Draft:ACR TI-RADS

ACR TI-RADS (Thyroid Imaging Reporting and Data System) is a standardized risk-stratification scoring system for thyroid nodules identified on ultrasound, developed by the American College of Radiology (ACR).[1]

Background

Thyroid nodules are extremely common, detected incidentally in up to 68% of patients undergoing neck ultrasound.[2] The vast majority are benign, and ACR TI-RADS was developed to reduce unnecessary fine-needle aspiration (FNA) biopsies while ensuring that malignant nodules are identified appropriately.

The system is modeled after BI-RADS (Breast Imaging Reporting and Data System), which similarly stratifies imaging findings into risk categories to guide management.

Scoring

ACR TI-RADS assigns points across five ultrasound feature categories:

Category Features scored
Composition Cystic/spongiform (0 pts), mixed (1 pt), solid (2 pts)
Echogenicity Anechoic/hyperechoic (1 pt), isoechoic (2 pts), hypoechoic (3 pts)
Shape Wider-than-tall (0 pts), taller-than-wide (3 pts)
Margin Smooth/ill-defined (0 pts), lobulated/irregular (2 pts), extrathyroidal extension (3 pts)
Echogenic foci None/large comet-tail (0 pts), macrocalcifications (1 pt), peripheral calcifications (2 pts), punctate echogenic foci (3 pts)

Points from all five categories are summed. Any number of findings in the echogenic foci category are added cumulatively.

Risk categories

TR Level Points Malignancy risk Management
TR1 0 Benign No FNA
TR2 2 Not suspicious No FNA
TR3 3 Mildly suspicious FNA if ≥ 2.5 cm; follow if ≥ 1.5 cm
TR4 4–6 Moderately suspicious FNA if ≥ 1.5 cm; follow if ≥ 1 cm
TR5 ≥ 7 Highly suspicious FNA if ≥ 1 cm; follow if ≥ 0.5 cm

Published malignancy rates range from less than 2% for TR1/TR2 nodules up to greater than 20% for TR5 nodules.[3]

Clinical use

ACR TI-RADS is widely adopted in North America and is recognized by the [[American Thyroid Association]] and other international societies. When multiple nodules are present, up to two nodules with the highest point totals are prioritized for biopsy, which may not necessarily be the largest nodules.

Several free online calculators have been developed to assist clinicians in applying the scoring criteria at the point of care.[4]

See also

References

  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. J Am Coll Radiol. 2017;14(5):587–595. doi:10.1016/j.jacr.2017.01.046
  2. ^ Grani G, Sponziello M, Pecce V, Ramundo V, Durante C. Contemporary Thyroid Nodule Evaluation and Management. J Clin Endocrinol Metab. 2020;105(9):2869–2883.
  3. ^ Tessler FN, et al. 2017.
  4. ^ "ACR TI-RADS Calculator". Retrieved 2026-06-09.

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