3. Intended Learning Objectives
1, Case mở đầu
2, Trình bày về phân loại Kwak TIRADS 2011
3, Trình bày về phân loại ARC TIRADS 2017
4, Thực hành đọc các case lâm sàng
5, Tóm tắt nội dung chính
4. I, Case Studies
A longitudinal
ultrasonography image
shows a single nodule
in a 45-year-old woman :
- Solid
- Very hypoechoic
- Taller than wide
- Irregular
- A puncatate echogenic
foci
In ACR-TI-RADS, it is TR5(15pts)
In Kwak-TI-RADS, it is TR5
FNA: papillary carcinoma
5. A longitudinal
sonography image
shows a single nodule
in a 63-year-old woman :
- Solid
- Very hypoechoic
- Taller than wide
- Smooth
- A puncatate echogenic
foci
FNA: Follicular lesion
6. A longitudinal
ultrasonography shows a
single:
- iso-hypoechoic
- thyroid nodule with
regular hypoechoic
margins (arrowheads) and
- a taller-than-wide shape
7. In TI-RADS by Kwak, it is TI-RADS 4b (2 suspicious US features)
In ACR-TI-RADS, it is TR 4 (moderately suspicious);
The fine-needle aspiration cytology confirmed a benign nodule.
8.
9. II, Kwak TI-RADS 2011
This was proposed by Jin Joung Kwak in 2011
Imaging features
The following features were considered suspicious:
- solid component
- hypoechogenicity, especially marked hypoechogenicity
- microlobulated or irregular margins
- microcalcifications
- taller than wide shape
10. Category definitions
TI-RADS 1: negative (0% risk of malignancy)
TI-RADS 2: benign (0% malignancy)
TI-RADS 3: probably benign (1.7% malignancy)
◉no suspicious features on ultrasound
TI-RADS 4a: low suspicion for malignancy (3.3% malignancy)
◉one suspicious feature
TI-RADS 4b: intermediate suspicion for malignancy (9.2% malignancy)
◉two suspicious features
TI-RADS 4c: moderate concern but not classic for malignancy (44.4-72.4% malignancy)
◉three or four suspicious features
TI-RADS 5: highly suggestive of malignancy (>87.5% malignancy)
◉five suspicious features
11. Management guidelines
The study included only nodules ≥1 cm in greatest dimension. The authors
suggested, as with BI-RADS, that biopsy candidates were those nodules
categorized as TI-RADS category 4 or 5, meaning demonstrating at least one
suspicious sonographic feature.
Nhược điểm của hệ thống phân loại này là các dấu hiệu nghi ngờ thì có giá trị
tiên đoán dương tính ngang nhau
12.
13. III, ACR Thyroid Imaging, Reporting and Data System (TI-RADS) 2017
19. Solid or completely
solid: 2 pst
otherwise-solid
nodules that
contain small
cystic components
that occupy no
more than
approximately
5% of the overall
volume should be
classified as solid
20. Spongiform 0.9cm nodule in
a 59-year-old woman.
More than 50% of the
nodule is composed of
small cystic spaces. The
nodule received 0 points
for composition because
of its spongiform
designation and no
additional points in other
categories (TR1).
21. Sagittal sonogram of a 4.6-
cm benign colloid nodule
in a 65-year-old woman. It
was classified as solid
(composition score of 2),
although small cystic
components were present.
With 1 more point for
isoechogenicity and none
in other categories, its
point total was 3 (TR3)
22. - For nodules that contain morthan minimal solid components as mixed
cystic and solid, the solid component helps determine management:
+ the presence of punctate echogenic foci (PEF) or macro- or peripheral
calcifications
+ position: isolated, masslike, and protrude into the fluid are more suspicious
+ the interface between solid mural components and the cyst wall: acute
angles
+ flow at color or power Doppler: not reliably indicate that the solid
component is malignant
23. Mixed cystic and solid
papillary cancer in a 39-
year-old man has a
lobulated solid mural
component with punctate
echogenic foci (PEF). The
nodule received 1 point for
composition, 1 for its
isoechoic solid component,
and 3 for PEF, for a total of
5 (TR4).
24. Benign mixed cystic and
solid nodule (1 point) in a
40-year-old woman. The
1-point isoechoic solid
component is distributed
around the periphery. The
nodule received 2 points
(TR2).
31. Completely anechoic cysts that otherwise mimic markedly hypoechoic
nodules: the presence of flow within a uniformly hypoechoic nodule
confidently characterizes it as solid. Or use Elastography
32. Phân vân: tổn thương nang hoặc đặc=> ĐÀN HỒI MÔ KO PHẢI NANG=>
TI RADS 4=> FNA : FOLLICULAR LESION.
33. 3, Shape
Choose 1
Should be assessed on a transverse image with measurements parallel to sound
beam for height and perpendicular to sound beam for width
This can usually be assessed by visual inspection
41. 5, Echogen foci
Choose all that apply
• Large comet-tail artifacts (0 pts): V-shaped, >1mm, in cystic components
• Macrocalcifications (1 pts ): Cause acoustic shadowing
• Peripheral (rim) calcifications (2 pts ): Complete or incomplete along
margin
• Punctate echogenic foci (3 pts ): May have small comet-tail artifacts
42.
43. Transverse sonogram shows
2.0-cm markedly
hypoechoic papillary
carcinoma (arrows) in a
24-year-old woman. The
nodule received 2 points
for solid composition and
3 for marked
hypoechogenicity,
totaling 5 points (TR4)
44. Transverse sonogram of a taller-
than-wide papillary cancer in a
47-year-old man. In addition to
3 points for shape, the nodule
warranted 2 points for solid
composition, 1 point for
isoechogenicity, and 3 points for
numerous punctate echogenic
foci, for a total of 9 points
(TR5).
45. Transverse sonogram in a 52-
year-old woman shows a benign
follicular nodule with a smooth
margin (arrows). The nodule
was assigned 2 points for solid
composition and 1 for
isoechogenicity, for a total of 3
points (TR3).
46. Papillary carcinoma bulging the
thyroid border in a 24-year-old
woman. No invasion was
demonstrated at surgery. The
nodule received 2 points for solid
composition, 2 for
hypoechogenicity, 3 for taller-
than-wide shape, and 2 for a
lobulated margin. Its point total
was 9 (TR5)
47. Sonogram of the left thyroid
lobe in a 42-year-old man.
Minute bright dots representing
the speckle pattern of normal or
nonmalignant tissue (arrow)
should not be misinterpreted as
punctate echogenic foci.
48. Small comet-tail artifacts and
additional echogenic foci
(punctate echogenic foci [PEF])
in a papillary carcinoma in a 54-
year-old woman. In addition to
3 points for PEF, the nodule
was assigned 2 points for solid
composition, 2 for
hypoechogenicity, and 2 for a
lobulated margin, for a total of
9 points (TR5).
49. Advantages of ARC TIRADS 2017
- Easy to apply across a wide gamut of ultrasound practices;
- Able to classify all thyroid nodules
- Evidence based to the greatest extent possible.
In a recent study, they were associated with aggregate cancer risks of 0.3%,
1.5%, 4.8%, 9.1%, and 35.0%, respectively
50.
51. If multiple nodules are present only the four highest scoring nodules (not
necessarily the largest) should be scored, reported, and followed up.
Biopsy is recommended only if one or two nodules have high point totals
that would warrant FNA, regardless of whether multiple nodules are present
Predominantly cystic or spongiform nodules are inherently benign. If these
features are present no further points will be added (automatically TR1)
53. Defines clinically important growth as a 20% increase in at least two nodule
dimensions and a minimal increase of 2 mm, or a 50% or greater increase
in volume
Nodules that do not grow substantially over the course of 5 years (based on
comparison between initial and 5-year sonograms) may be considered
benign
65. solid 2 pts
Very hypoechoic 3pts
Taller than wide 3 pts
Smooth 0 pts
Punctate echoic foci 3pts
⇒ sum 11pts
=> TI RADS 5 (PPV > 20%) nhưng nếu theo ACR thì nhân này chưa đủ tiêu
chuẩn kích thước để FNA=> 1 năm sau siêu âm lại
FNA: phình giáp keo
