Scoring is determined from five categories of ultrasound findings (figure 2). The higher the cumulative score, the higher the TR (TI-RADS) level and the likelihood of malignancy.

One score is assigned from each of the following categories:

  • composition: (choose one)
    • cystic or completely cystic *: 0 points
    • spongiform *: 0 points
    • mixed cystic and solid: 1 point
    • solid or almost completely solid: 2 points
  • echogenicity: (choose one)
    • anechoic: 0 points
    • hyper- or isoechoic: 1 point
    • hypoechoic: 2 points
    • very hypoechoic: 3 points
  • shape: (choose one) (assessed on the transverse plane)
    • wider than tall: 0 points
    • taller than wide: 3 points
  • margin: (choose one)
    • smooth: 0 points
    • ill-defined: 0 points
    • lobulated/irregular: 2 points
    • extra-thyroidal extension: 3 points

Any and all findings in the final category are also added to the other four scores.

  • echogenic foci: (choose one or more)
    • none: 0 points
    • large comet-tail artifact: 0 points
    • macrocalcifications: 1 point
    • peripheral/rim calcifications: 2 points
    • punctate echogenic foci: 3 points

The findings in each category were detailed in the ACR committee’s 2015 publication on a reporting lexicon 2. If multiple nodules are present only the four highest-scoring nodules (not necessarily the largest) should be scored, reported, and followed up.

* Predominantly cystic or spongiform nodules are inherently benign. If these features are present no further points will be added (automatically TR1).