Thyroid nodules with indeterminate cytopathology: a constant challenge in everyday practice. The effectiveness of clinical decisions using diagnostic tools available in Poland

Abstract

The study proves a low malignancy risk in Bethesda category III and IV thyroid nodules in the Polish population -6.7% and 11.3%, respectively. Universal referral for surgery of these indeterminate thyroid nodules leads to overtreatment, with patients unjustifiably being exposed to possible life-long complications. A concurrent analysis of the clinical risk factors and a thyroid nodule ultrasound pattern may be not sufficiently effective in refining the malignancy risk in thyroid nodule after obtaining an indeterminate cytopathology result. The analysis points to the urgent need for new tools to be created for the Polish population in the management of thyroid nodules with an indeterminate cytopathology result, in order to minimize the number of redundant thyroid surgical procedures, as well as to optimally determine the extent of the primary surgical procedure, if necessary.

Current controversies in the management of patients with indeterminate thyroid nodules

“…Schneider et al 48 found that 30% of patients with CITNs had an insufficient initial thyroidectomy (under-or overtreatment). The study by Kotecka Blicharz et al 4 concluded that the vast majority of patients were overtreated by using TT instead of lobectomy resulting in postoperative complications such as hypoparathyroidism, recurrent laryngeal nerve palsy, and hypothyroidism. Some authors proposed "watchful waiting" as a strategic management option in certain patients with AUS/FLUS in the event of low epidemiological and radiological risk or according to the patients' preferences.…”

“…The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), which is commonly used, has a 97% sensitivity, a 50.7% specificity, a 3% falsenegative rate, and a 0.5% false-positive rate. 4 However, 25% of all FNAC diagnoses are in a gray zone of uncertain cytology; they are referred to as "cytologically indeterminate TNs" (CITNs). In these categories, no or little colloid is detected, and it is difficult to distinguish malignant tumors (follicular variant of PTC and follicular carcinoma) from benign lesions (nodular adenomatous goiter and follicular adenoma).…”

“…8 Although 70-80% of CITNs have benign histology after surgery, they remain a clinically challenging group, and an accurate estimation of their ROM is critical. 4,5 In addition, being heterogeneous categories, their management remains difficult as to whether a conservative approach with long-term observation or surgical intervention should be chosen. 9 According to TBSRTC, the recommended strategy for Bethesda III TNs is a repeat FNAC, molecular testing, or diagnostic lobectomy, whereas in Bethesda IV TNs, the usual management is molecular testing or diagnostic lobectomy.…”

Risk assessment of cytologically indeterminate thyroid nodules with integrated molecular testing and repeat biopsy: a surgical decision-oriented tool

“…In other words, many patients may have undergone unnecessary surgeries. Therefore, the challenge lies in distinguishing between benign and malignant ITNs before surgery [15]. Some research indicates that a single test can help in the management of ITNs.…”

Risk assessment of cytologically indeterminate thyroid nodules with integrated molecular testing and repeat biopsy: a surgical decision-oriented tool

“…Therefore, the challenge lies in distinguishing between benign and malignant ITNs before surgery. (15) Some research indicates that a single test can help in the management of ITNs. Carcinoembryonic antigen (CEA) and calcitonin are helpful for distinguishing medullary thyroid cancer from other types of thyroid cancer.…”