Objective: To evaluate the effectiveness of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) and to analyze the causes of unclear diagnoses following BSRTC adoption. Study Design: According to the BSRTC, we reclassified cytologic samples originally diagnosed as ‘indeterminate’ with sequential surgical resection. Then, we analyzed the causes of cases, which were recategorized as ‘atypia undetermined significance/follicular lesion of undetermined significance (AUS/FLUS)’. Results: According to the BSRTC, 154 ‘indeterminate’ cases were reclassified as follows: unsatisfactory, n = 5 (3.2%); benign, n = 43 (27.9%); AUS/FLUS, n = 77 (50.0%); suspicious for a follicular neoplasm, n = 7 (7.1%); suspicious for a Hürthle cell neoplasm, n = 4 (2.6%); suspicious for malignancy, n = 15 (9.7%), and malignancy, n = 3 (1.9%). Then, the AUS/FLUS group was analyzed according to the scenarios proposed by the BSRTC. Fifty-nine (58.9%) cases of AUS/FLUS were due to suboptimal preparation. In addition, papillary microcarcinoma and coexisting Hashimoto’s thyroiditis caused inconclusive diagnoses. Conclusion: The BSRTC can be easily applied to thyroid fine-needle aspiration. We were able to reclassify indeterminate thyroid nodules into more detailed categories and thus reduce the number of cases classified as indeterminate. However, suboptimal preparation, papillary microcarcinoma, and coexisting Hashimoto’s thyroiditis precluded cytopathologists from making definitive diagnoses.

Keywords:
Fine-needle aspiration, Indeterminate diagnosis, Bethesda System for Reporting Thyroid Cytopathology, Thyroid
1.
Soderstrom N: Puncture of goiters for aspiration biopsy. Acta Med Scand 1952;144:237–244.
2.
Gerhard R, da Cunha Santos G: Inter- and intraobserver reproducibility of thyroid fine needle aspiration cytology: an analysis of discrepant cases. Cytopathology 2007;18:105–111.
3.
Redman R, Yoder BJ, Massoll NA: Perceptions of diagnostic terminology and cytopathologic reporting of fine-needle aspiration biopsies of thyroid nodules: a survey of clinicians and pathologists. Thyroid 2006;16:1003–1008.
4.
Wang HH: Reporting thyroid fine-needle aspiration: literature review and a proposal. Diagn Cytopathol 2006;34:67–76.
5.
Cibas ES, Ali SZ: NCI Thyroid FNA State of the Science Conference: the BSRTC for reporting thyroid cytopathology. Am J Clin Pathol 2009;132:658–665.
6.
Williams MD, Suliburk JW, Staerkel GA, Busaidy NL, Clayman GL, Evans DB, Perrier ND: Clinical significance of distinguishing between follicular lesion and follicular neoplasm in thyroid fine-needle aspiration biopsy. Ann Surg Oncol 2009;16:3146–3153.
7.
Wang CC, Friedman L, Kennedy GC, Wang H, Kebebew E, Steward DL, Zeiger MA, Westra WH, Wang Y, Khanafshar E, Fellegara G, Juan Rosai J, LiVolsi V, Lanman RB: A large multicenter correlation study of thyroid nodule cytopathology and histopathology. Thyroid 2011;21:243–251.
8.
Somma J, Schlecht NF, Fink D, Khader SN, Smith RV, Cajigas A: Thyroid fine needle aspiration cytology: follicular lesions and the gray zone. Acta Cytol 2010;54:123–131.
9.
Rabaglia JL, Kabbani W, Wallace L, Holt S, Watumull L, Pruitt J, Snyder WH, Nwariaku FE: Effect of the BSRTC for reporting thyroid cytopathology on thyroidectomy rates and malignancy risk in cytologically indeterminate lesions. Surgery 2010;148:1267–1272.
10.
Nga ME, Kumarasinghe MP, Tie B, Sterrett GF, Wood B, Walsh J, Nguyen H, Whyte A, Frost FA: Experience with standardized thyroid fine-needle aspiration reporting categories: follow-up data from 529 cases with ‘indeterminate’ or ‘atypical’ reports. Cancer Cytopathol 2010;118:423–433.
11.
Lewis CM, Chang KP, Pitman M, Faquin WC, Randolph GW: Thyroid fine-needle aspiration biopsy: variability in reporting. Thyroid 2009;19:717–723.
12.
Lee K, Jung CK, Lee KY, Bae JS, Lim DJ, Jung SL: Application of BSRTC for reporting thyroid aspiration cytology. Korean J Pathol 2010;44:521–527.
13.
Layfield LJ, Morton MJ, Cramer HM, Hirschowitz S: Implications of the proposed thyroid fine-needle aspiration category of ‘follicular lesion of undetermined significance’: a five-year multi-institutional analysis. Diagn Cytopathol 2009;37:710–714.
14.
Jo VY, Stelow EB, Dustin SM, Hanley KZ: Malignancy risk for fine-needle aspiration of thyroid lesions according to the BSRTC for reporting thyroid cytopathology. Am J Clin Pathol 2010;134:450–456.
15.
Faquin WC, Baloch ZW: Fine-needle aspiration of follicular patterned lesions of the thyroid: diagnosis, management, and follow-up according to National Cancer Institute (NCI) recommendations. Diagn Cytopathol 2010;38:731–739.
16.
Ali SZ, Cibas ES: The BSRTC for Reporting Thyroid Cytopathology. New York, Springer, 2010.
17.
Guidelines of the papanicolaou society of cytopathology for fine-needle aspiration procedure and reporting: the Papanicolaou Society of Cytopathology Task Force on Standards of Practice. Diagn Cytopathol 1997;17:239–247.
18.
Ali SZ: Thyroid cytopathology: Bethesda and beyond. Acta Cytol 2011;55:4–12.
19.
Kini SR, Miller JM, Hamburger JI: Cytopathology of Hürthle cell lesions of the thyroid gland by fine needle aspiration. Acta Cytol 1981;25:647–652.
20.
Renshaw AA, Wang E, Wilbur D, Hughes JH, Haja J, Henry MR: Interobserver agreement on microfollicles in thyroid fine-needle aspirates. Arch Pathol Lab Med 2006;130:148–152.
21.
Baloch ZW, LiVolsi VA, Asa SL, Rosai J, Merino MJ, Randolph G, Vielh P, DeMay RM, Sidawy MK, Frable WJ: 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. Diagn Cytopathol 2008;36:425–437.
22.
Yassa L, Cibas ES, Benson CB, Frates MC, Doubilet PM, Gawande AA, Moore FD Jr, Kim BW, Nosé V, Marqusee E, Larsen PR, Alexander EK: Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation. Cancer 2007;111:508–516.
23.
Williams MD, Suliburk JW, Staerkel GA, Busaidy NL, Clayman GL, Evans DB, Perrier ND: Clinical significance of distinguishing between follicular lesion and follicular neoplasm in thyroid fine-needle aspiration biopsy. Ann Surg Oncol 2009;16:3146–3153.
24.
Theoharis CG, Schofield KM, Hammers L, Udelsman R, Chhieng DC: The Bethesda thyroid fine-needle aspiration classification system: Year 1 at an academic institution. Thyroid 2009;19:1215–1223.
25.
Tysome JR, Chandra A, Chang F, Puwanarajah P, Elliott M, Caroll P, Powrie J, Hubbard JG, Clarke SE, Jeannon JP, Simo R: Improving prediction of malignancy of cytologically indeterminate thyroid nodules. Br J Surg 2009;96:1400–1405.
26.
Shi Y, Ding X, Klein M, Sugrue C, Matano S, Edelman M, Wasserman P: Thyroid fine-needle aspiration with atypia of undetermined significance: A necessary or optional category? Cancer 2009;117:298–304.
27.
Renshaw AA: Should ‘atypical follicular cells’ in thyroid fine-needle aspirates be subclassified? Cancer Cytopathol 2010;118:186–189.
28.
Min SK, Seo J, Jun SY, Min K, Park HR: The analysis of indeterminate category in thyroid fine needle aspiration. Korean J Pathol 2010;44:657–661.
29.
Ljung BM: Thyroid fine-needle aspiration: smears versus liquid-based preparations. Cancer 2008;114:144–148.
30.
Rossi ED, Raffaelli M, Zannoni GF, Pontecorvi A, Mulè A, Callà C, Lombardi CP, Fadda G: Diagnostic efficacy of conventional as compared to liquid-based cytology in thyroid lesions: evaluation of 10,360 fine needle aspiration cytology cases. Acta Cytol 2009;53:659–666.
31.
Friguglietti CU, Dutenhefner SE, Brandao LG, Kulcsar MA: Classification of papillary thyroid microcarcinoma according to size and fine-needle aspiration cytology: behavior and therapeutic implications. Head Neck 2011;33:696–701.
32.
Repplinger D, Bargren A, Zhang YW, Adler JT, Haymart M, Chen H: Is Hashimoto’s thyroiditis a risk factor for papillary thyroid cancer? J Surg Res 2008;150:49–52.
33.
Kini SR: Thyroid Cytopathology: an Atlas and Text. Philadelphia, Lippincott Williams and Wilkins, 2008, pp 513.
34.
Duskova J, Tretinik P: Papillary thyroid carcinoma: an easy fine needle aspiration biopsy diagnosis? Acta Cytol 2011;55:120–130.
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2012
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