Rationale and Objectives
To estimate the diagnostic performance of the currently used ultrasound (US)-based
risk stratification systems (RSSs) (American Thyroid Association, American Association
of Clinical Endocrinologists, American College of Endocrinology, and Association Medici
Endocrinology Medical Guidelines for Clinical Practice for the Diagnosis and Management
of Thyroid Nodules, European Thyroid Association Guidelines for Ultrasound Malignancy
Risk Stratification of Thyroid Nodules in Adults [EU-TIRADS], American College of
Radiology Thyroid Imaging Reporting and Data System [ACR-TIRADS], Chinese Guidelines
for Ultrasound Malignancy Risk Stratification of Thyroid Nodules [C-TIRADS], and Thyroid
Imaging Reporting and Data System Developed by Kwak et al [Kwak-TIRADS]) for atypia
of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS)
thyroid nodules.
Materials and Methods
This retrospective study included 514 consecutive AUS/FLUS nodules in 481 patients
with final diagnosis. The US characteristics were reviewed and classified using the
categories defined by each RSS. The diagnostic performance was evaluated and compared
using a generalized estimating equation method.
Results
Of the 514 AUS/FLUS nodules, 148 (28.8%) were malignant and 366 (71.2%) were benign.
The calculated malignancy rate increased from the low-risk to high-risk categories
for all RSSs (all P < .001). Interobserver correlation for both US features and RSSs showed substantial
to almost perfect agreement. The diagnostic efficacy of Kwak-TIRADS (AUC = 0.808) and C-TIRADS (AUC = 0.804) were similar (P = .721) and higher than those of other RSSs (all P < .05). The EU-TIRADS and Kwak-TIRADS exhibited similar sensitivity (86.5% vs 85.1%,
P = .739) and were only higher than that of the C-TIRADS (all P < .05). The specificity of C-TIRADS and ACR-TIRADS were similar (78.1% vs 72.1%,
P = .06) and were higher than those of other RSSs (all P < .05).
Conclusion
Currently used RSSs can provide risk stratification for AUS/FLUS nodules. Kwak-TIRADS
and C-TIRADS have the highest diagnostic efficacy in identifying malignant AUS/FLUS
nodules. A detailed knowledge of the benefits and shortcomings of the various RSSs
is essential.
Abbreviations:
US (Ultrasound), TIRADS (Thyroid Imaging Reporting and Data System), ATA (American Thyroid Association), AACE/ACE/AME (American Association of Clinical Endocrinologists, American College of Endocrinology, and Association Medici Endocrinology Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules), ACR (American College of Radiology), C-TIRADS (Chinese Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules), EU-TIRADS (European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults), Kwak-TIRADS (Thyroid Imaging Reporting and Data System Developed by Kwak et al), FNA (Fine-needle aspiration), AUS/FLUS (Atypia of undetermined significance or follicular lesions of undetermined significance), RSS (Risk stratification system), ROM (Risk of malignancy), AUC (Areas under the receiving operator characteristics curve), PTC (Papillary thyroid carcinoma), FTC (Follicular thyroid carcinoma), MTC (Medullary thyroid carcinoma), NIFTP (Noninvasive follicular thyroid neoplasm with papillary-like nuclear features), NPV (Negative predictive value), PPV (Positive predictive value), CI (Confidence intervals)Key Words
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References
- 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
- The 2017 Bethesda System for Reporting Thyroid Cytopathology.J Am Soc Cytopathol. 2017; 6: 217-222
- Subclassification of the Bethesda Category III (AUS/FLUS): a study of thyroid FNA cytology based on ThinPrep slides from the National Cancer Center in China.Cancer Cytopathol. 2021; 129: 642-648
- Malignancy risk and characteristics of thyroid nodules with two consecutive results of atypia of undetermined significance or follicular lesion of undetermined significance on cytology.Eur Radiol. 2015; 25: 2601-2607
- Ultrasound-based nomogram for predicting the pathological nodal negativity of unilateral clinical N1a papillary thyroid carcinoma in adolescents and young adults.Acad Radiol. 2023; https://doi.org/10.1016/j.acra.2022.11.025
- 2021 Korean Thyroid Imaging Reporting and Data System and Imaging-Based Management of Thyroid Nodules: Korean Society of Thyroid Radiology Consensus Statement and Recommendations.Korean J Radiol. 2021; 22: 2094-2123
- Can repeat biopsies change the prognoses of AUS/FLUS nodule?.Eur Thyroid J. 2020; 9: 92-98
- Implications of a suspicious afirma test result in thyroid fine-needle aspiration cytology: an institutional experience.Cancer Cytopathol. 2014; 122: 737-744
- Effectiveness of molecular testing techniques for diagnosis of indeterminate thyroid nodules: a randomized clinical trial.JAMA Oncol. 2021; 7: 70-77
- BRAF(V600E) mutation as a predictor of thyroid malignancy in indeterminate nodules: a systematic review and meta-analysis.Eur J Surg Oncol. 2017; 43: 1219-1227
- Molecular cytopathology for thyroid nodules: a review of methodology and test performance.Cancer Cytopathol. 2016; 124: 14-27
- ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White Paper of the ACRTI-RADS Committee.J Am Coll Radiol. 2017; 14: 587-595
- Thyroid Imaging Reporting and Data System for US features of nodules: a step in establishing better stratification of cancer risk.Radiology. 2011; 260: 892-899
- 2020 Chinese Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: The C-TIRADS.Endocrine. 2020; 70: 256-279
- European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS.Eur Thyroid J. 2017; 6: 225-237
- American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules--2016 Update.Endocr Pract. 2016; 22: 622-639
- Diagnostic performance of practice guidelines for thyroid nodules: thyroid nodule size versus biopsy rates.Radiology. 2019; 291: 92-99
- An international survey on utilization of five thyroid nodule risk stratification systems: a needs assessment with future implications.Thyroid. 2022; 32: 675-681
- Diagnostic accuracy of Thyroid Imaging Reporting and Data System in the prediction of malignancy in nodules with atypia and follicular lesion of undetermined significance cytologies.Clin Endocrinol. 2017; 86: 584-590
- Diagnostic performance of ultrasound patterns by K-TIRADS and 2015 ATA guidelines in risk stratification of thyroid nodules and follicular lesions of undetermined significance.AJR Am J Roentgenol. 2019; 213: 444-450
- Diagnostic value of TI-RADS vlassification system and next generation genetic sequencing in indeterminate thyroid nodules.Acad Radiol. 2021; 28: 1685-1691
- The combination of BRAF(V600E) mutation and Chinese Thyroid Imaging Reporting and Data System is helpful in the management of AUS/FLUS thyroid nodules.Endocrine. 2022; 78: 507-516
- Clinical aspects of Hashimoto's thyroiditis.Endocr Dev. 2014; 26: 158-170
- Malignancy risk stratification of thyroid nodules: comparison between the Thyroid Imaging Reporting and Data System and the 2014 American Thyroid Association Management Guidelines.Radiology. 2016; 278: 917-924
- Combining radiomics with ultrasound-based risk stratification systems for thyroid nodules: an approach for improving performance.Eur Radiol. 2021; 31: 2405-2413
- The Eighth Edition AJCC Cancer Staging Manual: continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging.CA Cancer J Clin. 2017; 67: 93-99
- Nomenclature revision for encapsulated follicular variant of papillary thyroid carcinoma: a paradigm shift to reduce overtreatment of indolent tumors.JAMA Oncol. 2016; 2: 1023-1029
- Do ultrasound patterns and clinical parameters inform the probability of thyroid cancer predicted by molecular testing in nodules with indeterminate cytology?.Thyroid. 2021; 31: 1673-1682
- American Thyroid Association sonographic risk and afirma gene expression classifier alone and in combination for the diagnosis of thyroid nodules with Bethesda category III cytology.Thyroid. 2020; 30: 1613-1619
- The measurement of observer agreement for categorical data.Biometrics. 1977; 33: 159-174
- 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. 2021; 12763897
- Elastography and Doppler may bring a new perspective to TIRADS, altering conventional ultrasonography dominance.Acad Radiol. 2022; 29: e25-e38
- Combining the American Thyroid Association's ultrasound classification with cytological subcategorization improves the assessment of malignancy risk in indeterminate thyroid nodules.Thyroid. 2021; 31: 922-932
- Limitations of the 2015 ATA guidelines for prediction of thyroid cancer: a review of 1947 consecutive aspirations.J Clin Endocrinol Metab. 2018; 103: 3496-3502
- Differences between ATA, AACE/ACE/AME and ACR TI-RADS ultrasound classifications performance in identifying cytological high-risk thyroid nodules.Eur J Endocrinol. 2018; 178: 595-603
- Thyroid nodules with indeterminate cytology: utility of the American Thyroid Association sonographic patterns for cancer risk stratification.Thyroid. 2018; 28: 1004-1012
- Clinical outcome for atypia of undetermined significance in thyroid fine-needle aspirations: should repeated FNA be the preferred initial approach?.Am J Clin Pathol. 2011; 135: 770-775
- Thyroid cytology-nuclear versus architectural atypia within the "Atypia of undetermined significance/follicular lesion of undetermined significance" Bethesda category have significantly different rates of malignancy.Cancer Cytopathol. 2017; 125: 245-256
- Thyroid follicular carcinoma: sonographic features of 50 cases.AJR Am J Roentgenol. 2010; 194: 44-54
- Performance of current ultrasound-based malignancy risk stratification systems for thyroid nodules in patients with follicular neoplasms.Eur Radiol. 2022; 32: 3617-3630
Article info
Publication history
Published online: May 22, 2023
Accepted:
April 22,
2023
Received in revised form:
April 22,
2023
Received:
February 21,
2023
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2023 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved All rights reserved.
