CLAUSEWITZ'S "FOG OF WAR" AND THE DIFFICULTY OF ASSESSING THE RISK OF MALIGNANCY OF THYROID NODULES BETHESDA III-IV IN CORRELATION WITH THE EU-TIRADS CLASSIFICATION

AUTHORS:
M. Sola (Manresa, Spain) , M. Saladich (Manresa, Spain) , N. Guardia (Manresa, Spain) , A. Osorio (Manresa, Spain) , M. Bardaji (Manresa, Spain) , P. Collera (Manresa, Spain)
Background:
The management of thyroid nodules is based on the Bethesda and TIRADS classification. We analyzed our results using a correlation of both methods to assess the risk of malignancy (ROM) to show that this estimation is especially uncertain in the thyroid nodules Bethesda III-IV. The issue of uncertainty is not new, the Prussian military theorist, Carl von Clausewitz (1832), studied the psychological aspects of war and provided the term "fog of war".
Methods:
All patients who underwent a total or hemithyroidectomy from January 2022 to November 2023 were included in this study. The results of TI-RADS and Bethesda classification were correlated with the pathologic results.
Results:
During this period, 218 patients had thyroid surgery. Bethesda group III was associated with a ROM of 41%; in association with a TI-RADS 5 the ROM increased to 58%. Bethesda IV had a ROM of 60%, only if combined with TI-RADS 5, ROM reached 100%. We found that the ROM was more accurate using the Bethesda combined with the TIRADS classification, especially nodules TIRADS 5; but in Bethesda II and III, despite the TIRADS, the ROM was still very uncertain.
Conclusions:
The "fog of war" refers to the diminished level of accuracy of the information provided. According to Clausewitz, "a sensitive and discriminating judgment is called to scent out the truth." Despite many advances, preoperative cancer risk assessment for most thyroid nodules remains imprecise, and the treatment still depends on the surgeon preferences.