Unlike the core biopsy, decalcification is not required for the clot section. C This system also contains guidelines for the diagnosis and treatment of indeterminate or suspicious for malignancy cases. Warthin's tumor : the presence of oncocytic epithelium. S It is the hope of all contributors to this project that this terminology proposal will be a valuable first step toward uniformity and consensus in the reporting of thyroid FNA interpretations. {t+[O-]:KtJE]+ZhoZo$ZfqemI,W69l]g]EuGnWMGow" elP~G>6?{LsTY?R+-jW:E#x( xtT} . Human immunodeficiency virus (HIV)-associated cystic lymphoepithelial lesions. Open in a separate window This interpretation applies to cellular samples that are composed exclusively (or almost exclusively) of Hrthle cells. Histogenesis of medullary carcinoma of the thyroid. Should atypical follicular cells in thyroid fine-needle aspirates be subclassified? To collect as many cells as possible from sparsely cellular urine, the specimen should have which of the following techniques applied? sharing sensitive information, make sure youre on a federal If resected, virtually all benign follicular nodules turn out to be nodules of a multinodular goiter or follicular adenomas. Fine-needle aspiration (FNA) has an essential role in the evaluation of euthyroid patients with a thyroid nodule. et al. "Demystifying the Bone Marrow Biopsy: A Hematopathology Primer." Some cases may present with diagnostic difficulty if the specimen consists mainly of necrotic debris or if the tumor is extremely sclerotic (the paucicellular variant)[40,53]. 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]. Seventeen . B) 600 view of trilineage hematopoiesis. In adult mammalian testes, spermatids, most notably step 17-19 spermatids in stage IV-VIII tubules, are aligned with their heads pointing toward the basement membrane and their tails toward the tubule lumen. These specimens demonstrate inadequate cellularity, poor fixation and preservation, obscuring blood or ultrasound gel, or a combination of the above factors. A: Ideally, blasts should be calculated on the aspirate smear differential count; however, in cases where blasts express CD34, then a CD34 count on the core biopsy might be possible. Retrieved from https://www.hematology.org/education/trainees/fellows/trainee-news/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer. . This category includes specimens with unequivocal cytologic evidence of a malignant neoplasm. We reviewed the English literature regarding Thyroid Cytopathology systems in order to identify the most suitable methodology, taking into account our prospective as well. 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. . Sparsely definition, in a thinly distributed way; not thickly or densely: Michigan's Upper Peninsula is very sparsely populated, as more than 90% of it is forested. Q: Can flow cytometry be performed on the core biopsy? A review of the English literature was conducted, and data were analyzed and summarized and integrated from the authors perspective. Cytological diagnosis of paucicellular variant of anaplastic carcinoma of thyroid: report of two cases. Herein lies everything you were afraid to ask. Ohori NP, Nikiforova MN, Schoedel KE, LeBeau SO, Hodak SP, Seethala RR, Carty SE, Ogilvie JB, Yip L, Nikiforov YE. In cell biology, a paraspeckle is an irregularly shaped compartment of the cell, approximately 0.2-1 m in size, [1] found in the nucleus ' interchromatin space. 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. Pan-keratin is the most reliable positive immunostain in UTCs, acquiring an expression ranging from 50% to 100%. These features could be intranuclear inclusions, nuclear grooves, or psammoma calcifications; (6) DC VI Malignant (Figures (Figures55--7).7). Asa This variant of PTC is not common, but it is important to be recognized as it may be confused with a Hurthle cell neoplasm[44]. van Heerden Descriptive comments that follow are used to subclassify the malignancy and summarize the results of special studies, if any. Before the routine use of thyroid FNA, the percentage of surgically resected thyroid nodules that were malignant was 14%.1 With current thyroid FNA practice, the percentage of resected nodules that are malignant surpasses 50%.2. The risk of malignancy in the HCLUS category was significantly lower than in the other subtypes of AUS. The nucleoli are usually small and eccentric; however, rare oncocytic variants of PTC can show prominent nucleoli. Help . LiVolsi Apart from imaging studies, serological or immunohistochemical studies can be used to secure diagnosis, when the FNA indicated suspicious for MTC or suspicious for lymphoma. , eds. Note extensive red blood cells in the background. Extra smeared slides are kept unstained for possible subsequent ancillary staining (e.g., MPO, PAS, esterases). B) 1,000 view. 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. The cancer cells are also elongated, with a height-to-weight ratio of at least 3:1. Statistics . For full access to this pdf, sign in to an existing account, or purchase an annual subscription. It was apparent from the discussions at the conference and the Web postings that the primary purpose of terminology is clarity of communication. Rathan Quick tip: Flow cytometry cannot be performed on the clot section after the clot has set and after fixation in formalin. A benign result is obtained in 60% to 70% of thyroid FNAs. Alexander hbbd``b`$Ks ^ View an interactive bone marrow core biopsy online. III CS The separation of these four components allows for multiple sources of data collection and offers insurance against otherwise compromised specimens. 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. It is critical that cytopathologists communicate thyroid FNA interpretations to referring physicians in terms that are succinct, unambiguous, and clinically helpful. The management of cases with papillary microcarcinomas, i.e., tumors less than 1.0 cm in diameter, is still controversial. Cerutti JM. Jo VY, Stelow EB, Dustin SM, Hanley KZ. A benign follicular nodule is the most common benign pattern that is, an adequately cellular specimen composed of varying proportions of colloid and benign follicular cells arranged as macrofollicle and macrofollicle fragments. Note: Please review ASHs disclaimerregarding the use of the information contained in these articles. Preparation Methods 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. Such atypia may result from a variety of benign cellular changes, but in some cases may reflect an underline malignancy which has been suboptimally sampled or has intermediate diagnostic features[20-22]. M The nuclei have conventional PTC nuclear features that distinguish it from Hurthle cell neoplasms[35]. For clarity of communication, TBSRTC recommends that each report begin with 1 of 6 general diagnostic categories. Why do some investigations yield more, or less, information than others? A: Probably, yes. Some components are more useful for particular studies. Surgical intervention consisted of a 15 7 7-cm segmental mastectomy specimen that contained a large, ill-defined, irregular pink-tan . Anderson Cancer Center, Houston, Edward B. Stelow, MD, Department of Pathology, University of Virginia Health System, Charlottesville, Jerry Waisman, MD, Department of Pathology, New York University of Medicine, New York, Helen H. Wang, MD, DrPH, Department of Pathology, Beth Israel-Deaconess Medical Center, Boston, MA, Philippe Vielh, MD, PhD, Department of Pathology, Institut de Cancerologie Gustave Roussy, Villejuif, France, Grace C. H. Yang, MD, Department of Pathology, Weill Medical College of Cornell University, New York, NY, Matthew A. Zarka, MD, Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale. 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.. Your patients cytopenias remain unexplained. In: Ali SZ, Cibas ES, editors. Walfish As a library, NLM provides access to scientific literature. I These indeterminate results imply surgeons to consider alternative therapies (e.g., thyroid lobectomy with intraoperative frozen section). Baloch ZW, Cibas ES, Clark DP, Layfield LJ, Ljung BM, Pitman MB, Abati A. Figure 3. H The site is secure. 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. In this selected population, 20% to 25% of patients with AUS prove to have cancer after surgery, but this is undoubtedly an overestimate of the risk for all AUS interpretations.2,10 The risk of malignancy is certainly lower and probably closer to 5% to 15%. Schlinkert Cibas gynecologic cytology specimens 3. It is not widely agreed whether this neoplasm is a variant of PTC or not, although it seems to have the same RET gene rearrangements as PTC. Description of a distinctive morphological variant and report of 7 cases. 36.3-50 mL); all 3 scantly cellular specimens had volumes below this median value. The Bethesda System For Reporting Thyroid Cytopathology. Note the trabecular bone (*) with trilineage hematopoiesis including megakaryocytes, granulocytic precursors, and erythroid islands presented in 2D following formalin fixation and paraffin processing. Management guidelines for patients with thyroid nodules and differentiated thyroid cancer. To help the cells stay on the slide: a. add acetic acid to the fixative b. fix in neutral ID Research is directed to the identification of molecular markers that, in conjunction with FNA, can identify patients with a malignant nodule. The TBSRTC classifies thyroid follicular lesions with microfollicle predominance and lack of colloid into the suspicious for follicular neoplasm category. One nucleus has an apparent intranuclear pseudoinclusion (arrow). 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]. Pathology and Genetics of Tumours of Endocrine Organs, Genetic and biological subgroups of low-stage follicular thyroid cancer. The main purpose of thyroid FNA is to identify patients with higher risk for malignancy, and to prevent unnecessary surgeries for benign conditions. Flat sheets showing enlarged, pale nuclei with finely granular chromatin of a papillary Ca case ( 40 pap stain on ThinPrep slide) (diagnostic categories VI). There was also a great difference regarding the percentage of the cases classified into the TIR 2/ DC II (benign) category (83.9%) compared with approximately half (55.4%) of the cases in the 6-tiered system. Dottorini Phenotyping hematopoietic cells. Reduce red blood cells in smears iii. Malignancy risk for fine-needle aspiration of thyroid lesions according to the Bethesda System for Reporting Thyroid Cytopathology. The molecular testing proved to have a high specificity, although the sensitivity was quite low (60%). JR VanderLaan PA, Marqusee E, Krane JF. After patient preparation, sedation, and the procedure itself, a bone marrow investigation provides four specimen types for pathologist review (Figure 1): the bone marrow core biopsy, the bone marrow touch imprint, the bone marrow aspirate smear, and the bone marrow clot particle. Fine-needle aspiration (FNA) cytology is an important diagnostic tool in patients with thyroid lesions. Gough The most common malignant diagnosis made after surgery in cases initially classified as AUS/FLUS is PTC, usually of the follicular variant (PTC-FV)[24,25]. Q: Can the core biopsy determine the blast count? Wright-Giemsa staining of the marrow aspirate smear. Hematoxylin-eosinstained sections of the clot particle. Wu HH, Rose C, Elsheikh TM. The National Cancer Institute Thyroid fine needle aspiration state of the science conference: a summation. The significance and clinical value of a CFO result depend in large part on sonographic correlation. V In FNA specimens of this variant, the cancer cells appear more profuse, granular or vacuolated compared to regular PTC. 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. Theoharis CG, Schofield KM, Hammers L, Udelsman R, Chhieng DC. 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]. Moreover, a lower percentage of cases in the European system was placed into the TIR 4 and TIR 5 categories as well, compared with the American system. (A) A representative case classified as diagnostic category (DC) III (atypia of undetermined significance) showing sparsely cellular specimen (x15; scale bar, 200 m). In the World Health Organization classification, Hrthle cell adenoma and Hrthle cell carcinoma are considered oncocytic variants of FA and FC, respectively.24 Studies suggest, however, that follicular and Hrthle cell tumors have different underlying genetics.4,25 For this reason, and because they have such distinctive morphologic features, it is helpful to specify that a sample raises the possibility of a Hrthle cell rather than a follicular neoplasm. The interpretation should provide clinically relevant information that will assist referring physicians in the management of patients. Bone core biopsy. Until recently there were no uniform criteria for the various diagnostic categories in thyroid cytopathology. Because of the mixture of oncocytes with lymphocytes on smears, this tumor should be distinguished from Hashimoto thyroiditis or a follicular lesion with oncocytic changes[44]. 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. official website and that any information you provide is encrypted CS O American Society of Hematology. . 2021 L Street NW, Suite 900,Washington, DC 20036, Phone 202-776-0544Toll Free 866-828-1231Fax 202-776-0545, Copyright 2023 by American Society of Hematology, Support Opportunities|Privacy Policy|Terms of Service|Contact Us, Helping hematologists conquer blood diseases worldwide, Demystifying the Bone Marrow Biopsy: A Hematopathology Primer, https://www.hematology.org/education/trainees/fellows/trainee-news/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer, Relative quantity of different cell types, Provides material for flow and molecular studies. Its clinical utilization is significant, as it can define whether a recently emerged thyroid nodule should be managed expectantly or surgically, and can assist in selecting the appropriate surgical procedure when necessary[3]. et al. This conference established the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), a 6-tiered diagnostic classification system based on a probabilistic approach[8,9]. Deveci VA The main purpose of thyroid FNA is to stratify higher risk patients for surgery, and to prevent unnecessary surgeries for benign conditions. 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]. Three of the 28 specimens (11%) were sparsely cellular, and the rest (89%) were at least moderately cellular. Amrikachi The Bethesda System for Reporting Thyroid Cytopathology is the most widely used system for the diagnosis of thyroid FNA specimens. et al. While the V600E and K601E mutations were almost equally observed in the AUS/FLUS category, there was a slight predominance of K601E mutation in SFN/SHN category. Centrifuge the specimen again and decant the entire supernatant. 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 Ultrasound guidance is preferable than palpation-guided FNA for small nodules (< 1 cm), cystic lesions and when a prior FNA is nondiagnostic[13]. Table: Comparative advantages and drawbacks of the marrow aspirate versus the core biopsy. Baloch Since it is a two-dimensional specimen and reveals cells in cut section, it is not ideal for assessment of dysplasia (a marrow aspirate is preferred), but it is extremely useful in identifying possible reasons for a dry tap (a term for when liquid marrow cannot be aspirated during the bone marrow procedure), since the architecture can show fibrosis, sheets of cohesive plasma cells, or metastatic tumor which could result in a dry tap. The morphologic findings are very similar to that of the aspirate smear, with the caveat that it only represents the cells that slough off. Benson These cells constitute more than 50% of tumor volume[44]. The positive predictive value of a malignant FNA interpretation is 97% to 99%. Chemotherapy or radiotherapy usually cannot change the dismal prognosis of this cancer. Grant The Bethesda system for reporting thyroid cytopathology: An experience of 1,382 cases in a community practice setting with the implication for risk of neoplasm and risk of malignancy. 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? Cross PA, Poller D. The Bethesda thyroid terminology and progress towards international agreement on thyroid FNA cytology reporting. Thyroid, Cytopathology, Nodule, Papillary cancer, Fine needle, Biopsy. It generally affects elderly patients presenting as a firm mass rapidly growing in the neck infiltrating extrathyroidal tissues, such as muscle, trachea, esophagus, skin, bone and cartilage[49]. Handle sparsely cellular specimens ii. The discs are 2 mm thick in the unprocessed state, but less thick when processed, and sometimes slightly . These specimens typically show sheets of bland thyroid follicular cells, which represent flattened macrofollicles. Unless specified as ND/UNS, the FNA specimen is considered adequate for evaluation. Inclusion in an NLM database does not imply endorsement of, or agreement with, Cochand-Priollet What is the hematopathologist looking for when assembling all the parts to report back in consultation with you? Therefore, it is not prudent to remove every thyroid nodule we encounter in our medical practice. On the other hand a definitive diagnosis of a low-grade lymphoma (usually a MALT lymphoma) is even more difficult. Contribution of molecular testing to thyroid fine-needle aspiration cytology of follicular lesion of undetermined significance/atypia of undetermined significance. et al. Hematology.org.https://www.hematology.org/education/trainees/fellows/trainee-news/2021/demystifying-the-bone-marrow-biopsy-a-hematopathology-primer(label-accessed May 01, 2023).

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