Nationwide web survey on implementing the 2023 ETA guidelines for second-line management thyroid nodules with atypia...

Thyroid nodules affect up to 70% of adults undergoing ultrasonography. The European Thyroid Association (ETA) recently issued high-quality guidelines outlining management options. However, their implementation in routine practice remains uncertain. This study examined guideline adoption and barriers, focusing on nodules with atypia of undetermined significance (AUS), a particularly challenging cytological category.

From November 2023 to April 2024, members of the Hellenic Endocrine Society (HES) participated in a web-based survey concerning management of a 2.5 cm thyroid nodule with fine-needle aspiration (FNA) cytology results of AUS. The scenario varied based on the nodule's sonographic risk, namely, as intermediate (EU-TIRADS 4) or high (EU-TIRADS 5). The questionnaire also collected demographic information and inquired about reasons for non-adherence to the guidelines.

The response rate was 25%. For an EU-TIRADS 4 nodule, 61% chose to repeat FNA, whereas only 23% would repeat FNA for an EU-TIRADS 5 nodule, despite the 2023 ETA guidelines recommending this approach as the next step in both cases. More experienced endocrinologists were less likely to opt for repeat FNA and more likely to choose total thyroidectomy in the first scenario, whereas experience did not influence preferences in the second scenario. Reasons for non-compliance were skepticism regarding the recommendations, limited access to reliable neck ultrasonography, and molecular testing, and a shortage of high-volume surgeons.

Greek endocrinologists deviate from the 2023 ETA guidelines for the management of thyroid nodules with AUS cytology in daily clinical practice. These findings highlight the need for targeted educational strategies and enhancement of clinical infrastructure in Greece.