Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : TC06 - TC10 Full Version

Diagnostic Value of Applying ACR-TIRADS on Thyroid Nodule Biopsies at a Tertiary Care Centre in the United Arab Emirates: A Prospective Observational Study

Published: November 1, 2023 | DOI:
Anoop Kumar Pandey, Maneesha Pandey, Arvind Kavishwar, Mani Jain

1. Specialist Radiologist, Department of Radiology, Medeor Hospital, Bur Dubai, Dubai, UAE. 2. Consultant Endocrinologist, Department of Endocrinology, Aster Jubilee Medical Center, Bur Dubai, Dubai, UAE. 3. Biostatistician, Division of Non Communicable Diseases, ICMR-NIRTH (Indian Council of Medical Research National institute for Research in Tribal Health), Jabalpur, Madhya Pradesh, India. 4. Specialist Radiologist, Department of Radiology, Medeor Hospital, Bur Dubai, Dubai, UAE.

Correspondence Address :
Anoop Kumar Pandey,
Specialist, Department of Radiology, Medeor Hospital, Bur Dubai, Dubai, United Arab Emirates.


Introduction: Incidental thyroid nodules are commonly encountered in clinical practice, and only a minority of these are malignant. Suspicious nodules on ultrasound are subjected to Fine Needle Aspiration Biopsy (FNAB) to rule out malignancy and determine appropriate management. In the United Arab Emirates, medical professionals from various countries practice, and there are no well-established local best practice guidelines for thyroid nodule biopsies.

Aim: To determine the percentage of thyroid nodules in which FNAB would be considered unnecessary by applying the American College of Radiology (ACR)-Thyroid Imaging Reporting and Data System (TIRADS) 2017 guidelines.

Materials and Methods: A prospective observational study was conducted in the Radiology Department of Belhoul Speciality Hospital, Dubai, United Arabs Emirates from January 2018 to December 2019. A total of 142 thyroid nodules were studied, and FNABs were performed. Two experienced radiologists assigned ACR-TIRADS categories to the nodules. The nodules were divided into groups: Fine-Needle Aspiration (FNA) indicated and FNA not indicated. Surgically resected nodules underwent histopathological examination, and benign or malignant categorisation was based on histopathological findings. Cases with Bethesda II cytology were considered benign, Bethesda V and VI were considered malignant, and 35 cases with Bethesda I, III, or IV cytology were excluded from the study. The final study cohort included 107 nodules with available final reference standard diagnoses. Data were analysed using International Business Machine Statistical Package for Social Sciences (IBM SPSS) Statistics 26.0, and sensitivity, specificity, Positive Predictive Value (PPV), Negative Predictive Value (NPV), and Diagnostic Odds Ratio (DOR) {each with 95% Confidence Interval (CI)} were calculated.

Results: Out of the 107 nodules included in the study, 15 (14%) were malignant, and 92 (86%) were benign. Applying ACR-TIRADS, biopsy was not indicated in 54 out of 107 patients, resulting in an “unnecessary” biopsy rate of 50.5%. Only two out of the 15 malignant cases were assigned to the FNAC not indicated group due to their subcentimetre size. Therefore, the sensitivity, NPV, and false negative rate of these criteria were 86.7%, 96.3%, and 3.7%, respectively.

Conclusion: The ACR-TIRADS guidelines are highly reliable, and if strictly followed, almost half of thyroid nodule biopsies can be safely avoided. However, since ACR-TIRADS does not recommend FNA for subcentimetre thyroid nodules, a few small malignancies may experience delayed diagnosis.


American college of radiology-thyroid imaging reporting and data system Cytodiagnosis, Fine needle biopsy, Thyroid neoplasm, Ultrasonography

Since up to 68% of adults show thyroid nodules on high-resolution ultrasound (1), incidental thyroid nodules are a common clinical occurrence. The majority of these incidental thyroid nodules are benign in nature, and only a minority of them have suspicious or malignant features requiring further management (2). FNA is currently the most commonly used technique to determine the nature of the nodule and guide its management (3). However, performing FNA on every single nodule is impractical due to their high prevalence. Therefore, it is crucial to accurately determine which nodules should be sampled and which can be safely followed-up clinically. Various national and international thyroid societies have developed ultrasound-based risk stratification systems aiming to detect the highest possible percentage of thyroid malignancies while minimising unnecessary FNAB procedures (4),(5),(6),(7),(8),(9),(10),(11),(12). Several large retrospective studies and a few prospective studies [13,14] have been conducted to validate these risk stratification systems and evaluate their relative strengths and weaknesses.

Recent studies involving large databases (13),(14),(15),(16),(17),(18),(19),(20),(21) have concluded that, compared to other systems, the 2017 American College of Radiology-Thyroid Imaging Reporting and Data System (ACR-TIRADS) more effectively reduces unnecessary biopsies performed on benign thyroid nodules. Additionally, another recent study found that using ACR-TIRADS, all thyroid nodules could be classified, whereas a minority of nodules remained unclassified using the Korean Society of Thyroid Radiology TIRADS and American Thyroid Association (ATA) guidelines (22).

Based on the results from previous studies, authors decided to apply only the ACR-TIRADS system in the present study. In the United Arab Emirates, medical professionals from various countries practice, and there are no well-established local best practice guidelines for thyroid nodule biopsies. Therefore, authors conducted a prospective observational study to evaluate the potential impact of applying the ACR-TIRADS system on thyroid nodule sampling in the study institution. Our study aimed to determine the percentage of nodules in which FNAB would have been considered unnecessary according to ACR-TIRADS guidelines, and to calculate the accuracy of such recommendations.

Material and Methods

A prospective observational study was conducted in the radiology department of Belhoul Speciality Hospital from January 2018 to December 2019. All patients (n=142) consecutively referred for thyroid nodule FNAB to the radiology department were enrolled in the study. The patients were referred by general physicians, surgeons, otorhinolaryngologists, and endocrinologists. The study received ethics approval from the Hospital’s Ethics Committee (BSH/MOM/EC/17/002), and written informed consent was obtained from the patients.

Study Procedure

Pre-FNA Ultrasound examination and TIRADS scoring: Prior to each biopsy, each nodule was carefully examined using an iU 22 ultrasound system (Philips Healthcare, Bothell, Washington) with a 12 MHz linear array transducer. These images were evaluated by two radiologists experienced in thyroid imaging and were assigned a TIRADS score according to the recommendation of ACR-TIRADS (23). The two radiologists reviewed the images together and assigned the TIRADS score by consensus.

Each nodule was given a score based on its composition, echogenicity, shape, margin, and the presence or absence of echogenic foci within the nodule (Table/Fig 1),(Table/Fig 2)a-f. Nodules with spongiform composition or mostly cystic nodules were given a 7score of 0. Solid nodules were assigned two points, while mixed solid-cystic nodules were given one point. Anechoic, isoechoic, hyperechoic, hypoechoic, and very hypoechoic nodules were assigned 0, 1, 2, and 3 points, respectively. Based on shape, nodules wider than tall received 0 points, whereas nodules taller than wide received 3 points. Nodules with smooth or ill-defined margins were given 0 points. Nodules with lobulated or irregular margins were assigned two points, and nodules with extrathyroid extension received three points. Nodules without any echogenic foci or with only large comet tail artifacts were given a score of 0. Nodules with macrocalcification were assigned one point, and those with rim calcification received two points. Nodules with microcalcification represented by tiny punctuate echogenic foci were given three points. The maximum size of each nodule was also recorded.

All the scores were added, and a total score was calculated for each nodule. Nodules with a total score of 0 were grouped into the TR1 category, while those with a score of 2 were assigned to the TR2 category. Nodules with a total score of 3 were categorised as TR3. Nodules with a total score of 4 to 6 were placed in the TR4 category. Any nodule with a total score of 7 or more was classified as TR5. Therefore, all nodules were divided into these five TR categories.

Grouping of nodules on based on indication for FNA: According to ACR-TIRADS (23), TR1 and TR2 nodules are not suspicious for malignancy and thus do not require investigation with FNA. TR3 nodules are only mildly suspicious, so FNA is recommended for them only when their sizes are 2.5 cm or larger. Similarly, according to ACR-TIRADS recommendations, TR4 nodules, which are moderately suspicious, should be sampled if they have a size of 1.5 cm or larger. TR5 nodules, considered highly suspicious, should be sampled if they have a size of 1 cm or larger.

Based on these ACR-TIRADS recommendations, we categorised the nodules in our study into two groups. Group-I consisted of nodules in which FNAB was indicated, and Group-II consisted of nodules in which FNAB was not indicated (Table/Fig 3).

Fine Needle Aspiration Biopsy (FNAB): All cases underwent US-guided FNAB performed by an intervention fellowship-trained radiologist (AKP). In each case, two passes were made from the nodule using a 22-gauge needle. No suction was used, and the needle was traversed several times from one margin to another margin of the nodule in multiple directions. The slides were prepared and fixed with alcohol. In cystic lesions, aspirated fluid was also stored in a sterile container and sent to the laboratory for evaluation of any malignant cells. Each specimen was analysed by experienced cytopathologists and classified according to the Bethesda classification (24).

Reference standard diagnosis: For cases that were surgically managed, the reference standard diagnosis (benign vs. malignant) was based on histopathological examination of the resected nodule. However, when the nodule was managed conservatively, the reference standard was FNA cytology. Nodules were considered benign when assigned Bethesda Class II and malignant when classified as Bethesda Class V or VI. All nodules with cytology results of Bethesda Class I, III, or IV were excluded from the study, except in cases where repeat FNACs yielded conclusive results or surgical management was performed.

Statistical Analysis

For the purpose of the present study, biopsies ordered in cases where they were not indicated according to the 2017 ACR-TIRADS guidelines were considered “unnecessary,” and the unnecessary biopsy rate was calculated. The ACR recommendation regarding FNA was then compared with the reference standard diagnosis (benign vs. malignant) to estimate its sensitivity, specificity, PPV, NPV, and DOR, each with a 95% Confidence Interval (CI). The data were analysed using IBM SPSS Statistics 26.0 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp).


A total of 142 thyroid nodules were enrolled in the present study and were assessed sonographically and underwent Ultrasonography (US)-guided fine needle biopsy. Out of the 142 nodules, 35 nodules (24.6%) were excluded from the analysis because their reference standard diagnoses were inconclusive. The final study cohort included 107 nodules for which final reference standard diagnoses were available. These nodules had a size range of 6 mm to 58 mm, with a mean size of 24.72±12.14 mm. The total study population consisted of 24 males and 83 females, with a mean age of 39.35±8.28 years and an age range of 22 to 70 years. Fifteen cases (14%) met the reference standard criteria for malignancy (Table/Fig 3). In all of these cases, the diagnosis was based on histological findings; thirteen cases were papillary thyroid cancers, including one follicular variant of papillary carcinoma, and two were follicular thyroid cancers. The remaining 92 nodules (86%) were considered benign according to the reference standard criteria. Out of these, only five cases underwent surgery, and their final diagnosis was based on benign histopathology. In the other 87 cases, the nodules yielded Bethesda Class-II cytology and were thus considered benign.

When applying the ACR-TIRADS 2017 criteria, biopsy was not indicated in 54 out of 107 patients, resulting in an "unnecessary" biopsy rate of 50.5% (Table/Fig 3). According to these guidelines, only two out of the 15 malignant cases would have been assigned to the FNAB not indicated group (Group-II). Therefore, the sensitivity and NPV of these criteria for diagnosing malignancy in our study were 86.7% and 96.3%, respectively. The DOR was 8.45 (95% CI=1.8030% to 39.6031%, z=2.708, p=0.0068) (Table/Fig 4).

The two missed cancers in this system were subcentimetre TR5 nodules. Since FNAC is not indicated in nodules less than a centimetre in size, regardless of their sonographic features, these nodules were placed in Group-II.


If it is possible to accurately differentiate “benign” nodules from “suspicious” nodules based on their ultrasound morphological features, it would help authors avoid many unnecessary FNABs on benign nodules without the risk of missing any malignancies. In the present single-centre prospective observational study, authors found that 50.5% of thyroid nodule biopsies could have been avoided by using ACR-TIRADS sonographic risk assessment criteria. This unnecessary biopsy rate of 50.5% calculated in the present study is comparable to the rates calculated in previous, much larger studies. For example, the percentage of thyroid nodules in which ACR-TIRADS guidelines would have avoided FNAB was 53.4% and 57.8% in studies conducted by Grani G et al., and Ha EJ et al., respectively [13,21]. This inference has the potential to significantly impact the clinical management of thyroid nodules, as unnecessary FNABs cause a substantial burden on the healthcare system and considerable anxiety for patients. By strictly and universally applying these guidelines for sonographic risk assessment of nodules, almost half of the nodules referred for biopsy can be managed conservatively, thus significantly reducing biopsy-related costs and patient discomfort.

In the present cohort, the ACR criteria were found to have high sensitivity (86.7%) and high NPV (96.3%), with a false negative rate of only 3.7%. This is comparable to a previous study by Grani G et al., on unselected nodules, in which researchers found a sensitivity of 83.3%, NPV of 97.8%, and false negative rate of 2.2% (13). A recently published meta-analysis of 16 studies calculated the pooled sensitivity and specificity of ACR-TIRADS to be 89% and 70%, respectively, which is comparable to our results (25). In the present study, only two subcentimetre malignant nodules were assigned to the FNAC deferrable group as per ACR-TIRADS guidelines. The disadvantage of this would have been that the diagnosis of these two cases of subcentimetre papillary carcinoma would have been delayed until they reached a size larger than 1 cm. However, since the cumulative risk of distant metastasis and cancer-specific mortality from such subcentimetre papillary cancers is very low (26), such a delay would not affect the overall prognosis. Similar to ACR-TIRADS recommendations, the ATA (27) and the Korean Society of Thyroid Radiology also do not recommend routine biopsy of nodules smaller than 1 cm, even if they are highly suspicious (28). Subcentimetre thyroid nodules with highly suspicious ultrasonographic characteristics should be managed with active surveillance. A risk-stratified approach for active surveillance of such nodules has been suggested by Brito JP et al., which is based on the ultrasound features of the nodule, patient characteristics, as well as the expertise and experience of the medical team (29).

The specificity and PPV of the ACR guidelines in the present study were only 56.5% and 24.5%, respectively. Since these guidelines are essentially rule-out tests that primarily aim to avoid biopsies of many sonographically benign-appearing nodules, such low specificity and PPV are not surprising.


The present study included a small number of cases from a single centre. The cohort of thyroid nodules included in this study was identified for FNA by other physicians, and the criteria supporting these requests were not known. Another limitation of the present study was that the reference standard used was not error-free. For example, a benign (Bethesda Class II) cytology report was considered sufficient to classify the nodule as benign. However, the false negative rate in these cytologies is very low, estimated to be 3.7% in a recent meta-analysis (30) and even lower (<1%) in prospective series of cytologically benign nodules with no high suspicion ultrasound features (31). Additionally, authors excluded 35 nodules with non diagnostic or indeterminate cytology, which may have introduced a selection bias. However, the proportion of nodules with such cytological reports is consistent with those reported in other cytological studies (31).


In conclusion, if thyroid nodules are carefully selected for FNA based on their size and sonographic morphology, following the ACR-TIRADS recommendations, almost half of the thyroid nodule biopsies requested by physicians can be safely avoided. This may have a significant impact on clinical practice in the United Arab Emirates and other countries where there are no well-established local practice guidelines for thyroid nodule biopsies. In the present study cohort, ACR-TIRADS had a sensitivity of 86.7% for detecting malignant nodules, with an NPV of 96.3% and a false negative rate of 3.7%. The only caveat is that due to the application of a size threshold for selecting nodules for FNA, a few small malignancies may have a delayed diagnosis.


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DOI and Others

DOI: 10.7860/JCDR/2023/64876.18662

Date of Submission: Apr 19, 2023
Date of Peer Review: Jun 30, 2023
Date of Acceptance: Jul 21, 2023
Date of Publishing: Nov 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. No

• Plagiarism X-checker: Apr 21, 2023
• Manual Googling: Jul 03, 2023
• iThenticate Software: Jul 19, 2023 (16%)

ETYMOLOGY: Author Origin


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