Original Investigation|Articles in Press

Comparative Study of C-TIRADS, ACR-TIRADS, and EU-TIRADS for Diagnosis and Management of Thyroid Nodules

      Rationale and Objectives

      Chinese Thyroid Imaging Reporting and Data Systems (C-TIRADS) was developed to provide a more simplified tool for stratifying thyroid nodules. Here we aimed to validate the efficacy of C-TIRADS in distinguishing benign from malignant and in guiding fine-needle aspiration biopsies in comparison with the American College of Radiology TIRADS (ACR-TIRADS) and European TIRADS (EU-TIRADS).

      Materials and Methods

      This study retrospectively included 3438 thyroid nodules (≥10 mm) in 3013 patients (mean age, 47.1 years ± 12.9) diagnosed between January 2013 and November 2019. Ultrasound features of the nodules were evaluated and categorized according to the lexicons of the three TIRADS. We compared these TIRADS by using the area under the receiver operating characteristic curve (AUROC), the area under the precision-recall curve (AUPRC), sensitivity, specificity, net reclassification improvement (NRI), and unnecessary fine-needle aspiration biopsy (FNAB) rate.


      Of the 3438 thyroid nodules, 707 (20.6%) were malignant. C-TIRADS showed higher discrimination performance (AUROC, 0.857; AUPRC, 0.605) than ACR-TIRADS (AUROC, 0.844; AUPRC, 0.567) and EU-TIRADS (AUROC, 0.802; AUPRC, 0.455). The sensitivity of C-TIRADS (85.3%) was lower than that of ACR-TIRADS (89.1%) but higher than that of EU-TIRADS (78.4%). The specificity of C-TIRADS (76.9%) was similar to that of EU-TIRADS (78.9%) and higher than that of ACR-TIRADS (69.5%). The unnecessary FNAB rate was lowest with C-TIRADS (21.2%), followed by ACR-TIRADS (41.7%) and EU-TIRADS (58.3%). C-TIRADS obtained significant NRI for recommending FNAB over ACR-TIRADS (19.0%, P < 0.001) and EU-TIRADS (25.5%, P < 0.001).


      C-TIRADS may be a clinically applicable tool to manage thyroid nodules, which warrants thorough tests in other geographic settings.


      ACR-TIRADS (American College of Radiology Thyroid Imaging Reporting and Data System), AUPRC (area under the precision-recall curve), AUROC (area under the receiver operating characteristic curve), C-TIRADS (Chinese Thyroid Imaging Reporting and Data System), EU-TIRADS (European Thyroid Imaging Reporting and Data System), FNAB (fine-needle aspiration biopsy), NRI (Net Reclassification Index)

      Key Words

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        • Durante C.
        • Grani G.
        • Lamartina L.
        • et al.
        The diagnosis and management of thyroid nodules: a review.
        JAMA. 2018; 319: 914-924
        • Haugen B.R.
        • Alexander E.K.
        • Bible K.C.
        • et al.
        2015 American Thyroid Association Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer.
        Thyroid. 2016; 26: 1-133
        • Bahl M.
        Incidental thyroid nodules in the National Lung Screening Trial: estimation of prevalence, malignancy rate, and strategy for workup.
        Acad Radiol. 2018; 25: 1152-1155
        • Russ G.
        • Bonnema S.J.
        • Erdogan M.F.
        • et al.
        European Thyroid Association guidelines for ultrasound malignancy risk stratification of thyroid nodules in adults: the EU-TIRADS.
        Eur Thyroid J. 2017; 6: 225-237
        • Tessler F.N.
        • Middleton W.D.
        • Grant E.G.
        • et al.
        ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee.
        J Am Coll Radiol. 2017; 14: 587-595
        • Zhou J.
        • Yin L.
        • Wei X.
        • et al.
        2020 Chinese guidelines for ultrasound malignancy risk stratification of thyroid nodules: the C-TIRADS.
        Endocrine. 2020; 70: 256-279
        • Ha E.J.
        • Na D.G.
        • Baek J.H.
        • et al.
        US fine-needle aspiration biopsy for thyroid malignancy: diagnostic performance of seven society guidelines applied to 2000 thyroid nodules.
        Radiology. 2018; 287: 893-900
        • Kim P.H.
        • Suh C.H.
        • Baek J.H.
        • et al.
        Unnecessary thyroid nodule biopsy rates under four ultrasound risk stratification systems: a systematic review and meta-analysis.
        Eur Radiol. 2021; 31: 2877-2885
        • Magri F.
        • Chytiris S.
        • Croce L.
        • et al.
        Performance of the ACR TI-RADS and EU TI-RADS scoring systems in the diagnostic work-up of thyroid nodules in a real-life series using histology as reference standard.
        Eur J Endocrinol. 2020; 183: 521-528
        • Ruan J.L.
        • Yang H.Y.
        • Liu R.B.
        • et al.
        Fine needle aspiration biopsy indications for thyroid nodules: compare a point-based risk stratification system with a pattern-based risk stratification system.
        Eur Radiol. 2019; 29: 4871-4878
        • Xu T.
        • Wu Y.
        • Wu R.X.
        • et al.
        Validation and comparison of three newly-released Thyroid Imaging Reporting and Data Systems for cancer risk determination.
        Endocrine. 2019; 64: 299-307
        • Yoon J.H.
        • Han K.
        • Kim E.K.
        • et al.
        Diagnosis and management of small thyroid nodules: a comparative study with six guidelines for thyroid nodules.
        Radiology. 2017; 283: 560-569
        • Layfield L.J.
        • Cibas E.S.
        • Gharib H.
        • et al.
        Thyroid aspiration cytology: current status.
        CA Cancer J Clin. 2009; 59: 99-110
        • Zhou J.
        • Song Y.
        • Zhan W.
        • et al.
        Thyroid imaging reporting and data system (TIRADS) for ultrasound features of nodules: multicentric retrospective study in China.
        Endocrine. 2021; 72: 157-170
        • Qi Q.
        • Zhou A.
        • Guo S.
        • et al.
        Explore the diagnostic efficiency of Chinese Thyroid Imaging Reporting and Data Systems by comparing with the other four systems (ACR TI-RADS, Kwak-TIRADS, KSThR-TIRADS, and EU-TIRADS): a single-center study.
        Front Endocrinol (Lausanne). 2021; 12: 763897
        • Liu Z.
        • Liu D.
        • Ma B.
        • et al.
        History and practice of thyroid fine-needle aspiration in China, based on retrospective study of the practice in Shandong University Qilu Hospital.
        J Pathol Transl Med. 2017; 51: 528-532
        • Pencina M.J.
        • D'Agostino Sr, R.B.
        • D'Agostino Jr, R.B.
        • et al.
        Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond.
        Stat Med. 2008; 27: 157-172
        • Horvath E.
        • Majlis S.
        • Rossi R.
        • et al.
        An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management.
        J Clin Endocrinol Metab. 2009; 94: 1748-1751
        • Russ G.
        • Trimboli P.
        • Buffet C.
        The new era of TIRADSs to stratify the risk of malignancy of thyroid nodules: strengths, weaknesses and pitfalls.
        Cancers (Basel). 2021; 134316
        • Castellana M.
        • Castellana C.
        • Treglia G.
        • et al.
        Performance of five ultrasound risk stratification systems in selecting thyroid nodules for FNA.
        J Clin Endocrinol Metab. 2020; 105dgz170
        • Zhu H.
        • Yang Y.
        • Wu S.
        • et al.
        Diagnostic performance of US-based FNAB criteria of the 2020 Chinese guideline for malignant thyroid nodules: comparison with the 2017 American College of Radiology guideline, the 2015 American Thyroid Association guideline, and the 2016 Korean Thyroid Association guideline.
        Quant Imaging Med Surg. 2021; 11: 3604-3618
        • Leboulleux S.
        • Tuttle R.M.
        • Pacini F.
        • et al.
        Papillary thyroid microcarcinoma: time to shift from surgery to active surveillance?.
        Lancet Diabetes Endocrinol. 2016; 4: 933-942
        • Richman D.M.
        • Benson C.B.
        • Doubilet P.M.
        • et al.
        Assessment of American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) for pediatric thyroid nodules.
        Radiology. 2020; 294: 415-420
        • Fisher S.B.
        • Perrier N.D.
        The incidental thyroid nodule.
        CA Cancer J Clin. 2018; 68: 97-105
        • Wang T.S.
        • Sosa J.A.
        Thyroid surgery for differentiated thyroid cancer – recent advances and future directions.
        Nat Rev Endocrinol. 2018; 14: 670-683
        • Dobruch-Sobczak K.
        • Adamczewski Z.
        • Dedecjus M.
        • et al.
        Summary of meta-analyses of studies involving TIRADS classifications (EU-TIRADS, ACR-TIRADS, and K-TIRADS) in evaluating the malignant potential of focal lesions of the thyroid gland.
        J Ultrason. 2022; 22: 121-129
        • Middleton W.D.
        • Teefey S.A.
        • Reading C.C.
        • et al.
        Multiinstitutional analysis of thyroid nodule risk stratification using the American College of Radiology Thyroid Imaging Reporting and Data System.
        AJR Am J Roentgenol. 2017; 208: 1331-1341