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Incremental Value of Doppler Vascularity Beyond ACR TI-RADS in Thyroid Nodule Biopsy Decision-Making: A 13-Year
Ilona Lavender1,2, Dee Nandurkar1
1Department of Radiology Monash Health Melbourne Victoria Australia.
Introduction:
The American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) does not include Doppler vascularity. We evaluated whether increased vascularity identifies clinically significant cytology among nodules that do not meet ACR TI-RADS fine needle aspiration (FNA) size thresholds.
Methods:
A retrospective cohort study conducted at a tertiary referral imaging service included 3383 thyroid nodules in 2932 patients undergoing ultrasound-guided FNA (January 2012-December 2025). Nodules were stratified into (1) ACR-indicated (met ACR TI-RADS size criteria); (2) vascularity-only (marked vascularity, ACR not indicated, excluding PET-avid and nuclear medicine cold nodules); and (3) other non-ACR indications. Outcomes were Bethesda category. Outcomes were categorised according to the Bethesda System for Reporting Thyroid Cytopathology. Bethesda IV-VI and Bethesda V-VI outcomes were analysed separately. Exact binomial 95% confidence intervals were calculated; exploratory between-group comparisons were performed descriptively.
Results:
Among ACR-indicated FNAs (n = 1036), Bethesda IV-VI occurred in 87 (8.4%, 95% CI 6.8-10.3) and Bethesda V-VI in 33 (3.2%, 95% CI 2.2-4.4). In the vascularity-only cohort (n = 82), Bethesda IV-VI occurred in 8 (9.8%, 95% CI 4.3-18.3) with 0 Bethesda V-VI (0%, 95% CI 0-4.4). Other non-ACR indications (n = 974) yielded Bethesda IV-VI in 50 (5.1%, 95% CI 3.8-6.7) and Bethesda V-VI in 11 (1.1%, 95% CI 0.6-2.0).
Conclusion:
In nodules that did not meet ACR TI-RADS FNA thresholds, increased vascularity led to additional FNAs with no malignant cytology (Bethesda V-VI) and a modest proportion of Bethesda IV results. These findings support adherence to ACR TI-RADS FNA thresholds without routine incorporation of vascularity alone.
