Comparative findings of lymphocytic thyroiditis and thyroid lymphoma. This is particularly true of the follicular variant of PTC, which can be difficult to distinguish from a benign follicular nodule.28 Other PTCs may be incompletely sampled and yield only a small number of abnormal cells.29 If only 1 or 2 characteristic features of PTC are present, if they are only focal and not widespread throughout the follicular cell population, or if the sample is sparsely cellular, a malignant diagnosis cannot be made with certainty. Half of patients present with significant compression of the upper respiratory and the digestive tract in the neck, resulting in dyspnea, hoarseness, dysphagia, and pain. Therefore, in the majority of patients in the AUS/FLUS category (72%-80%) the diagnosis will be resolved by repeat FNA, although 20%-28% of them will have AUS/FLUS on the repeat aspirate and thus require surgery. Amrikachi Describing methods to: i. A: Probably, yes. The majority of the thyroid FNA specimens, in the range of 60% to 70%, are classified as benign, whereas approximately 20% to 30% fall into the 3 categories of suspicious for follicular neoplasm, suspicious for malignancy, and malignant[19]. PG J The clinical and diagnostic impact of using standard criteria of adequacy assessment and diagnostic terminology on thyroid nodule fine needle aspiration. To collect as many cells as possible from sparsely cellular urine, the specimen should have which of the following techniques applied? Royal College of Physicians. Prognosis is dismal with a mean survival of 2.5 to 6 mo and an overall 5-year survival of 0% to 14%. After the aspirate, the most expected informative component of a bone marrow workup is likely the core needle biopsy. the contents by NLM or the National Institutes of Health. Federal government websites often end in .gov or .mil. McHenry Deveci LiVolsi of value in acquiring a cellular sample, possibly due to increasing hemodilution. The risk of malignancy of AUS/FLUS was only 6%, a quite lower value than the one reported elsewhere. RA This website is intended for pathologists and laboratory personnel but not for patients. In a study by Teixeira et al[29] the overall incidence of malignancy in the FNA-biopsied nodules characterized as FLUS was 16.2%, a higher value than the suggested 5% to 15%[10,29-31]. As a library, NLM provides access to scientific literature. et al. The discs are 2 mm thick in the unprocessed state, but less thick when processed, and sometimes slightly . The cancer cells are also elongated, with a height-to-weight ratio of at least 3:1. et al. The spindle-shaped morphology of these cells is helpful in distinguishing these cells from PTC[24,34]. Statistics . VanderLaan PA, Marqusee E, Krane JF. A moderately or markedly cellular sample is composed of a virtually exclusive population of Hrthle cells, yet the clinical setting suggests a benign Hrthle cell nodule, eg. By using redundancies across components, your consultant hematopathologists may offer insights into the architecture, morphology, immunostaining, and flow cytometry profiles of any identified hematologic entity. Baloch Neutrophils are the same as WBCs, and as you know, it is normal to gave some WBCs in the urine. The general category FN/SFN is a self-sufficient interpretation; narrative comments that follow are optional. VA We thank Diane Solomon, MD, for review of the manuscript and helpful comments. Zubair W. Baloch, MD, PhD, served as chair of the Terminology and Morphologic Criteria committee. The above panel correctly identified cancer in 78.2%, whereas cytology identified 58.9% of the thyroid cancers. From each FNA pass one to three smears are prepared and fixed in alcohol for Papanicolaou staining and air dried for Giemsa staining. These indeterminate aspirates may present with architectural atypia or nuclear atypia[21]. Such changes may represent atypical but benign cyst lining cells, but a papillary carcinoma cannot be entirely excluded (ThinPrep, Papanicolaou stain). (B) A case diagnosed as DC IV (suspicious for a follicular neoplasm) shows moderately cellular specimen with abundant microfollicles (x15; scale bar, 200 m) (C-F) Architectural alterations such as microfollicles (C and D), 3-dimensional branching (E), and architectural crowding (F) are frequently observed in cases categorized as DC IV 2023 ,https://www.hematology.org/education/trainees/fellows/trainee-news/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer. The neoplastic cells show a greater cell height than the tall cell variant and lack the obvious nuclear features of PTC. 144 0 obj <>stream Maybe a routine peripheral smear caught some circulating blasts. Ravetto The project participants hope that the adoption of this flexible framework will facilitate communication among cytopathologists, endocrinologists, surgeons, radiologists, and other health care providers; facilitate cytologic-histologic correlation for thyroid diseases; facilitate research into the epidemiology, molecular biology, pathology, and diagnosis of thyroid diseases; and allow easy and reliable sharing of data from different laboratories for national and international collaborative studies. Ghossein Clinical, cytologic, and immunohistochemical features of sarcomas Due to the decalcification and need for fixation, bone core biopsy slides are usually not available to review until the following day. Hematoxylin-eosinstained sections of the clot particle. Dr Love Will you tell me what sparsely cellular specimen And Bone core biopsy. On the other hand, these polarized spermatids also align across the plane of seminiferous epithelium, mimicking planar cell polarity (PCP . It is a point of great significance that Ohori et al[56] found a greater percentage of BRAF-mutated (V600E, K601E, and others) cases in the AUS/FLUS and SFN/SFN categories, rendering BRAF mutational testing a useful predictor of PTC diagnosis in these indeterminate cases. The separation of these four components allows for multiple sources of data collection and offers insurance against otherwise compromised specimens. Chronic sialadenitis: sparsely cellular specimen with fewer lymphocytes and germinal center fragments; no characteristic lymphoepithelial islands. A minor population of macrofollicles (intact spheres and fragments) can be present. Goellner See more. Specimen Adequacy and Non-diagnostic Thyroid Nodules Filie AC, Asa SL, Geisinger KR, Logani S, Merino M, Nikiforov YE, Clark DP. The individual tumor cells are enlarged, oval in shape with eosinophilic cytoplasm; the nuclei show elongation, oval shape, membrane thickening, chromatin clearing, grooves, and inclusions. . An inspiration for the thyroid proposal was the Bethesda System for reporting cervical cytology interpretations, first developed at an NCI workshop in 1988 and widely adopted in the United States for reporting Papanicolaou test results. There are three main methods of sample preparation; smears, liquid-based preparations, and cell block--these preparation methods may be used singly or in . Almost all patients with MTC have a significantly elevated serum calcitonin level, and in some cases these tumors can produce substances that can lead to paraneoplastic syndromes[35,44]. Piana S, Frasoldati A, Ferrari M, Valcavi R, Froio E, Barbieri V, Pedroni C, Gardini G. Is a five-category reporting scheme for thyroid fine needle aspiration cytology accurate? The benefit of thyroid FNA derives in large part from the ability to make a reliably benign interpretation that avoids unnecessary surgery. Thyroid FNA specimen a. S Evangelos P Misiakos, Dimitrios Schizas, Konstantinos Petropoulos, Anastasios Machairas, 3, Niki Margari, Christos Meristoudis, Aris Spathis, Petros Karakitsos, Department of Cytopathology, Attikon University Hospital, University of Athens School of Medicine, Attica, 12462 Athens, Greece. ES Bongiovanni et al[14] analyzed the differences between the 5-tiered and the 6-tiered diagnostic systems for reporting thyroid cytopathology, based in a large series of 7686 thyroid FNA specimens, collected from 3751 patients from several institutions from Italy, Switzerland, and the United States. Hamberger Such cases occur with some regularity, and they are best classified as suspicious for malignancy, qualified as suspicious for papillary carcinoma. Nodules called suspicious for papillary carcinoma are resected by lobectomy or thyroidectomy. As a medical procedure, bone marrow collection may sometimes have limitations in obtaining adequate specimens. You order a bone marrow analysis for your patient. In order to establish a standardized diagnostic terminology/classification system for reporting thyroid FNAC results, the National Cancer Institute (NCI) in the United States sponsored the NCI Thyroid FNA State of the Science Conference with a group of experts at Bethesda, MD, in October 2007[7]. A: No. Sparsely cellular specimen means exact what it says - cells are sparse. Lymphoepithelial cyst. The Bethesda System for Reporting Thyroid Cytopathology: Definitions, Criteria and Explanatory Notes. In 1966 Williams demonstrated that this tumor derives from the parafollicular cells, known also as calcitonin-producing C cells, which have an ectodermal neural crest origin[47]. Cibas Follicular cells arranged in a flat sheet, colloid and pigment-laden macrophages ( 40 pap stain on ThinPrep slide) (diagnostic categories II). The tall cell variant of PTC is an important subtype with a potentially aggressive clinical course. The core biopsy is useful for assessing overall marrow cellularity, trilineage hematopoiesis, and marrow architecture. L There is a predominance of Hrthle cells in a sparsely cellular aspirate with scant colloid. Anaplastic carcinoma of the thyroid: a review of 84 cases of spindle and giant cell carcinoma of the thyroid. hb```f``jg`e`bf@ a=TbO>9\!@)s\2q F)}w38|)0KQD[Vi>Rc@8[@5ii` .Q@q!d - `' }i@&QAz@%,700g& pL`r, l|Bj2"BTg]((@G@{2L2xVWA0Kk3\2 Ii Almost simultaneously, in Europe, the British Thyroid Association-Royal College of Physicians and the Italian Society for Anatomic Pathology and Cytopathology-International Academy of Pathology (SIAPEC-IAP) thyroid reporting systems, each comprised of 5 diagnostic classes, have been introduced[10,11]. Pu One nucleus has an apparent intranuclear pseudoinclusion (arrow). If no aspirate is collected, then an extra core biopsy specimen can be agitated to release cells for flow cytometry; however, this is not ideal. This document summarizes several years of work, begun as a Web-based discussion, followed by a live conference, and culminating in the production of a print and online atlas. Many laboratories have traditionally considered a macrophages-only sample unsatisfactory and included them in the ND/UNS category, with the understanding that, because the parenchyma of the nodule has not been sampled, one cannot exclude a cystic papillary carcinoma. RA A minor population of follicular cells show nuclear enlargement, often accompanied by prominent nucleoli, eg, Specimens from patients with a history of radioactive iodine, carbimazole, or other pharmaceutical agents, Repair due to involutional changes such as cystic degeneration and/or hemorrhage, There is an atypical lymphoid infiltrate (in which a repeated aspirate for flow cytometry is desirable), but the degree of atypia is insufficient for the general category suspicious for malignancy.. For most cases surgical resection is not an effective treatment and only palliative therapies are used. Open in a separate window The bone marrow aspirate is arguably the most straightforward aspect of the bone marrow workup. These features could be intranuclear inclusions, nuclear grooves, or psammoma calcifications; (6) DC VI Malignant (Figures (Figures55--7).7). Management of a solitary thyroid nodule. View an interactive bone marrow clot specimen online. In FNA specimens of this variant, the cancer cells appear more profuse, granular or vacuolated compared to regular PTC. Historically, terminology for thyroid FNA has varied significantly from one laboratory to another, creating confusion in some cases and hindering the sharing of clinically meaningful data among multiple institutions. Despite the fact that not all PTC were detected by this panel, a positive molecular test helped to refine the FLUS cases into high-risk and low-risk categories[61]. Q: Can your pathologist give you a preliminary assessment of the aspirate smear or flow cytometry analysis on the same day as a procedure if it was performed early in the morning? The atypical thyroid fine-needle aspiration: past, present, and future. Employing genetic markers to improve diagnosis of thyroid tumor fine needle biopsy. The heterogeneity of this category precludes outlining all scenarios for which an AUS interpretation is appropriate. The most widely known is the SIAPEC-IAP thyroid reporting system, which is also consists of 5 diagnostic classes[12]. VA A serum protein electrophoresis might have even shown a monotypic expansion. Rathan For some of the general categories, some degree of sub-categorization can be informative and is often appropriate; recommended terminology is shown in Table 1. A uniform reporting system for thyroid FNA will facilitate effective communication among cytopathologists, endocrinologists, surgeons, radiologists, and other health care providers; facilitate cytologic-histologic correlation for thyroid diseases; facilitate research into the epidemiology, molecular biology, pathology, and diagnosis of thyroid diseases, particularly neoplasia; and allow easy and reliable sharing of data from different laboratories for national and international collaborative studies. There are cyst-lining cells that may appear atypical owing to the presence of nuclear grooves, prominent nucleoli, elongated nuclei and cytoplasm, and/or intranuclear cytoplasmic inclusions in an otherwise predominantly benign-appearing sample.16. Patients with the sporadic forms of MTC or the familial MTC are most often middle-aged (mean age 50 years old), except in familial cases, in which they are relatively younger. Most (60%75%) prove to be papillary carcinomas, and the rest are usually FAs.2,10,12,30. Urine cytology-general principles Flashcards | Quizlet Search for other works by this author on: Fine-needle aspiration biopsy of thyroid nodules: impact on thyroid practice and cost of care, Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation, The Bethesda System for Reporting Thyroid Cytopathology, Diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference, The: National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference: a summation, Fine-needle aspiration cytology of the thyroid, 1980 to 1986, Long-term follow-up of patients with benign thyroid fine-needle aspiration cytologic diagnoses, Usefulness of fine-needle aspiration in the diagnosis of thyroid carcinoma: a retrospective study in 37,895 patients, Accuracy of thyroid fine-needle aspiration using receiver operator characteristic curves, Fine-needle aspiration of thyroid nodules: a study of 4703 patients with histologic and clinical correlations, Accuracy of fine-needle aspiration of thyroid: a review of 6226 cases and correlation with surgical or clinical outcome, Fine-needle aspiration cytology of the thyroid: a 12-year experience with 11,000 biopsies, Non-diagnostic fine-needle aspiration biopsy: a dilemma in management of nodular thyroid disease, Value of repeat fine needle aspiration (FNA) of the thyroid [abstract], Post thyroid FNA testing and treatment options: a synopsis of the National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference, Atypical cells in fine-needle aspiration biopsy specimens of benign thyroid cysts, NCCN thyroid carcinoma practice guidelines, Fine-needle aspiration of follicular lesions of the thyroid: diagnosis and follow-up, Diagnosis of follicular neoplasm: a gray zone in thyroid fine-needle aspiration cytology, Factors that predict malignant thyroid lesions when fine-needle aspiration is suspicious for follicular neoplasm., Thyroid cytology and the risk of malignancy in thyroid nodules: importance of nuclear atypia in indeterminate specimens, Fine-needle aspiration biopsy of the thyroid: an appraisal. SL Amyloid can be observed in close association with tumor cells, and can be distinguished from the thick colloid of PTC by performing a Congo-red stain. Nuclear atypia or pleomorphism and mitoses are uncommon. Primary angiosarcoma of breast: A case report and literature review. The thyroid nodules are aspirated 3 to 5 times with a 22-gauge or 25-gauge needle. For that reason the aspirate is then classified as AUS/FLUS to indicate the uncertainty of the findings. Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, Mazzaferri EL, McIver B, Sherman SI, Tuttle RM. The FNA aspirates of an MTC are usually composed of numerous cells, either presenting in cell aggregates or as a mixture of non-cohesive cells. Liquid-based preparation can also be made after a FNA pass, with the needle been rinsed in normal saline or ThinPrep solutions. Incidence of malignancy in thyroid nodules determined to be follicular lesions of undetermined significance on fine-needle aspiration. FCs have cytomorphologic features that distinguish them from benign follicular nodules. These include hypocellular smears with extensive cystic degeneration with rare follicular cells with nuclear atypia indicative of PTC. ?K !o Most primary thyroid malignancies with the exception of follicular and Hurthle cell carcinomas have unique cytological features which can differentiate primary malignancies from other thyroid lesions. Papillary thyroid carcinoma. This distinction cannot be made by FNA and is of no consequence to the patient. Another diagnostic option for patients with repeat ultrasonography-guided FNA of thyroid nodule with non-diagnostic cytology results, would be the utilization of ultrasonography-guided core needle biopsy[39]. ND/UNS results occur in 2% to 20% of cases but ideally should be limited to no more than 10% of thyroid FNAs, excluding samples composed exclusively of macrophages.810, Specimens that consist only of cyst contents (macrophages) are problematic. Until recently there were no uniform criteria for the various diagnostic categories in thyroid cytopathology. S ( a) In this sparsely cellular specimen, some of the cells had abundant cytoplasm and enlarged nuclei, some with prominent nucleoli. Hazard JB, Hawk WA, Crile G. Medullary (solid) carcinoma of the thyroid; a clinicopathologic entity. Since there is a considerable proportion of patients with a thyroid nodule who remain undiagnosed with FNA, molecular biology could be very helpful at that point. The management of cases with papillary microcarcinomas, i.e., tumors less than 1.0 cm in diameter, is still controversial. I The morphology is similar to that seen on the core biopsy. H The nuclear chromatin appears as salt and pepper type in a medullary carcinoma case ( 40 pap stain on ThinPrep slide) (diagnostic categories VI). MTC represents 3%-12% of thyroid cancers, the majority of which are sporadic. Theoharis C, Roman S, Sosa JA. Architectural atypia may present in smears with paucity of cells, which contain a few microfollicles, trabeculae, or crowded groups. An effort should be made to use this category as a last resort and limit its use to approximately 7% or fewer of all thyroid FNAs. Effect of the Bethesda system for reporting thyroid cytopathology on thyroidectomy rates and malignancy risk in cytologically indeterminate lesions. BRAF is not usually found in the follicular variant of papillary thyroid carcinoma, but is increasingly detectable in each step of dedifferentiation, including tall cell tumors and anaplastic cancer. Gross specimen was measuring about 2x2x1.5 cm in size, soft in consistency, brownish black in color and roughly oval in shape [Table/Fig-4]. ( a) In this sparsely cellular specimen, some cells have abundant cytoplasm, enlarged nuclei, and prominent nucleoli. Baloch ZW, LiVolsi VA. Fine-needle aspiration of thyroid nodules: past, present, and future. The differential diagnosis includes hyperplastic adenomatous nodules, follicular adenoma, follicular carcinoma, and follicular variant of PTC, where the nuclear features remain ill defined. Each of the categories has an implied cancer risk (ranging from 0% to 3% for the benign category to virtually 100% for the malignant category) that links it to a rational clinical management guideline Table 2. Nuclear grooves become an important diagnostic feature when associated with an oval, enlarged nucleus with fine chromatin[41]. However, this requires additional FNA passes or residual cellular material from the cytologic sample. sharing sensitive information, make sure youre on a federal The terms for reporting results should have an implied (or explicit) risk of malignancy on which recommendations for patient management (eg, annual follow-up, repeated FNA, surgical lobectomy, near total thyroidectomy) can be based.
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