The Role of "Critical" Ultrasound Reassessment in the Decision-Making of Bethesda III Thyroid Nodules

Background and Objectives: Bethesda III (BIII) thyroid nodules have an expected malignancy rate of 5-15%. Our purpose was to assess which US criteria are most associated with cancer risk, and the value of critical ultrasound (US) reassessment. Methods: From 2018 to 2022, 298 BIII nodules were enrolled for thyroidectomy (79 malignancies). We evaluated ultrasonographic data: hechogenicity, intralesional vascularization, spiculated margins, micro-calcifications, "taller than wide" shape, extra-thyroidal growth, size increase, as well as their association with histology. We also evaluated if the ultrasound reassessment modified the strategy. Results: Spiculated margins and microcalcification were significantly correlated with malignancy risk. Spiculated margins showed a specificity of 0.95 IC95% (0.93-0.98); sensitivity 0.70 IC95% (0.59-0.80). Microcalcifications showed a sensitivity of 0.87 CI95% (0.80-0.94); specificity 0.75 CI95% (0.72-0.83). The presence of these signs readdressed the strategy in 76/79 cases Then, the indication for surgery was appropriate in 75% of cases. Conclusions: Microcalcifications and spiculated margins should be routinely sought during a final ultrasound reassessment in BIII nodules. These signs allowed for a modification of the strategy in favor of surgery in 96% of the cases that were not otherwise referred to surgery. The importance of integrating ultrasound and cytology in the evaluation of BIII thyroid nodules is confirmed. Reassessment with ultrasound of BIII nodules allowed for a redirection of the surgical choice.