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Velez Torres JM, Curnow PM, Tjendra Y, Jorda M, Fernandez CG, Buitrago MG, Zuo Y, Cordero RR. Exploring the atypia of undetermined significance: Malignant ratio, ThyroSeq v3 positive call rate, molecular-derived risk of malignancy, and risk of malignancy as possible quality metric tools in thyroid cytology. Cancer Cytopathol 2024; 132:491-498. [PMID: 38594180 DOI: 10.1002/cncy.22820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND The atypia of undetermined significance (AUS) category is heterogeneous, leading to variations in its use. To prevent excessive usage, the AUS rate should be ≤10%. Although this recommendation aims to maintain diagnostic quality, it lacks supporting data. The AUS:Malignant (AUS:M) ratio has been proposed as a metric tool to evaluate AUS use. Furthermore, integrating ThyroSeq v3 (TSV3) positive call rate (PCR) and the molecular-derived risk of malignancy (MDROM) have been put forward as performance improvement tools. The authors reviewed their AUS:M ratios, TSV3 PCR, MDROM, and ROM. METHODS Thyroid aspirates evaluated in the laboratory (from August 2022 to September 2023) by seven cytopathologists (CPs) were identified. AUS:M ratio, MDROM, ROM, and TSV3 PCR results for the laboratory and each CP were recorded and analyzed. RESULTS A total of 2248 aspirates were identified (462 AUS and 80 malignant). The AUS:M ratio for the laboratory was 5.8 (CPs range, 2.8 to 7.3). The TSV3 PCR for the laboratory was 23% (CPs range, 11% to 41%). The MDROM for the laboratory was 19% (CPs range, 9% to 31%), whereas the ROM was 36% (CPs range, 29% to 50%). Linear regression analysis of AUS:M ratio versus TSV3 PCR and MDROM demonstrated a moderate positive correlation but a weak negative correlation to the ROM. Deviations from established targets were attributed to multiple factors. CONCLUSION The findings of this study underscore the importance of using a combination of metrics to evaluate diagnostic practices. By dissecting the practice patterns of each CP, the authors can measure different aspects of their performance and provide individualized feedback.
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Affiliation(s)
- Jaylou M Velez Torres
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Porshya M Curnow
- LabCorp of America, Department of Pathology and Laboratory Medicine, University of Miami Hospital, Miami, Florida, USA
| | - Youley Tjendra
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Merce Jorda
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Carmen Gomez Fernandez
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Monica Garcia Buitrago
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yiqin Zuo
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Roberto Ruiz Cordero
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
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Yang SP, Nga ME, Bundele MM, Chiosea SI, Tan SH, Lum JHY, Parameswaran R, Lim MY, Li H, Cheah WK, Sek KSY, Tan ATH, Loh TKS, Ngiam KY, Tan WB, Huang X, Ho TWT, Lim KH, Lim CM, Singaporewalla RM, Rao AD, Rao NCL, Chua DYK, Chin DCW, Wald AI, LiVolsi VA, Nikiforov YE, Tai ES. Performance of a multigene genomic classifier and clinical parameters in predicting malignancy in a Southeast Asian cohort of patients with cytologically indeterminate thyroid nodules. Cancer Cytopathol 2024; 132:309-319. [PMID: 38319805 DOI: 10.1002/cncy.22796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/27/2023] [Accepted: 12/18/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND Most thyroid nodules are benign. It is important to determine the likelihood of malignancy in such nodules to avoid unnecessary surgery. The primary objective of this study was to characterize the genetic landscape and the performance of a multigene genomic classifier in fine-needle aspiration (FNA) biopsies of cytologically indeterminate thyroid nodules in a Southeast Asian cohort. The secondary objective was to assess the predictive contribution of clinical characteristics to thyroid malignancy. METHODS This prospective, multicenter, blinded study included 132 patients with 134 nodules. Molecular testing (MT) with ThyroSeq v3 was performed on clinical or ex-vivo FNA samples. Centralized pathology review also was performed. RESULTS Of 134 nodules, consisting of 61% Bethesda category III, 20% category IV, and 19% category V cytology, and 56% were histologically malignant. ThyroSeq yielded negative results in 37.3% of all FNA samples and in 42% of Bethesda category III-IV cytology nodules. Most positive samples had RAS-like (41.7%), followed by BRAF-like (22.6%), and high-risk (17.9%) alterations. Compared with North American patients, the authors observed a higher proportion of RAS-like mutations, specifically NRAS, in Bethesda categories III and IV and more BRAF-like mutations in Bethesda category III. The test had sensitivity, specificity, negative predictive value, and positive predictive value of 89.6%, 73.7%, 84.0%, and 82.1%, respectively. The risk of malignancy was predicted by positive MT and high-suspicion ultrasound characteristics according to American Thyroid Association criteria. CONCLUSIONS Even in the current Southeast Asian cohort with nodules that had a high pretest cancer probability, MT could lead to potential avoidance of diagnostic surgery in 42% of patients with Bethesda category III-IV nodules. MT positivity was a stronger predictor of malignancy than clinical parameters.
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Affiliation(s)
- Samantha Peiling Yang
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
- Endocrinology Division, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Min En Nga
- Department of Pathology, National University Hospital, Singapore, Singapore
| | | | - Simion I Chiosea
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sze Hwa Tan
- Department of Pathology, Changi General Hospital, Singapore, Singapore
| | - Jeffrey H Y Lum
- Department of Pathology, National University Hospital, Singapore, Singapore
| | - Rajeev Parameswaran
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ming Yann Lim
- Department of Otorhinolaryngology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Hao Li
- Department of Otorhinolaryngology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Wei Keat Cheah
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Breast and Endocrine Surgery, Department of General Surgery, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Kathleen Su-Yen Sek
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
- Endocrinology Division, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Andre Teck Huat Tan
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
- Endocrinology Division, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Thomas Kwok Seng Loh
- Department of Otolaryngology-Head and Neck Surgery, National University Hospital, Singapore, Singapore
- Department of Otolaryngology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kee Yuan Ngiam
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wee Boon Tan
- Division of Endocrine Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
- Division of Endocrine Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Xinyong Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Changi General Hospital, Singapore, Singapore
| | | | - Keng Hua Lim
- Department of Otorhinolaryngology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Chwee Ming Lim
- Department of Otolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore, Singapore
- Department of Otolaryngology-Head and Neck Surgery, Duke-National University of Singapore Medical School, Singapore, Singapore
| | - Reyaz M Singaporewalla
- Endocrine and Head Neck Surgery Unit, Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Anil Dinkar Rao
- Endocrine and Head Neck Surgery Unit, Department of General Surgery, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Nandini C L Rao
- Department of Pathology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Dennis Yu Kim Chua
- Department of Otorhinolaryngology, Tan Tock Seng Hospital, Singapore, Singapore
| | - David Chao-Wu Chin
- Department of Otorhinolaryngology-Head and Neck Surgery, Changi General Hospital, Singapore, Singapore
| | - Abigail I Wald
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Virginia A LiVolsi
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | - Yuri E Nikiforov
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - E Shyong Tai
- Endocrinology Division, Department of Medicine, National University Hospital, Singapore, Singapore
- Endocrinology Division, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Bagıs M, Can N, Sut N, Tastekin E, Erdogan EG, Bulbul BY, Sezer YA, Kula O, Demirtas EM, Usta I. A Comprehensive Approach to the Thyroid Bethesda Category III (AUS) in the Transition Zone Between 2nd Edition and 3rd Edition of The Bethesda System for Reporting Thyroid Cytopathology: Subcategorization, Nuclear Scoring, and More. Endocr Pathol 2024; 35:51-76. [PMID: 38280141 PMCID: PMC10944398 DOI: 10.1007/s12022-024-09797-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 01/29/2024]
Abstract
Significant interobserver variabilities exist for Bethesda category III: atypia of undetermined significance (AUS) of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). Thus, subcategorization of AUS including AUS "nuclear" and AUS "other" is proposed in the recent 3rd edition of TBSRTC. This study investigated the impact of the nuclear features/architectural features/nuclear score (NS) (3-tiered)/subcategories and subgroups on risk of malignancy (ROM) in thyroid fine-needle aspirations (FNA). 6940 FNAs were evaluated. 1224 (17.6%) cases diagnosed as AUS were reviewed, and 240 patients (initial FNAs of 260 nodules and 240 thyroidectomies) were included. Subcategories and subgroups were defined according to TBSRTC 2nd and 3rd editions. Histological diagnostic groups included nonneoplastic disease, benign neoplasm, low-risk neoplasm, and malignant neoplasm. Overall, ROM was 30.7%. ROM was significantly higher in FNAs with nuclear overlapping (35.5%), nuclear molding (56.9%), irregular contours (42.1%), nuclear grooves (74.1%), chromatin clearing (49.4%), and chromatin margination (57.7%), and these features were independent significant predictors for malignancy. FNAs with NS3 had significantly higher ROM (64.2%). Three-dimensional groups were significantly more frequent in malignant neoplasms (35.7%). ROM was significantly higher in AUS-nuclear subcategory (48.2%) and in AUS-nuclear and architectural subcategory (38.3%). The highest ROM was detected in AUS-nuclear1 subgroup (65.2%). ROM was significantly higher in the group including AUS-nuclear and AUS-nuclear and architectural subcategories, namely "high-risk group" than the group including other subcategories, namely "low-risk group" (42.0%vs 13.9%). In conclusion, subcategorization may not be the end point, and nuclear scoring and evaluation of architectural patterns according to strict criteria may provide data for remodeling of TBSRTC categories.
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Affiliation(s)
- Merve Bagıs
- Department of Pathology, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey
| | - Nuray Can
- Department of Pathology, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey.
| | - Necdet Sut
- Department of Biostatistics, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey
| | - Ebru Tastekin
- Department of Pathology, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey
| | - Ezgi Genc Erdogan
- Department of Pathology, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey
| | - Buket Yilmaz Bulbul
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey
| | - Yavuz Atakan Sezer
- Department of General Surgery, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey
| | - Osman Kula
- Department of Radiology, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey
| | - Elif Mercan Demirtas
- Department of Pathology, Faculty of Medicine, Trakya University, 22030, Edirne, Turkey
| | - Inci Usta
- Department of Pathology, Adiyaman University Training and Research Hospital, 02040, Adiyaman, Turkey
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Juhlin CC, Baloch ZW. The 3 rd Edition of Bethesda System for Reporting Thyroid Cytopathology: Highlights and Comments. Endocr Pathol 2024; 35:77-79. [PMID: 38032439 DOI: 10.1007/s12022-023-09795-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/01/2023]
Affiliation(s)
| | - Zubair W Baloch
- Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Alden J, Lambrou D, Yang J. Two-tier subclassification of the Bethesda category III (atypia of undetermined significance/follicular lesion of undetermined significance) in thyroid cytology. Diagn Cytopathol 2024; 52:156-162. [PMID: 38095097 DOI: 10.1002/dc.25261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/31/2023] [Accepted: 11/24/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND The Bethesda category III, AUS/FLUS, comprises a heterogeneous group of thyroid lesions with variable risk of malignancy (ROM). This study evaluates ROM in two subgroups of this category based on nuclear atypia and architectural atypia. METHODS Cases in Bethesda category III were reported based on nuclear atypia (AUS) and architectural atypia (FLUS). ROM was calculated by comparing the cytologic diagnosis to the follow-up histologic diagnosis. RESULTS Among the 610 Bethesda category III cases in this study, 306 (50.2%) and 304 (49.8%) cases were reported as AUS and FLUS, respectively. One hundred and eighty six of 306 AUS (60.8%) and 193 of 304 FLUS (63.5%) cases underwent surgical intervention. ROM of the cases in Bethesda category III was 12.8% if all cases were counted and 20.6% if only surgical cases were counted. When analyzing separately, ROM of AUS cases was 17.0% and 28.0% with all cases and surgical cases only, respectively. For FLUS cases, ROM was 8.6% and 13.5% with all cases and surgical cases only, respectively. CONCLUSION In Bethesda category III, ROM in the cases with nuclear atypia was significantly higher than the cases with architectural atypia. Sub-classifying the Bethesda Category III cases with nuclear atypia and architectural atypia, respectively may better stratify the ROM.
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Affiliation(s)
- Jay Alden
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Denise Lambrou
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jack Yang
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Li Q, Yang L, Yang L, Jiang X, Li S. Utility of Six Ultrasound-Based Risk Stratification Systems in the Diagnosis of AUS/FLUS Thyroid Nodules. Acad Radiol 2024; 31:131-141. [PMID: 37225530 DOI: 10.1016/j.acra.2023.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/22/2023] [Accepted: 04/22/2023] [Indexed: 05/26/2023]
Abstract
RATIONALE AND OBJECTIVES To estimate the diagnostic performance of the currently used ultrasound (US)-based risk stratification systems (RSSs) (American Thyroid Association, American Association of Clinical Endocrinologists, American College of Endocrinology, and Association Medici Endocrinology Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules, European Thyroid Association Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules in Adults [EU-TIRADS], American College of Radiology Thyroid Imaging Reporting and Data System [ACR-TIRADS], Chinese Guidelines for Ultrasound Malignancy Risk Stratification of Thyroid Nodules [C-TIRADS], and Thyroid Imaging Reporting and Data System Developed by Kwak et al [Kwak-TIRADS]) for atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) thyroid nodules. MATERIALS AND METHODS This retrospective study included 514 consecutive AUS/FLUS nodules in 481 patients with final diagnosis. The US characteristics were reviewed and classified using the categories defined by each RSS. The diagnostic performance was evaluated and compared using a generalized estimating equation method. RESULTS Of the 514 AUS/FLUS nodules, 148 (28.8%) were malignant and 366 (71.2%) were benign. The calculated malignancy rate increased from the low-risk to high-risk categories for all RSSs (all P < .001). Interobserver correlation for both US features and RSSs showed substantial to almost perfect agreement. The diagnostic efficacy of Kwak-TIRADS (AUC=0.808) and C-TIRADS (AUC=0.804) were similar (P = .721) and higher than those of other RSSs (all P < .05). The EU-TIRADS and Kwak-TIRADS exhibited similar sensitivity (86.5% vs 85.1%, P = .739) and were only higher than that of the C-TIRADS (all P < .05). The specificity of C-TIRADS and ACR-TIRADS were similar (78.1% vs 72.1%, P = .06) and were higher than those of other RSSs (all P < .05). CONCLUSION Currently used RSSs can provide risk stratification for AUS/FLUS nodules. Kwak-TIRADS and C-TIRADS have the highest diagnostic efficacy in identifying malignant AUS/FLUS nodules. A detailed knowledge of the benefits and shortcomings of the various RSSs is essential.
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Affiliation(s)
- Qiang Li
- Department of Ultrasound, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, 3 Rd East Qingchun, Hangzhou 310016, China (Q.L., L.Y., L.Y., S.L.)
| | - Lu Yang
- Department of Ultrasound, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, 3 Rd East Qingchun, Hangzhou 310016, China (Q.L., L.Y., L.Y., S.L.)
| | - Liming Yang
- Department of Ultrasound, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, 3 Rd East Qingchun, Hangzhou 310016, China (Q.L., L.Y., L.Y., S.L.)
| | - Xianfeng Jiang
- Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, Hangzhou, China (X.J.)
| | - Shiyan Li
- Department of Ultrasound, Sir Run Run Shaw Hospital, Zhejiang University, School of Medicine, 3 Rd East Qingchun, Hangzhou 310016, China (Q.L., L.Y., L.Y., S.L.).
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7
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Terzi NK, Terzi T. Thyroid fine-needle aspiration cytology: malignancy rate in the category of indeterminate significant atypia/indeterminate significant follicular lesion. Ann Saudi Med 2024; 44:31-38. [PMID: 38311867 PMCID: PMC10839452 DOI: 10.5144/0256-4947.2024.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/09/2023] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Fine needle aspiration cytology (FNAC) is a standard preoperative diagnostic modality for thyroid nodules. The Bethesda Thyroid Cytopathology Reporting System (TBSRTC) defines the FNAC atypia group as atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS). OBJECTIVES Determine the risk of malignancy after surgical resection in patients with AUS/FLUS. DESIGN Retrospective. SETTING Pathology department of a tertiary care center. PATIENTS AND METHODS All thyroid FNACs between 2015 and 2023 that were diagnosed as AUS/FLUS in Turkey. Patient demographics, preoperative ultrasonographic features, and follow-up data were collected. MAIN OUTCOME MEASURES Relationship between AUS/FLUS diagnosis and final histopathological diagnosis. SAMPLE SIZE 562. RESULTS In total, 562 thyroid nodules were diagnosed as AUS/FLUS, and 267 (47.5%) were surgically excised. A malignant histopathological diagnosis was given in 28 cases (10.4%). Malignancy risk sensitivity of AUS/FLUS diagnosis was 75.68% (95% CI=58.80-88.23%), specificity was 55.24% (95% CI=50.91-59.52%), positive predictive value was 10.49% (95% CI=8.71-12.58%), and negative predictive value was 97.04% (95% CI=94.86-98.31%). In the ultrasonographic data, having symptomatic nodules, nodule calcification, and irregular nodule borders were all statistically significant signs of cancer in a one-variable analysis (P<.01). The presence of a family history emerged as a statistically significant prognostic marker for malignancy (P=.012). Although not statistically significant, the malignancy rate for nodules with nuclear atypia was 11.9%, significantly higher than the rate of 8.3% for nodules with architectural atypia only (P=0.32). CONCLUSIONS The diagnosis of AUS/FLUS has a high rate of predicting the risk of malignancy and should continue to be offered. In addition to cytopathological features, ultrasound data and family history should be taken into consideration when evaluating the case. LIMITATIONS Retrospective design and no molecular studies.
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Affiliation(s)
- Neslihan Kaya Terzi
- From the Department of Pathology, Faculty of Medicine, Canakkale Onsekiz Mart University, Canakkale, Turkey
| | - Tolga Terzi
- From the Clinic of Anesthesiology and Reanimation, Lapseki Public Hospital, Canakkale, Turkey
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Guzmán-Arocho YD, VanderLaan PA, Nishino M. Binary subclassification scheme (AUS-Nuclear versus AUS-Other) adequately risk-stratifies thyroid fine needle aspiration specimens classified as Atypia of Undetermined Significance. J Am Soc Cytopathol 2024; 13:23-32. [PMID: 37957061 DOI: 10.1016/j.jasc.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/28/2023] [Accepted: 10/10/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION The Bethesda System for Reporting Thyroid Cytopathology previously described 4 subclasses of atypia within the Atypia of Undetermined Significance (AUS) category: nuclear (AUS-Nuc), architectural (AUS-A), oncocytic (AUS-Onc), and atypia not otherwise specified (AUS-NOS). Accumulating evidence supports a binary AUS subclassification scheme based primarily on the presence of nuclear atypia only. The purpose of this study is to compare the risk stratification of binary versus 4-tier AUS subclassification systems among AUS nodules with molecular and/or histologic follow-up. MATERIALS AND METHODS Thyroid aspirates classified as AUS and tested using Afirma (Veracyte, Inc.) between 6/2013 and 7/2021 were included. For resected nodules, histological classification was considered as the final outcome. For unresected nodules, benign Afirma results were considered low-risk outcomes, similar to histologically benign nodules. Suspicious or nondiagnostic Afirma results were considered indeterminate outcomes. The prevalence of outcomes warranting surgery (noninvasive follicular thyroid neoplasm with papillary-like nuclear features [NIFTP] or cancer) was calculated for each AUS subclass. RESULTS A total of 559 AUS nodules with Afirma testing were identified. Excluding nodules with indeterminate molecular outcomes, NIFTP/cancer prevalence for AUS-Nuc was 21% (57/266), which was higher than that for AUS-A (6%, 11/188), AUS-Onc (8%, 4/53), and AUS-NOS (0%, 0/9). A binary AUS subclassification scheme based on nuclear atypia showed a significant difference in NIFTP/cancer prevalence (21% versus 6%, P < 0.0001). CONCLUSIONS Binary reporting of AUS subclasses based on nuclear atypia distinguishes cases with a higher risk of NIFTP/cancer. There is a low but non-negligible prevalence of NIFTP/cancer in cases without nuclear atypia.
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Affiliation(s)
- Yaileen D Guzmán-Arocho
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Michiya Nishino
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
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Loberg MA, Tigue ML, Gallant JN, Wang H, Canberk S, Weiss VL. Evolving approaches in paediatric thyroid cytopathology: A review. Cytopathology 2024; 35:60-69. [PMID: 37759375 PMCID: PMC11027193 DOI: 10.1111/cyt.13311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/22/2023] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
The guidelines for the workup of thyroid nodules have been established in adult populations and secondarily applied to paediatric populations. In particular, The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is commonly applied to both adult and paediatric thyroid nodules. However, as paediatric nodules have distinct molecular drivers and behavioural trajectories, there is renewed interest in diagnostic and management strategies that are paediatric specific. Here, we review key differences between paediatric and adult thyroid cancer and recent literature evaluating the use of TBSRTC in paediatric populations.
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Affiliation(s)
- Matthew A Loberg
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Megan L Tigue
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jean-Nicolas Gallant
- Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Huiying Wang
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sule Canberk
- i3S/ Institute of Molecular Pathology and Immunology of the University of Porto, Porto, Portugal
| | - Vivian L Weiss
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Jiragawasan C, Himakhun W. The risk of malignancy in the atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) category subgroups: a Thai institute experience. J Am Soc Cytopathol 2024; 13:16-22. [PMID: 37903698 DOI: 10.1016/j.jasc.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 08/28/2023] [Accepted: 09/15/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION This study investigated the rate of reporting and the risk of malignancy (ROM) for atypia of undetermined significance (AUS) subgroups in a Thai population. AUS, which is category III of the Bethesda System for Reporting Thyroid Cytopathology, is a problematic diagnosis for thyroid nodule management because the risks of malignancy are diverse. MATERIALS AND METHODS Patients who underwent thyroid fine needle aspirations between January 2015 and December 2019 were included in this retrospective study. Gender, age, and nodule features were described, and all slides were re-evaluated and categorized into 2 subgroups: AUS-Nuclear (including cytology atypia and cytologic and architectural atypia) and AUS-Other (including architectural atypia, oncocytic atypia, and atypia not otherwise specified). The lower and upper limits of ROM were calculated for each subgroup. RESULTS Of total, 258 out of 2995 fine needle aspirations (8.6%) were diagnosed as AUS. The patients were predominantly female (88.9%), with a mean age of 54.1 years. The average nodule size was 2.5 cm. Of the 258 AUS patients, 81 (38.9%) had histological correlations. The ROM for the AUS category was 9.1% to 23.5%. The ROM of the AUS-Nuclear and AUS-Other were 11.1% to 27.3% and 2.2% to 6.7%, respectively. Features of pseudonuclear inclusions had the highest ROM (33.3%-42.9%), followed by pale chromatin (28.57%-47.06%). CONCLUSIONS Less than ten percent of our interpretations were AUS, which is acceptable in our practice. Cytological atypia harbored the highest ROM. Studies of associations between cytology and histology may aid in improving diagnostic criteria for this population.
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Affiliation(s)
| | - Wanwisa Himakhun
- Department of Pathology, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand.
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11
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Martinez Coconubo D, Levy JJ, Kerr DA, Vaickus LJ, Vidis L, Glass RE, Gutmann EJ, Marotti JD, Liu X. Use of molecular testing results to analyze the overuse of atypia of undetermined significance in thyroid cytology. J Am Soc Cytopathol 2023; 12:451-460. [PMID: 37775434 DOI: 10.1016/j.jasc.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 08/31/2023] [Accepted: 09/03/2023] [Indexed: 10/01/2023]
Abstract
INTRODUCTION The suggested atypia of undetermined significance (AUS) rate for thyroid fine-needle aspiration biopsies is 10% or less. Prompted by a high institutional AUS rate, we examined using molecular testing results (MTR) as a potential quality metric tool to reduce the AUS rate. We correlated MTR with AUS cytologic findings, surgical pathology follow-up, and individual pathologist AUS rates. MATERIALS AND METHODS Demographic data, cytologic diagnoses, MTR, and surgical pathology diagnoses were retrospectively obtained. MTR were classified as either positive or negative. AUS rates and MTR proportions were compared among pathologists. The cytomorphologic features of 143 AUS cases were assessed and correlated with MTR. RESULTS Between 2017 and 2022, 710 of 3247 thyroid fine-needle aspirations were classified as AUS, with a yearly average rate of 22% (range = 19%-26%). AUS cases included: 331 (47%) with architectural atypia; 204 (29%) with oncocytic (Hürthle cell) atypia; 99 (14%) with combined architectural and cytologic atypia; and 76 (10%) with isolated cytologic atypia. Most AUS cases with molecular testing had negative MTR (360/492, 73%). AUS with cytologic atypia had higher positive MTR risk (logarithm of odds ratio = 1.27, 95% credible interval [0.5-2.04], P = 0.001). The average positive MTR rate by pathologist was 21.5% (range 0%-35%); higher positive MTR rates had better correlation with subsequent neoplastic/malignant histologic diagnoses. The MTR sensitivity for malignant disease was 89% and the negative predictive value was 91%. CONCLUSIONS MTR analysis reveals the importance of cytologic atypia as a determinant of malignancy risk in AUS cases. Periodic analysis of MTR data alongside individual pathologist AUS rates can help refine diagnostic criteria and potentially reduce AUS overuse.
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Affiliation(s)
- Daniel Martinez Coconubo
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Joshua J Levy
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Departments of Quantitative Biomedical Sciences, Dermatology and Epidemiology, Geisel School of Medicine, Hanover, New Hampshire
| | - Darcy A Kerr
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Louis J Vaickus
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Laura Vidis
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Ryan E Glass
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Edward J Gutmann
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jonathan D Marotti
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Xiaoying Liu
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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12
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Kang S, Kim E, Lee S, Kim JK, Lee CR, Kang SW, Lee J, Jeong JJ, Nam KH, Chung WY. Do large thyroid nodules (≥4 cm) without suspicious cytology need surgery? Front Endocrinol (Lausanne) 2023; 14:1252503. [PMID: 37732121 PMCID: PMC10508984 DOI: 10.3389/fendo.2023.1252503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/14/2023] [Indexed: 09/22/2023] Open
Abstract
Background Fine-needle aspiration biopsy (FNAB) is a good diagnostic tool for thyroid nodules; however, its high false-negative rate for giant nodules remains controversial. Many clinicians recommend surgical resection for nodules >4 cm owing to an increased risk of malignancy and an increased false-negative rate. This study aimed to examine the feasibility of this approach and investigate the incidence of malignancy in thyroid nodules >4 cm without suspicious cytology based on medical records in our center. Methods This was a retrospective analysis of 453 patients that underwent preoperative FNAB for nodules measuring >4 cm between January 2017 and August 2022 at Severance Hospital, Seoul. Results Among the 453 patients, 140 nodules were benign and 119 were indeterminate. Among 259 patients, the final pathology results were divided into benign (149) and cancerous (110) groups, and the prevalence of malignancy was 38.9% in the benign group and 55.5% in the indeterminate group. Among the malignancies, follicular carcinoma and follicular variants of papillary carcinoma were observed in 83% of the cytologically benign group and 62.8% of the indeterminate group. Conclusion Preoperative FNAB had high false-negative rates and low diagnostic accuracy in patients with thyroid nodules >4 cm without suspicious cytologic features; therefore, diagnostic surgery may be considered a treatment option.
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Affiliation(s)
- Seokmin Kang
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Eunjin Kim
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Sunmin Lee
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Jin Kyong Kim
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Cho Rok Lee
- Department of Surgery, Yongin Severance Hospital, Yongin-si, Republic of Korea
| | - Sang-Wook Kang
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Jandee Lee
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Jong Ju Jeong
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Kee-Hyun Nam
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
| | - Woong Youn Chung
- Department of Surgery, College of Medicine, Severance Hospital, Yonsei University, Seoul, Republic of Korea
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13
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Hess JR, Van Tassel DC, Runyan CE, Morrison Z, Walsh AM, Schafernak KT. Performance of ACR TI-RADS and the Bethesda System in Predicting Risk of Malignancy in Thyroid Nodules at a Large Children's Hospital and a Comprehensive Review of the Pediatric Literature. Cancers (Basel) 2023; 15:3975. [PMID: 37568791 PMCID: PMC10417028 DOI: 10.3390/cancers15153975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 06/24/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
While thyroid nodules are less common in children than in adults, they are more frequently malignant. However, pediatric data are scarce regarding the performance characteristics of imaging and cytopathology classification systems validated to predict the risk of malignancy (ROM) in adults and select those patients who require fine-needle aspiration (FNA) and possibly surgical resection. We retrospectively reviewed the electronic medical records of all patients 18 years of age or younger who underwent thyroid FNA at our institution from 1 July 2015 to 31 May 2022. Based on surgical follow-up from 74 of the 208 FNA cases, we determined the ROM for the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS) ultrasound risk stratification system and The Bethesda System for Reporting Thyroid Cytopathology and added our results to those of pediatric cohorts from other institutions already published in the literature. We found the following ROMs for 1458 cases using ACR TI-RADS (TR): TR1. Benign: 2.2%, TR2. Not Suspicious: 9.3%, TR3. Mildly Suspicious: 16.6%, TR4. Moderately Suspicious: 27.0%, and TR5. Highly Suspicious 76.5%; and for 5911 cases using the Bethesda system: Bethesda I. Unsatisfactory: 16.8%, Bethesda II. Benign: 7.2%, Bethesda III: Atypia of Undetermined Significance: 29.6%, Bethesda IV. Follicular Neoplasm: 42.3%, Bethesda V. Suspicious for Malignancy: 90.8%, and Bethesda VI. Malignant: 98.8%. We conclude that ACR TI-RADS levels imply higher ROMs for the pediatric population than the corresponding suggested ROMs for adults, and, in order to avoid missing malignancies, we should consider modifying or altogether abandoning size cutoffs for recommending FNA in children and adolescents whose thyroid glands are smaller than those of adults. The Bethesda categories also imply higher ROMs for pediatric patients compared to adults.
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Affiliation(s)
- Jennifer R. Hess
- Center for Cancer and Blood Disorders, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA; (J.R.H.); (A.M.W.)
| | - Dane C. Van Tassel
- Department of Radiology, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA;
| | - Charles E. Runyan
- Department of Radiology, Valleywise Hospital, Phoenix, AZ 85008, USA;
| | - Zachary Morrison
- Creighton Radiology Residency, Creighton University, Phoenix, AZ 85012, USA;
| | - Alexandra M. Walsh
- Center for Cancer and Blood Disorders, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA; (J.R.H.); (A.M.W.)
| | - Kristian T. Schafernak
- Division of Pathology, Laboratory Medicine, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA
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14
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Mashat A, Hilzenrat R, Masoudi H, Walker B, Wiseman SM. The influence of papillary features on the risk of malignancy in thyroid nodules diagnosed as atypia of undetermined significance or follicular lesion of undetermined significance. Am J Surg 2023; 225:857-860. [PMID: 36872125 DOI: 10.1016/j.amjsurg.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/06/2022] [Accepted: 02/23/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The objective of this study was to the assess the risk of malignancy in thyroid lesions that were diagnosed as AUS/FLUS when using a novel cytology subclassification system that is based on the presence or absence of papillary features. METHODS AUS/FLUS case cytology was re-reviewed and subclassified into minor or major concern groups based upon the absence or presence of papillary features, respectively. The risk of malignancy (ROM) was calculated and compared between the two groups. Inter-pathologist agreement in case subclassification was also measured. RESULTS The minor concern group had a 12.6% associated ROM, while the major concern group had a significantly higher ROM (58.4%), (P < 0.001). Based on 108 cases, the inter-pathologist agreement in case subclassification was 79%, and the κ value was 0.47. CONCLUSIONS The identification of papillary features significantly increases the ROM in thyroid lesions with an AUS/FLUS diagnosis.
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Affiliation(s)
- Abdullah Mashat
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Roy Hilzenrat
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Hamid Masoudi
- Department of Pathology & Laboratory Medicine, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Blair Walker
- Department of Pathology & Laboratory Medicine, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada.
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15
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Słowińska-Klencka D, Klencki M, Duda-Szymańska J, Popowicz B. Optimization of the Management of Category III Thyroid Nodules Using Repeat FNA and TIRADS. Cancers (Basel) 2022; 14:cancers14184489. [PMID: 36139649 PMCID: PMC9496843 DOI: 10.3390/cancers14184489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of the study was to examine the benefits of the joint use of repeat FNA (rFNA) and EU-TIRADS in category III nodules in relation to the kind of atypia: nuclear vs. architectural (denoted by AUS and FLUS respectively). The study included 127 AUS and 1739 FLUS nodules with a known category of EU-TIRADS. Repeat FNA was performed in 82 AUS and 934 FLUS nodules of which 57 and 515 were excised, respectively. AUS nodules had higher malignancy risk than FLUS nodules. EU-TIRADS showed higher accuracy for AUS nodules, the opposite to rFNA, that had higher accuracy for FLUS nodules. The combined criterion for AUS nodules (at least rFNA-V or EU-TIRADS-4) maximized sensitivity (92.3%) with acceptable specificity (70.0%); OR: 28.0. In the case of FLUS nodules, the combined criterion (rFNA-V or EU-TIRADS-5) maximized specificity (95.2%) with 57.7% sensitivity and a low percentage (13.9%) of positive nodules, OR: 27.0. In both types of nodules, the low risk category in EU-TIRADS and benign result of rFNA excluded cancer. Concluding, category III nodules with and without nuclear atypia differ in their risk of malignancy and, consequently, diagnostic criteria adopted for the evaluation of these nodules with rFNA and EU-TIRADS should be specific to AUS and FLUS nodules.
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Affiliation(s)
- Dorota Słowińska-Klencka
- Department of Morphometry of Endocrine Glands, Medical University of Lodz, 251 Pomorska Str., 92-213 Lodz, Poland
- Correspondence: (D.S.-K.); (M.K.)
| | - Mariusz Klencki
- Department of Morphometry of Endocrine Glands, Medical University of Lodz, 251 Pomorska Str., 92-213 Lodz, Poland
- Correspondence: (D.S.-K.); (M.K.)
| | - Joanna Duda-Szymańska
- Department of Pathomorphology, Medical University of Lodz, 251 Pomorska Str., 92-213 Lodz, Poland
| | - Bożena Popowicz
- Department of Morphometry of Endocrine Glands, Medical University of Lodz, 251 Pomorska Str., 92-213 Lodz, Poland
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16
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Gokozan HN, Dilcher TL, Alperstein SA, Qiu Y, Mostyka M, Scognamiglio T, Solomon JP, Song W, Rennert H, Beg S, Stern E, Goyal A, Siddiqui MT, Heymann JJ. Combining molecular testing and the Bethesda category III:VI ratio for thyroid fine‐needle aspirates: A quality‐assurance metric for evaluating diagnostic performance in a cytopathology laboratory. Cancer Cytopathol 2021; 130:259-274. [DOI: 10.1002/cncy.22542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/23/2021] [Accepted: 12/01/2021] [Indexed: 01/21/2023]
Affiliation(s)
- Hamza N. Gokozan
- Division of Cytopathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
- Division of Head and Neck Pathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Thomas L. Dilcher
- Division of Cytopathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Susan A. Alperstein
- Division of Cytopathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Yuqing Qiu
- Department of Population Health Sciences New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Maria Mostyka
- Division of Head and Neck Pathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Theresa Scognamiglio
- Division of Head and Neck Pathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - James P. Solomon
- Clinical Genomics Laboratory Department of Pathology and Laboratory Medicine New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Wei Song
- Clinical Genomics Laboratory Department of Pathology and Laboratory Medicine New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Hanna Rennert
- Division of Molecular and Genomic Pathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Shaham Beg
- Division of Cytopathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Evan Stern
- Division of Cytopathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Abha Goyal
- Division of Cytopathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Momin T. Siddiqui
- Division of Cytopathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
| | - Jonas J. Heymann
- Division of Cytopathology New York‐Presbyterian Hospital–Weill Cornell Medical College New York New York
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17
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Lee BWW, Bundele MM, Tan R, Fu EWZ, Chew AS, Wong JSH, Siew CCH, Lim BSP, Dalan R, Lim MY, Gan YJ, Li H. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features and the risk of malignancy in thyroid cytology: Data from Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2021; 50:903-910. [PMID: 34985102 DOI: 10.47102/annals-acadmedsg.2021243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The impact of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) on the risk of malignancy (ROM) in fine-needle aspiration cytology (FNAC) per The Bethesda System for Reporting Thyroid Cytopathology has not been well reported in Singapore. METHODS We retrospectively identified 821 thyroid nodules with preoperative FNAC from 788 patients out of 1,279 consecutive thyroidectomies performed between January 2010 and August 2016 in a tertiary general hospital in Singapore. Possible cases of NIFTP were reviewed for reclassification and the impact of NIFTP on ROM was analysed. RESULTS The incidence of NIFTP was 1.2% (10 out of 821). If NIFTP is considered benign, ROM in Bethesda I through VI were 8.6%, 3.5%, 26.3%, 20.0%, 87.7%, 97.0% versus 8.6%, 4.2%, 28.1%, 26.7%, 89.2% and 100% if NIFTP is considered malignant. Eight patients with NIFTP had follow-up of 15 to 110 months. One had possible rib metastasis as evidenced by I131 uptake but remained free of structural or biochemical disease during a follow-up period of 110 months. None had lymph node metastasis at presentation, nor locoregional or distant recurrence. CONCLUSION Classifying NIFTP as benign decreased ROM in Bethesda II through VI, but the benignity of NIFTP requires more prospective studies to ascertain. The impact of NIFTP on ROM in our institution also appears to be lower than that reported in the Western studies.
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Affiliation(s)
- Bryan Wei Wen Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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18
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Staibano P, Forner D, Noel CW, Zhang H, Gupta M, Monteiro E, Sawka AM, Pasternak JD, Goldstein DP, de Almeida JR. Ultrasonography and Fine-Needle Aspiration in Indeterminate Thyroid Nodules: A Systematic Review of Diagnostic Test Accuracy. Laryngoscope 2021; 132:242-251. [PMID: 34411290 DOI: 10.1002/lary.29778] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 07/01/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES/HYPOTHESIS Sonographic risk criteria may assist in further prognostication of indeterminate thyroid nodules (ITNs). Our aim was to determine whether sonographic criteria could further delineate the post-test probability of malignancy in ITNs. STUDY DESIGN Meta-analysis of diagnostic test accuracy. METHODS A systematic review of Web of Science, MEDLINE, EMBASE, and CINAHL was performed from inception to April 15, 2021. Eligible studies included those which reported ultrasonographic evaluations with the American Thyroid Association (ATA) or the Thyroid Imaging Reporting and Data System (TIRADS) in adult patients with ITNs. ATA or TIRADS were scored as low (negative) or high (positive) malignancy risk using a previously validated binary classification. Primary outcomes included pooled sensitivity, specificity, likelihood ratios, and diagnostic odds ratio for all sonographic criteria. Studies were appraised using Quality Assessment of Diagnostic Accuracy Studies and the data were pooled using bivariate random-effects models. RESULTS Seventeen studies were included in the analysis. For Bethesda III, ATA had a specificity (0.90, 95% confidence interval (CI): 0.74-0.94), but a sensitivity of 0.52 (95% CI: 0.25-0.77). Conversely, K-TIRADS had the highest sensitivity (0.78, 95% CI: 0.62-0.89) with a specificity of 0.53 (95% CI: 0.31-0.74). Furthermore, American College of Radiology and EU TIRADS had specificities of 0.60 (95% CI: 0.36-0.80) and 0.81 (95% CI: 0.73-0.87) with sensitivities of 0.70 (95% CI: 0.37-0.90) and 0.38 (95% CI: 0.20-0.60), respectively. There were few studies with Bethesda IV nodules. CONCLUSIONS Though dependent on malignancy rates, Bethesda III nodules with low-suspicion TIRADS features may benefit from clinical observation, whereas nodules with high-suspicion ATA features may require molecular testing and/or surgery. LEVEL OF EVIDENCE NA Laryngoscope, 2021.
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Affiliation(s)
- Phillip Staibano
- Department of Otolaryngology-Head and Neck Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David Forner
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Christopher W Noel
- Department of Otolaryngology-Head and Neck Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Han Zhang
- Department of Otolaryngology-Head and Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Michael Gupta
- Department of Otolaryngology-Head and Neck Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Eric Monteiro
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Anna M Sawka
- Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Endocrinology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jesse D Pasternak
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head and Neck Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head and Neck Surgery, University Health Network and University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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19
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Glass RE, Levy JJ, Motanagh SA, Vaickus LJ, Liu X. Atypia of undetermined significance in thyroid cytology: Nuclear atypia and architectural atypia are associated with different molecular alterations and risks of malignancy. Cancer Cytopathol 2021; 129:966-972. [PMID: 34399035 DOI: 10.1002/cncy.22495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/08/2021] [Accepted: 07/11/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Bethesda System for Reporting Thyroid Cytopathology contains an atypia of undetermined significance (AUS) category with heterogeneous and distinct inclusion criteria. The purpose of this study was to investigate differences in malignancy rates and molecular alterations based on the presence of different criteria. METHODS A laboratory information search was conducted to identify thyroid fine-needle aspiration specimens signed out as AUS. The cases were reclassified as architectural atypia (3A), cytologic atypia (3C), both architectural and cytologic atypia (3B), or Hürthle cell aspirate (3H). Surgical follow-up and concurrent molecular test results, if available, were collected. RESULTS Five hundred ten specimens, including 258 reclassified as 3A, 40 reclassified as 3B, 119 reclassified as 3C, and 86 reclassified as 3H, were identified. The risks of malignancy for the subcategories were 13.4%, 26.3%, 44.1%, and 13.8%, respectively. Additionally, BRAF V600E mutations were more prevalent in specimens with cytologic atypia (3B/3C), whereas low-risk alterations, including KRAS, PTEN, and PAX8-PPARy2, were more prevalent in those with architectural atypia (3A). CONCLUSIONS Subdividing AUS specimens on the basis of the type of atypia can yield categories associated with distinct molecular alterations and risks of malignancy.
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Affiliation(s)
- Ryan E Glass
- Department of Pathology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joshua J Levy
- Department of Quantitative Biomedical Sciences, Lebanon, New Hampshire
| | - Samaneh A Motanagh
- Department of Pathology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Louis J Vaickus
- Department of Pathology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Xiaoying Liu
- Department of Pathology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
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20
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Onken AM, VanderLaan PA, Hennessey JV, Hartzband P, Nishino M. Combined molecular and histologic end points inform cancer risk estimates for thyroid nodules classified as atypia of undetermined significance. Cancer Cytopathol 2021; 129:947-955. [PMID: 34314102 DOI: 10.1002/cncy.22489] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thyroid nodules classified as atypia of uncertain significance (AUS) on fine-needle aspiration cytology are heterogeneous. Prior studies reported a higher risk of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP)/cancer among AUS nodules that had cytologic (AUS-C) versus architectural (AUS-A) atypia; however, such studies were generally confined to resected cohorts, introducing bias into risk calculations. The authors hypothesized that combined histologic and molecular end points would permit clinically meaningful calculations of NIFTP/malignancy risk among AUS nodules. METHODS The study consisted of 279 thyroid nodules classified as AUS on initial fine-needle aspiration and tested by the Afirma Gene Expression Classifier (GEC) between June 2013 and October 2017. Results of GEC testing and histopathologic diagnoses were stratified by AUS classifiers. The AUS-A category was further subclassified as 1) hypocellular microfollicular or 2) cellular with mixed but predominantly microfollicular architecture. NIFTP/cancer risk was calculated for each subgroup, with the inclusion of unresected nodules that had benign GEC results as low-risk end points comparable to histologically benign nodules. RESULTS When only histologic end points were considered, there was no difference in NIFTP/cancer risk (25% vs 23%; P = .82). By using molecular and histologic end points, AUS cases with cytologic atypia trended toward higher NIFTP/cancer risk than AUS-A cases (14% vs 6%; P = .06). Furthermore, AUS-A cases showed a trend toward lower NIFTP/cancer risk for hypocellular microfollicular aspirates (3%) compared with cellular samples that had mixed/predominantly microfollicular architecture (13%; P = .18). CONCLUSIONS The inclusion of unresected benign GEC nodules in risk-of-malignancy calculations provides more accurate results, which may be helpful for informing patient management as well as quality improvement in the cytopathology laboratory.
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Affiliation(s)
- Allison M Onken
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Paul A VanderLaan
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - James V Hennessey
- Division of Endocrinology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Pamela Hartzband
- Division of Endocrinology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Michiya Nishino
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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21
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Ng DL, van Zante A, Griffin A, Hills NK, Ljung BM. A Large Thyroid Fine Needle Aspiration Biopsy Cohort with Long-Term Population-Based Follow-Up. Thyroid 2021; 31:1086-1095. [PMID: 33371796 PMCID: PMC9469749 DOI: 10.1089/thy.2020.0689] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Prior studies evaluating thyroid fine needle aspiration biopsies (FNABs) have limited the calculation of risk of malignancy (ROM) to cytologic specimens with corresponding histologic specimens, and clinical follow-up for those patients who do not undergo immediate surgery has been largely disregarded. Moreover, there is marked variability in how researchers have approached thyroid FNAB statistical analyses. This study addresses the urgent need for information from a large cohort of patients with long-term clinical follow-up to more accurately determine the performance of thyroid FNAB and ROM for each diagnostic category. Methods: A retrospective review of the University of California, San Francisco (UCSF), pathology database for thyroid FNABs from January 1, 1997, to December 31, 2004, was performed. Diagnoses were coded using the 2017 The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), and patients were matched to both the UCSF cancer registry and California Cancer Registry. Data were analyzed using the Kaplan-Meier method, and stratified by TBSRTC diagnostic category. Kaplan-Meier curves were used to estimate incidence rates of malignancy, stratified by FNAB category. Cox proportional hazards models were used to determine the instantaneous ROM. Results: Initial FNABs from 2207 patients were included. Median follow-up period after the first thyroid FNAB was 13.9 years (range: 10.5-18.4 years). During follow-up, there were 279 confirmed diagnoses of thyroid malignancy. Estimates derived from Kaplan-Meier curves demonstrated that the risk of having a thyroid malignancy was low for nondiagnostic and benign categories, intermediate for atypia of undetermined significance (AUS), follicular lesion of undetermined significance (FLUS), AUS/FLUS combined, and follicular neoplasm, and high for suspicious and malignant categories. A total of 52/1575 false-negative cases (3.2%) were identified. Excluding papillary microcarcinomas, the false-negative rate was 1.5% (23/1575). No patients with a false-negative diagnosis died of thyroid cancer during the follow-up period. Conclusions: Asymptomatic patients with low-risk clinical and radiologic features and initially benign or unsatisfactory biopsy are unlikely to develop thyroid malignancy and highly unlikely to die of thyroid cancer. FNAB is highly accurate in detecting malignancy. Additional studies evaluating similar large data sets after the adoption of TBSRTC and the integration of molecular testing are needed.
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Affiliation(s)
- Dianna L. Ng
- Department of Pathology, University of California, San Francisco, San Francisco, California, USA
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California, USA
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Annemieke van Zante
- Department of Pathology, University of California, San Francisco, San Francisco, California, USA
| | - Ann Griffin
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California, USA
| | - Nancy K. Hills
- Department of Epidemiology and Biostatistics, and University of California, San Francisco, San Francisco, California, USA
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Britt-Marie Ljung
- Department of Pathology, University of California, San Francisco, San Francisco, California, USA
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California, USA
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22
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Crescenzi A, Palermo A, Trimboli P. Cancer prevalence in the subcategories of the indeterminate class III (AUS/FLUS) of the Bethesda system for thyroid cytology: a meta-analysis. J Endocrinol Invest 2021; 44:1343-1351. [PMID: 33590467 DOI: 10.1007/s40618-021-01526-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/01/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE The indeterminate cytologic report represents a major challenge in the field of thyroid nodule. The indeterminate class III of the Bethesda classification system (i.e., AUS/FLUS) includes a heterogeneous group of subcategories characterized by doubtful nuclear and/or architectural atypia. The study aim was to conduct a systematic review and meta-analysis to evaluate the rate of malignancy in each subcategory of Bethesda III. METHODS PubMed, CENTRAL, and Scopus databases were searched until April 2020. Original articles reporting data on the subcategories of Bethesda III were included. The histological diagnosis was the reference standard to classify true/false negative and true/false positive cases. RESULTS The pooled cancer prevalence in each subcategory of Bethesda III was estimated using a random-effects model. Twenty-three papers with 4241 nodules were included. Overall, 1163 (27.4%) were malignant. The cancer rate observed in the subcategories ranged from 15%, in "Hürthle cell aspirates with low risk pattern", to 44%, in "Focal cytologic atypia". CONCLUSIONS The overall cancer rate found in the Bethesda III ranged more largely than that originally estimated (10-30%) and varied among any scenarios. These evidence-based data represent a reference for the clinical management of these patients.
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Affiliation(s)
- A Crescenzi
- Unit of Pathology, University Hospital Campus Bio-Medico, Rome, Italy
| | - A Palermo
- Unit of Endocrinology and Diabetes, Campus Bio-Medico University, Rome, Italy
| | - P Trimboli
- Clinic for Endocrinology and Diabetology, Lugano Regional Hospital, Ente Ospedaliero Cantonale, Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland.
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23
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Zhao H, Guo H, Zhao L, Cao J, Sun Y, Wang C, Zhang Z. Subclassification of the Bethesda Category III (AUS/FLUS): A study of thyroid FNA cytology based on ThinPrep slides from the National Cancer Center in China. Cancer Cytopathol 2021; 129:642-648. [PMID: 34139103 DOI: 10.1002/cncy.22417] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The atypia of an undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) category in the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) is a heterogeneous category, which includes various cell patterns. The subclassification of AUS/FLUS was suggested in the 2017 TBSRTC. However, the risk of malignancy (ROM) associated with different subgroups remains unresolved. Herein, AUS/FLUS aspirates were subclassified, from which the ROM of each subgroup was determined. METHODS All cases undergoing fine-needle aspiration (FNA) from July 2013 to December 2018 were reviewed. Of 12,913 thyroid FNAs, 1053 (8.2%) were AUS/FLUS. The slides of 222 patients with AUS/FLUS with surgical follow-up were reviewed and subclassified according to the recommendations of the 2017 TBSRTC. There were 195 aspirates consistently diagnosed as AUS/FLUS and subclassified as cytologic atypia 1 (AUS-C1); cytologic atypia 2 (AUS-C2); architectural atypia (AUS-A); cytologic and architectural atypia (AUS-C&A); Hürthle cell aspirates (AUS-H); atypia, not otherwise specified (AUS-NOS); and atypical lymphoid cells, rule out lymphoma (AUS-L). RESULTS Malignancy was identified in 83.3% (185 of 222) of the AUS/FLUS nodules. The AUS-C1 group was the most common (62.1%), followed by the AUS-C&A (12.8%), AUS-C2 (10.8%), AUS-H (6.7%), AUS-NOS (5.6%), AUS-L (1.5%), and AUS-A (0.5%) groups. AUS-C1 had the highest ROM (92.6%) among the groups and varied significantly from that of the AUS-C&A (P = .171), AUS-C2 (P = .001), AUS-H (P = .001), and AUS-NOS (P < .001) groups. CONCLUSIONS As a heterogeneous category of TBSRTC, the ROM for AUS/FLUS varies greatly among medical centers. Subclassification of AUS/FLUS might be helpful in identifying nodules with a high ROM in this category and improving the management of such nodules.
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Affiliation(s)
- Huan Zhao
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - HuiQin Guo
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - LinLin Zhao
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Cao
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue Sun
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cong Wang
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - ZhiHui Zhang
- Department of Pathology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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24
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Larcher de Almeida AM, Delfim RLC, Vidal APA, Chaves MCDCM, Santiago ACL, Gianotti MF, Gonçalves MDDC, Vaisman M, de Carvalho DP, Teixeira PDFDS. Combining the American Thyroid Association's Ultrasound Classification with Cytological Subcategorization Improves the Assessment of Malignancy Risk in Indeterminate Thyroid Nodules. Thyroid 2021; 31:922-932. [PMID: 33143569 DOI: 10.1089/thy.2019.0575] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: The risk of malignancy (RoM) of indeterminate thyroid nodules (ITNs) shows a high variability in interinstitutional cohorts. The RoM is partially associated with the cytological degree of atypia and the ultrasound (US) pattern. This study evaluated the cancer risk of ITNs by jointly considering the cytological subcategory and the American Thyroid Association (ATA)-based US risk classification. Methods: This study features a retrospective cohort from two Brazilian centers comprising 238 ITNs with confirmed outcomes. US classification, according to ATA-based guidelines, and cytological subcategorization were determined. The cytological subgroups were as follows: (1) nuclear atypia (NA) related to papillary thyroid carcinoma (PTC) but insufficient to categorize the cytology as suspicious for malignancy; (2) architectural atypia without NA (AA); (3) both architectural and nuclear atypia (ANA); (4) oncocytic pattern (OP) without NA; and (5) NA not related to PTC (NANP). NA was divided into three subgroups: nuclear size and shape, nuclear membrane appearance, and/or chromatin aspects. Results: The overall frequency of malignancy was 39.5%. Among the cytological subcategories, the highest RoM was related to the NA (43.9%) and to the ANA (43.5%), followed by AA (29.4%), and OP (9.4%). NA was positively and independently associated with cancer (odds ratio [OR]: 4.5; confidence interval [CI: 1.2-16.6]) as was the occurrence of ANA (OR 6.6 [CI 1.5-29.5]). AA and OP were not independently associated with cancer. Both ATA-based high- and intermediate-risk categories showed an independent association with cancer (OR 6.8 [CI 2.9-15.5] and OR: 2.6 [CI 1.1-5.8], respectively). ITNs with cytological findings of NA or ANA when combined with intermediate US patterns had RoM values of 47.5% and 56.7%, respectively. Both cytological subcategories, when combined with the ATA high-suspicion class reached an RoM >70%. The type of NA with the highest odds for cancer was related to the nuclear membrane (OR 11.5). Conclusions: The RoM of ITNs can reach almost 80% when both NA and ATA-based high-risk US features are present. The presence of such cytological features also increased the RoM in the ATA-based intermediate-risk US category. In addition, AA and OP were not independently related to higher cancer risk. These results strengthen the recommendations for combing cytological subcategorization and US risk classification in the workup for ITNs before the decision of a molecular testing, clinical observation, or diagnostic surgery.
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MESH Headings
- Adenocarcinoma, Follicular/diagnostic imaging
- Adenocarcinoma, Follicular/epidemiology
- Adenocarcinoma, Follicular/pathology
- Adenoma, Oxyphilic/diagnostic imaging
- Adenoma, Oxyphilic/epidemiology
- Adenoma, Oxyphilic/pathology
- Adult
- Biopsy, Fine-Needle
- Carcinoma, Neuroendocrine/diagnostic imaging
- Carcinoma, Neuroendocrine/epidemiology
- Carcinoma, Neuroendocrine/pathology
- Cohort Studies
- Female
- Humans
- Male
- Middle Aged
- Retrospective Studies
- Risk Assessment
- Societies, Medical
- Thyroid Cancer, Papillary/diagnostic imaging
- Thyroid Cancer, Papillary/epidemiology
- Thyroid Cancer, Papillary/pathology
- Thyroid Neoplasms/diagnostic imaging
- Thyroid Neoplasms/epidemiology
- Thyroid Neoplasms/pathology
- Thyroid Nodule/classification
- Thyroid Nodule/diagnostic imaging
- Thyroid Nodule/pathology
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Affiliation(s)
| | | | - Ana Paula Aguiar Vidal
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Marcos Feijó Gianotti
- General Surgical Service, Hospital Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Mario Vaisman
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Denise Pires de Carvalho
- Faculdade de Medicina, Instituto de Biofísica Carlos Chagas Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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25
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Kim K, Jung CK, Lim DJ, Bae JS, Kim JS. Clinical and pathologic features for predicting malignancy in thyroid follicular neoplasms. Gland Surg 2021; 10:50-58. [PMID: 33633961 DOI: 10.21037/gs-20-500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The cytologic findings of follicular neoplasm do not distinguish between benign follicular adenoma and follicular thyroid carcinoma (FTC). The objective of this retrospective study was to identify clinical and cytologic/pathologic features to predict malignancy in patients preoperatively diagnosed with follicular neoplasms. Methods In total, 416 patients with follicular neoplasms who underwent thyroidectomy were reviewed at Seoul St. Mary's Hospital (Seoul, Korea) from January 2010 to June 2018. Clinicopathological features were analyzed retrospectively by complete medical chart review and pathologic slide review. Results Thyroid malignancy/noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was diagnosed in 209 patients (50.2%). In total, 59 patients (14.2%) were diagnosed with FTC, 55 patients (13.3%) were diagnosed with follicular variant papillary thyroid carcinoma (fvPTC). The number of patients with PTC-related nuclear changes was higher in the malignancy/NIFTP group than in the benign group (16.3% vs. 1.9%, P<0.001). Multivariate analysis indicated that the significant risk factors for the diagnosis of malignancy/NIFTP include cytologic or pathologic diagnosis with PTC-related nuclear changes, NRAS mutation, and male sex. Conclusions The prevalence of malignancy in patients with a preoperative diagnosis of follicular neoplasm was much higher in our study than in previous reports. Cytologic or pathologic PTC-related nuclear changes is a useful predictor of the presence of malignancy. Further studies must be conducted to support our results.
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Affiliation(s)
- Kwangsoon Kim
- Department of Surgery, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Chan Kwon Jung
- Department of Hospital Pathology, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Dong-Jun Lim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Ja Seong Bae
- Department of Surgery, College of Medicine, the Catholic University of Korea, Seoul, Korea
| | - Jeong Soo Kim
- Department of Surgery, College of Medicine, the Catholic University of Korea, Seoul, Korea
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26
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Wong KS, Angell TE, Barletta JA, Krane JF. Hürthle cell lesions of the thyroid: Progress made and challenges remaining. Cancer Cytopathol 2020; 129:347-362. [PMID: 33108684 DOI: 10.1002/cncy.22375] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/31/2022]
Abstract
Hürthle cell-predominant thyroid fine needle aspirations (FNA) are encountered frequently in routine practice, yet they are often challenging to diagnose accurately and are associated with significant interobserver variability. This is largely due to the ubiquity of Hürthle cells in thyroid pathology, ranging from nonneoplastic conditions to aggressive malignancies. Although limitations in cytomorphologic diagnoses likely will remain for the foreseeable future, our knowledge of the molecular pathogenesis of Hürthle cell neoplasia and application of molecular testing to cytologic material have increased dramatically within the past decade. This review provides context behind the challenges in diagnosis of Hürthle cell lesions and summarizes the more recent advances in diagnostic tools.
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Affiliation(s)
- Kristine S Wong
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Trevor E Angell
- Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Justine A Barletta
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jeffrey F Krane
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
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27
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Kumarasinghe MP. Standardisation of thyroid cytology terminology and practice: are modifications necessary?-a narrative review. Gland Surg 2020; 9:1639-1647. [PMID: 33224841 DOI: 10.21037/gs-2019-catp-25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Universally accepted guidelines for diagnosis and management of any disease are desirable. Standardization of thyroid cytology reporting is aimed at guiding and improving clinical decision-making and management. However, socio-economic, and local factors and differences in disease prevalence and patterns require modification to suit local settings. 'One size fit all' approach is not possible for any disease diagnosis or management. The same concept is applicable in diagnosis and management of thyroid nodules. An additional special issue is the well-known high inter and intra-observer variability in the histological and cytological diagnosis of thyroid neoplasms. Despite this, thyroid cytology has a very significant influence in the management of thyroid diseases. An approach based on common principals with appropriate modifications that suits countries or continents is desirable and sustainable. The principals of TBSRTC have served as a framework for similar tiered classifications for reporting thyroid cytopathology. This article discusses globally available professional guidelines based on a common framework with appropriate modifications, with the universal aim of risk stratification of thyroid nodules.
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Affiliation(s)
- M Priyanthi Kumarasinghe
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Discipaline of Pathology and Laboratory Medicine, University of Western Australia, QEII Medical Centre, Nedlands, Australia
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28
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Nguyen TPX, Truong VT, Kakudo K, Vuong HG. The diversities in thyroid cytopathology practices among Asian countries using the Bethesda system for reporting thyroid cytopathology. Gland Surg 2020; 9:1735-1746. [PMID: 33224851 DOI: 10.21037/gs-20-404] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has been adopted and widely used among Asian countries. This study aims to investigate the application of TBSRTC in thyroid cytology practice among Asian countries. Methods We searched electronic databases including PubMed and Web of Science from 2010 to 2019. Meta-analysis of proportion and their 95% confidence intervals (CIs) were calculated using the random-effect model. Meta-regression and subgroup analysis were used to search for heterogeneity origins. Results We included 42 Asian studies with 84.953 fine-needle aspirations. Among six categories, benign was the most commonly diagnosed category. The resection rate (RR) and risk of malignancy (ROM) were highest in malignant and SM categories, and lowest among benign nodules. Thyroid cytology practice in Asia was characterized by a low RR and high ROM in patients with indeterminate thyroid nodules. There was a significant amount of heterogeneities of TBSRTC outputs (frequency, resection rate, and malignancy risk) among Asian countries. Meta-regression showed that the sources of heterogeneity might stem from the differences in study origin and the application of molecular testing. We highlighted the usefulness of preoperative molecular testing to select patients for surgery. Conclusions Our study provided insight regarding thyroid cytology practice among Asian countries. Active surveillance is commonly used in Asian practice resulting in a low RR and high ROM for indeterminate nodules. There are still variations in general thyroid cytology practice in Asia. Future guidelines and consensus regarding the application of TBSRTC in thyroid cytology practice among Asian countries are required.
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Affiliation(s)
| | - Vien Thanh Truong
- Department of Cardiology, The Christ Hospital Health Network, Cincinnati, OH, USA
| | - Kennichi Kakudo
- Department of Pathology and Thyroid Disease Center, Izumi City General Hospital, Izumi-city, Japan
| | - Huy Gia Vuong
- Department of Pathology, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA.,Stephenson Cancer Center, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
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29
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Ooi LY, Nga ME. Atypia of undetermined significance/follicular lesion of undetermined significance: Asian vs. non-Asian practice, and the Singapore experience. Gland Surg 2020; 9:1764-1787. [PMID: 33224854 DOI: 10.21037/gs-20-555] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Bethesda System for Reporting Thyroid Cytopathology has paved the way for comparisons of the practice of thyroid cytology in many different regions. However, there have been comparatively few studies documenting differences between Asian and non-Asian practice. Here, we aim to compare a few key parameters between the two regions, focusing on the indeterminate category of atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS). We compared its incidence, resection rates (RRs), risk of malignancy (ROM), rate of repeat fine needle aspiration (rFNA), ROMs of cytomorphologic subcategories of nuclear atypia (AUS-N) vs. architectural atypia (AUS-A), and, finally, the incidence of papillary thyroid carcinoma (PTC) vs. follicular neoplasms (FNs) in resected AUS/FLUS cases in Asian and non-Asian regions. Where possible, these metrics were compared with the Singapore experience from a tertiary referral institution. While the incidence of AUS/FLUS was similar in both regions, we found geographical differences in the RRs and ROMs, which may reflect a higher collective threshold for surgery in Asian countries. However, both cohorts showed higher ROMs in the AUS-N subcategory as compared to the AUS-A subcategory, supporting the subclassification of the AUS/FLUS based on the presence of nuclear atypia. We also observed a higher incidence of AUS-N coupled with a higher incidence of PTC in resected AUS/FLUS nodules in Asian cohorts, while AUS-A and follicular-patterned neoplasms featured more prominently in the non-Asian cohorts. These incidences may account for the starkly different molecular approaches that we noted-in Asian (chiefly Korean and Chinese) centers, BRAF mutational analysis was favored, while gene panels and gene expression classifiers were more frequently applied in non-Asian centers (chiefly in the United States of America). Overall, the data from Singapore appears more closely aligned to non-Asian trends, despite its geographical location in Southeast Asia and its predominantly Asian population. We conclude that there is significant heterogeneity in the outcomes of the AUS/FLUS categories between and within regions, which is only partially explained by regional variations, and may also reflect different regional diagnostic and management practices. This highlights the importance of understanding the local context in the interpretation of indeterminate Bethesda categories, rather than adopting a "one-size fits all" approach.
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Affiliation(s)
- Li Yin Ooi
- Department of Pathology, National University Hospital, Singapore
| | - Min En Nga
- Department of Pathology, National University Hospital, Singapore
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30
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Kroll-Wheeler L, Cantley R, Pang JC, Soles BS, Smola B, Jing X, Lew M. An institutional experience: A retrospective analysis of the effect of transitioning from follicular lesion of undetermined significance to atypia of undetermined significance with subclassified atypia on interobserver concordance, rates of neoplasia, and rates of malignancy. Diagn Cytopathol 2020; 49:31-38. [PMID: 32936526 DOI: 10.1002/dc.24611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/15/2020] [Accepted: 08/25/2020] [Indexed: 11/11/2022]
Abstract
INTRODUCTION The rate of malignancy (ROM) in thyroid fine needle aspirations (FNA) classified under "atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS), including Hürthle cell type (HLUS)" category of The Bethesda system for reporting thyroid cytopathology (TBSRTC) in literature is highly variable. The 2018 TBSRTC was updated to note a preferred categorization of AUS cases into subcategories. This study evaluates the impact of AUS subclassification on rates of neoplasia (RON), rates of malignancy (ROM), and cytopathologist (CP) concordance. METHODS 93 thyroid FNAs previously diagnosed as FLUS or HLUS from January 1, 2013 to December 31, 2014 with subsequent surgical resection were identified. Four CPs reclassified these cases using TBSRTC AUS subcategories of follicular cells with architectural and/or cytologic atypia, predominantly Hürthle cells, and atypical lymphocytes. RON and ROM were calculated for each diagnostic subcategory for each CP. RESULTS The original RON and ROM for FLUS cases were 31.4% and 15.1% and were 77.8% and 22.2% for HLUS cases. 10.8% of cases showed diagnostic concordance amongst the four CPs. The most frequently utilized subcategory was architectural atypia. RON ranges for architectural atypia, cytologic atypia, architectural and cytologic atypia, and predominantly Hürthle cells were 28.1% to 35.7%, 0% to 33.3%, 35.3% to 66.7%, and 57.1% to 87.5%. The range of ROM was 13.9% to 16.7%, 0% to 33%, 0% to 42.9%, and 0% to 25%, respectively. CONCLUSION RON for AUS predominantly Hürthle cells subcategory was higher than previously reported, which may indicate use for tailored patient management pathways. AUS subclassification can result in significant interobserver variability. Therefore, institutions may consider consensus/quality control sessions to optimize diagnostic concordance.
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Affiliation(s)
- Lauren Kroll-Wheeler
- Department of Pathology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan, USA
| | - Richard Cantley
- Department of Pathology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan, USA
| | - Judy C Pang
- Department of Pathology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan, USA
| | - Brian S Soles
- Department of Pathology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan, USA
| | - Brian Smola
- Department of Pathology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan, USA
| | - Xin Jing
- Department of Pathology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan, USA
| | - Madelyn Lew
- Department of Pathology, University of Michigan-Michigan Medicine, Ann Arbor, Michigan, USA
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Özkara SK, Bayrak BY, Turan G. High risk of malignancy in cases with atypia of undetermined significance on fine needle aspiration of thyroid nodules even after exclusion of NIFTP. Diagn Cytopathol 2020; 48:986-997. [PMID: 32745375 DOI: 10.1002/dc.24533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/31/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Fine needle aspiration cytopathology (FNAC) is the most reliable tool for evaluating thyroid nodules. However, diagnosing Bethesda category III, atypia/follicular lesion of undetermined significance (AUS/FLUS), is a major limitation. The aim of this study was to evaluate the risk of malignancy (RoM) in AUS/FLUS nodules. A systematic review was also carried out analyzing the largest series. METHODS Totally 1750 cases (9%) diagnosed with AUS/FLUS were evaluated retrospectively out of 19 392 cases within last 13 years. All patients undergoing surgery for AUS/FLUS were included into the study. Histopathology results were correlated; the impact of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) diagnosis on RoM is evaluated. RESULTS Of the 280 patients (16%) undergoing surgery, neoplasia were detected in 177 (RoN:63.2%) and malignancy in 119 (RoM:42.5%) of these neoplasia. Follicular variant of papillary thyroid carcinoma (FVPTC) was the commonest malignancy (55.5%). Additional 58 (20.7%) nodules were neoplastic, of which 26 (9.3%) were encapsulated follicular tumors with unknown malignancy potential (FT-UMP) and 32 (11.4%) were follicular adenomas. The remaining 103 patients (36.8%) had non-neoplastic nodules. After reevaluation of the encapsulated FVPTC cases, 20 of them were NIFTP and RoM dropped to 35.4% with a relative decrease of 16.7% and an absolute decrease of 7.1%. CONCLUSION In our series, 42.5% of nodules with AUS/FLUS were malignant; 63.2% of them were neoplastic. The RoM and RoN for AUS/FLUS nodules are still much higher than the revised expected RoM of international guidelines even after NIFTP cases excluded. Therefore, current recommendations should be reevaluated periodically in view of detailed clinicopathologic studies.
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Affiliation(s)
- Sevgiye Kaçar Özkara
- Faculty of Medicine, Department of Pathology, Kocaeli University, Kocaeli, Turkey
| | - Büşra Yaprak Bayrak
- Faculty of Medicine, Department of Pathology, Kocaeli University, Kocaeli, Turkey
| | - Gupse Turan
- Faculty of Medicine, Department of Pathology, Kocaeli University, Kocaeli, Turkey
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Zhao J, Yao X, Song C, Wang C. A comparative study of two liquid-based preparation methods: membrane-based and sedimentation in fine needle aspiration cytology diagnosis in thyroid nodules. World J Surg Oncol 2020; 18:13. [PMID: 31948446 PMCID: PMC6966855 DOI: 10.1186/s12957-020-1787-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/07/2020] [Indexed: 12/27/2022] Open
Abstract
Background As thyroid fine needle aspiration (FNA) shows a certain limitation in the diagnosis of conventional smears, novel approaches like liquid-based cytology (LBC) have been gradually applied recently. Studies have shown the difference between the conventional smears (CSs) and liquid-based smears on fine needle aspiration cytology (FNAC) diagnosis, but the impacts of different liquid-based preparation (LBP) methods, including membrane-based and sedimentation, on diagnosis are still not clear. In this study, the effects of liquid-based smears prepared by different methods on the cytological interpretation were studied. Methods A total of 221 thyroid liquid-based FNAC cases from January 2017 to October 2018 were collected. We retrospectively studied and compared the effects of the membrane-based and sedimentation LBP methods through The Bethesda System for Reporting Thyroid Cytopathology (TBS) diagnosis and risk of malignancy assessment. Besides, we made an evaluation on the diagnostic differences in the effects of different preparation methods on the cell morphology and tissue structure of papillary thyroid carcinoma (PTC) for more accurate FNAC diagnosis. Results Among the 221 cases reviewed, membrane-based method was applied in 153 cases and sedimentation in 68 cases. According to the diagnostic criteria of 2017 TBS, TBSVI and TBSV thyroid could be cytologically diagnosed by membrane-based (49.0% (75/153) and 25.5% (39/153)) and sedimentation (52.9(36/68) and 25(17/68)) methods, and both were confirmed as PTC through histopathological diagnosis after operation, with the malignancy degree as high as 100%. In addition, of the 30 cases that were diagnosed as TBSIII thyroid nodules with the membrane-based method, 15 cases were pathologically malignant after an operation, with the malignancy degree of 50% (15/30), while that in 11 cases using the sedimentation method was 45.4% (5/11). PTC could be detected in both the TBSIV and TBSII thyroid nodules diagnosed by membrane-based method, with the sensitivity of 87.0% (114/131) lower than that by sedimentation method (91.4% (53/58)), showing the lower consistency with the histopathological result (K = 0.635 vs K = 0.757). Among the membrane-based smears, 23.5% (36/153) had fewer follicular epithelial cells, 55.6% (20/36) of which were considered to be suspicious for PTC from cell karyotype and tissue arrangement. While among the sedimentation smears, 16.2% (11/68) had fewer follicular epithelial cells, and 63.6% (7/11) was suspicious for PTC. In 72.5% (95/131) membrane-based smears of PTC, the papillary and swirling structures were not obvious, showing as crowded syncytial cell masses, while in 55.2% (32/58) sedimentation smears, both structures were visible with obvious three-dimensional papillary structure, and the fibrovascular axis still remained. Conclusion LBP technique is feasible for FNAC diagnosis, and the sedimentation shows more advantages, like higher PTC detection rate and good consistency with postoperative histopathological diagnosis. A clear understanding of the subtle differences in the effects of membrane-based and sedimentation methods on the cell morphology and tissue structure could be conducive to the definitive diagnosis of PTC before operation.
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Affiliation(s)
- Juan Zhao
- Department of Pathology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), No. 568 Zhongxing North Road, Shaoxing, 312000, China
| | - Xiaofei Yao
- Department of Pathology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), No. 568 Zhongxing North Road, Shaoxing, 312000, China
| | - Chunjiao Song
- Medical Research Centre, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000, China
| | - Cheng Wang
- Department of Pathology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), No. 568 Zhongxing North Road, Shaoxing, 312000, China.
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Thakur A, Sarin H, Kaur D, Sarin D. Risk of malignancy in Thyroid "Atypia of undetermined significance/Follicular lesion of undetermined significance" and its subcategories - A 5-year experience. INDIAN J PATHOL MICR 2019; 62:544-548. [PMID: 31611437 DOI: 10.4103/ijpm.ijpm_319_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Atypia of undetermined significance/Follicular lesion of undetermined significance [AUS/FLUS] is a heterogeneous category with a wide range of risk of malignancy [ROM] reported in the literature. The Bethesda system for reporting thyroid cytopathology [TBSRTC], 2017 has recommended subcategorization of AUS/FLUS. Aims To evaluate the ROM in thyroid nodules categorized as AUS/FLUS, as well as separate ROM for each of the five subcategories. Settings and Design Retrospective analytic study. Methods and Materials A retrospective audit was conducted for all thyroid fine-needle aspiration cytology (FNAC) from January 2013 to December 2017. Slides for cases with follow-up histopathology were reviewed, classified into the five recommended subcategories, and differential ROM was calculated. Statistical Analysis Used z test for comparison of proportions was done to evaluate the difference in ROM among different subcategories of AUS/FLUS. The P value of less than 0.05 was taken as statistically significant. Results Total number of thyroid FNACs reported was 1,630, of which 122 were AUS/FLUS (7.5%). Histopathology was available in 49 cases, out of which 18 were malignant (ROM = 36.7%). The risk of malignancy (ROM) for nodules with architectural and cytologic atypia was higher (43.8%) than ROM for nodules with only architectural atypia (16.7%). Conclusions The sub-classification of AUS/FLUS into subcategories as recommended by TBSRTC, 2017 may better stratify the malignancy risk and guide future management guidelines.
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Affiliation(s)
- Abha Thakur
- Department of Pathology, Medanta-The Medicity Hospital, Gurgaon, India
| | - Haimanti Sarin
- Department of Pathology, Medanta-The Medicity Hospital, Gurgaon, India
| | - Dilpreet Kaur
- Department of Pathology, Medanta-The Medicity Hospital, Gurgaon, India
| | - Deepak Sarin
- Department of Head and Neck Oncology, Medanta-The Medicity Hospital, Gurgaon, India
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Semiquantitative assessment of cytomorphologic features can predict mutation status of thyroid nodules with indeterminate cytologic diagnosis. Hum Pathol 2019; 93:81-89. [PMID: 31437520 DOI: 10.1016/j.humpath.2019.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 01/21/2023]
Abstract
Molecular diagnostics increasingly direct the management of thyroid nodules with an indeterminate cytologic diagnosis. This study was undertaken to correlate cytomorphologic features with the molecular profiles in an effort to identify features predictive of molecular aberrations. One hundred eighty-nine thyroid nodules with an indeterminate thyroid cytology diagnosis (atypia of undetermined significance, suspicious for follicular lesion, and suspicious for malignancy) with an adequate sample submitted for targeted mutation detection by polymerase chain reaction or next-generation sequencing were assessed semiquantitatively for the following cytomorphologic parameters: cellularity, Hurthle cell changes, microfollicles, nuclear elongation, nuclear grooves, nuclear enlargement, nuclear atypia, extent of atypia, and colloid. Based on this evaluation, a cumulative cytomorphologic score (CCS) and a more simplified overall atypia score (OAS) were assigned to each case. Associations among mutational status and each of the aforementioned parameters, CCS, and OAS were determined. Of the 189 nodules with indeterminate cytology, 63 (33.3%) harbored at least 1 mutation. RAS and BRAF were the most common mutations, found in 34 (18.0%) and 13 (6.9%) cases, respectively. Both CCS and OAS were highly associated with the presence of all mutations (P < .0001) and with the presence of BRAF and RAS mutations in particular (all P < .01). Semiquantitative assessment of various cytomorphologic features in indeterminate thyroid cytology cases showed a strong association of higher OAS and CCS and incidence of BRAF and RAS mutations. Using a more objective approach to thyroid cytology can potentially decrease the overall number of indeterminate diagnoses, leading to fewer repeat procedures and unnecessary surgical procedures.
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Guleria P, Agarwal S, Iyer VK, Jain D, Mathur SR, Yadav D. Subcategorisation of AUS/FLUS thyroid lesions as per the 2017 Bethesda System for Reporting Thyroid Cytopathology: a retrospective study from a tertiary care centre analysing risk of malignancy (ROM) of the different subcategories. J Clin Pathol 2019; 72:771-777. [DOI: 10.1136/jclinpath-2019-205985] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 01/21/2023]
Abstract
AimsThe 2017 Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) recommends subclassification of atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS) into six subcategories. The present study evaluates the risk of malignancy (ROM) and risk of neoplasm (RON) among these.MethodsAll thyroid aspirates reported as AUS/FLUS over a 4.5-year period, with available histology, were reviewed and subclassified as per TBSRTC. ROM and RON were calculated and compared.ResultsOf 2554 thyroid aspirates, 281 (11.0%) were AUS/FLUS. Eighty-one with available histology were evaluated. ROM was 51.8%. Cytologic and architectural atypia (AUS-C&A) was the most prevalent (62.9%), followed by Hürthle cell type (19.6%), AUS-A (11.1%), AUS-not otherwise specified (NOS) (7.4%), cytologic atypia (AUS-C) (4.9%) and atypical lymphoid cells (1.2%). Papillary thyroid carcinoma (PTC) and adenomatous goitre (AG) were the most common histological diagnoses (27% each). On histology, AUS-C had 2/4 PTC and 2/4 AG on histology. AUS-A had 4/9 follicular neoplasm (FN) and 2/9 non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) while AUS C&A had 18/51 PTC, 13/51 AG, 11/51 NIFTP and 5/51 FN. ROM and RON were similar across subcategories, ROM was the highest for AUS-C&A (58.8%), AUS-C (50%) and AUS-NOS (50%). NIFTP reclassification as non-malignant reduced ROM to 35.8% (absolute reduction of 16% and a relative decrease of 31%) with the greatest relative decrease seen in AUS-A (50%), followed by AUS-C&A (37%), and none in others.ConclusionsAUS/FLUS subcategorisation helped to indicate risk for the more likely neoplasm, whether PTC or FN. ROM was the highest for cases with cytological atypia but did not differ significantly across different subcategories. NIFTP changed the ROM of AUS-A and AUS-C&A, since both NIFTP and FN have microfollicles.
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Cherella CE, Angell TE, Richman DM, Frates MC, Benson CB, Moore FD, Barletta JA, Hollowell M, Smith JR, Alexander EK, Cibas ES, Wassner AJ. Differences in Thyroid Nodule Cytology and Malignancy Risk Between Children and Adults. Thyroid 2019; 29:1097-1104. [PMID: 31298618 PMCID: PMC6707031 DOI: 10.1089/thy.2018.0728] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) is used to interpret fine-needle aspiration (FNA) cytology of thyroid nodules in children and adults. Nodule management is guided by the implied malignancy risk of each cytological category, which has been derived from adult populations. Whether these implied risks are applicable to pediatric thyroid nodules remains uncertain. We compared malignancy rates between pediatric and adult thyroid nodules within each cytological category. Methods: We evaluated consecutive thyroid nodules ≥1 cm that underwent FNA at the Boston Children's Hospital and Brigham and Women's Hospital from 1998 to 2016. All cytology was interpreted by a single cytopathology group according to the BSRTC. Malignancy rates were compared between pediatric (<19 years) and adult (≥19 years) patients. Results: Four hundred thirty pediatric thyroid nodules and 13,415 adult nodules were analyzed. Pediatric nodules were more likely to be malignant than adult nodules (19% vs. 12%, p = 0.0002). Within cytological categories, malignancy rates were higher in pediatric nodules than in adult nodules that were cytologically nondiagnostic (11% vs. 4%, p = 0.03), atypia of undetermined significance (AUS; 44% vs. 22%, p = 0.004), or suspicious for follicular neoplasm (SFN; 71% vs. 28%, p = 0.001). There were no significant differences between children and adults in the types of thyroid cancers diagnosed in these cytological categories. Among cytologically benign nodules, the difference in malignancy rates was statistically significant but clinically minimal (0.7% vs. 1%, p = 0.001). Malignancy rates did not differ between children and adults among nodules with cytology suspicious for papillary carcinoma (73% vs. 68%, p = 0.67) or positive for malignancy (97% vs. 95%, p = 1). Among the subset of nodules that were resected, the malignancy rate was higher in children than in adults only in nodules that were SFN (71% vs. 36%, p = 0.007). Conclusions: Among thyroid nodules that are cytologically AUS, SFN, or nondiagnostic, malignancy rates are higher in children than in adults. These discrepancies likely represent true differences in malignancy risk between pediatric and adult patients, rather than differences in cytological interpretation. Our findings provide pediatric-specific data to inform the optimal management of thyroid nodules in children, which may differ from that of adult nodules with equivalent cytology.
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Affiliation(s)
- Christine E. Cherella
- Thyroid Program, Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Trevor E. Angell
- Division of Endocrinology, Hypertension, and Diabetes, Brigham and Women's Hospital, Boston, Massachusetts
| | - Danielle M. Richman
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mary C. Frates
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carol B. Benson
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Francis D. Moore
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Justine A. Barletta
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Monica Hollowell
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - Jessica R. Smith
- Thyroid Program, Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Erik K. Alexander
- Division of Endocrinology, Hypertension, and Diabetes, Brigham and Women's Hospital, Boston, Massachusetts
| | - Edmund S. Cibas
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ari J. Wassner
- Thyroid Program, Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
- Address correspondence to: Ari J. Wassner, MD, Thyroid Program, Division of Endocrinology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115
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Chirayath SR, Pavithran PV, Abraham N, Nair V, Bhavani N, Kumar H, Menon UV, Menon AS. Prospective Study of Bethesda Categories III and IV Thyroid Nodules: Outcomes and Predictive Value of BRAF V600E Mutation. Indian J Endocrinol Metab 2019; 23:278-281. [PMID: 31641627 PMCID: PMC6683685 DOI: 10.4103/ijem.ijem_635_18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has emerged as the most controversial category because of its heterogeneity and inconsistent reporting. There is a definite paucity in data available from the Indian subcontinent about the outcome of nodules carrying Bethesda category III or Bethesda category IV diagnoses. AIMS AND OBJECTIVES The primary objective of our study was to determine the malignancy rate in Bethesda categories III and IV nodules. The secondary objectives were to determine predictive value of BRAFV600E mutation analysis on indeterminate thyroid nodules, predictive value of Thyroid image reporting and data system (TI-RADS) in malignancy prediction and to study the common histological variants in indeterminate nodules. MATERIALS AND METHODS This prospective study included 176 consecutive nodules of Bethesda categories III and IV, diagnosed over a period of 2 years from August 2015 to August 2017. A part of the fine needle aspirate was used to perform the BRAFV600E mutation analysis. The malignancy risk associated with these Fine needle aspiration Cytology categories were discussed with the patients. Those with Bethesda category IV diagnosis was advised surgery, whereas those with Bethesda category III were given the options of close follow-up with repeat FNA in 3 months or immediate surgery. RESULTS In our prospective study, there were 176 consecutive samples of categories III (140/79.5%) and IV (36/20.5%). Seventy-five (53.6%) category III nodules and 29 (80.6%) category IV nodules underwent immediate surgical excision. Fifty-five consecutive indeterminate cytology nodules were subjected for BRAFV600E. One of the samples was found to be positive for BRAF T1799A (V600E) mutation. The second sample harboured a missense mutation at position 1819 (TCC--GCC), wherein the codon 607 (TCC) coding for serine was substituted by alanine (GCC) which is a variant of unknown significance. In our study, the malignancy rate of Bethesda categories III and IV, which were triaged for immediate surgery were 54.6% and 72.4%, respectively. CONCLUSION Malignancy rate in Category III at our center was much higher than that described by ATA and by other studies published from centers around the world, including the only two studies from India. In view of the strikingly high malignancy rate in these indeterminate nodules, strong consideration to surgery should be given to patients with FNA results suggesting these two categories. BRAFV600E mutation analysis in FNA specimen has limited utility in improving the preoperative diagnostic rate for malignancy.
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Affiliation(s)
- Shiga Rappai Chirayath
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
| | - Praveen V. Pavithran
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
| | - Nithya Abraham
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
| | - Vasantha Nair
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
| | - Nisha Bhavani
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
| | - Harish Kumar
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
| | - Usha V. Menon
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
| | - Arun S. Menon
- Department of Endocrinology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
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Geramizadeh B, Bos-Hagh S, Maleki Z. Cytomorphologic, Imaging, Molecular Findings, and Outcome in Thyroid Follicular Lesion of Undetermined Significance/Atypical Cell of Undetermined Significance (AUS/FLUS): A Mini-Review. Acta Cytol 2018; 63:1-9. [PMID: 30380529 DOI: 10.1159/000493908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 09/19/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Since the introduction of the entity of "Atypical cell of undetermined significance /follicular lesion of undetermined significance" (AUS/FLUS) by The Bethesda System for Reporting Thyroid Cytology (TBSRTC) in 2007, there have been many published studies about the cytomorphologic criteria, subclassification, outcome, and management of patients with the diagnosis of AUS/FLUS. There have been many studies in different aspects of this indeterminate category, i.e., cytologic and molecular findings, ultrasonographic findings, and in some instances even core-needle biopsy to address a better and safer way of the management of patients with this fine-needle aspiration cytology diagnosis. The second edition of TBSRTC and the 2015 American Thyroid Association guidelines provide an update on the follow-up and management of AUS/FLUS. A multidisciplinary team consisting of pathologists, endocrinologists, surgeons, and radiologists should be involved in the diagnosis and management of AUS/FLUS, and all of them should be aware of the heterogeneity of this lesion for the prediction of the treatment and outcome. STUDY DESIGN In this review, we consider different research platforms (2008-2017) to find the best and key reports for the above-mentioned challenging aspects of AUS/FLUS. CONCLUSION AUS/FLUS is now a well-defined group of thyroid lesions, which can be most accurately diagnosed and managed with cytomorphology, molecular, and ancillary studies.
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Affiliation(s)
- Bita Geramizadeh
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Somayeh Bos-Hagh
- Department of Pathology, Medical School of Shiraz University, Shiraz University of Medical Sciences, Shiraz, Iran
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Maleki
- Division of Cytopathology, Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland,
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Eisa N, Khan A, Akhter M, Fensterwald M, Saleem S, Fananapazir G, Campbell MJ. Both Ultrasound Features and Nuclear Atypia are Associated with Malignancy in Thyroid Nodules with Atypia of Undetermined Significance. Ann Surg Oncol 2018; 25:3913-3918. [PMID: 30302643 DOI: 10.1245/s10434-018-6826-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND The optimal management of thyroid nodules that undergo fine-needle aspiration (FNA) with findings of atypia of undetermined significance (AUS) is unclear. Categorizing nodules by AUS subtype and ultrasound characteristics may improve risk stratification. Therefore, the purpose of this study is to evaluate the association between AUS subtype and ultrasound features on risk of malignancy (ROM). METHODS We performed a review of all patients with a thyroid nodule who underwent an FNA at our institution between January 2010 and November 2015. Patients with AUS were divided into groups with (1) nuclear atypia, (2) architectural atypia, or (3) Hurthle cell atypia. Their ultrasound features were assessed using the American Thyroid Association (ATA) thyroid nodule sonographic patterns. We conducted a univariate and multivariable analysis to determine the association between AUS subtype and other variables of interest with ROM. RESULTS Of the 3428 thyroid nodules that underwent FNA, 237 (6.9%) had AUS. Of the 97 surgically resected nodules, 67 (69%) were benign and 30 (31%) were malignant. On univariate analysis nuclear atypia (p < 0.01) was associated with a thyroid malignancy. On multivariable analysis, both ATA high-risk ultrasound features (p = 0.04, odds ratio [OR] 3.68) and nuclear atypia (p < 0.01, OR 11.8) were independently associated with a final diagnosis of thyroid carcinoma. CONCLUSIONS Nuclear atypia and ATA high-risk ultrasound features are useful in identifying patients with AUS that are at a higher risk of thyroid malignancy. Surgeons should take these factors into consideration when evaluating patients with AUS.
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Affiliation(s)
- Naseem Eisa
- Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Ahsan Khan
- School of Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Mutaal Akhter
- School of Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Molly Fensterwald
- School of Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Saba Saleem
- School of Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Ghaneh Fananapazir
- Department of Radiology, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Michael J Campbell
- Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA. .,University of California, Davis, Comprehensive Cancer Center, Sacramento, CA, USA.
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40
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Ullmann TM, Gray KD, Moore MD, Zarnegar R, Fahey TJ. Current controversies and future directions in the diagnosis and management of differentiated thyroid cancers. Gland Surg 2018; 7:473-486. [PMID: 30505769 DOI: 10.21037/gs.2017.09.08] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Despite the development of novel diagnostic, surgical, and chemotherapeutic approaches to differentiated thyroid cancers (DTCs), the diagnosis and management of these tumors remains controversial. The most recent American Thyroid Association (ATA) guidelines, released in 2015, reflect a recent shift towards less aggressive management for patients with DTCs. However, many clinicians have expressed concern that more conservative management will put patients at risk for disease recurrence and metastasis. In particular, the management of indeterminate nodules on fine needle aspiration (with special attention to genetic and epigenetic markers of malignancy), the extent of surgery for known differentiated cancers, the role of adjuvant radioactive iodine (RAI) therapy, and novel targeted treatments with tyrosine kinase inhibitors (TKIs) represent current areas of uncertainty and opportunities for future research. In this review, we examine the current state of the art in these areas, and address some of the questions that remain.
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Affiliation(s)
- Timothy M Ullmann
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Katherine D Gray
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Maureen D Moore
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Rasa Zarnegar
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Thomas J Fahey
- Department of Surgery, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
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41
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García Pascual L, Surralles ML, Morlius X, Garcia Cano L, González Mínguez C. Prevalence and associated malignancy of Bethesda category III cytologies of thyroid nodules assigned to the "cytological atypia" or "architectural atypia" groups. ACTA ACUST UNITED AC 2018; 65:577-583. [PMID: 30262240 DOI: 10.1016/j.endinu.2018.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/24/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To ascertain the prevalence of Bethesda category III cytologies and their malignancy rate, and to analyze differences in the second cytology, malignancy rate, type of carcinoma, and TNM stage between the cytological atypia (CA) and architectural atypia (AA) groups. PATIENTS AND METHOD A retrospective study of 973 biopsies. Bethesda category III cytologies were classified as CA when nuclear atypia was seen but they were not diagnostic or suspicious of malignancy, and as AA when smears had few cells but had a predominantly microfollicular pattern and minimal or absent colloid. The cytological and pathological results were correlated. RESULTS There were 87 (8.9%) Bethesda category III cytologies (34 CC, 53 AA). Second cytologies were performed in 23 patients (16 with CA, 7 with AA), and a benign result was found in 68.7% of CA and 71.4% of the AA group. Sixty-four patients (23 CA, 41 AA) underwent surgery and 15 of these (23.4%) had a malignant disease: 39.1% CA vs 14.6% AA (P=.029). There was a false negative result in the CA group. The follicular variant of papillary thyroid carcinoma was the most common malignancy (60%). There were no differences in type of carcinoma or TNM stage between CA and AA patients. CONCLUSIONS The reported prevalence of Bethesda category III cytologies was as expected. The malignancy rate was significantly higher in the CA group, but there were no differences in the result of the second cytology, type of carcinoma found, or TNM stage. The division of Bethesda category III cytologies is useful to provide a better stratification of the risk of malignancy.
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Affiliation(s)
- Luis García Pascual
- Servicio de Endocrinología, Hospital Universitari Mútua de Terrassa, Terrassa, España.
| | - Maria Lluïsa Surralles
- Servicio de Anatomía Patológica, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - Xavier Morlius
- Servicio de Anatomía Patológica, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - Laia Garcia Cano
- Servicio de Anatomía Patológica, Hospital Universitari Mútua de Terrassa, Terrassa, España
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42
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Lim JXY, Nga ME, Chan DKH, Tan WB, Parameswaran R, Ngiam KY. Subclassification of Bethesda Atypical and Follicular Neoplasm Categories According to Nuclear and Architectural Atypia Improves Discrimination of Thyroid Malignancy Risk. Thyroid 2018; 28:511-521. [PMID: 29596039 DOI: 10.1089/thy.2017.0274] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although The Bethesda System for Reporting Thyroid Cytopathology has provided clinicians with a standardized classification scheme for the diagnosis of thyroid fine-needle aspiration cytology (FNAC) specimens, the indeterminate categories of Bethesda III (B3)-atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS)-and Bethesda IV (B4)-follicular neoplasm/suspicious for follicular neoplasm (FN/SFN)-continue to pose challenges with regards to ideal diagnostic and therapeutic management. Having previously demonstrated the presence of nuclear atypia as a high-risk subgroup in B3, the objective of this study was to evaluate the malignancy rates in the B4 subgroup with nuclear atypia. METHODS A retrospective review of all thyroid FNACs diagnosed as B4 (FN/SFN) between 2008 and 2015 was conducted at a tertiary referral center in Singapore. Data on patient demographics, sonographic features, and final histological diagnosis were collected. This was compared to data from a previous analysis on all nodules diagnosed as B3 (AUS/FLUS) over a similar period. RESULTS A total of 137/309 (44.3%) and 88/111 (79.3%) FNACs diagnosed as B3 and B4, respectively, underwent surgical excision yielding final histopathological diagnoses. The malignancy rate of B4 was 31/88 (35.2%) compared to B3, which was 37/137 (27.0%). Subclassification based on the presence of architectural versus nuclear atypia showed significantly higher malignancy rates in B4 nodules with nuclear atypia (21.8% vs. 57.6%; p < 0.01). These findings corroborate previous results within the B3 category (malignancy rate of 14.7% vs. 36.8%; p < 0.01). The only sonographic features predictive of malignancy were the presence of macrocalcifications in B4 compared to irregularity of margins in B3. CONCLUSION The presence of nuclear atypia identifies subgroups with significant differential malignancy risks within both the B3 and B4 categories. This supports the notion that subclassification is a useful risk stratification tool that can guide diagnostic and therapeutic management of indeterminate thyroid nodules with heterogenous risk profiles.
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Affiliation(s)
- Joel Xue Yi Lim
- 1 Yong Loo Lin School of Medicine, National University of Singapore , Singapore
| | - Min En Nga
- 2 Department of Pathology, National University of Singapore , Singapore
| | | | - Wee Boon Tan
- 4 Division of Endocrine Surgery, National University of Singapore , Singapore
| | - Rajeev Parameswaran
- 4 Division of Endocrine Surgery, National University of Singapore , Singapore
| | - Kee Yuan Ngiam
- 4 Division of Endocrine Surgery, National University of Singapore , Singapore
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43
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Oosthuizen JL, Walker B, Todorovic E, Masoudi H, Wiseman SM. The presence of papillary features in thyroid nodules diagnosed as atypia of undetermined significance or follicular lesion of undetermined significance increases cancer risk and should influence treatment. Am J Surg 2018; 215:819-823. [PMID: 29422426 DOI: 10.1016/j.amjsurg.2017.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 12/15/2017] [Accepted: 12/19/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the influence of papillary features on risk of malignancy (ROM) within the Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance (AUS-FLUS) Bethesda System for Reporting Thyroid Cytopathology (BSRTC) diagnostic category. METHODS A Retrospective review of cases with an AUS-FLUS diagnosis that underwent a thyroidectomy was carried out, and cases were subcategorized based upon the presence of papillary features. RESULTS For the entire study population there were 93 (22%) of 427 FNAB specimens that had an AUS-FLUS diagnosis, and a 32% associated ROM. Papillary features were identified in 44 FNAB specimens (47% of the AUS-FLUS cases or 10% of the entire study population), and when present had a 45% ROM. The 49 FNAB specimens (53%) that did not exhibit papillary features had a significantly lower ROM (20%) than those that did have papillary features (p = 0.0069). CONCLUSIONS The presence of papillary features in a thyroid FNAB with an AUS-FLUS diagnosis is common, and is associated with a higher ROM than is currently suggested by the BSRTC.
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Affiliation(s)
- Jean L Oosthuizen
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Blair Walker
- Department of Pathology & Laboratory Medicine, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Emilija Todorovic
- Department of Pathology & Laboratory Medicine, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Hamid Masoudi
- Department of Pathology & Laboratory Medicine, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Vancouver, BC, Canada.
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Hang JF, Westra WH, Zhou AG, Cooper DS, Ali SZ. The impact of noninvasive follicular thyroid neoplasm with papillary-like nuclear features on the rate of malignancy for atypia of undetermined significance subcategories. Cancer Cytopathol 2018; 126:309-316. [PMID: 29424960 DOI: 10.1002/cncy.21981] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/11/2018] [Accepted: 01/22/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND The recent revision in terminology, with noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) replacing noninvasive follicular variant of papillary thyroid carcinoma, has reclassified the clinically indolent tumor as nonmalignant. The objective of this study was to evaluate the impact of this change on the rate of malignancy (ROM) for subcategories of an atypia of undetermined significance (AUS) diagnosis on fine-needle aspiration (FNA) cytology. METHODS Consecutive thyroid FNAs interpreted as AUS over a period of 4 years were retrospectively analyzed. The ROM for AUS subcategories, including atypia of undetermined significance with nuclear atypia (AUS-N), atypia of undetermined significance with a microfollicular pattern (AUS-F), atypia of undetermined significance with nuclear atypia and a microfollicular pattern (AUS-N/F), atypia of undetermined significance with Hürthle cells (AUS-H), and atypia of undetermined significance, not otherwise specified (AUS-NOS), were analyzed. RESULTS Of the 426 nodules interpreted as AUS, 244 were surgically excised. The incidence of NIFTP in each subcategory was as follows: 18% for AUS-N, 18% for AUS-F, 9% for AUS-N/F, 3% for AUS-H, and 0% for AUS-NOS. After the reclassification of NIFTP as nonmalignant, the ROM based on histologic follow-up significantly decreased from 43% to 26% for AUS-N (P < .001) and from 29% to 10% for AUS-F (P = .008). The ROM for AUS-N remained significantly higher than the ROM for AUS-F (P = .030). CONCLUSIONS A subset of resected AUS nodules can be reclassified as NIFTP, and that significantly decreases the ROM, especially for AUS-N and AUS-F. Nonetheless, AUS-N still harbors a substantially higher ROM than AUS-F. Cancer Cytopathol 2018;126:309-16. © 2018 American Cancer Society.
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Affiliation(s)
- Jen-Fan Hang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - William H Westra
- Department of Pathology, The Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amy G Zhou
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Syed Z Ali
- Department of Pathology, The Johns Hopkins Hospital, Baltimore, Maryland.,Department of Radiology, The Johns Hopkins Hospital, Baltimore, Maryland
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45
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Mosca L, da Silva LFF, Carneiro PC, Chacon DA, de Araujo-Neto VJF, de Araujo-Filho VJF, Cernea CR. Malignancy rates for Bethesda III subcategories in thyroid fine needle aspiration biopsy (FNAB). Clinics (Sao Paulo) 2018; 73:e370. [PMID: 29846414 PMCID: PMC5960075 DOI: 10.6061/clinics/2018/e370] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/20/2017] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Most thyroid diseases are nodular and have been investigated using ultrasound-guided fine needle aspiration biopsy (FNAB), the reports of which are standardized by the Bethesda System. Bethesda category III represents a heterogeneous group in terms of lesion characteristics and the malignancy rates reported in the literature. The objective of the present study was to evaluate the differences in the malignancy rates among Bethesda III subcategories. METHODS Data from 1,479 patients who had thyroid surgery were reviewed. In total, 1,093 patients (89.6% female, mean age 52.7 (13-89) years) were included, and 386 patients were excluded. FNAB results (based on Bethesda Class) and histopathological results (benign or malignant) for coincident areas were collected. Bethesda III patients were subcategorized according to cytopathological characteristics (FLUS: follicular lesion of undetermined significance, Bethesda IIIA; AUS: atypia of undetermined significance, Bethesda IIIB). Data were correlated to obtain the malignancy rates for each Bethesda category and the newly defined subcategory. RESULTS FNAB results for these patients were as follows: Bethesda I: 3.1%; Bethesda II: 18.6%; Bethesda III: 35.0%; Bethesda IV: 22.1%; Bethesda V: 4.1%; and Bethesda VI: 17.1%. The malignancy rates for Bethesda Class IIIB were significantly higher than those for Bethesda Class IIIA (p<0.001) and Bethesda Class IV (p<0.001). Bethesda Class IIIA showed significantly lower malignancy rates than Bethesda Class III overall (p<0.001) CONCLUSIONS: Improvements of the Bethesda System should consider this subcategorization to better reflect different malignancy rates, which may have a significant impact on the decision-making process.
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Affiliation(s)
- Leticia Mosca
- Disciplina de Cirurgia de Cabeca e Pescoco, Departamento de Cirurgia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Fernando Ferraz da Silva
- Departamento de Patologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Paulo Campos Carneiro
- Departamento de Patologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Danielle Azevedo Chacon
- Departamento de Patologia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | | | - Claudio Roberto Cernea
- Disciplina de Cirurgia de Cabeca e Pescoco, Departamento de Cirurgia, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
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46
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Rosario PW, Calsolari MR. Importance of cytological subclassification of thyroid nodules with Bethesda category III cytology (AUS/FLUS) into architectural atypia only and nuclear atypia: A prospective study. Diagn Cytopathol 2017; 45:604-607. [DOI: 10.1002/dc.23734] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 04/03/2017] [Accepted: 04/06/2017] [Indexed: 11/07/2022]
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