The Language of Cytopathology The Journey from Bethesda to ... The Bethesda System for Reporting Thyroid

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  • 11/19/2019


    The Language of Cytopathology

    The Journey from Bethesda to

    Paris and Beyond

    Syed Z. Ali, MD, FIAC, FRCPath

    Professor of Pathology and Radiology

    The Johns Hopkins Hospital

    Baltimore, Maryland


    Scientific Language or Terminology

    < aka Nomenclature >

    “As ideas are preserved and communicated by means

    of words, it necessarily follows that we cannot improve

    the language of any science, without at the same time

    improving the science itself; neither can we, on the

    other hand, improve a science without improving the

    language or nomenclature which belongs to it”

    Antoine-Laurent Lavoisier (1743-1794), French chemist

    On Reporting Terminology -

    “an accurate cytologic diagnosis of disease is

    both possible and desirable: therefore, the

    reports should be expressed in simple

    language that can be readily understood by the


    Leo Koss – Diagnostic Cytology and its Histopathologic Bases, 1st ed, 1961

  • 11/19/2019


    “The history of cytology is like a winding road, with many

    obstacles, detours and sudden turns. The roadside

    ravines are filled with discarded, once believed,

    obsolescent tools, ideas and personnel. Despite many

    roadblocks and potholes the traveler may find long

    stretches of neatly landscaped road with brightly

    illuminated directional signs and clearly visible names”

    Steve I. Hajdu

    Reporting Terminology Follows

    the History of Cytology

    Papanicolaou Classification

    For Cervical Cytology

     Class I – Absence of atypical or abnormal cells

     Class II – Atypical cytology but no evidence of


     Class III – Cytology suggestive of, but not diagnostic

    for, malignancy

     Class IV – Cytology strongly suggestive of malignancy

     Class V – Cytology conclusive of malignancy

    It all started from

    Bethesda Maryland, USA

  • 11/19/2019


    “The Architect”

    Diane Solomon


    National Institute of




    1994 (1988, 1991)

    2004 (2001)

    2015 (2014)

    The Bethesda System for

    Reporting Cervical Cytology

  • 11/19/2019


    154 registrants

     Pathologists

     Surgeons

     Endocrinologists

     Radiologists Andrea Abati 2007

     2006-2007 – “Terminology Committee” prepared a draft document

     2007 – Three online discussion periods

     2007 – October 22-23 “Bethesda” Live Conference

     2008 – Documents published in 2 journals

     2010 – Monograph published

    TBSRTC - History and Timeline

    NCI Thyroid FNA State of the Science Conference

    General agreement on need for defined categories

    • Clarity of communication

    • Exchange of data across institutions

    Discussion focused on number of categories and names

     Succinct, unambiguous, clinically relevant

     Endorsed by all in the multidisciplinary team

     Probabilistic approach

     Robust and reproducible morphologic criteria

     Well-defined clinical management algorithms

    Thyroid FNA Terminology < Prerequisites and Goals >

  • 11/19/2019


    TBSRTC 2010 - Probabilistic

    Approach andRelationship to

    Clinical Algorithms

    ROM (%) Management

    Nondiagnostic 1-4 Repeat FNA with US

    Benign 0-3 Follow-up

    AUS/FLUS 10-15 Repeat FNA

    SFN/FN 15-30 Lobectomy

    SFM 60-75 Lobectomy or total


    Malignant 97-99 Total thyroidectomy

    Digital Image Atlas –

    Over 35k copies sold (English ed)

    Andrea Abati

    John Abele

    Jacki Abrams

    Pedro de Agustin

    Erik Alexander

    Sylvia Asa

    Zubair Baloch

    Carol Benson

    Douglas Clark

    Beatrix Cochand-Priollet

    R. Mac DeMay

    Gerard Doherty

    Dan Duick

    Tarik El Sheikh

    Doug Evans

    Bill Faquin

    Armando Filie

    William Frable

    Hossein Gharib

    Kim Geisinger



    Jill Langer

    Lester Layfield

    Virginia Livolsi

    Britt-Marie Ljung

    Sanjay Logani

    Susan Mandel



    Maria Merino

    Claire Michael

    Bill Middleton

    Ted Miller

    Yuri Nikiforov

    Martha Pitman

    Celeste Powers

    Yolanda Oertel

    Steve Raab

    Greg Randolph

    Juan Rosai

    Leslie Scoutt

    Mary Sidawy

    Philippe Vielh

    Jerry Waisman

    Helen Wang

    Sam Wells

    Matt White

    The Bethesda System for Reporting Thyroid

    Cytopathology: Past, Present and Future

    (ICC, Yokohama May-June, 2016)

    Moderators – Syed Z. Ali, Philippe Vielh, (Ed Cibas)

    Group Leaders - William C. Faquin, Marc Pusztaszeri, Diana Rossi

    Contributors - Erik K. Alexander, Manon Auger, Zubair W. Baloch,

    Justin A. Bishop, Massimo Bongiovanni, Ashish Chandra,

    Béatrix Cochand-Priollet, David S. Cooper, Barbara A. Crothers,

    Tarik M. Elsheikh, Guido Fadda, William C. Faquin, Armando C. Filie, Pinar Firat, Mary C. Frates, Hossein Gharib, Michael R.

    Henry, SoonWon Hong, Jeffrey F. Krane, Kennichi Kakudo,

    Lester J. Layfield, Virginia A. LiVolsi, Claire W. Michael, Ritu

    Nayar, Michiya Nishino, Martha B. Pitman, Celeste N. Powers,

    Gregory W. Randolph, Andrew A. Renshaw, Miguel A. Sanchez,

    Fernando Schmitt, Vinod Shidham, Mary K. Sidawy,

    Gregg A. Staerkel, Edward B. Stelow, Paul A. VanderLaan, William H. Westra, Grace C. H. Yang, Matthew A. Zarka

    TBSRTC 2017

  • 11/19/2019


    TBSRTC 2017 - Probabilistic Approach

    and Relationship to Clinical Algorithms

    ROM (%) Management

    Nondiagnostic (1-4) 5-10 Repeat FNA with U/S

    Benign (0-3) 0-3 Follow-up

    AUS/FLUS (10-15) ~10-30 Repeat FNA, molec

    testing or lobectomy

    SFN/FN (15-30) 25-40 Molec testing, lobectomy

    SFM (60-75) 50-75 Near-total thyroidectomy

    or lobectomy

    Malignant (97-99) 97-99 Near-total thyroidectomy

    or lobectomy*

    The Journey from Bethesda to

    Paris and Beyond

  • 11/19/2019


     Three Hopkins Articles

     18th International Congress of Cytology - Paris

     American Society of Cytopathology - Orlando

     “The Paris System for Reporting Urinary Tract Cytology”

    2013 - Year of Urinary Tract


     A review of reporting systems and terminology for urine cytology. Owens CL, Vandenbussche CJ, Burroughs FH, Rosenthal DL.

    Cancer Cytopathol. 2013 Jan;121(1):9-14

     The Johns Hopkins Hospital template for urologic cytology samples: part I -creating the template. Rosenthal DL, Vandenbussche CJ, Burroughs FH,

    Sathiyamoorthy S, Guan H, Owens C. Cancer Cytopathol. 2013 Jan;121(1):15-20

     The Johns Hopkins Hospital template for urologic cytology samples: parts II and III: improving the predictability of indeterm inate

    results in urinary cytologic samples: an outcomes and cytomorphologic study. VandenBussche CJ, Sathiyamoorthy S,

    Owens CL, Burroughs FH, Rosenthal DL, Guan H. Cancer Cytopathol. 2013 Jan;121(1):21-8

    Dotty L. Rosenthal Philippe Vielh

    The Johns Hopkins

    Template for Urothelial

    Cytodiagnostic Categories

     No urothelial atypia/malignancy (NUAM)

     Urothelial carcinoma (specify)

     High grade (HGUC)

     Low grade (LGUC)

     Atypical urothelial cells of uncertain significance (AUC-US)

     Atypical urothelial cells, cannot exclude high grade urothelial carcinoma (AUC-H)

     Other________________________

    • 18th International Congress of Cytology, Paris, May, 2013 • “Paris Group” – All participants of two Urine Cytology Symposia

    • Outline of the Paris System for Reporting Urinary Cytology that is based on consensus, wide participation and evidence

    • Ultimate goal – detection of HGUC

    • Sponsorship by the ASC and IAC

    • Numerous face-to-face meetings

    Orlando, November 2013

    ASC, 61st Annual Meeting

  • 11/19/2019


    Create a Urinary Cytology Diagnostic/Reporting System

    that is -

     Highly reliable as a non-invasive tool to determine those

    patients who need immediate cystoscopy vs. those who can

    be followed at an interval based upon risk stratification of

    their diagnostic category

     Evidence-based involving cytopathologi