National Cancer Institute Thyroid Fine Needle Aspiration Research Articles

Italian consensus for the classification and reporting of thyroid cytology.

IntroductionThyroid nodules are diagnosed with increasing frequencyin clinical practice. The first step in the management ofpatients presenting with thyroid nodules is an accuratetriage of those who should be referred to surgery [1–5]. Inspite of the advances in ultrasound (US) imaging [6–8] andthe promising results of molecular analysis [9–16], thisbasic step still strongly relies on cytology [3]. Among theacronyms used to indicate the sampling technique forthyroid cytology (FNA, FNAB, FNAC, FNC), fine-needleaspiration (FNA) is the most frequently adopted and it willbe employed in this document. When the cytologicspecimen is obtained without aspiration the term FNC(fine-needle cytology) may be used [2].In the recent years, a variety of four- to six-tieredreporting schemes for thyroid cytology have been proposedby different societies and institutions, with the aim ofimproving the communication between cytopathologistsand clinicians [17].With the aim to standardize the diagnostic terminologyin thyroid FNA, in 2007 the United States National CancerInstitute (NCI) has proposed a reporting system for thyroidcytology based on the NCI Thyroid FNA State-Of-ScienceConsensus Conference [18]. This system has gained widediffusion and the atlas ‘‘The Bethesda System for Report-ing Thyroid Cytology’’ (BSRTC) provided well-definedcriteria with exhaustive explanatory notes [19]. Followingthe recommendations of the 2009 European Federation ofCytology Societies (EFCS) symposium aiming at theworldwide unification of the reporting systems for thyroidcytology [20], a working group of the Royal College ofPathologists (RCPath) updated the reporting systemalready in use in UK since 2007 [21] using criteria that aresimilar to those used in BSRTC [22].In Italy, a 5-tiered classification, proposed in 2007 bythe Italian Society for Anatomic Pathology and Cytologyjoint with the Italian Division of the International Academyof Pathology (SIAPEC-IAP) [2], is currently used by mostinstitutions. In 2012 the Italian Societies of Endocrinology,i.e., the Italian Thyroid Association (AIT), the ItalianAssociation of Clinical Endocrinologists (AME), the Ital-ian Society of Endocrinology (SIE) and the SIAPEC-IAPappointed a working panel of experts to update the formerconsensus in line with the indications of the EFCS. Thepresent document provides a reporting scheme for thyroidcytology and the suggested clinical actions. This Consen-sus is not meant to address in detail all the morphological

Impact of Bethesda System of Reporting for Thyroid Cytopathology

ABSTRACTFNAC though considered the gold standard diagnostic test in the evaluation of a thyroid nodule, has many issues regarding the terminologies and interpretation. The National Cancer Institute (NCI) hosted the NCI Thyroid Fine needle Aspiration State of the Science Conference in 2007, which acknowledged the importance of developing a uniform terminology for reporting thyroid FNA results to facilitate effective communication among cytopathologists, endocrinologist, surgeons, radiologists and other healthcare providers. The NCI Conference concluded the terminology and morphologic criteria which formed the framework for The Bethesda system for reporting thyroid cytopathology (TBSRTC). It is a 6 tiered ‘The Bethesda System for Reporting Thyroid Cytopathology’ (TBSRTC) for unifying the terminology and morphologic criteria along with the corresponding risk of malignancy. Bethesda also offers management approach for all the categories. Bethesda system is presently widely accepted in western countries and is being introduced in rest of the world. This system of reporting undoubtedly represents a major step toward standardization, reproducibility and ultimately improvement in clinical significance, usefulness and predictive value of thyroid FNAC. The problems faced by the cytopathologist while implementing Bethesda during reporting are centred on AUS/FLUS category. The heterogeneity of this low-risk category leads to significant variability in its reported percentage as well as reported rate of malignancy.How to cite this articleDhume V, Kavishwar V. Impact of Bethesda System of Reporting for Thyroid Cytopathology. Int J Otorhinolaryngol Clin 2014;6(1):15-22.

Reproducibility of 'The Bethesda System for reporting Thyroid Cytopathology': A MultiCenter Study with Review of the Literature.

To achieve the standardization of the thyroid FNA reporting, the National Cancer Institute (NCI) hosted the "NCI Thyroid Fine Needle Aspiration State of the Science Conference", which led to the formation of 'The Bethesda System for Reporting Thyroid Cytopathology' (TBSRTC). The present study was undertaken by 2 experts in thyroid FNA, who in a double blinded fashion, examined and re-classified 80 random FNA cases according to the 6 levels of TBSRTC for an inter-observer review, to study and assess the new terminology for ease of reproducibility and to note the rate of disagreement overall or in any particular category. The FNAs were reclassified in a double blinded fashion according to the 6 levels of TBSRTC which are: non diagnostic (ND); benign; atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS); follicular neoplasm/suspicious for a follicular neoplasm (FN/SFN), Hurthle cell type/suspicious for a follicular neoplasm, Hurthle cell type (FNHCT/SFNHCT); suspicious (SUS), and malignant. In the present study, the maximum number of cases was reclassified under the benign category (61.25% cases), followed by the FN/ SFN category and the AUS/FLUS category (11.25% and 10.00% respectively). An agreement was reached in 66 cases (82.5%); the experts disagreed in 14 cases-17.5% (where 1 expert did not agree with the other). Individually; a 93.87% agreement was noted for the lesions in the benign category, for 50% lesions in the AUS/FLUS category, for 66.66% lesions in the FN/SFN and the SUS categories, for 71.42% lesions in the FNHCT/ SFNHCT categories and for 100% lesions in the ND and the malignant categories. Thus, the maximum disagreement was noted in the AUS/FLUS category. The implementation of TBSTRC which stands for a unique, international and a universal terminology for reporting the thyroid cytology; should be encouraged in our country, because of its relative ease of reproducibility. Although there was a great deal of agreement in implementing TBSTRC in the present study; disagreements were seen in the categories of AUS/FLUS and FN/SFN in the study which was conducted at our centre. This corroborated with the findings of the studies which were done elsewhere.

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

The National Cancer Institute (NCI) sponsored the NCI Thyroid Fine Needle Aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The 2-day meeting was accompanied by a permanent informational website and several on-line discussion periods between May 1 and December 15, 2007 (http://thyroidfna.cancer.gov). This document summarizes matters regarding the utilization of ancillary studies in thyroid FNA (http://thyroidfna.cancer.gov/pages/info/agenda/).

Post‐thyroid FNA testing and treatment options: A synopsis of the National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference

The National Cancer Institute (NCI) sponsored the NCI Thyroid Fine Needle Aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The 2-day meeting was accompanied by a permanent informational Web site and several on-line discussion periods between May 1 and December 15, 2007 (http://thyroidfna.cancer.gov). This document addresses follow-up procedures and therapeutic options for suggested diagnostic categories. Follow-up options for "nondiagnostic" and "benign" thyroid aspirates are given. The value of ultrasound examination in the follow-up of "nondiagnostic" and "benign" thyroid aspirates is discussed. Ultrasound findings requiring reaspiration or surgical resection are described as are the timing and length of clinical and ultrasonographic surveillance for cytologically "benign" nodules. Options for surgical intervention are given for the diagnostic categories of "atypical/borderline," "follicular neoplasm," "suspicious for malignancy" and "malignant" (http://thyroidfna.cancer.gov/pages/info/agenda/).

Training, credentialing and re‐credentialing for the performance of a thyroid FNA: A synopsis of the National Cancer Institute Thyroid Fine‐Needle Aspiration State of the Science Conference

The National Cancer Institute (NCI) sponsored the NCI Thyroid Fine-Needle Aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The 2-day meeting was accompanied by a permanent informational website and several on-line discussion periods between May 1 and December 15, 2007 (http://thyroidfna.cancer.gov). This document summarizes matters regarding training for the performance of thyroid FNA via palpation; training for the performance of thyroid FNA via ultrasound imaging, and credentialing/re-credentialing for the performance of a thyroid FNA. (http://thyroidfna.cancer.gov/pages/info/agenda/)

Indications for thyroid FNA and pre‐FNA requirements: A synopsis of the National Cancer Institute Thyroid Fine‐Needle Aspiration State of the Science Conference

The National Cancer Institute (NCI) sponsored the NCI Thyroid Fine-Needle Aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The 2-day meeting was accompanied by a permanent informational website and several on-line discussions between May 1 and December 15, 2007 (http://thyroidfna.cancer.gov). This document summarizes the indications for performing an FNA of a nodule discovered by physical examination or an imaging study; the indications for using ultrasound versus palpation for guidance when performing a thyroid FNA; the issues surrounding informed consent for thyroid FNA; and the information required on a requisition form that accompanies a thyroid FNA specimen. (http://thyroidfna.cancer.gov/pages/info/agenda/)

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 (NCI) sponsored the NCI Thyroid Fine-needle Aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The two-day meeting was accompanied by a permanent informational website and several on-line discussion periods between May 1 and December 15, 2007 (http://thyroidfna.cancer.gov). This document summarizes matters regarding diagnostic terminology/classification scheme for thyroid FNA interpretation and cytomorphologic criteria for the diagnosis of various benign and malignant thyroid lesions. (http://thyroidfna.cancer.gov/pages/info/agenda/).

Techniques for thyroid FNA: A synopsis of the National Cancer Institute Thyroid Fine‐Needle Aspiration State of the Science Conference

The National Cancer Institute (NCI) sponsored the NCI Thyroid fine-needle aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The 2-day meeting was accompanied by a permanent informational website and several on-line discussion periods between May 1 and December 15, 2007 (http://thyroidfna.cancer.gov). This document summarizes matters addressing manual and ultrasound guided FNA technique and related issues. Specific topics covered include details regarding aspiration needles, devices, and methods, including the use of core needle biopsy; the pros and cons of anesthesia; the influence of thyroid lesion location, size, and characteristics on technique; the role of ultrasound in the FNA of a palpable thyroid nodule; the advantages and disadvantages of various specialists performing a biopsy; the optimal number of passes and tissue preparation methods; sample adequacy criteria for solid and cystic nodules, and management of adverse reactions from the procedure. (http://thyroidfna.cancer.gov/pages/info/agenda/)

The National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference: a Summation

On October 22 and 23, 2007, the National Cancer Institute (NCI) hosted NCI Thyroid Fine Needle Aspiration (FNA) State of the Science Conference, a two-day gathering in Bethesda, Maryland. Its mission was to establish a comprehensive interdisciplinary informational dialogue dedicated to thyroid FNA. Preparations for the conference began 18 months earlier with the designation of a steering committee, the appointment of nine working committees, coordination with co-sponsoring organizations, and the establishment of a dedicated permanent web site. The function of the website was to serve as a permanent educational tool for health care practitioners and patients alike, as well as to foster on-line dialogue. Six committees were charged with preparing summary documents based on literature reviews on the following subjects: 1. Indications/Pre-FNA requirements; 2. Training and Credentialing; 3. Technique; 4. Terminology and Morphologic Criteria; 5. Ancillary Studies; and 6. Post-FNA Options for Testing and Treatment. Three additional committees were formed, one each to oversee the website, publications ensuing from the conference and the establishment of an on-line educational cytopathology atlas. Literature reviews were limited to English language publications dating back to 1995, using PubMed as the search engine, with key words determined by the committee members. The first draft of the committees' summary documents (Review and Conclusions) was posted on the web site and open for on-line forum discussion from May 1-June 30, 2007. There were several subsequent drafts and on-line discussion periods (Aug 15 – Sept. 30, 2007 and Nov. 30-Dec. 15, 2007). The documents underwent revision after each comment period prior to re-posting on the web. The two-day live conference in October, attended by 154 registrants, comprised of pathologists, endocrinologists, surgeons, and radiologists, gave the committees an in-depth opportunity to present their conclusions and debate controversial areas. This is an abridged version of the topics reviewed at the conference and the website. This is not a standards of practice guideline, nor is it endorsed as such by the National Cancer Institute.