Ultrasound malignancy risk stratification of thyroid nodules based on the degree of hypoechogenicity and echotexture

  • Ji Ye Lee
  • Dong Gyu NaEmail author
  • So Jin Yoon
  • Hye Yun Gwon
  • Wooyul Paik
  • Taeeun Kim
  • Jin Yub Kim



The ultrasound (US) lexicon of nodule echogenicity and echotexture is one of the major differences among various risk stratification systems of thyroid nodules. This study aimed to stratify the US malignancy risk of thyroid nodules based on their degree of hypoechogenicity and echotexture.

Material and methods

This retrospective study included a total of 2255 consecutive thyroid nodules (≥ 1 cm) with final diagnoses (malignancy rate, 13%) from 2011 to 2016. Thyroid nodules were stratified according to the US degree of hypoechogenicity (mild, moderate, or marked hypoechogenicity) and echotexture (homogeneous vs. heterogeneous). The calculated malignancy risk was compared between each category.


There was no significant difference of malignancy risk between the homogeneous markedly hypoechoic and moderately hypoechoic nodules (p ≥ .18). However, the malignancy risks of markedly and moderately hypoechoic nodules were significantly higher than those of mildly hypoechoic nodules (p < .001). Heterogeneous predominantly hypoechoic thyroid nodules showed a significantly higher malignancy risk than predominantly iso- or hyperechoic thyroid nodules (p < .001). There were no significant differences of malignancy risk between heterogeneous predominantly hypoechoic and homogeneous hypoechoic nodules according to the degree of hypoechogenicity (p ≥ .12) and between heterogeneous predominantly iso- or hyperechoic nodules and homogeneous iso- or hyperechoic thyroid nodules (p = .36).


The malignancy risk of nodule hypoechogenicity is stratified as mild vs. moderate to marked hypoechogenicity, and the malignancy risk of nodules with heterogeneous echotexture is stratified by the predominant echogenicity of the nodules.

Key Points

• Thyroid nodule echogenicity is categorized as marked, moderate, or mild hypoechogenicity and iso- or hyperechogenicity with the reference standard of adjacent thyroid tissue and anterior neck muscles.

• The malignancy risk of thyroid nodule echogenicity is stratified as iso- or hyperechoic vs. mild vs. moderate or marked hypoechogenicity.

• The malignancy risk of nodules with heterogeneous echotexture is stratified by the predominant echogenicity.


Thyroid gland Thyroid nodule Ultrasonography Cytology Biopsy 



American College of Radiology


European Thyroid Association


Fine needle aspiration


Korean Society of Thyroid Radiology


Papillary thyroid carcinoma


Sternocleidomastoid muscles




Funding information

This research was supported by the Medical Research Promotion Program through the Gangneung Asan Hospital funded by the Asan Foundation (2018-C03).

Compliance with ethical standards


The scientific guarantor of this publication is Dong Gyu Na.

Conflict of interest

The authors declare that they have no competing interests.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was waived by the institutional review board.

Ethical approval

Institutional review board approval was obtained.


• Retrospective

• Cross-sectional study

• Performed at one institution

Supplementary material

330_2019_6527_MOESM1_ESM.docx (27 kb)
ESM 1 Supplementary Table 1. Malignancy risk stratified by degree of hypoechogenicity and echotexture, after excluding nodules with single benign FNA result and high suspicion US feature (n = 2176). Supplementary Table 2. Malignancy risk stratified by degree of hypoechogenicity and echotexture (Reader 2). (DOCX 27 kb)


  1. 1.
    Moon WJ, Jung SL, Lee JH et al (2008) Benign and malignant thyroid nodules: US differentiation--multicenter retrospective study. Radiology 247:762–770CrossRefGoogle Scholar
  2. 2.
    Campanella P, Ianni F, Rota CA, Corsello SM, Pontecorvi A (2014) Quantification of cancer risk of each clinical and ultrasonographic suspicious feature of thyroid nodules: a systematic review and meta-analysis. Eur J Endocrinol 170:R203–R211CrossRefGoogle Scholar
  3. 3.
    Brito JP, Gionfriddo MR, Al Nofal A et al (2014) The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. J Clin Endocrinol Metab 99:1253–1263CrossRefGoogle Scholar
  4. 4.
    Remonti LR, Kramer CK, Leitao CB, Pinto LC, Gross JL (2015) Thyroid ultrasound features and risk of carcinoma: a systematic review and meta-analysis of observational studies. Thyroid 25:538–550CrossRefGoogle Scholar
  5. 5.
    Na DG, Baek JH, Sung JY et al (2016) Thyroid imaging reporting and data system risk stratification of thyroid nodules: categorization based on solidity and echogenicity. Thyroid 26:562–572CrossRefGoogle Scholar
  6. 6.
    Kim EK, Park CS, Chung WY et al (2002) New sonographic criteria for recommending fine-needle aspiration biopsy of nonpalpable solid nodules of the thyroid. AJR Am J Roentgenol 178:687–691CrossRefGoogle Scholar
  7. 7.
    Haugen BR, Alexander EK, Bible KC et al (2016) 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid 26:1–133CrossRefGoogle Scholar
  8. 8.
    Shin JH, Baek JH, Chung J et al (2016) Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology consensus statement and recommendations. Korean J Radiol 17:370–395CrossRefGoogle Scholar
  9. 9.
    Gharib H, Papini E, Garber JR et al (2016) American Association of Clinical Endocrinologists, American College Of Endocrinology, and Associazione Medici Endocrinologi Medical guidelines for clinical practice for the diagnosis and management of thyroid nodules – 2016 update. Endocr Pract 22:622–639CrossRefGoogle Scholar
  10. 10.
    Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L (2017) European Thyroid Association guidelines for ultrasound malignancy risk stratification of thyroid nodules in adults: the EU-TIRADS. Eur Thyroid J 6:225–237CrossRefGoogle Scholar
  11. 11.
    Tessler FN, Middleton WD, Grant EG et al (2017) ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol 14:587–595CrossRefGoogle Scholar
  12. 12.
    Kim JH, Na DG, Lee H (2018) Ultrasonographic echogenicity and histopathologic correlation of thyroid nodules in core needle biopsy specimens. Korean J Radiol 19:673–681CrossRefGoogle Scholar
  13. 13.
    Hong MJ, Na DG, Baek JH, Sung JY, Kim JH (2017) Cytology-ultrasonography risk-stratification scoring system based on fine-needle aspiration cytology and the Korean-Thyroid Imaging Reporting and Data System. Thyroid 27:953–959CrossRefGoogle Scholar
  14. 14.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefGoogle Scholar
  15. 15.
    Ha EJ, Baek JH, Lee JH et al (2015) A focal marked hypoechogenicity within an isoechoic thyroid nodule: is it a focal malignancy or not? Acta Radiologica 56:814–819CrossRefGoogle Scholar
  16. 16.
    Lee HY, Baek JH, Ha EJ et al (2016) Malignant-looking thyroid nodules with size reduction: core needle biopsy results. Ultrasonography 35:327–334CrossRefGoogle Scholar
  17. 17.
    Delfim RLC, Veiga LCGD, Vidal APA, Lopes FPPL, Vaisman M, Teixeira PFDS (2017) Likelihood of malignancy in thyroid nodules according to a proposed Thyroid Imaging Reporting and Data System (TI-RADS) classification merging suspicious and benign ultrasound features. Arch Endocrinol Metab 61:211–221CrossRefGoogle Scholar
  18. 18.
    Wu MH, Chen CN, Chen KY et al (2016) Quantitative analysis of echogenicity for patients with thyroid nodules. Sci Rep 6:35632CrossRefGoogle Scholar
  19. 19.
    Isarangkul W (1993) Dense fibrosis. Another diagnostic criterion for papillary thyroid carcinoma. Arch Pathol Lab Med 117:645–646PubMedGoogle Scholar
  20. 20.
    Chen SJ, Yu SN, Tzeng JE et al (2009) Characterization of the major histopathological components of thyroid nodules using sonographic textural features for clinical diagnosis and management. Ultrasound Med Biol 35:201–208CrossRefGoogle Scholar
  21. 21.
    Persichetti A, Di Stasio E, Guglielmi R et al (2018) Predictive value of malignancy of thyroid nodule ultrasound classification systems: a prospective study. J Clin Endocrinol Metab 103:1359–1368CrossRefGoogle Scholar
  22. 22.
    Grani G, Lamartina L, Cantisani V, Maranghi M, Lucia P, Durante C (2018) Interobserver agreement of various thyroid imaging reporting and data systems. Endocr Connect 7:1–7CrossRefGoogle Scholar
  23. 23.
    Hoang JK, Middleton WD, Farjat AE et al (2018) Interobserver variability of sonographic features used in the American College of Radiology Thyroid Imaging Reporting and Data System. AJR Am J Roentgenol 211:162–167CrossRefGoogle Scholar
  24. 24.
    Itani M, Assaker R, Moshiri M, Dubinsky TJ, Dighe MK (2019) Inter-observer variability in the American College of Radiology Thyroid Imaging Reporting and Data System: in-depth analysis and areas for improvement. Ultrasound Med Biol 45:461–470CrossRefGoogle Scholar
  25. 25.
    Song YS, Kim JH, Na DG et al (2016) Ultrasonographic differentiation between nodular hyperplasia and neoplastic follicular-patterned lesions of the thyroid gland. Ultrasound Med Biol 42:1816–1824CrossRefGoogle Scholar
  26. 26.
    Ng SC, Kuo SF, Hua CC et al (2018) Differentiation of the follicular variant of papillary thyroid carcinoma from classic papillary thyroid carcinoma: an ultrasound analysis and complement to fine-needle aspiration cytology. J Ultrasound Med 37:667–674CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of Radiology, Eulji Medical CenterSeoulRepublic of Korea
  2. 2.Department of Radiology, Gangneung Asan Hospital, College of MedicineUniversity of UlsanGangneungRepublic of Korea
  3. 3.Department of Pathology, Gangneung Asan Hospital, College of MedicineUniversity of UlsanGangneungRepublic of Korea
  4. 4.Division of Endocrinology and Metabolism, Department of Internal Medicine, Gangneung Asan Hospital, College of MedicineUniversity of UlsanGangneungRepublic of Korea

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