Thyroid Dysfunction _________________________________________________________________________
THE 2023 BETHESDA SYSTEM FOR REPORTING THYROID CYTOPATHOLOGY
Diagnostic Category
Examples of Diagnostic Entities Risk of Malignancy
Management
Nondiagnostic
• Cyst fluid only • Virtually acellular specimen • Obscuring blood, clotting arti- facts, drying artifact, etc. • Consistent with FND • Consistent with CLT in proper clinical context • Consistent with granulomatous thyroiditis
5% to 20%
Repeat FNA with ultrasound
Benign
2% to 7%
Clinical and sonographic follow-up
AUS nuclear type or AUS other Overall 13% to 30% AUC nuclear 36% to 44% AUS other 15% to 23%
Repeat FNA, molecular testing, diag- nostic lobectomy, or surveillance
Atypia of undetermined significance (AUS) a
Follicular neoplasm (FN) FN or FN oncocytic type
23% to 34%
Molecular testing, diagnostic lobec- tomy Molecular testing, lobectomy, or near- total thyroidectomy
Suspicious for malig- nancy
Suspicious for: • Papillary thyroid carcinoma • Medullary thyroid carcinoma • Metastatic carcinoma • Lymphoma • Papillary thyroid carcinoma • High-grade follicular cell- derived thyroid carcinoma • Medullary thyroid carcinoma • Anaplastic carcinoma • Squamous cell carcinoma • Carcinoma with mixed features (specify) • Metastatic malignancy • Non-Hodgkin lymphoma
67% to 83%
Malignant
97% to 100%
Lobectomy or near-total thyroidectomy
CLT = chronic lymphocytic (Hashimoto) thyroiditis, FNA = fine-needle aspiration, FND = follicular nodule disease.
a AUS and follicular lesion of undetermined significance (FLUS) were considered synonymous as of the 2017 update; the term FLUS was discontinued in the 2023 update. Source: [32] Table 1
MULTINODULAR GOITERS Some thyroid glands have multiple nodules, referred to as multinodular goiters; this is generally a benign condition. Multinodular goiters are most common in postmenopausal women, and although it seems illogical, goiters can be seen in both hypothyroidism and hyperthyroidism. There are two types of goiters: endemic and sporadic. Endemic goiter is defined as thyroid enlargement that occurs in more than 10% of a population. Endemic goiters occur specifically in geographic areas known as “goiter belts,” which are areas with soil and water deficient in iodine. Generally, these are areas without access to salt water and seafood; historically in the United States, the Midwest and Great Lakes regions have been considered “goiter belts.” Coastal areas have a much lower incidence of goiters [10].
Sporadic goiters (more common in the United States) are a result of environmental or genetic factors that do not affect the general population and are not associated with specific geographical locations. Although the cause of sporadic goiter is usually unknown, they are thought to be the result of [7; 10; 33] : • Abnormal iodine metabolism, probably of genetic origin • Ingestion of large amounts of goitrogens from food sources, such as cabbage, soybeans, peanuts, peaches, peas, strawberries, radishes, rutabagas, and spinach • Ingestion of pharmaceutical goitrogens, such as glucocorticoids, dopamine, lithium, rifampin, adrenergic antagonists, methimazole, and thioca rbamates
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