The score selects TR1-TR5; maximum nodule size then selects no action, scheduled ultrasound follow-up, or FNA. Previously biopsied and PET-avid nodules require the documented exceptions.
{
"applicability": {
"use_for": "Risk stratification and size-based management of thyroid nodules characterized on ultrasound.",
"management_exceptions": [
"previously_biopsied_nodule",
"PET_avid_nodule",
"known_thyroid_malignancy"
]
},
"feature_groups": [
{
"id": "composition",
"selection": "choose_one",
"options": [
{
"id": "cystic_or_almost_completely_cystic",
"points": 0
},
{
"id": "spongiform",
"points": 0,
"stop_scoring_other_groups": true
},
{
"id": "mixed_cystic_and_solid",
"points": 1
},
{
"id": "solid_or_almost_completely_solid",
"points": 2
},
{
"id": "cannot_determine_due_to_calcification",
"points": 2
}
]
},
{
"id": "echogenicity",
"selection": "choose_one",
"options": [
{
"id": "anechoic",
"points": 0
},
{
"id": "hyperechoic_or_isoechoic",
"points": 1
},
{
"id": "hypoechoic",
"points": 2
},
{
"id": "very_hypoechoic",
"points": 3
},
{
"id": "cannot_determine",
"points": 1
}
]
},
{
"id": "shape",
"selection": "choose_one",
"options": [
{
"id": "wider_than_tall",
"points": 0
},
{
"id": "taller_than_wide",
"points": 3
}
]
},
{
"id": "margin",
"selection": "choose_one",
"options": [
{
"id": "smooth",
"points": 0
},
{
"id": "ill_defined",
"points": 0
},
{
"id": "lobulated_or_irregular",
"points": 2
},
{
"id": "extrathyroidal_extension",
"points": 3,
"caveat": "Obvious invasion should be considered malignant until proven otherwise."
},
{
"id": "cannot_determine",
"points": 0
}
]
},
{
"id": "echogenic_foci",
"selection": "choose_all_that_apply",
"options": [
{
"id": "none_or_large_comet_tail",
"points": 0
},
{
"id": "macrocalcifications",
"points": 1
},
{
"id": "peripheral_rim_calcifications",
"points": 2
},
{
"id": "punctate_echogenic_foci",
"points": 3
}
]
}
],
"score_operation": "Sum composition, echogenicity, shape, margin, and every applicable echogenic-foci point value.",
"score_map": [
{
"points": "0",
"outcome_code": "TR1"
},
{
"points": "2",
"outcome_code": "TR2"
},
{
"points": "3",
"outcome_code": "TR3"
},
{
"points": "4-6",
"outcome_code": "TR4"
},
{
"points": ">=7",
"outcome_code": "TR5"
}
],
"size_thresholds_mm": {
"TR1": {
"fna": "never",
"follow_up": "none"
},
"TR2": {
"fna": "never",
"follow_up": "none"
},
"TR3": {
"fna_if_gte": 25,
"follow_if_gte": 15,
"follow_if_lt_fna": true,
"follow_up_years": [
1,
3,
5
]
},
"TR4": {
"fna_if_gte": 15,
"follow_if_gte": 10,
"follow_if_lt_fna": true,
"follow_up_years": [
1,
2,
3,
5
]
},
"TR5": {
"fna_if_gte": 10,
"follow_if_gte": 5,
"follow_if_lt_fna": true,
"follow_up_years": [
1,
2,
3,
4,
5
]
}
},
"interval_change": {
"significant_growth": ">=20% increase in at least two dimensions with an absolute increase of >=2 mm",
"consequence": "Reapply the management threshold using the new size for the existing TR level."
},
"exceptions": [
{
"if": "previously biopsied",
"then": "TR classification may be reported, but management must incorporate pathology; ACR TI-RADS does not provide a standalone recommendation."
},
{
"if": "focal FDG-PET uptake and size >10 mm in a patient with normal life expectancy",
"then": "ACR FAQ recommends biopsy regardless of TR category; clinical context may alter this in patients with another malignancy."
}
],
"source_locator": "ACR TI-RADS Atlas and Assessment Categories chart; ACR Diagnostic Ultrasound Reporting Template; ACR TI-RADS FAQ 111-116."
}