Sengul and Sengul: Subdivision of intermediate suspicion, the 2021 K-TIRADS, and category III, indeterminate cytology, the 2017 TBSRTC, 2nd edition, in thyroidology: let bygones be bygones?
Mater artium necessitas ("Necessity is the mother of invention"). From time immemorial, disorders of the thyroid gland, situated in the anteroinferior region of the neck, have maintained their significance in human health. The modern management of follicular nodular thyroid disease requires the availability of advanced diagnostic and therapeutic modalities. This is to ensure the provision of accurate diagnoses and the recommendation of suitable treatment options in the field of thyroidology [1-4].
We have read with great respect the research article titled "Subcategorization of intermediate suspicion thyroid nodules based on suspicious ultrasonographic findings." This high-quality research appears to necessitate the subcategorization of category 4 (intermediate suspicion) according to the 2021 Korean Thyroid Imaging Reporting and Data System (K-TIRADS), based on suspicious ultrasound (US) findings [5,6]. We believe that Kim et al.'s [5] emphasis on the subdivision of "intermediate suspicion" is a significant and vital issue in the field of thyroidology, as published in Volume 42 of Ultrasonography.
We also note that it is essential for professionals such as endocrine surgeons, endocrine pathologists, endocrinologists, radiologists, head and neck surgeons, otorhinolaryngologists, and thyroidologists to stay updated on the expanding range of clinical presentations for the atypia of undetermined significance or follicular lesion of undetermined significance ("AUS/FLUS"), also known as category III of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), second edition. This knowledge is crucial to ensure appropriate clinical care and the effective use of fine-needle aspiration cytology, thereby minimizing the risk of overlooking thyroid malignancy.
We have proposed and recommended a subdivision concept for category III, TBSRTC: (1) category IIIA: AUS/FLUS without nuclear atypia (AUS/FLUS w/o NA) and (2) category IIIB: AUS/FLUS with nuclear atypia (AUS/FLUS w/NA) [7-10]. However, Kim et al. [5] stated that they focused on category 4 (intermediate suspicion) in the 2021 K-TIRADS and divided it into two subgroups: nodules without suspicious sonographic findings and nodules with suspicious findings.
It should be noted that K-TIRADS 4 includes three main sonographic groups: (1) solid hypoechoic nodules without any of the three suspicious US features (i.e., punctate echogenic foci, nonparallel orientation, or irregular margins), (2) entirely calcified nodules, and (3) partially cystic or isoechoic/hyperechoic nodules with any of the three aforementioned suspicious US features [6]. The authors have stated that they divided these groups based on suspicious US features. However, it remains unclear which types of echogenicity were used by the authors to divide the nodules in terms of suspicious US features.
It is important to clarify that while partially cystic or isoechoic/hyperechoic nodules (K-TIRADS 3) with any of the three suspicious US features are classified as K-TIRADS 4, solid hypoechoic nodules without any of the three suspicious US features (K-TIRADS 4) with any of the three suspicious US features are classified as K-TIRADS 5. Therefore, if the first group (with suspicious features) was considered, this study group would no longer be classified as K-TIRADS 4, but rather as high suspicion (K-TIRADS 5). Similarly, if the second group (without suspicious features) was considered, that study group would no longer be classified as K-TIRADS 4, but rather as low suspicion (K-TIRADS 3). Would the results of this valuable study not change if all these possibilities were considered separately in detail? Is it not essential—even crucial—in the field of thyroidology to clarify all the aforementioned categories with these mentioned conditions in each step of the discussion?
In conclusion, the debate continues regarding both intermediate (sonographic) suspicion and indeterminate thyroid nodules. To address these issues, thyroidologists may opt to work with subdivisions in the future, rather than insisting on a monolithic intermediate or indeterminate category. This approach could shed light on the subject. The saying "let bygones be bygones" may not apply here, as this issue certainly warrants further investigation. We thank Kim et al. [5] for their significant study.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

References

1. Sengul I, Sengul D. Comment on: "Evaluating treatment options in managing thyroid nodules with indeterminate cytology of TBSRTC in thyroidology: addendum aut non?". Rev Assoc Med Bras (1992) 2022;68:973–974.
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2. Sengul D, Sengul I, Soares JM Junior. Repercussion of thyroid dysfunctions in thyroidology on the reproductive system: conditio sine qua non? Rev Assoc Med Bras (1992) 2022;68:721–722.
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3. Sengul I, Sengul D. Hermeneutics for evaluation of the diagnostic value of ultrasound elastography in TIRADS 4 categories of thyroid nodules. Am J Med Case Rep 2021;9:538–539.
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4. Sengul D, Sengul I. Reassessing combining real-time elastography with fine-needle aspiration biopsy to identify malignant thyroid nodules. Am J Med Case Rep 2021;9:552–553.
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5. Kim H, Shin JH, Kim KE, Kim MK, Oh J, Hahn SY. Subcategorization of intermediate suspicion thyroid nodules based on suspicious ultrasonographic findings. Ultrasonography 2023;42:307–313.
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6. Ha EJ, Chung SR, Na DG, Ahn HS, Chung J, Lee JY, et al. 2021 Korean Thyroid Imaging Reporting and Data System and imagingbased management of thyroid nodules: Korean Society of Thyroid Radiology consensus statement and recommendations. Korean J Radiol 2021;22:2094–2123.
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7. Sengul I, Sengul D. Focusing on thyroid nodules in suspense: 10-15 mm with repeat cytology, category III, the Bethesda System for Reporting Thyroid Cytopathology, TBSRTC. Rev Assoc Med Bras (1992) 2021;67:166–167.
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8. Sengul I, Sengul D. Blurred lines for management of thyroid nodules in the era of atypia of undetermined significance/follicular lesion of undetermined significance: novel subdivisions of categories IIIA and IIIB in a possible forthcoming The Bethesda System for Reporting Thyroid Cytopathology, 3rd edition; amending versus unnecessary? Rev Assoc Med Bras (1992) 2021;67:1385–1386.
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9. Sengul I, Sengul D. May 25-31, International Thyroid Awareness Week & May 25, World Thyroid Day, 2022: indetermination of indeterminate cytology, AUS/FLUS, FN, SUSP, in thyroidology? Sanamed 2022;17:109–110.
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10. Sengul D, Sengul I, Pelikan A. Paraphrase for the impact of repeat fine-needle aspiration in thyroid nodules categorized as atypia of undetermined significance or follicular lesion of undetermined significance: a single center experience. Diagn Cytopathol 2021;49:452–453.
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