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JeanTramalloniJFIMBarcelonaNov1st2014
20101970 1990 20001980
45YEARSTECHNICALANDPRACTICALEVOLUTIONS
Kim2002
analogicalBmode
7,5MHz
US-guidedcytology
RealTimemode
US:nodularinventoryCytologyif>10mm
(noscreeningbasedonUSpaPern)
Colormode Elastography
firstbiopsythesuspiciousnodules
Lobectomy+fresh-mountstudyforeverycold,solid(andpalpable)nodule
(butonly10%ofcancersand30%ofcontrolateral
recurrences)ANDEM1995
>12MHzCompond
ConsensusSFE,ETA,ATA,BTA
TI-RADS
digitalBmode
USconfidenYalandnondecisionmaking
A REVOLUTION AFTER A LONG-STANDING EVOLUTION
Harmonic
Lymphnodes
1995:ANDEM:«mostofthecancersfeaturesasanhypoechoicnodulebutthevastmajorityofhypoechoicnodulesiscomposedofbenignlesions.»
2002:Kim:4majorsuspicionsigns:-microcalcificaYons-irregularormicrolobulatedmargins-markedhypoechogenicity-tallerthanwide
2005:Frates:USpaPernsareassociatedwithcancerrisk.
2009:HorvathintroducesforthefirstYmetheacronymofTIRADS,breathBIRADStransposiYontothyroid(10groups):eachUSpaPernisassociatedtocancerrisk.
2011:GRussintroducesafrenchTI-RADSversionincludingonly6riskgroups
2013:GRusssimplifiedTI-RADSV2including5riskgroups
Do US can be predictive of malignancy or benignancy?
TI-RADSSYSTEM
TI-RADSSYSTEM=SCORE:evaluaYonandguidelinesgroups+VOCABULARY+STANDARDISEDREPORT
• AcronymofThyroidImaging-ReporYngAndDatabaseSystem
• TransposiYonofbreastBI-RADSsystemtothyroid• QuanYtaYvecancerriskstraYficaYontoolforthyroid
TI-RADSSCORE MEANING PROPORTIONOF
NODULESRISKOFMALIGNANCY
(%)
2 BENIGN 3% 0
3 MOSTLYBENIGN 60%0.25
(1/400)
4A LOWRISKOFMALIGNANCY 33% 6
4B HIGHRISKOFMALIGNANCY 4,5% 69
5 ALMOSTSURELYMALIGNANT 0,5% 100
CANCERRISKSTRATIFICATION–TI-RADSSCOREV2PROSPECTIVESTUDY–4550nodules-USvsCYTOLOGY(2013)
TI-RADSSCORE MEANING NUMBEROF
NODULESRISKOFMALIGNANCY
(%)
2 BENIGN 3% 0
3 MOSTLYBENIGN 60%0.25
(1/400)
4A LOWRISKOFMALIGNANCY
4639(48%) 6
4B HIGHRISKOFMALIGNANCY
516(5%) 69
5 ALMOSTSURELYMALIGNANT
33(0,3%) 100
63%
CANCERRISKSTRATIFICATION–TI-RADSSCOREV2
TI-RADSSCORE MEANING NUMBEROF
NODULESRISKOFMALIGNANCY
(%)
2 BENIGN 259(3%) 0
3 MOSTLYBENIGN 4187(43%)0.25
(1/400)
4A FAIBLERISQUEDEMALIGNITÉ
4639(48%) 6
4B HIGHRISKOFMALIGNANCY 4,5% 69
5 ALMOSTSURELYMALIGNANT 0,5% 100
CANCERRISKSTRATIFICATION–TI-RADSSCOREV2
5%
TI-RADSSCORE MEANING NUMBEROF
NODULESRISKOFMALIGNANCY
(%)
2 BENIGN 259(3%) 0
3 MOSTLYBENIGN 4187(43%)0.25
(1/400)
4A LOWRISKOFMALIGNANCY 33% 6
4B HIGHRISKOFMALIGNANCY
516(5%) 69
5 ALMOSTSURELYMALIGNANT
33(0,3%) 100
CANCERRISKSTRATIFICATION–TI-RADSSCOREV2
0%
10%
20%
30%
40%
50%
60%
70%
PosiLvePredicLveValueofUSRussetal.JRadiol2011
0%
10%
20%
30%
40%
50%
60%
70%
PosiLvePredicLveValueofUSRussetal.JRadiol2011
75%
80%
85%
90%
95%
100%
NegaLvePredicLveValueofUSRussetal.JRadiol2011
75%
80%
85%
90%
95%
100%
NegaLvePredicLveValueofUSRussetal.JRadiol2011
TI-RADS score needs precise semiology
Tostudyanodule,trainyoureyes
watch,ingoodorder:shapeborderscontent
Todescribeit,useglossarywords
SHAPE
longitudinal transverse
dysharmonious
tallerthanwidetallerthanhightA/T>1
A
T
harmonious
MARGINS
welldefined
lobulated
blurred
CONTENT:ECHOGRAPHICSTRUCTURE
liquid
solid
mixed
CONTENT:ECHOGENICITYhypoechoic
mildly markedly
hypoechoic
isoechoic
hyperechoic
mildly markedly
CONTENT:ECHOGENICITY
colloidalgranulaYons
CONTENT:HYPERECHOICDOTSINCYSTICNODULES
comettailarYfact
CONTENT:HYPERECHOICDOTSINSOLIDNODULES
colloidalgranulaYons
microcalcificaYons
CONTENT:STIFFNESSATELASTOGRAPHY
PROBABLYBEGNIN
SUSPICIOUS
RAGOCLASSIFICATIONRAGOT.etal.JCEM2010
Strainelastography
CONTENT:STIFFNESSATELASTOGRAPHY
Strainelastography
CONTENT:STIFFNESSATELASTOGRAPHY
Sharewaveelastography
NODULARDESCRIPTIONGLOSSARY
SHAPE:regular/irregular(harmonious/dysharmonious)
MARGINS:well-defined/lobulated/bluredCONTENT:
-Echographicstructure:solid/mixed/liquid
-Echogenicity:hyperechoic/isoechoic markedhypoechogenicity/moderate homogeneous/heterogeneous
- hyperechoicdots:colloidalgranulaYons microcalcificaYons
- sYffnessatelastography- vascularizaYon:none/peripheral/mixed/central
VASCULARIZATIONPATERNISNOTATI-RADSITEM
mainlyperinodular
mixed,periandintranodular
mainlyintranodular
in practice, how to score ?
1)firstofalllookforanysignofsuspicion
-dysharmoniousshape-lobulatedorbluredmargins-microcalcificaYons-markedhypoechogenicity-sYffnessatelastography
-1or2signsofsuspicion-nosuspiciouslymphnode
SCORE4BHIGHLYSUSPECT
Riskofcancer:69%
-3to5signsofsuspicionand/or
-suspiciouslymphnode
SCORE5MALIGNANT
Riskofcancer:100%
5suspicionsigns
Whatisasuspiciouslymphnode?
AtleastoneofthefollowingcharacterisLcs-microcalcificaYons-parYallycysYcappearance-peripheralordiffuselyincreasedvascularizaYon-hyperechoicthyroidlikelymphnode
ETAguidelines2013:EurThyrJournal2013;2:147-159
nosuspicionsign
lookatechogenicity
(slightly)hypoechogenic
isoechogenichyperechogenic
4A 32
slightly
hypoechogenic
SCORE4A
SLIGHTLYSUSPICIOUS
riskofcancer:6%
BENIGNPATTERNS
VERYPROBABLYBENIGN
-nosuspicionsign-Isoechoicouhyperechoic
SCORE3Riskofcancer:0,25%
BENIGNPATTERNS
ALWAYSBENIGN-cysYcaspect-spongiformnodule-“Whiteknight”-singlemacrocalcificaYon-nodularhyperplasia
SCORE2Riskofcancer:0%
To make a long story short ...
SUSPICIOUS
-dysharmoniousshape-lobulatedorbluredmargins-microcalcificaYons-markedhypoechogenicity-sYffatelastography
-3to5signsand/or
-metastaYclymphnode
SCORE5
-1or2signs-nometastaYclymphnode
SCORE4B
-nomajorsuspicioussign-slightlyhypoechogenic
SCORE4A
BENIGNASPECTS
MOSTLYBENIGN
-nosuspicioussign-isoechoicorhyperechoic
SCORE3
ALWAYSBENIGN-cysYcaspect-spongiformnodule
-whiteknights-singlemacrocalcificaYon-nodularhyperplasia
SCORE2
- allnodulessightlyorstronglysuspicious(4A,4Band5)- allnoduleswhichincreaseinasignificantway
95%ofpapillarycarcinomas100%ofmedullarycarcinomas86%offollicularycarcinomas
• TaeHJetal.,Thyroid2007;17(5):461.DiagnosYcvalueofultrasonographytodisYnguishbetweenbenignandmalignantlesionsinthemanagementofthyroidnodules.• ItoYetal.,Thyroid2007;17,1269-1276UltrasonographicevaluaYonofthyroidnodulesin900paYents:comparisonamongultrasonographic,cytologicalandhistologicalfindings.• Horvathetal..JCEM,may2009,90(5),1748-51AnultrasonogramreporYngsystemforthyroidnodulesstraYfyingcancerriskforclinicalmanagement.• Parketal..Thyroid2009,19(11),257-64AproposalforathyroidimagingreporYnganddatasystemforultrasoundfeaturesofthyroidcarcinoma.• Kwaketal.,Radiology2011;260;892-99ThyroidImagingReporYngandDataSystemforUSfeaturesofnodules.AstepinestablishingbePerstraYficaYonofcancerrisk.• KwakJYetal.,KoreanJRadiol2013;14(1):110-117ImagereporYngandcharacterizaYonsystemforultrasounffeuturesofthyroidnodules:mulYcentrickoreanretrospecYvestudy• Russetal.JRadiol2011;92;701-13LesystèmeTI-RADSenéchographiethyroïdienne.• Russetal.EurJEndocrinol2013,168(5);649-55ProspecYveevaluaYonofthyroidimagingreporYnganddatasystemon4550noduleswithandwithoutelastography.
REFERENCES
• ETAguidelines2013:EurThyrJournal2013;2:147-159
THANK YOU FOR YOUR ATTENTION
