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Purpose <p>Management of Bethesda IV thyroid nodules is challenging due to their indeterminate nature and potential overtreatment. The aim was to evaluate the long-term outcomes of an active surveillance (AS) strategy for Bethesda IV nodules using clinical and ultrasound-based selection criteria in a middle-income setting without access to molecular testing.</p> Methods <p>Retrospective analysis of a multicenter observational cohort. Patients were enrolled between January 2016 and December 2024. Adults with cytologically confirmed Bethesda IV thyroid nodules &lt; 4&#xa0;cm, TI-RADS 2–4, and no high-risk clinical or radiologic features were offered AS. Patients with prior head and neck cancer, prior radiation, or suspicious lymphadenopathy were excluded. AS with structured clinical and ultrasound follow-up. Surgery was considered for significant growth (≥ 3&#xa0;mm), new suspicious features, or by clinical/patient decision.</p> Results <p>A total of 184 patients (88.6% women, 52.7% &lt;55 years) were included. At 48 months, 87.6% of nodules remained growth-free and 89.0% had not required surgery. Overall, 36 nodules (19.6%) showed growth; 26 patients (14.1%) underwent surgery. The malignancy rate was 7% for the full cohort and 46% among operated patients. Most malignant tumors were low-risk papillary carcinomas. No variable significantly predicted growth, but initial nodule size was associated with surgery (HR 1.06; 95% CI, 1.00–1.12; <i>P</i> = 0.04).</p> Conclusions <p>In this cohort, AS for Bethesda IV nodules demonstrated high stability, low malignancy rates, and low surgical conversion, supporting its feasibility in selected patients. In resource-limited settings, AS guided by clinical and ultrasound criteria may safely reduce unnecessary surgeries.</p>

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A real-world experience of active surveillance in Bethesda IV thyroid nodules

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2026年7月13日

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  • Juan José Santivañez,
  • Carlos Andrés García-Lozano,
  • Carlos Betancourt,
  • Juan Guillermo Sánchez,
  • Laura Viviana Mendieta,
  • David Figueroa-Bohórquez,
  • John Diaz,
  • Esteban Moreno-Castrillón,
  • Alvaro Sanabria

摘要

Purpose

Management of Bethesda IV thyroid nodules is challenging due to their indeterminate nature and potential overtreatment. The aim was to evaluate the long-term outcomes of an active surveillance (AS) strategy for Bethesda IV nodules using clinical and ultrasound-based selection criteria in a middle-income setting without access to molecular testing.

Methods

Retrospective analysis of a multicenter observational cohort. Patients were enrolled between January 2016 and December 2024. Adults with cytologically confirmed Bethesda IV thyroid nodules < 4 cm, TI-RADS 2–4, and no high-risk clinical or radiologic features were offered AS. Patients with prior head and neck cancer, prior radiation, or suspicious lymphadenopathy were excluded. AS with structured clinical and ultrasound follow-up. Surgery was considered for significant growth (≥ 3 mm), new suspicious features, or by clinical/patient decision.

Results

A total of 184 patients (88.6% women, 52.7% <55 years) were included. At 48 months, 87.6% of nodules remained growth-free and 89.0% had not required surgery. Overall, 36 nodules (19.6%) showed growth; 26 patients (14.1%) underwent surgery. The malignancy rate was 7% for the full cohort and 46% among operated patients. Most malignant tumors were low-risk papillary carcinomas. No variable significantly predicted growth, but initial nodule size was associated with surgery (HR 1.06; 95% CI, 1.00–1.12; P = 0.04).

Conclusions

In this cohort, AS for Bethesda IV nodules demonstrated high stability, low malignancy rates, and low surgical conversion, supporting its feasibility in selected patients. In resource-limited settings, AS guided by clinical and ultrasound criteria may safely reduce unnecessary surgeries.