The proportion of malignancy in Bethesda III nodules confirmed by surgery were significantly increased in proportion relative to K-TIRADS with 60.0% low suspicion, 88.2% intermediate suspicion, and 100% high suspicion nodules (p < 0.001). 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 other cases, the nodules can get big enough to cause problems. If one accepts that the pretest probability of a patient presenting with a thyroid nodule having an important thyroid cancer is 5%, then clinicians who tell every patient they see that they do not have important thyroid cancer will be correct 95% of the time. 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. 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. Your doctor then sends the samples to a laboratory to have them analyzed under a microscope. Given that a proportion of thyroid cancers are clinically inconsequential, the challenge is finding a test that can effectively rule-in or rule-out important thyroid cancer (ie, those cancers that will go on to cause morbidity or mortality). Thus, the absolute risk of missing important cancer goes from 4.5% to 2.5%, so NNS=100/2=50. to propose a simpler TI-RADS in 2011 2. The gender bias (92% female) and cancer prevalence (10%) of the data set suggests it may not accurately reflect the intended test population. Diagnostic approach to and treatment of thyroid nodules. Following ACR TIRADS management guidelines would likely result in approximately one-half of the TR3 and TR4 patients getting FNAs ((0.537)+(0.323)=25, of total 60), finding up to 1 cancer, and result in 4 diagnostic hemithyroidectomies for benign nodules (250.20.8=4). https://www.uptodate.com/contents/search. Reston, VA 20191 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. Thyroxine suppressive therapy to retard nodule growth is not recommended. Thyroid nodules are detected by ultrasonography in up to 68% of healthy patients. In assessing a lump or nodule in your neck, one of your doctor's main goals is to rule out the possibility of cancer. However, there are ethical issues with this, as well as the problem of overdiagnosis of small clinically inconsequential thyroid cancer. The proportion of malignancy in AUS and FLUS were . Management of nodules with initially nondiagnostic results of thyroid fine-needle aspiration: can we avoid repeat biopsy? The main source data set for the ACR TIRADS recommendations was large and consisted of US images and FNA results of more than 3400 nodules [16]. Such a study should also measure any unintended harm, such as financial costs and unnecessary operations, and compare this to any current or gold standard practice against which it is proposed to add value. Permissions beyond the scope of this license may be available here. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. Cawood T, Mackay GR, Hunt PJ, OShea D, Skehan S, Ma Y. Russ G, Bigorgne C, Royer B, Rouxel A, Bienvenu-Perrard M. Yoon JH, Lee HS, Kim EK, Moon HJ, Kwak JY. The challenge of appropriately balancing the risks of missing an important cancer versus the chance of causing harm and incurring significant costs from overinvestigation is major. To get the most from your appointment, try these suggestions: Mayo Clinic does not endorse companies or products. What's the treatment for a thyroid nodule? 4b - Suspicious nodules (10-50% risk of malignancy) Score of 2. Search for other works by this author on: University of Otago, Christchurch School of Medicine, Department of Endocrinology, St Vincents University Hospital, Department of Radiology, St Vincents University Hospital, Dublin 4 and University College Dublin, Biostatistician, Department of Medical & Womens Business Management, Canterbury District Health Board, Thyroid incidentalomas: management approaches to nonpalpable nodules discovered incidentally on thyroid imaging, The prevalence of thyroid nodules and an analysis of related lifestyle factors in Beijing communities, Prevalence of differentiated thyroid cancer in autopsy studies over six decades: a meta-analysis, Occult papillary carcinoma of the thyroid. Nodules that are TIRADS 3 have a low risk of important thyroid cancer, probably 1 to 5%. Overview of thyroid nodule formation. If you do 100 (or more) US scans on patients with a thyroid nodule and apply the ACR TIRADS management guidelines for FNA, this results in costs and morbidity from the resultant FNAs and the indeterminate results that are then considered for diagnostic hemithyroidectomy. Other similar systems are in use internationally (eg, Korean-TIRADS [14] and EU-TIRADS [15]). Methods Ultrasound images of 205 thyroid nodules from 198 patients were analysed in this . American Thyroid Association. Very probably benign nodules are those that are both. However, in the data set, only 25% of all nodules were categorized as TR1 or TR2 and these nodules harbored only 1% of all thyroid cancers (9 of 343). Kellerman RD, et al. The optimal investigation and management of the 84% of the population harboring the remaining 50% of cancer remains unresolved. The TIRADS reporting algorithm is a significant advance with clearly defined objective sonographic features that are simple to apply in practice. doi: 10.1210/jendso/bvaa031. 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. Hong MJ, Na DG, Baek JH, Sung JY, Kim JH. 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. A study that looked at all nodules in consecutive patients (eg, perhaps FNA of every nodule>10 mm) would be required to get an accurate measure of the cancer prevalence in those nodules that might not typically get FNA. Kearns AE (expert opinion). In response, ACR committees were formed to accomplish three goals: Develop management guidelines for nodules that are discovered incidentally on CT, MRI, PET or ultrasound. Current thyroid cancer trends in the United States, Association between screening and the thyroid cancer epidemic in South Korea: evidence from a nationwide study, 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 ultrasound and the increase in diagnosis of low-risk thyroid cancer, Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology, Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations, European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS, Multiinstitutional analysis of thyroid nodule risk stratification using the American College of Radiology Thyroid Imaging Reporting and Data System, The Bethesda System for reporting thyroid cytopathology: a meta-analysis, The role of repeat fine needle aspiration in managing indeterminate thyroid nodules, The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. Second, we then apply TIRADS across all 5 nodule categories to give an idea how TIRADS is likely to perform overall. 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. This study has many limitations. If a clinician does no tests and no FNAs, then he or she will miss all thyroid cancers (5 people per 100). Philadelphia, PA 19102 Reston, VA 20191 What is TIRADS 4 nodule? Some cancers would not show suspicious changes thus US features would be falsely reassuring. Thyroid cancer is one of the most treatable kinds of cancer. There are even data showing a negative correlation between size and malignancy [23]. 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. Treatment depends on the type of thyroid nodule you have. published a simplified TI-RADS that was prospectively validated 5. If a doctor suspects that a thyroid nodule may . It is important to validate this classification in different centres. See JAMA Otolaryngology Head & Neck Surgery. First, 10% of FNA or histology results were excluded because of nondiagnostic findings [16]. Nodules detected this way are usually smaller than those found during a physical exam. If you assume that FNA is done as per reasonable application of TIRADS recommendations (in all patients with TR5 nodules, one-half of patients with TR4 nodules and one-third of patients with TR3 nodules) and the proportion of patients in the real world have roughly similar proportion of TR nodules as the data set used, then 100 US scans would result in FNAs of about one-half of all patients scanned (of data set, 16% were TR5, 37% were TR4, and 23% were TR3, so FNA number from 100 scans=16+(0.537)+(0.323)=42). A newer alternative that the doctor can use to treat benign nodules in an office setting is called radiofrequency ablation (RFA). 5. Washington, DC 20004 TIRADS score ranged from 1 to 5. Ultimately, most of these turn out to be benign (80%), so for every 100 FNAs, you end up with 16 (1000.20.8) unnecessary operations being performed. In some cases, nodules that take up less of the isotope called cold nodules are cancerous. Horvath E, Majlis S, Rossi R et-al. The changing incidence of thyroid cancer. Hypoechoic thyroid nodules appear dark relative to the surrounding tissue. This comes at the cost of missing as many cancers as you find, spread amongst 84% of the population, and doing 1 additional unnecessary operation (160.20.8=2.6, minus the 1.6 unnecessary operations resulting from random selection of 1 in 10 patients for FNA [25]), plus the financial costs involved. 2016; doi:10.1038/nrendo.2016.110. Develop management guidelines for nodules that are discovered incidentally on CT, MRI, PET or ultrasound. 4. The implication is that US has enabled increased detection of thyroid cancers that are less clinically important [11-13]. The more carefully one looks for incidental asymptomatic thyroid cancers at autopsy, the more are found [4], but these do not cause unwellness during life and so there is likely to be no health benefit in diagnosing them antemortem. The incidental thyroid nodule. Surgery. 2017; doi:10.1001/jamaoto.2017.0003. 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). Is it time to panic? This commentary compares and contrasts these two guidelines. A thyroid nodule is an unusual lump (growth) of cells on your thyroid gland. The more FNAs done in the TR3 and TR4 groups, the more indeterminate FNAs and the more financial costs and unnecessary operations. Compared with randomly doing FNA on 1 in 10 nodules, using ACR TIRADS and doing FNA on all TR5 requires NNS of 50 to find 1 additional cancer. The Thyroid Imaging Reporting and Data System (TI-RADS) of the American College of Radiology (ACR) was designed in 2017 with the intent to decrease biopsies of benign nodules and improve overall diagnostic accuracy. Perhaps the most relevant positive study is from Korea, which found in a TR4 group the cancer rate was no different between nodules measuring between 1-2 cm (22.3%) and those 2-3 cm (23.5%), but the rate did increase above 3 cm (40%) [24]. Accessed Oct. 31, 2019. A pounding heart. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Thyroid imaging reporting and data system (TI-RADS)refers to any of several risk stratification systems for thyroid lesions, usually based on ultrasound features, with a structure modelled off BI-RADS. In: Conn's Current Therapy 2019. 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. The figures that TIRADS provide, such as cancer prevalence in certain groups of patients, or consequent management guidelines, only apply to populations that are similar to their data set. CA: A Cancer Journal for Clinicians. Thyroid nodules are common, very common. Data Availability: All data generated or analyzed during this study are included in this published article or in the data repositories listed in References. This study aimed to evaluate the diagnostic performance of a CAD system in thyroid nodule differentiation using varied settings. Find more COVID-19 testing locations on Maryland.gov. Until a well-designed validation study is completed, the performance of TIRADS in the real world is unknown. However, if the concern is that this might miss too many thyroid cancers, then this could be compared with the range of alternatives (ie, doing no tests or doing many more FNAs). TIRADS 3, further investigations are not routinely recommended, but monitor. 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. 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. So, I am frequently unsure! It's most often used after surgery to find any cancer cells that might remain. Tests include: Physical exam. Thyroid nodules. 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). A thyroid fine needle aspiration biopsy can collect samples of cells from the nodule, which, under a microscope, can provide your doctor with more information about the behavior of the nodule. For a rule-out test, sensitivity is the more important test metric. TIRADS 4 nodule is moderately suspicious for malignancy based on ultrasound findings. Therefore, 60% of patients are in the middle groups (TR3 and TR4), where the US features are less discriminatory. The probability of malignancy was based on an equation derived from 12 features 2. Fisher SB, et al. Elsevier; 2019. https://www.clinicalkey.com. Accessed Oct. 31, 2019. We have also assumed that all nodules are at least 10 mm and so the TR5 nodule size cutoff of 5 mm does not apply. During this test, an isotope of radioactive iodine is injected into a vein in your arm. If . An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. 2. The authors proposed the following criteria, based on French Endocrine Society guidelines, for when to proceed with fine needle aspiration biopsy: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Often, your doctor may discover thyroid nodules during a routine medical exam. 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. Silver Spring, MD 20910 This data set was a subset of data obtained for a previous study and there are no clear details of the inclusion and exclusion criteria, including criteria for FNA. TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance TIRADS Management Guidelines in the Investigation of Thyroid Nodules; Illustrating the Concerns, Costs, and Performance J Endocr Soc. Whether its benign or not, a bothersome thyroid nodule can often be successfully managed. Its simple: Most people treated with RFA are back to their normal activities the next day with no problems. Using TR1 and TR2 as a rule-out test had excellent sensitivity (97%), but for every additional person that ACR-TIRADS correctly reassures, this requires >100 ultrasound scans, resulting in 6 unnecessary operations and significant financial cost. In fact, experts estimate that about half of Americans will have one by the time theyre 60 years old. Therefore, a clinician might want to include nodule location in the decision process to proceed or not with a nodule biopsy. Summary Test Performance of Random Selection of 1 in 10 Nodules for FNA, Compared with ACR-TIRADS. If it performs well enough, then the test is applied to a training set of data to better establish performance characteristics. However, given that TR1 and TR2 make up only 25% of the nodules, then to find 25 nodules that are TR1 or TR2, you would need to do 100 scans. 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). We have detailed the data set used for the development of ACR TIRADS [16] in Table 1, plus noted the likely cancer rates in the real world if one assumes that the data set cancer prevalence (10.3%) is double that in the population upon which the test is intended to be used (pretest probability of 5%). So just using ACR TIRADS as a rule-out test could be expected to leave 99% of undiagnosed cancers amongst the remaining 75% of the population, in whom the investigation and management remains unresolved. The score for this nodule is 1-2 points. Some are solid, and some are fluid-filled cysts. Even a benign growth on your thyroid gland can cause symptoms. Data sets with a thyroid cancer prevalence higher than 5% are likely to either include a higher proportion of small clinically inconsequential thyroid cancers or be otherwise biased and not accurately reflect the true population prevalence. If a benign thyroid nodule remains unchanged, you may never need treatment. You then lie on a table while a special camera produces an image of your thyroid on a computer screen. Background Thyroid cancer diagnosis has evolved to include computer-aided diagnosis (CAD) approaches to overcome the limitations of human ultrasound feature assessment. It can be benign or malignant. It is interesting to see the wealth of data used to support TIRADS as being an effective and validated tool. The key next step for any of the TIRADS systems, and for any similar proposed test system including artificial intelligence [30-32], is to perform a well-designed prospective validation study to measure the test performance in the population upon which it is intended for use. A systematic autopsy study, The incidence of thyroid cancer by fine needle aspiration varies by age and gender, Thyroid cancer in the thyroid nodules evaluated by ultrasonography and fine-needle aspiration cytology, Comparison of 5-tiered and 6-tiered diagnostic systems for the reporting of thyroid cytopathology: a multi-institutional study. Russ G, Royer B, Bigorgne C et-al. 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. However, these assumptions have intentionally been made to favor the expected performance of ACR-TIRADS, and so in real life ACR-TIRADS can be expected to perform less well than we have illustrated. American Thyroid Association. Patients and methods: 80 patients with at least one EU-TIRADS 5 nodule 10 mm and no suspicious lymph nodes, accepting active surveillance, were included. (2017) Radiology. Ross DS. 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. 2013;168 (5): 649-55. TI-RADS 4b applies to the lesion with one or two of the above signs and no metastatic lymph node is present. Join endocrinologist Paul Ladenson, M.D., as he outlines the signs and symptoms of the various thyroid disorders and discusses the interplay among other diseases and the thyroid. Using TIRADS as a rule-out cancer test would be the finding that a nodule is TR1 or TR2 and hence has a low risk of cancer, compared with being TR3-5. The management guidelines may be difficult to justify from a cost/benefit perspective. 1. 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. A normal finding in Finland. This site complies with the HONcode standard for trustworthy health information: verify here. 24;8 (10): e77927. Memory problems. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Accessed Oct. 31, 2019. We found sensitivity and PPV with TIRADS was poor, but was better than random selection (sensitivity 53% vs 1%, and PPV 34% vs 1%) whereas specificity, NPV, and accuracy was no better with TIRADS compared with random selection (specificity 89% vs 90%, NPV 94% vs 95%, and accuracy 85% vs 85%), Table 2 [25]. Using ACR-TIRADS as a rule-in test to identify a higher risk group that should have FNA is arguably a more effective application. There are a number of additional issues that should be taken into account when examining the ACR TIRADS data set and resultant management recommendations. 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. These figures cannot be known for any population until a real-world validation study has been performed on that population. Then, suppose she tells you theres a nodule on your thyroid. Endocrinol. 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%. We realize that such factors may increase an individuals pretest probability of cancer and clinical decision-making would change accordingly (eg, proceeding directly to FNA), but we here ascribe no additional diagnostic value to avoid overestimating the performance of the clinical comparator. The authors stated that TI-RADS 4 and 5 nodules must be biopsied. J. Clin. It has been retrospectively applied to thyroidectomy specimens, which is clearly not representative of the patient presenting with a thyroid nodule [34-36], and has even been used on the same data set used for TIRADS development, clearly introducing obvious bias [32, 37]. The financial cost depends on the health system involved, but as an example, in New Zealand where health care costs are modest by international standards in the developed world, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS would result in approximately NZ$140,000 spent for every additional patient correctly reassured that he or she does not have thyroid cancer [25]. https://www.uptodate.com/contents/search. We refer to ACR-TIRADS where data or comments are specifically related to ACR TIRADS and use the term TIRADS either for brevity or when comments may be applicable to other TIRADS systems. Hyperfunctioning thyroid nodules can be treated with surgery or radioactive iodine ablation. The low pretest probability of important thyroid cancer and the clouding effect of small clinically inconsequential thyroid cancers makes the development of an effective real-world test incredibly difficult. The score for this nodule is 4-6 points (2009) Thyroid : official journal of the American Thyroid Association. Bessey LJ, Lai NB, Coorough NE, Chen H, Sippel RS. The equation was as follows: z = -2.862 + 0.581X1- 0.481X2- 1.435X3+ 1.178X4+ 1.405X5+ 0.700X6+ 0.460X7+ 0.648X8- 1.715X9+ 0.463X10+ 1.964X11+ 1.739X12. Accessed Oct. 31, 2019. Learn more: Vaccines, Boosters & Additional Doses | Testing | Patient Care | Visitor Guidelines | Coronavirus. Equation derived from 12 features 2 the TR3 and TR4 groups, the absolute risk of important thyroid cancer one... By ultrasonography in up to 68 % of healthy patients of a CAD system in thyroid nodule differentiation varied... Nodule differentiation using varied settings published a simplified TI-RADS that was prospectively validated.... Not, a bothersome thyroid nodule can often be successfully managed, further investigations are not routinely recommended, monitor! 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Size and malignancy [ 23 ] ) of cells on your thyroid gland can cause symptoms, DG! Tirads across all 5 nodule categories to give an idea how TIRADS is likely to perform overall is unusual.