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Updated: Sep 16, 2025

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Managing TBSRTC III thyroid nodules: evaluating repeat FNA, molecular testing, and surgery.

Christopher Dilli1, William Mi2, Daniel L Miller3

  • 1Saint Louis University School of Medicine, St. Louis, Missouri.

Journal of the American Society of Cytopathology
|July 11, 2025
PubMed
Summary

Repeat fine-needle aspiration (FNA) is a cost-effective strategy for managing thyroid nodules with atypia of undetermined significance (AUS), resolving nearly 50% of cases without impacting malignancy or surgical rates.

Keywords:
Atypia of undetermined significance (AUS)Cost-effectivenessFine-needle aspiration (FNA)Malignancy ratesMolecular testingThyroid nodules

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Area of Science:

  • Endocrinology
  • Oncology
  • Diagnostic Cytopathology

Background:

  • Thyroid nodules are common, with most being benign.
  • Atypia of undetermined significance (AUS) or Bethesda III nodules present management challenges.
  • Current options include surveillance, repeat FNA, molecular testing, and surgery, with molecular testing being costly.

Purpose of the Study:

  • To assess the feasibility and cost-effectiveness of repeat FNA for AUS nodules.
  • To compare repeat FNA outcomes with molecular testing and surgical intervention.
  • To evaluate the utility of prebiopsy ultrasonography in risk stratification.

Main Methods:

  • Retrospective multi-institutional study of 131 AUS nodules from 5 hospitals (2018-2024).
  • Nodules stratified by initial management: repeat FNA, molecular testing, or surgery.
  • Analysis of clinical, ultrasonography findings, malignancy rates, and estimated costs (Medicare rates).

Main Results:

  • Repeat FNA yielded a benign diagnosis in 48.7% and AUS in 35.9% of cases.
  • Repeat FNA was the most cost-effective management strategy.
  • No significant difference in malignancy or surgical intervention rates between repeat FNA and molecular testing.
  • Echogenic foci were the only ultrasonography finding significantly associated with malignancy.

Conclusions:

  • Repeat FNA is a cost-effective initial approach for AUS nodules, resolving approximately 50% of cases.
  • Outcomes regarding malignancy and surgical intervention are comparable to molecular testing.
  • Prebiopsy ultrasonography has limited value in predicting malignancy risk for AUS nodules.