Objective: To analysis retrospectively the value of The Thyroid Imaging Report and Data System recommended by American College of Radiology (ACR-TIRADS) 2017 and ultrasound elastographyalone or in combination for the differential diagnosis of benign and malignant thyroid nodules. Methods: From January 2012 to October 2017, 503 patients with 653 thyroid nodules underwent preoperative thyroid ultrasonography and thyroidectomy at the Integrated Chinese Traditional Medicine and Western Medicine Hospital were enrolled. General clinical information, thyroid ultrasound report, ultrasound elastography and results of postoperative pathology were collected. All the nodules were graded by ACR-TIRADS, elastography grading and scoring system. The four differential diagnostic categories were as follows:category 1, either elastography or ACR-TIRADS considered as malignant nodules; category 2, both elastography and ACR-TIRADS considered as malignant nodules; category 3, elastography score and grade of ACR-TIRADS added; category 4, elastography score and ACR-TIRADS score added. The postoperative pathological results were regarded as a gold standard to construct the receiver operating-characteristic curve (ROC), calculate the area under the curve (AUC), and the best cutoff value was defined according to the Yoden index. Results: The AUC of ACR-TIRADS was as high as that of ultrasound elastography (0.853 vs. 0.848, P=0.745). Category 1 had a differential diagnosis value with higher sensitivity (96.94%) and the negative predictive value (84.85%). The category 2 had a specificity of 88.96% and a positive predictive value of (95.53%). The sensitivity of category 3 was higher than that of category 4 (88.78% vs. 85.92%, P<0.001). There was no statistical difference between AUC of category 3 of category 4.(0.913 vs. 0.901, P=0.088). Conclusions: ACR-TIRADS is superior to ultrasound elastography in the differential diagnosis of benign and malignant thyroid nodules. Both category 3 and category 4 are superior to ACR-TIRADS or ultrasound elastography alone. The category 4 has a higher discriminatory value in the differential diagnosis of benign and malignant thyroid nodules.