Comparison of Diagnostic Performances of ATA Guidelines, ACR-TIRADS, and EU-TIRADS and Modified K-TIRADS: A Single Center Study of 4238 Thyroid Nodules

Abstract

Objectives

Several ultrasound-based risk stratification systems (RSSs) have been developed and introduced into clinical practice for managing thyroid nodules. However, there are essential differences among these systems. This study aimed to determine and compare the category-based diagnostic performance of four ultrasound-based risk stratification systems in the detection of thyroid cancer: ACR-TIRADS, ATA, K-TIRADS, and EU-TIRADS.

Methods

This study included 4238 nodules sampled by fine-needle aspiration biopsy between January 2018 and December 2021. Nodules were classified according to ultrasound imaging features and correlated with biopsy results. The diagnostic success of the risk stratification systems was evaluated and compared.

Results

Of the 4238 nodules, 3861 (91.1%) were benign and 376 (8.9%) were malignant. Malignancy was significantly higher in hypoechoic and marked hypoechoic nodules (p=0.001), and solid nodules (p=0.002). For detection of malignancy, areas under the receiving operator characteristics curves were 0.862, 0.850, 0.842, and 0.835 for 2017 ACR-TIRADS, EU-TIRADS, for K-TIRADS, and 2015 American Thyroid Association guidelines, respectively. EU-TIRADS showed the highest sensitivity (91%), whereas ACR-TIRADS had the highest specificity (87%). Compared to other risk stratification systems, ACR-TIRADS resulted in significantly fewer unnecessary biopsies (p=0.009).

Conclusion

All RSSs show high diagnostic accuracy and have their own advantages and disadvantages. When selecting an appropriate RSS, the population, the prevalence of the disease, and gender distribution should be considered.

Keywords

thyroid nodules - fine-needle aspiration - ultrasound - TIRADS classification

Publication History

Received: 09 September 2024

Accepted after revision: 09 December 2024

Accepted Manuscript online:
09 December 2024

Article published online:
29 January 2025

• References

• 1 Gharib H, Papini E, Garber JR. et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Andocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules – 2016 update. Endocr pract 2016; 22: 622-639
• 2 Leenhardt L, Erdogan MF, Hegedus L. et al. 2013 European thyroid association guidelines for cervical ultrasound scan and ultrasound-guided techniques in the postoperative management of patients with thyroid cancer. Eur Thyroid J 2013; 2: 147-159
• 3 Vaccarella S, Dal Maso L, Laversanne M. et al. The impact of diagnostic changes on the rise in thyroid cancer incidence: A population-based study in selected high-resource countries. Thyroid 2015; 25: 1127-1136
• 4 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
• 5 Russ G, Bonnema SJ, Erdogan MF. et al. European Thyroid Association Guidelines for ultrasound malignancy risk stratification of thyroid nodules in adults: The EU-TIRADS. Eur Thyroid J 2017; 6: 225-237
• 6 Ha EJ, Chung SR, Na DG. et al. 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
• 7 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
• 8 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: 587-595
• 9 Cibas ES, Ali SZ. The 2017 Bethesda system for reporting thyroid cytopathology. J Am Soc Cytopathol 2017; 6: 217-222
• 10 Figge JJ. Epidemiology of thyroid cancer. In: Wartofsky L, Van Nostrand D, Eds. Thyroid cancer: a comprehensive guide to clinical management. New York: Springer 2016; 9-15
• 11 Yoon JH, Lee HS, Kim EK. et al. Pattern-based vs. score-based guidelines using ultrasound features have different strengths in risk stratification of thyroid nodules. Eur Radiol 2020; 30: 3793-3802
• 12 Gao L, Xi X, Jiang Y. et al. Comparison among TIRADS (ACR TI-RADS and KWAK- TI-RADS) and 2015 ATA Guidelines in the diagnostic efficiency of thyroid nodules. Endocrine 2019; 64: 90-96
• 13 Ha EJ, Na DG, Moon WJ. et al. Diagnostic performance of ultrasound-based risk-stratification systems for thyroid nodules: Comparison of the 2015 American Thyroid Association Guidelines with the 2016 Korean Thyroid Association/Korean Society of Thyroid Radiology and 2017 American College of Radiology Guidelines. Thyroid 2018; 28: 1532-1537
• 14 Kim JS, Kim BG, Stybayeva G. et al Diagnostic performance of various ultrasound risk stratification systems for benign and malignant thyroid nodules: A meta-analysis. Cancers (Basel) 2023; 15: 424
• 15 Piticchio T, Russ G, Radzina M. et al. Head-to-head comparison of American, European, and Asian TIRADSs in thyroid nodule assessment: Systematic review and meta-analysis. Eur Thyroid J 2024; 13: e230242
• 16 Ho AS, Davies L, Nixon IJ. et al. Increasing diagnosis of subclinical thyroid cancers leads to spurious improvements in survival rates. Cancer 2015; 121: 1793-1799
• 17 Takami H, Ito Y, Okamoto T. et al. Therapeutic strategy for differentiated thyroid carcinoma in Japan based on a newly established guideline managed by Japanese Society of Thyroid Surgeons and Japanese Association of Endocrine Surgeons. World J Surg 2011; 35: 111-121
• 18 Ito Y, Miyauchi A, Kudo T. et al. Trends in the implementation of active surveillance for low-risk papillary thyroid microcarcinomas at Kuma Hospital: Gradual increase and heterogeneity in the acceptance of this new management option. Thyroid 2018; 28: 488-495
• 19 Saravana-Bawan B, Bajwa A, Paterson J. et al. Active surveillance of low-risk papillary thyroid cancer: A meta-analysis. Surgery 2020; 167: 46-55
• 20 Ahn HS, Kim HJ, Kim KH. et al. Thyroid cancer screening in South Korea increases detection of papillary cancers with no impact on other subtypes or thyroid cancer mortality. Thyroid 2016; 26: 1535-1540
• 21 Kim PH, Suh CH, Baek JH. et al. Diagnostic performance of four ultrasound risk stratification systems: A systematic review and meta-analysis. Thyroid 2020; 30: 1159-1168
• 22 Wu XL, Du JR, Wang H. et al. Comparison and preliminary discussion of the reasons for the differences in diagnostic performance and unnecessary FNA biopsies between the ACR TIRADS and 2015 ATA guidelines. Endocrine 2019; 65: 121-131