Score thyroid nodules using ACR TI-RADS (Thyroid Imaging Reporting and Data System). Evaluates 5 ultrasound features, calculates points, assigns TI-RADS level, and provides FNA recommendations.
The ACR Thyroid Imaging Reporting and Data System (TI-RADS), published by the American College of Radiology in 2017, is the standardized framework for risk-stratifying thyroid nodules on ultrasound. It assigns points based on five ultrasound feature categories — composition, echogenicity, shape, margins, and echogenic foci — then translates the total into one of five suspicion levels (TR1 through TR5) with size-dependent biopsy recommendations.
Thyroid nodules are extremely common, found in 50-67% of adults on ultrasound, but only 5-15% are malignant. The clinical challenge is identifying which nodules require fine-needle aspiration (FNA) biopsy while avoiding unnecessary biopsies on the vast majority of benign nodules. TI-RADS achieves this by systematically evaluating features known to correlate with malignancy: solid composition, hypoechogenicity, taller-than-wide shape, irregular margins, and punctate echogenic foci (microcalcifications).
This calculator implements the complete ACR TI-RADS point system with all scoring categories, translates points to TI-RADS levels, applies size-specific FNA thresholds, provides malignancy risk estimates, and includes a detailed breakdown showing exactly how each feature contributed to the total score.
TI-RADS is one of the most impactful radiology decision tools, reducing unnecessary thyroid biopsies by approximately half while maintaining high sensitivity for clinically significant cancers. Manual point addition across five categories is error-prone in busy clinical settings; this calculator ensures accurate tabulation and connects the score directly to size-specific management recommendations.
TI-RADS Points = Composition (0-2) + Echogenicity (0-3) + Shape (0-3) + Margin (0-3) + Echogenic Foci (0-3) TR1: 0 pts | TR2: 2 pts | TR3: 3 pts | TR4: 4-6 pts | TR5: ≥ 7 pts FNA: TR3 ≥ 2.5cm | TR4 ≥ 1.5cm | TR5 ≥ 1.0cm
Result: TI-RADS TR5 (7 points) — Highly Suspicious, FNA recommended
Solid (2) + hypoechoic (2) + wider-than-tall (0) + smooth (0) + punctate echogenic foci (3) = 7 points = TR5. At 15mm, this meets the TR5 FNA threshold of ≥ 1.0 cm. Malignancy risk > 20%.
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Taller-than-wide shape (3 points) and punctate echogenic foci / microcalcifications (3 points) are the strongest individual predictors of malignancy. Either alone contributes enough points to raise the TI-RADS level significantly. Together, they strongly suggest papillary thyroid carcinoma.
No. TI-RADS was designed to reduce unnecessary biopsies. TR1 and TR2 nodules require no FNA regardless of size. TR3 nodules need FNA only above 2.5 cm. Most incidentally discovered nodules are benign and require only surveillance or no follow-up.
FNA results are classified by Bethesda system (I-VI). Bethesda II (benign) = surveillance. Bethesda V-VI (suspicious/malignant) typically → surgery. Bethesda III-IV (indeterminate) may require molecular testing or repeat FNA. TI-RADS and Bethesda together guide management.
An isoechoic solid nodule with smooth margins, wider-than-tall shape, and no echogenic foci scores 3 points (TR3) — mildly suspicious with ~5% malignancy risk. While most are benign, follicular thyroid cancers can appear this way. Size threshold for FNA is 2.5 cm.
Purely cystic nodules are almost always benign (> 99%). They represent colloid cysts or degenerating adenomas. The ACR correctly assigns 0 points to cystic and spongiform compositions. Even mixed cystic-solid nodules (1 point) have lower malignancy risk than solid nodules.
ACR TI-RADS, EU-TIRADS, K-TIRADS, and ATA guidelines all risk-stratify thyroid nodules but differ in feature weighting and FNA thresholds. ACR TI-RADS is the most widely used in the US and has been shown to reduce unnecessary FNAs by 40-50% compared to older approaches while maintaining sensitivity for detecting cancer.