ORIGINAL ARTICLE

Thyroid Ultrasound Reporting Lexicon: White

Paper of the ACR Thyroid Imaging, Reporting
and Data System (TIRADS) Committee
Edward G. Grant, MD a, Franklin N. Tessler, MDb, Jenny K. Hoang, MBBS c, Jill E. Langer, MDd,
Michael D. Beland, MDe, Lincoln L. Berland, MDb, John J. Cronan, MDe, Terry S. Desser, MD f,
Mary C. Frates, MD g, Ulrike M. Hamper, MD h, William D. Middleton, MDi, Carl C. Reading, MD j,
Leslie M. Scoutt, MD k, A. Thomas Stavros, MD l, Sharlene A. Teefey, MDi

Abstract
Ultrasound is the most commonly used imaging technique for the evaluation of thyroid nodules. Sonographic findings are often not
specific, and definitive diagnosis is usually made through fine-needle aspiration biopsy or even surgery. In reviewing the literature, terms
used to describe nodules are often poorly defined and inconsistently applied. Several authors have recently described a standardized risk
stratification system called the Thyroid Imaging, Reporting and Data System (TIRADS), modeled on the BI-RADS system for breast
imaging. However, most of these TIRADS classifications have come from individual institutions, and none has been widely adopted in
the United States. Under the auspices of the ACR, a committee was organized to develop TIRADS. The eventual goal is to provide
practitioners with evidence-based recommendations for the management of thyroid nodules on the basis of a set of well-defined
sonographic features or terms that can be applied to every lesion. Terms were chosen on the basis of demonstration of consistency
with regard to performance in the diagnosis of thyroid cancer or, conversely, classifying a nodule as benign and avoiding follow-up. The
initial portion of this project was aimed at standardizing the diagnostic approach to thyroid nodules with regard to terminology through
the development of a lexicon. This white paper describes the consensus process and the resultant lexicon.
Key Words: Thyroid nodule, ultrasound, thyroid cancer, structured reporting, thyroid imaging
J Am Coll Radiol 2015;-:---. Copyright
2015 American College of Radiology

INTRODUCTION Although nodules are extremely common, the incidence of

The incidence of thyroid nodules has increased tremen- malignancy in them is relatively low, ranging between 1.6%
dously in recent years. The reasons for this increase are likely and 12% [2,3].
multifactorial but are largely attributed to widespread Ultrasound is superior to other modalities in charac-
application of high-resolution ultrasound to the thyroid it- terizing thyroid nodules. Unfortunately, the findings are
self and the frequent incidental detection of nodules on often not specific, and definitive diagnosis usually requires
other imaging modalities. In distinction to palpation, which fine-needle aspiration (FNA) biopsy or even surgery.
demonstrates nodules in only 5% to 10% of the population, Because nodules are so common, a significant burden is
autopsy and sonography detect them in at least 60% [1]. placed on the health care system, and considerable anxiety

a i
Keck School of Medicine, University of Southern California, Los Angeles, Washington University School of Medicine, St. Louis, Missouri.
California. j
Mayo Clinic College of Medicine, Rochester, Minnesota.
b k
University of Alabama at Birmingham, Birmingham, Alabama. Yale University, New Haven, Connecticut.
c l
Duke University School of Medicine, Durham, North Carolina. Sutter Medical Group, Englewood, Colorado.
d
University of Pennsylvania, Philadelphia, Pennsylvania. Corresponding author and reprints: Edward G. Grant, MD, Keck School of
e
Brown University, Providence, Rhode Island. Medicine, University of Southern California, Department of Radiology, 1500
f San Pablo Street, Los Angeles, CA 90033; e-mail: [email protected].
Stanford University Medical Center, Stanford, California.
g The authors have no conflicts of interest related to material discussed in this
Brigham and Women’s Hospital, Boston, Massachusetts.
h
Johns Hopkins University, School of Medicine, Baltimore, Maryland. article.

ª 2015 American College of Radiology

1546-1440/15/$36.00 n http://dx.doi.org/10.1016/j.jacr.2015.07.011 1
may occur in patients. Furthermore, the majority of thy- was drawn up. Frequency of use was the initial guide for
roid cancers are of the papillary type, which is typically determining which terms would be included in the lexicon.
indolent. Long-term studies by Ito et al [4] showed no The committee initially identified nine categories or
difference in outcomes between patients with biopsy- families of terms that could be applied to all thyroid nod-
proven carcinomas <1 cm undergoing thyroidectomy ules: nodule composition, echogenicity, characteristics of
and those followed with no surgical intervention. cystic/solid components, shape, size/dimensions, margins,
The literature regarding thyroid nodule characteriza- halo, echogenic foci, and flow/Doppler. Next, subcom-
tion with ultrasound is expansive, and several professional mittee members re-reviewed the literature to determine
organizations have put forth position or consensus state- whether there was evidence that the categories and terms
ments. The two best known in the United States are from had discriminatory value in distinguishing benign from
the American Thyroid Association (ATA) and the Society malignant nodules, which led to culling the category list.
of Radiologists in Ultrasound [5,6]. Because FNA biopsy is This process resulted in the selection of six final categories.
such an integral part of the workup of thyroid nodules, the Several of the original categories as well as numerous terms
American Society of Cytopathology convened its own were eliminated from the lexicon or incorporated into other
consensus panel to standardize reporting of biopsy results, groups based either on infrequency of use or lack of sta-
which is known as the Bethesda classification [7]. tistical agreement with regard to their diagnostic value.
Several authors have suggested a standardized risk Two members were assigned to develop definitions for each
stratification system called the Thyroid Imaging, Reporting category and its individual terms in a format used for other
and Data System (TIRADS), modeled on the BI-RADS ACR “RADS” lexicons.
system for breast imaging, which has received widespread
acceptance [8-10]. These proposals include the initial
THYROID ULTRASOUND CATEGORIES
report by Horvath et al [9], as well as subsequent proposals
by Kwak et al [8] and Park et al [10]. Despite these efforts, Category 1: Composition
none of these TIRADS classifications have been widely Definition.
adopted, particularly in the United States. n Composition describes the internal components of a
Our objective, therefore, was to develop a practical,
nodule, that is, the presence of soft tissue or fluid, and
standard lexicon for describing the sonographic charac-
the proportion of each.
teristics of thyroid nodules, with the ultimate aim of B Solid: Composed entirely or nearly entirely of soft
applying it to risk stratification and triage of nodules for
tissue, with only a few tiny cystic spaces (Fig. 1A).
consistent follow-up in clinical practice. B Predominately solid: Composed of soft tissue
components occupying 50% or more of the volume
of the nodule (Fig. 1B, online only).
METHODS B Predominately cystic: Composed of soft tissue
Beginning in 2012, a group of radiologists with expertise
components occupying less than 50% of the vol-
in thyroid imaging undertook a three-stage process under
ume of the nodule (Fig. 1C, online only).
the auspices of the ACR; a subcommittee was charged B Cystic: Entirely fluid filled.
with completing each one. The first effort, led by Lincoln B Spongiform: Composed predominately of tiny
Berland, MD, and Jenny Hoang, MBBS, was aimed at
cystic spaces (Fig. 1D, online only).
proposing recommendations for nodules discovered
incidentally on imaging. This work led to a white paper Background and Significance.
published in 2015 [11]. The work reported here on the n A nodule should fit into one of the foregoing five cate-

development of an ultrasound lexicon was led by Edward gories. However, rarely, it may be difficult to determine
Grant, MD, whereas the final stage, which will be if a nodule is filled with hemorrhagic material or is solid.
directed at risk stratification on the basis of the lexicon, Color Doppler flow may be useful in differentiating
will be led by Franklin Tessler, MD. between the two.
After an extensive literature review, relevant articles n Papillary thyroid carcinoma (PTC) is most commonly

were distributed to all subcommittee members. Each solid, but many solid nodules are also benign; a solid
radiologist was assigned three or four articles and was asked nodule has a 15% to 27% chance of being malignant [6].
to list terms used by the authors to describe thyroid nod- Some nodules undergo cystic degeneration or necrosis.
ules. ACR staff members collated the lists, and a master list A recent study of partially cystic nodules showed that the

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Volume - n Number - n Month 2015
 in 52 spongiform nodules was malignant [15]. When a
spongiform nodule was defined as tiny cystic spaces
involving the entire nodule, all 210 spongiform nod-
ules were benign on FNA biopsy [16].
Comment.
n Terms used to describe partially cystic or partially solid

nodules vary, with some authors breaking down the ratio

of the two into numerical values on the basis of per-
centage whereas others choose to be more descriptive.
The committee believed that the simple, subjective
description of predominately cystic versus predomi-
nately solid would suffice.
Fig 1. Composition. (A) Solid nodule: 46-year-old man with n Although somewhat controversial, the committee
3.5-cm solid, hypoechoic nodule. Margins are smooth.
agreed that finding several tiny cystic spaces in an
Macrocalcifications were identified on other sections.
Diagnosis: medullary carcinoma. (B, online only) Predomi- otherwise completely solid nodule would still allow it to
nately solid nodule: 63-year-old woman with a 1.6-cm be classified as solid.
predominately solid, hyperechoic nodule. Margins are
smooth. Note presence of punctate echogenic foci and foci Category 2: Echogenicity
with small comet-tail artifacts. Diagnosis: colloid nodule
Definition.
(Bethesda 2). (C, online only) Predominately cystic nodule:
n Level of echogenicity of the solid, noncalcified compo-
26-year-old man with a 4.5-cm predominately cystic nodule.
Note solid components along superior/posterior wall (arrow). nent of a nodule, relative to surrounding thyroid tissue
Diagnosis: cystic nodule, nondiagnostic (Bethesda 1). [8,10,15,17-19].
Appearance of aspirate was consistent with old blood. B Hyperechoic: Increased echogenicity relative to

Nodule recurred but no change over 2-year follow-up. (D, thyroid tissue (Fig. 2A, online only).
online only) Spongiform nodule: 49-year-old woman with B Isoechoic: Similar echogenicity relative to thyroid
1.9-cm spongiform nodule in left lobe of thyroid. Diagnosis:
tissue.
colloid nodule based on appearance, biopsy not performed.
B Hypoechoic: Decreased echogenicity relative to

thyroid tissue (Fig. 2B, online only).

B Very hypoechoic: Decreased echogenicity relative to
prevalence of malignancy was low whether the nodule was
predominately cystic (6.1%) or predominately solid adjacent neck musculature (Fig. 2C).
(5.7%) [12]. When evaluating a partially cystic nodule, it Background and Significance.
is important to evaluate the solid component. If the solid n The level of nodule echogenicity is associated with both
component is eccentrically (peripherally) located within a
benign and malignant lesions. Very hypoechoic nodules
partially cystic nodule and the margin of the solid
have low sensitivity but very high specificity. Hypo-
component has an acute angle with the wall of the nodule,
echogenicity is more sensitive but does not have high
the risk for malignancy is increased. Furthermore, if the
specificity [15,18,19].
solid component is hypoechoic, is lobulated, has an irreg-
ular border or punctate echogenic foci line, or has vascular Comment.
flow, the risk for malignancy is increased. If the solid n The echogenicity of the solid component of a nodule

component is isoechoic, is centrally located within should be compared with normal-appearing thyroid tis-
the nodule or, if peripheral, has no acute angle with the sue, usually immediately adjacent to the nodule. In the
nodule wall, or has a smooth margin, spongiform appear- setting of background abnormal thyroid tissue echogen-
ance, or comet tail artifacts, it is likely benign [13,14]. icity, such as in Hashimoto’s thyroiditis, the echogenicity
n Purely cystic nodules or spongiform nodules have a of the solid component should still be described relative to
very low risk for malignancy [6]. Two definitions of the adjacent thyroid tissue, but it may be noted that the
spongiform nodules have been proposed in the litera- background tissue is of altered echogenicity.
ture. When a spongiform nodule was defined as “the n If the nodule is of mixed echogenicity, it can be

aggregation of multiple microcystic components in described as “predominantly” hyperechoic, isoechoic,

more than 50% of the volume of the nodule,” only one or hypoechoic.

Journal of the American College of Radiology 3

Grant et al n Thyroid Ultrasound Reporting Lexicon
Fig 2. Echogenicity. (A, online only) Hyperechoic nodule:
63-year-old woman with 1.6-cm hyperechoic predominately Fig 3. Shape: 56-year-old woman with taller-than-wide nodule
solid, smooth nodule. Note punctate echogenic foci. Diagnosis: in left lobe of thyroid. Dimensions measured in the transverse
colloid nodule (Bethesda 2). (B, online only) Hypoechoic plane are 1.4 cm transverse  1.8 cm anteroposterior. Diagnosis:
nodule: 62-year-old man with 1.6-cm hypoechoic, solid nodule follicular variant, papillary carcinoma.
with smooth margins. Note large comet-tail artifact along
inferior border. Diagnosis: papillary carcinoma. (C) Very Category 4: Size
hypoechoic nodule: 55-year-old woman with 1.0-cm very
How the nodule should be measured:
hypoechoic left lobe nodule (N). Margins are smooth. Note
that nodule is less echogenic than adjacent strap muscles (S) n Use maximal diameter on the basis of longitudinal,
and essentially isoechoic to the common carotid artery (C). anteroposterior, and transverse measurements in cen-
Diagnosis: papillary carcinoma.
timeters per millimeter.
Background and Significance.
Category 3: Shape n Multiple studies have suggested that nodule size is not an
Term: taller-than-wide. independent predictor of malignancy risk in PTC. Tiny
Definition. nodules can harbor malignancy, and large nodules are
n A taller-than-wide shape is defined as a ratio of >1 in
often benign. In a Finnish autopsy study of 101 thyroid
the anteroposterior diameter to the horizontal diameter glands, investigators found small, occult thyroid cancers
when measured in the transverse plane (Fig. 3). in 36% [24]. As noted previously, the study by Ito et al
[4] showed no value in performing thyroidectomy on
Background and Significance. small cancers.
n Taller-than-wide shape is a major feature for the cate- n The correlation between nodule size and risk for ma-
gorization of thyroid nodules that are suspicious or lignancy remains controversial for nodules >1 cm. A
suggestive of malignancy. The corresponding pathologic 2013 study that included 7,346 nodules examined the
feature leading to this appearance is thought to be de- effect of nodule size on the prevalence of thyroid cancer.
creased compressibility. This finding is seen in 12% of At a threshold of 2 cm, the investigators found a statis-
thyroid nodules [8]. Sensitivity ranges between 40% and tically significant increase in cancer rate: 10.5% among
68%, specificity between 82% and 93%, positive pre- the nodules 1 to 1.9 cm in diameter versus 15% for
dictive value between 0.58 and 0.73, and negative pre- nodules >2 cm. Whether this is clinically significant is
dictive value between 0.77 and 0.88 [8,17,20-22]. doubtful. In this study, larger nodules, when cancerous,
Comment. were significantly more likely to have a histology other
than papillary carcinoma (follicular, Hurthle cell, or
n In studies that specify how measurements are made,
other rare malignancies) [25].
there are no significant differences comparing transverse
or longitudinal dimensions [20,23]. For simplicity and Comment.
consistency, the committee chose the ratio of >1 in the n Current thinking about biopsy of nodules <1 cm
anteroposterior diameter to the horizontal diameter in seems to be shifting to a more conservative approach.
the transverse plane. The most recent ATA guidelines [26] do not

4 Journal of the American College of Radiology

Volume - n Number - n Month 2015
 recommend biopsy of most lesions <1 cm. For nod-
ules larger than 1 cm, considering the uncertainty
between nodule size and malignancy risk, compared
with the more consistent data on the impact of other
sonographic features, we believe it is reasonable not to
include size in the TIRADS scoring system.

Category 5: Margins
Definition.
n Refers to the border or interface between the nodule

and the adjacent thyroid parenchyma or adjacent Fig 4. Margins. (A, online only) Smooth margin: 49-year-old
extrathyroidal structures. woman with 2.2-cm hypoechoic nodule with a smooth margin.
B Smooth: Uninterrupted, well-defined, curvilinear
Diagnosis: benign follicular nodule (Bethesda 2). (B) Irregular
edge typically forming a spherical or elliptical shape margin: 47-year-old woman with heterogeneously hyperechoic
(Fig. 4A, online only) 16-mm nodule with irregular margins. Note angulated borders
B Irregular margin: The outer border of the nodule is anteriorly. Diagnosis: papillary carcinoma. (C, online only)
Lobulated margin: 56-year-old man with 3.4-cm lobulated,
spiculated, jagged, or with sharp angles with or
hyperechoic nodule. Macrocalcifications were present in other
without clear soft tissue protrusions into the paren-
sections. Diagnosis: papillary carcinoma. (D, online only)
chyma. The protrusions may vary in size and conspi- Extrathyroidal extension: 73-year-old man with a large,
cuity and may be present in only one portion of the lobulated hypoechoic mass involving isthmus and left lobe. Note
nodule (Fig. 4B). loss of definition of tissue planes anteriorly suggesting
B Lobulated: Border has focal rounded soft tissue extrathyroidal invasion. Diagnosis: anaplastic carcinoma.
protrusions that extend into the adjacent paren-
chyma. The lobulations may be single or multiple n A halo may be due to a true fibrous capsule or a pseu-
and may vary in conspicuity and size (small lobu- docapsule. A uniform halo suggests a benign nodule
lations are referred to as microlobulated) (Fig. 4C, because most thyroid malignancies are unencapsulated.
online only). However, a complete or incomplete halo has been noted
B Ill-defined: Border of the nodule is difficult to
in 10% to 24% of thyroid carcinomas.
distinguish from thyroid parenchyma; the nodule n Extension of the nodule through the thyroid capsule
lacks irregular or lobulated margins. into the adjacent soft tissue structures indicates
B Halo: Border consists of a dark rim around the pe-
invasive malignancy [29].
riphery of the nodule. The halo can be described as
completely or partially encircling the nodule. In the Comment.
n Analysis of the literature about the reported sensitivity
literature, halos have been further characterized as
and specificity of margin features is challenging
uniformly thin, uniformly thick, or irregular in
because of previous nonuniformity in the definitions
thickness.
B Extrathyroidal extension: Nodule extends through
and the high rate of interobserver variability [15].
the thyroid capsule (Fig. 4D, online only). Category 6: Echogenic Foci
Background and Significance. Definition.
n A smooth border is more common in benign nodules, n Refers to focal regions of markedly increased echogen-

but between 33% and 93% of malignancies may have icity within a nodule relative to the surrounding tissue.
smooth borders [15,27]. Irregular and lobulated mar- Echogenic foci vary in size and shape and may be
gins are features suspicious for thyroid malignancy [28]. encountered alone or in association with several well-
These borders are considered to represent an aggressive known posterior acoustic artifacts.
growth pattern, although regions of thyroiditis can also B Punctate echogenic foci: “Dot-like” foci having no

have irregular margins. An ill-defined thyroid nodule posterior acoustic posterior artifacts. Kwak et al [8]
margin has not been shown to be statically significantly defined punctate foci/microcalcifications as being
associated with malignancy and is a common finding in <1 mm. Most authors define this feature on the
benign hyperplastic nodules and thyroiditis [15,27,29]. basis of appearance alone (Fig. 5A).

Journal of the American College of Radiology 5

Grant et al n Thyroid Ultrasound Reporting Lexicon
 B Macrocalcifications: When calcifications become the majority of such foci are found in benign nodules,
large enough to result in posterior acoustic shadow- and therefore the term microcalcification is a misnomer
ing, they should be considered macrocalcifications. [12]. The origins of punctate echogenic foci other than
Macrocalcifications may be irregular in shape from true psammomatous microcalcifications of PTC
(Fig. 5B, online only). are likely varied but, for example, have been shown to
B Peripheral calcifications: These calcifications occupy arise from the back walls of tiny unresolved cysts when
the periphery of the nodule. The calcification may seen in other organs such as the ovary or kidney.
not be completely continuous but generally involves Although seen in both benign and malignant nodules,
the majority of the margin. Peripheral calcifications multiple studies have shown high specificity for punctate
are often dense enough to obscure the central echogenic foci in malignant nodules [15,19,30,31].
components of the nodule (Fig. 5C, online only). n Macrocalcifications are generally considered to have an
B Comet-tail artifacts: A comet-tail artifact is a type of association with increased risk for malignancy, perhaps
reverberation artifact. The deeper echoes become slightly more than double the baseline risk [8,15,21].
attenuated and are displayed as decreased width, n For peripheral calcifications, studies have been con-
resulting in a triangular shape. If an echogenic focus flicting, with some demonstrating an increased associa-
does not have this feature, a comet-tail artifact tion with malignancy and others not [12,22].
should not be described (Fig. 5D, online only). n Recently, authors have subclassified comet-tail artifacts
into small and large types and found a prevalence of
Background and Significance.
malignancy of 15% in nodules that had echogenic foci
n Echogenic foci have been associated with both benign
with small comet-tail artifacts [12]. Conversely, when
and malignant lesions.
considering large comet-tail artifacts in cystic or
n Many authors have referred to all punctate echogenic
partially cystic nodules, multiple studies have shown a
foci in thyroid nodules simply as microcalcifications, but
strong association with benignity [12,32,33].
Comment.
n When present, the type of echogenic focus encoun-

tered within a given nodule should be specified. If

more than one type of echogenic focus is present in a
single nodule, each should be enumerated. If none are
present, this should be stated.

DISCUSSION
Ultrasound is the most commonly used imaging technique
in the evaluation of thyroid nodules, and its use has increased
the discovery of nodules greatly. With that in mind, and
given that there are conflicting recommendations from
Fig 5. Echogenic foci. (A) Punctate echogenic foci: 44-year-old
woman with 3.2-cm isoechoic smoothly marginated nodule. several societies, the ACR sponsored this TIRADS project.
Note numerous punctate echogenic foci with no posterior In keeping with other similar projects, the eventual goal of
acoustic artifacts. Diagnosis: colloid nodule (Bethesda 2). TIRADS is to provide practitioners with evidence-based
(B, online only) Macrocalcifications: 49-year-old woman with a recommendations formulated upon defined sonographic
1.7-cm hypoechoic, ill-defined nodule at the junction of the right features of a given nodule. This initial portion of our project
lobe and isthmus. Large shadowing echogenic structure was aimed at standardizing the diagnostic approach to thy-
(macrocalcification) is present in posterior portion of the nodule. roid nodules with regard to terminology.
Diagnosis: colloid nodule (Bethesda 2). (C, online only) Periph-
A wide array of terms has been used to describe the
eral calcifications: 43-year-old woman with 3.1-cm solid,
hyperechoic nodule with peripheral calcifications. Diagnosis: characteristics of thyroid nodules. Closely examining the
follicular carcinoma. (D, online only) Echogenic foci with large existing literature, we found that terms used to describe
comet-tail artifacts: 41-year-old man with 2.7-cm cystic nodule nodules are often poorly defined and inconsistently
containing multiple, mobile, echogenic foci with large comet-tail applied. Furthermore, multiple terms have often been
artifacts. Note tapering of comet tails posteriorly. Diagnosis: used to describe the same feature. This has led to
colloid nodule (Bethesda 2). confusion as to when and how these terms should be

6 Journal of the American College of Radiology

Volume - n Number - n Month 2015
applied and, in many cases, what they actually mean. ADDITIONAL RESOURCES
Clearly, inconsistent reporting leads to confusion about Additional resources can be found online at: http://dx.
recommendations for further management. doi.org/10.1016/j.jacr.2015.07.011.
Our committee sought to use terms already in com-
mon use in the literature rather than inventing new ones.
REFERENCES
We sought to provide concise written definitions with 1. Ezzat S, Sarti DA, Cain DR, Braunstein GD. Thyroid incidentalomas.
illustrations that can be used as a guide for practitioners. Prevalence by palpation and ultrasonography. Arch Intern Med
Terms that were chosen demonstrated consistency with 1994;154:1838-40.
2. Smith-Bindman R, Lebda P, Feldstein VA, et al. Risk of thyroid cancer
regard to performance in the diagnosis of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a
or to classifying a nodule as benign. Additionally, it was population-based study. JAMA Intern Med 2013;173:1788-96.
believed that features should be included that would be 3. Nam-Goong IS, Kim HY, Gong G, et al. Ultrasonography-guided
fine-needle aspiration of thyroid incidentaloma: correlation with
reproducible among various readers. pathological findings. Clin Endocrinol (Oxf) 2004;60:21-8.
Although Doppler was considered as a potential cate- 4. Ito Y, Miyauchi A, Inoue H, et al. An observational trial for papillary
gory, the committee did not recommend its inclusion on thyroid microcarcinoma in Japanese patients. World J Surg 2010;34:
28-35.
the basis of inconsistent literature about its value in 5. Cooper DS, Doherty GM, Haugen BR, et al. Revised American
differentiating cancer from benign nodules. One might Thyroid Association management guidelines for patients with thyroid
nodules and differentiated thyroid cancer. Thyroid 2009;19:
apply it technically (eg, to better define a subtle nodule),
1167-214.
but this is not something that would influence the 6. Frates MC, Benson CB, Charboneau JW, et al. Management of thy-
TIRADS classification. roid nodules detected at US: Society of Radiologists in Ultrasound
consensus conference statement. Radiology 2005;237:794-800.
Another problematic subject was nodule size. Again, 7. Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopa-
there is no consistent information in the literature that thology. Am J Clin Pathol 2009;132:658-65.
equates increasing size to an increased incidence of can- 8. Kwak JY, Han KH, Yoon JH, et al. Thyroid Imaging Reporting and
Data System for US features of nodules: a step in establishing better
cer. On the other side of the size spectrum, the recent stratification of cancer risk. Radiology 2011;260:892-9.
guidelines published by the ATA [26] state that only 9. Horvath E, Majlis S, Rossi R, et al. An ultrasonogram reporting system
nodules greater than 1 cm should be evaluated, unless for thyroid nodules stratifying cancer risk for clinical management.
J Clin Endocrinol Metab 2009;94:1748-51.
there are compelling circumstances, such as a lesion that 10. Park JY, Lee HJ, Jang HW, et al. A proposal for a thyroid imaging
bulges the thyroid capsule or has accompanying abnormal reporting end data system for ultrasound features of thyroid carcinoma.
lymph nodes or nodules in patients with high-risk clinical Thyroid 2009;19:1257-64.
11. Hoang JK, Langer JE, Middleton WD, et al. Managing incidental
factors. Reviewing the literature, we found that charac- thyroid nodules detected on imaging: white paper of the ACR Incidental
teristics of thyroid nodules other than size are more Thyroid Findings Committee. J Am Coll Radiol 2015;12:143-50.
closely associated with benign or malignant lesions, and 12. Malhi H, Beland MD, Cen SY, Allgood E, Daley K, Martin SE,
Cronan JJ, Grant EG. Echogenic foci in thyroid nodules: significance
we prefer that these form the basis for our standardized of posterior acoustic artifacts. AJR Am J Roentgenol 2014;203:1310-6.
evaluation of thyroid nodules. 13. Kim DW, Lee EJ, In HS, Kim SJ. Sonographic differentiation of
partially cystic thyroid nodules: a prospective study. AJNR Am J
Neuroradiol 2010;31:1961-6.
14. Henrichsen TL, Reading CC, Charboneau JW, Donovan DJ, Sebo TJ,
TAKE-HOME POINTS Hay ID. Cystic change in thyroid carcinoma: prevalence and estimated
volume in 360 carcinomas. J Clinical Ultrasound 2010;38:361-6.
n The goal of this project is to standardize terminology 15. Moon WJ, Jung SL, Lee JH, Na DG, Baek JH, et al. Benign and
malignant thyroid nodules: US differentiation-multicenter retrospec-
applied to thyroid nodules, such that all practitioners tive study. Radiology 2008;247:762-70.
approach their evaluation in a similar fashion. 16. Bonavita JA, Mayo J, Babb J, Bennett G, Oweity T, Macari M, Yee J.
n The establishment of a lexicon is an essential initial Pattern recognition of benign nodules at ultrasound of the thyroid:
which nodules can be left alone? AJR Am J Roentgenol 2009;193:
step that provides a structured method for evalua- 207-13.
tion. The imager is directed to evaluate specific 17. Ahn SS, Kim E-K, Kang DR, Lim S-K, Kwak JY, Kim MJ. Biopsy of
aspects of the nodule in an orderly fashion and is thyroid nodules: comparison of three sets of guidelines. AJR Am J
Roentgenol 2010;194:31-7.
provided with a set of well-defined terms and fea- 18. Frates MC, Benson CB, Doubilet PM, et al. Prevalence and distri-
tures within each area of that evaluation. bution of carcinoma in patients with solitary and multiple thyroid
n The aim is to decrease the variation seen in reporting of nodules on sonography. J Clin Endocrinol Metab 2006;91:3411-7.
19. Papini E, Guglielmi R, Bianchini A, et al. Risk of malignancy in
thyroid nodules in current practice. The ultimate goal nonpalpable thyroid nodules: predictive value of ultrasound and color-
is to develop guidelines for follow-up on the basis of Doppler features. J Clin Endocrinol Metab 2002;87:1941-6.
statistics associated with the terms in the lexicon. 20. Moon HJ, Kwak JY, Kim EK, Kim MJ. A taller-than-wide shape
in thyroid nodules in transverse and longitudinal ultrasonographic

Journal of the American College of Radiology 7

Grant et al n Thyroid Ultrasound Reporting Lexicon
 planes and the prediction of malignancy. Thyroid 2011;21: 27. Chan BK, Desser TS, McDougall IR, et al. Common and uncommon
1249-53. sonographic features of papillary thyroid carcinoma. J Ultrasound Med
21. Moon HJ, Sung JM, Kim EK, Yoon JH, Youk JH, Kwak JY. Diag- 2003;22:1083-90.
nostic performance of gray-scale US and elastography in solid thyroid 28. Kim EK, Park CS, Chung WY, et al. New sonographic criteria for
nodules. Radiology 2012;262:1002-13. recommending fine-needle aspiration biopsy of nonpalpable solid
22. Kim HG, Moon HJ, Kwak JY, Kim EK. Diagnostic accuracy of the nodules of the thyroid. AJR Am J Roentgenol 2002;178:687-91.
ultrasonographic features for subcentimeter thyroid nodules suggested 29. Hoang JK, Lee WK, Lee M, et al. US features of thyroid malignancy:
by the revised American Thyroid Association guidelines. Thyroid pearls and pitfalls. Radiographics 2007;27:847-60.
2013;23:1583-90. 30. Miofo B, Takoeto EO, Tambe J, Blanc F, Fotsin JG. Reliability of
23. Chen SP, Hu YP, Chen B. Taller-than-wide sign for predicting thyroid Thyroid Imaging Reporting and Data System (TIRADS) classification
microcarcinoma: comparison and combination of two ultrasono- in differentiating benign from malignant thyroid nodules. Open J
graphic planes. Ultrasound Med Biol 2014;40:2004-11. Radiol 2013;3:103-7.
24. Harach HR, Franssila KO, Wasenius VM. Occult papillary carcinoma 31. Iannuccilli JD, Cronan JJ, Monchik JM. Risk of malignancy as
of the thyroid. A “normal” finding in Finland. A systematic autopsy assessed by sonographic criteria: the need for biopsy. J Ultrasound Med
study. Cancer 1985;56:531-8. 2004;23:1455-64.
25. Kamran SC, Marqusee E, Kim MI, et al. Thyroid nodule size and 32. Ahuja A, Chick W, King W, Metreweli C. Clinical significance of the
prediction of cancer. J Clin Endocrinol Metab 2013;98:564-70. comet-tail artifact in thyroid ultrasound. J Clinical Ultrasound
26. Haugen BR, Alexander EK, Bible KC, et al. 2015 American 1996;24:129-33.
Thyroid Association management guidelines for patients with 33. Beland MD, Kwon L, Delellis RA, Cronan JJ, Grant EG. Non-
thyroid nodules and differentiated thyroid cancer. Thyroid. In shadowing echogenic foci in thyroid nodules are certain appearances
press. enough to avoid thyroid biopsy? J Ultrasound Med 2011;30:753-60.

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