The risk of malignancy in the HCLUS category was significantly lower than in the other subtypes of AUS. Specifically, the ultrasound image of the malignant nodule, as well as the patients general condition and age and other comorbidities should be taken into account when planning surgery. Comparative findings of lymphocytic thyroiditis and thyroid lymphoma. Approximately 3% to 7% of thyroid FNAs have conclusive features of malignancy, and most are papillary carcinomas.1013 Malignant nodules are usually removed by thyroidectomy, with some exceptions (eg, metastatic tumors, non-Hodgkin lymphomas, and undifferentiated carcinomas). The discussions and conclusions regarding terminology and morphologic criteria from the NCI meeting, summarized in the publications by Baloch et al,4,5 form the framework for the terminology presented here and in atlas form.3 It is intended as a flexible framework that can be modified to suit the needs of the particular laboratory and the patients it serves. Johnson However, this requires additional FNA passes or residual cellular material from the cytologic sample. Bongiovanni M, Krane JF, Cibas ES, Faquin WC. Core tip: Fine-needle aspiration (FNA) cytology is widely used for the diagnosis of thyroid nodules, although cases with indeterminate results are not rare. The use of molecular markers can further increase the diagnostic value of FNA samples for the detection of thyroid cancer. Reduce red blood cells in smears iii. Preparation Methods For example, increased serum calcitonin levels and/or strong immunoresponce of chromogranin which is disclosed after multiple FNA tests can indicate the diagnosis of a medullary carcinoma. [2] First documented in HeLa cells, where there are generally 10-30 per nucleus, [3] Paraspeckles are now known to also exist in all human primary cells, transformed cell lines and . Preparations for the conference began 18 months earlier with the designation of a steering committee, coordination with cosponsoring organizations, and the establishment of a dedicated, permanent Web site. In this review we analyze current literature regarding Thyroid Cytopathology Reporting systems trying to identify the most suitable and practical methodology to use in everyday clinical practice. Histogenesis of medullary carcinoma of the thyroid. Surgical intervention consisted of a 15 7 7-cm segmental mastectomy specimen that contained a large, ill-defined, irregular pink-tan . Thyroid aspiration cytology: current status. Careers, Unable to load your collection due to an error. AS In several countries the Cytological Communities have adopted the first system or the other, as there is still an ongoing dispute on whether the 5-tiered system or the 6-tiered system is more efficient[12]. Amyloid can be observed in close association with tumor cells, and can be distinguished from the thick colloid of PTC by performing a Congo-red stain. ZW Salivary Glands and Other Head and Neck Structures Moreover, a lower percentage of cases in the European system was placed into the TIR 4 and TIR 5 categories as well, compared with the American system. (10%) For clarity of communication, TBSRTC recommends that each report begin with 1 of 6 general diagnostic categories. Handle sparsely cellular specimens ii. In conclusion, patients who require repeated FNAs for indeterminate diagnoses will be resolved by repeat FNA in a percentage of 72%-80%. While there are advantages and disadvantages to each component regarding turnaround time, comprehensiveness, and diagnostic utility (Table), their synergism provides ample information for your consultant hematopathologists. These formalin specimens are embedded in paraffin blocks and sectioned by histotechnologists to provide a two-dimensional cross-section of the clotted tissue. Benign cyst-lining cells are typically polygonal or fusiform with abundant cytoplasm, well-defined cellular borders, sometimes enlarged, grooved nuclei, and small distinct nucleoli. Fine-needle aspiration in the work-up of thyroid nodules. Flat sheets showing enlarged, pale nuclei with finely granular chromatin of a papillary Ca case ( 40 pap stain on ThinPrep slide) (diagnostic categories VI). O Cases that demonstrate the nuclear features of papillary carcinoma are excluded from this category. Many laboratories have traditionally considered a macrophages-only sample unsatisfactory and included them in the ND/UNS category, with the understanding that, because the parenchyma of the nodule has not been sampled, one cannot exclude a cystic papillary carcinoma. Urine cytology-general principles Flashcards | Quizlet Q: Can flow cytometry be used for assessment of morphologic dysplasia? The FNA specimens show enlarged follicular cells arranged in monolayer sheets and follicular groups in a background of thin and thick colloid (Figure (Figure6).6). There is a predominance of Hrthle cells in a sparsely cellular aspirate with scant colloid. Thyroid FNA specimen a. Kocjan G, Cochand-Priollet B, de Agustin PP, Bourgain C, Chandra A, Daneshbod Y, Deery A, Duskova J, Ersoz C, Fadda G, et al. According to the Bethesda system for reporting thyroid cytopathology, a specimen . Highly cellular specimens are ideal for smeared preparations, whereas sparsely cellular specimens will require multiple centrifugation steps and special cell consolidation processing. The spindle-shaped morphology of these cells is helpful in distinguishing these cells from PTC[24,34]. Adequacy issues usually arise in sparsely cellular specimens, since low cellularity or inadequate representation may pose potential for missing a significant pathological process including malignancy. MTC was first described by Horn et al[45] in 1951, and it was first recognized as a unique clinicopathological entity by Hazard et al[46], in 1959. It was apparent from the discussions at the conference and the Web postings that the primary purpose of terminology is clarity of communication. The atypia of undetermined significance/follicular lesion of undetermined significance: malignant ratio: a proposed performance measure for reporting in The Bethesda System for thyroid cytopathology. Without the bone marrow matrix, these slides contain only cells directly from the marrow and can be stained and assessed both for lineage and cytologic morphology, with high correlations to what may be seen on aspirate and biopsy. "Agar Cell-Suspension": A Novel Technique for Processing Clear Specimens. For that reason the aspirate is then classified as AUS/FLUS to indicate the uncertainty of the findings. The differential diagnosis for the latter includes hyperplastic adenomatoid nodule with Hurthle cell change, Hurthle cell adenoma, and Hurthle cell carcinoma; (5) DC V Suspicious for malignancy. Like the marrow aspirate smear, touch imprint preparations provide a quick turnaround time (i.e., do not need decalcification) and great morphologic detail (if the aspirate smears are paucispicular or hemodiluted). Cytologic features of histologically proven follicular adenoma and Cellularity may in part be due to the LBC technique in comparison with smears made after sedimentation, . 2023 ,https://www.hematology.org/education/trainees/fellows/trainee-news/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer. Maybe a routine peripheral smear caught some circulating blasts. Cibas Since there is a considerable proportion of patients with a thyroid nodule who remain undiagnosed with FNA, molecular biology could be very helpful at that point. Baloch BRAF mutation has become a specific marker for PTC and its variants[54]. Gross specimen was measuring about 2x2x1.5 cm in size, soft in consistency, brownish black in color and roughly oval in shape [Table/Fig-4]. How to Interpret Thyroid Fine-Needle Aspiration Biopsy Reports: A Guide In such laboratories, macrophages only often constituted the great majority of ND/UNS cases, with rates that ranged from 15% to 30%.2,9,11,12 Other laboratories considered the risk of a false-negative result negligible and reported macrophages only as benign.10,11 At the 2007 NCI Conference, it was decided that cyst-fluid-only (CFO) cases should be considered a clearly identified subset of ND/UNS. Although these cytomorphologic features do not permit distinction from a follicular adenoma (FA), they are reportable as follicular neoplasm (FN) or suspicious for a follicular neoplasm (SFN), leading to a definitive diagnostic procedure, usually lobectomy.12,15,17 The term suspicious for a follicular neoplasm is preferred by some laboratories over follicular neoplasm for this category because a significant proportion of cases (up to 35%) prove not to be neoplasms but rather hyperplastic proliferations of follicular cells, most commonly those of multinodular goiter.10,1821 About 15% to 30% of cases called FN/SFN prove to be malignant.2,10,19,22 The majority of FN/SFN cases turn out to be FAs or adenomatoid nodules of multinodular goiter, both of which are more common than FC. The cytological diagnosis of PTC is based mainly on the characteristic nuclear morphology. Sparsely cellular and contains atypical lymphoid cells Suspicious for malignancy, not otherwise specified Other primary thyroid malignancies like anaplastic carcinoma and poorly differentiated carcinoma Suboptimal cellularity or preservation can lead to uncertainty and result in a suspicious for malignancy interpretation Cytology images A print atlas, with more than 40 contributing authors Appendix 1, is in press.3. However, nuclear grooves can be seen also in several thyroid diseases such, as Hashimotos thyroiditis, multinodular goiter, Hurthle cell tumors and medullary carcinoma[42,43]. Cibas ES. In order to establish a standardized diagnostic terminology/classification system for reporting thyroid FNAC results, the National Cancer Institute (NCI) in the United States sponsored the NCI Thyroid FNA State of the Science Conference with a group of experts at Bethesda, MD, in October 2007[7]. The molecular diagnosis and management of thyroid neoplasms. Heitz Zubair W. Baloch, MD, PhD, served as chair of the Terminology and Morphologic Criteria committee. the contents by NLM or the National Institutes of Health. It usually behaves as an indolent malignant tumor; however, an aggressive clinical course with decreased survival has been reported in some histologic variants of PTC[41]. If resected, virtually all benign follicular nodules turn out to be nodules of a multinodular goiter or follicular adenomas. The malignancy rate of the AUS/FLUS category is estimated to be between 5% and 15%[10], which is intermediate between that of the benign category (0%-3%) and that of the SFN category (15%-30%). This category includes the diagnoses of nodular goiter, nodular goiter with hyperplastic nodules, colloid nodules, cyst contents with/without benign follicular cells, and lymphocytic thyroiditis; (3) DC III Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance (Figure (Figure2).2). LiVolsi . Hahn SY, Shin JH, Han BK, Ko EY, Ko ES. Marchevsky AM, Walts AE, Bose S, Gupta R, Fan X, Frishberg D, Scharre K, Zhai J. Evidence-based evaluation of the risks of malignancy predicted by thyroid fine-needle aspiration biopsies. Impact of proto-oncogene mutation detection in cytological specimens from thyroid nodules improves the diagnostic accuracy of cytology. The nucleoli are usually small and eccentric; however, rare oncocytic variants of PTC can show prominent nucleoli. Enlarged follicular cells arranged in monolayer sheets and follicular groups with nuclear elongation and chromatin clearing in a follicular variant of PTC case ( 40 pap stain on ThinPrep slide) (diagnostic categories VI). Extensive research is going on in this field; an important step for the introduction of new molecular markers in the diagnosis of molecular tumors could be the clinical testing of FNA samples in large multicenter trials. A uniform reporting system for thyroid FNA will facilitate effective communication among cytopathologists, endocrinologists, surgeons, radiologists, and other health care providers; facilitate cytologic-histologic correlation for thyroid diseases; facilitate research into the epidemiology, molecular biology, pathology, and diagnosis of thyroid diseases, particularly neoplasia; and allow easy and reliable sharing of data from different laboratories for national and international collaborative studies. See more. Cystic degeneration also is often found. Prognosis is dismal with a mean survival of 2.5 to 6 mo and an overall 5-year survival of 0% to 14%. VA The purpose of this diagnostic category is to identify a nodule that might be a follicular carcinoma (FC) and triage it for surgical lobectomy. A: No. J Both the European and the American systems are considered as a significant accomplishment and hold the promise for better classification of thyroid FNA results[6,10,11,17,18]. BRAF testing has been coupled successfully with the Bethesda Thyroid FNA classification system to offer molecular quality assurance on positive samples, as well as a diagnostic upgrade on samples of indeterminate diagnostic categories, such as AUS/FLUS and SFN/SHN[54]. Cross PA, Poller D. The Bethesda thyroid terminology and progress towards international agreement on thyroid FNA cytology reporting. Such cases occur with some regularity, and they are best classified as suspicious for malignancy, qualified as suspicious for papillary carcinoma. Nodules called suspicious for papillary carcinoma are resected by lobectomy or thyroidectomy. Verizon (United States of America)Cell Tower Map - CellMapper Pan-keratin is the most reliable positive immunostain in UTCs, acquiring an expression ranging from 50% to 100%. We thank Diane Solomon, MD, for review of the manuscript and helpful comments. Cibas 2. ES DA Since the malignancy rate of this category is quite high, TBSRTC recommends that most patients undergo a repeat thyroid FNA within 3 to 6 mo, in order to define the nature of atypia[24,26]. They can be sparsely cellular, because of the marked fibrosis and hyalinization encountered in some cases[19,51]. Yang J, Schnadig V, Logrono R, Wasserman PG. A minor population of macrofollicles (intact spheres and fragments) can be present. Alternatively, a more prominent than usual population of microfollicles may occur (and may be disproportionately apparent on a minority of smears) in a moderately or markedly cellular sample, but the overall proportion of microfollicles is not sufficient for a diagnosis of follicular neoplasm/suspicious for follicular neoplasm. Contribution of molecular testing to thyroid fine-needle aspiration cytology of follicular lesion of undetermined significance/atypia of undetermined significance. Recognizably benign cellular changes (eg, typical cyst lining cells, focal Hrthle cell change, changes ascribed to radioiodine therapy, black thyroid) should not be interpreted as AUS. A cellular specimen composed of Hrthle cells arranged in loosely cohesive sheets or isolated in a case diagnosed as Hrthle cell adenoma ( 40 pap stain on ThinPrep slide) (diagnostic categories IV). The FNA aspirates of an MTC are usually composed of numerous cells, either presenting in cell aggregates or as a mixture of non-cohesive cells. CellMapper is a crowd-sourced cellular tower and coverage mapping service. These can be highly useful when a core biopsy is suboptimal, demonstrates marked myelofibrosis, is a dry tap, or otherwise fails to provide adequate visual data for morphology, architecture, cellularity, and hematopoietic lineage assessments. PTC accounts for 80% of all thyroid malignancies and occurs more often in women with a 3:1 female-to-male ratio, with a mean age at presentation 30-40 years. It usually affects the elderly population, and often presents as a large and bulky tumor with extrathyroidal extension and metastases. The Bethesda System for Reporting Thyroid Cytopathology: Definitions, Criteria and Explanatory Notes. Neither of these patterns fits comfortably into the benign category, but the changes are insufficient for any of the more . 92 0 obj <> endobj Rubenfeld The cells have abundant pink cytoplasm, basally located nuclei and nuclear features of conventional PTC. While their individual turnaround times vary, these specimens are usually reported together to make sure all aspects are accounted for, which can take approximately three days on average. The morphology is similar to that seen on the core biopsy. Williams ED. Rosen We also evaluated aspects of specimen quality that differed according to the use of ROSE. Such changes may represent atypical but benign cyst-lining cells, but a papillary carcinoma cannot be entirely excluded (ThinPrep, Papanicolaou stain). Sparsely cellular specimen means exact what it says - cells are sparse. The six-tier diagnostic approach includes the following six categories[8,15]: (1) Disctrict of columbia (DC)INondiagnostic or Unsatisfactory. Faquin WC, Cibas ES, Renshaw AA. MTC represents 3%-12% of thyroid cancers, the majority of which are sporadic. Goellner The tumor cells show nuclear elongation, chromatin clearing, but nuclear grooves and inclusions are rare[40]. These cells constitute more than 50% of tumor volume[44]. . Description of a distinctive morphological variant and report of 7 cases. In this review we analyze all literature regarding Thyroid Cytopathology Reporting systems trying to identify the most suitable methodology to use in clinical practice for the preoperative diagnosis of thyroid nodules. We welcome suggestions or questions about using the website. Ramzy . As such, if a dry tap is encountered during a bone marrow procedure, it may be beneficial to obtain two bone core biopsies to send to the laboratory. Redman R, Yoder BJ, Massoll NA. The most common scenarios can be described as follows: There is a prominent population of microfollicles in an aspirate that does not otherwise fulfill the criteria for follicular neoplasm/suspicious for follicular neoplasm. This situation may arise when a predominance of microfollicles is seen in a sparsely cellular aspirate with scant colloid.
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