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World J Methodol. May 20, 2022; 12(3): 148-163
Published online May 20, 2022. doi: 10.5662/wjm.v12.i3.148
Assessment of diagnostic capacity and decision-making based on the 2015 American Thyroid Association ultrasound classification system
Luis-Mauricio Hurtado-Lopez, Alfredo Carrillo-Muñoz, Felipe-Rafael Zaldivar-Ramirez, Erich Otto Paul Basurto-Kuba, Blanca-Estela Monroy-Lozano
Luis-Mauricio Hurtado-Lopez, Department of Surgery, Thyroid Clinic, Hospital General de Mexico, Mexico City 06720, Mexico
Alfredo Carrillo-Muñoz, Felipe-Rafael Zaldivar-Ramirez, Erich Otto Paul Basurto-Kuba, Blanca-Estela Monroy-Lozano, Thyroid Clinic, General Surgery Service, Hospital General de Mexico, Mexico 06726, Mexico
Author contributions: Hurtado-López LM contributed to conceptualization; and all authors contributed in methodology, investigation, original drafting, and final approval.
Conflict-of-interest statement: The authors declare that they have no conflict of interest to disclose.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Luis-Mauricio Hurtado-Lopez, MD, PhD, Chief Doctor, Professor, Surgeon, Department of Surgery, Thyroid Clinic, Hospital General de Mexico, Dr. Balmis 148, Doctores, Cuauhtemoc, Mexico City 06720, Mexico.
Received: December 22, 2021
Peer-review started: December 22, 2021
First decision: February 8, 2022
Revised: February 27, 2022
Accepted: April 24, 2022
Article in press: April 24, 2022
Published online: May 20, 2022

This study evaluates the American Thyroid Association (ATA) ultrasound (US) classification system for the initial assessment of thyroid nodules to determine if it indeed facilitates clinical decision-making.


To perform a systematic review and meta-analysis of the diagnostic value of the ATA US classification system for the initial assessment of thyroid nodules.


In accordance with the PRISMA statement for diagnostic test accuracy, we selected articles that evaluated the 2015 ATA US pattern guidelines using a diagnostic gold standard. We analyzed these cases using traditional diagnostic parameters, as well as the threshold approach to clinical decision-making and decision curve analysis.


We reviewed 13 articles with 8445 thyroid nodules, which were classified according to 2015 ATA patterns. Of these, 46.62% were malignant. No cancer was found in any of the ATA benign pattern nodules. The Bayesian analysis post-test probability for cancer in each classification was: (1) Very-low suspicion, 0.85%; (2) Low, 2.6%; (3) Intermediate, 6.7%; and (4) High, 40.9%. The net benefit (NB), expressed as avoided interventions, indicated that the highest capacity to avoid unnecessary fine needle aspiration biopsy (FNAB) in the patterns that we studied was 42, 31, 35, and 43 of every 100 FNABs. The NB calculation for a probability threshold of 11% for each of the ATA suspicion patterns studied is less than that of performing FNAB on all nodules.


These three types of analysis have shown that only the ATA high-suspicion diagnostic pattern is clinically useful, in which case, FNAB should be performed. However, the curve decision analysis has demonstrated that using the ATA US risk patterns to decide which patients need FNAB does not provide a greater benefit than performing FNAB on all thyroid nodules. Therefore, it is likely that a better way to approach the assessment of thyroid nodules would be to perform FNAB on all non-cystic nodules, as the present analysis has shown the ATA risk patterns do not provide an adequate clinical decision-making framework.

Keywords: Thyroid nodule, Thyroid cancer, Ultrasound, Bayesian analysis, Systematic review, Meta-analysis

Core Tip: There is no analysis that evaluates the real diagnostic value of the 2015 American Thyroid Association thyroid nodule risk patterns and their usefulness for clinical decision-making; thus, we undertook this study to quantify both values.