2D-Shear Wave Elastography Increases the Diagnostic Accuracy of the TIRADS-ACR and ATA Classification Systems in Thyroid Nodule Selection: Cytological and Histological Correlation

Abstract

Purpose

The aim was to evaluate whether elastography changes the accuracy of thyroid nodule malignancy risk classification using the TI-RADS ACR and ATA systems.

Materials and Methods

This was a prospective study with 191 nodules (180 patients). Nodule assessments by B-mode ultrasonography (US) and 2-dimensional shear wave elastography (2D-SWE) were compared with a) fine-needle aspiration biopsy cytological (Bethesda II) and b) post-resection histology results (Bethesda III–VI). Nodules were divided into benign and malignant. B-mode US evaluated echogenicity, composition, dimensions, contours, limits, and presence of halo and echogenic foci. Elastography classified nodules from I (completely softened) to IV (completely hard). The mean nodule deformation value (assessed in m/s and kPa), the deformation ratio between nodule and thyroid parenchyma (TDR), and the deformation ratio between nodule and pre-thyroid musculature (MDR) were calculated.

Results

The significant univariate parameters for B-mode were hypoechogenicity, halo, microcalcifications, irregular contours, and ill-defined limits. All parameters were significant for elastography. The MDR (in kPa) was the best elastographic parameter: nodules with MDRs> 1.53 exhibited a higher chance of malignancy (AUC-ROC=0.831). B-mode ACR-TIRADS had an AUC of 0.678; 95% CI: 0.596–0.760, while ATA had an AUC of 0.680; 95%: 0.597–0.763. Multivariable analysis indicated that the combination of prognostic models with any elastographic parameter increased performance. ATA classification, combined with elastogram pattern and MDR (in kPa), increased the AUC to 0.892; 95% IC: 0.845–0.939.

Conclusion

2D-SWE can increase the accuracy of the most widespread B-mode prognostic models: TI-RADS ACR and ATA.

Zusammenfassung

Ziel

Es sollte untersucht werden, ob die Elastografie die Genauigkeit der Klassifizierung des Malignitätsrisikos von Schilddrüsenknoten mittels TI-RADS-ACR- und ATA-Systemen verbessert.

Material und Methoden

Es handelte sich um eine prospektive Studie mit 191 Knoten (180 Patienten). Die Beurteilung der Knoten mittels der B-Mode-Sonografie (US) und 2-dimensionaler Schallwellen-Elastografie (2D-SWE) wurde a) mit den zytologischen Befunden der Feinnadel-Punktion (Bethesda II) und b) mit den histologischen Befunden nach Resektion (Bethesda III–VI) verglichen. Die Knoten wurden in benigne und maligne unterteilt. Im B-Mode-US wurden Echogenität, Zusammensetzung, Abmessungen, Konturen, Grenzen und das Vorhandensein von Halo und echogenen Foci untersucht. Die Elastografie klassifizierte die Knoten von I (vollständig weich) bis IV (vollständig hart). Der mittlere Knoten-Verformungswert (in m/s und kPa), das Verhältnis der Verformbarkeit zwischen Knoten und Schilddrüsen-Parenchym (TDR) und das Verformungsverhältnis zwischen Knoten und präthyreoidaler Muskulatur (MDR) wurden berechnet.

Ergebnisse

Die signifikanten univariaten Parameter für den B-Mode waren Hypoechogenität, Halo, Mikroverkalkungen, unregelmäßige Konturen und unklare Grenzen. Für die Elastografie waren alle Parameter signifikant. Der MDR (in kPa) war der beste elastografische Parameter: Knoten mit einem MDR >1,53 entsprachen einem höheren Risiko für Malignität (AUC-ROC=0,831). B-Mode-ACR-TIRADS hatte eine AUC von 0,678 (95%-KI: 0,596–0,760), während ATA eine AUC von 0,680 (95%-KI: 0,597–0,763) hatte. Die multivariable Analyse zeigte, dass die Kombination von prognostischen Modellen mit einem beliebigen elastografischen Parameter die Leistung erhöhte. Die ATA-Klassifizierung in Kombination mit dem Elastogramm-Muster und dem MDR (in kPa) erhöhte die AUC auf 0,892 (95%-KI: 0,845–0,939).

Schlussfolgerung

Die 2D-SWE kann die Genauigkeit der am weitesten verbreiteten B-Mode-Prognosemodelle TI-RADS-ACR und -ATA erhöhen.

Keywords

thyroid - ultrasound - ACR TI-RADS (American College of Radiology Thyroid Imaging Reporting and Data System) - thyroid nodules - shear wave elastography

Publikationsverlauf

Eingereicht: 21. Juni 2024

Angenommen nach Revision: 05. März 2025

Accepted Manuscript online:
05. März 2025

Artikel online veröffentlicht:
14. August 2025

• References

• 1 Baş H, Üstüner E, Kula S. et al. Elastography and Doppler May Bring a New Perspective to TIRADS, Altering Conventional Ultrasonography Dominance. Acad Radiol 2022; 29: e25-e38
• 2 Cantisani V, De Silvestri A, Scotti V. et al. US-Elastography With Different Techniques for Thyroid Nodule Characterization: Systematic Review and Meta-analysis. Front Oncol 2022; 12: 845549
• 3 Cantisani V, Grazhdani H, Ricci P. et al. Q-elastosonography of solid thyroid nodules: assessment of diagnostic efficacy and interobserver variability in a large patient cohort. Eur Radiol 2014; 24: 143-150
• 4 Grant EG, Tessler FN, Hoang JK. et al. Thyroid Ultrasound Reporting Lexicon: White Paper of the ACR Thyroid Imaging, Reporting and Data System (TIRADS) Committee. J Am Coll Radiol 2015; 12: 1272-1279
• 5 Haugen BR, Alexander EK, Bible KC. 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
• 6 Koc AM, Adıbelli ZH, Erkul Z. et al. Comparison of diagnostic accuracy of ACR-TIRADS, American Thyroid Association (ATA), and EU-TIRADS guidelines in detecting thyroid malignancy. Eur J Radiol 2020; 133: 109390
• 7 David E, Grazhdani H, Tattaresu G. et al. Thyroid Nodule Characterization: Overview and State of the Art of Diagnosis with Recent Developments, from Imaging to Molecular Diagnosis and Artificial Intelligence. Biomedicines 2024; 12: 1676
• 8 Moraes PHM, Takahashi MS, Vanderlei FAB. et al. Multiparametric Ultrasound Evaluation of the Thyroid: Elastography as a Key Tool in the Risk Prediction of Undetermined Nodules (Bethesda III and IV)-Histopathological Correlation. Ultrasound Med Biol 2021; 47: 1219-1226
• 9 Cibas ES, Ali SZ. The 2017 Bethesda System for Reporting Thyroid Cytopathology. Thyroid 2017; 27: 1341-1346
• 10 Friedrich-Rust M, Vorlaender C, Dietrich CF. et al. Evaluation of Strain Elastography for Differentiation of Thyroid Nodules: Results of a Prospective DEGUM Multicenter Study. Ultraschall in Med 2016; 37: 262-270
• 11 Cantisani V, David E, Grazhdani H. et al. Prospective Evaluation of Semiquantitative Strain Ratio and Quantitative 2D Ultrasound Shear Wave Elastography (SWE) in Association with TIRADS Classification for Thyroid Nodule Characterization. Ultraschall in Med 2019; 40: 495-503
• 12 Yeon EK, Sohn YM, Seo M. et al. Diagnostic Performance of a Combination of Shear Wave Elastography and B-Mode Ultrasonography in Differentiating Benign From Malignant Thyroid Nodules. Clin Exp Otorhinolaryngol 2020; 13: 186-193
• 13 Petersen M, Schenke SA, Firla J. et al. Shear Wave Elastography and Thyroid Imaging Reporting and Data System (TIRADS) for the Risk Stratification of Thyroid Nodules-Results of a Prospective Study. Diagnostics (Basel) 2022; 12: 109
• 14 Yang BR, Kim EK, Moon HJ. et al. Qualitative and Semiquantitative Elastography for the Diagnosis of Intermediate Suspicious Thyroid Nodules Based on the 2015 American Thyroid Association Guidelines. J Ultrasound Med 2018; 37: 1007-1014
• 15 Săftoiu A, Gilja OH, Sidhu PS. et al. The EFSUMB Guidelines and Recommendations for the Clinical Practice of Elastography in Non-Hepatic Applications: Update 2018. Ultraschall in Med 2019; 40: 425-453
• 16 Tian W, Hao S, Gao B. et al. Comparing the Diagnostic Accuracy of RTE and SWE in Differentiating Malignant Thyroid Nodules from Benign Ones: a Meta-Analysis. Cell Physiol Biochem 2016; 39: 2451-2463
• 17 Mistry R, Hillyar C, Nibber A. et al. Ultrasound Classification of Thyroid Nodules: A Systematic Review. Cureus 2020; 12: e7239
• 18 Celletti I, Fresilli D, De Vito C. et al. TIRADS, SRE and SWE in INDETERMINATE thyroid nodule characterization: Which has better diagnostic performance?. Radiol Med 2021; 126: 1189-1200
• 19 Okasha HH, Mansor M, Sheriba N. et al. Role of elastography strain ratio and TIRADS score in predicting malignant thyroid nodule. Arch Endocrinol Metab 2021; 64: 735-742
• 20 Liu Z, Jing H, Han X. et al. Shear wave elastography combined with the thyroid imaging reporting and data system for malignancy risk stratification in thyroid nodules. Oncotarget 2017; 8: 43406-43416