thyroid tirads classification practical applications

1. Jean Tramalloni
JFIM Barcelona
Nov 1st 2014

2. 2010 1970 1990 2000 1980
45 YEARS TECHNICAL AND PRACTICAL EVOLUTIONS
Kim
2002
analogical
B mode
7,5 MHz
US-guided cytology
Real Time
mode
US : nodular inventory
Cytology if > 10 mm
(no screening based on US paPern)
Color mode Elastography
first biopsy the
suspicious
nodules
Lobectomy + fresh-mount
study for every cold, solid
(and palpable) nodule
(but only 10% of cancers and
30% of controlateral
recurrences)
ANDEM 1995
> 12 MHz
Compond
Consensus
SFE, ETA,
ATA,BTA
TI-RADS
digital
B mode
US confidenYal
and non decision making
A REVOLUTION AFTER A LONG-STANDING EVOLUTION
Harmonic
Lymphnodes

3. 1995 : ANDEM : « most of the cancers features as an hypoechoic nodule but
the vast majority of hypoechoic nodules is composed of benign lesions. »
2002 : Kim : 4 major suspicion signs :
- microcalcificaYons
- irregular or microlobulated margins
- marked hypoechogenicity
- taller than wide
2005 : Frates : US paPerns are associated with cancer risk.
2009 : Horvath introduces for the first Yme the acronym of TIRADS, breath
BIRADS transposiYon to thyroid (10 groups) : each US paPern is associated to
cancer risk.
2011 : G Russ introduces a french TI-RADS version including only 6 risk groups
2013 : G Russ simplified TI-RADS V2 including 5 risk groups
Do US can be predictive of
malignancy or benignancy?

4. TI-RADS SYSTEM
TI-RADS SYSTEM =
SCORE : evaluaYon and guidelines groups
+ VOCABULARY
+ STANDARDISED REPORT
• Acronym of Thyroid Imaging-ReporYng And Database System
• TransposiYon of breast BI-RADS system to thyroid
• QuanYtaYve cancer risk straYficaYon tool for thyroid

5. TI-RADS
SCORE
MEANING
PROPORTION OF
NODULES
RISK OF MALIGNANCY
(%)
2 BENIGN 3% 0
3 MOSTLY BENIGN 60%
0.25
(1/400)
4A
LOW RISK OF
MALIGNANCY
33% 6
4B
HIGH RISK OF
MALIGNANCY
4,5% 69
5
ALMOST SURELY
MALIGNANT
0,5% 100
CANCER RISK STRATIFICATION– TI-RADS SCORE V2
PROSPECTIVE STUDY– 4550 nodules- US vs CYTOLOGY (2013)

6. TI-RADS
SCORE
MEANING
NUMBER OF
NODULES
RISK OF MALIGNANCY
(%)
2 BENIGN 3% 0
3 MOSTLY BENIGN 60%
0.25
(1/400)
4A
LOW RISK OF
MALIGNANCY
4639 (48%) 6
4B
HIGH RISK OF
MALIGNANCY
516 (5%) 69
5
ALMOST SURELY
MALIGNANT
33 (0,3%) 100
63%
CANCER RISK STRATIFICATION– TI-RADS SCORE V2

7. TI-RADS
SCORE
MEANING
NUMBER OF
NODULES
RISK OF MALIGNANCY
(%)
2 BENIGN 259 (3%) 0
3 MOSTLY BENIGN 4187 (43%)
0.25
(1/400)
4A
FAIBLE RISQUE DE
MALIGNITÉ
4639 (48%) 6
4B
HIGH RISK OF
MALIGNANCY
4,5% 69
5
ALMOST SURELY
MALIGNANT
0,5% 100
CANCER RISK STRATIFICATION– TI-RADS SCORE V2
5%

8. TI-RADS
SCORE
MEANING
NUMBER OF
NODULES
RISK OF MALIGNANCY
(%)
2 BENIGN 259 (3%) 0
3 MOSTLY BENIGN 4187 (43%)
0.25
(1/400)
4A
LOW RISK OF
MALIGNANCY
33% 6
4B
HIGH RISK OF
MALIGNANCY
516 (5%) 69
5
ALMOST SURELY
MALIGNANT
33 (0,3%) 100
CANCER RISK STRATIFICATION– TI-RADS SCORE V2

9. 0%
10%
20%
30%
40%
50%
60%
70%
PosiLve PredicLve Value of US
Russ et al. J Radiol 2011

10. 0%
10%
20%
30%
40%
50%
60%
70%
PosiLve PredicLve Value of US
Russ et al. J Radiol 2011

11. 75%
80%
85%
90%
95%
100%
NegaLve PredicLve Value of US
Russ et al. J Radiol 2011

12. 75%
80%
85%
90%
95%
100%
NegaLve PredicLve Value of US
Russ et al. J Radiol 2011

13. TI-RADS score needs
precise semiology
To study a nodule, train your eyes
watch, in good order :
shape
borders
content
To describe it, use glossary words

14. SHAPE
longitudinal transverse
dysharmonious
taller than wide taller than hight
A/T >1
A
T
harmonious

15. MARGINS
well defined
lobulated
blurred

16. CONTENT : ECHOGRAPHIC STRUCTURE
liquid
solid
mixed

17. CONTENT : ECHOGENICITY
hypoechoic
mildly markedly

18. hypoechoic
isoechoic
hyperechoic
mildly markedly
CONTENT : ECHOGENICITY

19. colloidal granulaYons
CONTENT : HYPERECHOIC DOTS
IN CYSTIC NODULES
comet tail arYfact

20. CONTENT : HYPERECHOIC DOTS
IN SOLID NODULES
colloidal granulaYons
microcalcificaYons

21. CONTENT : STIFFNESS
AT ELASTOGRAPHY
PROBABLY
BEGNIN
SUSPICIOUS
RAGO CLASSIFICATION RAGO T. et al. JCEM 2010
Strain elastography

22. CONTENT : STIFFNESS
AT ELASTOGRAPHY
Strain elastography

23. CONTENT : STIFFNESS
AT ELASTOGRAPHY
Share wave elastography

24. NODULAR DESCRIPTION GLOSSARY
SHAPE: regular/irregular (harmonious/dysharmonious)
MARGINS: well-defined/lobulated/blured
CONTENT:
- Echographic structure: solid/mixed/liquid
- Echogenicity: hyperechoic/isoechoic
marked hypoechogenicity/moderate
homogeneous/heterogeneous
- hyperechoic dots: colloidal granulaYons
microcalcificaYons
- sYffness at elastography
- vascularizaYon: none/peripheral/mixed/central

25. VASCULARIZATION PATERN
IS NOT A TI-RADS ITEM
mainly perinodular
mixed, peri and intranodular
mainly intranodular

26. in practice, how to score ?
1) first of all look for any sign of suspicion
- dysharmonious shape
- lobulated or blured margins
- microcalcificaYons
- marked hypoechogenicity
- sYffness at elastography

27. - 1 or 2 signs of suspicion
- no suspicious lymph node
SCORE 4B
HIGHLY SUSPECT
Risk of cancer : 69%

28. - 3 to 5 signs of suspicion
and/or
- suspicious lymph node
SCORE 5
MALIGNANT
Risk of cancer : 100%

29. 5 suspicion signs

30. What is a suspicious lymph node ?
At least one of the following characterisLcs
- microcalcificaYons
- parYally cysYc appearance
- peripheral or diffusely increased vascularizaYon
- hyperechoic thyroid like lymph node
ETA guidelines 2013 : Eur Thyr Journal 2013;2:147-159

31. no suspicion sign
look at echogenicity
(slightly)
hypoechogenic
isoechogenic
hyperechogenic
4A 3
2

32. slightly
hypoechogenic
SCORE 4A
SLIGHTLY SUSPICIOUS
risk of cancer : 6%

33. BENIGN PATTERNS
VERY PROBABLY BENIGN
- no suspicion sign
- Isoechoic ou hyperechoic
SCORE 3
Risk of cancer : 0,25%

34. BENIGN PATTERNS
ALWAYS BENIGN
- cysYc aspect
- spongiform nodule
- “White knight”
- single macrocalcificaYon
- nodular hyperplasia
SCORE 2
Risk of cancer : 0%

35. To make a long story short ...

36. SUSPICIOUS
- dysharmonious shape
- lobulated or blured margins
- microcalcificaYons
- marked hypoechogenicity
- sYff at elastography
- 3 to 5 signs
and/or
- metastaYc
lymph node
SCORE 5
- 1 or 2 signs
- no metastaYc
lymph node
SCORE 4B
- no major suspicious sign
- slightly hypoechogenic
SCORE 4A

37. BENIGN ASPECTS
MOSTLY BENIGN
- no suspicious sign
- isoechoic or hyperechoic
SCORE 3
ALWAYS BENIGN
- cysYc aspect
- spongiform nodule
- white knights
- single macrocalcificaYon
- nodular hyperplasia
SCORE 2

38. - all nodules sightly or strongly suspicious (4A, 4B and 5)
- all nodules which increase in a significant way
95% of papillary carcinomas
100% of medullary carcinomas
86% of folliculary carcinomas

39. • Tae HJ et al., Thyroid 2007;17(5) : 461.
DiagnosYc value of ultrasonography to disYnguish between benign and
malignant lesions in the management of thyroid nodules.
• Ito Y et al., Thyroid 2007; 17, 1269-1276
Ultrasonographic evaluaYon of thyroid nodules in 900 paYents : comparison
among ultrasonographic, cytological and histological findings.
• Horvath et al.. JCEM, may 2009, 90(5), 1748-51
An ultrasonogram reporYng system for thyroid nodules straYfying cancer risk for clinical management.
• Park et al.. Thyroid 2009, 19 (11), 257-64
A proposal for a thyroid imaging reporYng and data system for ultrasound features of thyroid
carcinoma.
• Kwak et al., Radiology 2011; 260; 892-99
Thyroid Imaging ReporYng and Data System for US features of nodules. A step in establishing bePer
straYficaYon of cancer risk.
• Kwak JY et al., Korean J Radiol 2013; 14(1): 110-117
Image reporYng and characterizaYon system for ultrasounf feutures of thyroid nodules: mulYcentric
korean retrospecYve study
• Russ et al. J Radiol 2011;92;701-13
Le système TI-RADS en échographie thyroïdienne.
• Russ et al. Eur J Endocrinol 2013, 168 (5); 649-55
ProspecYve evaluaYon of thyroid imaging reporYng and data system on 4550 nodules with and
without elastography.
REFERENCES
• ETA guidelines 2013 : Eur Thyr Journal 2013;2:147-159

40. THANK YOU
FOR YOUR ATTENTION