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The aim was to evaluate the long-term outcomes of an active surveillance (AS) strategy for Bethesda IV nodules using clinical and ultrasound-based selection criteria in a middle-income setting without access to molecular testing.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Retrospective analysis of a multicenter observational cohort. Patients were enrolled between January 2016 and December 2024. Adults with cytologically confirmed Bethesda IV thyroid nodules\u2009&lt;\u20094\u00a0cm, TI-RADS 2\u20134, and no high-risk clinical or radiologic features were offered AS. Patients with prior head and neck cancer, prior radiation, or suspicious lymphadenopathy were excluded. AS with structured clinical and ultrasound follow-up. Surgery was considered for significant growth (\u2265\u20093\u00a0mm), new suspicious features, or by clinical\/patient decision.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A total of 184 patients (88.6% women, 52.7% &lt;55 years) were included. At 48 months, 87.6% of nodules remained growth-free and 89.0% had not required surgery. Overall, 36 nodules (19.6%) showed growth; 26 patients (14.1%) underwent surgery. The malignancy rate was 7% for the full cohort and 46% among operated patients. Most malignant tumors were low-risk papillary carcinomas. No variable significantly predicted growth, but initial nodule size was associated with surgery (HR 1.06; 95% CI, 1.00\u20131.12;\n                      <jats:italic>P<\/jats:italic>\n                      = 0.04).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In this cohort, AS for Bethesda IV nodules demonstrated high stability, low malignancy rates, and low surgical conversion, supporting its feasibility in selected patients. In resource-limited settings, AS guided by clinical and ultrasound criteria may safely reduce unnecessary surgeries.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s12020-026-04678-5","type":"journal-article","created":{"date-parts":[[2026,7,13]],"date-time":"2026-07-13T07:28:18Z","timestamp":1783927698000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["A real-world experience of active surveillance in Bethesda IV thyroid nodules"],"prefix":"10.1007","volume":"91","author":[{"given":"Juan Jos\u00e9","family":"Santiva\u00f1ez","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos Andr\u00e9s","family":"Garc\u00eda-Lozano","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlos","family":"Betancourt","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan Guillermo","family":"S\u00e1nchez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura Viviana","family":"Mendieta","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Figueroa-Boh\u00f3rquez","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John","family":"Diaz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Esteban","family":"Moreno-Castrill\u00f3n","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5563-8840","authenticated-orcid":false,"given":"Alvaro","family":"Sanabria","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,7,13]]},"reference":[{"key":"4678_CR1","doi-asserted-by":"publisher","first-page":"317","DOI":"10.1001\/jamaoto.2014.1","volume":"140","author":"L Davies","year":"2014","unstructured":"L. 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