Each variable is valued at 1 for the presence of the following and 0 otherwise: The above systems were difficult to apply clinically due to their complexity, leading Kwak et al. official website and that any information you provide is encrypted Thus, the absolute risk of missing important cancer goes from 5% (with no FNAs) to 2.5% using TIRADS and FNA of all TR5, so NNS=100/2.5=40. The implication is that US has enabled increased detection of thyroid cancers that are less clinically important [11-13]. National Library of Medicine The system has fair interobserver agreement 4. You can then get a more thorough medical evaluation, including a biopsy, which is a small sample of tissue from the nodule to look at under the microscope. Before However, there are ethical issues with this, as well as the problem of overdiagnosis of small clinically inconsequential thyroid cancer. When it reflected an absent enhancement in CEUS, the nodule was judged as CEUS-TIRADS 3. It is this proportion of patients that often go on to diagnostic hemithyroidectomies, from which approximately 20% are cancers [12, 17, 21], meaning the majority (80%) end up with ultimately unnecessary operations. Recently, the American College of Radiology (ACR) proposed a Thyroid Imaging Reporting and Data System (TI-RADS) for thyroid nodules based on ultrasonographic features. 2022 Jan 6;2022:5623919. doi: 10.1155/2022/5623919. Federal government websites often end in .gov or .mil. The arrival time, enhancement degree, enhancement homogeneity, enhancement pattern, enhancement ring, and wash-out time were analyzed in CEUS for all of the nodules. Anderson TJ, Atalay MK, Grand DJ, Baird GL, Cronan JJ, Beland MD. Endocrine (2020) 70(2):25679. Clinical Application of C-TIRADS Category and Contrast-Enhanced Ultrasound in Differential Diagnosis of Solid Thyroid Nodules Measuring 1 cm. If a guideline indicates that FNA is recommended, it can be difficult to oppose this based on other factors. A key factor is the low pretest probability of important thyroid cancer but a higher chance of finding thyroid cancers that are very unlikely to cause ill health during a persons lifetime. The optimal investigation and management of the 84% of the population harboring the remaining 50% of cancer remains unresolved. Many of these papers share the same fundamental problem of not applying the test prospectively to the population upon which it is intended for use. 283 (2): 560-569. MeSH The category definitions were similar to BI-RADS, based on the risk of malignancy depending on the presence of suspicious ultrasound features: The following features were considered suspicious: The study included only nodules 1 cm in greatest dimension. Third, when moving on from the main study in which ACR TIRADS was developed [16] to the ACR TIRADS white paper recommendations [22], the TIRADS model changed by the addition of a fifth US characteristic (taller than wide), plus the addition of size cutoffs. Tom James Cawood, Georgia Rose Mackay, Penny Jane Hunt, Donal OShea, Stephen Skehan, Yi Ma, TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance, Journal of the Endocrine Society, Volume 4, Issue 4, April 2020, bvaa031, https://doi.org/10.1210/jendso/bvaa031. Whereas using TIRADS as a rule-in cancer test would be the finding that a nodule is TR5, with a sufficiently high chance of cancer that further investigations are required, compared with being TR1-4. In a clinical setting, this would typically be an unselected sample of the test population, for example a consecutive series of all patients with a thyroid nodule presenting to a clinic, ideally across multiple centers. Test performance in the TR3 and TR4 categories had an accuracy of less than 60%. For those that also have 1 or more TR3, TR4, or TR5 nodules on their scan, they cannot have thyroid cancer ruled out by TIRADS because the possibility that their non-TR1/TR2 nodules may be cancerous is still unresolved. Thyroid nodules are detected by ultrasonography in up to 68% of healthy patients. A 38-year-old woman with a nodule in the right-lobe of her thyroid gland. Most nodules and swellings are not cancerous. View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, American College of Radiology: ACR TI-RADS, Korean Society of Thyroid Radiology: K-TIRADS, iodinated contrast-induced thyrotoxicosis, primary idiopathic hypothyroidism with thyroid atrophy, American Thyroid Association (ATA)guidelines, British Thyroid Association (BTA)U classification, Society of Radiologists in Ultrasound (SRU)guidelines, American College of Radiology:ACR TI-RADS, postoperative assessment after thyroid cancer surgery, ultrasound-guided fine needle aspiration of the thyroid, TIRADS (Thyroid Image Reporing and Data System), colloid type 1:anechoic with hyperechoic spots, nonvascularised, colloid type 2: mixed echogenicity with hyperechoic spots,nonexpansile, nonencapsulated, vascularized, spongiform/"grid" aspect, colloid type 3: mixed echogenicity or isoechoic with hyperechoic spots and solid portion, expansile, nonencapsulated, vascularized, simple neoplastic pattern: solid or mixed hyperechoic, isoechoic, or hypoechoic;encapsulated with a thin capsule, suspicious neoplastic pattern: hyperechoic, isoechoic, or hypoechoic;encapsulated with a thick capsule; hypervascularised; with calcifications (coarse or microcalcifications), malignant pattern A: hypoechoic, nonencapsulated with irregular margins, penetrating vessels, malignant pattern B: isoechoic or hypoechoic, nonencapsulated, hypervascularised, multiple peripheral microcalcifications, malignancy pattern C: mixed echogenicity or isoechoic without hyperechoic spots, nonencapsulated, hypervascularised, hypoechogenicity, especially marked hypoechogenicity, "white knight" pattern in the setting of thyroiditis (numerous hyperechoic round pseudonodules with no halo or central vascularizaton), nodular hyperplasia (isoechoic confluent micronodules located within the inferior and posterior portion of one or two lobes, usually avascular and seen in simple goiters), no sign of high suspicion (regular shape and borders, no microcalcifications), high stiffness with sonoelastography (if available), if >7 mm, biopsy is recommended if TI-RADS 4b and 5 or if patient has risk factors (family history of thyroid cancer or childhood neck irradiation), if >10 mm, biopsy is recommended if TI-RADS 4a or if TI-RADS 3 that has definitely grown (2 mm in two dimensions and >20% in volume). The site is secure. Multivariate factors logistic analysis was performed and a CEUS diagnostic schedule was established. In a patient with normal life expectancy, a biopsy should be performed for nodules >1cm regardless of the ACR TI-RADS risk category. Mao S, Zhao LP, Li XH, Sun YF, Su H, Zhang Y, Li KL, Fan DC, Zhang MY, Sun ZG, Wang SC. The actual number of inconclusive FNA results in the real-world validation set has not been established (because that study has not been done), but the typical rate is 30% (by this we mean nondiagnostic [ie, insufficient cells], or indeterminate [ie, atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS)/follicular neoplasm/suspicious for follicular neoplasm [Bethesda I, III, IV]). Perhaps surprisingly, the performance ACR-TIRADS may often be no better than random selection. Based on the methodology used to acquire the data set, the gender bias, and cancer rate in the data set, it is unlikely to be a fair reflection of the population upon which the test is intended to be applied, and so cannot be considered a true validation set. Unauthorized use of these marks is strictly prohibited. The specificity of TIRADS is high (89%) but, perhaps surprisingly, is similar to randomly selecting of 1 in 10 nodules for FNA (90%). We examined the data set upon which ACR-TIRADS was developed, and applied TR1 or TR2 as a rule-out test, TR5 as a rule-in test, or applied ACR-TIRADS across all nodule categories. Endocrinol. TIRADS does not perform to this high standard. Sensitivity of ACR TIRADS was better than random selection, between 74% to 81% (depending on whether the size cutoffs add value) compared with 1% with random selection. In patients with thyroid nodules, ultrasonography (US) has been established as a primary diagnostic imaging method and is essential for treatment decision. Those working in this field would gratefully welcome a diagnostic modality that can improve the current uncertainty. doi: 10.12659/MSM.936368. For this, we do not take in to account nodule size because size is not a factor in the ACR TIRADS guidelines for initial FNA in the TR1 and TR2 categories (where FNA is not recommended irrespective of size) or in the TR5 category (except in TR5 nodules of0.5 cm to<1.0 cm, in which case US follow-up is recommended rather than FNA). J Med Imaging Radiat Oncol (2009) 53(2):17787. If it performs well enough, then the test is applied to a training set of data to better establish performance characteristics. doi: 10.1007/s12020-020-02441-y It should also be on an intention-to-test basis and include the outcome for all those with indeterminate FNAs. For TIRADS to add clinical value, it would have to clearly outperform the comparator (random selection), particularly because we have made some assumptions that favor TIRADS performance. Methodologically, the change in the ACR-TIRADS model should now undergo a new study using a new training data set (to avoid replicating any bias), before then undergoing a validation study. government site. However, the consequent management guidelines are difficult to justify at least on a cost basis for a rule-out test, though ACR TIRADS may provide more value as a rule-in test for a group of patients with higher cancer risk. The financial costs and surgical morbidity in this group must be taken into account when considering the cost/benefit repercussions of a test that includes US imaging for thyroid cancer. Other similar systems are in use internationally (eg, Korean-TIRADS [14] and EU-TIRADS [15]). All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. It is also relevant to note that the change in nodule appearance over time is poorly predictive of malignancy. spiker54. proposed a system with five categories, which, like BI-RADS, each carried a management recommendation 2. These nodules are relatively common and are usually harmless, but there is a very low risk of thyroid cancer. In the TR3 category, there was a gradual difference in cancer rate in those 1-2 cm (6.5%), and those 2-3 cm (8.4%) and those>3 cm (11.3%). A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. Friedrich-Rust M, Meyer G, Dauth N et-al. The data set was 92% female and the prevalence of cancerous thyroid nodules was 10.3% (typical of the rate found on histology at autopsy, and double the 5% rate of malignancy in thyroid nodules typically quoted in the most relevant literature). The authors stated that TI-RADS 4 and 5 nodules must be biopsied. The area under the curve was 0.916. Results: Among the 228 C-TIRADS 4 nodules, 69 were determined as C-TIRADS 4a, 114 were C-TIRADS 4b, and 45 were C-TIRADS 4c. Tessler F, Middleton W, Grant E. Thyroid Imaging Reporting and Data System (TI-RADS): A Users Guide. This study aimed to assess the performance and costs of the American College of Radiology (ACR) Thyroid Image Reporting And Data System (TIRADS), by first looking for any important issues in the methodology of its development, and then illustrating the performance of TIRADS for the initial decision for or against FNA, compared with an imagined clinical comparator of a group in which 1 in 10 nodules were randomly selected for FNA. Finally, someone has come up with a guide to assist us GPs navigate this difficult but common condition. Attempts to compare the different TIRADS systems on data sets that are also not reflective of the intended test population are similarly flawed (eg, malignancy rates of 41% [29]). If one assumes that in the real world, 25% of the patients have a TR1 or TR2 nodule, applying TIRADS changes the pretest 5% probability of cancer to a posttest risk of 1%, so the absolute risk reduction is 4%. ACR TIRADS has not been applied to a true validation set upon which it is intended to be used, and therefore needs to be considered with caution when applying it to the real-world situation. The chance of finding cancer is 1 in 20, whereas the chance of testing resulting in an unnecessary operation is around 1 in 7. Applying ACR-TIRADS across all nodule categories did not perform well, with sensitivity and specificity between 60% and 80% and overall accuracy worse than random selection (65% vs 85%). They are found . Cao H, Fan Q, Zhuo S, Qi T, Sun H, Rong X, Xiao X, Zhang W, Zhu L, Wang L. J Ultrasound Med. and transmitted securely. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. Any additional test has to perform exceptionally well to surpass this clinicians 95% negative predictive performance, without generating false positive results and consequential harm. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 100 nodules in the validation cohort. Kwak JY, Han KH, Yoon JH et-al. The diagnostic performance of CEUS-TIRADS was significantly better than CEUS and C-TIRADS. In ACR TI-RADS, points in five feature categories are summed to determine a risk level from TR1 to TR5 . Taken as a capsule or in liquid form, radioactive iodine is absorbed by your thyroid gland. Refer to separate articles for the latest systems supported by various professional societies: A TI-RADS was first proposed by Horvath et al. The frequency of different Bethesda categories in each size range . Im on a treatment plan with my oncologist, my doctor, and Im about to start my next round of treatments. Bookshelf All of the C-TIRADS 4 nodules were re-graded by CEUS-TIRADS. FNA, fine-needle aspiration; US, ultrasound; CEUS, contrast-enhanced, A 38-year-old woman with a nodule in the right-lobe of her thyroid gland., A 35-year-old woman with a nodule in the left-lobe of her thyroid gland., The ROC curves of C-TIRADS, CEUS, and CEUS-TIRADS of 228 nodules in the. 24;8 (10): e77927. We then compare the diagnosis performance of C-TIRADS, CEUS, and CEUS-TIRADS by sensitivity, specificity, and accuracy. Radiology. And because thyroid cancer is often diagnosed in a persons late 30s or 40s, most of us are often diagnosed after the symptoms have already begun. Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: can we avoid repeat biopsy? In a cost-conscious public health system, one could argue that after selecting out those patients that clearly raise concern for a high risk of cancer (ie, from history including risk factors, examination, existing imaging) the clinician could reasonably inform an asymptomatic patient that they have a 95% chance of their nodule being benign. Zhang B, Tian J, Pei S, Chen Y, He X, Dong Y, Zhang L, Mo X, Huang W, Cong S, Zhang S. Wildman-Tobriner B, Buda M, Hoang JK, Middleton WD, Thayer D, Short RG, Tessler FN, Mazurowski MA. First, 10% of FNA or histology results were excluded because of nondiagnostic findings [16]. That particular test is covered by insurance and is relatively cheap. It is interesting to see the wealth of data used to support TIRADS as being an effective and validated tool. (2017) Radiology. Data Availability: All data generated or analyzed during this study are included in this published article or in the data repositories listed in References. Differentiation of Thyroid Nodules (C-TIRADS 4) by Combining Contrast-Enhanced Ultrasound Diagnosis Model With Chinese Thyroid Imaging Reporting and Data System Front Oncol. The findings that ACR TIRADS has methodological concerns, is not yet truly validated, often performs no better than random selection, and drives significant costs and potential harm, are very unsettling but result from a rational and scientific assessment of the foundational basis of the ACR TIRADS system. Your health care provider will examine your neck to feel for changes in your thyroid, such as a lump (nodule) in the thyroid. Quite where the cutoff should be is debatable, but any cutoff below TR5 will have diminishing returns and increasing harms. . For example, a previous meta-analysis of more than 25,000 FNAs showed 33% were in these groups [17]. It helps to decide if a thyroid nodule is benign or malignant by combining multiple features on ultrasound. Methods: Thyroid nodules (566) subclassified as ACR-TIRADS 3 or 4 were divided into three size categories according to American Thyroid Association guidelines. Using TR5 as a rule-in test was similar to random selection (specificity 89% vs 90%). Now, the first step in T3N treatment is usually a blood test. Whilst the details of the design of the final validation study can be debated, the need for a well-designed validation study to determine the test characteristics in the real-world setting is a basic requirement of any new test. If a clinician does no tests and no FNAs, then he or she will miss all thyroid cancers (5 people per 100). This is a specialist doctor who specializes in the treatment and diagnosis of thyroid cancer. A prospective validation study that determines the true performance of TIRADS in the real-world is needed. The chance of finding a consequential thyroid cancer during follow-up is correspondingly low. Reference article, Radiopaedia.org (Accessed on 05 Mar 2023) https://doi.org/10.53347/rID-21448. It is important to validate this classification in different centres. Whilst we somewhat provocatively used random selection as a clinical comparator, we do not mean to suggest that clinicians work in this way. Dr. Ron Karni, Chief of the Division of Head and Neck Surgical Oncology at McGovern Medical School at UTHealth Houston discusses Thyroid Nodules. . Well, there you have it. If a patient presented with symptoms (eg, concerns about a palpable nodule) and/or was not happy accepting a 5% pretest probability of thyroid cancer, then further investigations could be offered, noting that US cannot reliably rule in or rule out thyroid cancer for the majority of patients, and that doing any testing comes with unintended risks. 5. The sensitivity, specificity, and accuracy of CEUS were 78.7%, 87.5%, and 83.3% respectively. Only a small percentage of thyroid nodules are cancerous. Cheng H, Zhuo SS, Rong X, Qi TY, Sun HG, Xiao X, Zhang W, Cao HY, Zhu LH, Wang L. Int J Endocrinol. We aimed to assess the performance and costs of the American College of Radiology Thyroid Image Reporting And Data System (ACR-TIRADS). Many studies have not found a clear size/malignancy correlation, and where it has been found, the magnitude of the effect is modest. That particular test is covered by insurance and is relatively cheap. The system is sometimes referred to as TI-RADS Kwak 6. TI-RADS 1: Normal thyroid gland. The summary of test performance of random selection, ACR TIRADS as a rule-out test, ACR TIRADS as a rule-in test, and ACR TIRADS applied across all TIRADS categories are detailed in Table 2, and the full data, definitions, and calculations are given elsewhere [25]. The truth is, most of us arent so lucky as to be diagnosed with all forms of thyroid cancer, but we do live with the results of it. A newer alternative that the doctor can use to treat benign nodules in an office setting is called radiofrequency ablation (RFA). The vast majority of nodules followed-up would be benign (>97%), and so the majority of FNAs triggered by US follow-up would either be benign, indeterminate, or false positive, resulting in more potential for harm (16 unnecessary operations for every 100 FNAs). Thyroid nodules are common, affecting around one-half of the population and become increasingly common with advancing age [1, 2]. ectomy, Parotid gland surgery, Transoral laser microsurgery, Transoral robotic surgery, Oral surgery, Parotid gland tumor, Skin cancer, Tonsil cancer, Throat cancer, Salivary gland tumor, Salivary gland cancer, Thyroid nodule, Head and neck cancer, Laryngeal cancer, Tongue . Tessler FN, Middleton WD, Grant EG, et al. The more FNAs done in the TR3 and TR4 groups, the more indeterminate FNAs and the more financial costs and unnecessary operations. Of note, we have not taken into account any of the benefits, costs, or harms associated with the proposed US follow-up of nodules, as recommended by ACR-TIRADS. The area under the curve was 0.803. To illustrate the effect of the size cutoffs we have given 2 examples, 1 where the size cutoffs are not discriminatory and the cancer rate is the same above and below the size cutoff, and the second example where the cancer risk of the nodule doubles once the size goes above the cutoff. A meta-analysis, This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (, Mitoguardin2 is Associated with Hyperandrogenism and Regulates Steroidogenesis in Human Ovarian Granulosa Cells, Factors Associated with Diabetes Distress among Patients with Poorly Controlled Type 2 Diabetes, Serum adiponectin and leptin is not related to skeletal muscle morphology and function in young women, Association Between Metabolic Syndrome Inflammatory Biomarkers and COVID-19 Severity, Long-term outcome of body composition, ectopic lipid and insulin resistance changes with surgical treatment of acromegaly, Volume 7, Issue 4, April 2023 (In Progress), The Journal of Clinical Endocrinology & Metabolism, https://www.uptodate.com/contents/diagnostic-approach-to-and-treatment-of-thyroid-nodules, https://doi.org/10.6084/m9.figshare.11640168.v, http://creativecommons.org/licenses/by-nc-nd/4.0/, Receive exclusive offers and updates from Oxford Academic, 1 in 10 nodules having FNA, assuming pretest probability of cancer of 5%, Negative test being TR1 or TR2; positive test meaning TR3, TR4, or TR5, Positive test meaning TR5; negative test meaning TR1-4, Positive test meaning TR5, TR4 above size cutoff and TR3 above size cutoff; negative test meaning TR1, TR2, TR3 Below Size Cutoff or TR4 below size cutoff, Positive Test Meaning TR5, TR4 Above Size Cutoff and TR3 Above Size Cutoff; negative test meaning TR1, TR2, TR3 below size threshold or TR4 below size cutoff. A subdivision into 4a (malignancy between 5 and 10%) and 4b (malignancy between 10 and 80%) was optional. Later arrival time, hypo-enhancement, heterogeneous enhancement, centripetal enhancement, and rapid washout were risk factors of malignancy in multivariate analysis. Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L. Middleton WD, Teefey SA, Reading CC, et al. Thyroid Nodules. 4. Disclaimer. Write for us: What are investigative articles. The health benefit from this is debatable and the financial costs significant. Castellana M, Castellana C, Treglia G, Giorgino F, Giovanella L, Russ G, Trimboli P. Oxford University Press is a department of the University of Oxford. For the calculations, we assume an approximate size distribution where one-third of TR3 nodules are25 mm and half of TR4 nodules are15 mm. There are two suspicious signs with the nodule (solid and irregular margin) and it was defined as C-TIRADS 4b. Thyroid radiology practice has an important clinical role in the diagnosis and non-surgical treatment of patients with thyroid nodules, and should be performed according to standard practice guidelines for proper and effective clinical care. Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. This paper has only examined the ACR TIRADS system, noting that other similar systems exist such as Korean TIRADS [14]and EU TIRADS [15]. Furuya-Kanamori L, Bell KJL, Clark J, Glasziou P, Doi SAR. TIRADS ( T hyroid I maging R eporting and D ata S ystem) is a 5-point scoring system for thyroid nodules on ultrasound, developed by the American College of Radiology ( hence also termed as ACR- TIRADS). These appear to share the same basic flaw as the ACR-TIRADS, in that the data sets of nodules used for their development is not likely to represent the population upon which it is intended for use, at least with regard to pretest probability of malignancy (eg, malignancy rate 12% for Korean TIRADS [26]; 18% and 31% for EU TIRADS categories 4 and 5 [27, 28]). Learn how t. 2021 Dec 7;101(45):3748-3753. doi: 10.3760/cma.j.cn112137-20210401-00799. Radiofrequency ablation uses a probe to access the benign nodule under ultrasound guidance, and then treats it with electrical current and heat that shrinks the nodule. To establish a CEUS-TIRADS diagnostic model to differentiate thyroid nodules (C-TIRADS 4) by combining CEUS with Chinese thyroid imaging reporting and data system (C-TIRADS). Among thyroid nodules detected during life, the often quoted figure for malignancy prevalence is 5% [5-8], with UptoDate quoting 4% to 6.5% in nonsurgical series [9], and it is likely that only a proportion of these cancers will be clinically significant (ie, go on to cause ill-health). Anti-thyroid medications. Symptoms and Causes Diagnosis and Tests Management and Treatment Prevention Outlook / Prognosis Living With Frequently Asked Questions Overview The NNS for ACR TIRADS is such that it is hard to justify its use for ruling out thyroid cancer (NNS>100), at least on a cost/benefit basis. The pathological result was Hashimotos thyroiditis. 5 The modified TI-RADS was composed of seven ultrasound features in identifying benign and malignant thyroid nodules, such as the nodular texture, nodular Save my name, email, and website in this browser for the next time I comment. Those wishing to continue down the investigative route could then have US, using TIRADS or ATA guidelines or other measures to offer some relative risk-stratification. The risk of malignancy was derived from thyroid ultrasound (TUS) features. Therefore, using TIRADS categories TR1 or TR2 as a rule-out test should perform very well, with sensitivity of the rule-out test being 97%. The ACR TIRADS management flowchart also does not take into account these clinical factors. Lancet (2014) 384(9957): 1848:184858. The gold test standard would need to be applied for comparison. Instead, it has been applied on retrospective data sets, with cancer rates far above 5%, rather than on consecutive unselected patients presenting with a thyroid nodule [33]. PMC If one decides to FNA every TR5 nodule, from the original ACR TIRADS data set, 34% were found to be cancerous, but note that this data set likely has double the prevalence of thyroid cancer compared with the real-world population. The flow chart of the study. to propose a simpler TI-RADS in 2011 2. There are a number of additional issues that should be taken into account when examining the ACR TIRADS data set and resultant management recommendations. We assessed a hypothetical clinical comparator where 1 in 10 nodules are randomly selected for fine needle aspiration (FNA), assuming a pretest probability of clinically important thyroid cancer of 5%. The test may cycle back between being used on training and validation data sets to allow for improvements and retesting. Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. Clinicians should be using all available data to arrive at an educated estimate of each patients pretest probability of having clinically significant thyroid cancer and use their clinical judgment to help advise each patient of their best options.
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