27/08/2019

WHAT SHOULD BE THE AIM OF ANY

THE BETHESDA SYSTEM FOR CLASSIFICATION/REPORTING SYSTEM?
REPORTING THYROID
CYTOPATHOLOGY 1-better communication between pathologists and oncologists
2nd edition 2-better patient management

SULE CANBERK, MD, MIAC

“Cancer signaling & metabolism research group” Porto, Portugal

Well-established categories by
1 Cancer Signalling and Metabolism Group - Instituto de Patologia Clear recommendations for -High diagnostic power Reproducibility
e Imunologia Molecular da Universidade do Porto (Ipatimup), -Definition
each category -High screening power in -especially in
2 Instituto de Investigação e Inovação em Saúde da Universidade -ROM
do Porto (i3S) undetermined categories undetermined categories
-benchmark of each category

Thyroid cytology
Cyst fluid only
Reduce the
cases in ND
category

-AUS/FLUS
Diagnose L -FN/SFN
-SFM I-NONDIAGNOSTIC/
UNSATISFACTORY CATEGORY
Insufficient for
diagnosis Virtually acellular specimen
J
• These terms are synonymous

BENIGN MALIGNANT • The laboratory should choose the

one it prefers
Other (obscuring blood, clotting
artifact, drying artefact, etc.)

Reduce false negative ratio Reduce false positive ratio

Ø ADEQUACY CRITERIA:
• High quality specimens require: -Minimum of six groups of well-visualized follicular cells Ø ROM-5-10%
Ø REPEAT FNA UNDER US
• Proficient collection -with at least ten cells per group GUIDANCE
• excellent slide preparation -preferably on a single slide Ø Annual benchmark <10%

• processing
• staining • Exceptions:
WHY ND CATEGORY • Solid nodules with cytologic atypia
• Cellularity : • Solid nodules with inflammation
EXIST? • Colloid nodules
• Is dependent not only to on the
technique of the aspirator

• but also, on the inherent nature of

the lesion

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15.2% of initial FNAs

defined as ND and 4.7% of
the ND nodules showing Nodular Goiter Ø ROM-0-3%
malignancy.

Hyperplastic (adenomatoid) nodules

II-BENIGN Colloid nodules

CATEGORY
Nodules in Graves’ disease

BENIGN FOLLICULAR NODULE

• Is the most commonly
encountered entity of thyroid Thyroiditis
The findings of the present study showed that thyroid FNAs • Encompasses a group of benign
that were performed by a core group of specialists under lesions
ultrasound guidance with on-site evaluation were all Uncommon subset of M acrofollicular
“quantitatively” ND. However, for institutions where the
“qualitative” ND samples yield a significant clinical problem, follicular adenomas Normofollicular
as ATA guidelines were also referred, mutational analysis
could aid in patient management

Ø CRITERIA
Benign hyperplasia/ solitary hyperplastic nodules/ Cellular aspirates,
COLLOID •LOOSE
•WATERY
long endothelial formations

Multinodular goiter, Hashimoto thyroiditis, toxic goiter

FOLLICULAR CELLS •ISOLATED
•HONEYCOMB

•Hürthle cells
•Microfollicles
EXTRAS
P atte rn atyp ia
•Papillary hyperplasia
•Overlapping N u cle ar atyp ia
•Nuclear atypia

PATTERN ATYPIA IN BENIGN ENTITIES

•DOI: 10.1159/000353823

Nuclear pleomorphism, large nucleus, hyperchromasia/ hypochromasia,

prominent nucleoli, occasional grooves, INCI like formations

INCI: What was

Long-term hypothyroidism, toxic multinodular goiter, post therapy Graves’ it, again?
disease, previous FNA effects, dishormonogenetic goiter, drying artefact

The pseudoinclusions (INCI) in PTC are large and occupy more

than 50% of the nuclear area and are more optically clear than
the surrounding nuclear chromatin
NUCLEAR ATYPIA IN BENIGN ENTITIES www.papsociety.org

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ATYPIA OF UNDETERMINED
SIGNIFICANCE (AUS);
(NUCLEAR ATYPIA) This category is reserved for specimens that contain cells with
architectural and/or nuclear atypia that is not sufficient to be classified
as SFM or M categories

III- FOLLICULAR LESION OF

UNDETERMINED
AUS/FLUS; SIGNIFICANCE;
The atypia is more marked that can be ascribed confidently to benign
changes.
CATEGORY (ARCHITECTURAL ATYPIA)

• Only 1 term should be used either

AUS or FLUS
• it is suggested to add a note describing the pattern of the
lesion
• Nuclear atypia,
Highest ROM HOW MUCH ATYPIA? WE JUST MENTIONED BOTH
• Pattern atypia, NUCLEAR AND PATTERN ATYPIA IN BENIGN CATEGORY!!!
• Hürthle cells,
• NOS (not other wise specified)
Lowest ROM

Ø ROM 10-30%
Ø REPEAT FNA ,
MOLECULAR TESTS

AUS/ FLUS OR LOBECTOMY

New benchmark-10%

• This shouldn’t be a ‘’first solution’’ category…but ‘’Last solution’’ category

• This shouldn’t be‘’i don’t have any idea’’ or‘’i am being cautious’’ category but ‘’i
am sensing’’ category
• The factors that may cause unnecessary AUS/FLUS rates
• Medications (anti-coagulants, anti-thyroid drugs (Thionamides),
• Thyroiditis (Sclerotic-fibrosing variant)
• Prior external beam RT or radioactive iodine therapy

The samples should be at least

“moderately cellular”

Follicular lesion or follicular proliferation

Predominant of microfollicles or
significant cell crowding

• Nodular hyperplasia (Nodular Goiter)

• Follicular adenoma
• Follicular variant of papillary carcinoma
IV-Follicular • Follicular carcinoma
Colloid is scant or absent

Neoplasm/Suspicious
for a follicular
• NIFTP
Ø CRITERIA *Cases with mild nuclear features (increased
nuclear size, nuclear contour irregularity,
and/or chromatin clearing) of PTC and

neoplasm This category is a “SCREENING TEST”-selecting for Rare/mild nuclear atypia

*without presence of true papillae and INCI

surgery those nodules with a greater probability should be signed with a note, saying: NIFTP
is included
of malignancy
Sparsely cellular aspirates are out
of this category, could be AUS or
FLUS.
Only 1 term should be used either SFN or FN
Exclusion criteria

Cases with suspicious or definitive

nuclear features for PTC are out of
this category, could be SFM or M .

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Ø ROM 25-40%
Ø MOLECULAR TESTS
OR LOBECTOMY
WHAT IS MICROFOLLICLE?

• Crowded, flat groups of less than 15 follicular cells arranged in a circle that at least
2/3 complete
• Microfollicles tend to be relatively uniform in size
• Trabeculae –overlapping cells in ribbon form also can be seen in the lesions that
are included to this category

Ø ROM 65-75%
Ø MOLECULAR TESTS
OR LOBECTOMY or
Ø 1-6.3% of total Very heterogenous category SUBTOTAL
FNA cases
Suspicious for malignancy category THYROIDECTOMY

V-Suspicious Some cytomorphologic features • Suspicious for papillary thyroid carcinoma

raise a strong suspicion of
for malignancy malignancy but not sufficient for a
category conclusive diagnosis
• Due to the possibility of NIFTP, some cases may require an optional note to suggest lobectomy
• Suspicious for medullary thyroid carcinoma
• Serum calcitonin level
• IHC (when CB is available)

• Suspicious for malignant thyroid lymphoma

Problems in this category • Recommendation to repeat FNA with flow cytometry
Suboptimal sampling • Suspicious for metastatic cancer
Suboptimal cellular preservation Specimens that are suspicious for a
Unusual variants of PTC or MTC follicular and Hürthle cell neoplasm • Clinical history
• IHC
Overlapping cytomorphologic are excluded from this category
features of other thyroid lesions

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Ø ROM 65-75%
Ø MOLECULAR TESTS
Suspicious for malignancy category OR LOBECTOMY or
SUBTOTAL Although several nuclear alterations
-Patterns of suspicious for PTC THYROIDECTOMY
are characteristic, none of them is
diagnostic of PTC in isolation or low
• PATTERN A
frequency
• Patchy nuclear changes pattern VI-Malignant
• PATTERN B
• Incomplete nuclear changes pattern Category The minimum criteria and number
• PATTERN C
• Sparsely cellular specimen pattern of neoplastic cells necessary for an
• PATTERN D Ø ROM 97-99%
Ø Implies 1-6% false unequivocal diagnosis are uncertain
• Cystic degeneration pattern positive rate
Ø 5% of all thyroid FNAs,
and probably not definable, either
majority is PTC cytologically or histopathologically.

Malignant category

• Papillary thyroid carcinoma

• Due to the possibility of NIFTP, some cases may require an optional note to suggest lobectomy
• Medullary thyroid carcinoma
• Poorly differentiated thyroid carcinoma
• Anaplastic thyroid carcinoma
• Lymphoma
• Metastatic cancers
• Others