Thyroid Imaging Reporting and Data Systems: Applicability of the "Taller than Wide" Criterium in Primary/Secondary Care Units and the Role of Thyroid Scintigraphy

Abstract

Background: To examine the applicability of the "taller than wide" (ttw) criterium for risk assessment of thyroid nodules (TNs) in primary/secondary care units and the role of thyroid scintigraphy therein.

Methods: German bicenter study performed in a setting of primary/secondary care. Patient recruitment and analysis in center A was conducted in a prospective manner. In center B, patient data were retrieved from a database that was originally generated by prospective data collection. TNs were assessed by ultrasound and thyroid scans, mostly fine needle biopsy and occasionally surgery and others. In center A, only patients who presented for the first time were included. The inclusion criterion was any TN ≥ 10 mm that had at least the following two sonographic risk features: solidity and a ttw shape. In center B, consecutive patients who had at least ttw and hypofunctioning nodules ≥ 10 mm were retrieved from the above-mentioned database. The risk of malignancy was determined according to a mixed reference standard and compared with literature data.

Results: In center A, 223 patients with 259 TNs were included into the study. For further analysis, 200 nodules with a reference standard were available. The overall malignancy rate was 2.5% (upper limit of the 95% CI: 5.1%). After the exclusion of scintigraphically hyperfunctioning nodules, the malignancy rate increased slightly to 2.8% (upper limit of the 95% CI: 5.7%). Malignant nodules exhibited sonographic risk features additional to solidity and ttw shape more often than benign ones. In addition to the exclusion of hyperfunctioning nodules, when considering only nodules without additional US risk features, i.e., exclusively solid and ttw-nodules, the malignancy rate decreased to 0.9% (upper limit 95% CI: 3.7%). In center B, from 58 patients, 58 ttw and hypofunctioning TNs on thyroid scans with a reference standard were available. Malignant nodules from center B were always solid and hypoechoic. The overall malignancy rate of hypofunctioning and ttw nodules was 21%, with the lower limit of the 95% CI (one-sided) being 12%.

Conclusions: In primary/secondary care units, the lowest TIRADS categories for indicating FNB, e.g., applying one out of five sonographic risk features, may not be appropriate owing to the much lower a priori malignancy risk in TNs compared to tertiary/quaternary care units. Even the combination of two sonographic risk features, "solidity" and "ttw", may only be appropriate in a limited fashion. In contrast, the preselection of TNs according to hypofunctioning findings on thyroid scans clearly warranted FNB, even when applying only one sonographic risk criterion ("ttw"). For this reason, thyroid scans in TNs may not only be indicated to rule out hyperfunctioning nodules from FNB but also to rule in hypofunctioning ones.

Keywords: Thyroid Imaging Reporting and Data Systems; fine needle biopsy; risk of malignancy; taller than wide; thyroid nodule; thyroid scintigraphy.

Figure 1

This ttw nodule in the left thyroid lobe has contact with the dorsal contour of the lobe ((a) = transversal/(b) = sagittal) complying with a pole concept of benign nodule growth [10]. The nodule is slightly hypoechoic with a smooth border, a small central cyst, and no calcifications. On the thyroid scan, the nodule is indifferent (c). The FNB result was between Bethesda II and III. Hemithyroidectomy revealed microfollicular adenoma.

Figure 2

This ttw nodule in the right thyroid lobe has no direct contact with the dorsal contour and causes/follows no anatomic “horn” ((a) = transversal/(b) = sagittal) [10]. It is isoechoic, irregularly bordered, and has some central microcalcifications. Note also the central and dorsal acoustic attenuation of the US signal. The surrounding thyroid parenchyma is slightly hypoechoic because of an autoimmune thyroiditis. On the thyroid scan, the nodule is hypofunctioning (c). FNB showed follicular neoplasia and surgery revealed a papillary carcinoma with central sclerosis.