ACR TI-RADS Score Calculator
ACR TI-RADS Score Calculator
Score a thyroid nodule on the five ACR TI-RADS ultrasound features, with echogenic foci added rather than chosen, and read the TR level against the nodule’s size.
ACR TI-RADS
5 features + size → TR1–TR5A solid, hypoechoic, wider-than-tall nodule with a lobulated margin and punctate echogenic foci, maximum diameter 1.8 cm
Five features, then the size
- Echogenic foci
- the only additive category. Rim plus punctate is 2 + 3 = 5 points, in the ACR’s own worked example
- TR level
- decided by the points alone. Size plays no part in it
- Size
- decides what the TR level means — nothing, follow-up, or fine-needle aspiration
- Thresholds
- inclusive. “FNA if ≥1.5 cm” means a nodule measuring exactly 1.5 cm is aspirated
- A total of 1
- has no row in the published chart. This calculator reads it as TR1, which is consequence-free — TR1 and TR2 are managed identically
Worked example
A solid, hypoechoic, wider-than-tall nodule with a lobulated margin and punctate echogenic foci, maximum diameter 1.8 cm
Composition solid → 2; echogenicity hypoechoic → 2
Shape wider-than-tall → 0; margin lobulated or irregular → 2
Echogenic foci: punctate present → 3; no macrocalcification and no rim calcification → foci total 3
2 + 2 + 0 + 2 + 3 = 9 points
9 points is 7 or more → TR5, highly suspicious, observed malignancy rate 35%
TR5 is aspirated from 1.0 cm, and this nodule is 1.8 cm → fine-needle aspiration recommended
The ACR TI-RADS point chart
| Category | Feature | Points |
|---|---|---|
| Composition | Cystic or almost completely cystic | 0 |
| Composition | Spongiform | 0 |
| Composition | Mixed cystic and solid | 1 |
| Composition | Solid or almost completely solid | 2 |
| Echogenicity | Anechoic | 0 |
| Echogenicity | Hyperechoic or isoechoic | 1 |
| Echogenicity | Hypoechoic | 2 |
| Echogenicity | Very hypoechoic | 3 |
| Shape | Wider-than-tall | 0 |
| Shape | Taller-than-wide | 3 |
| Margin | Smooth | 0 |
| Margin | Ill-defined | 0 |
| Margin | Lobulated or irregular | 2 |
| Margin | Extra-thyroidal extension | 3 |
| Echogenic foci (add all that apply) | None, or large comet-tail artefacts | 0 |
| Echogenic foci (add all that apply) | Macrocalcifications | 1 |
| Echogenic foci (add all that apply) | Peripheral (rim) calcifications | 2 |
| Echogenic foci (add all that apply) | Punctate echogenic foci | 3 |
TR level, size threshold and malignancy risk
| TR level | Points | Fine-needle aspiration | Ultrasound follow-up | Observed rate | ACR estimated risk |
|---|---|---|---|---|---|
| TR1 — benign | 0 | Not recommended | Not recommended | 0.3% | <2% |
| TR2 — not suspicious | 2 | Not recommended | Not recommended | 1.5% | <2% |
| TR3 — mildly suspicious | 3 | ≥2.5 cm | ≥1.5 cm | 4.8% | <5% |
| TR4 — moderately suspicious | 4 – 6 | ≥1.5 cm | ≥1.0 cm | 9.1% | 5 – 20% |
| TR5 — highly suspicious | ≥7 | ≥1.0 cm | ≥0.5 cm | 35% | >20% |
What TI-RADS does not do
| Question | Answer |
|---|---|
| Does a high TR level mean cancer? | No. TR5 carried a 35% observed malignancy rate, so two out of three TR5 nodules were benign. The level sets the threshold for sampling, not the diagnosis. |
| Does a TR1 or TR2 reading exclude cancer? | Not absolutely — the estimated risk is under 2%, not zero. Published series have found cancers in nodules that did not meet the criteria for aspiration, usually small ones. |
| Does size change the TR level? | Never. Size decides what to do about a level; it contributes no points. |
| Does it tell you anything about thyroid function? | Nothing at all. Score the ultrasound here and interpret the biochemistry separately — TSH and free T4 are a different question. |
| Does it replace the nodule’s measurements? | No. Volume and growth over time are followed separately — see the thyroid nodule volume calculator. |
| Is thyroglobulin useful in a nodule? | No. It is a post-operative tumour marker and has no role in nodule assessment — see the thyroglobulin page. |
Echogenic foci add up, and the size decides what the level means
ACR TI-RADS scores a thyroid nodule on five ultrasound features and sorts the total into five levels: TR1 at 0 points, TR2 at 2, TR3 at 3, TR4 at 4 to 6 and TR5 at 7 or more. The level on its own is not the answer. What the chart actually produces is a sampling threshold, and that threshold is a size: TR3 nodules are aspirated from 2.5 cm, TR4 from 1.5 cm, TR5 from 1.0 cm, and nothing at all is done about a TR1 or TR2 nodule however large it is. Below those numbers there is a second, smaller set — follow-up ultrasound from 1.5 cm for TR3, 1.0 cm for TR4 and 0.5 cm for TR5 — and below 0.5 cm nothing is recommended at any level. That is why this calculator asks for the maximum diameter and why the verdict changes as you change it, without the points total moving at all.
The feature most often scored wrongly is echogenic foci, because it is the only category in the chart that adds. The other four are single-choice: a nodule has one composition, one echogenicity, one shape and one margin. But a nodule can have rim calcification and punctate echogenic foci, and the ACR’s own worked example is explicit that the total is then 3 + 2 = 5 points, not 3. A calculator that offers echogenic foci as a single dropdown silently loses those two points and can drop a nodule from TR5 to TR4 — which moves its aspiration threshold from 1.0 cm to 1.5 cm. This page asks three separate questions for that reason, and prints the foci subtotal beside the answer so it can be checked.
Two smaller traps. An ill-defined margin is not a suspicious finding in this system: it scores 0, the same as a smooth margin, which surprises people who expect indistinctness to count against a nodule. And taller-than-wide is worth three points from a single measurement comparison on the transverse image, so it is the one feature where a careless assessment moves the level on its own. Where a feature cannot be determined at all, the white paper’s convention is to score the more suspicious option — composition that cannot be assessed is scored as solid.
What the level means is worth stating plainly, because the numbers are less alarming than the labels. TR5 — “highly suspicious” — carried an observed malignancy rate of 35% in the dataset the reproductions quote, so roughly two in three TR5 nodules were benign. TR4 was 9.1%. The point of the system is not to predict cancer but to stop the enormous number of incidentally found nodules from all being biopsied, and it buys that by accepting that a few small cancers will sit below the size thresholds and be followed rather than sampled. Published series have looked for exactly those nodules and found them. So a TI-RADS level is a recommendation about a needle, not a diagnosis, and a nodule with a feature the chart does not capture — rapid growth, hoarseness, a suspicious node, a history of neck irradiation — is still a nodule a clinician should look at. This supports a clinician’s judgement rather than replacing it. It is arithmetic on the figures entered, and it knows nothing about the patient in front of you.
Frequently asked questions
What are the ACR TI-RADS point ranges for TR1 to TR5?
TR1 is 0 points, TR2 is 2 points, TR3 is 3 points, TR4 is 4 to 6 points and TR5 is 7 points or more. A total of 1 point has no row in the published chart; this calculator reads it as TR1, which changes nothing because TR1 and TR2 are managed identically.
When is fine-needle aspiration recommended?
For TR3 at 2.5 cm or more, TR4 at 1.5 cm or more and TR5 at 1.0 cm or more. TR1 and TR2 are not aspirated at any size. The thresholds are inclusive, so a TR4 nodule measuring exactly 1.5 cm meets the criterion.
Are echogenic foci points added together?
Yes, and this is the one category in the chart that works that way. The ACR’s worked example gives punctate echogenic foci plus rim calcification as 3 + 2 = 5 points. The other four feature categories are single-choice.
Does the nodule’s size change its TR level?
No. The TR level comes from the points alone. Size decides what the level means — nothing, surveillance, or aspiration — which is why this page asks for the maximum diameter separately.
What is the malignancy risk at each TI-RADS level?
The observed rates quoted for the reference dataset are 0.3% for TR1, 1.5% for TR2, 4.8% for TR3, 9.1% for TR4 and 35% for TR5. The ACR white paper’s separately stated estimated risks are under 2% for TR1–TR2, under 5% for TR3, 5–20% for TR4 and over 20% for TR5.
Related calculators
References
- Tessler FN, Middleton WD, Grant EG, et al. ACR Thyroid Imaging, Reporting and Data System (TI-RADS): white paper of the ACR TI-RADS Committee. J Am Coll Radiol. 2017;14(5):587–95.
- Tessler FN, Middleton WD, Grant EG. Thyroid Imaging Reporting and Data System (TI-RADS): a user’s guide. Radiology. 2018;287(1):29–36 — names Figure 1 of the white paper as the source of the point chart.
- American College of Radiology. TI-RADS announcement — TR1 0 points, TR2 2 points, TR3 3 points, TR4 4 to 6 points, TR5 7 points or more, with fine-needle aspiration at ≥2.5 cm for TR3, ≥1.5 cm for TR4 and ≥1 cm for TR5. Verified independently for this page.
- Investigating thyroid nodules. Australian Prescriber, Table 1 — the TI-RADS levels with both the fine-needle aspiration and the ultrasound follow-up size thresholds (TR3 ≥1.5 cm, TR4 ≥1 cm, TR5 ≥0.5 cm) and the estimated malignancy risks. Verified independently for this page.
- Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26(1):1–133.
Medical Disclaimer: The tools and content provided here are for educational and reference purposes only. They are not intended to substitute for professional medical advice, diagnosis, or treatment. Clinical decisions should always be based on the comprehensive assessment of a qualified healthcare professional.