Reassessing the role of intraoperative frozen section in thyroid surgery in resource-limited settings: Time for selective use?

ABSTRACT Thyroid nodules are a prevalent clinical concern globally, with a rising incidence attributed to enhanced screening and diagnostic capabilities. In India, palpable thyroid nodules are notably common, affecting up to 12.2% of the population. The 2023 Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) provides a standardized classification for fine-needle aspiration (FNA) results, categorizing nodules from nondiagnostic (Category I) to malignant (Category VI). While FNA effectively diagnoses 75%–80% of nodules, 20%–25% remain indeterminate (Bethesda III and IV). In settings like India, where advanced molecular diagnostics (e.g. Afirma Genomic sequencing classifier (GSC), Thyroseq v3) may be financially inaccessible to a significant portion of the population, intraoperative frozen section (FS) has traditionally been employed. FS offers a rapid intraoperative assessment, potentially guiding immediate surgical decisions and avoiding a second surgery if malignancy is confirmed. However, the actual clinical utility and necessity of FS, especially in indeterminate categories, are widely debated. Pathologists in India are often requested to perform FS on cytologically indeterminate nodules (Bethesda III and IV) to obtain a definitive diagnosis. The 2023 Bethesda update and recent Indian studies report malignancy rates of 15%–35% in Bethesda IV nodules, further reducing the expected yield of routine FS. This review article aims to reassess the role of FS in thyroid surgery, particularly focusing on its diagnostic performance in follicular thyroid nodules, considering its limitations, and analyzing its cost-effectiveness within the unique healthcare landscape of India.