π¦ ACR TI-RADS Thyroid Calculator
Five ultrasound features, one TR level.
ACR TI-RADS level
For informational purposes only, not medical advice.
ACR TI-RADS scores five ultrasound features, composition, echogenicity, shape, margin, and echogenic foci, into points that map to TR1 (benign) through TR5 (highly suspicious). A solid (2), hypoechoic (2), wider-than-tall (0), smooth-margined (0) nodule with punctate echogenic foci (4) totals 8 points: TR5. At 1.2 cm, ACR guidance is FNA recommended.
Published by the American College of Radiology in 2017, TI-RADS standardized what radiologists mean by suspicious and, just as set size thresholds so tiny low-risk nodules stop getting biopsied. Fewer unnecessary FNAs with no missed cancers was the entire goal.
How to Use This Calculator
Take the five feature descriptions from the ultrasound report and select the matching option for each, then enter the nodule's largest dimension. The points, TR level, and management recommendation appear together.
Select composition and echogenicity from the report's wording. Solid and hypoechoic features score highest.
Select shape, margin, and echogenic foci. Taller-than-wide shape and punctate foci carry the heaviest points.
Enter nodule size in centimeters and read the TR level with the ACR biopsy or follow-up threshold for that level.
Points and TR Levels
| TR level | FNA threshold | Follow-up threshold |
|---|---|---|
| TR1, TR2 | Not recommended | Not recommended |
| TR3 | 2.5 cm or larger | 1.5 cm or larger |
| TR4 | 1.5 cm or larger | 1.0 cm or larger |
| TR5 | 1.0 cm or larger | 0.5 cm or larger |
The size thresholds are the system's quiet genius: a TR5 nodule under 1 cm gets watched, not needled, because subcentimeter papillary cancers rarely change outcomes. Suspicion sets the level; size sets the action.
Worked Example
Ultrasound describes a 1.2 cm solid, hypoechoic, wider-than-tall nodule with smooth margins and punctate echogenic foci. Points: composition 2, echogenicity 2, shape 0, margin 0, foci 4, totaling 8. That maps to TR5, highly suspicious.
At 1.2 cm, a TR5 nodule meets the 1.0 cm FNA threshold, so guidance is FNA recommended. Had the same nodule measured 0.8 cm, the answer would be follow-up ultrasound instead, the system deliberately avoiding biopsy of tiny lesions even highly suspicious ones.
Reading Your Result
TR1 and TR2 need nothing further, which covers the large majority of nodules found incidentally. TR3 and TR4 live in the middle: big enough to biopsy at larger sizes, watched at smaller ones. TR5 earns respect but not panic; even highly suspicious nodules are usually papillary cancers with excellent prognoses when appropriately managed.
My take: the most common real-world error is biopsying below threshold out of anxiety. TI-RADS exists precisely to give clinicians permission not to needle small nodules, and the data since 2017 supports that restraint.
Limits
TI-RADS applies to nodules on ultrasound, not to diffuse thyroid disease, and it does not incorporate molecular testing or clinical risk factors like radiation exposure or family history. Suspicious lymph nodes or extrathyroidal extension change management beyond the nodule score. The radiologist's full report, not the point total alone, guides care.
Related Tools
Thyroid function touches metabolism broadly: the BMR calculator and ideal weight calculator frame the metabolic context, and the BMI calculator tracks body composition alongside.
For informational purposes only, not medical advice. Consult a healthcare professional.
Frequently Asked Questions
What does TI-RADS stand for?
Thyroid Imaging Reporting and Data System, from the American College of Radiology (2017). It standardizes how ultrasound features of thyroid nodules are scored and reported, mapping five features to TR1 through TR5 risk levels with management guidance.
What do TR1 through TR5 mean?
TR1 is benign, TR2 not suspicious, TR3 mildly suspicious, TR4 moderately suspicious, and TR5 highly suspicious for malignancy. The levels come from point totals: 0, 2, 3, 4-6, and 7+ respectively.
When does a thyroid nodule need biopsy?
Per ACR: TR3 at 2.5 cm+, TR4 at 1.5 cm+, TR5 at 1.0 cm+. TR1 and TR2 nodules are not biopsied regardless of size. These thresholds deliberately avoid biopsying small low-risk nodules.
What are punctate echogenic foci?
Tiny bright dots on ultrasound, the TI-RADS term for what many reports call microcalcifications. They score 4 points, the single heaviest feature, because they associate strongly with papillary thyroid cancer.
What does taller-than-wide mean?
A nodule whose anteroposterior dimension exceeds its transverse dimension, suggesting growth against tissue planes rather than along them. It scores 3 points and is a classic malignancy-associated shape.
Can TI-RADS miss cancer?
No system is perfect, but validation studies show ACR TI-RADS catches the cancers that matter while cutting unnecessary biopsies roughly in half versus older approaches. Clinical risk factors and lymph node findings supplement the nodule score.
What happens after a TR5 result?
Usually fine-needle aspiration if the nodule meets the size threshold, then management based on cytology. Most TR5 nodules that prove malignant are papillary cancers with very high cure rates.
Does TI-RADS apply to all thyroid findings?
No, it scores discrete nodules on ultrasound. Diffuse enlargement, thyroiditis patterns, and already-known cancers follow different pathways. It also does not replace clinical risk assessment.
How is TI-RADS different from ATA guidelines?
The American Thyroid Association system uses pattern recognition (which pattern the nodule matches), while ACR TI-RADS uses point scoring of individual features. Both are validated; ACR TI-RADS is more detailed feature-by-feature and biopsies fewer nodules.
Who should interpret my TI-RADS score?
The radiologist who performed the ultrasound and your referring clinician together. This calculator reproduces the scoring for education; management decisions weigh the full report, history, and exam.