TI-RADS 4c applies to the lesion with three to five of the above signs and/or a metastatic lymph node is present. Treatment of patients with the left lobe of the thyroid gland, tirads 3 Thyroid nodules are very common and benign in most cases. TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance J Endocr Soc. This data set was a subset of data obtained for a previous study and there are no clear details of the inclusion and exclusion criteria, including criteria for FNA. EU-TIRADS 2 category comprises benign nodules with a risk of malignancy close to 0%, presented on sonography as pure/anechoic cysts ( Figure 1A) or entirely spongiform nodules ( Figure 1B ). Ultrasound (US) risk-stratification systems for investigation of thyroid nodules may not be as useful as anticipated. -, Lee JH, Shin SW. Overdiagnosis and Screening for Thyroid Cancer in Korea. For example, a previous meta-analysis of more than 25,000 FNAs showed 33% were in these groups [17]. Would you like email updates of new search results? 2. The equation was as follows: z = -2.862 + 0.581X1- 0.481X2- 1.435X3+ 1.178X4+ 1.405X5+ 0.700X6+ 0.460X7+ 0.648X8- 1.715X9+ 0.463X10+ 1.964X11+ 1.739X12. Results: Among the 228 C-TIRADS 4 nodules, 69 were determined as C-TIRADS 4a, 114 were C-TIRADS 4b, and 45 were C-TIRADS 4c. Full data including 95% confidence intervals are given elsewhere [25]. Interobserver Agreement of Thyroid Imaging Reporting and Data System (TIRADS) and Strain Elastography for the Assessment of Thyroid Nodules. These final validation sets must fairly represent the population upon which the test is intended to be applied because the prevalence of the condition in the test population will critically influence the test performance, particularly the positive predictive value (PPV) and negative predictive value (NPV). Radiology. 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 system has fair interobserver agreement 4. Become a Gold Supporter and see no third-party ads. The pathological result was Hashimotos thyroiditis. If one decides to FNA every TR5 nodule, from the original ACR TIRADS data set, 34% were found to be cancerous, but note that this data set likely has double the prevalence of thyroid cancer compared with the real-world population. There are even data showing a negative correlation between size and malignancy [23]. 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. To establish a CEUS-TIRADS diagnostic model to differentiate thyroid nodules (C-TIRADS 4) by combining CEUS with Chinese thyroid imaging reporting and data system (C-TIRADS). proposed a system with five categories, which, like BI-RADS, each carried a management recommendation 2. Unable to load your collection due to an error, Unable to load your delegates due to an error. Check for errors and try again. eCollection 2020 Apr 1. Dr. Ron Karni, Chief of the Division of Head and Neck Surgical Oncology at McGovern Medical School at UTHealth Houston discusses Thyroid Nodules. Those working in this field would gratefully welcome a diagnostic modality that can improve the current uncertainty. Bookshelf The more FNAs done in the TR3 and TR4 groups, the more indeterminate FNAs and the more financial costs and unnecessary operations. Taken as a capsule or in liquid form, radioactive iodine is absorbed by your thyroid gland. The site is secure. See this image and copyright information in PMC. The high prevalence of thyroid nodules combined with the generally indolent growth of thyroid cancer present a challenge for optimal patient care. -, Zhou J, Yin L, Wei X, Zhang S, Song Y, Luo B, et al. The CEUS-TIRADS combining CEUS analysis with C-TIRADS could make up for the deficient sensibility of C-TIRADS, showing a better diagnostic performance than US and CEUS. In CEUS analysis, it reflected as equal arrival time, iso-enhancement, homogeneity, and diffuse enhancement, receiving a score of 0 in the CEUS model. Thyroid nodules are solid or fluid-filled lumps that form within your thyroid, a small gland located at the base of your neck, just above your breastbone. The authors stated that TI-RADS 4 and 5 nodules must be biopsied. The risk of malignancy was derived from thyroid ultrasound (TUS) features. Performing FNA on TR5 nodules is a relatively effective way of finding thyroid cancers. Tessler F, Middleton W, Grant E. Thyroid Imaging Reporting and Data System (TI-RADS): A Users Guide. 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. TIRADS Management Guidelines in the Investigation of Thyroid Nodules 1 Most thyroid nodules are detected incidentally when imaging is performed for another indication. The management guidelines may be difficult to justify from a cost/benefit perspective. Your health care provider will examine your neck to feel for changes in your thyroid, such as a lump (nodule) in the thyroid. 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. These appear to share the same basic flaw as the ACR-TIRADS, in that the data sets of nodules used for their development is not likely to represent the population upon which it is intended for use, at least with regard to pretest probability of malignancy (eg, malignancy rate 12% for Korean TIRADS [26]; 18% and 31% for EU TIRADS categories 4 and 5 [27, 28]). 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]. Thyroid nodules - Diagnosis and treatment - Mayo Clinic Thyroid Nodules: Causes, Symptoms & Treatment - Cleveland Clinic 3, 4 The modified TI-RADS based on the ACR TI-RADS scoring system was sponsored by Wang et al. Unable to process the form. The financial cost depends on the health system involved, but as an example, in New Zealand where health care costs are modest by international standards in the developed world, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS would result in approximately NZ$140,000 spent for every additional patient correctly reassured that he or she does not have thyroid cancer [25]. Results: Haymart MR, Banerjee M, Reyes-Gastelum D, Caoili E, Norton EC. In a patient with normal life expectancy, a biopsy should be performed for nodules >1cm regardless of the ACR TI-RADS risk category. Thus, the absolute risk of missing important cancer goes from 4.5% to 2.5%, so NNS=100/2=50. Metab. With the right blood tests, you can see if you have a thyroid nodule, and if so, you can treat it with radioactive iodine. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. In which, divided into groups such as: Malignant 3.3%; malignancy 9.2%; malignant 44.4 - 72.4%, malignant. By CEUS-TIRADS diagnostic model combining CEUS with C-TIRADS, a total of 127 cases were determined as malignancy (111 were malignant and 16 were benign) and 101 were diagnosed as benign ones (5 were malignant and 96 were benign). If a clinician does no tests and no FNAs, then he or she will miss all thyroid cancers (5 people per 100). It should also be on an intention-to-test basis and include the outcome for all those with indeterminate FNAs. View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, American College of Radiology: ACR TI-RADS, Korean Society of Thyroid Radiology: K-TIRADS, iodinated contrast-induced thyrotoxicosis, primary idiopathic hypothyroidism with thyroid atrophy, American Thyroid Association (ATA)guidelines, British Thyroid Association (BTA)U classification, Society of Radiologists in Ultrasound (SRU)guidelines, American College of Radiology:ACR TI-RADS, postoperative assessment after thyroid cancer surgery, ultrasound-guided fine needle aspiration of the thyroid, TIRADS (Thyroid Image Reporing and Data System), colloid type 1:anechoic with hyperechoic spots, nonvascularised, colloid type 2: mixed echogenicity with hyperechoic spots,nonexpansile, nonencapsulated, vascularized, spongiform/"grid" aspect, colloid type 3: mixed echogenicity or isoechoic with hyperechoic spots and solid portion, expansile, nonencapsulated, vascularized, simple neoplastic pattern: solid or mixed hyperechoic, isoechoic, or hypoechoic;encapsulated with a thin capsule, suspicious neoplastic pattern: hyperechoic, isoechoic, or hypoechoic;encapsulated with a thick capsule; hypervascularised; with calcifications (coarse or microcalcifications), malignant pattern A: hypoechoic, nonencapsulated with irregular margins, penetrating vessels, malignant pattern B: isoechoic or hypoechoic, nonencapsulated, hypervascularised, multiple peripheral microcalcifications, malignancy pattern C: mixed echogenicity or isoechoic without hyperechoic spots, nonencapsulated, hypervascularised, hypoechogenicity, especially marked hypoechogenicity, "white knight" pattern in the setting of thyroiditis (numerous hyperechoic round pseudonodules with no halo or central vascularizaton), nodular hyperplasia (isoechoic confluent micronodules located within the inferior and posterior portion of one or two lobes, usually avascular and seen in simple goiters), no sign of high suspicion (regular shape and borders, no microcalcifications), high stiffness with sonoelastography (if available), if >7 mm, biopsy is recommended if TI-RADS 4b and 5 or if patient has risk factors (family history of thyroid cancer or childhood neck irradiation), if >10 mm, biopsy is recommended if TI-RADS 4a or if TI-RADS 3 that has definitely grown (2 mm in two dimensions and >20% in volume). 5. Endocrine (2020) 70(2):25679. 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 . TIRADS Management Guidelines in the Investigation of Thyroid Nodules (2009) Thyroid : official journal of the American Thyroid Association. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 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. PLoS ONE. Radzina M, Ratniece M, Putrins DS, Saule L, Cantisani V. Cancers (Basel). The sensitivity, specificity, and accuracy of CEUS-TIRADS were 95.7%, 85.7%, and 92.1% respectively. Lancet (2014) 384(9957): 1848:184858. If the nodule got a score of more than 2 in the CEUS schedule, CEUS-TIRADS added 1 category. Hypoechoic Nodule on Thyroid: Cancer Risk, Next Steps, Outlook - Healthline sharing sensitive information, make sure youre on a federal 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%). Another clear limitation of this study is that we only examined the ACR TIRADS system. Doctors use radioactive iodine to treat hyperthyroidism. Thyroid nodules are lumps that can develop on the thyroid gland. As it turns out, its also very accurate and detailed. The other thing that matters in the deathloops story is that the world is already in an age of war. Bethesda, MD 20894, Web Policies Instead, it has been applied on retrospective data sets, with cancer rates far above 5%, rather than on consecutive unselected patients presenting with a thyroid nodule [33]. PMC Thyroid Nodules - Diagnosis, Treatment, & More - YouTube In patients with thyroid nodules, ultrasonography (US) has been established as a primary diagnostic imaging method and is essential for treatment decision. The test that really lets you see a nodule up close is a CT scan. This assumption is obviously not valid and favors TIRADS management guidelines, but we believe it is helpful for clarity and illustrative purposes. Thyroid nodules come to clinical attention when noted by the patient; by a clinician during routine physical examination; or during a radiologic procedure, such as carotid ultrasonography, neck or chest computed tomography (CT), or positron emission tomography (PET) scanning. A total of 228 thyroid nodules (C-TIRADS 4) were estimated by CEUS. 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]). Please enable it to take advantage of the complete set of features! 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. 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. Later arrival time, hypo-enhancement, heterogeneous enhancement, centripetal enhancement, and rapid washout were risk factors of malignancy in multivariate analysis. Tirads 5 thyroid gland: is a thyroid gland with 5 or more lesions, the rate of malignancy accounts for 87.5%. 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. In 2009, Park et al. Current thyroid cancer trends in the United States, Association between screening and the thyroid cancer epidemic in South Korea: evidence from a nationwide study, 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 ultrasound and the increase in diagnosis of low-risk thyroid cancer, Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology, Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations, European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS, Multiinstitutional analysis of thyroid nodule risk stratification using the American College of Radiology Thyroid Imaging Reporting and Data System, The Bethesda System for reporting thyroid cytopathology: a meta-analysis, The role of repeat fine needle aspiration in managing indeterminate thyroid nodules, The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. 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. Ultrasonogram Reporting System for Thyroid Nodules Stratifying Cancer There are two suspicious signs with the nodule (solid and irregular margin) and it was defined as C-TIRADS 4b. (2017) Radiology. doi: 10.1111/j.1754-9485.2009.02060.x However, many patients undergoing a PET scan will have another malignancy. Shin JH, Baek JH, Chung J, et al. Thyroid Cancer: Diagnosis, Treatment and Follow-Up | IntechOpen With the question "Evaluate treatment results for thyroid disease Tirads 3, Tirads 4? Thyroid Nodules: When to Worry | Johns Hopkins Medicine 2022 Jul;41(7):1753-1761. doi: 10.1002/jum.15858. Until a well-designed validation study is completed, the performance of TIRADS in the real world is unknown. As a result, were left looking like a complete idiot with the results. The financial costs and surgical morbidity in this group must be taken into account when considering the cost/benefit repercussions of a test that includes US imaging for thyroid cancer. Finally, someone has come up with a guide to assist us GPs navigate this difficult but common condition. Reference article, Radiopaedia.org (Accessed on 05 Mar 2023) https://doi.org/10.53347/rID-21448. 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 clinical comparator of a group in which 1 in 10 nodules were randomly selected for FNA. In the case of thyroid nodules, there are further challenges. However, given that TR1 and TR2 make up only 25% of the nodules, then to find 25 nodules that are TR1 or TR2, you would need to do 100 scans. That particular test is covered by insurance and is relatively cheap. Thyroid Nodule Characterization: How to Assess the Malignancy Risk. 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. Noticeably benign pattern (0% risk of malignancy) TI-RADS 3: Probably benign nodules (<5% risk of malignancy) TI-RADS 4: 4a - Undetermined nodules (5-10% risk of malignancy) Score of 1. Such guidelines do not detail the absolute risk of finding or missing a cancer, nor the often excellent outcome of the treatment of thyroid cancer, nor the potential for unnecessary operations. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. -, Fresilli D, David E, Pacini P, Del Gaudio G, Dolcetti V, Lucarelli GT, et al. The Thyroid Imaging Reporting And Data System (TI-RADS) was developed by the American College of Radiology and used by many radiologist in Australia. We have also assumed that all nodules are at least 10 mm and so the TR5 nodule size cutoff of 5 mm does not apply. Second, we then apply TIRADS across all 5 nodule categories to give an idea how TIRADS is likely to perform overall. The problem is that many people dont know that they have a thyroid nodule, so they dont know how to treat it. Russ G, Royer B, Bigorgne C et-al. Therefore, 60% of patients are in the middle groups (TR3 and TR4), where the US features are less discriminatory. Thyroid Nodules: Advances in Evaluation and Management | AAFP If one assumes that in the real world, 25% of the patients have a TR1 or TR2 nodule, applying TIRADS changes the pretest 5% probability of cancer to a posttest risk of 1%, so the absolute risk reduction is 4%. Required fields are marked *. Given that a proportion of thyroid cancers are clinically inconsequential, the challenge is finding a test that can effectively rule-in or rule-out important thyroid cancer (ie, those cancers that will go on to cause morbidity or mortality). -. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. This is a specialist doctor who specializes in the treatment and diagnosis of thyroid cancer. TR5 in the data set made up 16% of nodules, in which one-half of the thyroid cancers (183/343) were found. 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. Therefore, using TIRADS categories TR1 or TR2 as a rule-out test should perform very well, with sensitivity of the rule-out test being 97%. The sensitivity, specificity, and accuracy of C-TIRADS were 93.1%, 55.3%, and 74.6% respectively. However, there are ethical issues with this, as well as the problem of overdiagnosis of small clinically inconsequential thyroid cancer. Learn how t. National Library of Medicine PPV was poor (20%), NPV was no better than random selection, and accuracy was worse than random selection (65% vs 85%). It has been retrospectively applied to thyroidectomy specimens, which is clearly not representative of the patient presenting with a thyroid nodule [34-36], and has even been used on the same data set used for TIRADS development, clearly introducing obvious bias [32, 37]. 19 (11): 1257-64. 2020 Chinese Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules: The. eCollection 2022. Therefore, for every 25 patients scanned (100/4=25) and found to be either TR1 or TR2, 1 additional person would be correctly reassured that they do not have thyroid cancer. Jin Z, Zhu Y, Lei Y, Yu X, Jiang N, Gao Y, Cao J. Med Sci Monit. Your email address will not be published. Your email address will not be published. tirads 4 thyroid nodule treatment - yaeyamasyoten.com J. Clin. All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. They're common, almost always noncancerous (benign) and usually don't cause symptoms. Such data should be included in guidelines, particularly if clinicians wish to provide evidence-based guidance and to obtain truly informed consent for any action that may have negative consequences. The ACR TIRADS white paper [22] very appropriately notes that the recommendations are intended to serve as guidance and that professional judgment should be applied to every case including taking into account factors such as a patients cancer risk, anxiety, comorbidities, and life expectancy. An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. Cystic or almost completely cystic 0 points. The more important test metric for diagnosing a disease is the specificity, where a positive test helps rule-in the disease. Cheng H, Zhuo SS, Rong X, Qi TY, Sun HG, Xiao X, Zhang W, Cao HY, Zhu LH, Wang L. Int J Endocrinol. 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. To develop a medical test a typical process is to generate a hypothesis from which a prototype is produced. They will want to know what to do with your nodule and what tests to take. Now, the first step in T3N treatment is usually a blood test. 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]. Very probably benign nodules are those that are both. TI-RADS 2: Benign nodules. Keywords: The frequency of different Bethesda categories in each size range . Some cancers would not show suspicious changes thus US features would be falsely reassuring. Thyroid surgery, Microvascular reconstruction, Neck surgery, Reconstructive surgery, Facial reconstruction, Parathyroid. A newer alternative that the doctor can use to treat benign nodules in an office setting is called radiofrequency ablation (RFA). Objective: To determine whether the size of thyroid nodules in ACR-TIRADS ultrasound categories 3 and 4 is correlated with the Bethesda cytopathology classification. ", the doctor would like to answer as follows: With the information you provided, you have a homophonic nucleus in the right lobe. The CEUS-TIRADS category was 4a. J Adolesc Young Adult Oncol (2020) 9(2):2868. Ultrasound classification of thyroid nodules: does size matter? Zhonghua Yi Xue Za Zhi. EU-TIRADS 1 category refers to a US examination where no thyroid nodule is found; there is no need for FNAB. TIRADS 5: probably malignant nodules (malignancy >80%). Therefore, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS to correctly rule out thyroid cancer in 1 additional patient would require more than 100 US scans (NNS>100) to find 25 TR1 and TR2 patients, triggering at least 40 additional FNAs and resulting in approximately 6 additional unnecessary diagnostic hemithyroidectomies at significant economic and personal costs. They are found . 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). The flow chart of the study. The system is sometimes referred to as TI-RADS Kwak 6. A thyroid nodule is an unusual lump (growth) of cells on your thyroid gland. TI-RADS 1: normal thyroid gland TI-RADS 2: benign nodule TI-RADS 3: highly probable benign nodule TI-RADS 4a: low suspicion for malignancy TI-RADS 4b: high suspicion for malignancy TI-RADS 5: malignant nodule with more than two criteria of high suspicion Imaging features TI-RADS 2 category Constantly benign patterns include simple cyst 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. The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 100 nodules in the validation cohort. 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. 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. The Thyroid Imaging Reporting and Data System (TI-RADS) of the American College of Radiology (ACR) was designed in 2017 with the intent to decrease biopsies of benign nodules and improve overall . ACR TI-RADS FAQ : RADS - Reporting and Data Systems Support Thyroid nodule size from 1.5 - 2.5cm: Periodic follow-up every 6 months. Department of Endocrinology, Christchurch Hospital. Because we have a lot of people who have been put in a position where they dont have the proper education to be able to learn what were going through, we have to take this time and go through it as normal. It is limited by only being an illustrative example that does not take clinical factors into account such as prior radiation exposure and clinical features. 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. Thyroid imaging reporting and data system (TI-RADS) Thyroid Nodules. Epub 2021 Oct 28. To illustrate the effect of the size cutoffs we have given 2 examples, 1 where the size cutoffs are not discriminatory and the cancer rate is the same above and below the size cutoff, and the second example where the cancer risk of the nodule doubles once the size goes above the cutoff. Among thyroid nodules detected during life, the often quoted figure for malignancy prevalence is 5% [5-8], with UptoDate quoting 4% to 6.5% in nonsurgical series [9], and it is likely that only a proportion of these cancers will be clinically significant (ie, go on to cause ill-health). All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. Diag (Basel) (2021) 11(8):137493. J Med Imaging Radiat Oncol (2009) 53(2):17787. 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.