Loading calculators...
Fetching calculator categories and tools for this section.
Preparing tools and content for you. This usually takes a second.
Fetching calculator categories and tools for this section.
Score five ultrasound features with the ACR TI-RADS point system, classify TR1–TR5, and see size-based FNA thresholds. Pairs with thyroid medication dosing when hypothyroidism is separately managed. Educational—not a radiology report.
Last updated: June 5, 2026
Feature selection must come from qualified thyroid ultrasound. TI-RADS guides FNA consideration— cytology or surgery confirms malignancy.
Size gates FNA thresholds (TR3 ≥2.5, TR4 ≥1.5, TR5 ≥1.0 cm)
Classification
TR3 — Mildly suspicious
3 points
Malignancy risk
~5%
FNA indicated?
Not by size alone
Biopsy recommendation
No FNA yet — 1.5 cm below 2.5 cm TR3 threshold
Follow-up guidance
Follow-up ultrasound in 1–2 years (≥1.5 cm)
Interpretation
Mildly suspicious (3 points). ~5% malignancy risk — size-gated FNA at ≥2.5 cm.
Score breakdown
TR1 — spongiform 0 pts
TR1
No FNA regardless of size
TR2 — mixed only 1 pt
TR2
3.0 cm — still no FNA
TR3 — default 3 pts, 1.5 cm
TR3
Follow-up ultrasound in 1–2 years (≥1.5 cm)
TR4 — 6 pts, 1.8 cm
TR4
FNA recommended — 1.8 cm ≥ 1.5 cm TR4 threshold
TR5 — 11 pts, 1.2 cm
TR5
FNA strongly recommended — 1.2 cm ≥ 1.0 cm TR5 threshold
Tessler et al. JACR 2017 point assignments — educational reference.
| Feature | Pts | Note |
|---|---|---|
| Cystic or almost completely cystic | 0 | Fluid-filled — lowest suspicion |
| Spongiform | 0 | Honeycomb pattern — benign-appearing |
| Mixed cystic and solid | 1 | Partially solid — mild elevation |
| Solid or almost completely solid | 2 | Most common in cancers but nonspecific alone |
| Feature | Pts | Note |
|---|---|---|
| Anechoic | 0 | Pure fluid component |
| Hyperechoic or isoechoic | 1 | Same or brighter than thyroid parenchyma |
| Hypoechoic | 2 | Darker than parenchyma — suspicious |
| Very hypoechoic | 3 | Darker than strap muscles — highly suspicious |
| Wider than tall | 0 |
| Taller than wide | 3 |
| Smooth | 0 |
| Ill-defined | 0 |
| Lobulated or irregular | 2 |
| Extrathyroidal extension | 3 |
| None or large comet-tail artifacts | 0 |
| Macrocalcifications | 1 |
| Peripheral (rim) calcifications | 2 |
| Punctate echogenic foci | 3 |
| Level | Points | Risk | FNA threshold | Follow-up |
|---|---|---|---|---|
| TR1 | 0 | <1% | No FNA any size | No routine follow-up |
| TR2 | 1–2 | <2% | No FNA any size | No routine follow-up |
| TR3 | 3 | ~5% | FNA if ≥2.5 cm | US follow-up if ≥1.5 cm (1–2 years) |
| TR4 | 4–6 | 5–20% | FNA if ≥1.5 cm | US follow-up if ≥1.0 cm (~1 year) |
| TR5 | ≥7 | >20% | FNA if ≥1.0 cm | Close surveillance if ≥0.5 cm (6–12 months) |
| TR level | FNA size | Follow-up size | Rationale |
|---|---|---|---|
| TR1–TR2 | None | None | Benign/not suspicious — avoid unnecessary FNA |
| TR3 | ≥2.5 cm | ≥1.5 cm | Balance cancer detection vs benign biopsy rate |
| TR4 | ≥1.5 cm | ≥1.0 cm | Intermediate risk — lower size bar than TR3 |
| TR5 | ≥1.0 cm | ≥0.5 cm | High risk — biopsy smaller nodules; surveil sub-1 cm |
No FNA yet — 1.5 cm below 2.5 cm TR3 threshold — Follow-up ultrasound in 1–2 years (≥1.5 cm)
| System | Method | Use |
|---|---|---|
| ACR TI-RADS | 5-feature point sum → TR1–TR5 | Most common in US radiology; this calculator |
| EU-TIRADS | Pattern-based (EU guidelines) | European practice; different category labels |
| K-TIRADS | Korean Society of Thyroid Radiology | Emphasizes suspicious patterns; different thresholds |
| ATA sonographic patterns | High/moderate/low suspicion patterns | American Thyroid Association — pattern not points |
| Category | Typical action |
|---|---|
| I — Nondiagnostic | Repeat FNA, often with on-site adequacy |
| II — Benign | Routine follow-up per TR level/size |
| III — AUS/FLUS | Repeat FNA, molecular testing, or lobectomy |
| IV — Follicular neoplasm | Surgical consultation; molecular markers may guide |
| V — Suspicious for malignancy | Near-total/total thyroidectomy typically discussed |
| VI — Malignant | Surgery; papillary most common |
| Feature | Points | Association |
|---|---|---|
| Punctate echogenic foci | 3 | Papillary microcalcifications |
| Taller-than-wide shape | 3 | Invasive growth pattern |
| Very hypoechoic | 3 | Solid hypoechoic cancers |
| Extrathyroidal extension | 3 | Locally advanced disease |
| Lobulated margin | 2 | Infiltrative border |
| Hypoechoic solid | 4 | Common but less specific alone |
Educational disclaimer: This calculator applies ACR TI-RADS 2017 point math for learning and workflow support. It does not interpret ultrasound images, perform FNAs, or replace radiology/endocrine judgment. Do not delay care for suspicious nodules based on this page alone.
Share with radiology, endocrine, and primary care teams.
Suggested hashtags: #TIRADS #Thyroid #Radiology #Ultrasound #Calculator