Fine needle aspiration biopsy indications for thyroid nodules: compare a point-based risk stratification system with a pattern-based risk stratification system

  • Jing-liang Ruan
  • Hai-yun Yang
  • Rong-bin Liu
  • Ming Liang
  • Ping Han
  • Xiao-lin XuEmail author
  • Bao-ming LuoEmail author
Head and Neck



We aim to compare the diagnostic performance to assess thyroid nodules and reliability for recommending fine needle aspiration biopsy (FNAB) between American College of Radiology thyroid image reporting and data system (ACR TI-RADS) and American Thyroid Association (ATA) guidelines.


In total, this retrospective study included 1001 consecutive thyroid nodules in 918 patients from May 2016 to December 2017. US features of the thyroid nodules, including composition, echogenicity, shape, margins, echogenic foci, and size, were reviewed and were classified according to ACR TI-RADS and ATA guidelines, respectively. The diagnostic performance to assess thyroid nodules and reliability for recommending fine needle aspiration biopsy were compared between ACR TI-RADS and ATA guidelines.


Of the 1001 thyroid nodules, 609 (60.8%) were benign and 392 (39.2%) were malignant. The sensitivity, specificity, PPV, NPV, and accuracy were 96.7%, 77.3%, 73.3%, 97.3%, and 84.9%, respectively, for ACR TI-RADS and 99.2%, 16.1%, 43.2%, 97.0%, and 48.7%, respectively, for ATA guidelines. AUC of ACR TI-RADS was significantly greater than ATA guidelines (0.935 (0.918, 0.949) vs 0.884 (0.862, 0.903), p < 0.001). Biopsy yield of malignancy, biopsy rate of malignancy, and unnecessary FNAB rate were 59.5%, 91.3%, and 40.5%, respectively, for ACR TI-RDS and 38.5%, 97.4%, and 61.5%, respectively, for ATA guidelines.


ACR TI-RADS was more accurate than ATA guidelines for differentiating malignant thyroid nodules from benign nodules and more reliable than ATA guidelines for recommending thyroid nodules for FNAB.

Key Points

Malignant risk of thyroid nodules can be stratified by ultrasound.

• American College of Radiology guidelines were more accurate for differentiating malignant thyroid nodules from benign nodules.

• American College of Radiology guidelines were more reliable for recommending thyroid nodules for biopsy.


Fine needle aspiration biopsy Biopsy; Guidelines Thyroid nodules Ultrasound 

Abbreviations and acronyms


American College of Radiology


American Thyroid Association


Area under the curve


Fine needle aspiration biopsy


Negative predictive value


Positive predictive value


Papillary thyroid cancer


Thyroid image reporting and data system





This study has received funding by Natural Science Foundation of Guangdong Province (2016A030313306) and National Natural Science Foundation of China (81671704).

Compliance with ethical standards


The scientific guarantor of this publication is Prof. Bao-ming Luo.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products of services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.


• retrospective

• diagnostic or prognostic

• performed at one institution


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Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of Ultrasound, Sun Yat-sen Memorial HospitalSun Yat-sen UniversityGuangzhouChina
  2. 2.Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial HospitalSun Yat-sen UniversityGuangzhouChina
  3. 3.Department of Otolaryngology, Head and Neck Surgery, Sun Yat-sen Memorial HospitalSun Yat-sen UniversityGuangzhouChina

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