Tiroid Nodüllerine Bethesda Sınıflaması Eşliğinde Güncel Yaklaşımlar
Özet
Tiroit bezinin boyutunun artmasıyla oluşan tiroid nodülleri, normal popülasyonda ultrasonografi (USG) taramalarında %50-%60 oranında görülebilen ve özellikle kadınlarda daha sık rastlanan lezyonlardır. Çoğu asemptomatik ve ötiroid olan bu nodüllerde temel amaç, malignite riskini doğru değerlendirmektir. Nodüllerin tanısal yönetiminde klinik bulguların yanı sıra tiroid fonksiyon testleri, USG özellikleri ve ince iğne aspirasyon biyopsisi (İİAB) temel parametreleri oluşturur. ATA kılavuzuna göre yüksek ve orta şüpheli USG bulgularında 1 cm'nin, düşük şüphelilerde ise 1.5 cm'nin üzerindeki nodüllere İİAB önerilmektedir. İİAB sitopatolojisinin raporlanmasında altı tanısal kategoriye sahip Bethesda Sınıflaması kullanılmakta olup, bu kategoriler Bethesda 1'den (yetersiz) Bethesda 6'ya (malignite) kadar değişen oranlarda malignite riski taşır. Sitolojisi önemi belirsiz atipi (Bethesda 3) veya folliküler neoplazi (Bethesda 4) gelen hastalarda yaklaşım tartışmalı olsa da; şüpheli USG bulguları, >4 cm nodül boyutu, aile öyküsü, radyasyon maruziyeti veya pozitif moleküler mutasyonlar (BRAFV600E vb.) varlığında malignite riskinin artması sebebiyle total tiroidektomi tercih edilmektedir. İİAB sonucu benign gelen veya İİAB için uygun olmayan nodüllerin takipleri ise USG'deki risk sınıflamasına göre 6 ila 24 ay arasındaki periyotlarla yapılmaktadır.
Thyroid nodules, which cause an increase in the size of the thyroid gland, are lesions that can be detected at a rate of 50%-60% in ultrasonography (USG) screenings within the normal population and are observed more frequently especially in women. The primary objective regarding these nodules, most of which are asymptomatic and euthyroid, is to accurately evaluate the risk of malignancy. Along with clinical findings, thyroid function tests, USG features, and fine-needle aspiration biopsy (FNAB) constitute the fundamental parameters in the diagnostic management of nodules. According to the ATA guideline, FNAB is recommended for nodules larger than 1 cm with high and intermediate suspicion USG findings, and larger than 1.5 cm for low suspicion findings. The Bethesda System, which consists of six diagnostic categories, is utilized in reporting FNAB cytopathology, and these categories carry varying risks of malignancy ranging from Bethesda 1 (non-diagnostic) to Bethesda 6 (malignancy). Although the approach remains controversial for patients with atypia of undetermined significance (Bethesda 3) or follicular neoplasia (Bethesda 4), total thyroidectomy is preferred due to the increased risk of malignancy in the presence of suspicious USG features, nodule size >4 cm, family history, radiation exposure, or positive molecular mutations such as BRAFV600E. The follow-up of nodules with benign FNAB results or those unsuitable for FNAB is conducted with intervals between 6 to 24 months based on the risk classification in USG.
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