Comparison of risk of malignancy in a subgroup with atypia of undetermined significance/follicular lesion of undetermined significance: A meta‐analysis

Ahn, Sang Hyun; Kim, BS Seong Dong; Jeong, Woojin

doi:10.1002/hed.24768

Cited by 28 publications

(15 citation statements)

References 26 publications

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“…The 2017 BSRTC recommends providing a sub-classification of the AUS/FLUS category 7132. In a meta-analysis including 15 articles, the risk of malignancy varied between these subcategories, with the highest value found for the cytological atypia category (44%, 37% to 52%) 139. Another systematic review that evaluated 20 studies and specifically compared indeterminate thyroid nodules with and without nuclear atypia confirmed increased odds of malignancy in those with nuclear atypia (3.63, 3.06 to 4.35) 140…”

Section: Estimating the Risk Of Thyroid Cancer And Management After Tmentioning

confidence: 99%

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

Ospina

Iñiguez-Ariza

Castro

2020

BMJ

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Thyroid nodules are extremely common and can be detected by sensitive imaging in more than 60% of the general population. They are often identified in patients without symptoms who are undergoing evaluation for other medical complaints. Indiscriminate evaluation of thyroid nodules with thyroid biopsy could cause a harmful epidemic of diagnoses of thyroid cancer, but inadequate selection of thyroid nodules for biopsy can lead to missed diagnoses of clinically relevant thyroid cancer. Recent clinical guidelines advocate a more conservative approach in the evaluation of thyroid nodules based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy. Moreover, newer evidence suggests that for patients with indeterminate thyroid biopsy results, a combined assessment including the initial ultrasound risk stratification or other ancillary testing (molecular markers, second opinion on thyroid cytology) can further clarify the risk of thyroid cancer and the management strategies. This review summarizes the clinical importance of adequate evaluation of thyroid nodules, focuses on the clinical evidence for diagnostic tests that can clarify the risk of thyroid cancer, and highlights the importance of considering the patient’s values and preferences when deciding on management strategies in the setting of uncertainty about the risk of thyroid cancer.

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Section: Estimating the Risk Of Thyroid Cancer And Management After Tmentioning

confidence: 99%

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

Ospina

Iñiguez-Ariza

Castro

2020

BMJ

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“…Therefore, more strict and objective diagnostic qualifiers are required in the diagnosis of nuclear/cytologic atypia and SM. 46,47 Despite the recommendations that AUS/FLUS be used as a "last resort" diagnostic category, and that it should represent no greater than 10% of all TBSRTC diagnoses at a particular institution, there is considerable variability in its utilization at different centers, with reported rates ranging from 0.8% to 27.1%. 3 The RoM for this category also vary widely among institutions, ranging from 12.5% to 50%.…”

Section: Discussionmentioning

confidence: 99%

High risk of malignancy in cases with atypia of undetermined significance on fine needle aspiration of thyroid nodules even after exclusion of NIFTP

Özkara

Bayrak

Turan

2020

Diagnostic Cytopathology

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Background: Fine needle aspiration cytopathology (FNAC) is the most reliable tool for evaluating thyroid nodules. However, diagnosing Bethesda category III, atypia/ follicular lesion of undetermined significance (AUS/FLUS), is a major limitation. The aim of this study was to evaluate the risk of malignancy (RoM) in AUS/FLUS nodules. A systematic review was also carried out analyzing the largest series. Methods: Totally 1750 cases (9%) diagnosed with AUS/FLUS were evaluated retrospectively out of 19 392 cases within last 13 years. All patients undergoing surgery for AUS/FLUS were included into the study. Histopathology results were correlated; the impact of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) diagnosis on RoM is evaluated. Results: Of the 280 patients (16%) undergoing surgery, neoplasia were detected in 177 (RoN:63.2%) and malignancy in 119 (RoM:42.5%) of these neoplasia. Follicular variant of papillary thyroid carcinoma (FVPTC) was the commonest malignancy (55.5%). Additional 58 (20.7%) nodules were neoplastic, of which 26 (9.3%) were encapsulated follicular tumors with unknown malignancy potential (FT-UMP) and 32 (11.4%) were follicular adenomas. The remaining 103 patients (36.8%) had nonneoplastic nodules. After reevaluation of the encapsulated FVPTC cases, 20 of them were NIFTP and RoM dropped to 35.4% with a relative decrease of 16.7% and an absolute decrease of 7.1%. Conclusion: In our series, 42.5% of nodules with AUS/FLUS were malignant; 63.2% of them were neoplastic. The RoM and RoN for AUS/FLUS nodules are still much higher than the revised expected RoM of international guidelines even after NIFTP cases excluded. Therefore, current recommendations should be reevaluated periodically in view of detailed clinicopathologic studies.

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“…In comparison, in a study by Guleria et al, 14 62.9% of AUS thyroid FNAs were subcategorized into a combined cytologic and architectural atypia subcategory with a RON of 68.6% and a ROM of either 58.8% (if the entity of noninvasive follicular thyroid neoplasm with papillary‐like nuclear features [NIFTP] is considered malignant) or 37.3% (if NIFTP is considered not malignant). However, the limited data available of RON and ROM for an AUS subcategorization of both architectural and cytologic atypia precludes a meaningful conclusion on its clinical significance 17 . Further evaluation of a combined subcategory across institutions may further elucidate utility of this combination of atypia.…”

Section: Discussionmentioning

confidence: 99%

An institutional experience: A retrospective analysis of the effect of transitioning from follicular lesion of undetermined significance to atypia of undetermined significance with subclassified atypia on interobserver concordance, rates of neoplasia, and rates of malignancy

Kroll-Wheeler

Cantley

Pang

et al. 2020

Diagnostic Cytopathology

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Introduction The rate of malignancy (ROM) in thyroid fine needle aspirations (FNA) classified under “atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS), including Hürthle cell type (HLUS)” category of The Bethesda system for reporting thyroid cytopathology (TBSRTC) in literature is highly variable. The 2018 TBSRTC was updated to note a preferred categorization of AUS cases into subcategories. This study evaluates the impact of AUS subclassification on rates of neoplasia (RON), rates of malignancy (ROM), and cytopathologist (CP) concordance. Methods 93 thyroid FNAs previously diagnosed as FLUS or HLUS from January 1, 2013 to December 31, 2014 with subsequent surgical resection were identified. Four CPs reclassified these cases using TBSRTC AUS subcategories of follicular cells with architectural and/or cytologic atypia, predominantly Hürthle cells, and atypical lymphocytes. RON and ROM were calculated for each diagnostic subcategory for each CP. Results The original RON and ROM for FLUS cases were 31.4% and 15.1% and were 77.8% and 22.2% for HLUS cases. 10.8% of cases showed diagnostic concordance amongst the four CPs. The most frequently utilized subcategory was architectural atypia. RON ranges for architectural atypia, cytologic atypia, architectural and cytologic atypia, and predominantly Hürthle cells were 28.1% to 35.7%, 0% to 33.3%, 35.3% to 66.7%, and 57.1% to 87.5%. The range of ROM was 13.9% to 16.7%, 0% to 33%, 0% to 42.9%, and 0% to 25%, respectively. Conclusion RON for AUS predominantly Hürthle cells subcategory was higher than previously reported, which may indicate use for tailored patient management pathways. AUS subclassification can result in significant interobserver variability. Therefore, institutions may consider consensus/quality control sessions to optimize diagnostic concordance.

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Comparison of risk of malignancy in a subgroup with atypia of undetermined significance/follicular lesion of undetermined significance: A meta‐analysis

Abstract: The cytologic atypia had a significantly higher risk of malignancy than the architectural atypia group, and it should be considered as a separate category.

Cited by 28 publications

References 26 publications

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

Thyroid nodules: diagnostic evaluation based on thyroid cancer risk assessment

High risk of malignancy in cases with atypia of undetermined significance on fine needle aspiration of thyroid nodules even after exclusion of NIFTP

An institutional experience: A retrospective analysis of the effect of transitioning from follicular lesion of undetermined significance to atypia of undetermined significance with subclassified atypia on interobserver concordance, rates of neoplasia, and rates of malignancy

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