bethesda 4 thyroid nodule management

Thyroid nodules are common; their prevalence in the general population is high, the percentages vary depending on the mode of discovery: 2–6 % (palpation), 19–35 % (ultrasound) and 8–65 % (autopsy data) [2–4]. Benign and malignant thyroid nodules: US differentiation--multicenter retrospective study. The impact of assessing specimen adequacy and number of needle passes for fine-needle aspiration biopsy of thyroid nodules.Â, Kuru B, Gulcelik NE, Gulcelik MA, Dincer H. The false-negative rate of fine-needle aspiration cytology for diagnosing thyroid carcinoma in thyroid nodules.Â, Giles WH, Maclellan RA, Gawande AA, et al. The thyroid nodule. Molecular tests have been developed in an attempt to determine whether an indeterminate nodule is benign or malignant. Thyroid incidentalomas detected on 18 F-fluorodeoxyglucose-positron emission tomography/computed tomography: Thyroid Imaging Reporting and Data System (TIRADS) in the diagnosis and management of patients. Overview of molecular biomarkers for enhancing the management of cytologically indeterminate thyroid nodules and thyroid cancer.Â, Fukahori M, Yoshida A, Hayashi H, et al. For nodules with the cytology reported as suspicious for malignancy, after consideration of clinical and US risk factors and patient preference, molecular tests (seven-gene mutation and rearrangement panel) can be considered if it would alter the surgical decision making, which is the recommended modality of management [1, 69, 104]. 1997;126(3):226–31. Alexander EK, Schorr M, Klopper J, et al. AACE/ACE disease state commentary: molecular diagnostic testing of thyroid nodules with indeterminate cytopathology. Thyroid ultrasound should be performed in all those suspected or known to have a nodule to confirm the presence of a nodule, evaluate for additional nodules and cervical lymph nodes and assess for suspicious sonographic features. Orija IB, Pineyro M, Biscotti C, Reddy SS, Hamrahian AH. The evaluation of a thyroid nodule in a pregnant woman should be done in same way as one would in nonpregnant state. Association between BRAF V600E mutation and mortality in patients with papillary thyroid cancer.Â. Cherella CE, Feldman HA, Hollowell M, et al. Ultrasonography-guided fine-needle aspiration of thyroid incidentaloma: correlation with pathological findings. Prevalence by palpation and ultrasonography.Â, Hegedüs L. Clinical practice: the thyoid nodule.Â, Guth S, Theune U, Aberle J, et al. FNA biopsy is recommended for nodules > 1 cm with high suspicion features (solid hypoechoic nodule or solid hypoechoic component of a partially cystic nodule with either one or more of features: irregular margin or microcalcification or taller than wide shape or rim calcification or evidence of extra thyroidal extension; estimated malignancy risk of 70–90 %) or > 1 cm with intermediate suspicion features (hypoechoic solid nodule with smooth margins without microcalcification, extra thyroidal extension or taller than wide shape; estimated malignancy risk 10–20 %). CAS  2010;254(1):292–300. 2006;29(9):771–5. Evaluation of the sensitivity, specificity, and accuracy of the TI-RADS system compared to standard thyroid ultrasound evaluation was found to be 87%, 44%, and 52% respectively.37, Comparison between the three societies’ reporting systems. Ultrasound will help confirm the thyroid nodule/s, assess the size, location and evaluate the composition, echogenicity, margins, presence of calcification, shape and vascularity of the nodules and the adjacent structures in the neck including the lymph nodes. 1974;228(7):866–9. Arch Intern Med. Decision analysis of discordant thyroid nodule biopsy guideline criteria. Preoperative diagnosis of benign thyroid nodules with indeterminate cytology.Â, Nikiforov YE, Carty SE, Chiosea SI, et al. 1984;144(3):474–6. The accuracy of thyroid nodule ultrasound to predict thyroid cancer: systematic review and meta-analysis. Combined studies with sodium pertechnetate Tc 99 m and radioactive iodine. Tests are expensive and in deciding their use in management of indeterminate nodules, one should also consider the pretest probability of malignancy with clinical risk features, sonographic characteristics and the size of the nodule, the degree of patient concern and patient preferences, and if the patient would be able to come back for a follow up. 2008;93(3):809–14. Centralized molecular testing for oncogenic gene mutations complements the local cytopathologic diagnosis of thyroid nodules. J Clin Endocrinol Metab. The associations between RAS mutations and clinical characteristics in follicular thyroid tumors: new insights from a single center and a large patient cohort.Â. 2015;158(5):1314–22. Over the years there has been a change in guidelines with regards to judiciously selecting the thyroid nodules for further evaluation with FNA. Very high prevalence of thyroid nodules detected by high frequency (13MHz) ultrasound examination.Â, Bartolotta TV, Midiri M, Runza G, et al. Nondiagnostic thyroid fine-needle aspiration cytology: management dilemmas. Chambon G, Alovisetti C, Idoux-Louche C, et al. 2009;16(11):3125–31. Thyroid scintigraphy is useful to determine the functional status of a nodule. Fadda G, Rossi ED, Raffaelli M, et al. MicroRNA expression profile helps to distinguish benign nodules from papillary thyroid carcinomas starting from cells of fine-needle aspiration. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Am Surg. Molecular tests have impacted the management strategies in this category. This limits post-surgical hypothyroidism in benign nodules.BS V (suspicious for malignancy): Malignancy is suspected on cytology but not with high certainty.42,43 Pre-NIFTP, this category carried a 50–75% risk of malignancy, which has reduced to 45–60 % with the implementation of NIFTP. E: aparsa@hawaii.edu. These are a common finding in the general population, majority being diagnosed incidentally during neck imaging. 1 In recent decades, there has been an overall increase in the prevalence of thyroid nodules, including those among adolescents and young adults; 2 however, mortality rates still remain low in many countries worldwide. Important ultrasonographic features identified by each society. The molecular tests which have the most available data are: Afirma Gene-expression Classifier [68], seven-gene panel of genetic mutations and rearrangements [69] and galectin-3 immunohistochemistry [70]. If no or scant follicular tissue is obtained, the absence of malignant cells does not mean a negative biopsy in patients with nondiagnostic FNA. 2001;7(3):202–20. Thyroid nodules are common and carry a 4–6.5 % risk of malignancy. Nodules are typically measured on three different axis planes (anterior-posterior, transverse, and longitudinal). Natural history and outcomes of cytologically benign thyroid nodules in children. Google Scholar. 2005;15(7):708–17. With increased detection of nodules and lack of consistent assessment protocols, surgery has been a favored treatment modality for both malignant and benign nodules. [6] The name comes from the location (Bethesda, Maryland) of the conference that established the system. Clin Cancer Res. 1975;16(8):713–5. The median nodule size for AUS/FLUS was 2.1 cm (range 0.7 to 8 cm), for SFN was 2.4 cm (range 0.5 to 10 cm), for HCN was 2.2 cm (range 0.5 to 9.3 cm), and for SM was 1.6 cm (range 0.5 to 6 cm). Impact of mutational testing on the diagnosis and management of patients with cytologically indeterminate thyroid nodules: a prospective analysis of 1056 FNA samples. Regardless of criteria used to determine the risk of malignancy, FNA is frequently required to cytologically determine if a nodule is malignant. Risk for malignancy of thyroid nodules as assessed by sonographic criteria: the need for biopsy.Â, Chan BK, Desser TS, McDougall IR, et al. Power Doppler US pattern of vascularity and spectral Doppler US parameters in predicting malignancy in thyroid nodules.Â, Miyauchi A, Ito Y, Oda H. Insights into the management of papillary microcarcinoma of the thyroid.Â, Miyauchi A. Comprehensive history with focus on risk factors predicting malignancy (Table 1 [1, 3, 13]) should be part of the initial evaluation of a patient with thyroid nodule. QJM. The interpretation of the features which comprise this category is based entirely on the observer which results in poor reproducibility and a second review by experienced high volume cytopathologist can be considered [99, 100]. HG provided guidance regarding the literature. Clinical trials of active surveillance of papillary microcarcinoma of the thyroid.Â. If the patient has subclinical hyperthyroidism (low TSH with normal FT4), management depends on clinical risk of complications (atrial fibrillation in patients over the age of 60 to 65 years and osteoporosis in postmenopausal women) and the degree of TSH suppression [82–84]. Fine-needle aspiration may miss a third of all malignancy in palpable thyroid nodules: a comprehensive literature review. 1994;69(1):44–9. In a patient with normal or elevated TSH, ultrasound remains the method of choice to determine initial risks of malignancy of a thyroid nodule. 1982;73(3):381–4. 2014;99(1):119–25. 2009;19(11):1159–65. This is one of the scenarios where a subcentimeter thyroid nodule associated with these abnormal cervical lymph nodes should undergo FNA. Predictive value of serum calcitonin levels for preoperative diagnosis of medullary thyroid carcinoma in a cohort of 5817 consecutive patients with thyroid nodules. 1997;82(11):3563–9. Cervical lymph nodes should be assessed. In contrast, benign nodule predicting US characteristics include purely cystic nodule (< 2 % risk of malignancy) [39], spongiform appearance (99.7 % specific for benign thyroid nodule) [40, 42–44]. Google Scholar. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. No funding was received in the publication of this article. Gharib H, Papini E, Garber JR, et al. 2009;17(3):211–5. Leenhardt L, Hejblum G, Franc B, et al. 2009;9:14. Shambaugh 3rd GE, Quinn JL, Oyasu R, Freinkel N. Disparate thyroid imaging. Though thyroid nodules are common, their clinical significance is mainly related to excluding malignancy (4.0 to 6.5% of all thyroid nodules) [3, 7–9], evaluating their functional status and if they cause pressure symptoms. FLUS/AUS category includes lesions with focal architecture or nuclear atypia whose significance cannot be further determined and specimens that are limited because of poor fixation or obscuring blood [98]. Highly accurate diagnosis of cancer in thyroid nodules with follicular neoplasm/suspicious for a follicular neoplasm cytology by ThyroSeq v2 next-generation sequencing assay. Other classification systems such as UK-RCPath (Royal College of Pathology) or Italian AME Consensus and modifications of these systems are also used to report cytology results [13]. Appl Immunohistochem Mol Morphol. It is used as a rule out test to identify benign nodules. Baloch ZW, LiVolsi VA, Asa SL, et al. CAS  Nikiforov YE, Carty SE, Chiosea SI, et al. FNA using real time ultrasound is preferred as it allows for a safe, accurate, and cost-effective method for cytologic evaluation.39,40 It also helps minimize complications including trauma to nearby vital structures (i.e., carotid artery, trachea, jugular veins). Am Heart J. While the main focus of this article is the evaluation of thyroid nodules via ultrasound and cytology, we must not forget biochemical testing. 2008;150(1):49–52. 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. The risk of malignancy in nodules reported as benign is 0–3 % [85–88]. Gharib H. Fine-needle aspiration biopsy of thyroid nodules: advantages, limitations, and effect. © 2021 BioMed Central Ltd unless otherwise stated. Very low suspicion: These nodules have a <3% risk of malignancy, and are solid, isoechoic or hyperechoic. Also in patients with the clinical risk factors mentioned in Table 1 and with the high pretest likelihood for thyroid cancer associated with these features, FNA at sizes lower than those recommended can be considered [1, 13]. Nondiagnostic or unsatisfactory smears (~15 % of all FNAs) have inadequate number of cells to make a diagnosis and result from cystic fluid without cells, bloody smears, or improper techniques in preparing slides [11, 64–67]. Eur J Endocrinol. A marked hypoechogenic nodule is even darker and compares the nodule echogenicity to surrounding infrahyoid or strap muscles rather than normal thyroid tissue. The natural history of the benign thyroid nodule: what is the appropriate follow-up strategy?Â. Intermediate suspicion: Nodules are hypoechoic, solid, oval (wider-than-tall) and have smooth margins. Article  2012;167(3):393–400. 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. The nodular characteristics that are associated with a higher likelihood of malignancy include a shape that is taller than wide measured in the transverse dimension, hypoechogenicity, irregular margins, microcalcifications, and absent halo [35–41]. 1996;4(2):319–35. The clinical risk factors, US characteristics (Elastography in addition can be considered in these cases), patient preference and availability/feasibility of the molecular tests should be considered in the decision making process. Nikiforov YE, Ohori NP, Hodak SP, et al. Castro MR, Gharib H. Continuing controversies in the management of thyroid nodules. Cite this article. Nam-Goong IS, Kim HY, Gong G, et al. The Bethesda system for reporting thyroid cytopathology.Â, Liu X, Medici M, Kwong N, et al. According to the Bethesda Classification scheme, FNA of the nodules yields six major results with subsequent different management for each category. Erdogan MF, Gursoy A, Kulaksizoglu M. Long-term effects of elevated gastrin levels on calcitonin secretion. 2014;271(1):272–81. Shi Y, Ding X, Klein M, et al. Yoon DY, Lee JW, Chang SK, et al. Biondi B, Cooper DS. Some scores such as Mcgill thyroid nodule scores have been tried in pre-operative decision making in thyroid nodules [97].

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