-, Lee JH, Shin SW. Overdiagnosis and Screening for Thyroid Cancer in Korea. As noted previously, we intentionally chose the clinical comparator to be relatively poor and not a fair reflection of real-world practice, to make it clearer to what degree ACR TIRADS adds value. TI-RADS 1: Normal thyroid gland. TI-RADS 4b applies to the lesion with one or two of the above signs and no metastatic lymph node is present. Anderson TJ, Atalay MK, Grand DJ, Baird GL, Cronan JJ, Beland MD. Putting aside any potential methodological concerns with ACR TIRADS, it may be helpful to illustrate how TIRADS might work if one assumed that the data set used was a fair approximation to the real-world population. J Adolesc Young Adult Oncol (2020) 9(2):2868. No focal lesion. If the proportions of patients in the different TR groups in the ACR TIRADs data set is similar to the real-world population, then the prevalence of thyroid cancer in the TR3 and TR4 groups is lower than in the overall population of patients with thyroid nodules. At the time the article was created Praveen Jha had no recorded disclosures. The flow chart of the study. It is this proportion of patients that often go on to diagnostic hemithyroidectomies, from which approximately 20% are cancers [12, 17, 21], meaning the majority (80%) end up with ultimately unnecessary operations. Given the need to do more than 100 US scans to find 25 patients with just TR1 or TR2 nodules, this would result in at least 50 FNAs being done. If one accepts that the pretest probability of a patient presenting with a thyroid nodule having an important thyroid cancer is 5%, then clinicians who tell every patient they see that they do not have important thyroid cancer will be correct 95% of the time. 3, 4 The modified TI-RADS based on the ACR TI-RADS scoring system was sponsored by Wang et al. Many studies have not found a clear size/malignancy correlation, and where it has been found, the magnitude of the effect is modest. Thyroid nodules are a common finding, especially in iodine-deficient regions. At best, only a minority of the 3% of cancers would show on follow-up imaging features suspicious for thyroid cancer that correctly predict malignancy. For a rule-out test, sensitivity is the more important test metric. The low pretest probability of important thyroid cancer and the clouding effect of small clinically inconsequential thyroid cancers makes the development of an effective real-world test incredibly difficult. The most common reason for our diagnosis is the thyroid nodule, a growth that often develops on the thyroid, the organ that controls our metabolism. A re-analysis of thyroid imaging reporting and data system ultrasound scoring after molecular analysis is a cost-effective option to assist with preoperative diagnosis of indeterminate thyroid . The site is secure. (2009) Thyroid : official journal of the American Thyroid Association. 4b - Suspicious nodules (10-50% risk of malignancy) Score of 2. Until TIRADS is subjected to a true validation study, we do not feel that a clinician can currently accurately predict what a TIRADS classification actually means, nor what the most appropriate management thereafter should be. Save my name, email, and website in this browser for the next time I comment. Using TR5 as a rule-in test was similar to random selection (specificity 89% vs 90%). In 2009, Park et al. ; Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology. This allows patients with a TR1 or TR2 nodule to be reassured that they have a low risk of thyroid cancer, rather than a mixture of nodules (not just TR1 or TR2) not being able to be reassured. For TIRADS to add clinical value, it would have to clearly outperform the comparator (random selection), particularly because we have made some assumptions that favor TIRADS performance. The detection rate of thyroid cancer has increased steeply with widespread utilization of ultrasound (US) and frequent incidental detection of thyroid nodules with other imaging modalities such as computed tomography, magnetic resonance imaging, and, more recently, positron emission tomography-computed tomography, yet the mortality from thyroid cancer has remained static [10, 11]. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Other similar systems are in use internationally (eg, Korean-TIRADS [14] and EU-TIRADS [15]). The other one-half of the cancers that are missed by only doing FNA of TR5 nodules will mainly be in the TR3 and TR4 groups (that make up 60% of the population), and these groups will have a 3% to 8% chance of cancer, depending upon whether the population prevalence of thyroid cancer in those being tested is 5% or 10%. Disclaimer. In the TR3 category, there was a gradual difference in cancer rate in those 1-2 cm (6.5%), and those 2-3 cm (8.4%) and those>3 cm (11.3%). There are inherent problems with studies addressing the issue such as selection bias at referral centers and not all nodules having fine needle aspiration (FNA). Performance of Contrast-Enhanced Ultrasound in Thyroid Nodules: Review of Current State and Future Perspectives. 7. At the time the article was last revised Yuranga Weerakkody had We first estimate the performance of ACR TIRADS guidelines recommended approach to the initial decision to perform FNA, by using TR1 or TR2 as a rule-out test, or using TR5 as a rule-in test because applying TIRADS at the extremes of pretest cancer risk (TR1 and TR2 for lowest risk, and TR5 for highest risk), is most likely to perform best. Diag (Basel) (2021) 11(8):137493. For this, we do take into account the nodule size cutoffs but note that for the TR3 and TR4 categories, ACR TIRADS does not detail how it chose the size cutoffs of 2.5 cm and 1.5 cm, respectively. A newer alternative that the doctor can use to treat benign nodules in an office setting is called radiofrequency ablation (RFA). 8600 Rockville Pike There are a number of additional issues that should be taken into account when examining the ACR TIRADS data set and resultant management recommendations. Perhaps the most relevant positive study is from Korea, which found in a TR4 group the cancer rate was no different between nodules measuring between 1-2 cm (22.3%) and those 2-3 cm (23.5%), but the rate did increase above 3 cm (40%) [24]. Given that ACR TIRADS test performance is at its worst in the TR3 and TR4 groups, then the cost-effectiveness of TIRADS will also be at its worst in these groups, in particular because of the false-positive TIRADS results. Cheng H, Zhuo SS, Rong X, Qi TY, Sun HG, Xiao X, Zhang W, Cao HY, Zhu LH, Wang L. Int J Endocrinol. TIRADS can be welcomed as an objective way to classify thyroid nodules into groups of differing (but as yet unquantifiable) relative risk of thyroid cancer. Lancet (2014) 384(9957): 1848:184858. The proportion of malignancy in Bethesda III nodules confirmed by surgery were significantly increased in proportion relative to K-TIRADS with 60.0% low suspicion, 88.2% intermediate suspicion, and 100% high suspicion nodules (p < 0.001). Full data including 95% confidence intervals are given elsewhere [25]. A 38-year-old woman with a nodule in the right-lobe of her thyroid gland. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. Castellana M, Castellana C, Treglia G, Giorgino F, Giovanella L, Russ G, Trimboli P. Oxford University Press is a department of the University of Oxford. Park JY, Lee HJ, Jang HW, Kim HK, Yi JH, Lee W, Kim SH. The prevalence of incidental thyroid cancer at autopsy is around 10% [3]. Data Set Used for Development of ACR TIRADS [16] and Used for This Paper The possible cancer rate column is a crude, unvalidated estimate, calculated by proportionately reducing the cancer rates by 10.3%: 5% to reflect the likely difference in the cancer rate in the data set used (10.3%) and in the population presenting with a thyroid nodule (5%). government site. The key next step for any of the TIRADS systems, and for any similar proposed test system including artificial intelligence [30-32], is to perform a well-designed prospective validation study to measure the test performance in the population upon which it is intended for use. The CEUS-TIRADS category was 4c. Diagnosis and Management of Small Thyroid Nodules: A Comparative Study with Six Guidelines for Thyroid Nodules. Careers. However, there are ethical issues with this, as well as the problem of overdiagnosis of small clinically inconsequential thyroid cancer. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 24;8 (10): e77927. 5 The modified TI-RADS was composed of seven ultrasound features in identifying benign and malignant thyroid nodules, such as the nodular texture, nodular Tirads 5 thyroid gland: is a thyroid gland with 5 or more lesions, the rate of malignancy accounts for 87.5%. It is interesting to see the wealth of data used to support TIRADS as being an effective and validated tool. The actual number of inconclusive FNA results in the real-world validation set has not been established (because that study has not been done), but the typical rate is 30% (by this we mean nondiagnostic [ie, insufficient cells], or indeterminate [ie, atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS)/follicular neoplasm/suspicious for follicular neoplasm [Bethesda I, III, IV]). Therefore, 60% of patients are in the middle groups (TR3 and TR4), where the US features are less discriminatory. We have detailed the data set used for the development of ACR TIRADS [16] in Table 1, plus noted the likely cancer rates in the real world if one assumes that the data set cancer prevalence (10.3%) is double that in the population upon which the test is intended to be used (pretest probability of 5%). When it reflected an absent enhancement in CEUS, the nodule was judged as CEUS-TIRADS 3. doi: 10.1089/jayao.2019.0098 A prospective validation study that determines the true performance of TIRADS in the real-world is needed. Symptoms and Causes Diagnosis and Tests Management and Treatment Prevention Outlook / Prognosis Living With Frequently Asked Questions Overview 4. Thyroid nodule size from 1.5 - 2.5cm: Periodic follow-up every 6 months. Check for errors and try again. Thyroid nodules are very common and benign in most cases. Ultimately, most of these turn out to be benign (80%), so for every 100 FNAs, you end up with 16 (1000.20.8) unnecessary operations being performed. There remains the need for a highly performing diagnostic modality for clinically important thyroid cancers. A systematic autopsy study, The incidence of thyroid cancer by fine needle aspiration varies by age and gender, Thyroid cancer in the thyroid nodules evaluated by ultrasonography and fine-needle aspiration cytology, Comparison of 5-tiered and 6-tiered diagnostic systems for the reporting of thyroid cytopathology: a multi-institutional study. So, for 100 scans, if FNA is done on all TR5 nodules, this will find one-half of the cancers and so will miss one-half of the cancers. The nodules were scored, measured and assigned to one of five TI-RADS levels (TR): TR1 - benign, TR2 - not suspicious, TR3 - mildly suspicious, TR4 - moderately suspicious, TR5 - highly suspicious. The flow chart of the study. The area under the curve was 0.803. Outlook. We realize that such factors may increase an individuals pretest probability of cancer and clinical decision-making would change accordingly (eg, proceeding directly to FNA), but we here ascribe no additional diagnostic value to avoid overestimating the performance of the clinical comparator. A key factor is the low pretest probability of important thyroid cancer but a higher chance of finding thyroid cancers that are very unlikely to cause ill health during a persons lifetime. They are found . Quite where the cutoff should be is debatable, but any cutoff below TR5 will have diminishing returns and increasing harms. All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. As it turns out, its also very accurate and detailed. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. The sensitivity, specificity, and accuracy of C-TIRADS were 93.1%, 55.3%, and 74.6% respectively. The system has fair interobserver agreement 4. That particular test is covered by insurance and is relatively cheap. That particular test is covered by insurance and is relatively cheap. However, these assumptions have intentionally been made to favor the expected performance of ACR-TIRADS, and so in real life ACR-TIRADS can be expected to perform less well than we have illustrated. Cawood T, Mackay GR, Hunt PJ, OShea D, Skehan S, Ma Y. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M. Yoon JH, Lee HS, Kim EK, Moon HJ, Kwak JY. PMC . Very probably benign nodules are those that are both. The. 19 (11): 1257-64. Jin Z, Zhu Y, Lei Y, Yu X, Jiang N, Gao Y, Cao J. Med Sci Monit. If the nodule got a score of 2 in the CEUS schedule, the CEUS-TIRADS category remained the same as before. If the nodule got a score of more than 2 in the CEUS schedule, CEUS-TIRADS added 1 category. Before These publications erroneously add weight to the belief that TIRADS is a proven and superior model for the investigation of thyroid nodules. For those that also have 1 or more TR3, TR4, or TR5 nodules on their scan, they cannot have thyroid cancer ruled out by TIRADS because the possibility that their non-TR1/TR2 nodules may be cancerous is still unresolved. With the right blood tests, you can see if you have a thyroid nodule, and if so, you can treat it with radioactive iodine. A minority of these nodules are cancers. FNA, fine-needle aspiration; US, ultrasound; CEUS, contrast-enhanced ultrasound; C-TIRADS, Chinese imaging reporting and data system. Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: can we avoid repeat biopsy? Test performance in the TR3 and TR4 categories had an accuracy of less than 60%. eCollection 2022. The truth is, most of us arent so lucky as to be diagnosed with all forms of thyroid cancer, but we do live with the results of it. The .gov means its official. Thyroid surgery, Microvascular reconstruction, Neck surgery, Reconstructive surgery, Facial reconstruction, Parathyroid. Bethesda, MD 20894, Web Policies PLoS ONE. Here at the University of Florida, we are currently recruiting endocrinologists to work with us to help people with thyroid nodules. In 2013, Russ et al. Thyroid nodules with TIRADS 4 and 5 and diameter lower than 12 mm, are highly suspicious for malignancy and should be considered as indications for fine needle aspiration biopsy. Using TIRADS as a rule-out cancer test would be the finding that a nodule is TR1 or TR2 and hence has a low risk of cancer, compared with being TR3-5. As it turns out, its also very accurate and detailed. Unable to process the form. It is important to validate this classification in different centres. Thyroid Nodule Characterization: How to Assess the Malignancy Risk. After repeat US-guided FNA, some patients achieve a cytological diagnosis, but typically two-thirds remain indeterminate [18], accounting for approximately 20% of initial FNAs (eg, 10%-30% [12], 31% [19], 22% [20]). Cystic or almost completely cystic 0 points. The process of establishing of CEUS-TIRADS model. A robust validation study is required before the performance and cost-benefit outcomes of any of the TIRADS systems can be known. This approach likely performs better than randomly selecting 1 in 10 nodules for FNA, but we intentionally made assumptions that would favor the performance of ACR TIRADS to illustrate that if a poor clinical comparator cannot clearly be beaten, then the clinical value that such new systems bring is correspondingly poor. The findings that ACR TIRADS has methodological concerns, is not yet truly validated, often performs no better than random selection, and drives significant costs and potential harm, are very unsettling but result from a rational and scientific assessment of the foundational basis of the ACR TIRADS system. In addition, changes in nomenclature such as the recent classification change to noninvasive follicular thyroid neoplasm with papillary-like nuclear features would result in a lower rate of thyroid cancer if previous studies were reported using todays pathological criteria. Conclusions: Summary Test Performance of Random Selection of 1 in 10 Nodules for FNA, Compared with ACR-TIRADS. Methodologically, the change in the ACR-TIRADS model should now undergo a new study using a new training data set (to avoid replicating any bias), before then undergoing a validation study. They will want to know what to do with your nodule and what tests to take. 2018;287(1):29-36. The provider may also ask about your risk factors, such as past exposure to radiation and a family history of thyroid cancers. TI-RADS 2: Benign nodules. Hong MJ, Na DG, Baek JH, Sung JY, Kim JH. {"url":"/signup-modal-props.json?lang=us"}, Jha P, Weerakkody Y, Bell D, et al. Kwak JY, Han KH, Yoon JH et-al. Tom James Cawood, Georgia Rose Mackay, Penny Jane Hunt, Donal OShea, Stephen Skehan, Yi Ma, TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance, Journal of the Endocrine Society, Volume 4, Issue 4, April 2020, bvaa031, https://doi.org/10.1210/jendso/bvaa031. The process of validation of CEUS-TIRADS model. We then compare the diagnosis performance of C-TIRADS, CEUS, and CEUS-TIRADS by sensitivity, specificity, and accuracy. Lin JD, Chao TC, Huang BY, Chen ST, Chang HY, Hsueh C. Bongiovanni M, Crippa S, Baloch Z, et al. Unfortunately, the collective enthusiasm for welcoming something that appears to provide certainty has perhaps led to important flaws in the development of the models being overlooked. doi: 10.1007/s12020-020-02441-y Other limitations include the various assumptions we have made and that we applied ACR TIRADS to the same data set upon which is was developed. Thus, the absolute risk of missing important cancer goes from 4.5% to 2.5%, so NNS=100/2=50. Would you like email updates of new search results? 1 Most thyroid nodules are detected incidentally when imaging is performed for another indication. We examined the data set upon which ACR-TIRADS was developed, and applied TR1 or TR2 as a rule-out test, TR5 as a rule-in test, or applied ACR-TIRADS across all nodule categories. Thyroid nodules could be classified into one of 10 ultrasound patterns, which had a corresponding TI-RADS category. The present study evaluated the risk of malignancy in solid nodules>1 cm using ACR TI-RADS. The more important test metric for diagnosing a disease is the specificity, where a positive test helps rule-in the disease. 2020 Chinese Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: The. 2021 Dec 7;101(45):3748-3753. doi: 10.3760/cma.j.cn112137-20210401-00799. The test may cycle back between being used on training and validation data sets to allow for improvements and retesting. Yoon JH, Han K, Kim EK, Moon HJ, Kwak JY. Methods: Thyroid nodules (566) subclassified as ACR-TIRADS 3 or 4 were divided into three size categories according to American Thyroid Association guidelines. Tessler FN, Middleton WD, Grant EG, et al. Endocrinol. These cutoffs are somewhat arbitrary, with conflicting data as to what degree, if any, size is a discriminatory factor. The diagnostic performance of CEUS-TIRADS was significantly better than CEUS and C-TIRADS. Become a Gold Supporter and see no third-party ads. Shin JH, Baek JH, Chung J, et al. To establish a contrast-enhanced ultrasound (CEUS) diagnostic schedule by CEUS analysis of thyroid nodules of C-TIRADS 4. So just using ACR TIRADS as a rule-out test could be expected to leave 99% of undiagnosed cancers amongst the remaining 75% of the population, in whom the investigation and management remains unresolved. Bastin S, Bolland MJ, Croxson MS. Role of Ultrasound in the Assessment of Nodular Thyroid Disease. What does highly suspicious thyroid nodule mean? Those wishing to continue down the investigative route could then have US, using TIRADS or ATA guidelines or other measures to offer some relative risk-stratification. A negative result with a highly sensitive test is valuable for ruling out the disease. The more FNAs done in the TR3 and TR4 groups, the more indeterminate FNAs and the more financial costs and unnecessary operations. Now, the first step in T3N treatment is usually a blood test. The implication is that US has enabled increased detection of thyroid cancers that are less clinically important [11-13]. In 2017, the Thyroid Imaging Reporting and Data System (TI-RADS) Committee of the American College of Radiology (ACR) published a white paper that presented a new risk-stratification system for classifying thyroid nodules on the basis of their appearance at ultrasonography (US). 2009;94 (5): 1748-51. Write for us: What are investigative articles. Therefore, the rates of cancer in each ACR TIRADS category in the data set where they used four US characteristics can no longer be assumed to be the case using the 5 US characteristics plus the introduction of size cutoffs. J Med Imaging Radiat Oncol (2009) 53(2):17787. These patients are not further considered in the ACR TIRADS guidelines. Haugen BR, Alexander EK, Bible KC, et al. TI-RADS 4c applies to the lesion with three to five of the above signs and/or a metastatic lymph node is present. Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. Whereas using TIRADS as a rule-in cancer test would be the finding that a nodule is TR5, with a sufficiently high chance of cancer that further investigations are required, compared with being TR1-4. It should also be on an intention-to-test basis and include the outcome for all those with indeterminate FNAs. Some cancers would not show suspicious changes thus US features would be falsely reassuring. It would be unfair to add these clinical factors to only the TIRADS arm or only to the clinical comparator arm, and they would cancel out if added to both arms, hence they were omitted. The specificity of TIRADS is high (89%) but, perhaps surprisingly, is similar to randomly selecting of 1 in 10 nodules for FNA (90%). PET-positive thyroid nodules have a relatively high malignancy rate of 35%. So, the number needed to scan (NNS) for each additional person correctly reassured is 100 (NNS=100). And because thyroid cancer is often diagnosed in a persons late 30s or 40s, most of us are often diagnosed after the symptoms have already begun. This study aimed to assess the performance and costs of the American College of Radiology (ACR) Thyroid Image Reporting And Data System (TIRADS), by first looking for any important issues in the methodology of its development, and then illustrating the performance of TIRADS for the initial decision for or against FNA, compared with an imagined The authors proposed the following criteria, based on French Endocrine Society guidelines, for when to proceed with fine needle aspiration biopsy: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 100 nodules in the validation cohort. Using ACR-TIRADS as a rule-in test to identify a higher risk group that should have FNA is arguably a more effective application. The NNS for ACR TIRADS is such that it is hard to justify its use for ruling out thyroid cancer (NNS>100), at least on a cost/benefit basis. All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. TIRADS 5: probably malignant nodules (malignancy >80%). [The diagnostic performance of 2020 Chinese Ultrasound Thyroid Imaging Reporting and Data System in thyroid nodules]. Zhonghua Yi Xue Za Zhi. The following article describes the initial iterations proposed by individual research groups, none of which gained widespread use. The optimal investigation and management of the 84% of the population harboring the remaining 50% of cancer remains unresolved. Most thyroid nodules aren't serious and don't cause symptoms. Your email address will not be published. Tessler F, Middleton W, Grant E. Thyroid Imaging Reporting and Data System (TI-RADS): A Users Guide. An official website of the United States government. The area under the curve was 0.916. (2017) Radiology. Endocrine (2020) 70(2):25679. This assumption is obviously not valid and favors TIRADS management guidelines, but we believe it is helpful for clarity and illustrative purposes. doi: 10.1016/S0140-6736(14)62242-X In patients with thyroid nodules, ultrasonography (US) has been established as a primary diagnostic imaging method and is essential for treatment decision. However, the consequent management guidelines are difficult to justify at least on a cost basis for a rule-out test, though ACR TIRADS may provide more value as a rule-in test for a group of patients with higher cancer risk. There are two suspicious signs with the nodule (solid and irregular margin) and it was defined as C-TIRADS 4b. I have some serious news about my thyroid nodules today. Those working in this field would gratefully welcome a diagnostic modality that can improve the current uncertainty. We refer to ACR-TIRADS where data or comments are specifically related to ACR TIRADS and use the term TIRADS either for brevity or when comments may be applicable to other TIRADS systems. As a result, were left looking like a complete idiot with the results. For this, we do not take in to account nodule size because size is not a factor in the ACR TIRADS guidelines for initial FNA in the TR1 and TR2 categories (where FNA is not recommended irrespective of size) or in the TR5 category (except in TR5 nodules of0.5 cm to<1.0 cm, in which case US follow-up is recommended rather than FNA). However, in the data set, only 25% of all nodules were categorized as TR1 or TR2 and these nodules harbored only 1% of all thyroid cancers (9 of 343). The risk of malignancy was derived from thyroid ultrasound (TUS) features. If your doctor found a hypoechoic nodule during an ultrasound, they may simply do some additional testing to make sure there's . A 35-year-old woman with a nodule in the left-lobe of her thyroid gland. K-TIRADS category was assigned to the thyroid nodules. If a clinician does no tests and no FNAs, then he or she will miss all thyroid cancers (5 people per 100). Anti-thyroid medications. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) has achieved high accuracy in categorizing the malignancy status of nearly 950 thyroid nodules detected on thyroid ultrasonography. ectomy, Parotid gland surgery, Transoral laser microsurgery, Transoral robotic surgery, Oral surgery, Parotid gland tumor, Skin cancer, Tonsil cancer, Throat cancer, Salivary gland tumor, Salivary gland cancer, Thyroid nodule, Head and neck cancer, Laryngeal cancer, Tongue . Epub 2021 Oct 28. Any additional test has to perform exceptionally well to surpass this clinicians 95% negative predictive performance, without generating false positive results and consequential harm. Data sets with a thyroid cancer prevalence higher than 5% are likely to either include a higher proportion of small clinically inconsequential thyroid cancers or be otherwise biased and not accurately reflect the true population prevalence. J. Clin. NCI Thyroid FNA State of the Science Conference, The Bethesda System for reporting thyroid cytopathology, ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee, Thyroid nodule size at ultrasound as a predictor of malignancy and final pathologic size, Impact of nodule size on malignancy risk differs according to the ultrasonography pattern of thyroid nodules, TIRADS management guidelines in the investigation of thyroid nodules; an illustration of the concerns, costs and performance, Thyroid nodules with minimal cystic changes have a low risk of malignancy, [The Thyroid Imaging Reporting and Data System (TIRADS) for ultrasound of the thyroid], Malignancy risk stratification of thyroid nodules: comparison between the Thyroid Imaging Reporting and Data System and the 2014 American Thyroid Association Management Guidelines, Validation and comparison of three newly-released Thyroid Imaging Reporting and Data Systems for cancer risk determination, Machine learning-assisted system for thyroid nodule diagnosis, Automatic thyroid nodule recognition and diagnosis in ultrasound imaging with the YOLOv2 neural network, Using artificial intelligence to revise ACR TI-RADS risk stratification of thyroid nodules: diagnostic accuracy and utility, A multicentre validation study for the EU-TIRADS using histological diagnosis as a gold standard, Comparison among TIRADS (ACR TI-RADS and KWAK- TI-RADS) and 2015 ATA Guidelines in the diagnostic efficiency of thyroid nodules, Prospective validation of the ultrasound based TIRADS (Thyroid Imaging Reporting And Data System) classification: results in surgically resected thyroid nodules, Diagnostic performance of practice guidelines for thyroid nodules: thyroid nodule size versus biopsy rates, Comparison of performance characteristics of American College of Radiology TI-RADS, Korean Society of Thyroid Radiology TIRADS, and American Thyroid Association Guidelines, Performance of five ultrasound risk stratification systems in selecting thyroid nodules for FNA.
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