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ACR TI-RADS: Pitfalls, Solutions,
and Future Directions
Rafel R. Tappouni, MD
Jason N. Itri, MD, PhD
Teresa S. McQueen, MD
Neeraj Lalwani, MD
Jao J. Ou, MD, PhD
Abbreviations: ACR = American College of
Radiology, ATA = American Thyroid Associa-
tion, BI-RADS = Breast Imaging Reporting and
Data System, FNAB = fine-needle aspiration bi-
opsy, LI-RADS = Liver Imaging Reporting and
Data System, TI-RADS = Thyroid Imaging Re-
porting and Data System, TR = TI-RADS
RadioGraphics 2019; 39:0000–0000
https://doi.org/10.1148/rg.2019190026
Content Codes:
From the Department of Radiology, Wake For-
est Baptist Medical Center, 1 Medical Center
Blvd, Winston-Salem, NC 27157. Presented as
an education exhibit at the 2018 RSNA Annual
Meeting. Received February 16, 2019; revision
requested May 9 and received June 7; accepted
July 29. For this journal-based SA-CME ac-
tivity, the authors R.R.T. and J.N.I. have pro-
vided disclosures (see end of article); all other
authors, the editor, and the reviewers have
disclosed no relevant relationships. Address
correspondence to R.R.T. (e-mail: rtappoun@
wakehealth.edu).
See discussion on this article by Hoang (pp
13–15).
©
RSNA, 2019
SA-CME Learning Objectives
After completing this journal-based SA-CME
activity, participants will be able to:
■■Discuss thyroid cancer incidence and
implications of overdiagnosis.
■■Compare thyroid nodule risk stratifica-
tion systems with an emphasis on ACR
TI-RADS.
■■Recognize potential pitfalls and chal-
lenges related to TI-RADS implementa-
tion and describe potential solutions.
See rsna.org/learning-center-rg.
1
Neurologic/Head and Neck Imaging
The high prevalence of thyroid nodules combined with the gener-
ally indolent growth of thyroid cancer present a challenge for op-
timal patient care. Risk classification models based on US features
have been created by multiple professional societies, including
the American College of Radiology (ACR), which published the
Thyroid Imaging Reporting and Data System (TI-RADS) in 2017.
ACR TI-RADS uses a standardized lexicon for assessment of thy-
roid nodules to generate a numeric scoring of features, designate
categories of relative probability of benignity or malignancy, and
provide management recommendations, with the aim of reducing
unnecessary biopsies and excessive surveillance. Adopting ACR
TI-RADS may require practice-level changes involving image ac-
quisition and workflow, interpretation, and reporting. Significant
resources should be devoted to educating sonographers and radi-
ologists to accurately recognize features that contribute to the scor-
ing of a nodule. Following a system that uses approved terminology
generates reproducible and relevant reports while providing clar-
ity of language and preventing misinterpretation. Comprehensive
documentation facilitates quality improvement efforts. It also cre-
ates opportunities for outcome data and other performance metrics
to be integrated with research. The authors review ACR TI-RADS,
describe challenges and potential solutions related to its imple-
mentation based on their experiences, and highlight possible future
directions in its evolution.
©
RSNA, 2019 • radiographics.rsna.org
Introduction
Thyroid nodules are common in adults. They are identified inci-
dentally in 20%–68% of patients at high-resolution US, in 25% at
contrast-enhanced CT, and in 16%–18% at MRI (1–3). The female-
to-male ratio is around 4:1, and the prevalence increases with age.
Approximately half of women over 70 years of age are found to have
a nodule (4). Improvements in imaging technologies and increased
use of imaging have led to a significant increase in the rates of
nodule detection, resulting in more fine-needle aspiration biopsies
(FNABs) and a higher reported incidence of thyroid cancer (1,5).
The rise in thyroid cancer incidence is unevenly distributed through-
out the world. From 1993 to 1997, South Korea’s thyroid cancer
screening program demonstrated an incidence rate of 12.2 per 100 000
people. This number rose to 60.1 by 2013 (6,7). In the United States
between 1975 and 2009, the rate of thyroid cancer incidence nearly
tripled, as did the rate of thyroidectomy. The reported overall mortality
due to thyroid malignancy showed no significant change (5).
The increase in diagnosis without apparent impact on survival
is primarily attributable to the relatively nonaggressive growth of
papillary carcinoma, which is the most common subtype of thyroid
cancer (5). Most thyroid cancers are subclinical (8). This is validated
2 November-December 2019 radiographics.rsna.org
Teaching Points
■■ Improvements in imaging technologies and increased use of
imaging have led to a significant increase in the rates of nod-
ule detection, resulting in more fine-needle aspiration biopsies
(FNABs) and a higher reported incidence of thyroid cancer.
■■ The Thyroid Imaging Reporting and Data System (TI-RADS)
of the American College of Radiology (ACR) was designed in
2017 with the intent to decrease biopsies of benign nodules
and improve overall diagnostic accuracy. This system is found-
ed on a previously published lexicon and constructed so that
all thyroid nodules can be classified on the basis of TI-RADS
(TR) categories that stratify risk.
■■ Thyroid nodules smaller than 5 mm should generally be ig-
nored. In nodules larger than 5 mm, still images and cine clips
should be obtained in transverse and sagittal planes, depend-
ing on the relevant US features. If multiple nodules are found,
then the four nodules that are the largest or most suspicious
should undergo imaging and be cataloged.
■■ The ACR recommends that FNAB should be limited to a maxi-
mum of two nodules and any suspicious lymphadenopathy.
If multiple nodules meet the criteria for FNAB, then the two
with the highest point totals (and then largest size as a tie-
breaker) are the most appropriate to biopsy.
■■ There are several opportunities to introduce quality measures
in thyroid imaging. A standard lexicon and structured report-
ing system are available to convey relative risk of malignancy,
and radiologists are involved in the performance of US-guided
biopsies.
by the rate of thyroid nodules discovered during
autopsy, which is relatively high at 6%–11% (9).
Therefore, it would appear that overdiagnosis is a
major component of these decades-long increases
in thyroid cancer (5–7).
Overtreatment of indolent papillary thyroid
cancer is a related concern. In several active
surveillance trials in Japan, small papillary thyroid
cancers were managed successfully with surveil-
lance rather than thyroidectomy (10,11). A cost
analysis performed by the Japanese Health Care
Insurance System found that the 10-year total cost
of immediate surgery was 4.1 times more expensive
than active surveillance (12). In the United States,
the estimated total cost of thyroid cancer treatment
from 2010 to 2019 was $21.6 billion, of which
$4.5 billion can be attributed to extra cost from
increased incidence (13). This suggests that pre-
venting overdiagnosis and overtreatment of thyroid
cancer may save money, provided that a reasonable
system for risk stratification can be established.
Among various systems that have been pub-
lished and studied, the Thyroid Imaging Reporting
and Data System (TI-RADS) of the American
College of Radiology (ACR) was designed in 2017
with the intent to decrease biopsies of benign nod-
ules and improve overall diagnostic accuracy (14).
This system is founded on a previously published
lexicon (15) and constructed so that all thyroid
nodules can be classified on the basis of TI-RADS
(TR) categories that stratify risk. Unique to this
system are specific FNAB and sonographic follow-
up recommendations based on a combination of
TR category and nodule size.
We highlight some pitfalls, challenges, and
potential solutions related to implementation
of ACR TI-RADS and provide an algorithmic
approach based on the system. We also present
opportunities for quality improvement and pos-
sible future directions.
Thyroid Nodule Risk
Classification Systems
There are several thyroid nodule risk classifica-
tion systems focused on US characterization.
Some systems use simple pattern recognition,
while others rely on the presence or absence of
a specific finding. Rather than quantify imaging
findings, some complex systems use weighted
risk for them and have multiple risk categories
(16). Regardless of the strategy, a combination
of nodule morphology and size metrics is used.
The American Thyroid Association (ATA)
system includes an atlas of sonographic fea-
tures that can be used to categorize nodules
with one of six descriptive patterns (17). In the
Korean Society of Thyroid Radiology TIRADS
(K-TIRADS), sonographic features are used to
determine the need for biopsy on the basis of
risk stratification into four total categories (18).
The purpose of the European Thyroid Associa-
tion TIRADS (EU-TIRADS) is to help detect
cancer with high sensitivity while maintaining
high negative predictive value. It was modeled
after the 2009 Breast Imaging Reporting and
Data System (BI-RADS) (19,20) and was modi-
fied and validated with a prospective study (21).
These systems (as well as ACR TI-RADS) are
summarized in Table 1.
Other recommendations include the Kwak
TI-RADS (22); the Society of Radiologists in
Ultrasound guidelines published in 2005 (23);
the American Association of Clinical Endo-
crinologists, American College of Endocrinol-
ogy, and Associazione Medici Endocrinologi
guidelines updated in 2010 and 2018 (24); and
the National Comprehensive Cancer Network
guidelines published in 2014 (25).
Overview of ACR TI-RADS
ACR TI-RADS is designed to decrease biopsies
of benign nodules and improve diagnostic ac-
curacy (14). This system was based on the US
features defined in the ACR’s previously pub-
lished lexicon (15) and constructed so that all
thyroid nodules can be classified with TI-RADS
categories, as follows: TR1 = benign, TR2 = not
suspicious for malignancy, TR3 = mildly suspi-
RG  •  Volume 39  Number 7 Tappouni et al  3

Table 1: Thyroid Nodule Risk Classification Systems

System Society Year Description Highlights

ATA American 2006 Atlas of sonographic features Nodule size plays an important
Thyroid As- Updates in 2009 for classification of nodules role in determining whether
sociation and 2015 Six descriptive patterns biopsy is recommended
K- Korean Society
2011 Sonographic features deter- Separate risk stratification of
TIRADS of Thyroid Update in 2016 mine need for biopsy on the cervical lymph nodes for
Radiology basis of risk stratification nodal metastasis
Four categories from low to
high suspicion
EU- European 2017 Nodule classification modeled Designed to have high sensitiv-
TIRADS Thyroid As- after BI-RADS ity while maintaining high
sociation Five categories from normal to negative predictive value
high risk
ACR TI- American 2017 Founded on published lexicon Specific FNAB and sonograph-
RADS College of Five categories from benign to ic follow-up recommenda-
Radiology highly suspicious tions based on a combination
of category and nodule size

Table 2: TI-RADS Scoring of Nodule Characteristics

Nodule
Characteristic US Features with Point Values
Composition Cystic = 0, spongiform = 0, mixed solid-cystic = 1, solid = 2, indeterminate = 2
Echogenicity Anechoic = 0, isoechoic = 1, hyperechoic = 1, indeterminate = 1, hypoechoic = 2, very hy-
poechoic = 3
Shape Wider than tall = 0, taller than wide = 3
Margin Smooth = 0, ill defined = 0, irregular = 2, lobulated = 2, extrathyroidal extension = 3
Echogenic foci None = 0, comet-tail artifact = 0, macrocalcifications = 1, peripheral or rim = 2, punctate = 3
Note.—Points are totaled by adding single selections from the composition, echogenicity, shape, and margin
categories to selections from the echogenic foci category, which allows multiple selections.

cious, TR4 = moderately suspicious, and TR5
= highly suspicious. On the basis of review of
the available literature, these categories were
established by the TI-RADS Committee. The
approximate risk for nodule malignancy is esti-
mated at 2% or less for TR1 and TR2, 2.1%–5%
for TR3, 5.1%–20% for TR4, and greater than
20% for TR5.
Assessing a nodule with TI-RADS involves
a comprehensive evaluation of its composition,
echogenicity, shape, margin, and echogenic
foci. Points are assigned to each US feature,
with higher values indicating greater degrees of
suspicion (Table 2). The total score of a nodule
is used to assign its TR category. In conjunction
with nodule size, the TR category helps deter-
mine recommendations for FNAB and follow-
up (Table 3). The method of scoring echogenic
foci and calcifications is unique to TI-RADS, in
that the points attributed to these features are
additive and given more weight than in other
systems.
Specific sonographic follow-up recommenda-
tions are based on a combination of TR category
and nodule size. Unlike the ATA system, ACR
TI-RADS eliminates a recommendation for
FNAB of nodules with certain features, as they
are highly likely to be benign. Overall, TI-RADS
has a higher size threshold for recommending
biopsy compared with other systems. This is
based on the rationale that most thyroid can-
cers are papillary cancers. Localized papillary
cancers smaller than 1 cm, also referred to as
papillary microcarcinoma, typically have negli-
gible clinical significance.
ACR TI-RADS has been validated by mul-
tiple studies (26–29). In a study of 2847 patients
with biopsy results proven by using pathologic
analysis, ACR TI-RADS classification was
98.8% specific for diagnosing benign nodules
at the cost of missing a small number of papil-
lary cancers in TR2 and TR3 nodules that were
smaller than 2.5 cm (30). In a study comparing
seven society guidelines, ACR TI-RADS had
4 November-December 2019 radiographics.rsna.org

Table 3: TI-RADS Scoring with Management Recommendations Based on Cumulative Score

TI-RADS Category Point Score Definition Management Recommendations

TR1 0 Benign No FNAB
TR2 2 Not suspicious No FNAB
TR3 3 Mildly suspicious FNAB ≥2.5-cm nodule
Follow up ≥1.5-cm nodule at 1, 3, and 5 y
TR4 4–6 Moderately suspicious FNAB ≥1.5-cm nodule
Follow up ≥1-cm nodule at 1, 2, 3, and 5 y
TR5 >6 Highly suspicious FNAB ≥1-cm nodule
Follow up ≥0.5 cm nodule annually until 5 y

Table 4: TI-RADS Challenges, Pitfalls, and Solutions

Category Challenges and Pitfalls Solutions

Imaging and Image acquisition: still vs cine
workflow Measuring: dimensions and number of
nodules
Structured Reporting format: basic vs advanced
reporting How to discern what to report
Multiple low-risk similar-appearing lesions
Perception gap: wording for TR4 or TR5
nodules <1 cm
Interpretation and Consistently characterize spongiform nodules
interobserver One vs two nodules: single conglomerate vs
variability multiple adjacent nodules
Punctate foci vs calcification in wall vs
comet-tail artifact
Ill-defined vs lobulated nodules
Background calibration of atrophic or het-
erogeneous nodules
Solid component vs debris in cyst
Implementation, Radiology model vs endocrinology model
quality im- Radiologic-pathologic correlation and pa-
provement, and tient tracking
future directions
Still images and cine clips of nodule
Measure three dimensions
Pick list–driven advanced structured report
Limit to maximum of four nodules
Multiple similar lesions: characterize the largest
Modify wording for TR4 or TR5 nodules <1 cm
Technologist education
Technique optimization
Dedicated cine clip of area
Peer learning
Double reading
Unify models among radiologists in entire
health system
Align with endocrinology model
FNAB recommendation and results tracking

the lowest rate of unnecessary thyroid nodule
FNAB at 25.3% (31).
Challenges, Pitfalls, and Solutions
Implementing new departmental or institutional
guidelines for assessment of a specific condi-
tion or organ system presents many challenges.
Practice-wide adoption of ACR TI-RADS can
present issues related to education, workflow, and
adherence to interpretation and reporting stan-
dards. We highlight several potential pitfalls and
challenges related to ACR TI-RADS with some
proposed solutions (Table 4).
Imaging, Workflow,
and Structured Reporting
When managing multiple sites, establishing a uni-
fied sonographer protocol is an essential first step
to achieve consistency of service.
First, still images are obtained in the trans-
verse and sagittal orientations. Next, US cine
clips of each lobe and the isthmus are obtained in
the transverse and sagittal planes.
Thyroid nodules smaller than 5 mm should
generally be ignored. In nodules larger than
5 mm, still images and cine clips should be ob-
tained in transverse and sagittal planes, depend-
ing on the relevant US features (Table 2). If mul-
tiple nodules are found, then the four nodules
that are the largest or most suspicious should
undergo imaging and be cataloged. Each nodule
is measured in anterior-posterior, transverse, and
craniocaudal dimensions.
Before starting the program, it is crucial to edu-
cate and train sonographers to recognize relevant
TI-RADS US features. It is also important to de-
velop a worksheet or equivalent annotation system
to assist the sonographer in documenting nodules
RG  •  Volume 39  Number 7 Tappouni et al  5
and other information that should be brought to
the radiologist’s attention. An illustration of the
thyroid gland could be used to mark the loca-
tion of a nodule, with adjacent spaces in which
to record measurements and TI-RADS–specific
features (Fig 1). Associated imaging findings such
as lymph nodes can be similarly illustrated.
Structured reporting has been shown to in-
crease report homogeneity and language unifor-
mity, standardize conclusions and recommenda-
tions, and lead to better communication between
radiologists and clinicians (32). Three levels of
structured reporting have been described. The
first is use of headings such as “Indications,”
“Comparison,” “Findings,” and “Impression.”
The second level adds organ systems as subhead-
ings. This is also known as itemized reporting.
The third level adds standardized terminology
and language (33,34). TI-RADS reports are best
suited for the third level, as standardized terms
are available to describe thyroid nodules.
A TI-RADS–specific structured report can be
designed by using dictation software that can cre-
ate templates with customizable fields. This enables
input of various types of standardized text and
numeric values. Features such as pick lists allow
selection of designated options in a field, which
improves adherence to terminology. On the basis
of ACR recommendations, default components
for such a report include a general assessment of
Figure 1.  Sample portion of a sonogra-
pher worksheet. An example annotation
of a nodule in the left upper thyroid lobe
is included. TI-RADS recommends that
no more than four nodules be indexed,
so there are four available positions in
which to document nodules.
Figure 2.  Sample template built by us-
ing PowerScribe 360 Reporting (Nuance
Communications; Burlington, Mass). This
structured reporting scheme features pick
lists, which allow toggling between the
component fields and their associated op-
tions. When paired with the sonographer
worksheet in Figure 1, a synoptic report
of the nodule characteristics is created.
the thyroid gland, a comprehensive description
of up to four nodules to index their size, location,
core US features, numeric score and TI-RADS
category, any change from a prior examination (if
applicable), and a final recommendation (Fig 2).
Information Included in the Report
Radiologists are faced with several challenges when
generating a meaningful structured report of a
thyroid US examination, especially when there are
several nodules. When multiple nodules are pres-
ent, the sonographer should identify the four most
concerning nodules and measure them. Cine clips
of the entire thyroid gland should be obtained to
demonstrate the nodules. The radiologist should
also identify the four most concerning nodules and
describe them using the standard lexicon.
Careful comparison with any prior images helps
determine if there has been threshold growth,
which is defined as enlargement by 20% and 2
mm in two dimensions or a 50% increase in the
volume of the nodule. If there is evidence that the
TR category has increased but the nodule still
does not warrant biopsy because of size criteria,
then follow-up in 1 year is needed, and the prior
surveillance recommendations are superseded.
A major component of TI-RADS is the detailed
lexicon that provides definitions for US features.
Various descriptive terms that were once com-
monly used to describe imaging features are no
6 November-December 2019 radiographics.rsna.org
Figure 3.  Multiple spongiform nodules in the same patient. US images show multiple similar-appearing low-risk nodules. Only the
largest one needs to be characterized in the structured report.
longer in use, since they do not serve a specific
purpose in a structured characterization. Examples
of these terms include “white knight,” “giraffe
hide,” and “halo,” which are not used in TI-RADS
because of the inconsistency of pattern percep-
tion and debatable correlation with risk of disease.
In addition, the term “dominant,” while seeming
intuitive, is discouraged because of the relative
unimportance of size in assessing a nodule.
For clarity of reporting, we recommend that
multiple nodules of identical appearance and
point score can be grouped together, thereby
requiring that only the largest nodule be indexed
(Fig 3). This is especially true for nodules with
relatively low suspicion, as there is little to no
reason for repetitive documentation of benign-
appearing nodules.
The description of TI-RADS categories must
be worded carefully, particularly if FNAB is not
recommended. This eliminates confusion for the
clinician and avoids provoking anxiety in a pa-
tient who may be attempting to parse the details
of a report. For example, a TR4 nodule smaller
than 1 cm can be labeled as “moderately suspi-
cious” but may not require action. However, this
seeming discordance in language may not make
sense to a layperson or even to a provider. It may
be best for radiologists to use their discretion in
these situations (Fig 4). We have removed most
of these unnecessarily alarming phrases from our
structured reports.
The ACR recommends that FNAB should be
limited to a maximum of two nodules and any
suspicious lymphadenopathy (Fig 5). If multiple
nodules meet the criteria for FNAB, then the two
with the highest point totals (and then largest
size as a tiebreaker) are the most appropriate to
biopsy. Common reporting challenges and pro-
posed solutions are provided in Table 5.
Interpretation and Interobserver
Variability
Accurate interpretation of thyroid nodule features
is an essential component of any classification
Figure 4.  Moderately suspicious nodule. US
image shows a solid hypoechoic thyroid nodule
smaller than 1 cm and designated as a TR4 nod-
ule. The recommendations and wording used to
report such nodules are at the discretion of the
interpreting radiologist.
system. Although TI-RADS parameters allow only
the four most suspicious nodules to be indexed,
a thyroid gland with many nodules could still be
tedious to evaluate.
We propose an algorithmic approach that can
help stratify nodules for indexing (Fig 6). A few key
features are used to measure the level of suspicion
before proceeding to a full assessment. First, com-
position is assessed. Spongiform and cystic nodules
are benign and do not require action, so these
features would take the lowest priority in reporting.
If the nodule is neither spongiform nor cystic, then
the presence and appearance of peripheral calcifica-
tions are assessed, as these are suspicious features.
Any applicable features from the echogenic foci
choices are included and added to the total score.
Peripherally calcified nodules can be described
with two parameters. The internal architecture
may be obscured by shadowing, making the
composition and echogenicity indeterminate.
Also, a nodule may have an irregular or lobulated
margin characterized by a pattern of interrupted
peripheral calcification. In both cases, more points
are assigned so that the category of the nodule
increases to TR4 or TR5.
RG  •  Volume 39  Number 7 Tappouni et al  7
Figure 5.  Three mildly to moderately suspicious thyroid nodules in the same patient. (a) US image shows a TR4 nodule with macro-
calcification in the isthmus. (b) US image demonstrates a TR3 nodule measuring 2.6 cm. (c) US image shows a TR3 nodule measur-
ing 3.1 cm. All three nodules meet FNAB criteria, but biopsy should be recommended only for the two largest and most suspicious
nodules, which are the nodules in a and c in this case.
Table 5: Reporting Challenges and Proposed Solutions
Reporting Challenge
Too many nodules to report
Multiple nodules of same TI-RADS category or
multiple low-risk nodules
Multiple high-risk nodules
TR4 nodule <1 cm
Thyroid nodule discovered at carotid US
Inconsistent language
If the nodule does not have peripheral calci-
fication or cystic or spongiform morphology, a
full feature assessment of the nodule should be
performed.
By following this algorithmic approach, the
radiologist can quickly differentiate suspicious
from benign nodules and focus effort on nodules
that must be indexed.
Radiologist agreement for nodule features
ranges from fair to moderate (35–37). A spongi-
form nodule is defined as having interleaved cys-
tic spaces in more than 50% of the nodule. This
type of nodule can be challenging to interpret
(Fig 7) because of the specificity of the lexicon
definition.
Other features can present problems during
image interpretation. It is sometimes difficult to
differentiate punctate echogenic foci that represent
microcalcifications from the comet-tail artifact that
indicates inspissated colloid (Fig 8). It is debated
whether to add points for echogenicities along the
walls of cystic spaces. Also, it can be troublesome
to obtain an accurate measurement of a nodule in
a patient with a background multinodular gland or
a significantly heterogeneous gland (Fig 9).
Interpretation could be affected by operator
dependence. Sonographer inexperience and poor
Solution
Catalog a maximum of four nodules ranked by point total
Index and characterize the largest
Recommend biopsy for up to two nodules
Radiologist discretion to not require follow-up
Recommend dedicated thyroid US
Computerized synoptic reporting with options limited to TI-
RADS official lexicon
technique could depict imaging features in an
inaccurate or misleading fashion. It is mandatory
that all personnel be taught the TI-RADS lexicon
and trained how to perform all relevant imaging
examinations, including how to acquire cine clips.
Inconsistency in reporting imaging features can
undermine the scoring system.
Fortunately, agreement on the overall TI-
RADS category is generally more consistent
across readers than agreement on individual
features, and agreement for recommendation
to pursue biopsy is even higher (35,37). This is
a strength of TI-RADS, as maintaining reason-
able recommendations for treatment is an im-
portant factor from the perspective of patient-
centered care.
To reduce interreader variability, radiologists
should be aware of their own risk preference,
conduct regular peer learning meetings to discuss
discrepant cases, and obtain second opinion con-
sultations when there is uncertainty.
Implementation and Quality Measures
There are several opportunities to introduce
quality measures in thyroid imaging. A standard
lexicon and structured reporting system are avail-
able to convey relative risk of malignancy, and
8 November-December 2019 radiographics.rsna.org

Figure 6.  Flowchart shows an algorithmic approach to interpreting and classifying a thyroid nodule by using ACR TI-RADS features.
While all components should be reported as required, useful checkpoints include evaluation of composition and peripheral calcifica-
tion. A nodule with these characteristics may be placed immediately into higher-suspicion categories. This is an efficient way to stratify
indexed nodules.

Figure 7.  Challenges of evaluation of spongiform nodules. (a) US image shows a smaller
superficial nodule with characteristic tiny spaces and a large comet-tail artifact caused by col-
loid content. The larger nodule also has spongiform imaging findings in its upper portion, but
since this constitutes less than 50% of its composition, it is considered to be solid. (b) US image
shows a spongiform nodule in a different patient. This nodule demonstrates both stereotypical
features with at least 50% involvement of the nodule.

radiologists are involved in the performance of
US-guided biopsies.
Currently, there are two existing national quality
measures that can be applied to thyroid nodules.
Merit-based Incentive Payment System (MIPS)
measure 406 (“Appropriate Follow-up Imaging for
Incidental Thyroid Nodules in Patients”) is applied
to incidental thyroid nodules identified at CT and
MRI. MIPS measure 265 (“Biopsy Follow-up”)
ensures that the performing physician has reviewed
RG  •  Volume 39  Number 7 Tappouni et al  9

Figure 8.  Comet-tail artifact. US image

shows a comet-tail artifact in a thyroid
nodule. The artifact was initially inter-
preted as a punctate echogenic focus.
The nodule was subsequently biopsied
and determined to be benign.

Figure 9.  Difficult interpretation of nodules. (a) US image shows a heterogeneous nodule that appears to span the
length of the thyroid lobe. (b) US image demonstrates improved conspicuity of an interface between two abutting
nodules. This image was obtained after the sonographer made subtle adjustments to the insonation angle and other
technical parameters, which revealed imaging features that had been obscured slightly by a macrocalcification.

the biopsy results and communicated them to the
referring physician and patient. There are oppor-
tunities for new quality measures in the areas of
diagnostic accuracy, appropriateness, efficiency,
and patient-centered care.
Diagnostic Accuracy.—Since there are data
regarding the expected rates of malignancy for
TR1–TR5 nodules, measures such as positive
predictive value (PPV) for TR3–TR5 nodules and
negative predictive value for TR2 nodules can be
benchmarked to national data. PPV measures ex-
ist in the ACR Lung Cancer Screening Registry
and CT Colonography Registry (38).
Appropriateness.—Given that multiple guide-
lines are available to help stratify thyroid nodules
by risk, quality measures for biopsy and follow-
up imaging can be based on established guide-
lines (39). The existing MIPS measures can be
updated to reflect current recommendations that
are based on nodule morphology and patient age
as well as nodule size.
Efficiency.—Thyroid biopsy techniques vary
among different practitioners. There is an incon-
sistent use of resources such as on-site cytopa-
thologists who determine if biopsy samples are
adequate for diagnosis. Quality measures re-
flecting diagnostic yield (or nondiagnostic rate),
false-positive rate, and false-negative rate can be
compared across providers who perform these
procedures to ensure optimal procedural tech-
nique and avoid unnecessary repeat biopsies.
Patient-centered Care.—One opportunity to
improve patient-centered care involves measuring
and managing patient anxiety and pain related to
US-guided biopsies. Another opportunity is the
creation of patient-friendly documents that help
patients understand the results of their thyroid US,
provide guidance on how they can get more in-
formation, and what the next steps may be. These
types of activities allow radiologists to be more
engaged with patients, assist with shared decision
making, and address issues that are important to
patients and their family members (40).
It may be challenging to incorporate ACR
TI-RADS into quality measures at the local and
national levels. Multiple practice guidelines, as
described earlier in this article, can lead to differ-
ent criteria for biopsy and lack of reconciliation
with regards to biopsy and imaging follow-up.
Thyroid US may be performed and its results
interpreted not by radiologists, but by endocri-
nologists who use ATA guidelines.
10 November-December 2019 radiographics.rsna.org
Figure 10.  Follicular neoplasm. (a) Axial PET/CT image depicts a hypermetabolic nodule in the left thyroid
lobe. (b) US image reveals a corresponding TR4 nodule in the left lobe, which was biopsied and shown to
be a follicular neoplasm.
In this environment, it is important for radiolo-
gists interpreting thyroid US images to establish
good relationships with endocrinologists and otolar-
yngology surgeons to gain their professional respect
and garner trust in TI-RADS. It is also important
to be familiar with ATA guidelines, as some patients
may undergo repeat imaging or FNAB in a radiol-
ogy department after an initial endocrinologist visit.
Future Directions
As acknowledged by the TI-RADS Committee in
the initial white paper, a number of situations are
not addressed in its current scope. The primary
focus is on assessment of US features, but it may
be possible to make recommendations for man-
agement more specific through inclusion of other
clinical and imaging factors.
For instance, a pretest probability risk profile
based on personal and family history (eg, ra-
diation exposure, multiple endocrine neoplasia
syndrome, and first-degree relatives with thyroid
cancer) could be incorporated. Given the broad
range of research topics possible, we offer a few
thoughts based on our experience, which could
potentially shape the future of TI-RADS.
US Evaluation Guided
by FDG-PET Activity
Diffuse thyroid gland uptake can be seen in
thyroiditis or Graves disease. Focal uptake,
which is seen mostly in thyroid nodules, can be
seen in benign and malignant conditions (41).
Incidental hypermetabolic thyroid nodules can
be a relatively common finding at fluorine 18
fluorodeoxyglucose (18F-FDG) PET/CT (42).
The malignancy rate in hypermetabolic thyroid
nodules ranges broadly from 14% to 81%, but a
rate of 50% is often quoted in the nuclear medi-
cine literature (43). Many of these hypermeta-
Figure 11.  TR5 nodule in a patient with a his-
tory of papillary cancer. US image obtained for
preoperative evaluation shows a nodule that had
previously been biopsied at a different facility
and shown to be papillary cancer. It was evalu-
ated to be a TR5 or highly suspicious nodule.
bolic nodules subsequently undergo US with or
without FNAB (Fig 10).
In a large retrospective study, the incidence of
malignancy in biopsied focal hypermetabolic thy-
roid lesions was 21.4%. Nodules exhibiting a ratio
of thyroid maximum standardized uptake value
(SUVmax) to background SUVmax greater than 2
were shown to be correlated with malignancy and
should be examined with US and possibly undergo
FNAB (43). Because of this, PET activity might be
considered a future factor in TI-RADS by adding
points to a nodule with hypermetabolic activity.
Additional Granularity
Other structured reporting systems such as BI-
RADS and LI-RADS (Liver Imaging Reporting
and Data System) contain categories that can be
applied to TI-RADS. One example is a thyroid
nodule that is known to be malignant but has
not been (or potentially will not be) treated.
This would be analogous to the BI-RADS 6 cat-
RG  •  Volume 39  Number 7 Tappouni et al  11
Figure 13.  Discordance between imaging fea-
tures of a nodule and tissue sampling results. US
image depicts a nodule that was initially classified
as TR4 and subsequently biopsied. Pathologic
analysis revealed atypia of undetermined signifi-
cance. Repeat FNAB showed papillary cancer.
egory (Fig 11) and may be particularly impor-
tant when patient care is transferred to another
practice. A repeat and possibly discordant evalu-
ation can be avoided.
Conversely, patients with a history of thyroid-
ectomy or ablation who present with abnormal
imaging findings (Fig 12) should not receive an
evaluation out of context. These patients may ben-
efit from a posttreatment category as described in
LI-RADS (eg, TR viable or TR nonviable).
Indeterminate and
Discrepant FNAB Results
Analysis of thyroid nodule FNAB specimens
shows nondiagnostic or indeterminate results in
15%–20% of patients (1,4). Repeat US or FNAB
is often necessary to monitor the lesion, confirm
the diagnosis, or perform molecular testing. If re-
peat FNAB results are indeterminate, the patient
may undergo thyroidectomy or imaging surveil-
lance (1). Patients with suspicious nodules and
negative or indeterminate FNAB results should
undergo repeat biopsy or be referred to a surgeon
for possible thyroidectomy (Fig 13).
Figure 12.  Long-term follow-up
of two patients after thyroidectomy.
(a) US image shows a small nodule
in the thyroidectomy bed. The nod-
ule demonstrated stability over sev-
eral years, which suggests the pres-
ence of nonviable tissue. There was
no clinical concern for recurrence.
(b) US image in a different patient
demonstrates a lobulated nodule in
the thyroidectomy bed. The nodule
demonstrated hypervascularity and
growth over several examinations
and was a biopsy-proven recur-
rence of papillary cancer.
For example, a TR5 lesion with negative
FNAB results should undergo a repeat biopsy
because a sampling error may have taken place.
Providing a specific recommendation for repeat
biopsy or surgery referral may help in such
circumstances. It is also important to coordinate
with the referring physician to integrate this
information. When addressing the most chal-
lenging cases, it may be appropriate to hold an
interdisciplinary conference.
Inclusion of Contrast-enhanced US
and Elastography
In LI-RADS, the utility of contrast-enhanced
US to depict hepatocellular carcinoma is fully
recognized. As US is the dominant imaging
modality used in thyroid evaluation, contrast-
enhanced US could be used to extend TI-
RADS. Various studies showed a significant
increase in diagnostic accuracy when morpho-
logic analysis was augmented with contrast-
enhanced US (44,45).
Similarly, US elastography has been used for
assessment of mechanical properties in multiple
organs, including the liver, breast, and thyroid
(46). Combining elastography with B-mode US
features has shown some increase in the sensitiv-
ity and specificity of diagnosis (46,47).
Conclusion
The incidence of thyroid nodules is rapidly rising,
and careful risk stratification is an important ele-
ment in preventing overdiagnosis and excessive
treatment. The role of the radiologist is critical to
reduce unnecessary imaging and biopsies. One
way to accomplish this is by assessing US features
of thyroid nodules in a standardized fashion.
ACR TI-RADS provides a framework to gener-
ate structured reporting and consistently classify
nodules to provide appropriate management
recommendations.
Implementing ACR TI-RADS affects multiple
aspects of the imaging workflow and also has
12 November-December 2019 radiographics.rsna.org
pitfalls and challenges. We have presented some
solutions to issues encountered in our experi-
ence with this system. Ultimately, TI-RADS is
a framework with the potential for numerous
research opportunities and has innate flexibility
and extensibility for future modification.
Disclosures of Conflicts of Interest.—R.R.T. Activities related
to the present article: disclosed no relevant relationships. Ac-
tivities not related to the present article: consultant to Behold.ai
Technologies. Other activities: disclosed no relevant relation-
ships. J.N.I. Activities related to the present article: disclosed no
relevant relationships. Activities not related to the present article:
received compensation as an expert witness in multiple court
cases; institution received funding from Coverys Community
Healthcare Foundation; speaker for Moffitt Cancer Center.
Other activities: disclosed no relevant relationships.
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