Abstract
Objective
International guidelines recommend different approaches for the management of pediatric thyroid nodules with a finding of atypia of undetermined significance (AUS) on cytology. The American Thyroid Association (ATA) pediatric guidelines recommend surgery whereas the European Thyroid Association (ETA) guidelines recommend repeat fine-needle aspiration biopsy after six months. Our objective was to identify markers of malignancy in AUS cases and to discuss the management of pediatric AUS nodules.
Methods
Specimens from pediatric patients who underwent surgery due to AUS cytology were re-evaluated and subcategorized according to the 2023 Bethesda classification.
Results
Of the 20 cases included, 11 (55%) were histologically benign, while 9 (45%) were malignant. On the subcategorization of AUS, nuclear atypia was present in 14 patients (70%) and other atypia in 6 patients (30%). Of the cases with nuclear atypia, 64.3% were malignant (n=9), whereas no malignancy was detected in cases with other atypia (p=0.012). Among the cytopathological features, chromatin clearing, nuclear enlargement, and irregular margins were significantly associated with malignancy (p=0.035, p=0.003, and p=0.012, respectively). Adhering to ETA recommendations would delay diagnosis by at least 6 months in 45% of our malignant cases. Conversely, performing lobectomy according to ATA recommendations may lead to unnecessary surgery in 55% of our cases.
Conclusion
Based on our findings, lobectomy appears to be a more appropriate approach in AUS cases but only when nuclear atypia is present, to avoid diagnostic delay and unnecessary surgery. Guidelines should be updated according to the latest Bethesda classification.
Keywords: Pediatric thyroid nodules, rate of thyroid malignancy, thyroid fine needle aspiration biopsy, the Bethesda System for Reporting Thyroid Cytopathology Classification, atypia of undetermined significance, nuclear atypia
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