ObjectiveExisting guidelines for ultrasound-guided fine-needle aspiration biopsy lack specifications on sampling sites, but the number of biopsies improves diagnostic reliability. We propose the use of class activation maps (CAMs) and our modified malignancy-specific heat maps that locate important deep representations of thyroid nodules for class predictions.MethodsWe applied adversarial noise perturbations to the segmented concentric “hot” nodular regions of equal sizes to differentiate regional importance for the malignancy diagnostic performances of an accurate ultrasound-based artificial intelligence computer-aided diagnosis (AI-CADx) system using 2,602 retrospectively collected thyroid nodules with known histopathological diagnosis.ResultsThe AI system demonstrated high diagnostic performance with an area under the curve (AUC) value of 0.9302 and good nodule identification capability with a median dice coefficient >0.9 when compared to radiologists’ segmentations. Experiments confirmed that the CAM-based heat maps reflect the differentiable importance of different nodular regions for an AI-CADx system to make its predictions. No less importantly, the hot regions in malignancy heat maps of ultrasound images in comparison with the inactivated regions of the same 100 malignant nodules randomly selected from the dataset had higher summed frequency-weighted feature scores of 6.04 versus 4.96 rated by radiologists with more than 15 years of ultrasound examination experience according to widely used ultrasound-based risk stratification American College of Radiology (ACR) Thyroid Imaging Reporting and Data System (TI-RADS) in terms of nodule composition, echogenicity, and echogenic foci, excluding shape and margin attributes, which could only be evaluated on the whole rather than on the sub-nodular component levels. In addition, we show examples demonstrating good spatial correspondence of highlighted regions of malignancy heat map to malignant tumor cell-rich regions in hematoxylin and eosin-stained histopathological images.ConclusionOur proposed CAM-based ultrasonographic malignancy heat map provides quantitative visualization of malignancy heterogeneity within a tumor, and it is of clinical interest to investigate in the future its usefulness to improve fine-needle aspiration biopsy (FNAB) sampling reliability by targeting potentially more suspicious sub-nodular regions.