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Background  The malignancy risks of various echogenic foci in thyroid nodules are not consistent. The association between malignancy and echogenic foci and various Thyroid Imaging Reporting and Data System (TIRADS) in thyroid nodules has not been evaluated. We evaluated the malignancy probability and diagnostic performance of thyroid nodules with various echogenic foci and in combination with TIRADS.    Methods  This retrospective study was approved by Institutional Review Board. The data were retrospectively collected from January 2013 to December 2014. In total, 954 patients (mean age, 50.8 years; range, 13–86 years) with 1112 nodules were included. Using χ 2  test, we determined the prevalence of benign and malignant nodules among those with and without echogenic foci; we associated each of 6 echogenic foci types with benign and malignant nodules. Diagnostic performance was compared between the 6 types alone and in combination with various TIRADS.    Results  Among 1112 nodules, 390 nodules (35.1%) were found to have echogenic foci, and 722 nodules (64.9%) were not. Among nodules with echogenic foci, 254 nodules (65.1%) were malignant. The punctate echogenic foci with comet-tail artifact showed malignancy rate of 77.8% in solid and predominantly solid nodules. Our study demonstrated relatively low PPV (33.3–56.4%) in nodules with large echogenic foci without shadowing, macrocalcification, and peripheral curvilinear or eggshell echogenic foci with or without shadowing. However, when combined with high suspicion category of TIRADS, PPV increased to 50.0–90.9%.    Conclusion  Combination with TIRADS with different types of echogenic foci offer better stratification of the malignancy risk.    Electronic supplementary material  The online version of this article (10.1186/s12880-019-0328-2) contains supplementary material, which is available to authorized users.

Echogenic foci in thyroid nodules: diagnostic performance with combination of TIRADS and echogenic foci