The TI-RADS system provides a standardized scoring and reporting system for thyroid nodules based on their ultrasound features and associated malignancy risk. The system stratifies nodules into 5 categories (TR1 to TR5) based on their scores in 5 categories: composition, echogenicity, shape, margin, and echogenic foci. The scoring helps determine whether fine needle aspiration or follow up ultrasound is recommended. Example cases are provided to illustrate how the system can be applied in clinical practice.

1. Thyroid Imaging Reporting & Data System
(ACR TI-RADS)
Dr Haseeb Manzoor
Department Of Radiology
Shalamar Hospital

2. • TI-RADS is a reporting system for thyroid nodules proposed by the
american college of radiology (ACR)
• This uses a standardized scoring system for reports
• Malignancy risk stratification
• Provides users recommendations for:
• When to use fine needle aspiration (FNA)
• When to suggest ultrasound follow-up
• When to leave alone nodules

3. Scoring is based upon five ultrasound features of nodule
1. Composition
2. Echogencity
3. Shape
4. Margin
5. Echogenic foci

4. Composition: (choose 1)
• Cystic or completely cystic: 0 points
• Spongiform: 0 points
• Mixed cystic and solid: 1 point
• Solid or almost completely solid: 2 points

5. Composition: cystic or almost completely cystic

6. Composition: Spongiform
• Composed predominately (>50%) of tiny cystic spaces.
• Spongiform is a benign finding.
• If there is concern for irregular margins or suspicious echogenic
foci, reconsider your choice of spongiform.

7. Composition: Mixed cystic solid
• Composed of soft tissue and cystic spaces.
• Base all other characteristics on the solid component.
• Solid material that is eccentric and has an acute angle with the
nodule’s wall is suspicious.

8. Composition: Solid or almost completely solid
• Composed entirely or nearly entirely of soft tissue, with only a
few tiny cystic spaces

9. Echogenicity: (Choose 1)
• Anechoic: 0 Points
• Hyper- Or Isoechoic: 1 Point
• Hypoechoic: 2 Points
• Very Hypoechoic: 3 Points

10. Echogenicity: Anechoic
• Without soft tissue component.
• Applies to cystic or almost completely cystic nodules.

11. Echogenicity: Hyperechoic
• Increased echogenicity relative to thyroid tissue

12. Echogenicity: Isoechoic
• Similar echogenicity relative to thyroid tissue

13. Echogenicity: Hypoechoic
• Decreased echogenicity relative to thyroid tissue

14. Echogenicity: Very Hypoechoic
• Decreased echogenicity relative to adjacent neck musculature

15. Shape: (Choose 1)
(Assessed On The Transverse Plane)
(usually evident on visual inspection)
• Wider Than Tall: 0 Points
• Taller Than Wide: 3 Points

16. Shape: Wider-than-tall
• A wider-than-tall shape is defined as a ratio of ≤1
• (anteroposterior diameter / horizontal diameter)

17. Shape: Taller-than-wide
• A taller-than-wide shape is defined as a ratio of >1
• (anteroposterior diameter / horizontal diameter)

18. Margin: (Choose 1)
(If More Than One Type, Choose The Most Suspicious)
• Smooth: 0 Points
• Ill-defined: 0 Points
• Lobulated/Irregular: 2 Points
• Extra-thyroidal Extension: 3 Points

19. Margin: Smooth
• Uninterrupted, well-defined, curvilinear edge
• typically forming a spherical or elliptical shape

20. Margin: Ill-defined
• Border of the nodule is difficult to distinguish from thyroid
parenchyma

21. Margin: Irregular
• 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
• may be present in only one portion
of the nodule

22. Margin: 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

23. Margin: Extrathyroidal Extension
• Nodule extends through the thyroid margin

24. Echogenic Foci: (Choose 1 Or More) (Choose All That Apply)
• None: 0 Points
• Comet Tail Artefact: 0 Points
• Macrocalcifications: 1 Point
• Peripheral/Rim Calcifications: 2 Points
• Punctate Echogenic Foci: 3 Points

25. Echogenic Foci: Large Comet Tail
•A comet-tail artifact is a type of reverberation artifact.
•V-shaped echoes >1 mm deep to the echogenic focus
• Associated with colloid and are strongly indicative of benignity when
found within the cystic components of nodules.

26. Echogenic Foci: Macrocalcifications
• “Macrocalcifications” are coarse echogenic foci accompanied by
acoustic shadowing.

27. Echogenic Foci: Peripheral Calcifications
• Calcifications occupy the periphery of the nodule.
• May not be continuous but generally involves the majority of the
margin.
• Often dense enough to obscure the central components of the
nodule

28. Echogenic Foci: Punctate Echogenic Foci
• “Dot-like” foci less than 1 mm in diameter.
• Occasionally have small comet tail artifacts.
• In the solid components of thyroid nodules, they may correspond to
the psammomatous calcifications associated with papillary cancers
•small echogenic foci may be seen in spongiform nodules, where they
probably represent the back walls of minute cysts (not suspicious).

29. Assumptions (ACR)
• If margin cannot be determined, choose “ill-defined margin” (0
points).
• If echogenicity cannot be determined, choose “isoechoic” (1 point).
• If composition cannot be determined, choose “solid” (2 points).

30. Interpretation
TOTAL POINTS TIRADS CATEGORY MALIGNANCY RISK
0 TR 1 BENIGN
2 TR 2 NOT SUSPICIOUS
3 TR 3 MILDLY SUSPICIOUS
4-6 TR 4 MODERATELY SUSPICIOUS
7 OR MORE TR 5 HIGHLY SUSPICIOUS

31. Recommendations:
• TR1: no FNA required
• TR2: no FNA required
• TR3: ≥1.5 cm follow up,
≥2.5 cm FNA + follow up: 1, 3 and 5 years
• TR4: ≥1.0 cm follow up,
≥1.5 cm FNA + follow up: 1, 2, 3 and 5 years
• TR5: ≥0.5 cm follow up,
≥1.0 cm FNA + annual follow up for up to 5 years

32. • Discourage usage of the term dominant nodule, which is often
applied to the largest lesion in the gland.
• The threshold size for recommending FNA decreases as the US
features become more malignant appearing.
• If there are multiple nodules, the two with the highest ACR TI-RADS
grades should be sampled (rather than the two largest).
• FNA of suspicious cervical lymph nodes is recommended (globular
shape, loss of echogenic hilum, peripheral flow, heterogeneity with
cystic components and punctate echogenic foci).

34. EXAMPLE CASES

35. • Spongiform 0.9-cm nodule in a 59 year
old woman.
• More than 50% of the nodule is
composed of small cystic spaces.
• Composition: spongiform (0)
• Shape: wider than tall (0)
• Margin: smooth (0)
• Echogenic foci: none (0)
• Total points: 0 (TR1)

36. • Benign mixed cystic and solid nodule
in a 40 year-old woman. solid
component is distributed around the
periphery.
• Composition: mixed (1)
• Echogenicity: iso-echoic (1)
• Shape: wider than tall (0)
• Margin: smooth (0)
• Echogenic foci: none (0)
• Total points: 2 (TR2)

37. • Sagittal sonogram of a 4.6-cm benign
colloid nodule in a 65-year-old woman.
• Composition: almost solid (2)
• Echogenicity: iso-echoic (1)
• Shape: wider than tall (0)
• Margin: smooth (0)
• Echogenic foci: none (0)
• Total points: 3 (TR3)

38. • Mixed cystic and solid papillary cancer in
a 39-year-old man has a lobulated solid
mural component with punctate
echogenic foci (PEF).
• Composition: mixed (1)
• Echogenicity: iso-echoic (1)
• Shape: wider than tall (0)
• Margin: smooth (0)
• Echogenic foci: punctate echogenic foci
(3)
• Total points: 5 (TR4)

39. • Transverse sonogram of a taller-than
wide papillary cancer in a 47-year-old
man.
• Composition: solid (2)
• Echogenicity: iso-echoic (1)
• Shape: taller than wide (3)
• Margin: smooth (0)
• Echogenic foci: punctate echogenic foci
(3)
• Total points: 9 (TR5)

40. • Sagittal sonogram of a 1.2 cm
carcinoma with an irregular (spiculated)
margin in a 39-year-old woman.
• Composition: solid (2)
• Echogenicity: very hypoechoic (3)
• Shape: wider than tall (0)
• Margin: irregular (2)
• Echogenic foci: punctate echogenic foci
(3)
• Total points: 10 (TR5)

41. References
• ACR Thyroid Imaging, Reporting and Data System Lexicon Directory
• ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS
Committee
• Thyroid Imaging Reporting and Data System (TI-RADS): A User’s Guide