REVIEW ARTICLE
Approach to FNA of Thyroid Gland Cysts
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Esther Diana Rossi, MD, PhD,* Pietro Tralongo, MD,*
Vincenzo Fiorentino, MD,* Mariangela Curatolo, BD,* Carmine Bruno, MD,†
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Carmen De Crea, MD,‡ Marco Raffaelli, MD,‡ Alfredo Pontecorvi, MD,†
and Luigi Maria Larocca, MD*
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Abstract: Fine needle aspiration is a well-known procedure for the
diagnosis and management of thyroid lesions, representing the first
diagnostic tool for the definition of their nature. In clinical practice,
a thyroid nodule can be classified as solid, cystic, and partially cystic
based on its internal components. Different thyroid imaging
reporting systems and cytologic diagnostic systems have focused
their attention on solid nodules, which are more frequently linked
with a malignant outcome. In fact, numerous papers demonstrated
that nodules with microcalcifications, a taller-than-wide shape,
hypoechogeneity, and irregular margins, are more likely to be
malignant on histology. Nevertheless, according to the literature,
the risk of malignancy in a partially cystic thyroid nodule ranges
between 3.3 and 17-5%, including, for instance, the possible diag-
nosis of a cystic papillary thyroid carcinoma and other malignant
entities. Therefore, in the current review article, we are going to
discuss the approach to thyroid cystic lesions on fine needle aspi-
ration cytology.
Key Words: thyroid lesions, fine-needle aspiration cytology, cystic
lesions, malignant cystic lesions
(Adv Anat Pathol 2022;29:358–364)
ine needle aspiration (FNA) is the first and most
F important diagnostic tool in the evaluation of thyroid
lesions.1–4 In fact it is a rapid and safe procedure with very
few complications and it is commonly used in conjunction
with both the clinical and radiologic findings. The majority
of thyroid lesions are amenable to evaluation by FNA
especially under ultrasound guidance. Thyroid FNA is able
to discriminate between benign and malignant lesions in
over than 80% of the cases, so that it provides useful
information for the correct clinical and/or surgical treatment
of the thyroid nodules.5–7 The majority of ultrasound and
diagnostic classification systems have paid attention mainly
on solid lesions, emphasizing that some ultrasound features
are more commonly associated with a malignant
diagnosis.3,8–14 Among them, there is a unanimous agree-
ment for features as: hypoechogenity, spiculated margins,
From the *Division of Anatomic Pathology and Histology; †Division of
Endocrinology; and ‡Division of Endocrine-Surgery-Fondazione
Policlinico Universitario“Agostino Gemelli”-IRCCS, Rome Italy
Fondazione Policlinico Universitario “Agostino Gemelli”-IRCCS,
Rome, Italy.
The authors have no funding or conflicts of interest to disclose.
Reprints: Esther Diana Rossi, MD, PhD, MIAC - Division of Anatomic
Pathology and Histology – Fondazione Policlinico “Agostino
Gemelli” - IRCCS, Università Cattolica del Sacro Cuore, – Largo
Francesco Vito, 1 – 00168 Rome, Italy (e-mail: esther.
rossi@policlinicogemelli.it).
All figures can be viewed online in color at www.anatomicpathology.com.
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358 | www.anatomicpathology.com Adv Anat Pathol  Volume 29, Number 6, November 2022
Copyright r 2022 Wolters Kluwer Health, Inc. All rights reserved.
and taller-than-wide shape. Apart from these evidences,
cystic thyroid lesions are commonly detected on US evalu-
ation, showing a typical complete or partial anechoic pat-
tern, defined cytologically and histologically by marked
follicular dilatation, epithelial flattering, and colloid
material.11–14
The majority of these lesions have a large cystic com-
ponent, defining a pattern of partially cystic nodules, mostly
as a result from a degenerative process arising in solid
lesions. The occurence of a true cyst is rare.
Despite the frequent benign nature of the cystic nodule,
these lesions are challenging because the abundance of cyst
fluid may not exclude a malignancy when the number of
epithelial cells is scant. Specifically, both benign and
malignant neoplasms can be partially or completely cystic,
as cystic features are commonly encountered in follicular
adenoma/carcinoma and papillary thyroid carcinomas.4 In
fact, cystic changes in themselves do not exclude a malig-
nant lesion and the US finding of a cystic lesion is not
always synonymous of benign outcome. As predictable,
false-negative results are an important concern among
cytopathologists. Furthermore, some recent studies have
reported that the frequency of malignancy in cystic or par-
tially cystic thyroid nodules is similar to that of solid
nodules.15–17
There is a variable risk of malignancy (ROM) among
the mixed cystic nodules, ranging from 3.3% and 17-5%,
including for instance the possible diagnosis of a cystic
papillary thyroid carcinoma (PTC) and other malignant
entities.15–20 To note, these figures have the evident bias of
the histologic correlation, focusing on those cases, solid or
cystic, with a more evident suspicion for a malignant nature.
This assessment is also emphasized by the American Thy-
roid Association (ATA) guidelines, which recommend an
FNA in cases of cystic thyroid nodules with suspicious US
features or nodules > 1.5 cm.21
Among the published series, Garcia-Pascual docu-
mented an 11.1% risk of malignancy (ROM) among cystic
thyroid lesions classified as non-diagnostic on FNA cytol-
ogy (FNAC).22 By the way, this figure was even higher
among other authors as reported by Bellantone et al, who
found a 17.6% malignancy rate among cystic lesions.23
Nevertheless in a review paper by Shi et all, the incidence of
malignancy in partially cystic nodules varied between 5%
and 45.8% confirming that it is challenging to recognize the
risk factors for malignancy in cystic lesions.24 In contrast,
some other authors reported lower ROM.17–20 In a study by
Li et al, the ROM was 4.6%, while Frates et al assessed their
ROM at 7%.17,18 A large series of 1056 thyroid FNAC by
Lee et al confirmed the low rate of malignancy at around
5.4%.19
 Adv Anat Pathol  Volume 29, Number 6, November 2022
TABLE 1. Cytologic Criteria for Nondiagnostic Cystic Lesions (According to the Bethesda Thyroid System)
Morphologic Criteria
Nondiagnostic cystic It contains only macrophages with a noncohesive pattern,
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lesions characterized by abundant cytoplasm with brown hemosiderin
pigment in some of them
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Herein we aimed to identify the US risk factor and the
cytologic features able to discriminate benign versus
malignant cystic thyroid nodules so that a standard
approach can be followed for these lesions
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CYSTIC LESIONS IN CYTOLOGIC
CLASSIFICATION SYSTEMS
The different cytologic classification systems have
introduced and defined the possibility to diagnose cystic
lesions in thyroid FNAC.3,8–10,25,26 Despite the fact that
most of thyroid cystic lesions are benign, they are classified,
when entirely cystic, in the category of Non-diagnostic
lesions.3,8–10 This is mostly because the presence of only
macrophages and lack of thyrocytes cannot be diagnosed in
other categories. The Bethesda system underlined that the
risk of malignancy is low for these lesions if they are simple
and under 3cm.3 On the other hand, it is well-known that
younger patients with only cystic fluid have been shown to
have a slightly higher risk of malignancy, primarily papil-
lary cystic carcinoma. For this reason, these samples are
diagnosed as ND followed by the subcategory “cyst fluid
only”, for which specific management are clearly stated by
the Bethesda system.3 In detail, TBSRTC offers a specific
example of the sample report for that situation. The authors
suggested to using the Non-diagnostic category, according
to specific criteria as the lack of follicular cells and the
presence of only histiocytes (Table 1). A note including also
some recommendations such as a correlation with the cyst
size and complexity on ultrasound are necessary for the
further management of this type of lesions.3 In this regard,
the cytologic diagnosis should be always evaluated in line
with the proper clinical setting (eg, ultrasound evidence of a
simple, unilocular cyst), so that these specimens may be
considered clinically adequate, even though they are
reported as ND.
In addition, the Bethesda system suggests the possible
diagnosis of “colloid cyst” when the specimen is only com-
posed of abundant colloid material, which is satisfactory for
the diagnosis.3 In this evidence, the support of the echo-
graphic pattern is essential for a cytologic diagnosis.
Similar considerations are also discussed and under-
lined by other classification systems, including the British
system, the Australasian and the Italian systems.3,8–10,25–27
These latter systems also allocate cystic lesions into the ND
category, with a specific definition of their morphologic
features.
To note, the simple aspiration is also the initial man-
agement for both the diagnosis and the cyst volume reduc-
tion, which is higher for completely cystic lesions rather than
partially cystic nodules (LIM). Moreover, a simple drainage
of the cyst is an ineffective treatment as the recurrence rate is
approximately 80%.14–17
From a cytologic point of view we can differentiate a
completely cystic from a partially cystic thyroid nodules. In
a completely cystic lesion, the morphologic criteria show
cyst fluid and hemosiderin-laden macrophages and some
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Thyroid Gland Cysts
Management
Reaspiration necessary only if
ultrasound features are suspicious
watery colloids without follicular cells (Fig. 1). A partially
cystic thyroid nodule show sheet or aggregates of thyrocytes
(with benign and/or malignant features-according to the
nature of the lesion) admixed with a background composed
of hemosiderin-laden macrophages (Figs. 2A and B).
CYSTIC LESIONS IN ULTRASOUND
CLASSSIFICATION SYSTEMS
The prevalence of cancer in completely and/or partially
cystic and cystic thyroid nodules is variable but low in
several series, so that the best approach is to be able to
identify nodules with a higher risk of malignancy based on
their own ultrasound features,15–23 (Fig. 3). The US criteria
for evaluating cystic and partially cystic nodules are differ-
ent from those used for solid nodules. Nevertheless, the
presence of microcalcifications, hypoechogeneicity, and
eccentric solid components in partially cystic nodules are
likely to be correlated with a malignant outcome. In fact, the
eccentric location of the solid component, protruding into
the cystic cavity has been reported as a malignant finding.
Furthermore, the lack of regular and non-smooth margins is
an additional malignant suggestion. The detection of
microcalcification into the wall or the solid component of
either a partially cystic or a cystic nodule is highly specific
con a papillary thyroid carcinoma. The evidence of a color
Doppler flow signal in the nodule rather than at the
periphery is frequently suggestive of malignancy.
Several thyroid nodule US classification systems have
been published.10–14 Some of them highlight only simple US
patterns, while others rely on the presence of multiple US
features to categorize thyroid nodules. In 2009, Horvath
et al proposed a Thyroid Imaging, Reporting and Data
FIGURE 1. A completely cystic thyroid lesion. The nodule was
3 cm in size and an fine needle aspiration cytology was per-
formed. The cytological evaluation, with liquid based cytology-
LBC, showed fibrin-hemorragic debris and a background com-
posed of pigmented macrophages (LBC, ×40). LBC indicates liq-
uid based cytology.
www.anatomicpathology.com | 359
 Rossi et al
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FIGURE 2. A, B, A partially cystic nodule. The nodule showed few US suspicion features so that an fine needle aspiration cytology was
performed with LBC. The cytological findings show few clusters of small and benign follicular thyroid epithelial cells with numerous
macrophages diagnosed as a benign partially cystic adenomatous nodule (LBC-20X, and ×40). LBC indicates liquid based cytology.
Please see this image in color online.
System (TIRADS),28 further modified by Kwak et al.13 It
was based on the American College of radiology’s breast
imaging reporting and data system (BI-RADS). It was
accepted and then proposed by the American College of
Radiology (ACR), which is based upon the distribution of
US features in five categories (composition, echogenicity,
shape, margin, and echogenic foci).29 According to the
system, cystic lesions or lesions that are almost completely
cystic are benign and no further points will be added
TI-RADS 1). Similarly, in the other US classification
systems,10–14 cystic and partially cystic lesions are scored as
benign.
Several studies analyzed the US features and ROM for
cystic lesions, combining them with the cytologic classi-
fication systems, mostly with the Bethesda thyroid
system.30–33
In a series of 1342 thyroid lesions by Li et al, 281
(20.7%) cases were partially cystic lesions with fewer than
5% malignant outcome. The evaluation of the US features
demonstrated 84.6% sensitivity, 84% specificity and
FIGURE 3. Ultrasound evaluation of a benign cystic thyroid
nodule. Details pf the cystic component are evaluated during the
US exam leading to the decision of performing an fine needle
aspiration.
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Adv Anat Pathol  Volume 29, Number 6, November 2022
diagnostic accuracy, confirming that the US characteristics
can be used to prioritize nodules for FNAC.17
Kim et al compared 26 patients with benign cystic
nodules showing marked US hypoechogenicity and 38
patients with marked US hypoechogenicity in the US sus-
picious for PTC.34 While the authors did not find any dif-
ference in nodular size, margin, echogenic dot and vascu-
larity, they documented significant differences in the
nodular shape between the 2 groups with a lower prevalence
of taller than wide in the benign cystic group (11.5% vs.
39.5%, P = 0.022).
Park et all compared the US characteristics of 22 sur-
gically confirmed partially cystic papillary carcinomas, and
compared them with those of 80 benign partially cystic
nodules.35 They assessed that malignant partially cystic
thyroid nodules had a taller-than-wide shape (100%,
P < 0.001) and spiculated or microlobulated margin (58.3%,
P = 0.003). Other additional features linked with malig-
nancy are represented by eccentric configuration (68.0%,
P < 0.001), non-smooth margin (81.3%, P < 0.001), hypo-
echogenecity (30.0%, P < 0.042), and microcalcification
(89.5%, P < 0.001).
In another study, Peng et al discussed the diagnostic
accuracy of US in differentiating papillary thyroid micro-
carcinomas (PTMCs) from cystic thyroid nodules mimick-
ing malignancy, in nodules smaller than 10 mm in
diameter.36 The series included 162 cystic lesions and 150
PTMCs evaluated for US parameters. They concluded that
shape, rim calcification, and vascularity are valid criteria to
distinguish them.
Koo et al compared the US features of 33 cystic nod-
ules, which can mimic malignancies, after fine-needle aspi-
ration (FNA) with 47 malignant nodules.37 They reported
that all the cystic lesions were benign histology even though
several of their cystic nodules after aspiration were similar to
PTCs in their sonographic findings. Nevertheless the former
had shadowing and a halo (85% vs. 21%; P < 0.0001).
Lee et al included 392 partially cystic nodules which
were subclassified into 3 groups based on the amount of the
solid portion: (1) nodules in which the solid portion was
<50%; (2) nodules with the solid portion > or = 50%; and
group 3 included mixed echoic (spongy) nodules.19 The
 Adv Anat Pathol  Volume 29, Number 6, November 2022
authors also analyzed the features of the solid component,
its position, shape, margin, echogenicity, and micro/mac-
rocalcifications. Three hundred forty cases had adequate
material for a diagnosis, including 18 malignant and 317
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benign lesions with a malignancy rate of 5.4%. Considering
the 3 different subgroups, the highest malignant rate was
found in group 2, while it was 0 in group 3. Furthermore,
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the more accurate features for a malignant diagnosis were
represented by the eccentric location of the solid component
(P = 0.007) and microcalcifications (P < 0.001).
Lin et al38 studied a series of 6219 thyroid lesions
including 1983 cases with cystic nodules and 4236 solid masses.
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After FNAC, 506 of the patients with solid masses (11.9%)
underwent surgical treatment, compared with 143 of those with
cystic lesions (7.2%). They also evaluated the malignant rate,
which resulted in 29.8% for the solid group and 9.1% for the
cystic lesions. This data confirmed that the diagnostic accuracy
of FNAC in cystic masses after ultrasonographic examination
resembled that in solid thyroid nodules.
Liu et al in a study of 94 partially cystic nodules dis-
cussed the sonographic features that can be predictive evi-
dence of malignancy and they assessed the diagnostic effi-
cacy of these features.39 In detail, the authors demonstrated
that microcalcification, hypoechogenicity, and a solid com-
ponent ≥ 50% of the total volume were associated with
97.6% sensitivity, 32.7% specificity, 53.9% positive pre-
dictive value (PPV), and 94.4% negative predictive value
(NPV). The evaluation of these 3 parameters might be
helpful in the diagnosis of partially cystic lesions.
Ko et al studied the US features of 13 collapsing benign
cystic nodules (spontaneously or after FNAC) that dis-
tinguish such nodules from 26 malignant thyroid nodules.40
Their study included the evaluation of many US findings
such as internal content, shape, margin, echogenicity, pres-
ence of echogenic dots suggesting microcalcification and
macrocalcification, inner isoechoic rim, and low-echoic
halo. Their data confirmed that US features helpful for
differential diagnosis of CBCNs from PTMCs include
shape, margin, and the presence of an inner isoechoic rim
and a low-echoic halo.
MALIGNANT CYSTIC THYROID LESIONS
It is estimated that ~23% of the thyroid cystic lesions
are proved to be malignant41–45 (Table 2).
According to the literature, follicular neoplasms, PTC,
and medullary thyroid carcinoma (MTC) may have cystic
components, even though their scant cellularity is likely to
cause false-negative diagnosis.4
Among the malignant lesions, papillary thyroid carci-
noma (PTC) may be characterized by cystic changes more
frequently than other thyroid neoplasms4,41–45 (Fig. 4). The
FNA diagnosis of cystic thyroid lesions can be very tricky,
especially owing to low cellularity with some of these few
cells characterized by nuclear atypia and prominent nucleoli
mimicking thyroid malignancy, especially PTC. Fur-
thermore, the evidence of metaplastic squamous cells in
benign cysts can lead to a misdiagnosis of a malignant
tumor, and, to note, the histiocytoid epithelial cells in PTC
may be confused as histiocyte.41–45 Hashan et al discussed
the possibility that PTC presents rarely with aberrant fea-
tures resembling those of histiocytes in a cystic nodule.
These atypical histiocytes can be seen in cystic thyroid
lesions. Nevertheless, the morphologic features including
large cell size, pseudoinclusions, nuclear grooves, and
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Thyroid Gland Cysts
TABLE 2. Benign and Malignant Diagnoses With a Partial and/or
Complete Cystic Component
Benign Diagnoses Malignant Diagnosis
Nondiagnostic Cystic papillary thyroid carcinoma
Goiter Cystic medullary thyroid carcinoma
Thyroglossal duct cysts Atypical hitiocytoid cells
Branchial cleft cysts Any malignant entity with a cystic
component
Parathyroid cystis —
Epidermoid cysts —
multiple well-defined vacuoles, favor PTC over benign his-
tiocytes. Furthermore, immunocytochemical studies can
also be useful in confirming the diagnosis.46 A detailed
evaluation of these atypical cells is necessary to preventing
false-negative diagnosis of PTC.
In another paper, Renshaw reviewed a large series of
thyroid aspirates for specimens with unusual cells defined by
vacuolated, histocyte-like features without classic nuclear
changes of papillary carcinoma. These histiocytoid cells
were recognized in 6% of the samples analyzed. The mor-
phologic evaluation demonstrated that these cells resembled
histiocytes but were larger, more atypical, and keratin pos-
itive in the one specimen that was tested. The cells had
enlarged nuclei with abundant cytoplasm that often was
vacuolated. The awareness of their finding in thyroid FNAC
is likely to improve the accuracy of cytology.47
Although cystic colloid goiter and other cystic neo-
plasms can be easily recognized on FNAC, the possibility to
differentiate cystic PTC from cystic adenomatous nodules is
difficult because of the common features. In fact, in both
entities we might recognize foamy macrophages, atypical
histiocytes, spindle cells, squamous cells, anisonucleosis,
multinucleated giant cells, and calcification. Furthermore,
cells from PTC may show cytoplasmic hypervacuolization
and “bubble gum colloid”.
In a series by Mokhatari et al,48 including 73 cases of
cystic PTC, the authors found some peculiar features rep-
resented by small clusters with scalloped margins, cellular
swirls, and clusters with a cartwheel pattern.
FIGURE 4. A partially cystic papillary thyroid carcinoma (PTC).
The sample is composed of follicular thyroid epithelial cells
showing the nuclear features of PTC in a background with several
macrophages (LBC, 40X). LBC indicates liquid based cytology.
Please see this image in color online.
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 Rossi et al
TABLE 3. AAP cystic lesions.
Cystic thyroid lesions
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Completely cystic nodule
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Suspicious
FNAC
(if large cystic Clinical and/or
mass) surgical FU
(based on the
nodular size)
FU based on
Lin and Huang45 compared the accuracy of US and
FNAC in diagnosing cystic thyroid cancer Versus solid
thyroid cancers. They included 682 thyroid malignant
lesions subdivided as 583 (85.5%) solid masses, 80 (11.7%)
mixed masses, and 19 (2.8%) cystic masses. Among the
latter group of 19 cystic thyroid carcinoma, only 4 PTC
were diagnosed as malignant on both US and FNAC. They
concluded that the low rate of accurate diagnosis for the
cystic malignancy did not affect both the clinical staging and
the survival rates.
Henrichsen et al studied 380 thyroid nodules including
33 either partially (< 50% cystic component) or 9 exten-
sively cystic nodules ( > 50% cystic component of the nod-
ule). They concluded that 88% of thyroid cancers are solid
or with minimal (1–5%) cystic change. Only 2.5% of cancers
had a significant cystic component and they also show some
other sonographic findings worrisome for malignancy.49
MTC usually is a solid malignant lesions, even if it
rarely shows a cystic component. As reported by Fadda
et al,50 some hemorrhagic changes in medullary carcinomas,
mostly owing to presurgical FNAC, have been described.
Nevertheless, immunohistochemistry and/or serum calcito-
nin levels will help to solve the diagnostic dilemma in such
cases.3,4
Despite the fact that any malignant lesion is likely to
have a cystic component, it is rare for other malignant
lesions
OTHER CYSTIC LESIONS
Thyroglossal duct cysts, parathyroid cysts, epidermoid
cysts, branchial cleft cysts can all occur either in the thyroid
or around the thyroid (lateral midline cysts).3,4,50–52 These
entities are rare with an incidence of 0.6 to 3% for para-
thyroid cysts, 7% for thyroglossal cysts. The presence of
ciliated cells, lymphocytes, squamous, colloid, and keratin
are useful for the differential diagnosis.50–57 The presence of
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Adv Anat Pathol  Volume 29, Number 6, November 2022
Partially cystic nodule
Evaluation
of US solid Benign features
features
FNAC
FU based on
FNAC size
a water-clear fluid mostly suggests parathyroid cysts,
although a yellowish to brown cystic material is seen in
thyroid cysts/pseudocysts. To note, occasionally PTC can be
diagnosed in thyroglossal duct cysts.53–55 Furthermore, a
case report by Rumman et al described a thyroglossal
5×5 cm mixed solid and cystic mass in mid neck resulting in
a histopathological diagnosis of a poorly differentiated
carcinoma of insular type.58
MANAGEMENT OF CYSTIC LESIONS
The majority of cystic and partially cystic lesions are
asymptomatic so that the treatment is unnecessary.59–62
Nonetheless, some of them are likely to represent a palpable
mass with cosmetic problems or other complaints. To solve
these latter issues, the well-established, non-surgical treat-
ment includes a simple aspiration to reduce/eliminate the
cystic lesion and/or ethanol ablation.59–62 The former is
usually the first option for the treatment of a cystic lesion,
leading to both a diagnosis and a reduction of the cystic
volume. However, several cases have recurrences after
aspiration (from 50% to 80% of them), or if they show a
stronger viscosity difficultly aspirated with needles, US-
guided ethanol ablation has been recommended and it is
associated with good yields ranging from 68% to 97%
(58-61). The algorithm approach suggests to firstly identify
if the lesions are completely and partially cystic nodules. In
fact, based on this first discrimination, completely cystic
nodules can be clinically or surgically followed-up according
to the nodular size and symptoms. The performance of an
FNAC would result in macrophages and hemorrhagic-col-
loid debris, diagnosed in the ND category. In cases of a
partially cystic lesion, the US evaluation is the leading guide
for the further management. In fact, if there are some US
suspicious features, an FNAC should be performed fol-
lowed by clinical or surgical follow-up based on the cyto-
logic diagnosis. In cases without any evidence of suspicion
 Adv Anat Pathol  Volume 29, Number 6, November 2022
for malignancy, the decision of clinical and/or surgical fol-
low-up will be based on the nodular size and the symptoms
(Table 3).
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CONCLUSIONS
Data from literature show that the risk of malignancy
for a purely cystic nodule is minimal and estimated at <1%,
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while those with a partially cystic component should be
evaluated for the evidence of suspicious features.63,64
Because of the issues with adequacy, thyroid cysts are a
common cause of the false-negative results on FNA. The
key to evaluating FNA specimens of thyroid cysts is to
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obtain an adequate specimen containing follicular epi-
thelium, and then to assess all the components, paying
careful attention to the cytologic features of the epithelium
to exclude a possible cystic PTC.
Nonetheless, any type of thyroid lesion can undergo
cystic degeneration often as the consequences of hemor-
rhagic evolution after an FNA.
A combined evaluation of clinical, US, and cytologic
features is strongly suggested for either solid or cystic/par-
tially cystic nodules (Table 3).
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