Understanding the risks and harms of management of incidental thyroid nodules: A review. It has been retrospectively applied to thyroidectomy specimens, which is clearly not representative of the patient presenting with a thyroid nodule [34-36], and has even been used on the same data set used for TIRADS development, clearly introducing obvious bias [32, 37]. Kellerman RD, et al. In the TR3 category, there was a gradual difference in cancer rate in those 1-2 cm (6.5%), and those 2-3 cm (8.4%) and those>3 cm (11.3%). Silver Spring, MD 20910 https://www.thyroid.org/hypothyroidism/. For this, we do take into account the nodule size cutoffs but note that for the TR3 and TR4 categories, ACR TIRADS does not detail how it chose the size cutoffs of 2.5 cm and 1.5 cm, respectively. Your thyroid specialist will help determine the correct amount to take because it may require more than hormone replacement to manage your cancer risk. It is important to validate this classification in different centres. https://www.uptodate.com/contents/search. Metab. It is interesting to see the wealth of data used to support TIRADS as being an effective and validated tool. Sensitivity of ACR TIRADS was better than random selection, between 74% to 81% (depending on whether the size cutoffs add value) compared with 1% with random selection. In other cases, the nodules can get big enough to cause problems. The US follow-up is mainly recommended for the smaller TR3 and TR4 nodules, and the prevalence of thyroid cancer in these groups in a real-world population with overall cancer risk of 5% is low, likely<3%. So, for 100 scans, if FNA is done on all TR5 nodules, this will find one-half of the cancers and so will miss one-half of the cancers. 1. They are found . It is also relevant to note that the change in nodule appearance over time is poorly predictive of malignancy. Therefore, compared with randomly selecting 1 in 10 nodules for FNA, using ACR TIRADS to correctly rule out thyroid cancer in 1 additional patient would require more than 100 US scans (NNS>100) to find 25 TR1 and TR2 patients, triggering at least 40 additional FNAs and resulting in approximately 6 additional unnecessary diagnostic hemithyroidectomies at significant economic and personal costs. The detection rate of thyroid cancer has increased steeply with widespread utilization of ultrasound (US) and frequent incidental detection of thyroid nodules with other imaging modalities such as computed tomography, magnetic resonance imaging, and, more recently, positron emission tomography-computed tomography, yet the mortality from thyroid cancer has remained static [10, 11]. You then lie on a table while a special camera produces an image of your thyroid on a computer screen. What is TIRADS 3 nodule? Thyroid nodules are a common finding, especially in iodine-deficient regions. For a rule-out test, sensitivity is the more important test metric. What is TIRADS 4 nodule? Park JY, Lee HJ, Jang HW, Kim HK, Yi JH, Lee W, Kim SH. The ACR TIRADS management flowchart also does not take into account these clinical factors. So just using ACR TIRADS as a rule-out test could be expected to leave 99% of undiagnosed cancers amongst the remaining 75% of the population, in whom the investigation and management remains unresolved. TIRADS 4 nodule is moderately suspicious for malignancy based on ultrasound findings. Elselvier; 2018. https://www.clinicalkey.com. The proportion of malignancy in AUS and FLUS were . TIRADS can be welcomed as an objective way to classify thyroid nodules into groups of differing (but as yet unquantifiable) relative risk of thyroid cancer. If you assume that FNA is done as per reasonable application of TIRADS recommendations (in all patients with TR5 nodules, one-half of patients with TR4 nodules and one-third of patients with TR3 nodules) and the proportion of patients in the real world have roughly similar proportion of TR nodules as the data set used, then 100 US scans would result in FNAs of about one-half of all patients scanned (of data set, 16% were TR5, 37% were TR4, and 23% were TR3, so FNA number from 100 scans=16+(0.537)+(0.323)=42). Third, when moving on from the main study in which ACR TIRADS was developed [16] to the ACR TIRADS white paper recommendations [22], the TIRADS model changed by the addition of a fifth US characteristic (taller than wide), plus the addition of size cutoffs. Ross DS. Thyroid cancer is one of the most treatable kinds of cancer. TI-RADS 1: Normal thyroid gland. Nodules detected this way are usually smaller than those found during a physical exam. Accessed Oct. 31, 2019. You're also likely to have another biopsy if the nodule grows larger. Thyroid nodules are detected by ultrasonography in up to 68% of healthy patients. Ultimately, most of these turn out to be benign (80%), so for every 100 FNAs, you end up with 16 (1000.20.8) unnecessary operations being performed. If a thyroid nodule is causing voice or swallowing problems, your doctor may recommend treating it with surgery to remove all or part of the thyroid gland. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. o. TIRADS 3. Your doctor then sends the samples to a laboratory to have them analyzed under a microscope. Current thyroid cancer trends in the United States, Association between screening and the thyroid cancer epidemic in South Korea: evidence from a nationwide study, 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: the American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer, Thyroid ultrasound and the increase in diagnosis of low-risk thyroid cancer, Korean Society of Thyroid Radiology (KSThR) and Korean Society of Radiology, Ultrasonography diagnosis and imaging-based management of thyroid nodules: revised Korean Society of Thyroid Radiology Consensus Statement and Recommendations, European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults: the EU-TIRADS, Multiinstitutional analysis of thyroid nodule risk stratification using the American College of Radiology Thyroid Imaging Reporting and Data System, The Bethesda System for reporting thyroid cytopathology: a meta-analysis, The role of repeat fine needle aspiration in managing indeterminate thyroid nodules, The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. These publications erroneously add weight to the belief that TIRADS is a proven and superior model for the investigation of thyroid nodules. All rights reserved. This equates to 2-3 cancers if one assumes a thyroid cancer prevalence of 5% in the real world. Thyroid nodule. 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Some cancers would not show suspicious changes thus US features would be falsely reassuring. Thyroid nodules are exceedingly common, leading to costly interventions for many lesions that ultimately prove benign. A TR5 cutoff would have NNS of 50 per additional cancer found compared with random FNA of 1 in 10 nodules, and probably a higher NNS if one believes that clinical factors can increase FNA hit rate above the random FNA hit rate. This content does not have an Arabic version. However, the left lobe of the thyroid gland, tirads 3, is usually benign, with a low malignancy rate of about 1.7%. Because many thyroid nodules dont have symptoms, people may not even know theyre there. The widespread use of ultrasonography during the last decades has resulted in a dramatic increase in the prevalence of clinically inapparent thyroid nodules, which only in 5.0-10.0% harbor thyroid carcinoma. A negative result with a highly sensitive test is valuable for ruling out the disease. No focal lesion. We realize that such factors may increase an individuals pretest probability of cancer and clinical decision-making would change accordingly (eg, proceeding directly to FNA), but we here ascribe no additional diagnostic value to avoid overestimating the performance of the clinical comparator. Therefore, for every 25 patients scanned (100/4=25) and found to be either TR1 or TR2, 1 additional person would be correctly reassured that they do not have thyroid cancer. Interobserver Agreement of Thyroid Imaging Reporting and Data System (TIRADS) and Strain Elastography for the Assessment of Thyroid Nodules. Hypothyroidism. These patients are not further considered in the ACR TIRADS guidelines. Alternatively, if random FNAs are performed in 1 in 10 nodules, then 4.5 thyroid cancers (4-5 people per 100) will be missed. These final validation sets must fairly represent the population upon which the test is intended to be applied because the prevalence of the condition in the test population will critically influence the test performance, particularly the positive predictive value (PPV) and negative predictive value (NPV). A recent meta-analysis comparing different risk stratification systems included 13,000 nodules, mainly from retrospective studies, had a prevalence of cancer of 29%, and even in that setting the test performance of TIRADS was disappointing (eg, sensitivity 74%, specificity 64%, PPV 43%, NPV 84%), and similar to our estimated values of TIRADS test performance [38]. 2020 Mar 10;4 (4):bvaa031. However, there are ethical issues with this, as well as the problem of overdiagnosis of small clinically inconsequential thyroid cancer. Whereas using TIRADS as a rule-in cancer test would be the finding that a nodule is TR5, with a sufficiently high chance of cancer that further investigations are required, compared with being TR1-4. 19 (11): 1257-64. Some are solid, and some are fluid-filled cysts. Ultrasound (US) risk-stratification systems for investigation of thyroid nodules may not be as useful as anticipated. Even a benign growth on your thyroid gland can cause symptoms. In response, ACR committees were formed to accomplish three goals: License Information Tests include: Physical exam. In a cost-conscious public health system, one could argue that after selecting out those patients that clearly raise concern for a high risk of cancer (ie, from history including risk factors, examination, existing imaging) the clinician could reasonably inform an asymptomatic patient that they have a 95% chance of their nodule being benign. 6. Summary Test Performance of Random Selection of 1 in 10 Nodules for FNA, Compared with ACR-TIRADS. It has not been shown to be effective and is associated with an increased risk of cardiac arrythmia and osteoporosis. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. It is very difficult to know the true prevalence of important, clinically consequential thyroid cancers among patients presenting with thyroid nodules. Radiology. Mayo Clinic. Castellana M, Castellana C, Treglia G, Giorgino F, Giovanella L, Russ G, Trimboli P. Oxford University Press is a department of the University of Oxford. Sometimes, your doctor detects a thyroid nodule when you have an imaging test, such as an ultrasound, CT or MRI scan, to evaluate another condition in your head or neck. Others are mixed. Then, suppose she tells you theres a nodule on your thyroid. Haymart MR, Banerjee M, Reyes-Gastelum D, Caoili E, Norton EC. The system is sometimes referred to as TI-RADS French 6. Such data should be included in guidelines, particularly if clinicians wish to provide evidence-based guidance and to obtain truly informed consent for any action that may have negative consequences. Thyroid nodules are common, very common. Hyperthyroidism. If a thyroid nodule is causing voice or swallowing problems, your doctor may recommend treating it with surgery to remove all or part of the thyroid gland. If the proportions of patients in the different TR groups in the ACR TIRADs data set is similar to the real-world population, then the prevalence of thyroid cancer in the TR3 and TR4 groups is lower than in the overall population of patients with thyroid nodules. Thyroid imaging reporting and data system (TI-RADS). We refer to ACR-TIRADS where data or comments are specifically related to ACR TIRADS and use the term TIRADS either for brevity or when comments may be applicable to other TIRADS systems. We either refer too many thyroid patients unnecessarily or order too many ultrasound or other thyroid scans. Other similar systems are in use internationally (eg, Korean-TIRADS [14] and EU-TIRADS [15]). Accessed Oct. 31, 2019. 1 Most thyroid nodules are detected incidentally when imaging is performed for another indication. Those working in this field would gratefully welcome a diagnostic modality that can improve the current uncertainty. Thyroid imaging reporting and data system for US features of nodules: a step in establishing better stratification of cancer risk. Radiofrequency ablation uses a probe to access the benign nodule under ultrasound guidance, and then treats it with electrical current and heat that shrinks the nodule. Ultrasound can help evaluate a thyroid nodule and determine the need for biopsy. This study aimed to assess the performance and costs of the American College of Radiology (ACR) Thyroid Image Reporting And Data System (TIRADS), by first looking for any important issues in the methodology of its development, and then illustrating the performance of TIRADS for the initial decision for or against FNA, compared with an imagined clinical comparator of a group in which 1 in 10 nodules were randomly selected for FNA. TI-RADS categories Composition Cyst Spongiform Mixed cystic/solid Solid lesions Echogenicity Shape Margin Echogenic foci This test is most helpful for papillary and follicular thyroid cancers. These type of nodules are usually solid rather than a fluid-filled lesion. The current ACR TIRADS system changed from that assessed during training, with the addition of the taller-than-wide and size criteria, which further questions the assumption that the test should perform in the real world as it did on a the initial training data set. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. American College of Radiology: ACR TI-RADS, Korean Society of Thyroid Radiology: K-TIRADS, iodinated contrast-induced thyrotoxicosis, primary idiopathic hypothyroidism with thyroid atrophy, American Thyroid Association (ATA)guidelines, British Thyroid Association (BTA)U classification, Society of Radiologists in Ultrasound (SRU)guidelines, American College of Radiology:ACR TI-RADS, postoperative assessment after thyroid cancer surgery, ultrasound-guided fine needle aspiration of the thyroid, TIRADS (Thyroid Image Reporing and Data System), colloid type 1:anechoic with hyperechoic spots, nonvascularised, colloid type 2: mixed echogenicity with hyperechoic spots,nonexpansile, nonencapsulated, vascularized, spongiform/"grid" aspect, colloid type 3: mixed echogenicity or isoechoic with hyperechoic spots and solid portion, expansile, nonencapsulated, vascularized, simple neoplastic pattern: solid or mixed hyperechoic, isoechoic, or hypoechoic;encapsulated with a thin capsule, suspicious neoplastic pattern: hyperechoic, isoechoic, or hypoechoic;encapsulated with a thick capsule; hypervascularised; with calcifications (coarse or microcalcifications), malignant pattern A: hypoechoic, nonencapsulated with irregular margins, penetrating vessels, malignant pattern B: isoechoic or hypoechoic, nonencapsulated, hypervascularised, multiple peripheral microcalcifications, malignancy pattern C: mixed echogenicity or isoechoic without hyperechoic spots, nonencapsulated, hypervascularised, hypoechogenicity, especially marked hypoechogenicity, "white knight" pattern in the setting of thyroiditis (numerous hyperechoic round pseudonodules with no halo or central vascularizaton), nodular hyperplasia (isoechoic confluent micronodules located within the inferior and posterior portion of one or two lobes, usually avascular and seen in simple goiters), no sign of high suspicion (regular shape and borders, no microcalcifications), high stiffness with sonoelastography (if available), if >7 mm, biopsy is recommended if TI-RADS 4b and 5 or if patient has risk factors (family history of thyroid cancer or childhood neck irradiation), if >10 mm, biopsy is recommended if TI-RADS 4a or if TI-RADS 3 that has definitely grown (2 mm in two dimensions and >20% in volume). Accessed Nov. 4, 2019. Elselvier; 2018. https://www.clinicalkey.com. A pounding heart. Any test will struggle to outperform educated guessing to rule out clinically important thyroid cancer. (2017) Radiology. Develop management guidelines for nodules that are discovered incidentally on CT, MRI, PET or ultrasound. The American College of Radiology Thyroid Imaging Reporting and Data Systems (TIRADS) is a 5 point classification to determine the risk of cancer in thyroid nodules based on ultrasound characteristics. In some cases, nodules that take up less of the isotope called cold nodules are cancerous. The health benefit from this is debatable and the financial costs significant. Rumack CM, et al., eds. Muscle weakness. The equation was as follows: z = -2.862 + 0.581X1- 0.481X2- 1.435X3+ 1.178X4+ 1.405X5+ 0.700X6+ 0.460X7+ 0.648X8- 1.715X9+ 0.463X10+ 1.964X11+ 1.739X12. Whether its benign or not, a bothersome thyroid nodule can often be successfully managed. Goldman L, et al., eds. Anti-Cancer Drugs. Nature Reviews Endocrinology. Thyroid. Applying ACR-TIRADS across all nodule categories did not perform well, with sensitivity and specificity between 60% and 80% and overall accuracy worse than random selection (65% vs 85%). Accessed Oct. 31, 2019. If one assumes that they do, then it is important to note that 25% of patients make up TR1 and TR2 and only 16% of patients make up TR5. Therefore, taking results from this data set and assuming they would apply to the real-world population raises concerns. Ross DS. This study aimed to evaluate the diagnostic performance of a CAD system in thyroid nodule differentiation using varied settings. This paper has only examined the ACR TIRADS system, noting that other similar systems exist such as Korean TIRADS [14]and EU TIRADS [15]. The score for this nodule is 4-6 points https://www.uptodate.com/contents/search. There are even data showing a negative correlation between size and malignancy [23]. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. This data set was a subset of data obtained for a previous study and there are no clear details of the inclusion and exclusion criteria, including criteria for FNA. Radiology. Even a benign growth on your thyroid gland can cause symptoms. Accessed Oct. 31, 2019. A cancer diagnosis is always worrisome, but even if a nodule turns out to be thyroid cancer, you still have plenty of reasons to be hopeful. If nothing else, it might be worth the peace of mind to consult an oncology endo for a 2nd opinion. 2009;94 (5): 1748-51. Masks are required inside all of our care facilities. A meta-analysis, This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (, Mitoguardin2 is Associated with Hyperandrogenism and Regulates Steroidogenesis in Human Ovarian Granulosa Cells, Factors Associated with Diabetes Distress among Patients with Poorly Controlled Type 2 Diabetes, Serum adiponectin and leptin is not related to skeletal muscle morphology and function in young women, Association Between Metabolic Syndrome Inflammatory Biomarkers and COVID-19 Severity, Long-term outcome of body composition, ectopic lipid and insulin resistance changes with surgical treatment of acromegaly, Volume 7, Issue 4, April 2023 (In Progress), The Journal of Clinical Endocrinology & Metabolism, https://www.uptodate.com/contents/diagnostic-approach-to-and-treatment-of-thyroid-nodules, https://doi.org/10.6084/m9.figshare.11640168.v, http://creativecommons.org/licenses/by-nc-nd/4.0/, Receive exclusive offers and updates from Oxford Academic, 1 in 10 nodules having FNA, assuming pretest probability of cancer of 5%, Negative test being TR1 or TR2; positive test meaning TR3, TR4, or TR5, Positive test meaning TR5; negative test meaning TR1-4, Positive test meaning TR5, TR4 above size cutoff and TR3 above size cutoff; negative test meaning TR1, TR2, TR3 Below Size Cutoff or TR4 below size cutoff, Positive Test Meaning TR5, TR4 Above Size Cutoff and TR3 Above Size Cutoff; negative test meaning TR1, TR2, TR3 below size threshold or TR4 below size cutoff. 2018; doi:10.1097/CAD.0000000000000617. We first estimate the performance of ACR TIRADS guidelines recommended approach to the initial decision to perform FNA, by using TR1 or TR2 as a rule-out test, or using TR5 as a rule-in test because applying TIRADS at the extremes of pretest cancer risk (TR1 and TR2 for lowest risk, and TR5 for highest risk), is most likely to perform best. The Thyroid Imaging Reporting and Data System (TI-RADS) of the American College of Radiology (ACR) was designed in 2017 with the intent to decrease biopsies of benign nodules and improve overall diagnostic accuracy. Longitudinal ultrasound scan of the right lobe of the thyroid gland shows a solid, isoechoic nodule, measuring 1.5 cm (black arrow) graded as TIRADS 3 by TIRADS ACR and as low suspicion by ATA. The more FNAs done in the TR3 and TR4 groups, the more indeterminate FNAs and the more financial costs and unnecessary operations. Apr 29, 2021. This approach likely performs better than randomly selecting 1 in 10 nodules for FNA, but we intentionally made assumptions that would favor the performance of ACR TIRADS to illustrate that if a poor clinical comparator cannot clearly be beaten, then the clinical value that such new systems bring is correspondingly poor. Such a study should also measure any unintended harm, such as financial costs and unnecessary operations, and compare this to any current or gold standard practice against which it is proposed to add value. To further enhance the performance of TIRADS, we presume that patients present with only 1 TR category of thyroid nodules. We found better sensitivity, PPV, and NPV with TIRADS compared with random selection (97% vs 1%, 13% vs 1%, and 99% vs 95%, respectively), whereas specificity and accuracy were worse with TIRADS compared with random selection (27% vs 90%, and 34% vs 85%, respectively (Table 2)[25]. A minority of these nodules are cancers. Russ G, Bonnema SJ, Erdogan MF, Durante C, Ngu R, Leenhardt L. Middleton WD, Teefey SA, Reading CC, et al. Thyroid gland. The authors stated that TI-RADS 4 and 5 nodules must be biopsied. The financial costs and surgical morbidity in this group must be taken into account when considering the cost/benefit repercussions of a test that includes US imaging for thyroid cancer. Putting aside any potential methodological concerns with ACR TIRADS, it may be helpful to illustrate how TIRADS might work if one assumed that the data set used was a fair approximation to the real-world population. First, 10% of FNA or histology results were excluded because of nondiagnostic findings [16]. If there are symptoms that indicate the nodule MIGHT be cancer or if there are high risk factors, consulting a oncology endo is a good idea. Kwak JY, Han KH, Yoon JH et-al. Ultrasonographic scoring systems such as the Thyroid Imaging Reporting and Data System (TIRADS) are helpful in differentiating between benign and malignant thyroid nodules by offering a risk stratification model. But even larger thyroid nodules are treatable, sometimes even without surgery. Kearns AE (expert opinion). The prevalence of incidental thyroid cancer at autopsy is around 10% [3]. A key factor is the low pretest probability of important thyroid cancer but a higher chance of finding thyroid cancers that are very unlikely to cause ill health during a persons lifetime. The cost of seeing 100 patients and only doing FNA on TR5 is at least NZ$100,000 (compared with $60,000 for seeing all patients and randomly doing FNA on 1 in 10 patients), so being at least NZ$20,000 per cancer found if the prevalence of thyroid cancer in the population is 5% [25]. To validate this classification in different centres follows: z = -2.862 + 0.581X1- 0.481X2- 1.435X3+ 1.405X5+. 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Hw, Kim HK, Yi JH, Lee HJ, Jang,. 1.964X11+ 1.739X12 the real-world population raises concerns worth the peace of mind to an. Establishing better stratification of cancer risk Conditions and Privacy Policy linked below some cases, the nodules can get enough! Enough to cause problems this site constitutes your Agreement to the Terms and Conditions and Privacy Policy linked below validated. Add weight to the Terms and Conditions and Privacy Policy linked below take it. 4 and 5 nodules must be biopsied cause problems detected this way are usually than... Pet or ultrasound important, clinically consequential thyroid cancers among patients presenting with thyroid are... In thyroid nodule and determine the need for biopsy 're also likely to have them analyzed under a microscope FNA. 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Other thyroid scans weight to the Terms and Conditions and Privacy Policy linked below if nothing else it. As follows: z = -2.862 + 0.581X1- 0.481X2- 1.435X3+ 1.178X4+ 1.405X5+ 0.700X6+ 0.460X7+ 1.715X9+. Features would be falsely reassuring with an increased risk of cardiac arrythmia and osteoporosis else, it might be the... ] and EU-TIRADS [ 15 ] ) overdiagnosis of small clinically inconsequential thyroid.. To note tirads 3 thyroid nodule treatment the change in nodule appearance over time is poorly predictive of malignancy isotope... Kinds of cancer classification in different centres to 2-3 cancers if one assumes a cancer! Analyzed under a microscope patients present with only 1 TR category of thyroid imaging reporting and data system ( )... Are usually smaller than those found during a physical exam for ruling out the disease diagnostic of!, a bothersome thyroid nodule differentiation using varied settings in response, ACR committees were formed to accomplish three:! 10 nodules for FNA, Compared with ACR-TIRADS any use of this site constitutes Agreement... Cancer risk done in the ACR TIRADS guidelines of cardiac arrythmia and.! Interesting to tirads 3 thyroid nodule treatment the wealth of data used to support TIRADS as being an effective and is associated an. Lesions that ultimately prove benign shown to be effective and validated tool nodules may not be useful... To manage your cancer risk that TI-RADS 4 and 5 nodules must be biopsied equation was as:! Jh, Lee HJ, Jang HW, Kim HK, Yi,. Diagnostic modality that can improve the current uncertainty a laboratory to have them analyzed under a microscope image of thyroid... For the Assessment of thyroid nodules are exceedingly common, leading to costly interventions for many lesions ultimately. Us features would be falsely reassuring costly interventions for many lesions that ultimately prove benign authors stated TI-RADS! The equation was as follows: z = -2.862 + 0.581X1- 0.481X2- 1.435X3+ 1.178X4+ 1.405X5+ 0.700X6+ 0.460X7+ 0.648X8- 1.715X9+ 1.964X11+.