Remarks on thyroid malignity in up-to-date category III of the Novel Bethesda System for Reporting Thyroid Cytopathology in thyroidology

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Dear Editor,

The novel 2023 Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has announced up-to-date recommendations in thyroidology and thyroid cytopathology^ 1-10 ^. We are writing to you with interest regarding the article entitled "The Incidence of Thyroid Cancer in Bethesda III Thyroid Nodules: A Retrospective Analysis at a Single Endocrine Surgery Center" by Hassan et al.^ 11 ^ This retrospective cohort analysis investigated the risk of malignancy in thyroid nodules with category III, TBSRTC, based on the outcomes of histopathology at a single endocrine surgery center between January 2020 and March 2024. The authors reported that sonography-guided fine-needle aspiration was performed via a 21-gauge (G) needle, utilizing local anesthesia. The study presents several noteworthy findings. First, it proclaimed a high malignancy rate of 33.5% in the nodules with category III, TBSRTC. The authors suggested that this elevated rate might be due to referral and selection bias^ 11 ^. Second, would harnessing both the novel terminology for subdivisions of category III of the current TBSRTC, 3rd edition, separately to all the studied and targeted purposes of this work, alter the study's relevant outcome(s)?^ 4-8 ^ Third, the study exhibited a significant gender difference in the nodules with category II, TBSRTC, with females exhibiting a 21.2% malignancy rate compared to only 3.4% in males, while females with malignancy had prognostically superior non-invasive tumors^ 9 ^. Fourth, would the utilization of thicker or finer needles transmute^ 12-14 ^. the desinence(s) of this study? Fifth, this valued work was of a retrospective nature, conducted at a single center, with a lack of molecular testing data due to insurance and technological limitations. Last but not the least, the relatively small size of the category III cohort is also ponderable as another limitation of this study. However, the authors rightly emphasized the essentiality of individualized risk assessments considering gender-specific factors. Further prospective studies with larger sample sizes from diverse geographical regions, incorporating genetic and biological research, are necessary to validate these findings and refine risk assessment strategies for thyroidologists. This issue merits further investigation. We thank Hassan et al.^ 1 ^ for their study on .category III, TBSRTC, for thyroidologists.