ACR TI-RADS

Composition(Choose 1)

Echogenicity(Choose 1)

Shape(Choose 1)

Margin(Choose 1)

Echogenic foci (Choose all that apply)

Add points from all categories to determine Tl-RADS level

TR1
Benign
No FNA

0 points

2 points

3 points

4 to 6 points

7 points or more

TR5
Highly suspicious
FNA if ≥1 cm
Follow if ≥0.5 cm^*

TR3
Mildly suspicious
FNA if ≥2.5 cm
Follow if ≥1.5 cm

TR4
Moderately suspicious
FNA if ≥1.5 cm
Follow if ≥1 cm

TR2
Not suspicious
No FNA

Composition

Spongiform: Composed predominantly (>50%) of small cystic spaces. Do not add further points for other categories.
Mixed cystic and solid: Assign points for predominant solid component.
Assign 2 points if composition cannot be determined because of calcification.

End

Echogenicity

Anechoic: Applies to cystic or almost completely cystic nodules.
Hyperechoic/isoechoic/hypoechoic: Compared to adjacent parenchyma.
Very hypoechoic: More hypoechoic than strap muscles.
Assign 1 point if echogenicity cannot be determined.

Shape

Taller-than-wide: Should be assessed on a transverse image with measurements parallel to sound beam for height and perpendicular to sound beam for width.
This can usually be assessed by visual inspection.

Margin

Lobulated: Protrusions into adjacent tissue.
Irregular: Jagged, spiculated, or sharp angles.
Extrathyroidal extension: Obvious invasion = malignancy.
Assign 0 points if margin cannot be determined.

Echogenic foci

Large comet-tail artifacts: V-shaped, >1 mm, in cystic components.
Macrocalcifications: Cause acoustic shadowing.
Peripheral: Complete or incomplete along margin.
Punctate echogenic foci: May have small comet-tail artifacts.

^*Refer to discussion of papillary microcarcinomas for 5–9 mm TR5 nodules.