and D.D. WebThese games can be full of glitches or bugs that range from virtually harmless to completely and utterly game breaking. Article WebIn the wasteland, it makes sense because it's too dangerous for most people to venture out in. Uzzan, B. et al. Surgery 156, 14711476 (2014). Despite the American Association of Clinical Endocrinologist and American Thyroid Association Guidelines against the use of thyroid hormone therapy in suppressive doses for the treatment of thyroid nodules, some authors have estimated that almost one-fourth of clinicians prescribe thyroid hormone therapy in non-suppressive doses for thyroid nodules therapy8. Google Scholar. WebObjective: The Bethesda System of Reporting Thyroid Cytopathology classifies the indeterminate categories based on their differing risks of malignancy, as atypia of undetermined significance (AUS), follicular neoplasm/suspicious for follicular neoplasm (FLUS) and suspicious for malignancy. For the 35 (8.0%) patients with nodules classified as FN/SFN who underwent immediate surgery, the rate of malignancy was 28.6% (10/35). Yaprak Bayrak, B., Eruyar, A.T. Malignancy rates for Bethesda III and IV thyroid nodules: a retrospective study of the correlation between fine-needle aspiration cytology and histopathology. 2), in accordance with the Bethesda System for Reporting Thyroid Cytopathology guidelines. Thyroid 24, 11151120 (2014). Among them, 108 were diagnosed with AUS/FLUS (59 patients were AUS and 49 were FLUS) and 47 were diagnosed with FN/SFN (Fig. World J Surg. In the subgroup of patients with Bethesda system category IV TNs, there was a significantly decreased risk of cancer diagnosis when thyroid hormone therapy was applied for the treatment of thyroid lesions (OR=0.44, p=0.005) (Table4). Cytopathol. and D.D. Google Scholar. CAS However, this difference was not significant. The two groups of treated and untreated patients were comparable in age, clinical features, initial nodule volume and duration of L-T4 therapy. In this group of patients we observed increased levels of anti-thyroid peroxidase (TPO), anti-thyreoglobulin (Tg), and anti-thyroid-stimulating hormone receptor (TSHR) antibodies. The incidence of TSH NSTHT was also significantly lower in the patients with a final diagnosis of thyroid cancer than in patients with benign disease (p=0.004). also reported that PTC cases represented a majority of the malignant thyroid neoplasms [20]. Thus, if a surgery is inevitable in cases diagnosed with Bethesda category IV nodules, we suggest a diagnostic lobectomy as the most aggressive approach rather than total thyroidectomy. Of 1716 patients with FN/SFN on initial FNA, 440 (2.6%) were documented during follow-up. The aim of Bethesda category 4 is to identify a nodule that might be a follicular carcinoma. However, to date, the guidelines from 1996 have not been updated and have not recommended the use of thyroid hormone therapy in either suppressive or non-suppressive doses for the treatment of thyroid nodules8. The main statistically significant parameter in aspect of the occurrence of thyroid malignancy in this group of patients was taking or not NSTHT. and JavaScript. Haugen, B. R. et al. Cytological diagnosis achieved sensitivity Of 14 patients with FN/SFN and AUS/FLUS and family history of thyroid cancer (14/73 additionally excluded; Fig. BMC Endocr Disord. Additionally, there are very few data about the influence of non-suppressive thyroid hormone therapy on the progression of these lesions. Fine-needle aspiration cytology (FNAC) has become a well-established modality in the diagnosis, staging and follow-up of thyroid nodules. WebBethesda categories III and IV encompass varying risks of malignancy. The process used to obtain oral consent was deemed to be acceptable and was approved by the Bioethics Committee of Wroclaw Medical University. We also aimed to establish whether there is an association between these cytological categories and malignancy rates in patients, based on data collected over 6years at a single institution. Acta Cytol. Including all resected nodules, the rates of malignancy for all patients triaged to surgery were 25 and 27.6%, respectively. Provided by the Springer Nature SharedIt content-sharing initiative. WebBethesda Category III, IV, and V Thyroid Nodules: Can Nodule Size Help Predict Malignancy? and D.D. BYB and ATE ensured that questions related to the accuracy or integrity of any part of the work, are appropriately investigated, resolved, and the resolution documented in the literature. Cibas, E. S. & Ali, S. Z. This is the category with the greatest uncertainty, as follicular carcinomas resemble benign follicular neoplasms at the cellular level, making it difficult to distinguish between benign and carcinogenic nodules without additional indication. Register for free and gain unlimited access to: - Clinical News, with personalized daily picks for you 2012;367:70515. 2018;40(9):18818. Nodule size alone was not predictive of malignancy in J. Endocrinol. Busra Yaprak Bayrak. Kuru, B., Atmaca, A. Head Neck. 2016;26(1):1133. CAS Web8 Best: Wolfenstein: The New Order. The rates of malignancy among patients who underwent surgery were 25% for category III and 27.6% for category IV, with no significant differences between categories (p=0.67). One of the potentially dangerous byproducts of that process is a reactive oxygen species called the superoxide radical. When comparing the localisation of nodules in the AUS/FLUS and FN/SFN groups, nodules in both groups were more frequently located in the right lobe of the thyroid (60.2 and 61.7%, respectively). Some malignancy criteria such as thyroidal or tumoral capsular and/or lymphovascular invasion are determinative when establishing a cancer diagnosis, which represents a significant limitation of the FNAC method. However, there are controversial data about the risk of malignancies, recurrence and clinical management of nodules in Bethesda categories III and IV, as the reported risks of malignancy vary significantly, from 10 to 30% to 2540% (including noninvasive follicular thyroid neoplasm with papillary-like nuclear features [NIFTP]), respectively [4]. The mean age, gender and thyroid nodule size in the current study are comparable to other reports [8, 16, 18]. In the present study, the rate of malignancy among patients who underwent immediate surgery was 16% for class III and 28.6% for class IV. The steps for patient selection are presented in Fig. Thyroid. Including the 12 nodules that were resected (after repeat FNAC), the rate of malignancy for all patients triaged to surgery was 27.6% (13/47; Table2). and Z.F. Biomed Res. Horne MJ, Chhieng DC, Theoharis C, Schofield K, Kowalski D, Prasad ML, Hammers L, Udelsman R, Adeniran AJ. Each of these diagnostic categories in Turkish patients were comparable to our findings. 2019 Mar;30(1):815. Fine-needle aspiration cytology (FNAC) has become a well-established diagnostic technique. Wolfenstein: The New Order falls into a similar camp with the 2016 reboot of DOOM. However, there are not yet efficient and cost-effective for routine clinical use; therefore, genetic pathways for thyroid cancer are being investigated experimentally using new genetic technologies. J. Clin. Other authors suggest additional diagnostic procedures, such as a core needle biopsy or a molecular testing, to be used when indeterminate cytology is present10,24. and Z.F. Part of The first group consisted of patients with thyroid cancer (n=97), and the second group were patients with benign thyroid disease (n=435). Furthermore, predicting the exact risk of malignancy in undetermined thyroid nodules is limited in that not all resected nodules undergo histopathologic analysis. Among the six categories in this classification, the third category is known as atypia of undetermined significance and follicular lesion of undetermined significance (AUS/FLUS), and the fourth category is known as follicular neoplasm and suspicious for follicular neoplasm (FN/SFN)1,3. Regarding histopathological findings, benign lesions included nodular goitre, Hurtle cell adenoma, follicular adenoma, granulomatous thyroiditis and lymphocytic thyroiditis. Since 2009, The Bethesda System for Reporting Thyroid Cytopathology has been used to classify FNAC findings based on the risk of malignancy [4, 5]. Future research should also examine whether there is a correlation between patient demographics and malignancy rates. The main indication for L-T4 non-suppressive therapy for thyroid nodules is its potential role in reducing their size. Thus, currently, numerous of clinical characteristics have been described that increase or decrease the risk of malignancy of Bethesda category III and IV nodules. Cancer Cytopathol. With regard to future objectives, molecular assays are gaining importance for determining the need for surgical interventions for thyroid lesions. Predominantly microfollicular smear in thyroid FNA w no colloid. Manganese superoxide dismutase serves as an antioxidant by converting that dangerous species into hydrogen peroxide, which another enzyme can break down into water, thereby relieving the cell of the danger. Article Article American Thyroid Association guidelines on the Management of Thyroid Nodules and Differentiated Thyroid Cancer Task Force Review and recommendation on the proposed renaming of encapsulated follicular variant papillary thyroid carcinoma without invasion to noninvasive follicular thyroid neoplasm with papillary-like nuclear features. Of the 133 nodules that required repeated FNAC, 52 (39.1%) were identified as Bethesda class I, 48 (36.1%) as Bethesda class II and 33 (24.8%) as class III. Supervision: K.K., D.D., B.W., K.S. volume9, Articlenumber:8409 (2019) The current study included a large single-center cohort of patients with TNs classified as AUS/FLUS and FN/SFN with all individuals undergoing surgery (n=532). Diagn. Bethesda System for Reporting Thyroid Cytopathology, Noninvasive follicular thyroid neoplasm with papillary-like nuclear features, Follicular lesion of undetermined significance, Follicular neoplasm / suspicious for follicular neoplasm. Thus, follow-up of suspicious nodules and repeated FNAC is usually recommended for the clinical management of thyroid nodules [24]. The first question is, Which nodules assigned to the AUS/FLUS and FN/SFN categories should be considered for surgical treatment and which can be safely observed? The second question is, Is thyroid hormone therapy for patients with category III and IV nodules safe? It would be a very helpful diagnostic tool for clinicians to choose the more appropriate therapeutic approach. On the basis of data contained in Table2, Cochran-Mantel-Haenszel analysis of the association between thyroid hormone therapy and the final diagnostic variables was performed, with the parameter of the Bethesda category as a confounding factor. Diagn. The datasets analysed during the current study are available from the corresponding author on reasonable request. Metab. In conclusion, the prevalence of patients with Bethesda System category III and IV thyroid nodules who take NSTHT is high. Cancer Cytopathol. Patients presenting thyroid nodules with a cytological analysis suggestive of Bethesda classes I, II, V and VI were excluded from the evaluation, along with those diagnosed with Bethesda III and IV with no follow-up data. All procedures performed in studies involving human participants were in accordance with the 1964 Helsinki declaration. The FN/SFN category presents the greatest uncertainty, as follicular carcinomas resemble benign follicular neoplasms at the individual cellular level, hence limiting the ability of pathologist to accurately diagnose these nodules unless the tissue demonstrates any vascular or capsular invasion [7]. Bethesda categories II, V and VI are well established, and therefore not subject to any disagreement in terms of their malignancy rates [6]. In these biopsies not enough thyroid cells were obtained to render a Gene expression assays using FNAC material may demonstrate a high predictive value for cytologically indeterminate thyroid nodules diagnosed as Bethesda classes III and IV. In a study by Tepeoglu et al., the rates of malignancy for AUS/FLUS and FN/SFN were 12.7 and 35.0% for 1021 cases, respectively. Selection of study group from 4,716 individuals referred for surgery from 2008 to 2017. RSS2.0, https://twitter.com/edusqo/status/764141628890181632, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3477437/, papillary architecture in thyroid anomalies, fat-containing anomalies of the thyroid gland. 3). Walts AE, Mirocha J, Bose S. Follicular lesion of undetermined significance in thyroid FNA revisited. - And More, Close more info about Study Examines Malignancy Rates for Thyroid Nodule Bethesda Categories III and IV, Outdoor Air Pollutants May Be Linked to Development of Thyroid Nodules, American Association of Endocrine Surgeons Publishes Guidelines for Thyroid Disease Surgery, Active Surveillance Feasible for Papillary Thyroid Microcarcinomas, Malignancy rates for Bethesda III and IV thyroid nodules: a retrospective study of the correlation between fine-needle aspiration cytology and histopathology. The diagnosis and management of thyroid nodules: a review. This study provided a more precise correlation of malignancy rates with thyroid nodules classified as Bethesda categories III (25.0%) and IV (27.6%), which were consistent with estimates provided in previous literature. Google Scholar. However, there are very few data regarding the influence of TSH non-suppressive thyroid hormone therapy (NSTHT) on the risk of malignancy in patients in the aforementioned categories. This also leads to different approaches to choosing the best therapies. In the authors department, all patients with FN/SFN category TNs and selected individuals with AUS/FLUS category TNs are qualified to surgery. Gharib, H. et al. To determine accurate malignancy rates for nodules classified as Bethesda III or IV, data from 155 patients who underwent thyroidectomies were analyzed. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Patients with Bethesda System category IV TNs represented a completely different situation. In our study, the mean age of 155 patients classified as AUS/FLUS or FN/SFN was 52.5years, the percentage of female patients was 85.2% and the mean size of nodules was 1.9cm, in accordance with previous studies. The histopathological specimens were analyzed by two pathologists experienced in thyroid diseases. For some of the general categories, some degree of sub-categorization can be informative and is often appropriate; However, this approach to management is still controversial and not accepted by some researchers9,10,11. There were no cases of NIFTP among our thyroidectomy patients. Multiple endocrine neoplasia (MEN) syndrome in family history was observed in 6 patients (6/73 additionally excluded; Fig. Article Others suggest that the variability in diagnosis is attributable to differences in the populations analyzed, pharmacological management, selection of TNs and classification bias1. Clinical outcome for atypia of undetermined significance in thyroid fine-needle aspirations: should repeated FNA be the preferred initial approach? Because almost 65% of the population have thyroid nodules, this practice may increase the risk of iatrogenic complications in some individuals, especially in the elderly9,10. 2016;60(3):198204. Puzziello et al. The criteria for reporting under TBSRTC category IV are :* Cytopathol. Bongiovanni, M., Spitale, A., Faquin, W. C., Mazzucchelli, L. & Baloch, Z. W. The Bethesda System for Reporting Thyroid Cytopathology: a meta-analysis. Google Scholar. Home > E. Pathology by systems > Endocrine system > Thyroid gland > thyroid Bethesda category 4. Seven tornadoes were reported in the Florida Panhandle and southern Georgia on Thursday. Acta Cytol. They are reportable as FN or SFN. To obtain https://doi.org/10.1038/s41598-019-44931-8, DOI: https://doi.org/10.1038/s41598-019-44931-8. Oral Oncol. The other important issue that the large group of malignant tumors assigned to Bethesda System categories III and IV turned out to be microcarcinomas. Sci. FLUS nodules are characterized by extensive Hurthle cells with moderate cellularity, scant colloid with no apparent increase in lymphoid cells, and follicular epithelial cell clusters showing a microfollicular pattern in the focal area. Though the risk of malignancy for category III and IV TNs has been estimated, some authors suggest, that the risk of malignancy for patients with AUS/FLUS and FN/SFN category nodules depends upon the specific clinical situation3,6. Invest. Current practice in patients with differentiated thyroid cancer, Effect of withdrawal of thyroid hormones versus administration of recombinant human thyroid-stimulating hormone on renal function in thyroid cancer patients, Follow-up of differentiated thyroid cancer what should (and what should not) be done, Pattern analysis for prognosis of differentiated thyroid cancer according to preoperative serum thyrotropin levels, A pre-ablative thyroid-stimulating hormone with 3070 mIU/L achieves better response to initial radioiodine remnant ablation in differentiated thyroid carcinoma patients, Clinical outcomes of patients with T4 or N1b well-differentiated thyroid cancer after different strategies of adjuvant radioiodine therapy, The relationship between ultrasound findings and thyroid function in children and adolescent autoimmune diffuse thyroid diseases, The influence of thyroid hormone medication on intra-therapeutic half-life of 131I during radioiodine therapy of solitary toxic thyroid nodules, The role of metabolic setting in predicting the risk of early tumour relapse of differentiated thyroid cancer (DTC), http://creativecommons.org/licenses/by/4.0/. Ho, A. S. et al. WebThe Bethesda system suggests a six category classification system to report thyroid FNAB results: 1. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. studied 541 AUS thyroid nodules in patients with a median age of 54years, 80.4% of whom were females, and the median nodule size was 1.9cm [8]. Although fine-needle aspiration cytology (FNAC) is widely used to determine the risk for malignancy in thyroid nodules, cytologically indeterminate thyroid nodules remain a diagnostic challenge in approximately 10% to 30% of patients undergoing thyroidectomy. We obtained oral consent from the participants instead of written consent because the data were analyzed anonymously and retrospectively on the basis of medical records. Google Scholar. Currently, in the area of Lower Silesian Region (Poland), where all of the participants of our study live, we do not observe any deficiency of iodine in a diet, so no influence on the thyroid malignancy is observed. UG-FNAB: ultrasound guided fine needle aspiration biopsy, AUS/FLUS: atypia of undetermined significance or follicular lesion of undetermined significance, FN/SFN: follicular neoplasm or suspicious for follicular neoplasm, TNs: thyroid nodules, MEN: multiple endocrine neoplasm, TSH: thyroid stimulating hormone. Google Scholar. 2). - Case Studies This situation exists because of the significant variability in malignancy rates associated with categories III and IV described in the literature5,13,14,15,16,17 as well as the significant difference in the percentage of cases with histopathology verification18,19. Thyroid nodules (TNs) assigned to the Bethesda System categories III and IV include numerous clinical characteristics, which increase or decrease the risk of malignancy. 2008;5:6. These two categories of TBSRTC are the most controversial cytological groups and are managed completely differently by many departments. Ho AS, Sarti EE, Jain KS, Wang H, Nixon IJ, Shaha AR, Shah JP, Kraus DH, Ghossein R, Fish SA, Wong RJ, Lin O, Morris LG. The study was approved by Kocaeli Derince Training and Research Hospital Clinical Research Ethics Committee of Health Sciences University, Turkey (Protocol number: 202031). Thyroid. Formal analysis: K.K. After clinical and radiological diagnosis, the FNA procedure was performed under ultrasound guidance. BMC Endocr Disord 20, 48 (2020). Contact | We did not observed any clinical or biochemical statistically significant differences between these two groups of patients (with NSTHT and without NSTHT). 1). Logistic regression analysis for predicting the occurrence of thyroid cancer in association with NSTHT was performed for both subgroups. 1). https://doi.org/10.1186/s12902-020-0530-9, DOI: https://doi.org/10.1186/s12902-020-0530-9. The authors declare no competing interests. Comparing the Bethesda System for Reporting Thyroid Cytopathology, the choice for the management of nodules may be determined by a cytopathological follow-up or molecular testing, which becomes instrumental to rule out cancer judiciously and reduce unnecessary thyroidectomies [25]. Kantor, E. D., Rehm, C. D., Haas, J. S., Chan, A. T. & Giovannucci, E. L. Trends in prescription drug use among adults in the United States from 19992012. Many years ago, it was suggested that thyroid hormone therapy in non-suppressive doses reduced or stabilized the size of thyroid nodules12. AUS nodules consist of follicular cells that are mostly benign in appearance. TIRAD 4 (A) has moderately hypoechogenic and has no high suspicious US features. In conclusion, our study demonstrates that the prevalence of patients with Bethesda System category III and IV TNs who take thyroid hormone therapy is high. It was estimated that this benefit did not outweigh the potential harm of iatrogenic hyperthyroidism. However, patients with Bethesda System category IV TNs were represented at a significantly higher rate in the cancer subgroup when compared with patients with benign thyroid disease, and patients with Bethesda System category III TNs were represented at a significantly lower rate in the cancer than in the noncancer subgroup (p=0.003). However, we did not investigate the influence of TSH NSTHT on the risk of malignancy. and Z.F. Class 4. American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. If yes, does the safety extend to both categories? In our previous study, we presented a description of the clinical features of TNs classified in the AUS/FLUS category and suggested that these lesions had malignant potential. Although we did not perform an analysis of the correlation of age, gender and nodule size with the malignancy rate, we believe that these results are valuable as they are consistent with the literature. 2016;22(5):62239. Malignancy rate in thyroid nodules classified as Bethesda category III (AUS/FLUS). Bethesda category III nodules are further categorized as atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS). The nonparametric Mann-Whitney test was used to compare quantitative variables, while the chi-square test or chi-square test for independence were used to compare dependent or independent qualitative data. Int. Tepeolu M, Bileziki B, Bayraktar SG. On the other hand, we cannot estimate the real risk of malignancy associated with the AUS/FLUS and FN/SFN categories because only a minority of these cases undergo surgery. Writing original draft: K.K. Endocrinol. & Olson, M. T. Malignancy risk and reproducibility associated with atypia of undetermined significance on thyroid cytology. Pract. 2013;20(1):605. Other exclusion criteria included individuals who had clinical symptoms of malignancy, nodules with dimensions larger than 4cm, thyroid autoimmunity, previous neck and head radiotherapy and surgery, or family history of thyroid cancer and other thyroid diseases. Get the most important science stories of the day, free in your inbox. The result of these varied opinions is that there is no strict indication for the treatment of thyroid nodules assigned to AUS/FLUS and FN/SFN categories. Evaluation of the thyroid nodule. However, the absolute level of risk and malignancy is still unclear for thyroid nodules assigned to Bethesda categories III and IV [10, 11]. Among the cases in Bethesda category IV (n=440), 35 (8.0%) underwent immediate surgery, 96 (21.8%) underwent repeat FNAC in 13months, and 309 (70.2%) were observed at 3-month intervals via ultrasonography to measure the size and content of the nodule. Thyroid 26, 1133 (2016). A total of 814 (59.63%) of these patients underwent thyroidectomy. All patients had UG-FNAB performed a minimum of 1 month to a maximum 6 months before admission and surgical treatment in our department. Horne et al. Res. 4th ed. Webbethesda category 5 is dangerous. Mathur et al. 2017;27(4):4813. A tertiary centers experience with second review of 3885 thyroid cytopathology specimens. Logistic regression analysis was performed for determination of the impact of thyroid hormone therapy on thyroid cancer occurrence. Malignancy rates for Bethesda III and IV thyroid nodules: a retrospective study of the correlation between fine-needle aspiration cytology and histopathology, https://doi.org/10.1186/s12902-020-0530-9, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. I just feel like 200 years is a long time to have the opportunity to We hope youre enjoying the latest clinical news, full-length features, case studies, and more. J. Clin. Haugen BR, Sawka AM, Alexander EK, Bible KC, Caturegli P, Doherty GM, Mandel SJ, Morris JC, Nassar A, Pacini F, Schlumberger M, Schuff K, Sherman SI, Somerset H, Sosa JA, Steward DL, Wartofsky L, Williams MD. 2017;16(1):e12871. Of the 12(33.3%) cases diagnosed as Bethesda category 2 on cytology, 9(75%) were TN and 3(25%) were FN on histopathology; 2(100%) of the 2(5.6%) cases diagnosed as Bethesda category 3 on cytology turned out to be FP on histopathology. In our clinic, all patients classified as FN/SFN qualify for surgery, while selected individuals classified as AUS/FLUS qualify for repeated UG-FNAB six months after the previous biopsy or for surgery. The L-T4 doses were adjusted to obtain a serum TSH in range 0.44.0 mlU/mL and range 1.120.36g/kg. Rosario, P. W. Thyroid nodules with atypia or follicular lesions of undetermined significance (Bethesda Category III): importance of ultrasonography and cytological subcategory. Conceptualization: K.K. By submitting a comment you agree to abide by our Terms and Community Guidelines. Slider with three articles shown per slide. - Conference Coverage Of the 96 nodules that required repeat FNAC, 31 (32.3%) were identified as Bethesda class I, 53 (55.2%) as Bethesda class II and 12 (12.5%) as class IV. The next very important issue worthy of closer analysis is the role and impact of thyroid hormone therapy in the management of TNs. GraphPad version 3.062003 software was used for statistical analyses. McIver B. Contribution of molecular testing to thyroid fine-needle aspiration cytology of follicular lesion of undetermined significance/atypia of undetermined significance. If you find something abusive or that does not comply with our terms or guidelines please flag it as inappropriate. (Image credit: Bethesda) After years of waiting, Bethesda has finally shown off Starfield -- and it looks both expansive and generic. The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. 1. PubMedGoogle Scholar. Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegeds L, Paschke R, Valcavi R, Vitti P. AACE/ACE/AME task force on thyroid nodules, American association of clinical endocrinologists, American college of endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid Nodules-2016 update. Karimi-Yazdi A, Motiee-Langroudi M, Saedi B, Ensani F, Amali A, Memari F, Dabiri M, Seifmanesh H. Diagnostic value of fine-needle aspiration in head and neck lymphoma: a crosssectional study. The proportion of malignancy in Bethesda III nodules confirmed by surgery were significantly increased in proportion

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