ACR: Guidelines for Reduction of Unnecessary Thyroid Nodule Biopsies
The American College of Radiology (ACR) recently published new guidelines for assessing which thyroid nodules require biopsy or sonographic follow-up using an ultrasound-based risk stratification system. The Thyroid Imaging, Reporting and Data System (TI-RADS) is based on the ACR’s widely accepted Breast Imaging, Reporting and Data System used to assess breast lesions.
Using previously published lexicon and data on 3800 nodules and over 100,000 cancers, the researchers developed guidelines that were easy to apply across a wide range of ultrasound practices and were able to classify all thyroid nodules. According to the authors, the guidelines are “designed to identify most clinically significant malignancies while reducing the number of biopsies performed on benign nodules.”2
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The guidelines use appearance to classify the malignancy of the nodule, and there are 5 categories of appearance, which include the following: composition, echogenicity, shape, margin, and echogenic foci. Physicians can select 1 of 2 choices in the shape categories, wider-than-taller or taller-than wider, and can choose among 4 options in the other 4 categories. Each choice is valued using points ranging from 0 to 3, with more suspicious features awarded more points, which are then added to determine the nodule’s TI-RADS level.
The TI-RADS level ranges from TI1 (benign) to TR5 (high suspicion of malignancy). If a patient’s nodule points add up to zero, the nodule is categorized as TR1 and the guidelines recommend no follow-up or fine-needle aspiration. However, if the points add up to 7 or more, the nodule is classified as TR5 and the guidelines recommend fine-needle aspirations for nodules that are 1 centimeter or greater, and recommend follow-up for nodules that are 0.5 centimeters or greater.
In addition, the authors recommend limiting fine-needle aspiration to 2 nodules per patient as biopsies of 3 or more nodules has shown to be poorly tolerated by patients with no additional benefits.
“The ACR TI-RADS is designed to balance the benefit of identifying clinically important cancers against the risk and cost of subjecting patients with benign nodules or indolent cancers to biopsy and treatment,” the authors state.
“Our recommendations for follow-up ultrasound substantially mitigate the possibility that significant malignancies will remain undetected over time and are concordant with the increasing trend toward active surveillance, or ‘watchful waiting,’ for low-risk thyroid cancer.”2
—Melissa Weiss
Reference:
1] Tessler FN, Middleton WD, Grant EG, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee [published online March 31, 2017]. J Am Coll Radiol. http://dx.doi.org/10.1016/j.jacr.2017.01.046.
2] Hansen J. UAB-led blue-ribbon committee creates ultrasound scoring system for thyroid nodules to reduce unnecessary biopsies [press release]. Birmingham, AL: University of Alabama; June 16, 2017. https://www.uab.edu/news/innovation/item/8429-uab-led-blue-ribbon-committee-creates-ultrasound-scoring-system-for-thyroid-nodules-to-reduce-unnecessary-biopsies. Accessed June 19, 2017.