A nomogram combining ultrasound features and TI-RADS parameters can differentiate between malignant and benign thyroid nodules, according to research published January 22 in Ultrasound in Medicine & Biology.
Investigators led by Lina Pang from Fourth Military Medical University in Xi'an, Shaanxi Province, China found that their nomogram achieved high predictive performance in evaluating TI-RADS thyroid nodules categories 3, 4, and 5.
“A method of integrating information from multiple ultrasound modalities should be developed to improve diagnostic accuracy as a further supplementary tool for the risk stratification performance of the current TI-RADS,” they wrote.
The American College of Radiology (ACR) created TI-RADS based on gray-scale ultrasound features. The system helps stratify risk for thyroid nodules. From TI-RADS, the following imaging features should be considered suspicious: solid exhibition, hypoechogenicity, irregular margin, taller-than-wide shape, and microcalcifications.
However, newer ultrasound methods such as elastography and contrast-enhanced ultrasound (CEUS) have been shown to further improve lesion detection.
Pang and co-authors described their work in developing and validating their predictive nomogram. They based their nomogram on combined imaging features of gray-scale ultrasound, elastography, and CEUS to distinguish malignant from benign lesions. The lesions were categorized as either 3, 4, or 5 based on TI-RADS.
Of the thyroid nodules scanned between 2014 and 2018, the team included 669 that fit the TI-RADS category criteria. Of these, 455 were included in the training cohort and 214 were placed in a validation cohort.
The researchers highlighted that the nomogram achieved high predictive performance in both cohorts.
| Performance of predictive nomogram on evaluating thyroid lesions | ||
|---|---|---|
| Measure | Training cohort | Validation cohort |
| Area under the curve (AUC) | 0.93 | 0.93 |
| Sensitivity | 84% | 86% |
| Specificity | 88% | 87% |
| Positive predictive value | 91% | 87% |
| Negative predictive value | 81% | 86% |
The team also reported that the AUC for the combined nomogram was significantly higher than those of each individual modality. These included TI-RADS, elastography, and CEUS (p < 0.005 for all).
Finally, the AUCs of the validation cohort were 0.93 and 0.93, respectively, for senior and junior radiologists.
The study authors suggested that their nomogram could serve in a supplementary role for thyroid nodule risk stratification alongside TI-RADS. However, they called for prospective studies to validate their results.
They also highlighted that it has the potential to include more diagnostic information that could help avoid unnecessary biopsies.
“This nomogram also could supply more helpful information for nodules less than 1 cm without fine-needle aspiration indications in ACR TI-RADS,” the authors wrote.
The study can be found in full here.
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnie.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
