TIRADS.pptx. .............................

Thyroid imaging and reporting system

1. TIRADS MODERATOR: DR.M.PRASANTHI MDRD PRESENTOR:DR.G.E.C.V.SAGAR

2. Thyroid is a single midline endocrine organ in the anterior neck. It is responsible for thyroid harmone production. Lies in the visceral space completely enveloped by pretracheal fascia. Extends from C5 to T1 and lies anterior to thyroid and cricoid cartilages and the first five or six tracheal rings.

3. Normal measurements Normal thyroid gland length- 5cm Ap diameter- 2cm isthmus -0.5 cm

4. Radiological imaging USG- high frequency linear transducer used CT MRI

5. TIRADS Thyroid Imaging Reporting and Data Systems Categorization of nodules ACR guidelines Risk stratification system Point based

6. The five ultrasound features of thyroid nodules used in TI-RADS are: composition, echogenicity , shape, margin and punctate echogenic foci. Each item is given points.

7. Cystic lesions or lesions that are almost completely cystic and spongiform lesions are benign  (TI-RADS 1).

8. Cyst It is a typical cyst. No further evaluation is needed.

9. Spongiform Spongiform nodules have a sponge-like appearance, with at least 50% cystic composition of tiny cystic parts.  No further characterization is needed.

10. Mixed cystic/solid In mixed cystic/solid lesions the amount of cystic and solid parts is not important. This lesion gets 1 point for the mixed cystic/solid composition.

11. Solid lesions The lesion in A is almost completely solid. While there are small cystic parts, it is not considered a spongiform nodule, because the small cystic parts are far less than 50% of the total nodule. The lesion in B is completely solid. In solid nodules at least 95% of the nodule should be solid. 

12. An anechoic lesion should be completely black, which means that it is cystic. No further characterization is needed. Hyperechoic and isoechoic lesions  both get 1 point The echogenicity is compared with normal thyroid parenchyma

13. Hypoechoic means that a lesion is more hypoechoic than normal thyroid parenchyma. If the echogenicity cannot be assed, for example because of calcifications, 1 point is given for the echogenicity .

14. A very hypoechoic lesion is more hypoechoic than normal muscle. Notice that the tumor is more hypoechoic in comparison to the strap muscles.

15. The shape should be assesed in the axial plane. A taller-than-wide shape is a strong predictor of malignancy, and therefore gets 3 points. 

16. The margin is often best assessed on the anterior side. Smooth: the margin is completely smooth Ill-defined: the margins of the nodule cannot be clearly defined from the thyroid parenchyma. This is a benign feature and should be distinguished from the irregular margin. Lobulated or irregular: margins are lobulated , spiculated , irregular or angulated. Extra-thyroidal extension: difficult to analyze on ultrasound, there should be clear invasion of nearby structures.

17. Ill-defined nodule. Notice how only some small parts of the border of the nodule can be defined (arrow). Most of its margin is indistinct from the thyroid parenchyma. 0 points in TI-RADS

18. A nodule with irregular angulated margins. 2 points in TI-RADS

19. The image shows an irregular lobulated margin of the anterior surface. 2 points in TI-RADS.

20. There is a nodule which has exophytic growth with compression of the nearby structures. However, there is no frank invasion, there this does not classify as extra thyroidal extension .

21. Echogenic foci is the only category where multiple options are possible and you have to choose all that apply. Points will be added to the total score. This means that when both punctate echogenic foci and rim calcifications are present, the TI-RADS points are 3 + 2 = 5 points

22. Comet tail artefact 0 points is given for: No echogenic foci. Large comet tail artefacts > 1 mm

23. Macrocalcification This nodule has large macrocalcifications with acoustic shadowing. TI-RADS: 1 point.

24. Rim calcification Peripheral rim calcifications can be complete or incomplete. TI-RADS: 2 points

25. Microcalcifications Punctate echogenic foci are also knows as microcalcifications . They are a strong predictor of malignancy and therefore get 3 points.  In the normal thyroid there also may be echogenic foci visible. Punctate echogenic should be called in the situation where they are obvious and only visible within the nodule

26. RISK OF MALIGNANCY

27. Congenital thyroid abnormalities Aplasia / hypoplasia of one lobe or whole gland Ectopic thyroid Radionucleide scans to detect ectopic thyroid tissue

28. Multinodular goitre Multiple nodules with hemorrhage, calcification, scarring and cyst formation. USG irregular showing diffuse inhomogenous echogenicity or multiple focal hypoechoic nodules

29. Acute suppurative thyroiditis USG: Ill defined , hypoechoic , heterogenous mass Internal debris Septa +/- lymphnodes

30. Dequervain thyroiditis Self limiting USG Poorly defined region of decreased echogenicity with decreased vascularity in the affected areas. Bilateral or unilateral

31. Hashimoto’s ( chronic autoimmune lymphocytic) USG Diffuse coarsed echotexture Hypoechoic micronodules ( 1-6mm) Lobules are surrounded by multiple linear echogenic coarse fibrous septations COLOUR DOPPLER Normal or decreased flow, but occasionally there might be hypervascularity

32. Lobules are surrounded by multiple linear echogenic coarse fibrous septations

33. Graves disease Hyperfunctioning gland USG Inhomogenous diffusely hypoechoic gland C/D Hypervasular Psv-70 cm/sec

34. Thyroid malignancies 1. PAPILLARY CARCINOMA- MOST COMMON 2.FOLLICULAR 3.ANAPLASTIC 4.MEDULLARY 5.LYMPHOMA

35. Papillary carcinoma USG Hypoechogenicity microcalcification - fine punctate Hypervascularity Low grade Lymphatic spread cystic/ follicular variant

36. Follicular carcinoma USG Hypoechoic illdefined lesion with thick irregular capsule Types: Minimally invasive- encapsulated Invasive- not well encapsulated with vascular invasion

37. Medullary carcinoma Multicentric Parafollicular C cells USG Hypoechoic solid nodules with coarse internal calcifications Involved lymphnodes typically calcify

38. Anaplastic carcinoma Fatal- elderly women, long standing goitre USG Hypoechoic lesion encasing the vessels CT extent/calcification/necrosis