Clinicopathological factors increased the risk of malignancy in thyroid nodules with atypical or follicular lesions of undetermined significance (AUS/FLUS) risk factor of malignancy in thyroid nodule with AUS/FLUS

Objective: To evaluate the efficacy of the ultrasound based Thyroid Imaging Reporting and Data System (TIRADS)in estimating risk of malignancy in thyroid nodules by correlating it with Bethesda system of thyroid cytopathology. Methods: A retrospective single center study was conducted in a specialty hospital in UAE from November 2017 to November 2019 on 259 thyroid nodules which underwent ultrasound and fine needle aspiration cytology (FNAC). Thyroid nodules were evaluated using American College of Radiology (ACR) TIRADS and categorized as benign (TR1), not suspicious (TR2), mildly suspicious (TR3), moderately suspicious (TR4), or highly suspicious (TR5) for malignancy. The risk of malignancy associated with each TIRADS category was evaluated by comparing it with the Bethesda system classification of cytopathology. Results: Ultrasound and FNAC data of 259 nodules was reviewed. Out of these 33 (12.7%) nodules were excluded because FNAC revealed atypia of undetermined significance or follicular lesion of undetermined significance. The estimated risk of malignancy in TR 3 was 13.6%, in TR4 was 27% and TR5 was 63.6%. There was statistically significant correlation between –TIRADS and Bethesda system using Chi-square test (p<0.001). The receiver operating curve (ROC) analysis revealed specificity of 81.3 % [95% CI, 74.9-86.6%], NPV of 91 % [95% CI, 87.1–93.8%] and accuracy of 77.9% [95% CI, 71.9–83.1%] in differentiating benign from malignant nodules. Conclusion: The ultrasound based ACR- TIRADS scoring correlates well with the Bethesda cytopathology in thyroid nodule risk stratification. Thus, it can be used as a simple and effective tool to decide further management and avoid unnecessary FNAC and surgeries in thyroid nodules.

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MON-484 Thyroid Nodules: Not so Simple to Manage

Journal of the Endocrine Society ◽

10.1210/jendso/bvaa046.013 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

Author(s):

Alegyari Figueroa Cruz ◽

Yineli Ortiz Torres ◽

Victor J Carlo Chévere ◽

Jose M Garcia-Mateo

Keyword(s):

Decision Making ◽

Papillary Thyroid Carcinoma ◽

Thyroid Carcinoma ◽

Thyroid Nodule ◽

Thyroid Nodules ◽

Papillary Thyroid ◽

Risk Of Malignancy ◽

History Of ◽

Bethesda System ◽

Undetermined Significance

Abstract Thyroid Nodules: Not So Simple to Manage Thyroid nodules diagnosis and malignancy risk stratification remains a challenge for decision making between conservative vs invasive management. The development of the clinical guidelines provides alternatives for evaluation and management for thyroid nodules, but can be used for all patients? A 43 y/o female without known past medical history is referred to the endocrine service by her primary care physician for evaluation of a thyroid nodule. She was presenting with 1 month history of mild discomfort on the neck and was evaluated with thyroid US that was relevant for multiple bilateral solid nodules measuring <1.0cm and a one spongiform measuring 1.7 x 1.2 x 1.3cm in the right lobe extending minimally to the capsule laterally and to the carotid artery wall. Patient denies cough, hoarseness, odynophagia, shortness of breath, family history of thyroid cancer or radiation exposure. On examination there were no goiter nor palpable thyroid nodules, as well as no clinical signs and symptoms of thyroid disease. Patient is clinically and biochemically euthyroid with a very low suspicion thyroid nodule (3% estimated malignancy risk). Despite nodule is below the 2.0cm cutoff point for fine needle aspiration biopsy (FNAB) according to American Association of Clinical Endocrinologist (AACE) and American Thyroid Association (ATA) guidelines, it was done based on additional suspicious sonographic features detect by the endocrinologist on evaluation of ultrasound images. FNAB was performed and reveals Atypia of undetermined significance/Follicular Lesion of undetermined significance (AUS/FLUS) Bethesda system category III with a risk of malignancy of 5–15%. Patient was reluctant to surgery given the very low risk nodule and biopsy results of AUS/FLUS. In order to further manage this patient with undetermined significance thyroid nodule, Gene Expression Classifier (GEC) Molecular Analysis (AFIRMA) was performed. AFIRMA test was done with a second FNAB that also reveals AUS/FLUS but was found positive for BRAFv600, Bethesda system category IV: Suspicious of Papillary Thyroid Carcinoma. BRAFv600 is the only mutation that have high specificity (99%) for papillary thyroid carcinoma and is associated with increased disease-specific mortality, aggressive histologic phenotypes, lymph node metastases, extrathyroidal extension and risk of recurrence. Based on this data patient now have 95% risk of malignancy and requires surgical therapy. Patient preferred total thyroidectomy over lobectomy; pathology results shows 2.0cm Papillary Thyroid Carcinoma Stage I (T1N0M0). Despite very low risk nodule finding, malignancy was diagnosed. As depicted in this case, thyroid nodules aren’t so simple to manage, and their management should involve imaging and pathology findings along with clinical judgement and patient individualization in decision making process.

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Atypia and Follicular Lesions of Undetermined Significance in Subsequent Biopsy Result: What Clinicians Need to Know

Journal of Clinical Medicine ◽

10.3390/jcm10143082 ◽

2021 ◽

Vol 10 (14) ◽

pp. 3082

Author(s):

Krzysztof Kaliszewski ◽

Dorota Diakowska ◽

Marta Rzeszutko ◽

Łukasz Nowak ◽

Urszula Tokarczyk ◽

...

Keyword(s):

Thyroid Nodules ◽

Significant Risk ◽

Significant Risk Factor ◽

Decision Making Process ◽

Histopathological Diagnosis ◽

Follicular Lesions ◽

Risk Of Malignancy ◽

Bethesda System ◽

The Bethesda System ◽

Undetermined Significance

Atypia and follicular lesions of undetermined significance (AUS/FLUS) is the most controversial category of The Bethesda System. The risk of malignancy (ROM) in this group is estimated as 5–15%, however, the occurrence of two or more subsequent biopsy results with AUS/FLUS diagnosis makes these clinical situations more complex. We evaluated the ROM and prognostic value of aggressive ultrasound (US) features in 342 patients with thyroid nodules (TNs) with subsequent biopsy results of AUS/FLUS. We assessed US features and compared them with the final histopathological diagnosis. Overall, 121 (35.4%) individuals after first AUS/FLUS diagnosis underwent surgery and 221 (64.6%) patients had repeated biopsies. The ROM after first, second, and third biopsies with subsequent AUS/FLUS diagnosis were 7.4%, 18.5%, and 38.4% respectively. We demonstrated significantly higher rates of occurrence of aggressive US features in patients with malignancy (p < 0.0001). The age <55 years old was also a significant risk factor for TC (p = 0.044). Significant associations were found between aggressive US features and malignancy in patients after first diagnosis of AUS/FLUS (p < 0.05). The juxtaposition of US features with the number of biopsy repetitions of TN with consecutive AUS/FLUS diagnoses may simplify the decision-making process in surgical management. Two or three consecutive biopsy results with AUS/FLUS diagnosis increases the ROM.

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Comparison of elastography and conventional ultrasonography in the diagnostics of thyroid nodules, elastographic features of follicular lesions of undetermined significance

Endocrine Abstracts ◽

10.1530/endoabs.35.p594 ◽

2014 ◽

Author(s):

Martyna Wojtaszek-Nowicka ◽

Kamil Brzozowski ◽

Joanna Lukowska ◽

Stanislaw Sporny ◽

Bozena Popowicz ◽

...

Keyword(s):

Thyroid Nodules ◽

Follicular Lesions ◽

Undetermined Significance

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Surgical Outcome of Thyroid Nodules with Atypia of Undetermined Significance and Follicular Lesion of Undetermined Significance in Fine Needle Aspiration Biopsy

World Journal of Endocrine Surgery ◽

10.5005/jp-journals-10002-1220 ◽

2017 ◽

Vol 9 (3) ◽

pp. 100-103

Author(s):

Saad Alqahtani ◽

Saif Alsobhi ◽

Riyadh I Alsalloum ◽

Saleh N Najjar ◽

Hindi N Al-Hindi

Keyword(s):

Fine Needle Aspiration ◽

Surgical Outcome ◽

Thyroid Nodules ◽

Fine Needle Aspiration Biopsy ◽

Needle Aspiration ◽

Aspiration Biopsy ◽

Fine Needle ◽

Risk Of Malignancy ◽

Needle Aspiration Biopsy ◽

Undetermined Significance

ABSTRACT Aim To correlate selected clinical and ultrasonographic (US) characteristics with the final histopathological diagnosis in patients with atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS), and whether this information can be used in planning the surgical approach. Materials and methods It is a retrospective study including the operated cases of AUS/FLUS from 2011 to 2014 treated at one center. Results This cohort included 87 women and 28 men. To test for independence between categorical variables, the chi-square test was used. There was no significant correlation between age or US variables and final pathological diagnosis. However, final diagnosis of malignancy was higher in men compared with women (64.3 and 41.4% respectively; p = 0.035). Furthermore, a significant association between the diagnosis of repeated fine needle aspiration biopsy (FNAB) and the final pathological diagnosis was noted (benign vs malignant, p = 0.005). Conclusion The FNAB has a significant role in the assessment of thyroid nodules. Our results showed no correlation between age, US variables, and the risk of malignancy. Male gender is associated with higher risk of malignancy. Clinical significance Determining the risk of malignancy and prediction of surgical outcome may help triaging cases for repeat FNA or proceeding to surgery. How to cite this article Alqahtani S, Alsobhi S, Alsalloum RI, Najjar SN, Al-Hindi HN. Surgical Outcome of Thyroid Nodules with Atypia of Undetermined Significance and Follicular Lesion of Undetermined Significance in Fine Needle Aspiration Biopsy. World J Endoc Surg 2017;9(3):100-103.

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The Risk For Malignancy of the Thyroid Nodule is Modulated by Gender, Echotexture, and Intranodular Lymphocytic Thyroiditis

Hormone and Metabolic Research ◽

10.1055/a-0994-0489 ◽

2019 ◽

Vol 51 (09) ◽

pp. 559-567 ◽

Cited By ~ 1

Author(s):

Salvatore Arena ◽

Salvatore Benvenga

Keyword(s):

At Risk ◽

Thyroid Nodule ◽

Thyroid Nodules ◽

Chronic Lymphocytic Thyroiditis ◽

Lymphocytic Thyroiditis ◽

Malignancy Rate ◽

Risk Of Malignancy

AbstractBased on the American (Bethesda, 2017) or Italian (SIAPEC 2014) cytological categories of thyroid nodules, the risk of malignancy and management vary. This risk is 5–10% or<3% (benign or TIR2), 6–18% or<10% (AUS/FLUS or TIR3A), 10–40% or 15–30% (FN/SFN or TIR3B), 45–60% or 60–80% (suspicious or TIR4), 94–96% or 95% (malignant or TIR5). In 408 thyroid nodules evaluated cytologically, we computed the malignancy rate in each category considering gender (325 females, 83 males), echotexture (268 isoechoic, 140 hypoechoic), intranodular chronic lymphocytic thyroiditis (ICLT: 113 with and 295 without); histology (263 benign, 145 malignant). It was 0–1.7% for the benign categories, except hypoechoic/ICLT+ve nodules of females (25%); 0–2.3% for the AUS/FLUS category, except isoechoic/ICLT–ve nodules of males (11.1%) and hypoechoic/ICLT–ve nodules of females (22.2%). For the FN/SFN category, rate was the most variable (from 0% in isoechoic/ICLT+ve nodules of males to 100% in hypoechoic/ICLT–ve nodules of males). The 30% threshold for risk was passed in four subgroups, and the 40% threshold in two subgroups (45% in isoechoic/ICLT–ve nodules of males, 80% in hypoechoic/ICLT+ve nodules of females). For the suspicious category, rate was 100% in males, except those with isoechoic/ICLT–ve nodules (75%), and>80% in females with hypoechoic nodules. For the malignant category, rate was always 100%. In conclusion, particular groups of nodules (based on gender, echotexture, and ICLT) within the cytologically benign through the suspiciously malignant category are at risk of malignancy substantially greater (even 100%) than the standard one. Accordingly, the suggested management cannot be standardized.

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Rate of malignancy for thyroid nodules with AUS/FLUS cytopathology in a tertiary care center – a retrospective cohort study

Journal of Otolaryngology - Head and Neck Surgery ◽

10.1186/s40463-021-00530-0 ◽

2021 ◽

Vol 50 (1) ◽

Author(s):

Kalpesh Hathi ◽

Tarek Rahmeh ◽

Vicki Munro ◽

Victoria Northrup ◽

Ali Sherazi ◽

...

Keyword(s):

Thyroid Nodules ◽

Care Center ◽

Tertiary Care ◽

Treatment Pathway ◽

Malignancy Rate ◽

Risk Of Malignancy ◽

Bethesda System ◽

Thyroid Cytopathology ◽

The Bethesda System ◽

Undetermined Significance

Abstract Background Thyroid nodules are stratified through fine-needle aspiration (FNA) and are often categorized using The Bethesda System for Reporting Thyroid Cytopathology, which estimates the risk of malignancy for six cytopathological categories. The atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS) categories have varying malignancy rates reported in the literature which can range from 6 to 72.9%. Due to this heterogeneity, we assessed the malignancy rate and effectiveness of repeat FNA (rFNA) for AUS/FLUS thyroid cytopathology at our institution. Methods Electronic health records of patients with AUS/FLUS thyroid cytopathology on FNA at our center since the implementation of the Bethesda System on May 1, 2014–December 31, 2019 were retrospectively reviewed. Patient demographics, treatment pathway, and pathology results were collected. The treatment pathway of the nodules, the rFNA results, and the malignant histopathology results were reported. Malignancy rates were calculated as an upper and lower limit estimate. Results This study described 182 AUS/FLUS thyroid nodules from 177 patients. In total, 24 thyroid nodules were deemed malignant upon histopathology, yielding a final malignancy rate of 13.2–25.3%. All of the malignancies were variants of papillary thyroid carcinoma. The malignancy rate of the nodules which underwent resection without rFNA (21.5%) was lower than the malignancy rate of the nodules which underwent resection after rFNA (43.8%). 45.5% of the rFNA results were re-classified into more definitive categories. Conclusion The malignancy rate of AUS/FLUS thyroid cytopathology at our center is in line with the risk of malignancy stated by the 2017 Bethesda System. However, our malignancy rate is lower than some other Canadian centers and approximately half of our rFNAs were re-classified, highlighting the importance of establishing center-specific malignancy and rFNA re-classification rates to guide treatment decisions.

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Diagnostic Accuracy of the Bethesda System of Reporting Thyroid Cytopathology in the Evaluation of Thyroid Nodule in a Tertiary Care Hospital of Kolkata

Journal of Evidence Based Medicine and Healthcare ◽

10.18410/jebmh/2021/46 ◽

2021 ◽

Vol 8 (05) ◽

pp. 241-245

Author(s):

Sweta Verma ◽

Mita Saha Dutta Chowdhury ◽

Souradeep Ray ◽

Ruma Guha

Keyword(s):

Diagnostic Accuracy ◽

Thyroid Nodule ◽

Thyroid Nodules ◽

Tertiary Care ◽

Needle Aspiration ◽

Care Hospital ◽

Risk Of Malignancy ◽

Needle Aspiration Cytology ◽

Thyroid Cytopathology ◽

The Bethesda System

BACKGROUND Thyroid cancer has the most rapidly increasing incidence of all major cancers in India. The overall prevalence of thyroid malignancy is approximately 1 - 5 % of all cancers in women and less than 2 % in men. Thyroid nodules are a common clinical finding and have a reported prevalence of 4 – 7 % in the general population. The vast majority of these nodules are non-neoplastic or benign and the risk of malignancy varies from 5 to 10 %. Fine needle aspiration cytology (FNAC) is an efficient and reliable means for the evaluation of thyroid nodules. A key challenge for clinicians is to choose which thyroid nodule is to be investigated further and treated. Early detection and treatment of malignant thyroid nodules is associated with excellent outcomes. The aim of our study is to compare and correlate between fine needle aspiration cytology and histopathology of resected specimen and to determine the diagnostic accuracy of TBSRTC (The Bethesda System for Reporting Thyroid Cytopathology) in thyroid nodule. METHODS This is a cross sectional validation study conducted in a tertiary care hospital (R.G. Kar Medical College) of Kolkata to find the sensitivity, specificity and diagnostic accuracy of TBSRTC in evaluation of thyroid nodule. RESULTS We have observed that TBSRTC is highly sensitive and specific in stratifying the malignancy risk of thyroid nodule. CONCLUSIONS It aids the clinician to choose the thyroid nodules which require further evaluation and intervention. It also guides the clinician to decide the operability of thyroid nodule. TBSRTC is highly accurate and is highly specific in stratifying the risk of malignancy of thyroid nodule. KEYWORDS TBSRTC, FNAC, Thyroid Nodules, Thyroid Cancer

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Triple diagnostic test in the evaluation of thyroid nodules

International Surgery Journal ◽

10.18203/2349-2902.isj20211309 ◽

2021 ◽

Vol 8 (4) ◽

pp. 1264

Author(s):

Snigdha Kamini ◽

Jainendra K. Arora ◽

Sunil Kumar Jain

Keyword(s):

Thyroid Nodule ◽

Sensitivity And Specificity ◽

Thyroid Nodules ◽

Histopathological Examination ◽

Clinical Score ◽

Triple Test ◽

Follicular Lesions ◽

Unnecessary Procedures ◽

Sensitivity Specificity ◽

The Bethesda System

Background: Thyroid nodules are a common endocrine disease whose prevalence in India is approximately 12.2%. Although most patients with suspected nodules have benign conditions, the overestimation of malignancy leads to the performance of unnecessary procedures. No clinical, radiological and cytological parameters has singularly shown significant impact on clinical practice and post-operative histopathological examination remains the gold standard in the diagnosis of malignancy.Methods: 55 patients with thyroid nodules were evaluated and the Clinical assessment findings were recorded by McGill thyroid nodule score, ultrasonography findings using TIRADS and FNAC findings by the Bethesda system. The triple test was then used to classify them and these results were compared with the HPE of the post-operative specimen.Results: The sensitivity and specificity of TIRADS, FNAC were higher as compared to clinical score; clinical score had lowest sensitivity of 72.73%. The sensitivity, specificity, PPV, NPV and accuracy of triple test was 100%. Triple test had higher sensitivity, specificity and accuracy in differentiating thyroid nodules as compared to any of the three parameters used individually.Conclusions: Triple test has higher accuracy, sensitivity and specificity in determining the nature of thyroid nodule than each of the parameters used individually and it is especially useful in follicular lesions. On the basis of the results of this study, we conclude that the triple test can reliably be used to differentiate benign and malignant nodules preoperatively.

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Papillary thyroid cancer in an adolescent with a toxic single nodular goiter

Problems of Endocrinology ◽

10.14341/probl2017632114-116 ◽

2017 ◽

Vol 63 (2) ◽

pp. 114-116 ◽

Cited By ~ 1

Author(s):

Olga S. Rogova ◽

Goar F. Okminyan ◽

Lubov N. Samsonova ◽

Elena V. Kiseleva ◽

Oleg Yu. Latyshev ◽

...

Keyword(s):

Thyroid Cancer ◽

Thyroid Nodule ◽

Papillary Thyroid Cancer ◽

Thyroid Nodules ◽

Fine Needle Aspiration Biopsy ◽

Nodular Goiter ◽

Needle Aspiration ◽

Papillary Thyroid ◽

Risk Of Malignancy ◽

Functional Autonomy

The rate of nodular goiter in children ranges from 0.05 to 5.1%; in this case, the risk of thyroid cancer in childhood amounts to 3―70% of all cases of thyroid pathology. Therefore, the main issue is the differential diagnosis of a nosological variant of a thyroid nodule, which defines the optimal therapeutic tactics for a particular patient. The risk of malignancy is traditionally believed to be low in the case of decompensated functional autonomy of a thyroid nodule; therefore, the need for fine needle aspiration biopsy (FNAB) followed by cytomorphological analysis of the aspirate is avoided in most cases. The presented clinical case demonstrates papillary cancer in an adolescent with a toxic single nodular goiter. A thyroid ultrasound examination revealed a nodular lesion in the boy. An increase in the thyroid size and thyrotoxicosis manifestation occurred 3 years later. A cytomorphological study identified follicular neoplasia; scintigraphy revealed a hot nodule. Surgical treatment was planned. Antithyroid therapy was prescribed to prepare for surgery. After compensation of thyrotoxicosis, hemithyroidectomy was performed. A histological examination diagnosed papillary thyroid cancer, which required repeated thyroidectomy followed by radioiodine I131 ablation. The postoperative period was uneventful; the patient well tolerated suppressive levothyroxine therapy. Therefore, the presence of a toxic single nodular goiter does not exclude thyroid cancer, which defines the need to discuss the indications for FNAB of thyroid nodules in children.

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