The main purpose of thyroid FNA is to stratify higher risk patients for surgery, and to prevent unnecessary surgeries for benign conditions. Thyroid FNA specimen a. Because of its aggressive, infiltrative nature, patients with an undifferentiated carcinoma often require a tracheostomy as an emergency procedure. These indeterminate results imply surgeons to consider alternative therapies (e.g., thyroid lobectomy with intraoperative frozen section). For patients with large tumors (> 4 cm), the best approach could be a total thyroidectomy, considering the fact that large tumors have an elevated risk of malignancy[40]. Fine-needle aspiration (FNA) has an essential role in the evaluation of euthyroid patients with a thyroid nodule. 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. The hallmark of this diagnostic category is a disturbed cytoarchitecture: follicular cells are arranged predominantly in microfollicular or trabecular arrangements. If resected, virtually all benign follicular nodules turn out to be nodules of a multinodular goiter or follicular adenomas. Theoharis C, Roman S, Sosa JA. 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. Gough government site. Author contributions: Misiakos EP, Margari N, Meristoudis C, Petropoulos K, and Spathis A contributed significantly in preparation, collection of data, writing and critically revising the manuscript; Machairas N, Schizas D, Karakitsos P and Machairas A contributed in data analysis, and writing the manuscript. The diagnosis of MTC can be confirmed by simply measuring serum calcitonin levels, which are markedly elevated in the majority of cases (> 10 pg/mL)[48]. They found that apart from the TIR III category, for the TIR 1/DCI(unsatisfactory/nondiagnostic) category the percentage of cases in the 5-tiered system was greater than twice the percentage of cases in the 6-tiered system (7.5% vs 3%). et al. Immunohistochemistry test for specific biomarkers (i.e., calcitonin, thyroglobulin) will easily distinguish MTC from other thyroid malignancies. S et al. 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]. Recognizably benign cellular changes (eg, typical cyst lining cells, focal Hrthle cell change, changes ascribed to radioiodine therapy, black thyroid) should not be interpreted as AUS. Pathology Outlines - Suspicious for malignancy et al. Cross PA, Poller D. The Bethesda thyroid terminology and progress towards international agreement on thyroid FNA cytology reporting. The precious cell block | Journal of Clinical Pathology In some cases psammoma bodies may be present[35,44]. A review of the English literature was conducted, and data were analyzed and summarized and integrated from the authors perspective. Ultrasound guidance is preferable than palpation-guided FNA for small nodules (< 1 cm), cystic lesions and when a prior FNA is nondiagnostic[13]. The double needle from the same aspirate procedure is used to cut a core biopsy of optimal length (longer is better; i.e., more data). American Society of Hematology. 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. Therefore, detailed neuronal morphology is required to understand normal neuronal function . This technique is conclusive for the majority of cases suspicious for PTC, lymphoma, or follicular neoplasm after previous incomplete FNA results. After the aspirate, the most expected informative component of a bone marrow workup is likely the core needle biopsy. B) 600 view of trilineage hematopoiesis. Use freshly squeaky-cleaned slides. These changes are not pathognomonic, as they are frequently detected in some PTCs, especially in the follicular variant, and in benign lesions as well, such as follicular adenomas. While their individual turnaround times vary, these specimens are usually reported together to make sure all aspects are accounted for, which can take approximately three days on average. The 2-day live conference in October 2007, attended by 154 registrants including pathologists, endocrinologists, surgeons, and radiologists, gave the committees an in-depth opportunity to present their conclusions and debate controversial areas. Hahn SY, Shin JH, Han BK, Ko EY, Ko ES. The most common sites are the lungs, bone, liver and brain. Human immunodeficiency virus (HIV)-associated cystic lymphoepithelial lesions. A) 20 view of the bone marrow aspirate reveals a deeply basophilic smear of cells. Walfish Explaining the use and composition of pre-fixatives and their effect on cellular morphology 4. Figure 2. Histogenesis of medullary carcinoma of the thyroid. b=D`.+u{tZ>aSW}\b_ ^/:'!!TQf1H7y` fY0Xa8 You order a bone marrow analysis for your patient. These specimens are differentially used to study morphology, assess lineage, perform cell counts and differentials, triage and send for appropriate immunohistochemical stains, perform flow cytometry, and send ancillary cytogenetic and molecular genetic studies. The adequacy of a thyroid FNA is defined by both the quantity and quality of the cellular and colloid components. In a large study with 1382 cases in a community practice setting, in the United States, Wu et al[32] diagnosed AUS in 27% of cases, ranging from 10% to 47% among pathologists participating in the study. View an interactive bone marrow core biopsy online. The nuclear chromatin is similar to that seen in other neuroendocrine tumors, i.e., salt and pepper type (Figure (Figure7).7). Quick tip: If the bone marrow is involved by metastatic carcinoma or clusters of cohesive plasma cells, these abnormal cells may not be amenable to aspiration and may cause a dry tap; however, a bone core biopsy will identify them. The atypia of undetermined significance/follicular lesion of undetermined significance: malignant ratio: a proposed performance measure for reporting in The Bethesda System for thyroid cytopathology. Renshaw AA. Map ; Apps; Tools . 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]. The FNA specimens show enlarged follicular cells arranged in monolayer sheets and follicular groups in a background of thin and thick colloid (Figure (Figure6).6). Cytologic features of histologically proven follicular adenoma and As a result they may be not diagnosed through the FNA test, resulting in a false-negative test[44]. Cytopreparatory Techniques | SpringerLink Handle sparsely cellular specimens ii. The difficulties in securing diagnosis of a diffuse large B-cell lymphoma derive from the inadequate sampling technique and/or insufficient preservation of the specimen. . The reason is that in approximately 10%-30% of cases, cytology is indeterminate and nondiagnostic[4]. et al. III 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]. Single neurons, as the basic unit of the brain, consist of a cell body and processes, including dendrites and axons. Giorgadze The sample is composed of numerous monomorphic lymphoid cells. Reduce red blood cells in smears iii. FNA is diagnostic of many thyroid conditions (eg, papillary carcinoma, lymphocytic thyroiditis), but, with regard to follicular carcinoma, it is better considered a screening test. Presence of cell group with nuclear crowding, increased nuclear-cytoplasmic ratio, irregularities in nuclear membrane and micro-nuclei ( 40 pap stain on ThinPrep slide) (diagnostic categories V). 8600 Rockville Pike Nikiforov YE, Ohori NP, Hodak SP, Carty SE, LeBeau SO, Ferris RL, Yip L, Seethala RR, Tublin ME, Stang MT, et al. Verizon (United States of America)Cell Tower Map - CellMapper If the nodule is almost entirely cystic, with no worrisome sonographic features, an endocrinologist might proceed as if the CFO were a benign result. Bukhari MH, Niazi S, Hanif G, Qureshi SS, Munir M, Hasan M, Naeem S. An updated audit of fine needle aspiration cytology procedure of solitary thyroid nodule. B) 1,000 view. a. crush method b. cytocentrifuge c. fine needle aspiration d. liquid-based b. cytocentrifuge cytocentrifugation is the most common method of handling sparsely cellular specimens such as urine or spinal fluid 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]. Fine-needle aspiration (FNA) cytology is an important diagnostic tool in patients with thyroid lesions. (iii) Cytologic and architectural atypia: Specimen Adequacy and Non-diagnostic Thyroid Nodules Colombo Nuclear grooves become an important diagnostic feature when associated with an oval, enlarged nucleus with fine chromatin[41]. Yang 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. BRAF mutation detection in indeterminate thyroid cytology specimens: underlying cytologic, molecular, and pathologic characteristics of papillary thyroid carcinoma. Report of the Thyroid Cancer Guidelines Update Group. Several systems have been proposed for the cyropathologic diagnosis of the thyroid nodules. At low magnification, aspirates of PTC are typically cellular, epithelium-rich structures. of value in acquiring a cellular sample, possibly due to increasing hemodilution. ES Highly cellular specimens are ideal for smeared preparations, whereas sparsely cellular specimens will require multiple centrifugation steps and special cell consolidation processing. Cytopreparatory Techniques | SpringerLink MTC was first described by Horn et al[45] in 1951, and it was first recognized as a unique clinicopathological entity by Hazard et al[46], in 1959. Like the marrow aspirate smear, touch imprint preparations provide a quick turnaround time (i.e., do not need decalcification) and great morphologic detail (if the aspirate smears are paucispicular or hemodiluted). A complete bone marrow biopsy examination usually involves the review of these four specimens noted here in a slide tray: A) marrow aspirate smear, B) marrow core biopsy, C) clot section, and D) touch imprint preparation. Unless specified as ND/UNS, the FNA specimen is considered adequate for evaluation. The use of molecular markers can further increase the diagnostic value of FNA samples for the detection of thyroid cancer. Therefore the diagnosis SFM, suspicious for thyroid carcinoma is an indication for surgery. Aspirates where malignancy is suspected but cannot be determined due to: Overlapping cytological features with other thyroid lesions, Specimens suspicious for a follicular or Hrthle cell neoplasm (see, Specimens with a minor degree of atypia, primarily cytologic or architectural (see, Frozen section has limited utility for suspicious for malignancy nodules (, 55 year old man with colon cancer metastasis within a NIFTP which was cytologically suspected of PTC (, 58 year old woman with mammary analogue secretory carcinoma of the thyroid which was cytologically suspected of PTC (, 63 year old man with follicular variant of papillary thyroid carcinoma presenting as a toxic nodule which was cytologically suspected of follicular variant of PTC (, 63 year old woman with hyalinizing trabecular tumor which was cytologically suspected of hyalinizing trabecular tumor (, 71 year old man with mixed medullary and follicular cell carcinoma of the thyroid which was cytologically suspected of thyroid carcinoma (, Pattern A (patchy nuclear changes): moderate to high cellularity, nuclei showing enlargement, pallor, grooves, irregularity or molding but absence of nuclear pseudoinclusions, psammoma bodies and papillary architecture, Pattern B (incomplete nuclear changes): nuclei showing enlargement with mild pallor and grooves, absence of nuclear irregularity, nuclear molding, nuclear pseudoinclusions, psammoma bodies and papillary architecture, Pattern C (sparsely cellular specimen): poor cellularity, presence of many findings suggesting papillary thyroid carcinoma, Pattern D (cystic degeneration): cystic degeneration based on foamy histiocytes, scattered clusters of follicular cells with the nuclei showing enlargement, pallor, grooves, absence of nuclear pseudoinclusions, psammoma bodies and papillary architecture, large, atypical, histiocytoid cells with enlarged nuclei and without abundant vacuolated cytoplasm (, Monomorphic population of isolated small or medium sized cells with a high nuclear cytoplasmic ratio, Nuclei are eccentrically located, with smudged chromatin, Numerous monomorphic small to intermediate sized lymphoid cells, Sparsely cellular and contains atypical lymphoid cells, Suspicious for malignancy, not otherwise specified, Other primary thyroid malignancies like anaplastic carcinoma and poorly differentiated carcinoma, Suboptimal cellularity or preservation can lead to uncertainty and result in a suspicious for malignancy interpretation, Usually surgical management similar to that of malignant nodules (, In suspicious for papillary thyroid carcinoma cases with low risk features ( 1 cm, without extrathyroidal extension and clinical metastasis), active surveillance is an option (, Molecular testing with high positive predictive value (, For suspicious for medullary thyroid carcinoma, Measuring serum calcitonin level or calcitonin immunostaining are recommended (, Repeat fine needle aspiration to obtain cells for flow cytometry (, A few follicular cells showing nuclear enlargement, pale and powdery chromatin and nuclear grooves are present, Correlation with serum calcitonin level or immunostaining might be helpful for definitive diagnosis if clinically indicated, Re-aspiration for flow cytometry might be helpful to better characterize the lymphocyte population if clinically indicated, Microfollicular architecture with minimal nuclear features of, Trabecular growth pattern of the cells with nuclear grooves and abundant nuclear pseudoinclusions, intratrabecular hyaline material, Nuclear changes of follicular cells with focal enlargement, grooves, prominent nucleoli and chromatin clearing in the lymphocytic background, An abundance of lymphocytes and plasma cells does not exclude the possibility of a coexisting, Numerous lymphocytes, few follicular cells, Elongated cells with pale chromatin, nuclear grooves and relatively large nucleoli, Spindle shaped morphology of the cell and nucleus, reminiscent of reparative epithelium in cervical Pap smears, Follicular variant of papillary thyroid carcinoma. Goellner Anaplastic carcinoma of the thyroid. A benign result is obtained in 60% to 70% of thyroid FNAs. Baloch ZW, LiVolsi VA. Fine-needle aspiration of the thyroid: today and tomorrow. Q: Can flow cytometry be used for assessment of morphologic dysplasia? 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.. The high sensitivity rate, as well as the high negative prognostic value of BRAF testing in AUS/FLUS and SFN/SFN categories have been also demonstrated by Alexander et al[57]. Alexander Faquin Diagnostic terminology for reporting thyroid fine needle aspiration cytology: European Federation of Cytology Societies thyroid working party symposium, Lisbon 2009. Before Sarasota Memorial Health Care System. Careers, Unable to load your collection due to an error. McHenry As such, the redundancies in place discussed here and the compound output of the four major components have synergistic effects on diagnostic evaluation. et al. Figure 5. G Therefore, it is not prudent to remove every thyroid nodule we encounter in our medical practice. Without the bone marrow matrix, these slides contain only cells directly from the marrow and can be stained and assessed both for lineage and cytologic morphology, with high correlations to what may be seen on aspirate and biopsy. On the other hand a definitive diagnosis of a low-grade lymphoma (usually a MALT lymphoma) is even more difficult. Mazzaferri EL. The 2017 Bethesda System for Reporting Thyroid Cytopathology hbbd``b`$Ks ^ Atypia of Undetermined Significance/Follicular Lesion of - Springer Utilization of ancillary studies in thyroid fine needle aspirates: a synopsis of the National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. Papillary thyroid carcinoma. CA Unlike complete blood counts (CBCs), which produce fast results, a bone marrow analysis requires a more in-depth analysis and, as a more invasive procedure, necessitates built-in redundancies to ensure the highest-quality results. Preoperative diagnostic categories of fine needle aspiration - PLOS VanderLaan PA, Marqusee E, Krane JF. Whenever a specific diagnosis (eg, lymphocytic thyroiditis) can be rendered and whenever there is any atypia, the specimen is, by definition, adequate for evaluation. EK Figure 4. The term benign follicular nodule applies to the most common benign pattern: an adequately cellular specimen composed of varying proportions of colloid and benign follicular cells arranged as macrofollicles and macrofollicle fragments.
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