A practical approach to follicular-patterned thyroid neoplasms: Diagnostic criteria, molecular genetics, and patient management
Year: 2026
Type: article
Abstract: Classification of follicular-patterned thyroid neoplasms has evolved considerably over the past two decades, driven by advances in molecular diagnostics and a deeper understanding of tumor biology. The 2016 reclassification of a subset of non-invasive encapsulated follicular variants of papillary thyroid carcinoma to non-invasive follicular thyroid neoplasms with papillary-like nuclear features (NIFTP) catalyzed a greater shift toward risk-stratified diagnosis and management, culminating in the three-tier stratification system of the 2022 WHO Classification of Endocrine and Neuroendocrine Tumors and the updated 2025 American Thyroid Association (ATA) guidelines for differentiated thyroid cancer. In this review, we present a practical approach to diagnosing follicular-patterned thyroid neoplasms including papillary thyroid carcinoma, NIFTP, and follicular thyroid carcinoma. We examine the diagnostic utility and limitations of nuclear features, detailing the criteria and pitfalls of capsular and vascular invasion assessment, and outline high-risk histologic features that inform recurrence risk. We further explore the molecular landscape underlying these entities, centered on the BRAF p.V600E-like/ RAS -like (BVL-RL) spectrum, and discuss how nuclear, architectural, and molecular findings converge to guide diagnosis and clinical management. Throughout, we highlight how the 2025 ATA guidelines have formalized many of these histologic and molecular distinctions into risk-stratified management pathways. As classification and molecular understanding continue to evolve, ongoing refinement of diagnostic criteria and nomenclature remains necessary to reduce overdiagnosis, overtreatment, and improve outcomes in patients with follicular-patterned thyroid neoplasms.
Source: Human Pathology Reports
Authors: Ellen D. Willhoit, Nicole A. Cipriani
Institution: University of Chicago
Language: English
Subfield: Endocrinology, Diabetes and Metabolism
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $1,160
OpenAlex ID: W7223083603