Clinical management of thyroid aspirates diagnosed as atypia of undetermined significance in the Philippines

Abstract

Although the cytologic criteria of atypia of undetermined significance (AUS) are defined in The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), there is heterogeneity in its prevalence, utilization, interpretation, and management. To determine the current practices of physicians of various specialties in the management of thyroid lesions reported as AUS in fine-needle aspirates in the Philippines, a survey consisting of eighteen questions was sent to physicians of varied specialties. Survey questions included geographical location of practice, type of practice (whether in a private or government setting or with academic affiliation), annual patient load, primary operator of fine-needle aspiration (FNA), number of procedures performed, method used, whether by palpation or with ultrasound-guidance, preprocedure requirements, request for rapid on-site evaluation (ROSE), awareness and utilization of thyroid image reporting and data system (TI-RADS), knowledge of cytologic preparation of aspirates, utilization of TBSRTC nomenclature in the workplace, number of AUS that turned out benign, number of AUS that turned out malignant, management of AUS cases in the setting of patient and physician, utilization of frozen section, implication of surgery over repeat FNA. There were seventy four respondents composed of 20 (27%) otorhinolaryngologists, 15 (20%) pathologists, 14 (19%) endocrinologists, 13 (18%) radiologists, and 12 (16%) general surgeons, practicing in different institutions, with majority (58%) of the respondents based in the National Capital Region. AUS report was encountered by 58 respondents (78%) in up to 10% of their cases, eight respondents (11%) had AUS report in up to 20% of their cases and only one respondent (1%) had AUS report in more than 30% of the cases. Seven (10%), who were mainly radiologists, did not answer the question. Thirty nine physicians (53%) conservatized management with medical follow up and repeat FNA within the time frame prescribed in the Bethesda system, 11 (15%) referred patients with AUS for surgery, 16 (22%) had varied comments. Eight (11%) respondents, who were mainly radiologists, did not answer the question. The data shows that the approach to management of AUS is heterogenous amongst physician-specialists, although, majority of clinicians adhere to the practice guidelines of the American Thyroid Association. Deviation to the guidelines occur since approach to management of patients is individualized.

Önemi̇ Beli̇rsi̇z Ati̇pi̇li̇ Hastalardaki̇ Postoperati̇f Hi̇stopatoloji̇k Mali̇gni̇te Varliği

“…It is a well-known fact that there are racial/ethnic differences in the incidence and prognosis of thyroid cancer. Abelardo et al reported that the rates of AUSrelated thyroid malignancies in the Philippines and other Asian countries are much higher than in the general literature (11). This condition demonstrates that Bethesda Classification's category rates may vary in different countries.…”

Management of Atypia of Undetermined Significant Thyroid Nodule

“…Ogmen et al [11] reported 5.4% AUS cases in their study and 29.3% of those cases were histopathologically malignant. Study by Yassa et al 14 showed that repeat FNA can lead to 80% definitive diagnosis, however risk of inconclusive readings, nondiagnostic and AUS can occur in 20% -49.1% of nodules with previous AUS FNA readings [6,12] Core needle biopsy (CNB) was recently introduced as a safe and effective procedure in diagnosing indeterminate thyroid nodules to prevent overtreatment. Some studies reported that CNB can classify as much as 98% of indeterminate thyroid nodules.…”

“…Gao et al [14] reported that 50% of AUS cases become benign. Their center recommended a triage procedure of repeat FNA, US and BRAFV600E gene mutation.…”

“…Direct surgery after an AUS cytodiagnosis is performed by 15% of physicians in study by Abelardo et al [14] and this is mostly due to a strong malignancy risk of clinical and sonographic features. Wide variation of AUS was seen since 42% physicians received benign histo diagnosis after surgery, and 74% received malignant histologic [14] Other modalities such as Computerized analysis of nuclear images (CANI) also reported beneficial in AUS case. Hayashi et al [17] reported sensitivity and specificity in detecting malignancy that higher than 80% of AUS cases with CANI [17].…”

An economically efficient strategy for diagnosing atypia of undetermined significance or follicular lesion of undetermined significance thyroid nodules with ultrasound-based risk stratification systems and BRAFV600E testing

“…The incidence and malignancy rates of AUS/FLUS vary widely in recent studies, ranging from 0.8% to 28% and from 6% to 48%, respectively ( 2 , 4 , 5 ). Currently, there is no consensus on a standardized clinical approach for the treatment of these nodules ( 6 ). The 2015 American Thyroid Association (ATA) guidelines recommend repeat FNA ( 7 ).…”