Reporting thyroid fine needle aspiration by the bethesda system

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The Bethesda system of reporting Thyroid Cytopathology Presentation by Dr. Monika Nema

Dr. Monika Nema

Introduction

Fine needle aspiration is the removal of a sample of cells using a fine needle from a suspicious mass for diagnostic purposes.

Thyroid FNA is a currently growth area in pathology. One of the most commonly practiced areas in non gynecologic cytopathology.Dr. Monika Nema

Impact of Thyroid FNABest initial test for evaluating thyroid nodules.Accurate, simple, safe, cost effective, specific and sensitive.Decreased the number of patients requiring thyroid surgery .Decreased the cost of managing thyroid lesions .Increased the yield of finding thyroid malignancies at surgery.Dr. Monika Nema

Pathologists dont understand clinicians and they dont understand us

Dr. Monika Nema

However, there was never an effective linkage between these clinical management plans and thyroid FNA reporting, thus undermining the clinical utility of cytopathologic diagnoses.

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NCI Thyroid Fine Needle Aspiration State of the Science Conference

Dr. Monika Nema

In order to bridge this gap of communication, the National Cancer Institute (NCI) hosted the NCI Thyroid Fine Needle Aspiration State of the ScienceConference on 2007 in Bethesda. One of the recommendations endorsed by this program was the establishmentof a six-tiered diagnostic classification system5

Dr. Monika Nema

Dr. Monika Nema

Format of the ReportFor clarity of communication, BSRTC recommends that each thyroid FNA report begin with a general diagnostic category.For some of the general categories, some degree of subcategorization can be informative. Additional descriptive comments (beyond such subcategorization) are optional and left to the discretion of the cytopathologist.Notes and recommendations are not required but can be useful in certain circumstances.Dr. Monika Nema

Nondiagnostic/UnsatisfactoryDr. Monika Nema

Nondiagnostic/UnsatisfactoryA specimen is considered Nondiagnostic or Unsatisfactory if it fails to meet the adequacy criteria.

Dr. Monika Nema

Criteria for Adequacy

A specimen should display at least 6 groups of follicular cells, with each group composed of at least 10 cells preferably on a single slide.

There are 3 exceptions in which a cytodiagnosis of a thyroid lesion may be made in the absence of an adequate number of follicular epithelial cells:

A diagnosis of thyroiditis may be made if abundant inflammatory cells are present.

A benign colloid nodule may be diagnosed if abundant thick colloid is present as the presence of abundant colloid reliably identifies most benign processes.

A diagnosis of atypia or malignancy if atypical or malignant cells are identified.

Dr. Monika Nema

Extensive air-drying artifact

Extensive clotting artifactsDr. Monika Nema

Nondiagnostic/UnsatisfactoryCyst fluid, with or without histiocytes, and fewer than six groups of ten benign follicular cells.The risk of malignancy is low for these lesions if they are simple and under 3 cm.However, the possibility of a neoplastic lesion cannot be excluded.

Dr. Monika Nema

Nondiagnostic/UnsatisfactoryReporting pattern:-Example 1 (cystic lesion):NONDIAGNOSTIC.Cyst fluid only.Specimen processed and examined, but nondiagnostic because the specimen consists almost exclusively of histiocytes; interpretation is limited by insufficient follicular cells and/or colloid. Note: Recommend correlation with cyst size and complexity on ultrasound to assist with further management of the lesion.

Example 2:UNSATISFACTORY.Specimen processed and examined, but unsatisfactory due to poor fixation and preservation.Note: A repeat aspiration should be considered if clinically indicated.Dr. Monika Nema

Benign thyroid lesionDr. Monika Nema

Benign thyroid lesionSince most thyroid nodules are benign, a benign result is the most common FNA interpretation.Nodular goiter (NG) is the most commonly sampled lesion by FNA.Lymphocytic (Hashimotos) thyroiditis is the most commonly encountered form of thyroiditis.Dr. Monika Nema

Benign follicular noduleApplies to a cytologic sample that is adequate for evaluation and consists predominantly of colloid and benign-appearing follicular cells in varying proportions.Dr. Monika Nema

Benign Follicular NoduleCriteria Specimens are sparsely to moderately cellular.Colloid is viscous, shiny, and light yellow or gold in color (resembling honey or varnish) on gross examination. It is dark blue-violet-magenta with Romanowsky-type stains and green to orange-pink with the Papanicolaou stain . It may be thin or thick in texture.Dr. Monika Nema

Watery colloid has thin membrane/cellophane coating appearance

Thick colloid stained glass cracking appearance

honeycomb-like arrangement of follicular cells

Three-dimensional, variably sized balls/spheres are admixed with flat sheetsDr. Monika Nema

Follicular cell nuclei are dark, round to oval and show a uniformly granular chromatin pattern

Follicular cells may appear shrunken and degenerated when associated with abundant colloid

Minimal nuclear overlapping and crowding can occurDr. Monika Nema

Graves DiseaseAn autoimmune diffuse hyperplastic thyroid disorder.Commonly seen in middle-aged women .Usually diagnosed clinically due to hyperthyroidism. Do not require FNA for diagnosis.Dr. Monika Nema

Graves DiseaseAspirates similar features to non-Graves BFNs.Lymphocytes and oncocytes may be seen in the background. Follicular cells are arranged in flat sheets and loosely cohesive groups, with abundant delicate, foamy cytoplasm. Nuclei are often enlarged, vesicular, and show prominent nucleoli. Few microfollicles may be observed.

Dr. Monika Nema

Graves Disease

Stimulated follicular cells in Graves disease showing abundant cytoplasm and intracytoplasmic accumulation of thyroglobulin producing a pattern reminiscent of flameDr. Monika Nema

Lymphocytic (Hashimotos) ThyroiditisMost commonly affects middle-aged women Patients often develop diffuse thyroid enlargement.The designation Consistent with lymphocytic (Hashimotos) thyroiditis applies to a cytologic sample composed of many polymorphic lymphoid cells associated with Hrthle cells.Dr. Monika Nema

Hrthle cell

Also called Askanazy cell, oxyphilic cell, and oncocyte.

Defined morphologically as a thyroid follicular cell with an abundance of finely granular cytoplasm.

Most Hrthle cells have an enlarged, round to oval nucleus, and some have a prominent nucleolus.

Considered metaplastic, non-neoplastic follicular cells in reactive/hyperplastic conditions like lymphocytic (Hashimotos) thyroiditis (LT) and multinodular goiter (MNG).Dr. Monika Nema

Lymphocytic (Hashimotos) Thyroiditis

Hypercellular.

Polymorphic lymphoid population .

Hrthle cells.Dr. Monika Nema

Granulomatous (subacute, de Quervains)ThyroiditisSelf-limited inflammatory condition of the thyroid.

CriteriaThe cellularity is variable and depends on the stage of disease.Clusters of epithelioid histiocytes, i.e., granulomas, are present along with many multinucleated giant cells.The early stage demonstrates many neutrophils and eosinophils, similar to acute thyroiditis.In later stages the smears are hypocellular. They show giant cells surrounding and engulfing colloid , epithelioid cells, lymphocytes, macrophages, and scant degenerated follicular cells.

Dr. Monika Nema

Granulomatous (subacute, de Quervains)Thyroiditis

Dr. Monika Nema

Acute Thyroiditis A rare infectious condition of the thyroid.More commonly seen in immunocompromised patients.

CriteriaNumerous neutrophils are associated with necrosis, fibrin, macrophages, and blood.There are scant reactive follicular cells and limited to absent colloid.Bacterial or fungal organisms are occasionally seen in the background, especially in immunocompromised patients. Cultures and special stains for organisms may be helpful in these situations.Dr. Monika Nema

Acute Thyroiditis

There are numerous neutrophils, macrophages, and inflammatory debrisDr. Monika Nema

Riedels Thyroiditis/DiseaseThe rarest form of thyroiditis .Results in progressive fibrosis of the thyroid gland with extension into the soft tissues of the neck.CriteriaThe thyroid gland feels very firm on palpation.The preparations are often acellular.Collagen strands and bland spindle cells may be present.There are rare chronic inflammatory cells.Colloid and follicular cells are usually absent.Dr. Monika Nema

BenignREPORTING PATTERNThe general term Benign may be utilized in reporting.A more specific term may be used, depending on the associated clinical presentation.Example 1:BENIGN. Benign-appearing follicular cells, colloid, and occasional Hrthle cells consistent with a benign follicular nodule.

Example 2:BENIGN. Numerous polymorphic lymphoid cells and scattered Hrthle cells.NOTE: The findings are consistent with lymphocytic (Hashimotos)thyroiditis in the proper clinical setting.Dr. Monika Nema

Atypia of Undetermined Significance/Follicular Lesionof Undetermined SignificanceDr. Monika Nema

Atypia of Undetermined Significance/Follicular Lesionof Undetermined SignificanceSpecimens that contain cells (follicular, lymphoid, or other) with architectural and/or nuclear atypia that is not sufficient to be classified as suspicious for a follicular neoplasm, suspicious for malignancy, or malignant.Dr. Monika Nema

Predominance of microfollicles are seen in a sparsely cellular aspirate with scant colloid.

Interpretation of follicular cell atypia is