Thyroid nodule ultrasound risk stratification based on ACR TI-RADS 2017 guidelines
Location
Optional - helps identify nodule in report
Composition
Nodule Composition
Echogenicity
Internal Echogenicity
Shape
Nodule Shape
Margin
Nodule Margins
Echogenic Foci
Echogenic Foci
Select all that apply (points are additive)
Size
Required for size-specific FNA recommendations
cm
What is ACR TI-RADS?
The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is an evidence-based, standardized risk stratification system for thyroid nodules detected on ultrasound. Published in 2017, it helps radiologists communicate nodule findings consistently and guides clinical decisions about fine-needle aspiration (FNA) biopsy.
How TI-RADS Scoring Works
Points are assigned based on five ultrasound feature categories. The total determines the TI-RADS level (TR1-TR5) and corresponding malignancy risk:
Category
Points
Suspicion Level
Malignancy Risk
TR1
0
Benign
≤0.3%
TR2
2
Not suspicious
≤1.5%
TR3
3
Mildly suspicious
≤4.8%
TR4
4-6
Moderately suspicious
≤9.1%
TR5
≥7
Highly suspicious
≤35%
FNA Recommendations by Category
FNA recommendations depend on both TI-RADS category and nodule size:
TR1 & TR2: No FNA recommended regardless of size
TR3: FNA if ≥2.5 cm; follow-up if ≥1.5 cm
TR4: FNA if ≥1.5 cm; follow-up if ≥1.0 cm
TR5: FNA if ≥1.0 cm; follow-up if ≥0.5 cm
Key Features to Assess
Composition: Cystic, spongiform, mixed, or solid
Echogenicity: Anechoic to very hypoechoic
Shape: Wider-than-tall (benign) vs. taller-than-wide (suspicious)
Margin: Smooth, ill-defined, lobulated, or extra-thyroidal
Echogenic foci: Comet-tail, macro/peripheral calcifications, or punctate foci
References
1. ACR TI-RADS White Paper (Primary Reference)
Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, Teefey SA, 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(5):587-595.
doi:10.1016/j.jacr.2017.01.046PMID: 28372962
2. Thyroid Ultrasound Reporting Lexicon
Grant EG, Tessler FN, Hoang JK, Langer JE, Beland MD, Berland LL, 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(12 Pt A):1272-1279.
doi:10.1016/j.jacr.2015.07.011PMID: 26419308
3. TI-RADS Validation Study
Middleton WD, Teefey SA, Reading CC, Langer JE, Beland MD, Szabunio MM, et al. Multiinstitutional Analysis of Thyroid Nodule Risk Stratification Using the American College of Radiology Thyroid Imaging Reporting and Data System. AJR Am J Roentgenol. 2017;208(6):1331-1341.
doi:10.2214/AJR.16.17613PMID: 28267342
Disclaimer: This calculator is for educational and informational purposes only. It is not intended to replace professional medical judgment. Clinical decisions should always consider the full clinical context, patient history, and be made by qualified healthcare professionals.