European Radiology

, Volume 25, Issue 7, pp 2153–2162 | Cite as

Ultrasound-Based Risk Stratification for Malignancy in Thyroid Nodules: A Four-Tier Categorization System

  • Hyobin Seo
  • Dong Gyu NaEmail author
  • Ji-Hoon Kim
  • Kyung Won Kim
  • Ji Won Yoon



The purpose of this study was to stratify the malignancy risk of US features, with an emphasis on nodule echogenicity.


A total of 1,058 nodules of 824 consecutive patients (236 malignant and 822 benign) were included in this study. Malignancy risk of each nodule was analyzed according to US features, with an emphasis on nodule echogenecity, and was stratified into 4-tier categories.


In multivariate analysis, isoechogenicity, indistinct margin, non-solid internal content, and parallel orientation were predictive of benign nodules (P < 0.002), while hypoechogenicity, marked hypoechogenicity, spiculated/microlobulated margin, solid content, nonparallel orientation (taller than wide), microcalcification, and macrocalcification were predictive of malignancy (P ≤ 0.037). Although the presence of US features associated with malignancy was significantly predictive of malignancy in hypoechoic and markedly hypoechoic nodules (P ≤ 0.004), it was not associated with malignancy in isoechoic or hyperechoic nodules. Thyroid nodules could be stratified into four categories according to the malignancy risk: benign (risk 0 %), probably benign (risk ≤ 5 %), indeterminate (risk > 5 and < 50 %), and suspicion of malignancy (risk > 50 %).


The US-based four-tier categorization system will be useful for predicting the risk of malignancy and decisions regarding FNA for thyroid nodules.

Key Points

No US feature was predictive of malignancy in isoechoic nodules.

Isoechoic nodules without calcification can be included in the probably benign category.

We suggest a four-tier categorization stratified primarily by nodule echogenecity.

The four-tier categorization of thyroid nodules will be useful for FNA decisions.


Thyroid module Ultrasound Classification Diagnosis Thyroid cancer 



The scientific guarantor of this publication is Dong Gyu Na. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was waived by the Institutional Review Board. Methodology: retrospective, observational, multicenter study.


  1. 1.
    Paschke R, Hegedus L, Alexander E, Valcavi R, Papini E, Gharib H (2011) Thyroid nodule guidelines: agreement, disagreement and need for future research. Nat Rev Endocrinol 7:354–361PubMedCrossRefGoogle Scholar
  2. 2.
    Cibas ES, Ali SZ (2009) The Bethesda system for reporting thyroid cytopathology. Thyroid 19:1159–1165PubMedCrossRefGoogle Scholar
  3. 3.
    Moon WJ, Baek JH, Jung SL et al (2011) Ultrasonography and the ultrasound-based management of thyroid nodules: consensus statement and recommendations. Korean J Radiol 12:1–14PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Kwak JY, Koo H, Youk JH et al (2010) Value of US correlation of a thyroid nodule with initially benign cytologic results. Radiology 254:292–300PubMedCrossRefGoogle Scholar
  5. 5.
    Frates MC, Benson CB, Charboneau JW et al (2005) Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 237:794–800PubMedCrossRefGoogle Scholar
  6. 6.
    Moon WJ, Jung SL, Lee JH et al (2008) Benign and malignant thyroid nodules: US differentiation–multicenter retrospective study. Radiology 247:762–770PubMedCrossRefGoogle Scholar
  7. 7.
    Sharma A, Gabriel H, Nemcek AA, Nayar R, Du H, Nikolaidis P (2011) Subcentimeter thyroid nodules: utility of sonographic characterization and ultrasound-guided needle biopsy. AJR Am J Roentgenol 197:W1123–W1128PubMedCrossRefGoogle Scholar
  8. 8.
    Brito JP, Gionfriddo MR, Al Nofal A et al (2014) The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab 99:1253–1263PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Cooper DS, Doherty GM, Haugen BR et al (2009) Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 19:1167–1214PubMedCrossRefGoogle Scholar
  10. 10.
    Gharib H, Papini E, Paschke R et al (2010) American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and EuropeanThyroid Association Medical Guidelines for clinical practice for the diagnosis and management of thyroid nodules. Endocr Pract 16(Suppl 1):1–43PubMedCrossRefGoogle Scholar
  11. 11.
    National Comprehensive Cancer Network (2014) National Comprehensive Cancer Network Web site: Available via Accessed September 2014
  12. 12.
    Smith-Bindman R, Lebda P, Feldstein VA et al (2013) Risk of thyroid cancer based on thyroid ultrasound imaging characteristics: results of a population-based study. JAMA Intern Med 173:1788–1796PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Park JY, Lee HJ, Jang HW et al (2009) A proposal for a thyroid imaging reporting and data system for ultrasound features of thyroid carcinoma. Thyroid 19:1257–1264PubMedCrossRefGoogle Scholar
  14. 14.
    Horvath E, Majlis S, Rossi R et al (2009) An ultrasonogram reporting system for thyroid nodules stratifying cancer risk for clinical management. J Clin Endocrinol Metab 94:1748–1751PubMedCrossRefGoogle Scholar
  15. 15.
    Hambly NM, Gonen M, Gerst SR et al (2011) Implementation of evidence-based guidelines for thyroid nodule biopsy: a model for establishment of practice standards. AJR Am J Roentgenol 196:655–660PubMedCrossRefGoogle Scholar
  16. 16.
    Ozel A, Erturk SM, Ercan A et al (2012) The diagnostic efficiency of ultrasound in characterization for thyroid nodules: how many criteria are required to predict malignancy? Med Ultrason 14:24–28PubMedGoogle Scholar
  17. 17.
    Adamczewski Z, Lewinski A (2013) Proposed algorithm for management of patients with thyroid nodules/focal lesions, based on ultrasound (US) and fine-needle aspiration biopsy (FNAB); our own experience. Thyroid Res 6:6PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Kwak JY, Jung I, Baek JH et al (2013) Image reporting and characterization system for ultrasound features of thyroid nodules: multicentric Korean retrospective study. Korean J Radiol 14:110–117PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Russ G, Royer B, Bigorgne C, Rouxel A, Bienvenu-Perrard M, Leenhardt L (2013) Prospective evaluation of thyroid imaging reporting and data system on 4550 nodules with and without elastography. Eur J Endocrinol 15:649–655CrossRefGoogle Scholar
  20. 20.
    Sung JY, Na DG, Kim KS et al (2012) Diagnostic accuracy of fine-needle aspiration versus core-needle biopsy for the diagnosis of thyroid malignancy in a clinical cohort. Eur Radiol 22:1564–1572PubMedCrossRefGoogle Scholar
  21. 21.
    Paltiel HJ (2007) Sonography of pediatric renal tumors. Ultrason Clin 2:89–104CrossRefGoogle Scholar
  22. 22.
    Catalano O, Nunziata A, Siani A, Cosgrove DO (2009) Gray-scale ultrasound:imaging characteristics, fundamentals in oncologic ultrasound: sonographic imaging and intervention. Springer, Milan, p 31CrossRefGoogle Scholar
  23. 23.
    Kim GH, do Park Y, Kim S et al (2009) Is it possible to differentiate gastric GISTs from gastric leiomyomas by EUS? World J Gastroenterol 15:3376–3381PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Jeh SK, Jung SL, Kim BS, Lee YS (2007) Evaluating the degree of conformity of papillary carcinoma and follicular carcinoma to the reported ultrasonographic findings of malignant thyroid tumor. Korean J Radiol 8:192–197PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Sebag F, Vaillant-Lombard J, Berbis J et al (2010) Shear wave elastography: a new ultrasound imaging mode for the differential diagnosis of benign and malignant thyroid nodules. J Clin Endocrinol Metab 95:5281–5288PubMedCrossRefGoogle Scholar
  26. 26.
    Chen SJ, Yu SN, Tzeng JE et al (2009) Characterization of the major histopathological components of thyroid nodules using sonographic textural features for clinical diagnosis and management. Ultrasound Med Biol 35:201–208PubMedCrossRefGoogle Scholar
  27. 27.
    Seo HS, Lee DH, Park SH, Min HS, Na DG (2009) Thyroid follicular neoplasms: can sonography distinguish between adenomas and carcinomas? J Clin Ultrasound 37:493–500PubMedCrossRefGoogle Scholar
  28. 28.
    Kim DS, Kim JH, Na DG et al (2009) Sonographic features of follicular variant papillary thyroid carcinomas in comparison with conventional papillary thyroid carcinomas. J Ultrasound Med 28:1685–1692PubMedGoogle Scholar
  29. 29.
    Reading CC, Charboneau JW, Hay ID, Sebo TJ (2005) Sonography of thyroid nodules: a "classic pattern" diagnostic approach. Ultrason Q 21:157–165CrossRefGoogle Scholar
  30. 30.
    Rosai J (1992) In: Carcangiu ML, DeLelli Ronald A (eds) Atlas of tumor pathology: tumors of the thyroid gland. Armed Forces Institute of Pathology, WashingtonGoogle Scholar
  31. 31.
    Lee MJ, Kim EK, Kwak JY, Kim MJ (2009) Partially cystic thyroid nodules on ultrasound: probability of malignancy and sonographic differentiation. Thyroid 19:341–346PubMedCrossRefGoogle Scholar
  32. 32.
    Kim DW, Lee EJ, In HS, Kim SJ (2010) Sonographic differentiation of partially cystic thyroid nodules: a prospective study. AJNR Am J Neuroradiol 31:1961–1966PubMedCrossRefGoogle Scholar
  33. 33.
    Ito Y, Miyauchi A, Kihara M, Higashiyama T, Kobayashi K, Miya A (2014) Patient age is significantly related to the progression of papillary microcarcinoma of the thyroid under observation. Thyroid 4:27–34CrossRefGoogle Scholar
  34. 34.
    Kamran SC, Marqusee E, Kim MI et al (2013) Thyroid nodule size and prediction of cancer. J Clin Endocrinol Metab 98:564–570PubMedCrossRefGoogle Scholar
  35. 35.
    Moon HJ, Kwak JY, Kim MJ, Son EJ, Kim EK (2010) Can vascularity at power Doppler US help predict thyroid malignancy? Radiology 255:260–269PubMedCrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2015

Authors and Affiliations

  • Hyobin Seo
    • 1
  • Dong Gyu Na
    • 2
    Email author
  • Ji-Hoon Kim
    • 3
  • Kyung Won Kim
    • 4
  • Ji Won Yoon
    • 4
  1. 1.Department of Radiology, Gangnam CenterSeoul National University Hospital Healthcare System, 39F Gangnam Finance CenterSeoulKorea
  2. 2.Department of RadiologyHuman Medical Imaging and Intervention CenterSeoulKorea
  3. 3.Department of RadiologySeoul National University College of Medicine, Seoul National University HospitalSeoulKorea
  4. 4.Department of Internal MedicineSeoul National University College of Medicine, Seoul National University HospitalSeoulKorea

Personalised recommendations