Objective: To evaluate diagnostic value of Ruijin-thyroid imaging reporting and datasystem (RJ-TIRADS) combining with fine needle aspiration biopsy(FNAB) in thyroid nodules in elderly patients. Methods: From April 2017 to April 2020, a total of 117 patients (≥60 years old, 30 male and 87 female) with 129 thyroid nodules were enrolled from Department of Ultrasound,Suzhou Hospital Affiliated to Anhui Medical University and Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. All the patients were performed with ultrasound-guided FNAB and surgical treatment. Postoperative pathological diagnosis confirmed that 98 lesions were malignant and 31 were benign in all 129 thyroid nodules form patients. The data including size, internal structure, echo, morphology, margin and calcification of nodules on ultrasound imaging was collected and analyzed. Thyroid nodules were classified into three categories according to RJ-TIRADS classification as follows: Nodules without malignant characteristic(MC) were classified as category 3, nodules with one MC were classified as category 4A, nodules with 2 MC were classified as category 4B, nodules with 3-4 MC were classified as category 4C, nodules with 5 MC were classified as category 5. The diagnostic sensitivity,specificity, positive predictive value,negative predictive value and accuracy of RJ-TIRADS and FNAB alone or combination for malignant thyroid nodules in elderly patients were calculated regarding to the results of pathological biopsy. Results: There were significant differences between male and female patients with thyroid cancer in terms of solid (91.7% and 100%) lesions(P<0.05). The RJ-TIRADS classification results showed that cancer risk for patients with the category 4A-4C（59.3%, 88.4%, 100%） in elderly patients was higher than that in the general population（5.0%-20.0%, 21.0%-50.0%, 51.0%-90.0%）. The sensitivity, specificity and accuracy of FNAB in diagnosing thyroid nodules were 99.0%, 83.9% and 95.3%, higher respectively than ultrasound malignant characteristics, such as solid, low echo, aspect ratio of nodules >1, irregular margin, micro-calcification. Specificity and accuracy of FNAB in combination with RJ-TIRADS increased from 29%, 82.9% to 87.1%, 96.9% respectively. Conclusions: Solid nodules more often occur in the elderly female with thyroid cancer than male with thyroid cancer. Compared to the general population with RJ-TIRADS category 4, elderly patients classified as RJ-TIRADS category 4 have a higher risk of having thyroid cancer. FNAB combined with RJ-TIRADS may increase diagnosis value of thyroid nodules in the elderly.