TBSRTC uses two distinct categories for borderline lesions: âAUS/FLUSâ and âfollicular neoplasm or SFNâ, while the British system uses a single ThyIII category for all the borderline cases but with using âThyIIIaâ for possible neoplasm with atypia and âThyIIIfâ for possible neoplasm suggesting follicular neoplasm. 3 High Serum Thyrotropin Concentrations within the Reference Range: A Predictor of Malignancy in Nodular Thyroid … Dr. Eman Aljufairi conceived the study and participated in its design and coordination and helped draft the manuscript. It is clear that cases of AUS/FLUS were downgraded in the 5-tiered systems to the benign category resulting in fewer patients referred for surgery compared to the 6-tiered one (9.1% vs. In our study, interestingly, repeated FNA had been done in 7 cases only out of 85 cases, while surgical resection was done in 25 cases. RCPath's Guidance on the Reporting of Thyroid Cytology Specimens was first published in November 2009 and underwent a revision in 2015. Correlation of Ultrasound Findings With the Bethesda Cytopathology Classification for Thyroid Nodule Fine-Needle Aspiration: A Primer for Radiologists Matthew T. Heller 1 , Chris Gilbert 2 , N. Paul Ohori 3 and Mitchell E. Tublin 1 Definition / general. The system led to standardization of FNA reports based on six diagnostic categories: DC I = nondiagnostic, DC II = benign, DC III = atypia/follicular lesion of undetermined significance (AUS/FLUS), DC IV = follicular neoplasm/suspicion for a follicular neoplasm (FN/SFN), DC V = suspicious for malignancy, and DC VI = malignant (1). All of our cytopathologists were aware of TBSRTC, and adhered to its criteria and terminologies. Although the three categories of AUS/FLUS, FN/SFN, and suspicious for malignancy had previously been lumped together to comprise an “indeterminate” class (2), it is clear that when the FNA is in the suspicious for malignancy category (DC V), the patient should undergo thyroidectomy. The Bethesda system classifies thyroid FNAC into six categories. Nevertheless, none of these schemes have been implemented internationally. [78] Unfortunately, it was difficult to compile data before 2013 to compare our experience with TBSRTC to the British system. Eight published studies that included a total of 25,445 thyroid FNAs were selected for the meta-analysis. In comparison to the TBSRTC, the frequency of malignancy in our study was comparable for Category I (6.7% compared to 1%â4%), slightly higher in both Category II (15% compared to 0%â3%) and Category III (28% compared to 5%â15%), and close to TBSRTC in Category IV (22.2% compared to 15%â30%), Category V (72.8% compared to 60%â75%, and Category VI (100% compared to 97%â99%). The Bethesda System for Reporting Thyroid Cytopathology: a meta-analysis. Dr. Zainab Harb participated in the design of the study and writing the manuscript, and performed the statistical analysis. The malignant category (DC VI) was assigned to 5.4% of the FNAs (range, 2 to 16); 74% had histologic follow-up and 98.6% were malignant. The BSRTC proposed 6 categories in an attempt to standardize reporting of thyroid FNA. All slides were interpreted by one of five qualified cytopathologists. Revised Bethesda system for thyroid malignancies. The final histopathological diagnoses of cases in each category are summarized in Table 3. The Royal College of Pathologists system uses the Thy1-5 originally suggested categories but with expanded specifications for each category. This study presents our experience with the Bethesda system in 681 thyroid FNAs from 632 patients in the period between January 2013 and December 2016. The AUS/FLUS category (DC III) was assigned to 9.6% of the FNAs (range, 3 to 27); 39% had histologic follow-up and 15.9% were malignant. Thyroid nodules are nodules ... (Thyroid Imaging Reporting and Data Systems) are sonographic classification systems which describe the suspicious findings of thyroid nodules. Rapid assessment of adequacy was done by Diff-Quick staining. In conclusion, the 6-tiered system (TBSRTC) appears to be associated with more aggressive surgical management approach compared to the other systems.[1112]. The Bethesda System for Reporting Thyroid Cytopathology. A total of 632 patients underwent 681 FNAs during the study period. DC I = nondiagnostic, DC II = benign, DC III = atypia/follicular lesion of undetermined significance (AUS/FLUS), DC IV = follicular neoplasm/suspicion for a follicular neoplasm (FN/SFN), DC V = suspicious for malignancy, and DC VI = malignant (1) Similar to TBSRTC, all other reporting systems also provide categories for nondiagnostic cytology samples, benign lesions, and malignant lesions. While it is easy to diagnose most benign and straightforward malignant lesions, diagnostic challenges arise when aspirates are quantitatively or qualitatively inadequate to exclude a neoplastic process. The 6 diagnostic categories of TBSRTC were established from the probability of showing evidence of malignancy if a thyroid lesion placed into a specific category. Non-diagnostic/unsatisfactory, 2. [79], On the other hand, the Italian system uses TIR 3 for follicular proliferation (Indeterminate low risk) and TIR 4 for suspicious of malignancy (Indeterminate high risk). Some of these studies show even a higher risk of malignancy in Category III compared to Category IV, which is not consistent with TBSRTC proposal of a sequentially increasing implied risk of malignancy. Eventually, molecular markers may help to clarify which patients should be referred for surgery (2). Bethesda Category III . The Bethesda system used six categories for thyroid cytology reporting, and each category is supplemented by a list of criteria. HomeBrowse Articles About UsEditorial BoardFor AuthorsReviewer CornerSubscribeContact Us. The Bethesda System for Reporting Thyroid Cytopathology categorizes thyroid cytology findings into six groups, with each group assigned a putative malignancy risk. It can be divided into six categories: Thyroid cytopathology of Bethesda category III with clotting artifact In addition, whenever difficult cases were encountered, a second opinion from expert colleagues was sought. Epub July 25, 2012; doi: 10.1159/000339959. The system classifies the biopsy of the nodule into 6 categories, each with its associated malignancy risk and recommendations for management. FNAC outcomes are routinely classified using the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), facilitating appropriate clinical management. Aims. Bethesda categories III and IV encompass varying risks of malignancy. The Bethesda System for Reporting Thyroid Cytopathology is the system used to report whether the thyroid cytological specimen is benign or malignant. [3] Each diagnostic category is linked to a certain risk of malignancy and recommended clinical management that are summarized in Table 1. [2] These categories are nondiagnostic, benign, atypia of undetermined significance (AUS)/follicular lesion of undetermined significance (FLUS), follicular neoplasm/suspicious for follicular neoplasm (SFN), suspicious for malignancy, and malignant. These include medical records and the surgical pathology files. For clarity of communication, TBSRTC recommends that each report begin with 1 of 6 general diagnostic … (C) Professor, Department of Pathology McGill University Director, Cytopathology Laboratory Objectives: To determine the frequency of category 3 (atypia of undetermined significance [AUS]/follicular lesion of undetermined significance [FLUS]), category 4 (follicular neoplasm), and category 5 (suspicious for malignancy) of The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), the risk of malignancy (ROM) and the risk of neoplasia (RON) in these categories. Of the 681 thyroid nodules from 632 patients which underwent FNAC, surgery was done for 126 (18.5%) nodules for 119 patients, all of whom had histopathology available for review. The aim of this study is to analyze the thyroid cytology smears by Bethesda system and to correlate the diagnosis of cytopathology with histopathology, whenever surgery was done. There were 20 Bethesda IV nodules (Follicular neoplasm/SFN), with follow-up histopathology available in 9 cases and malignancy identified in 2 cases only (22% of those undergoing surgery, and 10% of the entire cohort), one of which turn out to be a poorly differentiated carcinoma. Many factors played a role in such variability including the institutionsâ experience in using TBSRTC, the cohort size, and the number of cases followed by surgery in addition to other causes such as sampling errors, particularly for cystic lesions and thyroid glands with multiple nodules, or technical reasons, including slide preparation, number of FNA passes, and use of image-guided methods. In patients in the suspicious for malignancy category, the data also show that there is a very high percentage of malignancy, 75%. Home » Professionals Portal » ATA Publications » Clinical Thyroidology Archive » January 2013 Volume 25 Issue 1 » Clin Thyroidol 2013;25:16â17. Background: The Bethesda System has been used to classify thyroid cytology in 6 categories besides presenting malignancy rates and respective approaches. Nikiforov YE, Ohori NP, Hodak SP, Carty SE, LeBeau SO, Ferris RL, Yip L, Seethala RR, Tublin ME, Stang MT, et al. [123456] The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was introduced in 2007 to standardize terminology used in reporting thyroid cytology. Until the introduction of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) in 2008, individual institutions had developed their own diagnostic categories. With regard to the possibility of malignancy for a given classification, the data corroborate the results anticipated when the classification was set up (1). Smears made were both fixed in alcohol and stained by Papanicolaou stain or air dried and stained with Giemsa stain. The cytopathology files were searched for all thyroid FNAs performed between 1 January 2013 and 31 December 2016. COMPETING INTERESTS STATEMENT BY ALL AUTHORS, LIST OF ABBREVIATIONS (In alphabetic Order). The rest were all benign thyroid lesions including one Hurthle cell neoplasm and one follicular adenoma. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has attempted to standardize reporting and cytological criteria in aspiration smears. [15] Regarding Category III, although the incidence of malignancy is slightly high, it is still within the range reported in the literature which is 6%â50%.[12131617]. CLINICAL THYROIDOLOGY ⢠JANUARY 2013 VOLUME 25 ⢠ISSUE 1 ⢠© 2013, ⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠⢠â¢, Change In Thyroid Nodule Volume Calculator, Find an Endocrinology â Thyroid Specialist, Clinical Thyroidology for the Public (CTFP). Each author has participated sufficiently in the work and takes public responsibility for appropriate portions of the content of this article. This system is made up of six categories which correlate to an estimated risk of malignancy. Am J Clin Pathol 2009;132:658-65. Internationally, The Bethesda Classification System (TBCS) is increasingly accepted, especially owing to a detailed specification of FNA suspicious for malignancy. This diagnostic category in TBSRTC is usually reserved for specimens that meet one of the following criteria: prominent population of microfollicles in an aspirate that does not fulfill the criteria for âfollicular neoplasm/SFN,â predominance of Hurthle cells in a sparsely cellular aspirate with scant colloid, interpretation of follicular cell atypia hindered by sample preparation artifacts, a moderately or markedly cellular sample composed of virtually exclusive population of Hurthle cells in the clinical setting suggestive of lymphocytic (Hashimoto) thyroiditis [Figure 1] and multinodular goiter, focal features suggestive of papillary carcinoma, atypical cyst lining cells, minor population of follicular cells showing nuclear enlargement with prominent nucleoli, or atypical lymphoid infiltrate. The purpose of the present report was to perform a meta-analysis of thyroid FNA studies in order to examine the validity of the system with regard to histologic outcomes and to assess the variability of the use of the six DCs between institutions. We compared the diagnostic value of pre-Bethesda and Bethesda classification systems in the differentiation of benign and malignant thyroid … A comparison between the percentage of cases in each Bethesda system category and the risk of malignancy in each category was done between our study and studies from the Middle East and worldwide, and it is summarized in Table 5. reported also an increase in the number of preoperative thyroid FNACs after the adoption of TBSRTC and an increase in patients undergoing thyroid surgery for indeterminate FNAC results. We did not review FNA cases again, but we relied on the original interpretation given by the five different cytopathologists that were working in Salmaniya Medical Complex in the period studied. Materials and Methods. This finding suggests that there may be a subjective element in categorizing a given FNA. Lastly, the nondiagnostic category (DC I) was assigned to 13% of the FNAs (range, 2 to 24); 16% had histologic follow-up and 16.8% were malignant. [13913] Moreover, studies that used the same number of cases with follow-up histopathology to study the distribution of the Bethesda system categories have shown less percentage of Category II cases (Benign) and higher percentage of Category V and VI cases (Suspicious for malignancy and Malignant). The benign category (DC II) was assigned to 59% of the FNAs (range, 39 to 74); 10.4% had histologic follow-up and 3.7% were malignant. 7, No. [25] That might reflect the difficulty that faces pathologists in classifying lesions into either Category III or IV. In addition, clinicians should always be aware of the malignancy rate in the Bethesda categories in their respective hospitals to improve the management decisions taken regarding patients with thyroid nodules. of Pathology, McGill University Page 1 Thyroid Thyroid CytopathologyCytopathology--Recent Advances and Update of The Bethesda System ManonAuger M.D., F.R.C.P. All authors read and approved the final manuscript. have compared between the 6-tiered Bethesda system and the 5-tiered Italian system and concluded that both systems show similar negative predictive values for the benign categories (Category II in TBSRTC and TIR 2) and positive predictive values for both the follicular neoplasm categories (Category IV and TIR 3) and the malignant categories (Category VI and TIR 5). The frequency of diagnosis of each Bethesda category reported in our institution is within the ranges reported in other cohorts, even the high frequency of diagnosis of Bethesda Category III (AUS/FLUS). Of the remaining cases, there were one Hurthle cell neoplasm, two follicular adenomas, and four adenomatoid nodules in multinodular goiter. Indeterminate, 4. Based on TBSRTC and supported by many studies, AUS/FLUS cases are found to have a lower malignancy risk on surgical follow-up than patients with an initial diagnosis of SFN on cytology, highlighting the importance of such distinction. There were 15 Bethesda I nodules (nondiagnosis) with follow-up histopathology. All pathologists can face the same difficulties when applying a new system and they have to get used to it with time. Epub August 31, 2011. doi: 10.1210/jc.2011-1469. Risk of malignancy: 1 - 4%. [2111718] That is biased by the fact that most of the cases referred for surgery are the high-risk cases, i. e. Category V and VI. • The exact clinical and surgical impact of re-classification … [12], At the end, our study is still limited by being a retrospective observational study likewise most of the other published studies. We have also compared our experience in using TBSRTC to other countries in the Middle East and worldwide. The suspicious for malignancy category (DC V) was assigned to 2.6% of the FNAs (range, 1 to 6); 74% had histologic follow-up and 75.2% were malignant. This is the first study to be published on the implementation of the TBSRTC in Bahrain and its diagnostic correlation with histopathology diagnosis. The authors recommend that the FNA be repeated when the diagnosis is AUS/FLUS; this seems reasonable given that the alternative is to operate on all of these patients when the overall possibility of malignancy is 16% (about the same as the nondiagnostic category). Fine-needle aspiration cytology (FNAC) of thyroid is the initial screening test for thyroid nodules. The main advantage of TBSRTC is the standardization of the terminologies used for reporting thyroid cytology. It is reasonable to consider removing DC V, from the “indeterminate” classification. The authors state that there are no conflicts of interest. Each category is linked to a malignancy risk and has a recommended clinical management. Prospective studies using the Bethesda System will give a better insight into the usefulness of the proposed nomenclature. It might also be related to the increased number of indeterminate FNACs undergoing surgery. Of these, malignancy was found in only one case, which was a papillary thyroid microcarcinoma (6.67%, 1/15). Based on the available scientific literature, a tiered diagnostic classification system, such as TBSRTC or even the other schemes, proved to be an excellent tool for the diagnosis and management of thyroid lesions. Of the 60 nodules diagnosed as Bethesda II (benign) on preoperative FNAC, nine nodules found to be malignant, yielding a malignancy rate of 15% (9/60) for those undergoing surgery, which represented around 2% of the total number of Category II nodules. The advantage of this approach is that each of these diagnostic categories is associated with a sequentially increasing implied risk of malignancy that converts into a recommendation for clinical and surgical management. The Bethesda system classifies thyroid FNAC into six categories. Bongiovanni et al. According to the management guidelines for Bethesda Category III nodules, repeat biopsy after 3 months should be done. [251617] Surprisingly, our study shows the highest risk of malignancy in the benign category compared to the other studies. Furthermore, studies from the Middle East, including our study, have shown high percentage of Category III cases (AUS/FLUS), but interestingly it was lower than studies done in the United States. [8] Kiernan et al. The Bethesda System for Reporting Thyroid Cytopathology is the system used to report whether the thyroid cytological specimen is benign or malignant on fine-needle aspiration cytology (FNAC). Reference centers have validated its use by comparing its proposed malignancy rates with those in in their populations. The most significant difference between the 5-tiered and 6-tiered systems was the decrease in percentage of cases classified as benign (83.9% vs. 55.4%), mainly due to the introduction of AUS/FLUS category. This study was conducted with approval from the Research and Ethics Committee in the Salmaniya Medical Complex in the Ministry of Health in Bahrain. ISSN (Print): 0974-5963ISSN (Online): 1742-6413, Its participation in the Public Health Emergency COVID-19 Initiative, Address: Department of Pathology, Salmanyia Medical Complex, Manama, Bahrain, The Bethesda System for Reporting Thyroid Cytopathology with implied risk of malignancy and recommended clinical management, Summary of 681 thyroid fine needle aspiration cytologys by The Bethesda System for Reporting Thyroid Cytopathology categories, Histopathology of 126 thyroid fine needle aspiration cytology nodules by The Bethesda System for Reporting Thyroid Cytopathology categories, Terminology of thyroid cytology reporting classifications, Comparison of percentage of cases in each Bethesda category and risk of malignancy on histopathology specimens between the present study and other studies from the Middle East and other countries. III ... • ATA initiatives to reduce the extent of surgery for many low- risk thyroid cancers (4 cm or smaller, without extra -thyroidal extension and lacking ... raise the possibility for lobectomy as initial surgical management. Surgery was done on 126 nodules from 119 patients with an overall rate of malignancy of 27.8% (35/126 nodules). Nondiagnostic or unsatisfactory (ND / UNS, < 10% of thyroid FNAs) Cyst fluid only (CFO) Virtually acellular specimen (need at least 6 groups of benign follicular cells, composed of at least 10 cells each for benign) Other (obscuring blood, clotting artifact, overly thick smear, etc.) In addition, they differ in the clinical management, where patients with AUS/FLUS should be followed up with repeated FNA or observation, and patients with SFN should undergo at least thyroid lobectomy to determine the type of the follicular lesion and rule out follicular carcinoma. Thyroid cytopathology reporting requires clear communication between pathologists, endocrinologists, radiologists, and surgeons. The Bethesda system assigns a risk of malignancy for each category. Dr. Safa Alshaikh had participated in design of the study, data collection, and drafting the manuscript. The Danish "Suspicious" group is very broad and includes atypia, follicular neoplasia and FNA suspicious of other malignancies. © Copyright 2021 – CytoJournal – All rights reserved.Published by Scientific Scholar on behalf of Cytopathology Foundation. Fine-needle aspiration cytology (FNAC) of thyroid nodules has higher sensitivity and predictive value for diagnosis than any other single diagnostic method. Each category is linked to a malignancy risk and has a recommended clinical management. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) established a standardized, category-based reporting system for thyroid fine-needle aspiration (FNA) specimens. The Bethesda system suggests a six category classification system to report thyroid FNAB results: 1. With regard to the distribution of cases, we noticed that studies with large cohorts have shown higher percentage of Category I cases (inadequate/nondiagnostic) compared to small cohorts, but it was within the ranges expected by TBSRTC. OBJECTIVE: The Bethesda classification was introduced in 2008 to provide standardisation in the evaluation of thyroid fine needle aspiration cytology (FNAC). To ensure the integrity and highest quality of CytoJournal publications, the review process of this manuscript was conducted under a double-blind model (authors are blinded for reviewers and vice versa) through automatic online system. [910] The new category of AUS/FLUS in TBSRTC includes a subset of lesions not easily classified as benign, suspicious or malignant, while SFN category is reserved for specimens suspicious of follicular carcinoma. [13] The higher percentage of this category may reflect our pathologistsâ carefulness in avoiding both false positive and false negative results. There were 28 Bethesda VI nodules (malignant), of which 12 underwent surgery and all (100%) were confirmed to be carcinoma, all papillary carcinomas including one case of follicular variant papillary carcinoma. The low number of follow-up FNAs and high number of surgical management for AUS/FLUS cases, most likely reflects treatment decisions and preferences by both clinicians and patients in our hospital and community. We use cookies to ensure that we give you the best experience on our website. Benign/Non-cancerous, 3. In patients with benign FNA or inadequate specimens who undergo surgery, it is likely that clinical factors, such as a family history of thyroid cancer, the size of the nodule, compressive symptoms, or suspicious findings on ultrasonography are the basis for the decision to perform surgery. thyroid FNA classification scheme to guide the clinical treatment of patients with thyroid nodules. This was a prospective study of 2… The high risk of malignancy (15%) noticed in Category II (benign) which should not exceed 3% needs further evaluation including both radiological and pathological correlation to exclude cases with incidental malignancy. However, they differ in terminologies used in reporting borderline lesions. There were 18 Bethesda V nodules (suspicious for malignancy), of which 11 underwent surgery and 8 (72.7%) were confirmed to be carcinoma, all are papillary carcinomas including three cases with follicular variant papillary carcinomas. This can happen when a cyst is aspirated or when the specimen is almost entirely composed of blood.
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