Section 2 The nodular goiter



TIRADS system has first described in 2009 by Horvath et al. The thyroid community has come a long way. Starting from the methodologically problematic findings of the first communication (e.g., see the definition of TI-RADS 6 category), search engines now report more than 700,000 hits for the term TIRADS. It should be noted that TIRADS was originally proposed in order to make it easier to compare the results of different working groups and the distribution of nodules in patients living in different areas and also for clinical management of nodular goiter patients.

The goal of thyroid experts and even the most recognized thyroid societies became TIRADS as the basis for the indication of cytological examination. This goal coincided with the idea that has shaped it since 2006, it is no exaggeration to say that it has reshaped everyday practice. This was due to the fact that, in contrast to the previous period, when cytology was performed for a size limit, all guidelines published after 2006 also took into account the presence of suspicious signs. There may have been a boom in the thyroid literature, perhaps never seen before, in terms of the number of publications dealing with TIRADS. More and more classifications have been made, while virtually all authors have concluded with unanimous enthusiasm that the use of TIRADS significantly reduces the number of unnecessarily performed cytologies.

Until recently, there was virtually no one to raise this extremely simple problem. If it was, a paper discussing the critical approach could not be accepted for publication. The only problem is whether we want to recognize a significant proportion of follicular cancers no larger than 2 or 2.5 cm, depending on the TIRDADS systems. If not, TIRADS is the panacea itself. If so, it is extremely difficult to imagine that a system based on ultrasound features suspicious of papillary cancer would also be capable of recognizing follicular cancers. This is because, in the case of all suspicious signs, it behaves practically in the opposite way to papillary cancer.

By now, however, the ice is broken, but compared to more than 700,000 supportive opinions, the impact of some different approaches is much smaller. I think for now... I say it with a heavy heart, but I am convinced that this enormous amount of work invested will most likely not be utilized where it seems obvious. One such benefit - and we have tried to emphasize this in previous chapters of the nodular goiter - is that the different approaches behind the different TIRADS systems need to be thought through. And these different approaches are very instructive from beginner to experienced.
Another benefit is that it has become clear that there is a significant, sometimes confusing, difference in the interpretation of individual characteristics even among highly experienced thyroid professionals. I wish we would be devoting one-hundreds of the energy spent on TIRADS to developing a more uniform interpretation.
Finally, I do not rule out the possibility that the community of thyroid professionals may decide that it is not a problem if a significant portion, roughly half, of follicular cancers smaller than 2-2.5 cm are not recognized.

I definitely ask the reader to read what is described here with a critical eye. But with the same critical approach, it is worth studying thyroid literature as well.

The Manual reviews the development and application of TIRADS systems. Based on the above, it is perhaps not surprising to take a critical approach. In the Courses, we present the practical use of TIRADS and the emerging pitfalls in comparative tables. The Case study section is based, as elsewhere, on voice narration videos. The Videolibrary is for practice. And this chapter is one of the six Exams in the Course.

Due to the importance of the topic, lectures of two well-known speakers will deal with this topic in Type 2 Webinar on 13 January, 2022.