Malignancy outcomes and the impact of repeat fine needle aspiration of thyroid nodules with Bethesda category III cytology: A multicenter experience

Abstract

Background: The clinical management of Bethesda III category thyroid nodules has some undefined points and differs among centers and conflicting malignancy rates are present in the literature. The aim of this study was to investigate the Bethesda category III thyroid nodule outcomes in our centers, to determine malignancy rates and also to evaluate clinical and sonographic features which may help to predict malignancy.Methods: This retrospective study included 333 patients with thyroid nodules who had Bethesda category III on fine needle aspiration (FNA) in three tertiary medical centers of Turkey.Results: Among 333 patients, 302 had appropriate follow up. Eighteen patients received thyroidectomy after the first FNA, with a malignancy rate of 38.89% (7/18) and 284 patients received a second FNA. After the second FNA, thyroidectomy was performed in 80 patients and 41 patients needed the third FNA. Thirteen thyroidectomies were performed after the third FNA. Totally 111 patients received thyroidectomy with a malignancy rate of 48.65% (54/111) among patients with surgery and the lower bound was detected as 17.88% (54/302). Of these patients the malignancy rates of patients receiving thyroidectomy with two and three FNAs were 47.50% (38/80) and 69.23% (9/13), respectively. Hypoechogenicity, microcalcification, and irregular margin were found as good predictors for malignancy. Conclusion:We demonstrated that the malignancy rate was 48.65% in patients receiving thyroidectomy. We showed a higher malignancy rate than the traditionally rate of 5%-15%. This study showed that repeat FNAs decrease the rate of unnecessary surgery performed for benign lesions by increasing the rate of malignancy detection.

Performance of Afirma genomic sequencing classifier and histopathological outcome in Bethesda category III thyroid nodules: Initial versus repeat fine‐needle aspiration

“…Several studies have demonstrated the importance of repeat FNA in thyroid nodules with an initial AUS diagnosis. Repeat FNA establishes a definitive diagnosis (TBSRTC category II or VI) in up to 50% of nodules with an initial diagnosis of AUS, reducing unnecessary surgical intervention in benign nodules and providing useful pre‐operative information for malignant nodules 10,11,15,16 . However, a notable portion of nodules remained as AUS after repeat aspiration.…”

“…Therefore, they claimed that repeat FNA did not improve the PPV of Afirma GEC testing of AUS nodules 27 . On the contrary, some studies demonstrated an increased rate of histology‐proven malignancy in thyroid nodules with pre‐operative repeat FNA while reducing unnecessary surgical treatment of benign thyroid nodules 11,16 . Further, other authors note that repeat FNA cytology can guide the selection of cytologically indeterminate thyroid nodules that warrant molecular test (GEC) 12,13 …”

“…These findings indicate that the pretest probability of malignancy (thus the performance characteristics of Afirma GSC) is similar whether (1) an endocrinologist/surgeon's assessment of concerning clinical/sonographic features is used to refine the selection of a nodule for potential molecular testing based on the initial AUS diagnosis or (2) repeat diagnosis of AUS is used to refine the selection of a nodule for potential molecular testing.Several studies have demonstrated the importance of repeat FNA in thyroid nodules with an initial AUS diagnosis. Repeat FNA establishes a definitive diagnosis (TBSRTC category II or VI) in up to 50% of nodules with an initial diagnosis of AUS, reducing unnecessary surgical intervention in benign nodules and providing useful pre-operative information for malignant nodules 10,11,15,16. However, a notable portion of nodules remained as AUS after repeat aspiration.…”

Optimization of the Management of Category III Thyroid Nodules Using Repeat FNA and TIRADS

“…It is one of the probable causes of discrepancies between reported results in that respect. Some studies showed a similar frequency of cancers in patients treated surgically after or without rFNA [ 21 , 22 , 23 ]; others indicated an increased rate of malignancy after rFNA, non-significantly [ 8 , 24 , 25 , 26 , 27 , 28 , 29 ] or significantly [ 20 , 30 , 31 , 32 , 33 ] and there are reports that suggested slightly lower malignancy rates in patients undergoing surgery after rFNA in comparison to those treated directly after the diagnosis of category III [ 34 , 35 ].…”