Korean J Radiol.  2020 Jan;21(1):108-116. 10.3348/kjr.2019.0215.

Concordance of Three International Guidelines for Thyroid Nodules Classified by Ultrasonography and Diagnostic Performance of Biopsy Criteria

  • 1Department of Radiology, College of Medicine, Kangwon National University, Kangwon National University Hospital, Chuncheon, Korea.
  • 2Department of Radiology, GangNeung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea. nndgna@gmail.com
  • 3Department of Radiology, Ajou University, School of Medicine, Suwon, Korea.
  • 4Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
  • 5Department of Radiology, Thyroid Center, Daerim St. Mary's Hospital, Seoul, Korea.
  • 6Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
  • 7Department of Radiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea.


To investigate the concordance of three international guidelines: the Korean Thyroid Association/Korean Society of Thyroid Radiology, American Thyroid Association, and American College of Radiology for thyroid nodules classified by ultrasonography (US) and the diagnostic performance of simulated size criteria for malignant biopsies.
A total of 2586 thyroid nodules (≥ 1 cm) were collected from two multicenter study datasets. The classifications of the thyroid nodules were based on three different guidelines according to US categories for malignancy risk, and the concordance rate between the different guidelines was calculated for the classified nodules. In addition, the diagnostic performance of criteria related to four different simulated biopsy sizes was evaluated.
The concordance rate of nodules classified as high- or intermediate-suspicion was high (84.1-100%), but low-suspicion or mildly-suspicious nodules exhibited relatively low concordance (63.8-83.8%) between the three guidelines. The differences in sensitivity, specificity, and accuracy between the guidelines were 0.7-19.8%, 0-40.9%, and 0.1-30.5%, respectively, when the original biopsy criteria were applied. The differences decreased to 0-5.9%, 0-10.9%, and 0.1-8.2%, respectively, when simulated, similar biopsy size criteria were applied. The unnecessary biopsy rate calculated with the original criteria (0-33.8%), decreased with the simulated biopsy size criteria (0-8.7%).
We found a high concordance between the three guidelines for high- or intermediate-suspicion nodules, and the diagnostic performance of the biopsy criteria was approximately equivalent for each simulated size criterion. The difference in diagnostic performance between the three guidelines is mostly influenced by the various size thresholds for biopsies.


Thyroid nodules; Thyroid cancer; Thyroid imaging reporting and data system; Ultrasonography; Size threshold; Guidelines

MeSH Terms

Sensitivity and Specificity
Thyroid Gland*
Thyroid Neoplasms
Thyroid Nodule*

Cited by  1 articles

Comparison of Thyroid Imaging Reporting and Data Systems in Malignancy Risk Stratification of Indeterminate Thyroid Nodules
Bo Hyun Kim
Endocrinol Metab. 2021;36(5):974-976.    doi: 10.3803/EnM.2021.1287.


1. Perros P, Boelaert K, Colley S, Evans C, Evans RM, Gerrard Ba G, et al. British Thyroid Association. Guidelines for the management of thyroid cancer. Clin Endocrinol Oxf. 2014; 81 Suppl 1:1–122.
2. Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association guidelines task force on thyroid nodules and differentiated thyroid cancer. Thyroid. 2016; 26:1–133.
3. Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegedüs L, et al. American Association of Clinical Endocrinologists, American College of Endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules–2016 update. Endocrine Practice. 2016; 22:Supple 1. 1–60.
4. Shin JH, Baek JH, Chung J, Ha EJ, Kim JH, Lee YH, et al. Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology. Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology consensus statement and recommendations. Korean J Radiol. 2016; 17:370–395.
5. Tessler FN, Middleton WD, Grant EG, Hoang JK, Berland LL, Teefey SA, et al. ACR thyroid imaging, reporting and data system (TI-RADS): white paper of the ACR TI-RADS committee. J Am Coll Radiol. 2017; 14:587–595.
6. Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L. European Thyroid Association guidelines for ultrasound malignancy risk stratification of thyroid nodules in adults: the EU-TIRADS. Eur Thyroid J. 2017; 6:225–237.
7. Ha EJ, Baek JH, Na DG. Risk stratification of thyroid nodules on ultrasonography: current status and perspectives. Thyroid. 2017; 27:1463–1468.
8. Middleton WD, Teefey SA, Reading CC, Langer JE, Beland MD, Szabunio MM, et al. Comparison of performance characteristics of American College of Radiology TI-RADS, Korean Society of Thyroid Radiology TIRADS, and American Thyroid Association guidelines. AJR Am J Roentgenol. 2018; 210:1148–1154.
9. Ha EJ, Na DG, Baek JH, Sung JY, Kim JH, Kang SY. US fine-needle aspiration biopsy for thyroid malignancy: diagnostic performance of seven society guidelines applied to 2000 thyroid nodules. Radiology. 2018; 287:893–900.
10. Ha EJ, Na DG, Moon WJ, Lee YH, Choi N. Diagnostic performance of ultrasound-based risk stratification systems for thyroid nodules: comparison of the 2015 ATA guidelines with the 2016 KTA/KSThR and 2017 ACR guidelines. Thyroid. 2018; 28:1532–1537.
11. Grani G, Lamartina L, Ascoli V, Bosco D, Biffoni M, Giacomelli L, et al. Reducing the number of unnecessary thyroid biopsies while improving diagnostic accuracy: toward the “Right” TIRADS. J Clin Endocrinol Metab. 2019; 104:95–102.
12. Ha SM, Baek JH, Na DG, Suh CH, Chung SR, Choi YJ, et al. Diagnostic performance of practice guidelines for thyroid nodules: thyroid nodule size versus biopsy rates. Radiology. 2019; 291:92–99.
13. Na DG, Baek JH, Sung JY, Kim JH, Kim JK, Choi YJ, et al. Thyroid imaging reporting and data system risk stratification of thyroid nodules: categorization based on solidity and echogenicity. Thyroid. 2016; 26:562–572.
14. Ha EJ, Moon WJ, Na DG, Lee YH, Choi N, Kim SJ, et al. A multicenter prospective validation study for the Korean thyroid imaging reporting and data system in patients with thyroid nodules. Korean J Radiol. 2016; 17:811–821.
15. Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Am J Clin Pathol. 2009; 132:658–665.
16. Jung CK, Min HS, Park HJ, Song DE, Kim JH, Park SY, et al. Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group. Pathology reporting of thyroid core needle biopsy: a proposal of the Korean Endocrine Pathology Thyroid Core Needle Biopsy Study Group. J Pathol Transl Med. 2015; 49:288–299.
17. Yoon JH, Lee HS, Kim EK, Moon HJ, Kwak JY. Malignancy risk stratification of thyroid nodules: comparison between the thyroid imaging reporting and data system and the 2014 American Thyroid Association management guidelines. Radiology. 2016; 278:917–924.
18. Hong MJ, Na DG, Baek JH, Sung JY, Kim JH. Impact of nodule size on malignancy risk differs according to the ultrasonography pattern of thyroid nodules. Korean J Radiol. 2018; 19:534–541.
19. Park JW, Kim DW, Kim D, Baek JW, Lee YJ, Baek HJ. Korean thyroid imaging reporting and data system features of follicular thyroid adenoma and carcinoma: a single-center study. Ultrasonography. 2017; 36:349–354.
20. Ito Y, Miyauchi A, Oda H. Low-risk papillary microcarcinoma of the thyroid: a review of active surveillance trials. Eur J Surg Oncol. 2018; 44:307–315.
21. Han JM, Kim WB, Kim TY, Ryu JS, Gong G, Hong SJ, et al. Time trend in tumour size and characteristics of anaplastic thyroid carcinoma. Clin Endocrinol (Oxf). 2012; 77:459–464.
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