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ECR2017 phân loại TIRADS mới

Thyroid nodules: histopathologic correlation with TIRADS
categories 3-5
Poster No.:



ECR 2017


Scientific Exhibit


M. Barcenas, J. Almanza, L. Sanchez, H. Murrieta; Mexico/MX


Head and neck, Interventional non-vascular, Oncology,

Ultrasound, Ultrasound-Colour Doppler, Biopsy, Statistics, Imaging
sequences, Pathology, Neoplasia, Cancer



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Aims and objectives
Thyroid nodules are very common, found in 4-8% of adults by palpation, in 10-41%
by ultrasound and 50% by pathological examination at autopsy. The prevalence of
thyroid nodules increases with age. The probability of a malignant nodule depends on
a wide variety of risk factors (1,2). Many studies have evaluated the ability to request
whether a thyroid nodule is benign or malignant, based on ultrasound findings (3,4,5,6).
The size of a nodule is not predictive of malignancy, since the likelihood of cancer in
a thyroid nodule has proven to be the same, regardless of ultrasound size. Several
echographic features have been found that are associated with an increased risk
of echogenicity, including the presence of calcifications, hypoechogenicity, irregular
margins, absence of a halo, predominantly solid composition and intranodular vascularity.
However, sensitivity, specificity and predictive values are extremely variable from one

study to another. (4,5,6,7,8). The characteristic with the highest sensitivity, in the range of
69 to 75% is the solid composition; however this characteristic has a rather low positive
predictive value, since a solid nodule has only a 15.6-27% probability of being malignant.

The terminology of TIRADS was first used by Horvath (13). They described 10 ultrasound
patterns of thyroid nodules and the relation of the rate of malignancy according to the
pattern. Shortly after Park proposed an equation to predict the probability of malignancy
in thyroid nodules based on 12 features by ultrasound (14).
For the present study, we used the Kwak proposal (15), which is based on adjusted
probability and risk of malignancy. Several characteristics such as hypoechogenicity,
marked hypoechogenicity, irregular or micorobulated margins, microcalcifications,
macrocalcifications and morphology higher than width were considered as independent
features of malignancy.
Definition of TIRADS categories:
TIRADS 1: Negative for pathological findings. Thyroid gland with normal ultrasound
TIRADS 2: Benign findings that have already been histopathologically proven on
occasion (fig 1).
TIRADS 3: Findings probably benign, without characteristics of malignancy by ultrasound
(fig 2).

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TIRADS 4A: Low suspicion of malignancy. Nodular image with an ultrasonographic
characteristic of malignancy (fig 3).
TIRADS 4B: Intermediate suspicion of malignancy. Nodular image with two
ultrasonographic features of malignancy (fig 4).
TIRADS 4C: Moderate but not classic suspected malignancy. Nodular image with three
or four ultrasonographic features of malignancy (fig 5).
TIRADS 5: Highly suggestive of malignancy. Five ultrasonographic features of
malignancy (fig 6).
Assess the relationship between TIRADS category and histopathologic diagnosis of
thyroid nodules that underwent ultrasound guided - fine needle aspiration.

Images for this section:

Fig. 1: Thyroid ultrasound of a 42-year-old female patient under follow-up by thyroid
nodule. A longitudinal and transverse image of the right, predominantly solid, echogenic
thyroid nodule, 7 mm in the longitudinal axis, diagnosed by prior BAAF as an adenomatoid
nodule. TIRADS 2.

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© Radiology, ABC medical center - Mexico/MX

Fig. 2: A longitudinal gray scale ultrasonographic image of the left thyroid lobe showing
nodular image of anechoic predominance, with small internal echoes of low level, no
characteristics of malignancy are observed. TIRADS 3.
© Radiology, ABC medical center - Mexico/MX

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Fig. 3: Ultrasound scan of the left thyroid lobe with solid nodule (characteristic of
malignancy), discretely hyperechoic to the parenchyma, with well defined borders and
hypoechoic halo. TIRADS 4A.
© Radiology, ABC medical center - Mexico/MX

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Fig. 4: Ultrasound transverse gray scale image of right and isthmus lobe with solid nodule,
hypoechoic to parenchyma, echogenicity similar to muscle, with well defined borders and
hypoechoic halo. TIRADS 4B.
© Radiology, ABC medical center - Mexico/MX

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Fig. 5: Longitudinal ultrasonographic image in gray scales of right thyroid lobe with solid
nodule, hypoechoic, with irregular borders and higher than width. TRIADS 4C.
© Radiology, ABC medical center - Mexico/MX

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Fig. 6: Longitudinal gray scale ultrasonographic image of the right thyroid lobe with a
solid, hypoechoic nodule with irregular borders, higher than width and with echogenic
images that are punctiform in the interior, representing microcalcifications. TIRADS 5.
© Radiology, ABC medical center - Mexico/MX

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Methods and materials
This investigation is descriptive. It is expected to describe the relation between thyroid
nodule TIRADS category and histopathologic result of ultrasound guided - fine needle
aspiration. It is also a transversal and retrospective study; procedures and study data
were collected from january 2011 to october 2016. STATA V12.0 was used to statistical

221 nodules of 221 patients (163 female, 58 male) were included. They were categorized
by ultrasound TIRADS classification; in categories 1 and 2 no results were found. In
categories 3 to 5 the nodules were distributed as presented figure 6. Definitive diagnosis
is based on cihologic results that were accommodated by four groups (malignant,
indeterminated, benign and nondiagnostic sample); the most frequent category was
benign (69.23%) and malignant category account for about 17.64% (figure 7).
The reported histopathological diagnosis was papillary carcinoma in 36 patients, as a
more frequent malignant diagnosis. On the other hand, goiter (n = 104) and adenoma (n =
31) were the most frequent benign diagnoses (figure 8). 22 We found 22 undifferenciated
tumors and two carcinomas of Hurthle cells. In 6 procedures the samples were
The table in Figure 9 shows the relationship between the categories of the TIRADS
variable and those of the BAAF pathology. The distribution of values shows a statistically
significant association between these two variables (P <0.001). It is observed that when
TIRADS values are higher, the percentages of malignant cases are higher. In turn, when
TIRADS values are lower, the percentages of benign cases are higher.

Images for this section:

Page 9 of 14

Fig. 7: Presentation frequency according to TIRADS category.
© Radiology, ABC medical center - Mexico/MX

Fig. 8: Presentation frequcency according to citopathological report.
© Radiology, ABC medical center - Mexico/MX

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Fig. 9: Presentation frequency according to citopathologic diagnostic.
© Radiology, ABC medical center - Mexico/MX

Fig. 10: Contingency table TIRADS * BAAF pathology.

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© Radiology, ABC medical center - Mexico/MX

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There is a gradual increase in correlation with the diagnosis of thyroid cancer as TIRADS
increases category. This study shows a statistically significant association between these
between TIRADS and BAAF pathology.
We have demostrared that when TIRADS values are higher, the percentages of
malignant cases are higher. In turn, when TIRADS values are lower, the percentages of
benign cases are higher.
Follow up in a short term is safety in TIRADS category 3.

Personal information

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