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Objectives <p>This study assessed the risk of malignancy (ROM) of nodules classified by five US risk stratification systems (US-RSSs) and evaluated the diagnostic performances of US-RSSs with biopsy criteria for diagnosing malignancy in focal [<sup>18</sup>F]fluorodeoxyglucose (FDG)-PET/CT thyroid incidentalomas (TIs).</p> Materials and methods <p>This retrospective cohort study included 216 patients with 236 [<sup>18</sup>F]FDG-PET/CT TIs, of whom 208 (96.3%) were oncology patients. The primary outcome included the diagnostic performances of five US-RSSs with biopsy criteria for diagnosing malignant tumors. Secondary outcomes included the ROM of nodules classified by US-RSSs and the diagnostic performance of US-RSS criteria combined with maximum standardized uptake value (SUVmax).</p> Results <p>The malignancy risk of intermediate-risk TIs was higher (33.8–48.2%) than the suggested ROM across all RSSs (<i>p</i> &lt; 0.01). Low-risk category TIs had a significantly higher ROM (&gt; 20%) only in Chinese-Thyroid Imaging Reporting and Data System (C-TIRADS; 35.0%, <i>p</i> &lt; 0.01). The sensitivity for overall and aggressive malignancies was highest (97.3% and 100%, respectively) in the American Thyroid Association system and Korean-TIRADS, but lower (86.7–90.7% and 80.0–86.7%, respectively) in other RSSs for 189 TIs &gt; 1 cm. American College of Radiology (ACR)-TIRADS showed the highest specificity (50.0%) and lowest unnecessary biopsy rate (30.2%, <i>p</i> &lt; 0.01). Combined SUVmax-US-RSS criteria demonstrated increased sensitivity in ACR-TIRADS (96.0%, <i>p</i> = 0.02), but also showed greater unnecessary biopsy rates (<i>p</i> &lt; 0.01).</p> Conclusion <p>Intermediate-risk TIs had greater ROM across RSSs, while low-risk TIs showed a significant increase only in C-TIRADS. Although US-RSSs can reduce unnecessary biopsies, European-TIRADS, ACR-TIRADS, and C-TIRADS demonstrated relatively lower sensitivity for aggressive malignancies.</p> Key Points <p><Emphasis Type="BoldItalic">Question</Emphasis> <i>The diagnostic performance of US risk stratification systems (US-RSS) from various professional societies remains unestablished in the assessment of focal [</i><sup><i>18</i></sup><i>F]fluorodeoxyglucose (FDG)-PET/CT thyroid incidentalomas.</i></p> <p><Emphasis Type="BoldItalic">Findings</Emphasis> <i>While US-RSSs reduce unnecessary biopsies, European-, American College of Radiology-, and Chinese-thyroid imaging reporting and data systems (TIRADS) demonstrated relatively lower sensitivity for aggressive malignancies.</i></p> <p><Emphasis Type="BoldItalic">Clinical relevance</Emphasis> <i>US-RSSs stratify malignancy risk in focal [</i><sup><i>18</i></sup><i>F]FDG-PET/CT incidentalomas, but lower biopsy size cutoffs may be needed for intermediate-risk nodules in European- and American College of Radiology-TIRADS and low-risk nodules in Chinese-TIRADS, based on oncology patients’ clinical context.</i></p> Graphical Abstract <p></p>

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Diagnostic performances of five US risk stratification systems for malignancy in focal [18F]FDG-PET/CT thyroid incidentalomas

  • 期刊论文

  • 发表日期：

    2025年9月22日

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  • Chae Young Shin,
  • Hye Shin Ahn,
  • Dong Gyu Na,
  • Hyo Sang Lee,
  • Eon-Woo Shin

摘要

Objectives

This study assessed the risk of malignancy (ROM) of nodules classified by five US risk stratification systems (US-RSSs) and evaluated the diagnostic performances of US-RSSs with biopsy criteria for diagnosing malignancy in focal [18F]fluorodeoxyglucose (FDG)-PET/CT thyroid incidentalomas (TIs).

Materials and methods

This retrospective cohort study included 216 patients with 236 [18F]FDG-PET/CT TIs, of whom 208 (96.3%) were oncology patients. The primary outcome included the diagnostic performances of five US-RSSs with biopsy criteria for diagnosing malignant tumors. Secondary outcomes included the ROM of nodules classified by US-RSSs and the diagnostic performance of US-RSS criteria combined with maximum standardized uptake value (SUVmax).

Results

The malignancy risk of intermediate-risk TIs was higher (33.8–48.2%) than the suggested ROM across all RSSs (p < 0.01). Low-risk category TIs had a significantly higher ROM (> 20%) only in Chinese-Thyroid Imaging Reporting and Data System (C-TIRADS; 35.0%, p < 0.01). The sensitivity for overall and aggressive malignancies was highest (97.3% and 100%, respectively) in the American Thyroid Association system and Korean-TIRADS, but lower (86.7–90.7% and 80.0–86.7%, respectively) in other RSSs for 189 TIs > 1 cm. American College of Radiology (ACR)-TIRADS showed the highest specificity (50.0%) and lowest unnecessary biopsy rate (30.2%, p < 0.01). Combined SUVmax-US-RSS criteria demonstrated increased sensitivity in ACR-TIRADS (96.0%, p = 0.02), but also showed greater unnecessary biopsy rates (p < 0.01).

Conclusion

Intermediate-risk TIs had greater ROM across RSSs, while low-risk TIs showed a significant increase only in C-TIRADS. Although US-RSSs can reduce unnecessary biopsies, European-TIRADS, ACR-TIRADS, and C-TIRADS demonstrated relatively lower sensitivity for aggressive malignancies.

Key Points

Question The diagnostic performance of US risk stratification systems (US-RSS) from various professional societies remains unestablished in the assessment of focal [18F]fluorodeoxyglucose (FDG)-PET/CT thyroid incidentalomas.

Findings While US-RSSs reduce unnecessary biopsies, European-, American College of Radiology-, and Chinese-thyroid imaging reporting and data systems (TIRADS) demonstrated relatively lower sensitivity for aggressive malignancies.

Clinical relevance US-RSSs stratify malignancy risk in focal [18F]FDG-PET/CT incidentalomas, but lower biopsy size cutoffs may be needed for intermediate-risk nodules in European- and American College of Radiology-TIRADS and low-risk nodules in Chinese-TIRADS, based on oncology patients’ clinical context.

Graphical Abstract