Singapore Med J 2018; 59(11): 578-583

Original Article
https://doi.org/10.11622/smedj.2018062

Diagnostic performance of ATA, BTA and TIRADS

sonographic patterns in the prediction of malignancy in
histologically proven thyroid nodules
Chiaw Ling Chng1, MBBS, MRCP, Hong Chang Tan1, MBBS, MRCP, Chow Wei Too2, MBBS, FRCR, Wei Ying Lim1, MBBS, MRCP,
Priscilla Pei Sze Chiam1, MBChB, MRCP, Ling Zhu1, MBBChir, MRCP, Nivedita Vikas Nadkarni3, PhD, Adoree Yi Ying Lim1, MBBS, MRCP

INTRODUCTION We aimed to compare the malignancy risk stratification of histologically proven thyroid nodules using
the 2015 American Thyroid Association (ATA) Management Guidelines, 2014 British Thyroid Association (BTA) Guidelines
for the Management of Thyroid Cancer and the Thyroid Imaging Reporting and Data System (TIRADS).
METHODS Thyroid nodules measuring > 1 cm resected over 5.5 years were retrospectively studied. Demographic
information as well as cytology and histopathology results were collected. Static ultrasonography (US) images and
radiologists’ reports of each resected nodules were reviewed and classified based on the above risk classification systems.
RESULTS A total of 167 thyroid nodules from 150 patients were examined. More malignant nodules were solid (78.4%
vs. 62.5%; p = 0.049) or hypoechoic (70.6% vs. 28.6%; p < 0.001), and had irregular margins (35.3% vs. 8.0%; p < 0.001),
taller-than-wide morphology (9.8% vs. 2.7%; p = 0.031), microcalcifications (33.3% vs. 8.0%; p < 0.001), disrupted rim
calcifications (9.8% vs. 0.9%; p = 0.012) or associated abnormal cervical lymphadenopathy (13.7% vs. 0.9%; p = 0.001)
compared with benign nodules. The guidelines’ diagnostic performance was: ATA – sensitivity 98.0%, specificity 17.3%,
positive predictive value (PPV) 35.0%, negative predictive value (NPV) 95.0%; BTA – sensitivity 90%, specificity 50.9%,
PPV 45.5%, NPV 91.8%; and TIRADS – sensitivity 94.0%, specificity 28.2%, PPV 37.3%%, NPV 91.2%.
CONCLUSION Sonographic patterns outlined by the three guidelines displayed high sensitivity and NPV. Although isolated
suspicious US features cannot predict malignancy risk, they should be considered when risk stratifying nodules that do
not fit into particular sonographic patterns based on current guidelines.

Keywords: thyroid cancer, thyroid nodule, ultrasonography

INTRODUCTION variations of TIRADS have been proposed. The TIRADS structure

Fine needle aspiration (FNA) is a standard initial step and an suggested by Kwak et al(6) predicts malignancy risks according to
invaluable tool in the assessment and evaluation of thyroid only the number of suspicious US features, and several studies
nodules. The addition of ultrasonography guidance in FNA (US- have proven that these US features are effective not only in risk
FNA) has been shown to improve the accuracy of the procedure stratification, but also in patient treatment.(7-9) However, it is often
and decrease the false-negative rate of a benign cytology difficult to compare the accuracy of different guidelines due to the
diagnosis.(1,2) While it has been reported that certain sonographic differing samples of the various studies from which the guidelines
features of a thyroid nodule are associated with an increased were established.
likelihood of malignancy, no single predictor has been found to The aim of the present study was to compare the malignancy
have a high positive predictive value (PPV) for cancer. Hence, risk stratification of histologically proven thyroid nodules using
many professional bodies have striven to produce guidelines the 2015 ATA Management Guidelines for Adult Patients with
to aid clinical decisions in the selection of thyroid nodules for Thyroid Nodules and Differentiated Thyroid Cancer,(3) the 2014
US-FNA, recommending that only nodules with suspicious US BTA Guidelines for the Management of Thyroid Cancer(4) and
characteristics be biopsied. the TIRADS classification proposed by Kwak et al.(6) We applied
In recent years, both the American Thyroid Association (ATA) these three sets of US risk classification systems to the same
and British Thyroid Association (BTA) have published guidelines sample to assess their diagnostic performance in the prediction
for US risk stratification of thyroid nodules.(3,4) Importantly, both of histologically confirmed malignancy.
guidelines emphasised sonographic patterns, rather than growth
of thyroid nodules, as the major deciding factor for biopsy. METHODS
The Thyroid Imaging Reporting and Data System (TIRADS), A total of 1,531 thyroid nodules underwent US-FNA at the
first proposed by Horvath et al,(5) was introduced to improve Department of Endocrinology, Singapore General Hospital,
communication between radiologists and physicians through Singapore, between January 2010 and June 2015. The decision
a standardised reporting format. Since its introduction, many to perform a biopsy on these nodules during the study period was

1
Department of Endocrinology, 2Department of Vascular and Interventional Radiology, Singapore General Hospital, 3Centre for Quantitative Medicine, Duke-NUS Medical
School, Singapore
Correspondence: Dr Chng Chiaw Ling, Senior Consultant, Department of Endocrinology, Singapore General Hospital, Level 3, Academia, 20 College Road, Singapore 169856.
[email protected]

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1a 1b 1c

Fig. 1 US images show the three sonographic patterns. (a) Left thyroid cyst, classified as ATA benign, BTA U2 and TIRADS 3, was shown to be a haemorrhagic
cyst on histology. (b) Left thyroid solid and hypoechoic nodule, classified as ATA intermediate suspicion, BTA U4 and TIRADS 4B, was shown to be a benign
nodular goitre on histology. (c) Right thyroid solid, hypoechoic nodule with taller-than-wide shape, irregular margins and microcalcifications, classified
as ATA high suspicion, BTA U5 and TIRADS 5, was shown to be papillary thyroid cancer on histology. ATA: American Thyroid Association Management
Guidelines; BTA: British Thyroid Association Guidelines for the Management of Thyroid Cancer; TIRADS: Thyroid Imaging Reporting and Data System

based on the 2009 ATA guidelines.(10) Of these thyroid nodules, features: hyperechogenicity; cystic; peripheral vascularity;
those that were surgically resected and measured more than 1 cm microcalcifications; or round shape.(14)
were studied retrospectively. Information such as the gender and The US appearances of these resected nodules were then
age of the patient during the US-FNA preceding surgery, as well classified based on the recent ATA guidelines, BTA guidelines and
as cytology and histopathology results, were collected from the TIRADS classification.(3,4,6) The three US risk stratification systems
hospital’s electronic medical case records and case notes. are shown in the Appendix. The ATA guidelines classify the US
At our institution, cytological results were broadly classified appearance of thyroid nodules into benign or low, intermediate
according to the Bethesda System for Reporting Thyroid or high suspicion of malignancy. The BTA guidelines classify the
Cytopathology(11) into the following categories: non-diagnostic; US appearance of thyroid nodules as U1 (normal), U2 (benign),
benign; atypia of undetermined significance or follicular lesion of U3 (indeterminate), U4 (suspicious) or U5 (malignant). The
undetermined significance; follicular neoplasm or suspicious for number of suspicious US features of each thyroid nodule was also
a follicular neoplasm; suspicious for malignancy; or malignant. counted based on the TIRADS classification proposed by Kwak
In addition, static US images and radiologists’ reports of each et al.(6) In this scoring system, a solid nodule, hypoechogenicity or
resected nodule were reviewed by two independent observers marked hypoechogenicity, microlobulated or irregular margins,
with 2–8 years’ experience in US-FNA to ensure the consistent microcalcifications or mixed calcifications, and a taller-than-wide
assignment of US risk category to each nodule. In the event of shape were considered suspicious US features. Thyroid nodules
disagreements between observers, they reviewed the US images without suspicious features (e.g. pure cyst or mixed solid-cystic
together to reach a consensus. nodules without any suspicious features) were classified as
All nodules were assessed for the following features: TIRADS Category 3. Thyroid nodules with one, two, three/four
size; composition; hypoechogenicity; microlobulated or or five suspicious features were classified as Categories 4A, 4B,
irregular margins; taller-than-wide shape; microcalcifications; 4C and 5, respectively. Examples of US images of thyroid nodules
macrocalcifications; disrupted rim calcifications; intranodular classified based on the three risk stratification systems are showed
vascularity; and abnormal cervical lymphadenopathy. Size was in Fig. 1. The study was approved by the SingHealth Centralised
measured at the maximum dimension. The composition of the Institutional Review Board.
nodule was classified as purely cystic, mixed or solid, based Data was analysed using IBM SPSS Statistics for Windows
on the ratio of the cystic to the solid portion of the nodule. version 21.0 (IBM Corp, Armonk, NY, USA). Baseline continuous
The echogenicity of the nodule was compared with that of the data was expressed as mean ± standard deviation, and categorical
surrounding parenchyma, and marked hypoechogenicity was data was expressed in percentages. Chi-square or Fisher’s exact
defined as lower echogenicity than that of the cervical strap test was used to test the association between the outcome
muscle. Echogenicity of a mixed solid-cystic nodule was assessed and categorical variables. t-test was used to test differences
based on the solid portion. Microcalcifications were defined as in the means of continuous variables by the outcome. The
tiny (< 1 mm in diameter), punctate and hyperechoic foci with diagnostic performance of the three US risk classification systems
or without acoustic shadows, while macrocalcifications were (i.e. sensitivity, specificity, PPV and negative predictive value
defined as > 1 mm in diameter. A taller-than-wide shape was [NPV]) was calculated. A p-value < 0.05 was considered as
defined as one having anteroposterior to transverse diameter ratio statistically significant.
≥ 1. Colour Doppler US images were assessed for intranodular
vascularity, and this was classified on a four-point scale as RESULTS
suggested by Fukunari et al, with Grades 3 and 4 considered We studied 167 thyroid nodules from 150 patients. The nodules
to be high intranodular vascularity.(12,13) Abnormal cervical were resected surgically during the five-and-a-half-year study
lymph nodes were defined as those that exhibit the following period. Surgical resection of these thyroid nodules revealed

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115 benign and 52 malignant histologies (34 papillary thyroid, goitres, and 17 patients elected surgery as the method of treatment
14 follicular thyroid, two medullary thyroid and two anaplastic for their thyroid nodules. Another nine patients who had non-
thyroid cancers). There were no significant differences in age diagnostic FNA cytology results also underwent surgery – five
(53.6 ± 13.0 years vs. 54.4 ± 12.4 years; p = 0.735) or gender had suspicious US findings and four opted for surgical resection
distribution (88.1% female vs. 83.7% female; p = 0.453) between of their thyroid nodules.
patients with benign nodules and those with malignant nodules. There were four cases with no US images. Three cases could
Surgery was performed on 87 nodules with benign cytologic not be assigned an ATA or a BTA classification: two nodules
findings from 77 patients for the following reasons: suspicious were solid-cystic in nature, but one had a taller-than-wide shape
US findings (n = 20); thyroid nodules showing substantial and the other had microcalcifications (both benign on histology),
growth (n = 6); and compression symptoms from large (> 5 cm) while the third nodule was solid and isoechoic on US but had
multinodular goitres or nodules (n = 26). Eight patients had surgery associated suspicious cervical lymphadenopathy (papillary thyroid
to treat their underlying Graves’ disease or toxic multinodular cancer on histology). A comparison of individual sonographic
characteristics between thyroid nodules with benign histologies
Table I. Comparison of ultrasonography (US) characteristics and those with malignant histologies is presented in Table I. There
between thyroid nodules with benign and malignant histology was no significant difference in the size of benign thyroid nodules
outcomes. compared to malignant ones. Compared with benign nodules,
US characteristic No. (%) p‑value significantly higher percentages of malignant nodules were solid
Benign Malignant (78.4% vs. 62.5%; p = 0.049) or hypoechoic (70.6% vs. 28.6%;
(n = 112) (n = 51) p < 0.001), had irregular margins (35.3% vs. 8.0%; p < 0.001),
Largest diameter* (cm) 3.1 ± 1.5 3.0 ± 1.7 0.528 taller-than-wide morphology (9.8% vs. 2.7%; p = 0.031),
Solid nodule 70 (62.5) 40 (78.4) 0.049† microcalcifications (33.3% vs. 8.0%; p < 0.001), disrupted rim
Hypoechogenicity 32 (28.6) 36 (70.6) < 0.001† calcifications (9.8% vs. 0.9%; p = 0.012) or associated abnormal
Irregular margins 9 (8.0) 18 (35.3) < 0.001† cervical lymphadenopathy (13.7% vs. 0.9%; p = 0.001).
Taller‑than‑wide morphology 3 (2.7) 5 (9.8) 0.031† The malignancy rates of the ATA categories were benign 0%,
Microcalcification 9 (8.0) 17 (33.3) < 0.001† very low suspicion 5.9%, low suspicion 14.3%, intermediate
Macrocalcification 26 (23.2) 11 (21.6) 1.000 suspicion 40.0% and high suspicion 67.5% (Table II), with
Disrupted rim calcification 1 (0.9) 5 (9.8) 0.012† significant differences among the various categories (p < 0.001).
Intranodular vascularity 14 (12.5) 12 (23.5) 0.105 The malignancy rates of the BTA categories were U2 8.2%,
Cervical lymph node 1 (0.9) 7 (13.7) 0.001† U3 22.6%, U4 44.8%, and U5 64.1% (p < 0.001). Based on the
TIRADS classification, the malignancy rates for Categories 3, 4A,
*Data presented as mean ± standard deviation. †Statistically significant.

Table II. Malignancy rates of thyroid nodules based on sonographic patterns and recommended malignancy rates based on the literature.
Classification No. of cases No. (%) Malignancy Recommended
(n = 160) Benign Malignant rate (%) malignancy
(n = 110) (n = 50) rate (%)
ATA
Benign 3 3 (2.7) 0 0 <1
Very low suspicion 17 16 (14.5) 1 (2.0) 5.9 <3
Low suspicion 70 60 (54.5) 10 (20.0) 14.3 5–10
Intermediate suspicion 30 18 (16.4) 12 (24.0) 40.0 10–20
High suspicion 40 13 (11.8) 27 (54.0) 67.5 > 70–90
BTA
Benign (U2) 61 56 (50.9) 5 (10.0) 8.2
Intermediate (U3) 31 24 (21.8) 7 (14.0) 22.6
Suspicious (U4) 29 16 (14.5) 13 (26.0) 44.8
Malignant (U5) 39 14 (12.7) 25 (50.0) 64.1
TIRADS
3 34 31 (28.2) 3 (6.0) 8.8 1.7
4A 46 39 (35.5) 7 (14.0) 15.2 3.3
4B 47 30 (27.3) 17 (34.0) 36.2 9.2
4C 32 10 (9.1) 22 (44.0) 68.8 44.4–72.4
5 1 0 (0) 1 (2.0) 100.0 87.5
BTA did not provide recommended malignancy rates for each U category in the guidelines. ATA: American Thyroid Association Management Guidelines; BTA: British
Thyroid Association Guidelines for the Management of Thyroid Cancer; TIRADS: Thyroid Imaging Reporting and Data System

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4B, 4C and 5 were 8.8%, 15.2%, 36.2%, 68.8% and 100.0%, the current literature for both the ATA guidelines and TIRADS
respectively (p < 0.001). The diagnostic performance of the ATA classification (Table II). The overall malignancy rate in our study
guidelines when considering benign and very-low-suspicion US was also high, at 31.7%. Since this is a retrospective analysis of
patterns as negative test outcomes and low-to-high-suspicion a highly selected group of patients undergoing thyroidectomy,
nodules as positive test outcomes was as follows: sensitivity these thyroid nodules may already be at higher risk for malignancy
98.0%, specificity 17.3%, PPV 35.0% and NPV 95.0%. The based on the managing physician’s clinical impression. All
US appearances that were benign and very low suspicion were three thyroid nodules that could not be assigned an ATA or a
considered negative test outcomes in our study because the ATA BTA classification would be classified as TIRADS Category 4A
guidelines recommend no FNA and observation without further based on the number of suspicious US features (which excluded
intervention, respectively, for these two categories. The diagnostic associated suspicious cervical lymphadenopathy) and considered
performance of the BTA guidelines when considering U2 as a low suspicion for malignancy. However, on histology, one of
negative test outcome and U3–U5 as positive test outcomes these three thyroid nodules was found to be a papillary thyroid
was as follows: sensitivity 90%, specificity 50.9%, PPV 45.5% cancer. A recent study noted that the malignancy risk was
and NPV 91.8%. The diagnostic performance of the TIRADS 18.2% for thyroid nodules that could not be classified into a
classification when considering Category 3 as a negative test specific pattern based on the latest ATA guidelines.(24) Hence,
outcome and Categories 4A–5 as positive test outcomes was as although isolated suspicious US features cannot predict the risk
follows: sensitivity 94.0%, specificity 28.2%, PPV 37.3% and of malignancy, they should be taken into consideration when
NPV 91.2%. risk stratifying nodules that do not fit into particular sonographic
patterns based on current guidelines. Our study also highlighted
DISCUSSION a few specific issues with the ATA guidelines that may need to be
US is an important diagnostic tool in predicting thyroid malignancy addressed, such as potentially worrisome features of malignancy
and selecting thyroid nodules that should be evaluated by FNA. that are not included among the patterns in the guidelines.(25)
In our study, there were higher percentages of malignant nodules The present study compared the diagnostic performance of
that were solid and had irregular margins, hypoechogenicity and three established US risk classification guidelines. Sensitivity
taller-than-wide morphology, microcalcifications, disrupted rim and NPV were ≥ 90% for all three guidelines. Among them, the
calcifications or associated abnormal cervical lymphadenopathy. ATA guidelines had the highest sensitivity and NPV. Notably,
These US features were also included in the ATA, BTA none of the thyroid nodules with sonographic patterns that were
and TIRADS guidelines. Nodule size and the presence of considered benign, and only one solid-cystic thyroid nodule with
macrocalcifications and intranodular vascularity were not a sonographic pattern associated with very low suspicion for
significantly different between benign and malignant nodules. In a malignancy, turned out to be malignant on eventual histology. The
recent meta-analysis conducted to determine the accuracy of US histology of this nodule was a 1.8-cm minimally invasive follicular
features in predicting malignancy, Brito et al found that thyroid thyroid cancer. In addition, out of the ten malignant nodules that
nodule size was not an accurate predictor of thyroid cancer were classified as low suspicion by ATA sonographic patterns,
across different size cut-offs.(15) The presence of intranodular six were follicular thyroid cancers, three were papillary thyroid
macrocalcifications was also not consistently associated with cancers and one was a medullary thyroid cancer. Studies have
thyroid cancer in previous studies.(16,17) However, the presence suggested that follicular thyroid cancers may exhibit differences in
of disrupted rim calcifications, which suggests tumour invasion sonographic appearance compared to papillary thyroid cancers,
in the area of disrupted calcification, is a feature associated with and may also have some features in common with follicular
malignancy.(18) In a retrospective study of 1,083 thyroid nodules, adenoma.(26,27) Although specificity and PPV were higher with
Moon et al reported that intranodular vascularity was seen in 31% the BTA guidelines and TIRADS classification compared to the
of benign thyroid nodules compared to 17% of malignant nodules. ATA guidelines, five nodules based on the BTA guidelines and
The authors thus concluded that this sonographic feature alone, three nodules based on the TIRADS classification, which were
or in combination with other suspicious malignant features on considered to have benign sonographic patterns, were found
grayscale US, is not useful in predicting thyroid malignancy.(19) to be thyroid cancers on final histology. The results of our
However, intranodular vascularity may correlate better with study confirmed the important role of sonographic patterns as
malignancy in follicular thyroid cancers compared to papillary a screening tool in identifying thyroid nodules warranting FNA,
thyroid cancers.(15,20,21) Although individual US features do not and suggest that US alone may not be specific enough to discern
provide strong evidence to confirm or rule out a diagnosis of benign nodules from malignant ones.
malignancy,(22,23) the combination of several suspicious US The main limitations of the present study were its retrospective
features into sonographic patterns improves the prediction of design and small numbers. Also, physicians reading the US
malignancy risk in these nodules. images were not blinded to the clinical information available,
In the present study, the malignancy rates of the thyroid such as cytology and histology findings. Each US image was
nodules increased with increasing suspicious sonographic patterns read independently by two observers, who then assigned a
based on the ATA, BTA and TIRADS categories. The malignancy sonographic pattern based on the pictorial classification outlined
rates in our study were higher than those recommended by by the guidelines used in this study. Although we did not study

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the interobserver correlation, two recent studies have reported Clin Endocrinol (Oxf) 2015; 83:711-6.
8. Moon HJ, Kim EK, Yoon JH, Kwak JY. Malignancy risk stratification in thyroid
moderate to substantial interobserver correlation for identification nodules with nondiagnostic results at cytologic examination: combination of
of nodule sonographic patterns.(23,28) We also did not have clinical thyroid imaging reporting and data system and the Bethesda System. Radiology
2015; 274:287-95.
information on risk factors for thyroid cancer, such as previous
9. Moon HJ, Kim EK, Kwak JY. Malignancy risk stratification in thyroid nodules
head and neck irradiation or family history of thyroid cancer, with benign results on cytology: combination of thyroid imaging reporting and
which might have influenced the decision to surgically remove data system and Bethesda system. Ann Surg Oncol 2014; 21:1898-903.
10. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules
the thyroid nodule. and Differentiated Thyroid Cancer, Cooper DS, Doherty GM, et al. Revised
The strength of the present study lies in the fact that only American Thyroid Association management guidelines for patients with thyroid
nodules and differentiated thyroid cancer. Thyroid 2009; 19:1167-214.
nodules that were resected were included and the final histology 11. Cibas ES, Ali SZ. The Bethesda System for reporting thyroid cytopathology.
was used as the reference standard, since the histology provides Thyroid 2009; 19:1159-65.
12. Fukunari N, Nagahama M, Sugino K, et al. Clinical evaluation of color Doppler
the greatest certainty on the eventual diagnosis. Previous studies imaging for the differential diagnosis of thyroid follicular lesions. World J Surg
that compared the diagnostic performance of different US 2004; 28:1261-5.
13. Baskin HJ, Sr, Duick DS, Levine RA. Thyroid Ultrasound and Ultrasound-Guided
guidelines had included only nodules that were diagnosed based
FNA Biopsy. New York: Springer-Verlag; 2013.
on cytologic findings.(24,29) This could result in some malignant 14. Leenhardt L, Erdogan MF, Hegedus L, et al. 2013 European thyroid association
nodules being missed and lead to potential bias in the results. This guidelines for cervical ultrasound scan and ultrasound-guided techniques in
the postoperative management of patients with thyroid cancer. Eur Thyroid J
is also the only local study to date that systematically examines 2013; 2:147-59.
the US features of thyroid nodules using established US risk 15. Brito JP, Gionfriddo MR, Al Nofal A, et al. The accuracy of thyroid nodule
ultrasound to predict thyroid cancer: systematic review and meta-analysis.
stratification systems. J Clin Endocrinol Metab 2014; 99:1253-63.
In conclusion, the results of the present study showed that 16. Wang N, Xu Y, Ge C, Guo R, Guo K. Association of sonographically detected
calcification with thyroid carcinoma. Head Neck 2006; 28:1077-83.
sonographic patterns outlined by the ATA guidelines, BTA 17. Shi C, Li S, Shi T, et al. Correlation between thyroid nodule calcification
guidelines and TIRADS classification have the high sensitivity morphology on ultrasound and thyroid carcinoma. J Int Med Res 2012; 40:350-7.
18. Park YJ, Kim JA, Son EJ, et al. Thyroid nodules with macrocalcification:
and NPV required for triaging of thyroid nodules for subsequent
sonographic findings predictive of malignancy. Yonsei Med J 2014; 55:339-44.
FNA. It is also important to note that current US criteria do not 19. Moon HJ, Kwak JY, Kim MJ, Son EJ, Kim EK. Can vascularity at power Doppler
replace FNA in establishing a definitive diagnosis in thyroid US help predict thyroid malignancy? Radiology 2010; 255:260-9.
20. Papini E, Guglielmi R, Bianchini A, et al. Risk of malignancy in nonpalpable
nodules. Several recent studies have suggested using the potential thyroid nodules: predictive value of ultrasound and color-Doppler features.
combination of US patterns, cytology results from FNA and J Clin Endocrinol Metab 2002; 87:1941-6.
21. Cappelli C, Castellano M, Pirola I, et al. The predictive value of ultrasound
molecular markers in enhancing stratification of the malignant findings in the management of thyroid nodules. QJM 2007; 100:29-35.
risk of thyroid nodules before recommending surgical resection, 22. Moon WJ, Jung SL, Lee JH, et al; Thyroid Study Group, Korean Society of
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However, molecular markers are yet to be widely available or 23. Remonti LR, Kramer CK, Leitão CB, Pinto LC, Gross JL. Thyroid ultrasound
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observational studies. Thyroid 2015; 25:538-50.
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APPENDIX

American Thyroid Association (ATA), British Thyroid Association (BTA) and Thyroid Imaging Reporting and Data System (TIRADS)
ultrasonography sonographic patterns
ATA classification
Benign Purely cystic nodules (no solid component)
Very low suspicion Spongiform or partially cystic nodules without any of the sonographic features described in low,
intermediate or high suspicion patterns
Low suspicion Isoechoic or hyperechoic solid nodule or partially cystic nodule with eccentric solid areas, without
microcalcification, irregular margin or extrathyroidal extension (ETE), or taller‑than‑wide shape
Intermediate suspicion Hypoechoic solid nodule with smooth margins without microcalcifications, ETE or taller‑than‑wide
shape
High suspicion Solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with one or
more of the following features: irregular margins (infiltrative, microlobulated), microcalcifications,
taller‑than‑wide shape, rim calcifications with small extrusive soft tissue component, evidence of
ETE
BTA classification
U1 (normal) Normal thyroid gland
U2 (benign) • Spongiform or honeycomb appearance
• Purely cystic nodule and nodules with a cystic component containing colloid (hyperechoic foci
with a ‘ring‑down’ sign)
• Egg‑shell type calcification around the periphery of a nodule
• Isoechoic or (mildly) hyperechoic nodule, typically with a surrounding hypoechoic halo
• Peripheral vascularity on colour flow or power Doppler
U3 (intermediate/equivocal) • Homogenous solid nodule with marked hyperechogenicity and halo
• Possible hypoechoic nodule with presence of equivocal echogenic foci or cystic change, or
presence of mixed or central vascularity
U4 (suspicious) • Solid, hypoechoic or very hypoechoic nodule
• Solid, hypoechoic nodule with disrupted peripheral calcification or lobulated outline
U5 (malignant) Solid, hypoechoic, lobulated/irregular outline with microcalcification, globular calcification,
intranodular vascularity taller‑than‑wide shape or characteristics associated with
lymphadenopathy
TIRADS classification
TIRADS 3 No suspicious ultrasonography feature*
TIRADS 4A One suspicious ultrasonography feature
TIRADS 4B Two suspicious ultrasonography features
TIRADS 4C Three or four suspicious ultrasonography features
TIRADS 5 Five suspicious ultrasonography features
*Suspicious features are solid nodule, hypoechogenicity or marked hypoechogenicity, microlobulated or irregular margins, microcalcifications or mixed
calcifications and a taller‑than‑wide shape.

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