JeanTramalloniJFIMBarcelonaNov1st2014

20101970 1990 20001980

45YEARSTECHNICALANDPRACTICALEVOLUTIONS

Kim2002

analogicalBmode

7,5MHz

US-guidedcytology

RealTimemode

US:nodularinventoryCytologyif>10mm

(noscreeningbasedonUSpaPern)

Colormode Elastography

firstbiopsythesuspiciousnodules

Lobectomy+fresh-mountstudyforeverycold,solid(andpalpable)nodule

(butonly10%ofcancersand30%ofcontrolateral

recurrences)ANDEM1995

>12MHzCompond

ConsensusSFE,ETA,ATA,BTA

TI-RADS

digitalBmode

USconfidenYalandnondecisionmaking

A REVOLUTION AFTER A LONG-STANDING EVOLUTION

Harmonic

Lymphnodes

1995:ANDEM:«mostofthecancersfeaturesasanhypoechoicnodulebutthevastmajorityofhypoechoicnodulesiscomposedofbenignlesions.»

2002:Kim:4majorsuspicionsigns:-microcalcificaYons-irregularormicrolobulatedmargins-markedhypoechogenicity-tallerthanwide

2005:Frates:USpaPernsareassociatedwithcancerrisk.

2009:HorvathintroducesforthefirstYmetheacronymofTIRADS,breathBIRADStransposiYontothyroid(10groups):eachUSpaPernisassociatedtocancerrisk.

2011:GRussintroducesafrenchTI-RADSversionincludingonly6riskgroups

2013:GRusssimplifiedTI-RADSV2including5riskgroups

Do US can be predictive of malignancy or benignancy?

TI-RADSSYSTEM

TI-RADSSYSTEM=SCORE:evaluaYonandguidelinesgroups+VOCABULARY+STANDARDISEDREPORT

• AcronymofThyroidImaging-ReporYngAndDatabaseSystem

• TransposiYonofbreastBI-RADSsystemtothyroid• QuanYtaYvecancerriskstraYficaYontoolforthyroid

TI-RADSSCORE MEANING PROPORTIONOF

NODULESRISKOFMALIGNANCY

(%)

2 BENIGN 3% 0

3 MOSTLYBENIGN 60%0.25

(1/400)

4A LOWRISKOFMALIGNANCY 33% 6

4B HIGHRISKOFMALIGNANCY 4,5% 69

5 ALMOSTSURELYMALIGNANT 0,5% 100

CANCERRISKSTRATIFICATION–TI-RADSSCOREV2PROSPECTIVESTUDY–4550nodules-USvsCYTOLOGY(2013)

TI-RADSSCORE MEANING NUMBEROF

NODULESRISKOFMALIGNANCY

(%)

2 BENIGN 3% 0

3 MOSTLYBENIGN 60%0.25

(1/400)

4A LOWRISKOFMALIGNANCY

4639(48%) 6

4B HIGHRISKOFMALIGNANCY

516(5%) 69

5 ALMOSTSURELYMALIGNANT

33(0,3%) 100

63%

CANCERRISKSTRATIFICATION–TI-RADSSCOREV2

TI-RADSSCORE MEANING NUMBEROF

NODULESRISKOFMALIGNANCY

(%)

2 BENIGN 259(3%) 0

3 MOSTLYBENIGN 4187(43%)0.25

(1/400)

4A FAIBLERISQUEDEMALIGNITÉ

4639(48%) 6

4B HIGHRISKOFMALIGNANCY 4,5% 69

5 ALMOSTSURELYMALIGNANT 0,5% 100

CANCERRISKSTRATIFICATION–TI-RADSSCOREV2

5%

TI-RADSSCORE MEANING NUMBEROF

NODULESRISKOFMALIGNANCY

(%)

2 BENIGN 259(3%) 0

3 MOSTLYBENIGN 4187(43%)0.25

(1/400)

4A LOWRISKOFMALIGNANCY 33% 6

4B HIGHRISKOFMALIGNANCY

516(5%) 69

5 ALMOSTSURELYMALIGNANT

33(0,3%) 100

CANCERRISKSTRATIFICATION–TI-RADSSCOREV2

0%

10%

20%

30%

40%

50%

60%

70%

PosiLvePredicLveValueofUSRussetal.JRadiol2011

0%

10%

20%

30%

40%

50%

60%

70%

PosiLvePredicLveValueofUSRussetal.JRadiol2011

75%

80%

85%

90%

95%

100%

NegaLvePredicLveValueofUSRussetal.JRadiol2011

75%

80%

85%

90%

95%

100%

NegaLvePredicLveValueofUSRussetal.JRadiol2011

TI-RADS score needs precise semiology

Tostudyanodule,trainyoureyes

watch,ingoodorder:shapeborderscontent

Todescribeit,useglossarywords

SHAPE

longitudinal transverse

dysharmonious

tallerthanwidetallerthanhightA/T>1

A

T

harmonious

MARGINS

welldefined

lobulated

blurred

CONTENT:ECHOGRAPHICSTRUCTURE

liquid

solid

mixed

CONTENT:ECHOGENICITYhypoechoic

mildly markedly

hypoechoic

isoechoic

hyperechoic

mildly markedly

CONTENT:ECHOGENICITY

colloidalgranulaYons

CONTENT:HYPERECHOICDOTSINCYSTICNODULES

comettailarYfact

CONTENT:HYPERECHOICDOTSINSOLIDNODULES

colloidalgranulaYons

microcalcificaYons

CONTENT:STIFFNESSATELASTOGRAPHY

PROBABLYBEGNIN

SUSPICIOUS

RAGOCLASSIFICATIONRAGOT.etal.JCEM2010

Strainelastography

CONTENT:STIFFNESSATELASTOGRAPHY

Strainelastography

CONTENT:STIFFNESSATELASTOGRAPHY

Sharewaveelastography

NODULARDESCRIPTIONGLOSSARY

SHAPE:regular/irregular(harmonious/dysharmonious)

MARGINS:well-defined/lobulated/bluredCONTENT:

-Echographicstructure:solid/mixed/liquid

-Echogenicity:hyperechoic/isoechoic markedhypoechogenicity/moderate homogeneous/heterogeneous

-  hyperechoicdots:colloidalgranulaYons microcalcificaYons

-  sYffnessatelastography-  vascularizaYon:none/peripheral/mixed/central

VASCULARIZATIONPATERNISNOTATI-RADSITEM

mainlyperinodular

mixed,periandintranodular

mainlyintranodular

in practice, how to score ?

1)firstofalllookforanysignofsuspicion

-dysharmoniousshape-lobulatedorbluredmargins-microcalcificaYons-markedhypoechogenicity-sYffnessatelastography

-1or2signsofsuspicion-nosuspiciouslymphnode

SCORE4BHIGHLYSUSPECT

Riskofcancer:69%

-3to5signsofsuspicionand/or

-suspiciouslymphnode

SCORE5MALIGNANT

Riskofcancer:100%

5suspicionsigns

Whatisasuspiciouslymphnode?

AtleastoneofthefollowingcharacterisLcs-microcalcificaYons-parYallycysYcappearance-peripheralordiffuselyincreasedvascularizaYon-hyperechoicthyroidlikelymphnode

ETAguidelines2013:EurThyrJournal2013;2:147-159

nosuspicionsign

lookatechogenicity

(slightly)hypoechogenic

isoechogenichyperechogenic

4A 32

slightly

hypoechogenic

SCORE4A

SLIGHTLYSUSPICIOUS

riskofcancer:6%

BENIGNPATTERNS

VERYPROBABLYBENIGN

-nosuspicionsign-Isoechoicouhyperechoic

SCORE3Riskofcancer:0,25%

BENIGNPATTERNS

ALWAYSBENIGN-cysYcaspect-spongiformnodule-“Whiteknight”-singlemacrocalcificaYon-nodularhyperplasia

SCORE2Riskofcancer:0%

To make a long story short ...

SUSPICIOUS

-dysharmoniousshape-lobulatedorbluredmargins-microcalcificaYons-markedhypoechogenicity-sYffatelastography

-3to5signsand/or

-metastaYclymphnode

SCORE5

-1or2signs-nometastaYclymphnode

SCORE4B

-nomajorsuspicioussign-slightlyhypoechogenic

SCORE4A

BENIGNASPECTS

MOSTLYBENIGN

-nosuspicioussign-isoechoicorhyperechoic

SCORE3

ALWAYSBENIGN-cysYcaspect-spongiformnodule

-whiteknights-singlemacrocalcificaYon-nodularhyperplasia

SCORE2

-  allnodulessightlyorstronglysuspicious(4A,4Band5)-  allnoduleswhichincreaseinasignificantway

95%ofpapillarycarcinomas100%ofmedullarycarcinomas86%offollicularycarcinomas

•  TaeHJetal.,Thyroid2007;17(5):461.DiagnosYcvalueofultrasonographytodisYnguishbetweenbenignandmalignantlesionsinthemanagementofthyroidnodules.•  ItoYetal.,Thyroid2007;17,1269-1276UltrasonographicevaluaYonofthyroidnodulesin900paYents:comparisonamongultrasonographic,cytologicalandhistologicalfindings.•  Horvathetal..JCEM,may2009,90(5),1748-51AnultrasonogramreporYngsystemforthyroidnodulesstraYfyingcancerriskforclinicalmanagement.•  Parketal..Thyroid2009,19(11),257-64AproposalforathyroidimagingreporYnganddatasystemforultrasoundfeaturesofthyroidcarcinoma.•  Kwaketal.,Radiology2011;260;892-99ThyroidImagingReporYngandDataSystemforUSfeaturesofnodules.AstepinestablishingbePerstraYficaYonofcancerrisk.•  KwakJYetal.,KoreanJRadiol2013;14(1):110-117ImagereporYngandcharacterizaYonsystemforultrasounffeuturesofthyroidnodules:mulYcentrickoreanretrospecYvestudy•  Russetal.JRadiol2011;92;701-13LesystèmeTI-RADSenéchographiethyroïdienne.•  Russetal.EurJEndocrinol2013,168(5);649-55ProspecYveevaluaYonofthyroidimagingreporYnganddatasystemon4550noduleswithandwithoutelastography.

REFERENCES

•  ETAguidelines2013:EurThyrJournal2013;2:147-159

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