Review: Clinical management of thyroid nodules with atypia of undetermined significance

Background and objectives

Fine needle aspiration cytology (FNAC) is a cost-efficient technique for the management of thyroid nodules. Changes in the World Health Organization classification of thyroid tumors can influence reliability of cytology. The 2023 Bethesda System for Reporting Thyroid Cytopathology has adapted cytological nomenclature to these changes. The aim of this paper was to review the management of atypia of undetermined significance (AUS) in our institution.


Retrospective review of thyroid FNAC diagnosed with AUS in a single hospital between 2014 and 2022. We analyzed the management of patients and the risk of malignancy associated with AUS.


AUS represented 7.5% of all thyroid FNAC diagnoses (273 patients). In 74.1% of the patients, FNAC was repeated, and 54.9% of the lesions were downgraded. Surgical resection of the nodule was performed in 38.2% of the patients, mostly after a repeat FNAC with upgrading. Ninety-one percent of the patients downgraded in the repeat FNAC did not undergo surgery. The risk of malignancy of the AUS category after repeat FNAC was 26.1%. AUS diagnosis was due to nuclear atypia in 32% of the patients, and we found a significant association between nuclear atypia and upgrading in repeat FNAC. Of the 96 patients who underwent surgery in our series, 42 had malignant lesions, including noninvasive follicular thyroid neoplasms with papillary-like features.


The clinical management of AUS patients includes repeat FNAC, which is strongly correlated with the risk of malignancy. Nuclear atypia seems to be more predictive of malignancy than architectural patterns.

Journal reference:

Fernández-Aceñero, M. J., et al. (2024). Atypia of Undetermined Significance in Thyroid Fine Needle Aspiration Cytology Revisited. Journal of Clinical and Translational Pathology.


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