*Article* **Use of Diagnostic Criteria from ACR and EU-TIRADS Systems to Improve the Performance of Cytology in Thyroid Nodule Triage**

**Davide Seminati <sup>1</sup> , Giulia Capitoli <sup>2</sup> , Davide Leni 3, Davide Fior 3, Francesco Vacirca 3, Camillo Di Bella 1, Stefania Galimberti <sup>2</sup> , Vincenzo L'Imperio <sup>1</sup> and Fabio Pagni 1,\***


**Simple Summary:** From a prospective series of 480 thyroid nodules, we compared the performances of the American College of Radiology (ACR) and the European Thyroid Association (EU) scoring systems in triaging thyroid nodules for fine-needle aspiration (FNA). FNA was recommended on 46.5% and 51.9% of the nodules using the ACR and EU-TIRADS scores, respectively. The ACR system demonstrated a higher specificity as compared to the EU-TIRADS (59.0% vs. 52.4%, *p* = 0.0012) in predicting ≥TIR3A/III (SIAPEC/Bethesda) nodules. Moreover, specific radiological features (i.e., echogenic foci and margins), combined with the cytological classes improved the specificity (97.5% vs. 91%, *p* < 0.0001) and positive predictive value (77.5% vs. 50.7%, *p* < 0.0001) of the cytology alone, maintaining an excellent sensitivity and negative predictive value.

**Abstract: Objective:** The American College of Radiology (ACR) and the European Thyroid Association (EU) have proposed two scoring systems for thyroid nodule classification. Here, we compared the ability of the two systems in triaging thyroid nodules for fine-needle aspiration (FNA) and tested the putative role of an approach that combines ultrasound features and cytology for the detection of malignant nodules. **Design and Methods:** The scores obtained with the ACR and EU Thyroid Imaging Reporting and Data Systems (TIRADS) from a prospective series of 480 thyroid nodules acquired from 435 subjects were compared to assess their performances in FNA triaging on the final cytological diagnosis. The US features that showed the highest contribution in discriminating benign nodules from malignancies were combined with cytology to improve its diagnostic performance. **Results:** FNA was recommended on 46.5% and 51.9% of the nodules using the ACR and EU-TIRADS scores, respectively. The ACR system demonstrated a higher specificity as compared to the EU-TIRADS (59.0% vs. 52.4%, *p* = 0.0012) in predicting ≥ TIR3A/III (SIAPEC/Bethesda) nodules. Moreover, specific radiological features (i.e., echogenic foci and margins), combined with the cytological classes improved the specificity (97.5% vs. 91%, *p* < 0.0001) and positive predictive values (77.5% vs. 50.7%, *p* < 0.0001) compared to cytology alone, especially in the setting of indeterminate nodules (TIR3A/III and TIR3B/IV), maintaining an excellent sensitivity and negative predictive value. **Conclusions:** The ACR-TIRADS system showed a higher specificity compared to the EU-TIRADS in triaging thyroid nodules. The use of specific radiological features improved the diagnostic ability of cytology.

**Keywords:** ultrasound imaging; thyroid nodule; thyroid carcinoma; fine-needle aspiration

**Citation:** Seminati, D.; Capitoli, G.; Leni, D.; Fior, D.; Vacirca, F.; Di Bella, C.; Galimberti, S.; L'Imperio, V.; Pagni, F. Use of Diagnostic Criteria from ACR and EU-TIRADS Systems to Improve the Performance of Cytology in Thyroid Nodule Triage. *Cancers* **2021**, *13*, 5439. https://doi.org/10.3390/ cancers13215439

Academic Editor: Fabio Medas

Received: 5 October 2021 Accepted: 26 October 2021 Published: 29 October 2021

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