hello everybody thanks for joining us today for the first installment of your ACR Tyra's webinar this one is on this is how we do it this session will be recorded and made available after the webinar ends my name is Jenny Hong and I'll be moderating and presenting today I'm in you're a geologist at jeek University now let me introduce you to our speakers today hi Bill hi Franklin hi Jenny hello dr. Franklin Tesla is a professor of radiology at University of Alabama at Birmingham he's had more than 30 years of thyroid ultrasound experience and a deep knowledge of the literature and he took on the role as a chair of the ACR thyroid committee and was a sensational leader through the process of working with him I also learnt that he was capable of writing very long emails dr. bill Middleton is a professor of radiology at Malik Wright Institute of radiology he is a national leader in thyroid ultrasound as well bill was a key member of the ACR tirades committee in particular he had available a multicenter study with the Society of radiologists in ultrasound and it's through his work with that society that we got a database of more than 3,400 nodules which allowed us to test our preliminary models and really make ACR tyrunt's evidence-based interesting fact about Bill since we're in the Olympics now is that bill was invited to participate in the Olympics not as an athlete but bill provided ultrasound to the athletes now my role on the committee is really pushing research forward we have several publications which are now in press and I am a principal investigator on a multicenter registry project which is funded by the ACR and also Akron three of us came together at our SNA and we really felt strongly that we're on a mission to change the way ferret ultrasound is performed we wanted to change the management of thyroid nodules for patients and also add to the value of radiologists and other providers and this is why we were motivated to do this webinar we were not asked to do it this is through our own initiative because we really feel strongly that the next step forward is to share what we can we know and what we can do with you none of us have any disclosures of relevance and here is the agenda when we got together we decided that one webinar was not enough so we have three and I'll tell you about the others later but first of all the agenda is for Franklin to take over first and he's going to describe ACR tae roads he's going to tell you about the rationale of the committee and he will give you some tips on implementation in your practice and how he can use it then bill is going to spend some time going through cases with you he's going to go through the lexicon of ACR tire ads so that you can interpret your nodules with confidence and then I'll finish off with a short presentation of the structured reporting template that you could use and also give you some web website where you can get some additional resources then the last part of the webinar hopefully a good 20 minutes of it will be time for you to ask questions and so feel free to send your questions in during the talks I'll collect them all at the end and we'll send them off to the speakers and they can answer your questions now remember I said this webinar is going to be recorded so if you still have to step away or you think that someone else you know would be interested you can access the recording after this webinar is finished another feature that we're going to add is some live blogging this is through a hashtag ACR tirades and you can mention radiology ACR or Franklin and myself now that we want to learn about you who are you are you a radiologist a radiology trainee a physician who is not a radiologist a stenographer or other send your quest your answers in in this time I also want to ignore illegal or antiques who has been organizing this webinar behind the scenes okay so 3/4 of you are radiologists great the next question for you is are you using ACR tirades yes no but you will be doing it in the next six months and no no plans in the near future now let's take a look at your answers great okay so I really think that this webinar is going to be of practical use to all of you particularly the more than 80% who are actually using it or will be using it in the near future now I'm going to give the presentation over to Franklin who was going to do the first part really laying down the foundation behind the the rationale implementation and tips to use in practice Franklin you should have control now Thank You Jenny for that kind introduction and thanks everybody for attending Thomas Wharton named the thyroid gland in the 17th century he thought that it resembled the ancient Greek shield that's depicted on this coin little did he know what he was starting because he certainly didn't know anything about thyroid nodules and in fact he thought that the function of the thyroid gland was to lubricate and insulate the neck the rationale for a CR tie rods is illustrated in this chart only a small percentage of thyroid nodules are detected by palpation less than 10% in some studies at autopsy series nodules are found in clinically normal thyroid glands in 50% whereas high resolution of ultrasound defined as being 13 megahertz or higher detects nodules in as many as 68 percent of thyroid glands and in fact I think this number is actually low in this study they use the threshold of 5 millimeters for defining a thyroid nodule but we frequently see nodules that are even smaller so thyroid nodules are extremely common and the problem is that the vast vast majority of them are benign only a small percentage less than 5% are malignant therefore we need to be able to figure out based on what we see which ones deserve for the retention several professional groups over the years have been involved in this effort in 2004 the Society of radiologists and ultrasound convened a consensus conference in Washington DC and this page from the radiology article that was published the following year shows the consensus statement that was presented here's a table from that paper on the Left we see ultrasound features starting out with more suspicious ones at the top such as micro calcifications down to less suspicious modules such as mixed solid and cystic and on the right you see the corresponding recommendations as the nodules become less suspicious the threshold for recommending an fna in terms of size goes up and that's a theme that we see in multiple risk stratification systems that have appeared since the American Thyroid Association has also published guidelines for management of thyroid nodules and this is a chart from their most recent set of recommendations from 2015 unlike the table that just showed you this is pattern based so there are a number of patterns of appearance of ultrasound for thyroid nodules and you look at a particular nodule pick the pattern that it most closely matches and determine management based on that unfortunately this is sometimes problematic because in the number of cases a particular Thurid nodule will not fit any one of these patterns and therefore won't be classified multiple other groups have been involved over the years as well several of them have used the acronym tie rods based on by rods which is famous in breast imaging this is the most recent one from the European thyroid Association it was published last year and they called it you tie rods EU for Europe and this is a chart from their paper and it shows that if you have a nodule in their scheme with at least one high suspicion feature which they defined as a non oval or round shape irregular margins microcalcifications our market decreased echogenicity they considered that high-risk although as you can see there's a wide range of of risks in that category and for that they say if the nodule is less than 10 millimeters you do either fna or follow it and F&A if it's larger than 10 millimeters 10 millimeters rather than 10 centimeters the there are two things about this I'd like to point out first of all is they identified a round shape as being a suspicious feature and I've found that a lot of small nodules which are hard to measure accurately when they're that tiny are round the other is that if you want to be picky about it there's their charge doesn't say what to do with a nodule if a nodule is actually exactly 10 millimeters because this says less and this says greater than but still they've adopted a general approach that's similar to what other groups have taken as all this was going on several people in different countries were looking at what all this was accomplishing in South Korea thyroid nodule screening has been offered for a small add-on cost since the late 1990s and early 2000s and since this was put in place as you could see in this chart the incidence of thyroid cancer mostly papillary rose tremendously but if you look at the line that's hugging the x-axis here that represents thyroid cancer mortality it remained extremely low throughout this period suggesting that this wasn't having a meaningful effect on patients this was highlighted in an article in the New England Journal of Medicine in 2016 that we quoted in our white paper and in this article was stated that over diagnosis of thyroid cancer accounted for a substantial percentage of cases of thyroid cancer in the u.s. which again suggested that we were seeing a lot of nodules that weren't clinically significant the a CR tie rods was presented in our lexicon paper which was published in the JCR in 2015 and this table shows the lexicon there are five categories that we'll return to in the tie rods chart ranging composition echogenicity shape margins and echogenic fossa and have highlighted in red the more suspicious features in each of those categories and bill middleton will be showing examples of these shortly in our deliberations we decided to do several things that departed from what other groups had done first of all we wanted to be points based and not pattern based for the reason I mentioned earlier related to the ATA guidelines second we wanted no half points because the math would be easier with integers third we decided not to have a B and C sub categories as souther some other systems have used again to make it simpler and finally no category for normal thyroid because you hardly ever see a normal thyroid anyway and that would be a good waste of a category remember that these are guidelines and not standards that is it's up to the practitioner who's reporting a thyroid nodule does it decide what to do in a given case and extenuating circumstances may apply this is the basis the central point of a CR tie rods it's our chart and this is meant to be put up in Reading Room's and elsewhere as I'll describe here are the five categories at the top composition echogenicity shape margin and echogenic fossa in each of these going from one to the other you choose the one category that applies for that the one feature rather that applies for that category whether its composition echogenicity shape and margin the only exception is echogenic fossa the last category because these features are not mutually exclusive and more than one of them may be present in a given nodule once you have all the points you add them up and you end up with a tie rods or TR level ranging from tier 1 to tier 5 and the annotations below TR 3 TR 4 and tier 5 indicate what management to recommend based on the maximum dimension of the nodule whether it's a fine needle aspiration fna or follow-up if follow-up is not if the nodule size is below the threshold for follow-up no further follow-up is recommended and the boxes at the bottom have explanatory notes that help apply each of these categories some of our decision-making in developing a CR tie rods was informed by a multi-institutional study that Bill Middleton and co-workers published later that year and as you can see as you go up from 0 to 10 points the risk of cancer goes up as you'd expect but still in the intermediate category of TR 4 you'll notice that the risk is still fairly low and it only goes up really much higher in the higher risk category of TR 5 I want to spend a moment or two on partially cystic nodules because I think these give people including myself problems it's important to recognize that the appearance of the solid component predominates and suspicious features of the solid component including eccentricity punctate echogenic fossa and lobule asian are concerning that's illustrated in this image from the literature that shows a partially cystic nodule that has a mural component that has some punctate echogenic foci and is lobulated and this was a papillary thyroid cancer a moment or two I know bill Middleton will return to this as well about spongiform nodules which are not suspicious to be spongiform they have to be comprised of at least 50% of small cystic spaces it's really easy to over call these and if any doubt is in this nodule it should be called solid the American Thyroid Association does some somewhat the same thing for mixed cystic and solid nodules and they call attention to these same features of eccentricity that I just mentioned a moment ago for deficient definition of growth we offer two options the first with just linear dimensions is a 20 percent increase in at least two nodule dimensions and a minimal increase of two millimeters or if you want to calculate the volume of 50 percent or greater increase and Bill we'll show you how to do that for follow-up intervals there was not a lot of good material and literature to go on but we thought that were for more for more suspicious nodules like tr-5 more frequent follow-up was warranted so annually for five years for tier five a little less 40 r4 and even less 40 r3 and the five-year threshold was based on some work that shows that if a nodule remains static in size not changing for five years it's very likely benign previously sampled nodules are not encompassed in a CRT rods and may require molecular or gene expression classifier testing and their management is usually driven by physician requests in multi nodular glands in which there are multiple nodules with similar characteristics or their confluent or there's diffuse heterogeneity fna is usually not indicated on the other hand in a multi nodular gland where one nodule is higher risks and the others based on our classification scheme fna may be warranted here's an example of a heterogeneous gland for which fna is not indicated lymph nodes are not formally included in a CR tie rods either however their appearance may influence the decision to biopsy a nodule the lymph nodes may be scanned at the time of the initial sonogram at the time of the FMA or subsequently after malignancy has been confirmed finally I want to close with a few points on implementation of a CR tie rods from a practical perspective first I think it's valuable to give everybody on the team including physician scenographer x' or whoever else may be involved the ACR lexicon and ACR tie rods white papers and then meet is a group to review so you're all on the same page in terms of what you're doing and how you're describing things second it's very helpful to make the chart available everywhere and by everywhere I mean not just in the reading rooms in the scanning rooms as well because as I'll mention shortly it's important for scenographer x' to be familiar with a CR tie rods to know which nodules to target for more images third it's important to agree on a routine scanning and reporting process and to use it consistently this implies of course not only to thyroid scanning but it especially applies here also it's important to agree on a reporting template and use it consistently and Jennie will be returning to that in a little while finally some practical points on how to use a CR tie rods in your practice first review prior scans to see what nodules were previously evaluated this helps you homed in on the same nodules on a subsequent scan second it's valuable to do an overview scan and again it's important for the sonographer ZnO what to look for so essentially start by scanning through the entire gland in this case we're just looking at the right lobe but start with the entire gland and get the lay of the land as it were decide what nodules look more suspicious which less suspicious and that will help determine which nodules warrant further imaging it's also important not to obsess over features that have identical or very similar point values for example hyper echoic and Iowa Public nodules have identical point scores so you don't really have to spend a lot of time considering whether they they're hyper or co-occur ISO echoic similarly with lobulated or irregular margin this is a lobulated nodule on the left in an irregular margin on the right they both have the same point score of two so you don't have to spend a lot of time deciding which one applies in a given nodule as well even if the features are slightly different in point scores if they're different by one point for example and applying one or the other doesn't change the TR level you don't have to worry about that determination as much as you might otherwise would fourth tip AC art I read says to formally report no more than four nodules with the highest point score that weren't F&A or follow-up ultrasound you do not have to classify every nodule in the gland that would be time-consuming and wasteful similarly you can recommend fna for no more than two nodules with the highest point scores that warrant fna now if you have several modules that have identical point scores or are in the same have the in the same level TR level you can decide which one to recommend biopsy on using other criteria some times such as size or where they are located in the gland but generally it's not productive to do a biopsy of more than two nodules in a given gland on reporting I report the I give recommendations per ACR tie rods but as I mentioned earlier it's important to consider extenuating circumstances including comorbidities and other factors such as family history or exposure to radiation it's important never to say just that a nodule is amenable to biopsy because every nodule is technically imitable to biopsy at least almost all of them are and it's incumbent on us to give recommendations and finally this is a question I receive often you don't have to report the suspicion level in fact I never do because patients see our reports and they will understand Billy wonder why a tr5 nodule is not being biopsied or followed and finally next steps will be continued evaluation of echo efficacy of our system system which I'm sure will be revised over time looking at the role of elastography or contrast and finally on an effort that I've embarked on recently which is to organize an international symposium to try to harmonize ACR tie rods with other systems because there's more commonality than there are our differences between the systems with that thank you very much for your attention thank you very much Franklin that was an excellent presentation it really helped to clarify some of the practical points of view how to get a co tyrunt's into your practice we're now going to hand the controls over to dr. bill Middleton who is going to do the next section on imaging examples using a CI ty Rhodes some people have sent in some questions already which is great keep them coming in we're going to collate them all at the end and answer them for you now gives the control over to dr. bill Middleton thank you Bill bill I'm sorry I I was on - so on mute so you may prefer that I be on mute my kids often want me on mute so I'm going to go over image analysis the first thing that you have to do when you encounter a module is to measure it and it's very important to use a consistent technique so that you can compare nodules over time the technique that ty Rad's recommends is to measure the longitudinal axis on a sagittal view when you look at your sagittal view which is shown in the bottom left you should mentally outline the nodule so in this case we have an ovoid nodule that is slightly off axis with respect to the long axis of the thyroid you want to measure in the long axis of the module itself so in this case this measurement would be like this on the transverse view we measure both the long axis on the transverse view and the short axis on the transverse view so two measurements are obtained on the transverse view if we outline the nodule here on this transverse view we can see that the long axis of the module is in disorientation so that would be one measurement and then you develop a line perpendicular to the long axis and you move that line to the point where the nodule is maximum diameter so this would be the second measurement in the transverse view so one measurement on a longitudinal view and two measurements on the transverse view here's an example of a transverse view where the technique wasn't quite right the long axis measurement here the number one measurement is probably done correctly but the short axis measurement number two is not perpendicular to the long axis so this would be better if the short axis were measured like this and that would shave a couple of millimeters off of that result now let's move on to analyzing two different characters of the module and the first which Franklin mentioned was composition composition is very important and it should be the first thing that you think about and it's divided into solid mixed solid in cystic cystic and spongiform so a solid nodule is defined as a nodule that is either completely solid or almost completely solid and by almost completely we mean greater than or equal to 95 percent solid those nodules get two points anything other than that is considered a mixed cystic and solid nodule cystic or spongy form so mixes thick and solid gets one point purely cystic nodules get zero points and spongiform nodules also get zero points spongiform nodules are nodules that have an appearance similar to the cut surface of a sponge as you see in the lower right hand corner they consist of cystic spaces of variable sizes that occupy at least 50% of the volume of the nodule and then in each category there's a can't tell feature and this occurs when you just can't figure out what the composition of the nodule is usually that's because there's so much shadowing from calcification so this is a figure similar to the one that Franklin showed you earlier and it comes from the SRU study that he mentioned on all of these figures the risk of cancer and percent is shown on the vertical axis and then the point distribution is shown on the horizontal axis with the lower points to the left and the higher points to the right and here you can see the solid nodules with the higher point value have a higher risk of malignancy than the mixed or the spongy nodules determining what is 95 percent can be somewhat difficult this is a little exercise that I did for myself assuming that we had a nodule that was mostly solid and spherical and with in that module was a spherical cystic component so if you image this module from slice to slice you would see images that looked like this sequentially as you pan through the solid component you see just solid elements and then as you pan through the Cystic component you see a cystic element this is a nodule that's 95 percent solid and this is an actual correlate this is an ovoid module where if you calculate the volume of the nodule itself it's 5.2 calculate the volume of this cyst it's point two seven CCS and that results in a five point two percent cystic component so in other words a ninety-five percent solid component so this type of nodule would be classified as solid or predominantly solid here's another nodule this is almost entirely solid although it does have a few little cystic spaces and in cases like this the cine clip is very helpful in having you kind of integrate the overall volume of cystic components this on the other hand is a mixed solid and cystic component or nodule it clearly has a predominance of solid elements within it but there's enough cystic component that it clearly is not 95 percent solid so this would be assigned one point and called mixed solid and cystic this is a spongiform nodule this is a nodule that is mixed solid and cystic but the cystic components predominate throughout the nodule and they vary in size and they occupy more than 90 or more than 50% of the nodule volume this is a spongy form nodule that has a lot of relatively large cystic areas this next module is a spongiform nodule where the cystic components are variable in shape if you look at the two static images above you can see that there is a solid appearing component here that's less than 50% and when you actually look at the cine clip you can see that even that solid component has a lot of little cystic spaces in it so this also is a spongiform module now in the can't tell category these are nodules where you just can't tell the composition and in this case there's extensive calcification mostly peripheral and the shadow precludes determination of the composition in this case you give the module two points for composition now let's move on to another very important category which is echoed Jena city the akka Genesis II should be of the nodule should be compared with the ipsilateral thyroid or and/or the strap muscles if there's not enough normal thyroid on the ipsilateral side to compare then you can compare to the contralateral side but try not to do that unless absolutely necessary hyper Co ik and ISO echoic modules are sort of self-explanatory and they get one point realize that if the thyroid gland itself is hypoechoic due to autoimmune disease I'm you still compare the nodule to the hypoechoic thyroid tissue hi polka modules are nodules that are less academic than the thyroid brinkema but are equal to or more echogenic than the strat muscles or the sternocleidomastoid muscle and they get two points very high poco ik modules are less echogenic than the thyroid and less echogenic than the overlying musculature they get three points and if you can't tell the echogenicity then you assign one point so here's that same graph you can see that as the point totals go up the risk of malignancy goes up and these are divided into solid modules and into mixed solid and cystic modules so this is a nodule that is relatively close in a Kachina City to the adjacent thyroid brinkema I think in this case you could tell that this is slightly hyper a quick sometimes a good way to accomplish that when you're in doubt is to squint when you squint you kind of blur everything and for whatever reason it makes it a little bit easier to determine echogenicity when you're squinting just be sure don't don't close your eyes completely that doesn't tend to work very well so this is a hyper echoic module that gets assigned one point this is another hyper Kowal now in this case you don't see much thyroid brinkema here but on the transverse view you can see some thyroid prink amount that is abnormally hypoechoic because this patient has Hashimoto's disease and you see the same thing here on the cine clip so you compare to the thyroid parenchymal that you have regardless of the engine isset II of the thyroid prink amount here's a large nodule there's really no adjacent thyroid prink a'mma to visualize so this would be hard to determine the Ekadasi T in cases like this it's very important that the sonographer x' find some place where they can display the nodule with adjacent normal parenchymal and in this case you can see there's a little bit of normal Prynne comma in the upper Pole that they have on the panoramic view in the nodule is the same echo Jenna City as that normal Prynne comma also remembers frankly mentioned earlier when you have a mixed cystic in solid nodule you determine antigenicity based on the solid non callable part of the nodule so if you looked at this overall nodule you might be tempted to say it's hypoechoic but when you really analyze the solid component here it's the same Mehcad Jenna City as the thyroid Prynne comma so this is an ISO echoic module here's a hypoechoic nodule hypo code modules get two points and this is clearly less echogenic than the adjacent thyroid Prynne coma but it's more a cadet neck than the muscle so this goes in the hypoechoic category also notice there's a lot of through transmission here behind this module that is fairly common with thyroid nodules in general and it does not mean that the module is cystic if you're in doubt whether or not a cystic are not always tricolor Doppler and if you see blood flow in it like this you you know that it's not a cystic module now here's another nodule that would fall into the hypoechoic category it is hypo coke to the thyroid tissue but it's ISO echoic to the overlying strap muscle you don't call a nodule very high poco ik until it reaches this degree of hypo action this until it's actually less echogenic than the overlying musculature and sometimes that's a little bit easier to determine if you turn your gain up just a little bit it somehow makes the difference in edges unicity more prominent so this is a nodule that's a little less echogenic than the overlying strap muscles here's another very hypoechoic nodule you see here on the static image this actually looks like it's cystic it's that hypoechoic about the same mekka channey City as the adjacent common carotid artery and you can see the marked hypo ANCA genus is here on the strap or on the cine clip again notice that the vascularity here is extremely high that so that clearly is not a complex cystic module now what about nodules where you can't tell here's another patient where there is so much calcification that you can't see what the composition or in this case what the echogenicity is so this gets one point and in this case we ended up by opps you can see how calcified it is because the module moves with the needle rather than the needle moving through the module the only reason that this was biopsied was because a node had been sampled while they were doing a lymphadenectomy for melanoma and a note came back is positive for a thyroid cancer next we move on to margins margins are divided into ill-defined smooth irregular lobulated and extra thyroid extension ill-defined is determined when the module is just really difficult to distinguish from the adjacent thyroid prink amount that makes it difficult to make an outline of the nodule or to measure the nodule that gets zero points smooth is self-explanatory that also gets zero points irregular or lobulated refers to either large or small ovulations Franklin showed you a couple of cases with relatively large lobule a shindig Euler sometimes is referred to as speculated or jagged those nodules get two points if you see extra thyroid extension and that means you clearly see some of the excuse me some of the module extending into the parathyroid tissues that gets three points now you can't call extra thyroid extension if there's just a bulge in the capsule you have to actually see extension a bulge in the capsule might indicate some extra canceler or extra thyroid extension but that's not necessarily the case again you can see smooth nodules have a lower risk than lobulated or irregular nodules here's an nigel that's relatively iso echoic that makes it hard to define the margins so this would fall into the ill-defined category here's a module where the margins are very well demarcated - nice round module this would also get zero points this is a nodule that irregular if you look at the static image you see all these little jagged speculations extending into the adjacent thyroid brinkema also seen on that cine clip and this is a nodule that's lobulated can see the lobule asians on this border and over on this border on the transverse and see them throughout on the contra or on the other view this is a nodule where you have clear cut extra thyroid extension there's a little piece of that module that's extending outside the margins of the thyroid better seen on the cine clip here and then finally our next to last is shape shape is determined on the transverse view and this is where we refer to nodules being wider than tall or taller than wide so wider than tall gets zero points and you occasionally will have nodules where the width is equivalent to the height you can call those not taller than wide they also get zero points if a nodule has a ap dimension greater than the transverse dimension that's called taller than wide and those get three points so those are basically nodules that are growing against the normal tissue planes so here's a transverse view of a spongiform notch or you can see that this dimension is bigger than this dimension this is a wider than tall nodule zero points here's a nodule where the two dimensions are identical so this is not wider than tall but it's not taller than Y so if it's not taller than wide you assign zero points and then finally these are two different patients with modules that are both taller than wide so this dimension in the AP Direction is greater than in the transverse direction finally we have echo genic fossa or calcifications and these are divided into comet tails macro peripheral and punctate echogenic fossa so if there are no calcification zero points comet tails are also zero points and that can only be diagnosed when the comet tail itself is greater than a millimeter macro calcifications are divided to find as calcifications that are shadowing they don't shadow it's not a macro calcification that gets one point peripheral calcifications can either be complete or partial they get two points and then punctate echogenic fossa are small reflectors that have no shadowing and have either no comet tails or maybe occasionally a small comet tail you can see how the risk of malignancy increases as the points for calcifications increase also notice that as Franklin mentioned earlier that you sometimes will have cases where there are different types of calcification so for instance this one has peripheral and macro calcification and notice that that combination there increases the risk of cancer above the risk for peripheral calcifications or macro calcifications individually this is a large comet tail which we get zero points we see it right here and we know that it's large because it's bigger than a millimeter at this depth and this scale this is 2.5 millimeters so if you take that 2.5 millimeters and compare it to that not that the comet tail you can see that it's almost 2.5 millimeters clearly more than a millimeter on the other hand this is a patient where there is a little comet tail associated with this module but if you look at the scale this is a millimeter here this is a very magnified image and when you compare the module to the scale this is less than one millimeter so this would fall under the punctate echogenic fossa category macro calcifications are our calcifications that shadow they're usually big and chunky like this they get one point occasionally you'll have a tiny little calcification as we see here that you'd be tempted to call a punctate oncogenic focus but if it shadows like this then it falls into the macro category these are peripheral calcifications peripheral calcifications can be very limited and partial or they can be extensive and thick and completely encompass the circumference of the module all of these would fall into the peripheral calcification category and receive two points and then we get to punctate echogenic foci or pef this is a module that's lobulated and has all these tiny little academic foci scattered throughout none of which have Comet tail's or shadowing you can see it a little better on the cine clip this is another nodule with punctate echogenic foci just to give you a feel for that and as I mentioned earlier some nodules have more than one type of calcification this module has some punctate echogenic fossa as well as some shadowing macro calcifications so this gets one point for macro caps three points for PE FS so a total point total of four and that does it for image analysis thank you all very much for your attention Jenny you can take over at this point right thank you so much bill beautiful imaging example is crystal clear presentation and we really appreciate this any clips that please everybody keep your eyes open don't squint or close your eyes as bill suggested so now with that you might be wondering how do I put this in practice what well how do I start and the first step is to use a structured reporting template as I mentioned I am running a multicenter study with the registry and so I wanted to show you what template we're using for our study this is a template and all of this is for just one nodule we'd be describing the nodule number the maximum size the other dimensions and the location then this part is the five features and it looks like a large piece of text but remember these are peak lists and so for composition you would just pick whether it was solid almost completely solid and here as part of the structured reporting template I thought this was a great idea to put in the points that is worse so you don't actually have to refer back to the chart each time then after you've assessed the nodule for all of these five features it's about adding the points up and from the top part you can add up the points and then based on the total points you choose a risk category and once again the risk category poklis has the definition of the points that's worth then if you're nigel has been imaged before there are three questions to put into the report is there a change and again there's the definition of change in the structured reporting template whether there's a changing features simply yes or no and you may choose to describe it further changing the risk category and then finally you give the thyroids recommendation based on the risk category and the nodule size now all of this is essential for a research registry because we need standardized data elements to collect the data and for those of you who are not participating in research you may be thinking well this is too long for my practice it's really not practical to use something like this can't I just freeze the free text what I'm seeing and then refer to the chart well let me show you a study that clearly shows that a structured reporting template like this with a checklist is very valuable this is a study that is now in press in J ACR it was a study that was performed with private practice radiologists at radiology partners and shout out to radiology Partners there this is a study that was performed in three phases in phase one we simply used free text of their reports in Phase two seven of these private practice radiologists were asked to use the tirades lexicon so just describing the five features and then in Phase three this was when the Thai rads paper was published and the radiologists were then given the structured reporting template again with the thyroids risk category and the management recommendations this is a graph that shows the management recommendations for each of those three phases with the dark blue being phase one of just free text the light blue being the structured reporting template without the recommendations and the gray being full ACR tyrunt's structured reporting template as you saw on that previous slide as you can see the number of biopsy recommendations for nodules recommended in mentioned in the impression of the report did not change at all and I was surprised with that result but what did change were nodules that were mentioned in the impression report that simply had no recommendation at all and without a definitive recommendation which was the case in a third of the nodules without ACR turrets then patients and the referrers were left with what to do and many of these nodules may have been biopsied or followed up unnecessarily what was also interesting in this study was the description of the features in phase one compared to Phase two and three in phase one which was just free text where radiologists were left to describe the nodule as they wish to composition was mentioned the most but still not all the time and features that are important such as shape margin and echogenic fossa were infrequently mentioned with the structured reporting template and a checklist in phase 3 all of these signs were mentioned for every nodule described in the impression of the report now the next question is just because it wasn't mentioned maybe if the feature wasn't there and it wasn't worth mentioning well then we looked at the frequency of the suspicious findings and we saw that tall and wide shape was not mentioned in free Tex but it wasn't a zero frequency up to eight percent of those nodules had at all than white shape when there was a checklist to look to and then same thing for suspicious margins one percent had a suspicious margin where it was a regular or lobulated but the frequency of a suspicious margin was much higher when the radiologists were prompted to use a structured reporting template and check off the margin and so as a result the average tyrunt's call in phase one was 3.1 which would make it a tie right three but in Phase two and three it was fall as an average which definitely makes it more suspicious so the result of this is that the same number of biopsies were recommended when there was a CI turrets that's not because a CIO has recommended more nodules but radiologists were seeing more of these suspicious findings when they had a checklist now if you're interested in using that structured reporting template these the the template is available on the ACI Tyra that's website he is the URL to access that website and on this website you'll see other educational resources we have the JSE publications an atlas and structured reporting template also for nodule biopsies the future webinars are here so mark these on your calendar and sign up now so you'll get the reminders the next one will be on case based review and frequently answered questions and I think that session is necessary because we don't have time to answer all the questions we've got too and then the final webinar will be the evidence behind why to adopt ACR turrets and comparison to other risk stratification systems so now we reach the point where we're taking your questions once again the URL for the ACR website is down the bottom for you to copy here and let me take a look at the questions I think I'll address the first question to Franklin this comes from Daniel and Carver also asked a similar question as well as tenman Franklin are you off mute I'm here yes okay so the question is what do you do with a tie rats for Tourette's 5 nodule which don't meet the size criteria for biopsy or follow-up in those cases I follow the recommendations as outlined in the white paper and we've discussed they I say specifically that no fna or follow-up is recommended I understand that some people are uncomfortable doing that but as bill mentioned and as I mentioned earlier in the intermediate category say tr4 which is actually higher than intermediate it's the almost the highest category the risk of cancer is still fairly low even based on Bill study even at six points the risk of cancer was less than 13% and in the highest category tr-5 we're recommending follow-up of very small nodules and at that level what we're doing is very congruent with what other professional groups are recommending I think it's really important here to get out of the mindset of having to identify and follow every cancer because thyroid cancer biologically is not the same as breast or lung cancer or other aggressive malignancies bill do you have anything to add to that no I did well I'm completely agree be you know the problem with thyroid cancer is not under diagnosis the problem is over diagnosis almost everybody agrees with that now and there's a lot of thyroid cancers that we you know that we're detecting that in the past would never have been detected and would never have been you know symptomatic so I don't I I don't think that people need to worry that much about missing these you know small cancers and by the way many of these nodules in the categories that you know that we're talking about will not be cancerous in fact in the tr4 category you know only at the most one out of five will be cancer and it will in most cases it will be less than that great bill I have a question for you it's about part eight echogenic fossa the question is from Claudia what do you do with small echogenic voci that don't look like micro calcifications and and and specifically on how do you distinguish them from tiny colloid calcifications do you ever struggle with that I struggle with that daily and that's a great question and I wish that there were a way to you know reliably tell the difference between PE FS and little areas of crystal and colloid reliably the the pattern that I take is if I see them and cystic components of a mixed cystic and solid nodule I don't worry about them if I see them in solid components of a solid nodule or a mixed solid in cystic module and there's not a long comet tail then I assume that their PE s okay that's very helpful okay Franklin back to you do you ever use tie rods for pediatric patients this is from Claudia in our Hospital the endocrinologist mainly a TA recommendations for pediatric patients that's an excellent question I've received it from some practitioners here at UAB as well formerly a CRT Reds only applies to the adult population I think that for pediatric patients that are in the close to adult range it's probably reasonable to apply a CRT rads but once you get to much younger patients who have a higher risk of cancer I think that I wouldn't say that all bets are off but you have to be much more careful about calling nodules saying that they're benign or don't need follow-up based on a CRT rods and there are several publications in the literature that address how to manage pediatric patients with thyroid nodules okay great bill this question is from you it's from Jimmy how do you classify margin for partially or MIG solid cystic nodules is imagine defined by the solid component or do you take the solid cystic component another good question that that sort of depends on the type of mixed cystic and solid module so if it's that type of nodule that Franklin showed from the Korean paper where there's a cyst with a mural nodule then you analyze the the margins of the mural module itself so the mural nodule may have you know lobulated borders that would that would at least in the way that I do it that would give them the two points for lobule Asians for other cystic and solid nodules you basically do it the same way as you do you know for the solid nodules you look at the periphery of the nodule and look for lobule a tional II will see with mixed cystic and solid nodules or you look for irregularity which is which is much less common with cystic and solid nodules thank you well I think that our time is up we have so many more questions to answer and as I mentioned before we are going to address it in the next webinar I thank you very much for your time everybody that signed in and listened and the people that are also listening after it's being recorded it's great that you've taken the time to learn more about ACR tirades and we're definitely wanting to hear your thoughts as they email us at ACR give us comments about how we can improve this and sign up for the next webinars thank you very much everybody Thank You Franklin thank you Bill and thank you Lauren for helping us organize this thanks everybody and thanks Jenny yes absolutely bye bye everybody see you next time bye Michael bye