Deviating from Thyroid Imaging Reporting and Data Systems (TI-RADS) guidelines in surgical planning for patients with parathyroid disease: What is the clinical impact?

Background: The American College of Radiology Thyroid Imaging Reporting and Data Systems standardizes thyroid nodule classification to assess malignancy risk. The use of preoperative ultrasound before parathyroidectomy often detects incidental thyroid nodules, prompting consideration of additional evaluation and/or concomitant thyroid surgery to minimize need for reoperative surgery. This study evaluated clinician adherence to Thyroid Imaging Reporting and Data Systems guidelines for patients with parathyroid disease and associated clinical outcomes.

Methods: A retrospective review of 992 patients undergoing parathyroidectomy (2019-2024) examined the role of Thyroid Imaging Reporting and Data Systems in preoperative planning and the clinical decision-making after incidental discovery of thyroid nodules. Descriptive and univariate statistical analyses were performed to compare guideline-concordant and discordant care.

Results: Of 957 patients with a formal preoperative ultrasound, 406 (42.4%) had at least 1 thyroid nodule with the Thyroid Imaging Reporting and Data Systems classification reported by a radiologist. Among those with a nodule, 154 (37.9%) underwent fine-needle aspiration and 56 (13.8%) underwent concomitant thyroid surgery for the nodule. Notably, 47 fine-needle aspiration procedures (30.5%) did not meet Thyroid Imaging Reporting and Data Systems criteria. Patients who received guideline-discordant fine-needle aspiration procedures were less likely to undergo thyroid surgery (12.8% vs 34.9%, P = .005) or receive a diagnosis of thyroid cancer (4.3% vs 16.8%, P = .037). Overall, most malignancies were low risk per American Thyroid Association guidelines (n = 20, 80.0%), regardless of Thyroid Imaging Reporting and Data Systems criteria.

Conclusion: Many patients undergoing parathyroidectomy receive additional interventions for incidental thyroid nodules. However, adherence to Thyroid Imaging Reporting and Data Systems guidelines may help reduce unnecessary surgery, because most identified malignancies are low risk. The long-term impact remains unclear, emphasizing the need for shared decision-making between surgeons and patients.