Abstract

Objective

To identify preoperative clinical factors associated with high-risk thyroid cytology (Bethesda V–VI) in patients undergoing thyroidectomy and to explore their association with cytological reclassification in initially non–high-risk nodules.

Methods

In this single-center retrospective study, 438 consecutive patients undergoing thyroidectomy between 2024 and 2025 were evaluated. After excluding Bethesda I cases, 415 patients were included. High-risk cytology (Bethesda V–VI) was the primary outcome. Age, sex, nodule size, bilateral involvement, toxic functional status, and cervical lymphadenopathy were assessed using logistic regression. A prespecified sensitivity analysis was restricted to Bethesda V cytology.

Results

High-risk cytology was identified in 151 patients (36.4%). In multivariable analysis, toxic functional status (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.07–0.54; p = 0.002) and larger nodule size (OR, 0.21; 95% CI, 0.15–0.30; p < 0.001) were independently associated with lower odds of high-risk cytology, whereas cervical lymphadenopathy was associated with higher odds (OR, 4.17; 95% CI, 1.87–9.31; p < 0.001). No independent associations were observed for age, sex, or bilaterality. The associations with toxic functional status and nodule size remained consistent in the sensitivity analysis. Among 127 patients who underwent repeat fine-needle aspiration, 19 (15.0%) were reclassified to high-risk cytology, with consistent findings.

Conclusion

Toxic functional status was associated with a lower likelihood of high-risk thyroid cytology, whereas cervical lymphadenopathy was associated with a higher likelihood. Similar patterns among patients undergoing repeat aspiration suggest that these routinely available clinical features may support follow-up decisions for initially non–high-risk nodules. Prospective studies are warranted to validate these findings.