Pediatric Thyroid Nodules: K-TIRADS/ACR TI-RADS Pediatric-Specific Biopsy Cutoff Incorporating Clinical Risk Factors.
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Background Pediatric thyroid nodules have a higher malignancy rate than adult nodules; yet, a pediatric-specific biopsy cutoff is lacking. Purpose To investigate the usefulness of repeat biopsy and a pediatric-specific biopsy cutoff incorporating risk factors to improve the diagnostic performance of the 2021 Korean Thyroid Imaging Reporting and Data System (K-TIRADS) and American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS). Materials and Methods US images of biopsy-confirmed pediatric thyroid nodules obtained at Seoul National University Hospital between January 2010 and December 2021 were retrospectively analyzed. The diagnostic performance of the aforementioned systems with the incorporation of risk factors (Hashimoto thyroiditis, previous radiation therapy, family history of thyroid cancer, or hereditary tumor syndrome) was evaluated. The McNemar test and the weighted generalized score statistic were used. Results Two hundred patients (median age, 16 years [IQR, 13-18 years]; 153 female; 17 children [age, <10 years] and 183 adolescents [age, 10-19 years]; 92 with risk factors) with 223 nodules (142 malignant nodules [64% of total nodules; 86% of 166 resected nodules]) were analyzed. Repeat biopsies owing to large size, interval growth, or category 4 and 5 revealed that six of 21 nodules (29%) initially categorized as benign were malignant postoperatively. Compared with the current guidelines, a modified K-TIRADS/ACR TI-RADS pediatric-specific biopsy cutoff (0.5 cm and 1.5 cm for category 4 nodules with and without risk factors, respectively, and 0.5 cm for all category 5 nodules) improved the sensitivity (85% [121 of 142] vs 78% [111 of 142] for K-TIRADS; 84% [119 of 142] vs 60% [85 of 142] for ACR TI-RADS; both P < .005) and missed malignancy rate (33% [21 of 64] vs 39% [31 of 79]; 30% [23 of 76] vs 46% [57 of 122]; both P < .05) for both systems and accuracy for ACR TI-RADS (74% [164 of 223] vs 71% [159 of 223]; 77% [172 of 223] vs 67% [150 of 223]; P = .30 and P = .002, respectively). Conclusion Applying a 0.5-cm biopsy cutoff in pediatric patients improved diagnostic performance for both category 4 nodules with risk factors and category 5 nodules. Repeat biopsy was required for pediatric thyroid nodules with discordant clinical and US findings. © RSNA, 2025 Supplemental material is available for this article.