O2188: Validation of PED TI-RADS for Pediatric Thyroid Nodule Risk Stratification: A Pediatric Surgical Oncology Research Collaborative Study

Saturday, September 27, 2025

1:32 PM - 1:37 PM MDT

Location: Colorado Convention Center, Mile High Ballroom 2B-3B

Background: Thyroid nodules in children and adolescents have a higher risk of malignancy than in adults, necessitating accurate preoperative risk stratification. The American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) is a validated tool guiding the management of thyroid nodules in adults, but studies investigating its application to pediatric nodules have shown mixed results, with some institutions noting a failure to designate malignant nodules for biopsy. Utilization of adult criteria may lead to delays in appropriate diagnosis of pediatric thyroid nodules and cancers. The modified Pediatric TI-RADS (PED TI-RADS) criteria were developed to help address limitations of ACR TI-RADS in pediatric practice and have demonstrated improvements in diagnostic accuracy while reducing unnecessary fine-needle aspiration biopsies (FNAB), but larger scale validation is needed.

Methods: This retrospective multi-institutional study was conducted through the Pediatric Surgical Oncology Research Collaborative with 22 participating institutions. Patients aged 0–21 years with thyroid nodules identified on ultrasound between 2021-2023 were included. PED TI-RADS, ACR TI-RADS, and American Thyroid Association (ATA) criteria were applied to assess FNAB recommendations, which were compared to final cytopathology or surgical pathology results. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy were calculated.

Results: A total of 947 thyroid nodules from 581 patients were analyzed. FNAB was recommended for 58.3% of nodules by PED TI-RADS criteria, 40.8% by ACR TI-RADS, and 74.8% by ATA (p < 0.001). Sensitivity and NPV for detecting malignancy on FNAB cytopathology were 93.0% and 92.4%, respectively for PED TI-RADS, 76.0% and 84.6% for ACR TI-RADS, and 90.4% and 81.6% for ATA guidelines (p < 0.001 when PED TI-RADS was compared to both ACR TI-RADS and ATA). Accuracy for predicting malignancy on FNAB cytopathology was 54.3% for PED TI-RADS, 63.6% for ACR TI-RADS, and 40.6% for ATA. Accuracy for predicting malignancy on surgical pathology was 62.8% for PED TI-RADS, 61.5% for ACR TI-RADS, and 54.9% for ATA. Missed malignancies on FNAB cytopathology was lowest for PED TI-RADS at 13, compared to 45 with ACR TI-RADS, and 18 with ATA criteria. The PED TI-RADS criteria outperformed ACR TI-RADS and ATA criteria, reducing unnecessary FNAB by 16.5% relative to ATA while maintaining a sensitivity for malignancy greater than 90%.

Conclusion: Applying PED TI-RADS criteria enhances malignancy risk stratification in pediatric thyroid nodules while reducing unnecessary FNABs relative to ATA criteria. This large, multi-institutional analysis supports the adoption of PED TI-RADS criteria as the primary diagnostic tool in pediatric thyroid nodule evaluation.

Presenting Author(s)

Shachi B. Srivatsa, MD, MPH (she/her/hers)

Surgical Oncology Research Fellow and General Surgery Resident
Nationwide Childrens Hospital, The Ohio State University College of Medicine
The Ohio State University Wexner Medical Center
Grandview Heights, Ohio

Co-Author(s)

EC

Emily R. Christison-Lagay, MD

Associate Professor
Yale School of Medicine, Yale New Haven Childrens Hospital
Guilford, Connecticut
TL

Timothy B. Lautz, MD

Associate Professor of Surgery
Ann & Robert H Lurie Children's Hospital of Chicago
Chicago, Illinois
Marcus Malek, MD, FACS, FAAP

Assistant Professor; Director of Pediatric Surgical Oncology
University of Pittsburgh
ML

Monica E. Lopez, MD, MS

Professor of Pediatric Surgery
Vanderbilt University School of Medicine
RW

Regan Williams, MD, MS, FAAP, FACS

Associate Professor
Departments of Surgery and Pediatrics, University of Tennessee Health Science Center
MS

Matthew M. Smith, MD, MPH

Associate Professor - Division of Pediatric Otolaryngology
Cincinnati Children's Hospital Medical Center
Daniel Rhee, MD, MPH

Associate Professor of Pediatric Surgery, Director, Pediatric Surgical Oncology Program
Johns Hopkins Department of Surgery
DC

Danielle B. Cameron, MD, MPH

Pediatric Surgeon, Assistant Professor of Surgery
Mass General for Children
Boston, Massachusetts
NP

Nelson Piche, MD

Associate professor of suregry
Chirurgien pediatrique, CHU Ste-Justine, Quebec, Canada
Jennifer M. Schuh, MD

Research Fellow
Children's Wisconsin
Children's Wisconsin
Milwaukee, Wisconsin
AF

Aodhnait S. Fahy, BMBCh PhD

Assistant Professor of Pediatric Surgery
Penn State Children's Hospital
Erin G. Brown, MD

Associate Professor
University of California, Davis
University of California, Davis
Sacramento, California
CH

Candace A. Haddock, MD

Director, Bowel Management Program
Valley Children's Hospital
Madera, California
Erika A. Newman, MD

Associate Professor
Pediatric Surgery, University of Michigan
HL

Hau Le, MD

Assistant Professor of Surgery, Director of Pediatric Surgical Oncology
American Family Children’s Hospital
Jeremy D. Prager, MD, MBA (he/him/his)

Professor of Pediatric Otolaryngology - Head & Neck Surgery
University of Colorado School of Medicine; Children's Hospital Colorado
University of Colorado School of Medicine, Colorado
SS

Shahab Shaffiey, MD, MSc

Pediatric Surgery Attending
Nicklaus Children’s Hospital
Miami, Florida
DR

David Rothstein, MD, MS

Pediatric Surgeon
Seattle Children's Hospital

Senior Author(s)

Jennifer H. Aldrink, MD

Professor of Surgery and Pediatrics
Nationwide Children's Hospital, The Ohio State University College of Medicine
Nationwide Children's Hospital, The Ohio State University College of Medicine
Columbus, Ohio