Thyroid nodules are a frequent clinical finding, with studies showing they appear in nearly two-thirds of the general population when ultrasound is used. While most are benign, a small but crucial percentage are malignant. This makes accurate, timely assessment essential for guiding patient care. The American College of Radiology’s Thyroid Imaging Reporting and Data System (TI-RADS) was designed to standardize the ultrasound-based evaluation of thyroid nodules and help determine when a fine needle aspiration (FNA) is appropriate.
Historically, TI-RADS scoring has been performed almost exclusively by radiologists. However, a new study by Alfuraih et al. may reshape that thinking. The study explored whether trained sonographers can accurately assign TI-RADS scores and how their assessments compare to those of radiologists, using histological biopsy findings as the reference standard.
The retrospective study included 168 patients with thyroid nodules that radiologists classified as TR3 or higher, considered suspicious enough to warrant further investigation. Both radiologists and sonographers independently scored these nodules using the ACR TI-RADS system. Their scores were then analyzed for consistency using Cohen’s Kappa, and diagnostic accuracy was compared against FNA and surgical biopsy results categorized using the Bethesda system.
Overall, the agreement between sonographers and radiologists was moderate, with a Kappa statistic of 0.504. Sonographers and radiologists agreed most often on characteristics like echogenicity and composition. However, they had significant differences when evaluating the margins of nodules, where agreement dropped to a Kappa of just 0.102. This finding is important because nodule margins are a strong predictor of malignancy. The lack of clear criteria in the TI-RADS guidelines for distinguishing margin types likely contributed to this variability.
One of the most striking outcomes was that both sonographers and radiologists achieved 100 percent sensitivity in detecting malignant or suspicious nodules. However, sonographers showed higher specificity at 44.6 percent compared to 29.3 percent for radiologists. This means sonographers produced fewer false positives in benign cases. When measuring overall diagnostic accuracy using area under the ROC curve (AUC), sonographers again slightly outperformed radiologists, with an AUC of 0.723 versus 0.662.
The implications of these findings are significant. With the increasing demand for thyroid ultrasounds and the limited availability of radiologists, trained sonographers could play a greater role in the preliminary assessment of thyroid nodules. By expanding sonographers’ responsibilities in this way, healthcare institutions may improve workflow efficiency, reduce diagnostic delays, and allow radiologists to focus on complex or high-risk cases.
The study authors noted several limitations, including a retrospective design and a focus on TR3 and higher nodules only. Despite these limitations, the results suggest that sonographers, when properly trained, can provide consistent and clinically useful TI-RADS assessments. This could be a meaningful step forward for departments looking to optimize resource allocation without compromising diagnostic quality.
To capitalize on this potential, structured training and standardization are essential. The study emphasized the need for improved clarity in TI-RADS criteria and ongoing education to reduce scoring variability. Training tools that offer consistent exposure to pathology, expert feedback, and opportunities for repetitive practice will be key to ensuring reliable performance.
How SonoSim Can Support Reliable TI-RADS Scoring
This is where SonoSim comes in. As institutions consider expanding sonographer responsibilities in thyroid imaging, a structured training solution is crucial. SonoSim provides a comprehensive ultrasound education ecosystem that removes many of the barriers associated with hands-on ultrasound training.
With SonoSim, learners can:
- Access thousands of real-patient ultrasound cases including thyroid nodules
- Practice image acquisition and interpretation in a simulated environment that mirrors real-world scanning
- Get expert-narrated findings videos to aid learning and reduce interpretation bias
- Use guided probe positioning and AI-driven feedback for repetitive, self-paced practice
- Build confidence and competency in TI-RADS scoring through targeted training pathways
Unlike traditional classroom-based education or limited clinical shadowing opportunities, SonoSim allows learners to practice as much as needed, whenever and wherever they choose. This type of deliberate practice is key to improving diagnostic accuracy and reducing variability across users.
The findings of this study underscore the importance of reliable training and the potential for sonographers to play a more prominent role in thyroid nodule evaluation. With SonoSim’s ultrasound training tools, programs can give their learners the standardized exposure, structured education, and expert guidance they need to succeed.
To learn how SonoSim can support your sonographers in mastering TI-RADS and advancing their clinical role, visit sonosim.com.