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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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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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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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Babajani A, Rahmani S, Raoufi M, Eidgahi ES, Dastjerdi AV, Behfarnia P, Khalili S, Moghaddam NA. Clinico-cytopathological subcategorization in thyroid nodules of atypia of undetermined significance/follicular lesion of undetermined significance using the TIRADS and Bethesda classifications. Front Endocrinol (Lausanne) 2023; 14:1135196. [PMID: 37313444 PMCID: PMC10258349 DOI: 10.3389/fendo.2023.1135196] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 04/28/2023] [Indexed: 06/15/2023] Open
Abstract
Introduction Bethesda category III - atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is a heterogeneous class of the Bethesda system for thyroid nodules. In order to clarify the therapeutic road for clinicians, this category was subclassified based on the cytopathological features. In this study, we evaluated the risk of malignancy, surgical outcome, demographic characteristics, and correlation of ultrasound features with the final outcome in patients with thyroid nodules based on AUS/FLUS subclassification. Method After evaluating 867 thyroid nodules from three different centers, 70 (8.07%) were initially diagnosed as AUS/FLUS. The cytopathologists re-interpreted the FNA samples and subclassified them into five subcategories: architectural atypia, cytologic atypia, cytologic and architectural atypia, and Hürthle cell AUS/FLUS, and atypia, which was not specified. Based on the suspicious ultrasound features, an appropriate ACR TI-RADS score was allocated to each nodule. Finally, the malignancy rate, surgical outcomes, and ACR TI-RADS scores were evaluated among Bethesda category III nodules. Results Among the 70 evaluated nodules, 28 (40%) were subclassified as Hürthle cell AUS/FLUS, 22 (31.42%) as cytologic and architectural atypia, 8 (11.42%) as architectural atypia, 7 (10%) as cytologic atypia, and 5 (7.14%) as atypia which was not specified. The overall malignancy rate was 34.28%, and the architectural atypia and Hürthle cell nodules displayed lower malignancy compared to other groups (P-Value<0.05). Utilizing ACR TI-RADS scores showed no statistical significance between Bethesda III subcategorization and ACR TI-RADS scores. However, ACR TI-RADS can be a reliable predictor for Hürthle cell AUS/FLU nodules. Conclusion ACR TI-RADS helps evaluate malignancy only in the Hürthle cell AUS/FLUS subcategory of AUS/FLUS. Besides, cytopathological reporting based on the suggested AUS/FLUS subclassification could help clinicians take appropriate measures to manage thyroid nodules.
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Affiliation(s)
- Amirhesam Babajani
- Oncopathology Research Center, Department of Molecular Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Pathology, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Rahmani
- Oncopathology Research Center, Department of Molecular Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Department of Pathology, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoomeh Raoufi
- Department of Radiology, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Shaarbaf Eidgahi
- Kidney Transplantation Complication Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Poya Behfarnia
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shayesteh Khalili
- Department of Internal Medicine, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Noushin Afshar Moghaddam
- Department of Pathology, School of Medicine, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Antonia TD, Maria LI, Ancuta-Augustina GG. Preoperative evaluation of thyroid nodules - Diagnosis and management strategies. Pathol Res Pract 2023; 246:154516. [PMID: 37196471 DOI: 10.1016/j.prp.2023.154516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/06/2023] [Indexed: 05/19/2023]
Abstract
Thyroid cancer is the most common endocrine malignancy, with increasing incidence over the past few decades. Fine needle aspiration (FNA) biopsy is the gold standard for preoperative diagnosis of thyroid malignancies. Nevertheless, this method renders indeterminate results in up to 30% of the cases. Therefore, these patients are often referred to unnecessary surgery to establish the diagnosis. To improve the accuracy of preoperative diagnosis, several other ways, such as ultrasonography, elastography, immunohistochemical analysis, genetic testing, and core needle biopsy, have been developed and can be used either in association with or as an alternative to FNA. This review aims to evaluate all these diagnostic tools to determine the most appropriate way of managing thyroid nodules and subsequently improve the selection of cases referred to surgery.
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Affiliation(s)
- Tapoi Dana Antonia
- Carol Davila University of Medicine and Pharmacy, Department of Pathology, Bucharest, Romania; University Emergency Hospital, Department of Pathology, Bucharest, Romania
| | - Lambrescu Ioana Maria
- Carol Davila University of Medicine and Pharmacy, Department of Cellular and Molecular Biology and Histology, Bucharest, Romania; Victor Babes National Institute of Pathology, Bucharest, Romania.
| | - Gheorghisan-Galateanu Ancuta-Augustina
- Carol Davila University of Medicine and Pharmacy, Department of Cellular and Molecular Biology and Histology, Bucharest, Romania; CI Parhon National Institute of Endocrinology, Bucharest, Romania
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Muacevic A, Adler JR, Sebeih H, Alessa MA, Alkaf HH, Bahaj A, Abdelmonim SK. Noninvasive Follicular Thyroid Neoplasm With Papillary-Like Nuclear Features: What a Surgeon Should Know. Cureus 2023; 15:e33649. [PMID: 36788866 PMCID: PMC9912993 DOI: 10.7759/cureus.33649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 01/13/2023] Open
Abstract
The inclusion of the less aggressive follicular form of papillary thyroid cancer (PTC) is associated with an increase in the incidence of the condition, with the follicular variant of PTC being the most common of all variants. The majority of individuals with the encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) are treated as though they have classic thyroid cancer, despite the availability of mounting evidence to contradict the aforementioned. According to numerous research, a certain type of noninvasive-EFVPTC (NI-EFVPTC) demonstrated poor histopathologic diagnostic reproducibility and has received aggressive treatment similar to that of a classical thyroid neoplasm. Therefore, to replace the term NI-EFVPC, a new nomenclature for these tumors, called "noninvasive follicular thyroid neoplasm with papillary-like nuclear characteristics" (NIFTP), was introduced in the year 2016. The present paper explores this recently introduced terminology, clinical, histologic, and molecular features, and diagnostic criteria.
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Liu X, Wang J, Du W, Dai L, Fang Q. Predictors of Malignancy in Thyroid Nodules Classified as Bethesda Category III. Front Endocrinol (Lausanne) 2022; 13:806028. [PMID: 35250863 PMCID: PMC8888873 DOI: 10.3389/fendo.2022.806028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/05/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine predictors of malignancy in surgically treated Bethesda category III nodules. METHODS Patients with surgically treated thyroid nodules classified as Bethesda category III were retrospectively enrolled. The association between clinical/sonographic features and postoperative pathology was evaluated using univariate and multivariate analyses. RESULTS A total of 188 nodules from 184 patients were included. The overall malignancy rate was 54.3%. In univariate analysis, male sex, aspect ratio >1, microcalcification, unclear boundary, BRAFV600E mutation, and nuclear atypia were significantly associated with malignant disease in Bethesda category III nodules. Multivariate analysis confirmed that male sex, aspect ratio >1, microcalcification, and BRAFV600E mutation were independent predictors of malignant disease. CONCLUSIONS Malignant disease was common in Bethesda category III nodules, and surgical treatment was strongly indicated in the presence of male sex, aspect ratio>1, microcalcification, and BRAFV600E mutation.
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Atypia and Follicular Lesions of Undetermined Significance in Subsequent Biopsy Result: What Clinicians Need to Know. J Clin Med 2021; 10:jcm10143082. [PMID: 34300248 PMCID: PMC8303631 DOI: 10.3390/jcm10143082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/07/2021] [Accepted: 07/09/2021] [Indexed: 12/16/2022] Open
Abstract
Atypia and follicular lesions of undetermined significance (AUS/FLUS) is the most controversial category of The Bethesda System. The risk of malignancy (ROM) in this group is estimated as 5–15%, however, the occurrence of two or more subsequent biopsy results with AUS/FLUS diagnosis makes these clinical situations more complex. We evaluated the ROM and prognostic value of aggressive ultrasound (US) features in 342 patients with thyroid nodules (TNs) with subsequent biopsy results of AUS/FLUS. We assessed US features and compared them with the final histopathological diagnosis. Overall, 121 (35.4%) individuals after first AUS/FLUS diagnosis underwent surgery and 221 (64.6%) patients had repeated biopsies. The ROM after first, second, and third biopsies with subsequent AUS/FLUS diagnosis were 7.4%, 18.5%, and 38.4% respectively. We demonstrated significantly higher rates of occurrence of aggressive US features in patients with malignancy (p < 0.0001). The age <55 years old was also a significant risk factor for TC (p = 0.044). Significant associations were found between aggressive US features and malignancy in patients after first diagnosis of AUS/FLUS (p < 0.05). The juxtaposition of US features with the number of biopsy repetitions of TN with consecutive AUS/FLUS diagnoses may simplify the decision-making process in surgical management. Two or three consecutive biopsy results with AUS/FLUS diagnosis increases the ROM.
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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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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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Xu XM, Angelova E, Clement CG. Outcome of atypia of undetermined significance/follicular lesion of undetermined significance in thyroid fine-needle aspirations: A six-year institutional experience. Diagn Cytopathol 2021; 49:915-920. [PMID: 33973739 DOI: 10.1002/dc.24771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is one of six diagnostic categories of The Bethesda System for Reporting Thyroid Cytopathology (BSRTC). The goal of our study is to assess the outcome of cases classified as AUS/FLUS at our institution. METHODS AUS/FLUS cases were identified by computer searching of the thyroid fine-needle aspiration (FNA) cases performed between 2010 and 2016. Outcomes were categorized as: follow-up surgery, repeat FNA or no follow-up available. Demographics, ultrasound findings and FNA diagnostic criteria were reviewed for AUS/FLUS cases with follow-up surgical pathology diagnosis. RESULTS Our AUS/FLUS thyroid FNA rate was 6% (117 out of 1984 FNAs). Only 15% of the AUS/FLUS cases had repeat FNA, while 41% underwent surgery. The risk of malignancy (ROM) for cases with follow-up surgery was 17%. When considering all AUS/FLUS cases, the ROM was 7%. Statistically, benign neoplasms were more likely to be single lesions on ultrasound comparing to malignant neoplasms, and to exhibit architectural atypia as opposed to non-neoplastic lesions on FNA. The malignancy rates among patients that directly went to surgical resection (17%) and patients having repeat FNA after the first AUS/FLUS diagnosis followed by surgery (29%) was not significantly different. However, repeat FNA was able to reclassify the majority of cases into more definitive categories. CONCLUSION The outcome of the thyroid FNAs diagnosed as AUS/FLUS in our institution meets the benchmark statistics for AUS/FLUS rate and ROM. This study constitutes a valuable quality assurance measure and serves as a baseline for subsequent quality improvement.
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Affiliation(s)
- Xiao-Meng Xu
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Evgeniya Angelova
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Cecilia G Clement
- Department of Pathology, University of Texas Medical Branch, Galveston, Texas, USA
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Kaliszewski K, Diakowska D, Rzeszutko M, Wojtczak B, Rudnicki J. The Correlation of Age with Prognosis of Atypia of Undetermined Significance and Follicular Lesion of Undetermined Significance in Thyroid Nodules. Cancer Manag Res 2021; 13:3101-3111. [PMID: 33854379 PMCID: PMC8041602 DOI: 10.2147/cmar.s304686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/10/2021] [Indexed: 12/02/2022] Open
Abstract
Purpose Although some prognostic variables and risk factors for thyroid cancer (TC) are age-related, the association between age and the risk of TC in patients with thyroid nodules (TNs) assigned to atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS) is poorly estimated. The aim of this study was to assess the histopathology of AUS/FLUS and the risk of TC according to the age of the patients at the time of AUS/FLUS diagnosis. Patients and Methods Among 5021 individuals treated for TNs at one institution from 2008 to 2018, 161 (3.2%) patients with 161 TNs assigned to the AUS/FLUS category (1 nodule per patient) were selected and stratified by age at initial diagnosis: <55 years, 55–75 years and >75 years. Logistic regression analysis was used to estimate the association of age with the risk of TC diagnosis. Results Ninety-one (56.52%) patients <55 years old, 58 (36.02%) patients 55–75 years old, and 12 (7.45%) individuals >75 years old were identified. There were 130 (80.7%) females and 31 (19.3%) males with a mean age of 50.6 ± 16.12 years. Among the evaluated TNs, 142 (88.2%) were ultimately diagnosed as benign, and 19 (11.8%) were diagnosed as malignant. Younger age in patients was significantly related to malignancy outcome (p=0.024 for age <55 years). Patients aged 55–75 years had a significantly lower risk of TC than the other age categories (p=0.040). The risks of high vascularity and fast tumor growth were significantly higher in the youngest category than in the other categories (age <55 years old: p=0.045 and p=0.002, respectively). Conclusion Although patients with TNs classified as AUS/FLUS by ultrasound-guided fine needle aspiration biopsy (UG-FNAB) are not typically qualified for surgery, it is worth noting that younger patients with an AUS/FLUS diagnosis might be at a higher risk of TC.
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Affiliation(s)
- Krzysztof Kaliszewski
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw 50-556, Poland
| | - Dorota Diakowska
- Department of Nervous System Diseases, Faculty of Health Science, Wroclaw Medical University, Wroclaw 51-618, Poland
| | - Marta Rzeszutko
- Department of Pathomorphology, Wroclaw Medical University, Wroclaw 50-368, Poland
| | - Beata Wojtczak
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw 50-556, Poland
| | - Jerzy Rudnicki
- Department of General, Minimally Invasive and Endocrine Surgery, Wroclaw Medical University, Wroclaw 50-556, Poland
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13
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Guleria P, Mani K, Agarwal S. Indian experience of AUS/FLUS diagnosis: is it different from rest of Asia and the West?-A systematic review and meta-analysis. Gland Surg 2020; 9:1797-1812. [PMID: 33224856 DOI: 10.21037/gs-20-392] [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: 12/13/2022]
Abstract
Background Atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is the most heterogeneous subcategory of the Bethesda system for thyroid cytopathology with laid down permissible limits of frequency and risk of malignancy (ROM). Due to differences in thyroid clinical practice worldwide, variations have been found in frequency, resection rates (RR) and ROM. Therefore, this systematic review and meta-analysis of AUS/FLUS across different regions was conducted and comparison of data from India was done with the rest of Asia and the West. Methods We searched PubMed and Google search engines from January 2009-Dec 2019 using terms "AUS Thyroid" and "FLUS Thyroid". Meta-analysis was performed using DerSimonian-Laird method and 95% confidence intervals were calculated using random effects model. Independent samples t-test was used to compare frequency, RR, and ROM of AUS/FLUS between India, rest of Asia and the West. Results Out of 15,000 studies on internet, 60 (18 Indian, 12 Asian and 30 Western) were included. Total aspirates were 201,657; 14,279 Indian, 62,448 Asian, 124,930 Western. Pooled estimates were: frequency 7.3% (6.3-8.3%), RR 41.9% (37.4-46.6%), ROM 33.3% (26.8-39.9%). Pooled prevalence of rate did not vary significantly across the three regions. Pooled prevalence of RR was highest in India (52.9%) and lowest in rest of Asia (26.5%); of ROM was highest in Asia (45.9%), lowest in the West (26.3%) (P<0.01). Statistical analysis demonstrated publication bias, limited to Indian and Western studies. Papillary thyroid carcinoma was the most common surgical diagnosis (87.9%; 1,082/1,231). Conclusions This meta-analysis showed differences in thyroid clinical practice followed in India, rest of Asia and the West. Although pooled prevalence of rate of AUS/FLUS was similar across the three, pooled RR and ROM varied. AUS/FLUS nodules were more frequently resected in Indian and Western studies than in rest of Asia. ROM was higher than recommended values in all three areas, being intermediate for India.
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Affiliation(s)
- Prerna Guleria
- Department of Laboratory Sciences and Molecular Medicine, Army Hospital Research and Referral, New Delhi, India
| | - Kalaivani Mani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Shipra Agarwal
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
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14
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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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15
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Popławska-Kita A, Wielogórska M, Poplawski Ł, Siewko K, Adamska A, Szumowski P, Myśliwiec P, Myśliwiec J, Reszeć J, Kamiński G, Dzięcioł J, Tobiaszewska D, Szelachowska M, Krętowski AJ. Thyroid carcinoma with atypical metastasis to the pituitary gland and unexpected postmortal diagnosis. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM190148. [PMID: 32168468 PMCID: PMC7077587 DOI: 10.1530/edm-19-0148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 02/21/2020] [Indexed: 12/19/2022] Open
Abstract
SUMMARY Papillary thyroid gland carcinoma is the most common type of malignancy of the endocrine system. Metastases to the pituitary gland have been described as a complication of papillary thyroid cancer in few reported cases since 1965. We report the case of a 68-year-old female patient with a well-differentiated form of thyroid gland cancer. Despite it being the most common malignant cancer of the endocrine system, with its papillary form being one of the two most frequently diagnosed thyroid cancers, the case we present is extremely rare. Sudden cardiac arrest during ventricular fibrillation occurred during hospitalization. Autopsy of the patient revealed papillary carcinoma of the thyroid, follicular variant, with metastasis to the sella turcica, and concomitant sarcoidosis of heart, lung, and mediastinal and hilar lymph nodes. Not only does atypical metastasis make our patient's case most remarkable, but also the postmortem diagnosis of sarcoidosis makes her case particularly unusual. LEARNING POINTS The goal of presenting this case is to raise awareness of the clinical heterogeneity of papillary cancer and promote early diagnosis of unexpected metastasis and coexisting diseases to improve clinical outcomes. Clinicians must be skeptical. They should not fall into the trap of diagnostic momentum or accept diagnostic labels at face value. Regardless of the potential mechanisms, clinicians should be aware of the possibility of the coexistence of thyroid cancer and sarcoidosis as a differential diagnosis of lymphadenopathy. This case highlights the importance of the diagnostic and therapeutic planning process and raises awareness of the fact that one uncommon disease could be masked by another extremely rare disorder.
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Affiliation(s)
| | | | | | | | | | - Piotr Szumowski
- Departments of Nuclear Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Myśliwiec
- 1st Clinic Department of General and Endocrine Surgery, Medical University of Bialystok, Bialystok, Poland
| | - Janusz Myśliwiec
- Departments of Nuclear Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Joanna Reszeć
- Departments of Medical Pathomorphology, Medical University of Bialystok, Bialystok, Poland
| | - Grzegorz Kamiński
- Department of Endocrinology and Radioisotopy Therapy, Military Institute of Medicine, Warsaw, Poland
| | - Janusz Dzięcioł
- Departments of Human Anatomy, Medical University of Bialystok, Bialystok, Poland
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16
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Gong JX, Gu JW, Ji F, Li K, Zhu Q, Gu FY, Chen Y, Ji QH. Clinical Study on Prelaryngeal Lymph Node Metastasis in Papillary Thyroid Carcinoma. Cancer Manag Res 2020; 12:1323-1327. [PMID: 32110106 PMCID: PMC7041594 DOI: 10.2147/cmar.s232884] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/26/2019] [Indexed: 11/27/2022] Open
Abstract
Objective This study aims to investigate the risk factors of prelaryngeal lymph node metastasis in papillary thyroid carcinoma and its clinical application value. Methods The clinical pathological features and metastatic risks were statistically analyzed by reviewing 254 patients with papillary thyroid carcinoma, who received their first operation and prelaryngeal lymph node dissection in our department. Results The detection of prelaryngeal lymph nodes, tumor size and any paratracheal lymph node metastasis were correlated with the number of paratracheal lymph node metastasis (P<0.05), but these were not correlated with age, gender, multiple foci, tumor size, any paratracheal lymph node metastasis, metastatic location, or foci location (P>0.05). Conclusion Paratracheal lymph node metastasis indicates a high possibility of prelaryngeal lymph node metastasis. Paratracheal lymph node dissection combined with prelaryngeal lymph node dissection should be simultaneously considered in operations for thyroid papilla carcinoma.
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Affiliation(s)
- Jin-Xing Gong
- Department Four of Surgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, People's Republic of China
| | - Jian-Wei Gu
- Department Four of Surgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, People's Republic of China
| | - Feng Ji
- Department Four of Surgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, People's Republic of China
| | - Kun Li
- Department Four of Surgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, People's Republic of China
| | - Qi Zhu
- Department Four of Surgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, People's Republic of China
| | - Fang-Ying Gu
- Department Four of Surgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, People's Republic of China
| | - Yan Chen
- Department Four of Surgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan 215300, People's Republic of China
| | - Qing-Hai Ji
- Head & Neck Surgery, Fudan University Shanghai Cancer Center, Shanghai 200000, People's Republic of China
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17
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Zajkowska K, Kopczyński J, Góźdź S, Kowalska A. Noninvasive follicular thyroid neoplasm with papillary-like nuclear features: a problematic entity. Endocr Connect 2020; 9:EC-19-0566.R1. [PMID: 32061158 PMCID: PMC7077601 DOI: 10.1530/ec-19-0566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 02/12/2020] [Indexed: 01/14/2023]
Abstract
Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) is a borderline thyroid tumour formerly known as noninvasive encapsulated follicular variant of papillary thyroid carcinoma. The prevalence of NIFTP is estimated at 4.4-9.1% of all papillary thyroid carcinomas worldwide; however, the rate of occurrence of NIFTP is eight times lower in Asian countries than in Western Europe and America. At the molecular level, NIFTP is characterised by the lack of BRAF V600E and BRAF V600E-like mutations or other high-risk mutations (TERT, TP53), and a high rate of RAS mutations, which is similar to other follicular-pattern thyroid tumours. The diagnosis of NIFTP can only be made after histological examination of the entire tumour removed during surgery, and is based on strictly defined inclusion and exclusion criteria. Although the diagnosis is postoperative, the combination of certain findings of preoperative tests including ultrasonography, cytology, and molecular testing may raise suspicion of NIFTP. These tumours can be effectively treated by lobectomy, although total thyroidectomy remains an option for some patients. Radioactive iodine and thyroid stimulating hormone suppression therapy are not required. NIFTP has an extremely good prognosis, even when treated conservatively with lobectomy alone. Nevertheless, it cannot be considered as a benign lesion. The risk of adverse outcomes, including lymph node and distant metastases, is low but not negligible.
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Affiliation(s)
| | | | - Stanisław Góźdź
- Faculty of Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Aldona Kowalska
- Endocrinology, Holycross Cancer Centre, Kielce, Poland
- Faculty of Health Sciences, Jan Kochanowski University, Kielce, Poland
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