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Endocrine Abstracts (2022) 81 OC3.1 | DOI: 10.1530/endoabs.81.OC3.1

ECE2022 Oral Communications Oral Communications 3: Thyroid 1 (6 abstracts)

Real world prospective application of ATA guidelines in over 500 aspirated thyroid nodules: Is it time for changing the size cut-offs for FNA?

Stamatina Ioakim 1 , George Zavros 2 , Michalis Picolos 3 , Akheel Syed 4,5 & Angelos Kyriacou 2,4,6


1Medical School, University of Milan, Milan, Italy; 2CEDM, Centre of Endocrinology, Diabetes & Metabolism, Limassol, Cyprus; 3Alithias Endocrinology Centre, Nicosia, Cyprus; 4Department of Diabetes, Endocrinology & Obesity Medicine, Salford Royal NHS Foundation & University Teaching Trust, Salford, United Kingdom; 5Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom; 6Medical School, European University of Cyprus, Nicosia, Cyprus


Introduction: The 2015 American Thyroid Association (ATA) guidelines on the management of thyroid nodules and cancer recommend specific size cut-offs for fine needle aspiration (FNA) cytology. We assessed the correlation between sonographic and cytological stratification as per the guidelines, with emphasis on the size cut-offs.

Methods: In a ‘real world’ prospective study, we sonographically stratified 562 thyroid nodules prior to performing ultrasound-guided FNA as cysts (1.4%), very low (3.9%), low (54.8%), intermediate (19.9%), or high (19.9%) risk. Their Bethesda cytological classification was B1, B2, B3, B4, B5 and B6 in 3.6%, 77.9%, 3.9%, 5%, 2.8% and 6.8% of nodules, respectively. Strong sonographic-cytological correlation was observed (P<0.0001); for example, B2 (benign) cytology was reported in 100% of very low, 91.2% of low, 81.3% of intermediate and 32% of high risk nodules. Excluding B1 (non-diagnostic) results and nodules without size data, the diagnostic performance of ATA-proposed cut-offs for FNA based on sonographic appearance was compared to higher cut-offs. Increasing the size-threshold for sonographically low and intermediate risk thyroid nodules would spare FNAs at the expense of missing a small proportion of B3–B6 cytological nodules and differentiated thyroid carcinomas (DTCs). The size cut-offs are compared against the cytological result of B2 (‘negative outcome’) or B3–B6 (‘positive outcome’). †Relative to number of available histopathology results. PPV, positive predictive value. NPV, negative predictive value.

Discussion: By increasing the size cut-off for low-risk nodules, the NPV value retains its excellent performance, whereas PPV remains unaffected with poor performance. By using a higher cut-off in intermediate-risk nodules, NPV and PPV performance remain unchanged. In high-risk nodules, both NPV and PPV perform poorly regardless of the size cut-off. The 20 mm and 40 mm cut-offs may have greater clinical significance in case of carcinoma, as they correspond to higher tumour grades (≥T2 and ≥T3), altering the clinical management.

Cut-offSensitivitySpecificityPPVNPVSpared FNAsMissed B3–B6 cytologyMissed DTCs†
Sonographic classification as per ATA guidelinesLow-risk (n=301)15 mm87.5%15.9%8.3%93.6%
20 mm58.3%42%8%92.1%80 (26.6%)70/4
40 mm4.2%93.9%5.6%91.9%236 (78.4%)201/15
Intermediate-risk (n=102)10 mm75%18.9%11%85%
20 mm8.3%88.9%9.1%87.9%71 (69.6%)81/7
High-risk (n=103)10 mm58.2%30.6%60.9%28.2%
20 mm13.4%88.9%69.2%35.6%51 (49.5%)3017/29

Conclusion: Our results suggest that increasing the ATA size cut-off from 15 mm to 20 mm in sonographically low-risk nodules is clinically safe whilst reducing FNAs.

Volume 81

European Congress of Endocrinology 2022

Milan, Italy
21 May 2022 - 24 May 2022

European Society of Endocrinology 

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