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a detailed description of the bethesda system for reporting thyroid cytopathlogy by dr. wakely

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Updating Thyroid Cytopathology: The Bethesda System

P.E. Wakely, Jr., M.D. Ohio State University Columbus, Ohi C l b Ohio U.S.A.

Thyroid Nodules

NEJM June 2007

FNA: the most specific & sensitive method to select suspicious nodules for surgery in 10-20% of thyroid FNA a precise diagnosis cannot be reached

NCI Thyroid FNA State of The Science Conference S i C fBethesda, MD October, 2007

Classification Scheme Proposed by ATA 2006 Inadequate Malignant li Indeterminate Benign Non-Diagnostic / UNSAT Benign ACUS AC S / FLUS S Suspicious for Neoplasm Follicular Hrthle

Suspicious for Malignancy

Malignant g

Classification Scheme Proposed by ATA 2006 Inadequate Malignant li Indeterminate Benign Non-Diagnostic / UNSAT Benign ACUS AC S / FLUS S Suspicious for Neoplasm Follicular Hrthle

Suspicious for Malignancy

Malignant g

Clinical Management Algorithms Benign follow Suspicious surgery Malignant surgery FLUS repeat FNA Non-diagnostic ti N di (includes cyst fluid only) repeat FNA usually after 3 months

This is not a standard of practice guideline i id li nor is it endorsed as such by the NCI.

NCI/Bethesda Conference - SuggestedTerminology for Reporting Thyroid FNA Nondiagnostic/ Unsatisfactory

Adequacy - according to the literature 6 groups, each 10 benign follicular cells groupsGoellner et al Acta Cytol 1987; 31:587-90

10 groups, each 20 b i follicular cells h benign f lli l llNguyen et al. Pathol Annu 1991;23:63-80

6 groups on at least 2 of 6 aspirates Hamburger etal. Diagn Cytopathol 1988;4:14-17

8 groups on at least 2 slides Kini SR. Guides to ClinicalAspiration Biopsy: Thyroid, 2nd ed. 1996 p py y

Adequacy in FNA The adequacy of FNA is highly dependent on The the skill and experience of the operator.http://thyroidfna.cancer.gov

Why not accept the obvious? Training in proper technique is crucial for the success of thyroid aspiration biopsy. Waisman et al. AJCP 2008;129:824.

also dependent on the inherent quality of the lesion, e.g. cystic, solid, calcified, fibrotic , g y , , ,

Adequacy Criterion at least 6 groups of follicular cells each with at least 10 benign appearing, well visualized well-visualized follicular cells exceptions thyroiditis abundant colloid any atypia

Non-Diagnostic

Thyroid Cysts result of cystic degeneration of an adenomatous nodule risk of malignancy 1- 4% in non-complex cysts 14% i mixed solid/cystic nodules & large cysts in i d lid/ i d l l

diagnose as Cyst Fluid Only and categorized as Non-Diagnostic / Unsatisfactory

NCI/Bethesda Conference - SuggestedTerminology for Reporting Thyroid FNA Nondiagnostic / Unsatisfactory Benign very l risk of malignancy (