ACR-TIRADS and Eu-TIRADS, are they so different?

Poster No.: C-2490

Congress: ECR 2019
Type: Educational Exhibit
Authors: F. Diaz, I. García Duitama, A. Radosevic, A. Solano, C. V.
Martinez Stocker, M. Vilas Gonzalez, A. Agustí; Barcelona/ES
Keywords: Head and neck, Thyroid / Parathyroids, Ultrasound, Ultrasound-
Colour Doppler, Structured reporting, Decision analysis, Diagnostic
procedure, Endocrine disorders, Neoplasia, Pathology
DOI: 10.26044/ecr2019/C-2490

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Learning objectives

- To describe in a concise and practical way two of the most used ultrasound-based
classification systems for thyroid nodules: the American College of Radiology (ACR)
TIRADS, and European (EU) TIRADS.

- Stablish the principal differences between both classification systems and the pros and
cons of both of them.

- To show in a practical way, by presenting common clinical cases, the main differences
between those systems.

- Review the accumulated evidence.

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Background

Thyroid nodules are quite common in general population, being found in up to 68% of
normal population (depending the serie) [1]. Most of them are asymptomatic, showing
benign appearance, and will never develop into a cancer. But few of them could develop
a cancer in a future. Ultrasound (US) is widespread and extremely useful for imaging
thyroid lesions, given the fact that some US features of thyroid nodules has been linked to
increased risk of malignancy in varying percentages. Unfortunately, none of such features
is enough sensible and specific to detect cancer alone, so we need a classification system
able to classify those findings and stratify them into determined risk groups, in order to
diagnose cancer and reduce unnecessary interventions for benign lesions.

In 2015 an american committee convened by the ACR presented a white paper for
approaching the thyroid nodules, and the appropiate lexicon to be used for the report.
The white paper was named ACR Thyroid Imaging, Reporting and Data System (ACR
TI-RADS) [2]. In 2017, the white paper was revised and updated, published in may 2017
[1] and its being widespread used since then.

The European thyroid association (ETA) convened a task force to create a guideline
and a risk stratification system, and also to establish a lexicon, a report template, and
a practical image guide, which was named EU-TIRADS. The report was published in
september 2017 [3].

There are other classification systems, namely BTA, ATA, AACE/ACE/AME and K-
TIRADS, that can be useful but it's discussion if beyond the goals of the poster.

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Images for this section:

Fig. 1: Figure 1. The 2017 ACR-TIRADS system.

© Tessler FN, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White
Paper of the ACR TI-RADS Committee. Journal of the American College of Radiology.
2017 May;14(5):587-95.

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Findings and procedure details

ACR-TIRADS

Is a scoring system, based in the US features of a given nodule. The higher the
score, the greater the risk of malignancy, which would imply performing complementary
interventions (namely FNA) for a better characterization of the lesion. Detailed description
of the nodules features' and scores can be found in Figure 1.

Fig. 1: Figure 1. The 2017 ACR-TIRADS system.

References: Tessler FN, et al. ACR Thyroid Imaging, Reporting and Data System (TI-
RADS): White Paper of the ACR TI-RADS Committee. Journal of the American College
of Radiology. 2017 May;14(5):587-95.

It stratifies nodules into the following suspicion groups: Fig. 1 on page 12

• TR1: Benign: Cancer risk 0.3%. In this case, FNA is not indicated.

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 • TR2: Not suspicious: Cancer risk 1.5%. Similarly to TR1, FNA not indicated.

• TR3: Mildly suspicious: Cancer risk 4,8%. FNA is indicated if nodule is more
or equal than 2.5cm, and follow up if more or equal than 1.5cm.

• TR4: Moderately suspicious: Cancer risk is 9.1%. FNA is indicated if nodule

is more or equal than 1.5cm, and follow up if more or equal than 1 cm.

• TR5: Highly suspicious: Cancer risk is 35%. FNA is indicated if nodule is more
or equal than 1 cm, and follow up if more or equal than 0.5cm.

EU-TIRADS

Its main goal was to develop simplified classification system, and by this means, to reduce
the interobserver variability and improve the reproductibility. It is based on "classic pattern
categories".

Fig. 2: EU-TIRADS algorithm for classification of nodules and FNA decision-making.

References: Russ G, et al. European Thyroid Association Guidelines for Ultrasound
Malignancy Risk Stratification of Thyroid Nodules in Adults: The EU-TIRADS.
European Thyroid Journal. 2017;6(5):225-37.

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It defines the following US categories:

• Normal gland, no nodules (EU-TIRADS 1).

• Benign (EU-TIRADS 2): Risk of malignancy close to 0%. FNA is not indicated,
unless compressive symptoms.

• Low risk (EU-TIRADS 3): Risk of malignancy 2-4%. Proceed to FNA if more
than 20mm.

• Intermediate risk (EU-TIRADS 4): Risk of malignancy 6-17%. Proceed to FNA

if more than 15mm.

• High Risk (EU-TIRADS 5): Risk of malignancy 26-87%. Proceed to FNA if

more than 10mm.

Table 1: EU-TIRADS SYSTEM. Categories are defined by the classic picture of

nodules.
References: Russ G, et al. European Thyroid Association Guidelines for Ultrasound
Malignancy Risk Stratification of Thyroid Nodules in Adults: The EU-TIRADS.
European Thyroid Journal. 2017;6(5):225-37.

ACR-TIRADS and EU-TIRADS: practical points and differences

Both the EU-TIRADS and ACR-TIRADS are practical, useful and very good
classifications systems recently developed. They share common characteristics, but also
several differences. Categorization differences are shown in Table 2 on page 13, and
the differences in terms of management are described in Table 3 on page 13 .

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Table 2: ACR/EU - TIRADS differences in terms of classification of nodules.
References: Hospital del Mar, Hospital del Mar - Barcelona/ES

Table 3: ACR/EU - TIRADS differences in terms of management of nodules by risk

category.
References: Hospital del Mar, Hospital del Mar - Barcelona/ES

• EU-TIRADS It is a system that assigns each lesion into a risk group

according to the presence of certain US findings.
• ACR-TIRADS is a score-based system, according to the US features of a
given nodule.
• In ACR-TIRADS, the score increases in a summatory way with every US
feature added. So, a nodule must have a sum of features to be classified

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 into a determined risk category, instead of a definitory feature alone, as used
by EU-TIRADS (5 definitory high risk characteristics).
• In EU-TIRADS, the threshold to perform FNA are 2cm (low risk - EU-
TIRADS 3), 1.5cm (intermediate risk - EU-TIRADS 4) and 1cm (high risk -
EU-TIRADS 5).
• In ACR-TIRADS, the threshold size to perform a FNA are 2.5cm (TR3),
1.5cm (TR4) and 1 cm (TR5).
• In EU-TIRADS 5, the guideline recommends repeating the FNA in 3 months
if the FNA result is benign, to exclude a false negative. Fig. 7 on page 18
Fig. 9 on page 20
• In EU-TIRADS, the threshold to indicate active surveillance is <1cm high-risk
nodules (EU-TIRADS 5). No specific recommendation is made for low and
intermediate risk nodules. Fig. 8 on page 19
• In ACR-TIRADS, the threshold size to initiate active surveillance are 1.5cm
(TR3), 1cm (TR4) and 0.5cm (TR5). The system states that performing a
biopsy of a nodule between 5 and 9mm can be appropriated under certain
circumstances (shared referring doctor - patient decision making).
• The EU-TIRADS includes a standardized reporting form, which is more
extensive, and may be more time consuming.
• Only the EU TIRADS includes a visual diagram of the thyroid gland, to
standardize nodule location for reporting. Fig. 3 on page 15
• The EU-TIRADS normal gland (1 category) doesn't exists in ACR-TIRADS,
in which such category 1 represents a benign nodule.
• EU-TIRADS 2 means a benign nodule, and ACR-TIRADS 2 means a non-
suspect nodule. Both of them have distinct US characteristics. EU-TIRADS 2
is the equivalent to ACR-TIRADS 1. Fig. 4 on page 15
• Although there are differences among systems in categories 1 and 2, they
don't imply changes in terms of patient's management.
• ACR-TIRADS 2 is an intermediate category, which is not included in the
EU-TIRADS. Fig. 10 on page 21 Fig. 12 on page 23 Fig. 13 on page
24
• The EUTIRADS states that there are 4 US characteristics (non oval shape,
irregular margins, microcalcifications or marked hypoechogenicity) that if
present, would be enough to classify a nodule as a high risk one. Such
findings where first described in 2002, having a high degree of specificity
(83-84%), but low sensitivity (26-59%). Fig. 11 on page 22
• The EU-TIRADS takes into account several factors and situations excluded
from the given scheme, which may reduce its usability. Examples to this:
macrocalcifications (ACR included with 1 point), and extrathyroidal extension
(ACR included with 3 points).
• The EU-TIRADS considers the possibility of a nodule formed by coalition of
smaller ones.
• Nodule growth seems to weigh less in EU-TIRADS than in ACR TIRADS.
In ACR-TIRADS, they tell us specific parameters to consider significant
growth: at least 20% in 2 diameters, at least 2mm or 50% or more increase
in volume.

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 • EU-TIRADS takes into account scars as very hypoechoic lesions, and
downscale its category. Such scars could be mistaken as a highly
suspicious nodule using ACR-TIRADS.
• Both systems recommend to check lymphadenopathies, specially in
the intermediate and high risk, and puncture them in case of suspiction.
Suspiction features are: globular shape, loss of normal echogenic hilium,
peripheral (intead of hilar) flow, heterogeneity and gland-like tisue within the
node. Fig. 5 on page 16 Fig. 6 on page 17
• Respecting the multinodular disease, the recommedation is to report at
least the 3 nodules with highest TIRADS (EU-TIRADS) and a maximun of 4
(ACR-TIRADS).

EU-TIRADS and ACR-TIRADS: The accumulated evidence

Both of them are newly developed or revisited systems designed to discriminate the high
risk lesions, reducing in this way, the unnecessary complementary explorations such as
FNA and surgery.

The ACR TIRADS has been used for a while, being a useful tool, with high degree of
sensibility and specificity, to discriminate the lesions.

The EU-TIRADS is even newer, and due to this, more studies are needed to demonstrate
its capacity to discriminate. We need more comparative studies with the most known
classification systems used nowadays.

A recent published article compared in a prospective way 5 of the most used classification
systems (ACR, ATA, AACE/ACE/AME, EU-TIRADS and K-TIRADS). It was shown
that all of them have a very good discriminatory capacity, reducing the number of
unnecessary biopsies, being particularly higher in the case of ACR. The article concluded
that ACR showed a better overall performance, classifying half of the biopsies as
unnecessary, with a false negative rate of 2% [4].

Other recent study published in 2018 studied the interobserver variability of the
classification systems AAC/ACE/AME, ACR, ATA, EU-TIRADS, K-TIRADS and the
interobserver concordance in the indication of FNA biopsy. When selecting the nodules
to be performed the FNA biopsy, which is the main objective of this classifications, the
interobserver agreement is substantial to almost perfect [5].

Another recent sudy from 2018 comparing and estimating the performance of ATA,
AACE/ACE/AME, ACR-TIRADS in discriminating high risk citology nodules. 1077
thyroides nodules submitted to FNA were classified according the classification systems.

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OR y ROC curves for the high risk categories were calculated. The ACR-TIRADS had
the highest área below the curve ROC for identifying high risk citology nodules. [6]

Other recent study in 2018 was conducted to evaluate the temporal stability of initial risk
calculated with 5 systems, and determine whether the risk class increases during the
follow up is indicative of malignancy. It was demonstrated that benign nodules tend to stay
stable in time, and changes that require biopsies are rare. Development of new nodules
are frequent, but few of them (less than 5%) are classified as a high risk. So, this means
that benign nodules could be followed in a secure way with less intense surveillance
protocols.[7]

A prospective study comprehending almost 1000 nodules submitted to FNA, in which the
US images were analyzed and classified by 4 experts, according the systems BTA, ATA
y ACE/AME/AACE. It was revealed that those classification systems had high PPV for
malignancy in high risk cases. [8]

Another study studied the validity of 6 US characteristics (mild hypoechogenicity, marked

hypoechogenicity, irregular/microlobulated margins, microcalcifications, taller than wide
shape and thin halo abscence) to stratify the thyroid nodules in iodine deficiency áreas in
Austria. It was demonstrated that all criteria but mild hypoechogenicity were significantly
more frequent in thyroid cancer than in benign nodules.This supports the use of EU-
TIRADS. Apart from the mild hypoechogenicity, the US criteria can be applied to stratify
the thyroid nodules risk in iodine deficiency areas in Austria.[9]

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Images for this section:

Fig. 1: Figure 1. The 2017 ACR-TIRADS system.

© Tessler FN, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): White
Paper of the ACR TI-RADS Committee. Journal of the American College of Radiology.
2017 May;14(5):587-95.

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Table 1: EU-TIRADS SYSTEM. Categories are defined by the classic picture of nodules.

© Russ G, et al. European Thyroid Association Guidelines for Ultrasound Malignancy

Risk Stratification of Thyroid Nodules in Adults: The EU-TIRADS. European Thyroid
Journal. 2017;6(5):225-37.

Table 2: ACR/EU - TIRADS differences in terms of classification of nodules.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Table 3: ACR/EU - TIRADS differences in terms of management of nodules by risk
category.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

Fig. 2: EU-TIRADS algorithm for classification of nodules and FNA decision-making.

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© Russ G, et al. European Thyroid Association Guidelines for Ultrasound Malignancy
Risk Stratification of Thyroid Nodules in Adults: The EU-TIRADS. European Thyroid
Journal. 2017;6(5):225-37.

Fig. 3: EU-TIRADS diagram for location of thyroid nodules.

© Russ G, et al. European Thyroid Association Guidelines for Ultrasound Malignancy

Risk Stratification of Thyroid Nodules in Adults: The EU-TIRADS. European Thyroid
Journal. 2017;6(5):225-37.

Page 15 of 28
Fig. 4: A 68 year old male patient, with an finding in an US neck examination: A small
(5mm) anechoic nodule, with posterior acoustic shadow, well delimited margins. This is
compatible with a thyroid cyst (ACR-TIRADS: 1, EU-TIRADS 2)

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 5: A left lobule isoechoic thyroid nodule, with few cystic component and
microcalcifications (not shown). Corresponds to a category ACR-TIRADS 4/ EU-TIRADS
5. In both cases, FNA is required.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 6: Same patient in previous figure. A cervical ipsilateral adenopathy was biopsied,
resulting to be lung cancer metastasis.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 7: An ACR-TIRADS 5/ EU-TIRADS 5 markedly hypoechoic, lobulated margins
thyroid nodule. Cytology demonstrated papillary carcinoma.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 8: An 85 year old male patient with diagnosis of multinodular goitier. In the right lobe,
we can see an isoechogenic, irregular margins, thin hypoechoic halo, with dimensions
of 17x10x23mm (ACR-TIRADS: 4, EU-TIRADS 5) . According to both ACR and EU-
TIRADS, it will require an FNA. Due to patient age, lack of compresive symptoms and
comorbidities, the team decided not to biopsy.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 9: A 60 year old female patient, with a very hypoechoic left lobe nodule (ACR-
TIRADS: 4, EU-TIRADS: 5). According to both systems, the nodule should be biopsied.
The FNA showed benign celularity.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 10: A mixed solid-cystic nodule, with a solid isoechoic part. It corresponds to ACR-
TIRADS 2 and EU-TIRADS 3. According to ACR, no follow up is needed. According to
EU-TIRADS, no FNA needed.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 11: An ACR-TIRADS 5 and EU-TIRADS 5 very hypoechoic nodule, having an AP
diameter greater than transverse. Doppler rule out the possibility of a cyst. Pathology
found a papillar carcinoma.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 12: An ACR-TIRADS 3/ EU-TIRADS 3 less than 20mm isoechoic nodule, without
significant changes from previous studies. According the classification in both of them,
none of them would require FNA study, but should be followed according to ACR-
TIRADS.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Fig. 13: An ACR-TIRADS 3/ EU-TIRADS 3 thyroid nodule, without significant changes
from the previous examinations. According to EU-TIRADS, follow-up is not mandatory.

© Hospital del Mar, Hospital del Mar - Barcelona/ES

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Conclusion

The ACR - TIRADS and EU-TIRADS are very good and useful scores to stratify the risk of
malignancy of a determined thyroid lesion. Owing the differences between both scores,
we recommend using one of them and clearly state the used one in the radiological report
to avoid confusion and offer an standardized management to patients.

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References

[1] Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, Teefey SA, Cronan
JJ, Beland MD, Desser TS, Frates MC, Hammers LW, Hamper UM, Langer JE,
Reading CC, Scoutt LM, Stavros AT. ACR Thyroid Imaging, Reporting and Data System
(TI-RADS): White Paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017
May;14(5):587-595.

[2]. Grant EG, Tessler FN, Hoang JK, Langer JE, Beland MD, Berland LL, Cronan JJ,
Desser TS, Frates MC, Hamper UM, Middleton WD, Reading CC, Scoutt LM, Stavros
AT, Teefey SA. Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid
Imaging, Reporting and Data System (TIRADS) Committee. J Am Coll Radiol. 2015
Dec;12(12 Pt A):1272-9.

[3] Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L.European Thyroid
Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules
in Adults: The EU-TIRADS. Eur Thyroid J. 2017 Sep;6(5):225-237.

[4]. Grani G, Lamartina L, Ascoli V, Bosco D, Biffoni M, Giacomelli L, Maranghi M, Falcone

R, Ramundo V, Cantisani V, Filetti S, Durante C. Reducing the Number of Unnecessary
Thyroid Biopsies While Improving Diagnostic Accuracy: Toward the "Right" TIRADS. J
Clin Endocrinol Metab. 2019 Jan 1;104(1):95-102.

[5]. Grani G, Lamartina L, Cantisani V, Maranghi M, Lucia P, Durante C. Interobserver

agreement of various thyroid imaging reporting and data systems. Endocr Connect. 2018
Jan;7(1):1-7.

[6]. Lauria Pantano A, Maddaloni E, Briganti SI, Beretta Anguissola G, Perrella E, Taffon
C, Palermo A, Pozzilli P, Manfrini S, Crescenzi A. Differences between ATA, AACE/ACE/
AME and ACR TI-RADS ultrasound classifications performance in identifying cytological
high-risk thyroid nodules. Eur J Endocrinol. 2018 Jun;178(6):595-603.

[7]. Grani G, Lamartina L, Biffoni M, Giacomelli L, Maranghi M, Falcone R, Ramundo

V, Cantisani V, Filetti S, Durante C. Sonographically Estimated Risks of Malignancy for
Thyroid Nodules Computed with Five Standard Classification Systems: Changes over
Time and Their Relation to Malignancy. Thyroid. 2018 Sep;28(9):1190-1197.

[8]. Predictive Value of Malignancy of Thyroid Nodule Ultrasound Classification Systems:

A Prospective Study. Persichetti A, Di Stasio E, Guglielmi R, Bizzarri G, Taccogna S,
Misischi I, Graziano F, Petrucci L, Bianchini A, Papini E. J Clin Endocrinol Metab. 2018
Apr 1;103(4):1359-1368.

[9]. Tugendsam C, Petz V, Buchinger W, Schmoll-Hauer B, Schenk IP, Rudolph K, Krebs

M, Zettinig G. Ultrasound criteria for risk stratification of thyroid nodules in the previously

Page 27 of 28
iodine deficient area of Austria - a single centre, retrospective analysis. Ultrasound criteria
for risk stratification of thyroid nodules in the previously iodine deficient area of Austria -
a single centre, retrospective analysis. Thyroid Res. 2018 May 9;11:3.

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