ArticleEuropean archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery2026
The role of cytological subcategorization in indeterminate thyroid nodules: Optimizing management strategies by refining malignancy risk stratification.
Article in European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
purposeIndeterminate Thy3a (Bethesda III equivalent) thyroid nodules pose significant diagnostic and therapeutic dilemmas. This study evaluates a novel institutional approach that utilizes cytological subcategorization by nuclear atypia, to refine malignancy risk and guide management between active surveillance (AS) and surgery.
methodsA retrospective cohort of adult patients with Thy3a cytology following ultrasound-guided aspiration (2019-2023) was reviewed. Exclusion criteria were incomplete records or < 2 years follow-up for the AS subgroup. Patients with non-nuclear atypia were offered surveillance unless symptomatic, while those with nuclear atypia were recommended for surgery. Primary outcomes included both histopathology-based (hROM) and overall estimated risk of malignancy (oROM), oncological outcomes including disease-free (DFS) and disease-specific survival (DSS).
results188 patients with 190 thy3a thyroid nodules met inclusion criteria (female = 66%, median age = 49 years). AS was followed in 56.4% (n = 71) of the non-nuclear atypia subgroup, while 89.1% (n = 57) of the nuclear atypia subgroup underwent surgery. From the AS Thy3a non-nuclear cohort, 95.8% (n = 68/71) remained stable for ≥ 24 months. hROM and oROM were significantly higher in the nuclear than non-nuclear atypia nodules (59.6% versus 23.6% and 55.6% versus 11.3%, both p<.001). On multivariable analysis, nuclear atypia was an independent predictor of malignancy. Overall, 95.7%, (n = 45/47) of malignant Thy3a nodules were low-risk differentiated thyroid cancers. Over a median 42-month follow-up, 5-year DFS and DSS were 95.3% and 97.9% respectively.
conclusionCytological subcategorization of Thy3a thyroid nodules by nuclear atypia offers a valuable tool for risk stratification, enabling a tailored management approach, minimizing unnecessary surgeries, while ensuring prompt surgical intervention for high-risk cases.
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