Recent research published in the Journal of Surgical Research demonstrates that thyroid nodule classification systems like TI-RADS and Bethesda provide diagnostic equity across racial groups, with Bethesda classification achieving superior sensitivity and specificity without significant performance differences between Black and white patients.
- Bethesda classification achieved higher overall sensitivity (89.3%) and specificity (60.6%) compared to TI-RADS (73.2% sensitivity, 49.0% specificity)
- Both classification systems showed no significant performance differences by race, supporting their applicability across diverse patient populations
- Study included 512 patients (64.7% white, 32.4% Black, 2.9% other) with 31.4% malignancy rate
- Receiver operating characteristic analysis showed Bethesda had superior discriminatory performance (0.87 vs. 0.67)
- Researchers recommend prospective validation in more racially diverse cohorts and biology-informed threshold adjustments for future refinement
Thyroid nodule classification systems offer diagnostic equity, though they could be refined, according to research published September 4 in the Journal of Surgical Research.
TI-RADS showed moderate sensitivity and low specificity, whereas fine-needle aspiration biopsy-derived Bethesda classification achieved stronger diagnostic accuracy across Black and white racial groups, wrote a team led by Andrea Gillis, MD, from the University of Alabama at Birmingham.
“Importantly, performance did not significantly differ by race for either classification system, supporting their applicability in this… cohort,” Gillis and colleagues wrote.
Ultrasound-based TI-RADS and Bethesda classifications stratify risk for thyroid nodules that may become malignant. Malgnancies are found in 5% to 15% of cases. These classification systems drive clinical decision-making.
The researchers noted that both systems were developed “without explicit consideration” of racial diversity. This raises concerns about their generalizability and whether they may unintentionally heighten racial disparities in thyroid care.
The Gillis team evaluated potential variations in diagnostic performance across racial groups, using the TI-RADS and Bethesda risk classification systems. It defined test-positive thresholds as TI-RADS 4 or higher and Bethesda III to VI.
The study included 512 patients, with 64.7% being white, 32.4% Black, and 2.9% “other” racial and ethnic groups. The researchers found a malignancy in 31.4% of the study cohort.
TI-RADS achieved an overall sensitivity of 73.2% and did not differ significantly by race (p = 0.43). It also achieved 49.0% overall specificity and was higher in Black patients (56.8%) than white patients (45.7%), although this difference did not achieve statistically significance (p = 0.09).
Bethesda achieved higher overall sensitivity (89.3%) and specificity (60.6%), with similar sensitivity across groups (p = 0.82). The group noted higher specificity in Black patients (68.5%) than white patients (56.6%), although this difference also did not achieve statistical significance (p = 0.06).
Finally, receiver operating characteristic analysis showed that Bethesda had superior discriminatory performance over TI-RADS (0.87 vs. 0.67).
The study authors suggested that the higher specificity in Black patients “may reflect underlying differences in tumor biology and referral pathways rather than systematic scoring bias.” They added that the results highlight the importance of ongoing refinement toward equitable and precise care.
“Future research should focus on prospective validation of these classification systems in more racially and ethnically diverse cohorts, exploration of biology-informed threshold adjustments, and the integration of known histologic subtype differences by race into scoring frameworks,” the authors wrote.
Read the full study 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)
