percent) Dominant nodule in a multinodular
goiter Follicular (10 percent)
Micro follicular
adenoma (fetal)
Medullary (5 to 10 percent) Other
Embryonal
adenoma
(trabecular)
Anaplastic (5 percent) Inflammatory thyroid disorders
Hürthle cell
adenoma
(oxyphilic,
oncocytic)
Other Subacute
thyroiditis
Thyroid
lymphoma 5
percent)
Chronic
lymphocytic
thyroiditis
Atypical adenoma Cyst Granulomatous
disease
Adenoma with
papillae
Simple cyst Developmental abnormalities
Signet-ring
adenoma
Cystic/solid tumors (hemorrhagic,
necrotic)
Dermoid
Rare unilateral lobe agenesis Dr Ahmed Esawy
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