Ch 4 TIRADS + Biopsies

Question 1

What does TIRADS stand for?

Answer 1

Thyroid imaging reporting + data system

Question 2

What is TIRADS?

Answer 2

-A 5 point classification system that uses u/s characteristics to determine the risk + suspicion for malignancy in thyroid nodules

-Developed TIRADS to help reduce the amount of biopsies being done

Question 3

List the 5 TIRAD classifications?

Answer 3

TR 1: benign (no FNA, 0 points)
TR 2: not suspicious (no FNA, 2 points)
TR 3: mildly suspicious
(FNA if >2.5cm, follow up if >1.5cm, 3 points)
TR 4: moderately suspicious
(FNA if >1.5cm, follow up if >1cm, 4-6 points)
TR 5: highly suspicious - some exceptions here
(FNA if >1cm, follow up if >0.5cm, >7 points)

Question 4

When would we not use TIRADS?

Answer 4

When a lesion is under 5mm or 0.5cm

Question 5

What size must a lesion be to have a biopsy done?

Answer 5

> 1cm

Question 6

What are the 4 composition options?

Answer 6

-Cystic or almost completely cystic (0 points)
-Spongiform (0)
-Mixed cystic + solid (1)
-Solid or almost completely solid (2)

Question 7

If composition can’t be determined, which option do we choose?

Answer 7

Solid

Question 8

What is spongiform composition?

Answer 8

When at least 50% of the nodule is comprised of tiny cysts

(if there are other features present like peripheral or macro calcs, do NOT classify as spongiform)

Question 9

What are the 4 echogenicity options?

Answer 9

-Anechoic (0 points)
-Hyperechoic/isoechoic (1)
-Hypoechoic (2)
-Very hypoechoic (3)

(all echogenicity is compared to thyroid, except very hypoechoic is compared to surrounding neck muscles)

Question 10

If the echogenicity can’t be determined, which option do we choose?

Answer 10

Isoechoic

Question 11

What are the 2 shape options?

Answer 11

-Wider than tall (0 points)
-Taller than wide (3 points)

(measured in TRV)

Question 12

What are the 4 margin options?

Answer 12

-smooth (0 points)
-ill defined (0)
-lobulated or irregular (2)
-extra thyroidal extension (3)

Question 13

If the margin can’t be determined, which option do we choose?

Answer 13

ill-defined

Question 14

What are the 4 echogenic foci options?

Answer 14

-None or large comet tail artifact (0 points)
-Macrocalcifications, large enough to produce shadowing (1)
-Peripheral rim calcifications (2)
-Punctate echogenic foci (3)

Question 15

What defines a large comet tail?

Answer 15

When the tail is >1mm + is V shaped

(this is a non-suspicious finding)

Question 16

Peripheral rim calcifications can be dense enough to obscure the internal components of the nodule, how would we describe the composition + echogenicity of it now?

Answer 16

Composition: solid
Echogenicity: isoechoic

Question 17

Do punctate echogenic foci have comet tails?

Answer 17

Foci <1mm sometimes can have a small comet tail

Question 18

Mixed cystic + solid lesions should be characterized by what?

Answer 18

The soft tissue component

Question 19

No further characterization is required for what type of nodule?

Answer 19

A spongiform nodule that is identified as TR 1

Question 20

What is a fine needle aspiration (FNA)?

Answer 20

-Cytological evaluation used to test for malignancy, confirm benignity or determine the nature of other lesions

-Considered minimally invasive
-Is an outpatient procedure
-Uses a smaller needle than a core biopsy

Question 21

What are complications with FNA?

Answer 21

-Risk of bleeding or infection (m/c)
-Voice hoarseness
-Seeding/spreading of cancer (rare)

Question 22

Does FNA or a core biopsy use a smaller needle?

Answer 22

FNA

Question 23

What is a core needle biopsy?

Answer 23

-Biopsy gun with a hollow core needle
-Obtains a larger amount of tissue
-Uses a larger needle than FNA
-Associated with more complications than FNA

(less repeat biopsies are needed b/c they are taking a greater sample, but this increases risk of complications)

Question 24

Explain how an u/s guided FNA procedure works?

Answer 24

-Sterile technique, local anesthetic + 25g needle used
-Same pt set up as for a thyroid u/s
-U/s guides the needle into the lesion of interest
-Multiple samples obtained from the lesion, placed into cytology fluid + sent to lab for testing

Question 25

What are limitations of an FNA?

Answer 25

-Inconclusive results or repeat biopsies needed (2/10)

-Lacks specificity for certain cancers (follicular carcinoma, hurthle cell carcinoma + lymphomas)

Question 26

How can we reduce the repeat rate of FNA’s?

Answer 26

-Can use u/s guidance
-By having an onsite tech to check the cells right away once they are drawn to ensure they will work for testing