ACR TI-RADS Calculator for Thyroid Nodules

Diagnoses benign versus malignant thyroid nodules based on ultrasound findings.

Refer to the text below the calculator for more information about the TI-RADS score and its usage.


The ACR TI-RADS (Thyroid Imaging Reporting and Data System) is a 5-point scoring system for thyroid nodules, based on ultrasound findings, developed by the American College of Radiology. It facilitates diagnosis of thyroid nodule and discrimination between benign or malignant.


TI-RADS Score Interpretation

ACR TI-RADS points TR grade Further actions
0 TR1 – Benign No Fine Needle Aspiration
1 - 2 TR2 – Not suspicious No Fine Needle Aspiration
3 TR3 – Mildly Suspicious FNA if ≥ 2.5 cm
Follow if ≥ 1.5 cm
4 - 6 TR4 – Moderately Suspicious FNA if ≥ 1.5 cm
Follow if ≥ 1 cm
≥ 7 TR5 – Highly Suspicious FNA if ≥ 1 cm
Follow if ≥ 0.5 cm*
* Refer to discussion of papillary microcarcinomas for 5-9 mm TR5 nodules.

1

Composition

2

Echogenicity

3

Shape

4

Margin

5

Echogenic foci (Choose all that apply)

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TI-RADS Explained

The ACR TI-RADS (Thyroid Imaging Reporting and Data System) is a 5-point scoring system for thyroid nodules, based on ultrasound findings, developed by the American College of Radiology and published in 2017.

It facilitates diagnosis of thyroid nodule and discrimination between benign or malignant so benefits identifying clinically important cancers whilst balancing the risk and cost of subjecting patients with benign nodules to biopsy and treatment.

TI-RADS Answer Choices Explanatory Notes
Composition Cystic or almost completely cystic (0)
Spongiform (0)
Mixed cystic and solid (1)
Solid or almost completely solid (2)
Indeterminate due to calcification (2)
Spongiform: Composed predominantly (>50%) of small cystic spaces. No further points are added for other categories.
Mixed cystic and solid: Assign points for predominant solid component.
Echogenicity Anechoic (0)
Hyperechoic or isoechoic (1)
Hypoechoic (2)
Very hypoechoic (3)
Cannot be determined (1)
Anechoic: Applies to cystic or almost completely cystic nodules.
Hyperechoic/isoechoic/hypoechoic: Compared to adjacent parenchyma.
Very hypoechoic: More hypoechoic than strap muscles.
Shape Wider than tall (0)
Taller than wide (3)
Shape should be assessed on a transverse image with measurements parallel to sound beam for height and perpendicular to sound beam for width.
Margin Smooth (0)
Ill-defined (0)
Lobulated or irregular (2)
Extra-thyroidal extension (3)
Cannot be determined (0)
Lobulated: Protrusions into adjacent parenchyma.
Irregular: Jagged, spiculated, or sharp angles.
Extrathyroidal extension: Obvious invasion of adjacent soft tissue or vascular structures.
Echogenic foci (Choose all that apply)
None or large comet-tail artifacts (0)
Macrocalcifications (1)
Peripheral (rim) calcifications (2)
Punctate echogenic foci (3)
Large comet-tail artifacts: V-shaped, >1 mm, in cystic components.
Macrocalcifications: Cause acoustic shadowing.
Peripheral calcifications: Complete or incomplete along margin.
Punctate echogenic foci: Non-shadowing, may have small comet-tail artifacts.

The number of thyroid nodules detected via ultrasound is increasing and whilst most are benign, it is essential to evaluate which may require further investigation via fine needle aspiration (FNA) cytology/ biopsy.

Nodules should be measured in three orthogonal planes and in case there are multiple nodules, not more than 4 nodules should be documented.

Growth may be defined as:

  • More than 20% increase in at lease two dimensions AND minimal increase of 2mm;
  • OR More than 50% increase in volume.

The ultrasound features in the ACR TI-RADS are categorized as benign, minimally suspicious, moderately suspicious, or highly suspicious for malignancy. Points are given for all the ultrasound features in a nodule, with more suspicious features being awarded additional points.

TI-RADS Score Interpretation

ACR TI-RADS points TR grade Further actions
0 TR1 – Benign No Fine Needle Aspiration
1 - 2 TR2 – Not suspicious No Fine Needle Aspiration
3 TR3 – Mildly Suspicious FNA if ≥ 2.5 cm
Follow if ≥ 1.5 cm
4 - 6 TR4 – Moderately Suspicious FNA if ≥ 1.5 cm
Follow if ≥ 1 cm
≥ 7 TR5 – Highly Suspicious FNA if ≥ 1 cm
Follow if ≥ 0.5 cm*
* Refer to discussion of papillary microcarcinomas for 5-9 mm TR5 nodules.

Some suspicious features of cervical nodes include:

  • Globular shape;
  • Loss of normal echogenic hilum;
  • Presence of peripheral rather than hilar flow;
  • Heterogeneity with cystic components;
  • Punctate echogenic foci that may represent microcalcifications.
 

References

Original reference

Tessler FN, Middleton WD, Grant EG et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017; 14: 587-595.

Other references

Vargas-Uricoechea H, Meza-Cabrera I, Herrera-Chaparro J. Concordance between the TIRADS ultrasound criteria and the BETHESDA cytology criteria on the nontoxic thyroid nodule. Thyroid Res. 2017; 10:1.

Virmani V, Hammond I. Sonographic patterns of benign thyroid nodules: verification at our institution. AJR Am J Roentgenol 2011; 196:891-895.

Middleton WD, Teefey SA, Reading CC, Langer JE, Beland MD, Szabunio MM, et al. Comparison of Performance Characteristics of American College of Radiology TI-RADS, Korean Society of Thyroid Radiology TIRADS, and American Thyroid Association Guidelines. AJR Am J Roentgenol. 2018; 210(5):1148-54.


Specialty: Oncology

Objective: Diagnosis

Year Of Study: 2017

Abbreviation: TI-RADS

Article By: Denise Nedea

Published On: July 13, 2020

Last Checked: July 13, 2020

Next Review: July 13, 2025