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Thyroid fine-needle aspiration reporting rates and outcomes before and after Bethesda implementation within a combined academic and community hospital system.

The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) was implemented with the goal of standardizing the practice of thyroid cytopathology. Prior to the BSRTC, there was no uniformity between laboratories and clinicians on the number of categories, nomenclature, and predictive value of each category. Therefore, a multidisciplinary conference was held at the National Cancer Institute in Bethesda, Maryland, in October 2007, and the proceedings were published in June 2008. (1-6) Ultimately, a uniform, 6-tiered reporting system was proposed with defined diagnostic categories, standardized nomenclature, and predictive risk of malignant outcomes for each diagnostic category. (7,8)

Since the BSRTC was introduced, the "atypia of undetermined significance or follicular lesion of undetermined significance" (AUS/FLUS) category has received significant attention within the cytology literature, and it has been the most controversial. The recommended target usage rate of this category was set at approximately 7% of all thyroid fine-needle aspiration biopsies (FNABs), with a risk of malignancy of 5% to 15%. (8) Given the reduced risk of malignancy compared with the "follicular neoplasm" or "suspicious for follicular neoplasm" category, the recommended management for a diagnosis of AUS/FLUS was a repeat FNAB in 3 to 6 months. (8) Several years after the creation of the AUS/ FLUS category, numerous laboratories have begun publishing their incidence rates for this category following retrospective reviews, and these rates have ranged from 2.1% to 18%. (9-18) These same studies have also reported their respective rates of malignancy as ranging from 6% to 48% for cases classified as AUS/FLUS with available follow-up. (9-12,14-19)

It was noted at the time of the National Cancer Institute State of the Science Conference that the original recommendations may need to be revisited. Recently published data suggest that there is still some variation in incidence and risk of malignancy for the AUS/FLUS category. Our study seeks to compare our laboratory data before and after BSRTC implementation with other published data and to identify common trends observed.

MATERIALS AND METHODS

This study was conducted with the approval of the Institutional Review Board of The Methodist Hospital Research Institute (IRB#0000653). This retrospective review was conducted in the Department of Pathology and Genomic Medicine of The Methodist Hospital in Houston, Texas. An electronic medical record search was performed on patient records from the period 2002-2005, prior to implementation of the BSRTC (mid-2008), and from the period 2009-2011, after implementation of the BSRTC. The search retrieved patient data for all thyroid FNABs performed at The Methodist Hospital in the Texas Medical Center and at community hospitals in The Methodist Hospital System.

Both ultrasound-guided and nonguided biopsies were included in the study, although almost all cases were performed with ultrasound guidance by an experienced radiologist with a 25-gauge needle. Immediate assessment was performed on Diff-Quik-stained smears for nearly all cases. Typically, 3 to 5 passes were performed, and smears were prepared from each pass using a Differential Quik Stain Kit (modified Giemsa, Polysciences Inc, Warrington, Pennsylvania) and a Papanicolaou stain (Sigma-Aldrich, St Louis, Missouri). In most cases, a subsequent ThinPrep (Hologic Inc, Marlborough, Massachusetts) slide was prepared from the CytoLyte needle rinse (Hologic Incorporated, Marlborough, Massachusetts). Slides were screened by a cytotechnologist and were reviewed by a board-certified cytopathologist or an anatomic pathologist with more than 20 years of experience. The recommended criteria for specimen adequacy were strictly followed. For a thyroid FNAB specimen to be considered satisfactory, at least a minimum of 6 groups of well-preserved/well-visualized cells were required. In the post-Bethesda era, the cyst contents with macrophages only and an insufficient number of follicular cells were considered unsatisfactory for evaluation.

Diagnoses were then reported in the 6-tiered BSRTC terminology for the 2009-2011 cases, and in a 4-tiered system for the 2002-2005 cases. The 4-tiered system prior to BSRTC included unsatisfactory, negative, suspicious, and positive for malignancy. At our institution, prior to implementation of the current BSRTC, the general category of suspicious" was further subclassified as either "suspicious for follicular neoplasm," "suspicious for Hurthle cell neoplasm," or "suspicious for malignancy." Therefore, our classification scheme was essentially similar to the BSRTC, except for the AUS/FLUS category, which did not exist prior to 2008.

All AUS/FLUS and "suspicious" cases were checked for available follow-up, including either a thyroidectomy or repeat FNAB, and the results were correlated with the previous cytology diagnosis. Data from the current study were then compared with similar data obtained from a review of the current peer-reviewed cytology literature and previously published data from our institution. (20)

RESULTS

For 2002-2005, a total of 3302 thyroid FNABs were performed in our hospital system prior to implementation of the current BSRTC. The breakdown of the cytologic diagnoses for all of these cases was based on a 4-tiered system, which was used until 2008. Diagnoses from the 2002-2005 FNABs were as follows: 72 (2.2%) unsatisfactory, 2797 (84.7%) negative, 309 (9.4%) suspicious, and 124 (3.8%) positive for malignancy.

For 2009-2011, a total of 3432 thyroid FNABs were performed in our hospital system following the implementation of the current BSRTC in mid-2008. The breakdown of the cytologic diagnoses based on the current BSRTC was as follows: 61 (1.8%) unsatisfactory, 3047 (88.8%) negative, 72 (2.1%) AUS/FLUS, 79 (2.3%) suspicious for follicular neoplasm, 27 (0.7%) suspicious for Hurthle cell neoplasm, 36 (1%) suspicious for malignancy, and 110 (3.2%) positive for malignancy. The above data are summarized in Table 1.

All thyroid FNABs for 2009-2011 with a diagnosis of AUS/ FLUS or "suspicious" were checked for any available follow-up material, including repeat FNAB or thyroidectomy. The results are summarized in Table 2. Of the 72 cases of AUS/ FLUS on cytologic evaluation, 31 cases (43%) had follow-up procedures: 11 were repeat FNABs, 18 were surgical resections, and 2 were both repeat FNAB and surgical resection. Of the 11 repeat FNABs, 2 were AUS/FLUS, 1 was positive for malignancy, and 1 was "suspicious for follicular neoplasm." Of the 18 surgical resections, 4 were positive for malignancy (papillary carcinomas) and 1 was a Hurthle cell neoplasm of uncertain malignant potential. The cases with both repeat FNAB and surgical resection were a benign adenomatous nodule and a follicular adenoma. Therefore, from the 31 AUS/FLUS cases with available follow-up, there were 6 (19%) with a confirmed malignant diagnosis.

Of the 79 cases classified as "suspicious for follicular neoplasm" on cytologic evaluation, 33 (41.8%) had follow-up histologic material (thyroidectomy/lobectomy) available, of which 7 (21.2%) were confirmed malignant. Of the 27 cases classified as "suspicious for Hurthle cell neoplasm" on cytologic evaluation, 11 (40.7%) had follow-up histologic material (thyroidectomy/lobectomy) available, of which 2 (18.2%) were confirmed malignant and 1 was classified as a Hurthle cell neoplasm of uncertain malignant potential. Of the 36 cases classified as "suspicious for malignancy" on cytologic evaluation, 16 (44.4%) had follow-up histologic material (thyroidectomy/lobectomy) available, of which 13 (81.3%) were confirmed malignant. The data above combined for a total of 142 cases classified as "suspicious." Of these, 60 (42.3%) had follow-up histologic material (thyroidectomy/lobectomy) available, of which 23 (38.3%) were confirmed malignant.

Table 2 also includes a comparison of previously published data from our institution for 2000-2005 regarding the histologic follow-up of all suspicious cases. (20) A comparison of the data from our laboratory was then made with similar recently published results from other laboratories using the BSRTC. (9-12,15-17,19,21,22) Tables 3 and 4 show the cumulative data gathered from our results and the published data of these other institutions.

COMMENT

The AUS/FLUS category has been a controversial category since the BSRTC was published in 2008. The controversy continues as additional data become available from laboratories. However, as more data are compiled, several trends have been identified from the AUS/FLUS category. Data from previous studies have shown an inverse relationship between the incidence of cases classified as AUS/FLUS and the percentage of these cases with malignant outcomes. (22) Our data fit with this trend because we have a low AUS/ FLUS rate of 2.1% and a slightly increased percentage (19%) of malignant outcomes within this category, compared with the recommended 15% risk of malignancy in the BSRTC.

Additionally, one conclusion from this inverse relationship was that because a high AUS/FLUS rate is linked to a lower malignancy rate, laboratories with a high incidence of AUS/FLUS might be overcalling benign FNABs rather than undercalling specimens more aptly classified as "suspicious for malignancy." (22) Our data also support this hypothesis, because our laboratory uses the AUS/FLUS category sparingly, and we have a slightly higher rate of malignant outcomes (19%). It is also of note that once the AUS/FLUS category was added to our lexicon, our rate of cases classified as "suspicious" was noted to decrease from 9.4% to 4.1%. Therefore, we believe that the introduction of the AUS/FLUS category may have caused our laboratory to classify cases as AUS/FLUS that, prior to the BSRCT, would have been classified as "suspicious." During this same time period, our rate of cases classified as "benign" actually slightly increased from 85% to 89%.

To determine whether our laboratory was underusing the AUS/FLUS category at the expense of sensitivity, we reviewed the rate of malignant outcomes in all cases classified as "suspicious" that had available follow-up. Our risks of malignancies for cases classified as "suspicious for follicular neoplasm," "suspicious for Hurthle cell neoplasm," and "suspicious for malignancy" were 21.2%, 27%, and 81.3%, respectively. Because our risks of malignancy for "suspicious for follicular neoplasm" and "suspicious for Hurthle cell neoplasm" were within the 15% to 30% recommended by the BSRTC, and our risk of malignancy for "suspicious for malignancy" was only slightly higher than the 60% to 75% recommended by the BSRTC, we believe that our use of the AUS/FLUS category was appropriate and only slightly at risk of being underused.

We also compared the rate of malignant outcomes after BSRTC with previously published pre-BSRTC data from our institution for 2000-2005. (20) Prior to BSRTC implementation, our risks of malignancies for suspicious cases subclassified a.s "suspicious for follicular neoplasm," "suspicious for Hurthle cell neoplasm," and "suspicious for malignancy" were 24.1%, 40.5%, and 82.9%, respectively. (20) This comparison shows similar risks of malignant outcomes for each of the categories before and after BSRTC. We believe this is also a result of using a system very similar to the BSRTC before its implementation at our institution.

Other recent studies have also shown that the incorporation of a consensus review or defined diagnostic morphologic criteria resulted in more than half of AUS/ FLUS cases being reclassified as benign. (22-24) Cytopathologists at our institution often seek a second opinion or consensus prior to classifying a case as AUS/FLUS, and this may be another reason why our incidence of AUS/FLUS is at the low end of published data. Additionally, by seeking another opinion prior to classifying a case as AUS/FLUS, our department has been able to limit the use of this category while still maintaining an appropriate rate of malignant outcomes within this category. Our 19% risk of malignancy is slightly above the 15% risk of malignancy in the BSRTC. The 19% risk of malignancy of AUS/FLUS in our laboratory may be overrepresented because this rate is calculated from only 43% of AUS/FLUS cases with available follow-up. It has also been previously suggested that the reported rates of malignancy may be elevated because they are calculated from a subset of nodules that were selected for surgery, and therefore do not account for an inherent selection bias. (18) By design, most patients with nodules classified as AUS/FLUS will have benign nodules and will not undergo surgical resection, and their outcomes will not be known. (25)

Other possibilities for such wide variation in the rate of AUS/FLUS cases among laboratories include differences in diagnostic threshold, experience, preparation methods, and the availability of rapid onsite evaluation. (25,26) Our institution routinely provides rapid onsite evaluation by a board-certified cytopathologist for adequacy at the time of biopsy. This is also done at the community hospitals in our system. Also, all thyroid FNABs are ultimately signed out by a board-certified cytopathologist or one of 3 anatomic pathologists, each with more than 20 years of experience signing out cytology specimens. This may also account for our laboratories' ability to limit the usage of the AUS/FLUS category without sacrificing sensitivity. One study did specifically address the issues of experience and board certification in cytopathology, and it noted statistical significance in the variation of AUS/FLUS rates between board-certified cytopathologists versus non-board-certified cytopathologists, although the study authors noted a small sample size (5 of 7 cytopathologists were board certified in cytopathology). (18)

Because of the wide variation in reported AUS/FLUS rates from early studies, some authors have attempted to resolve this dilemma with the creation of a standardized performance measure similar to the "atypical squamous cells of undetermined significance" to "squamous intraepithelial lesion" (ASCUS/SIL) ratio used for cervical/vaginal Papanicolaou tests. (26) One such proposed performance measure has been the AUS/M ratio, which would compare the AUS/ FLUS rate versus the malignant (M) rate. (26) This potential performance measure offers several advantages because it is a simple calculation, accounts for variations in cancer prevalence among different patient populations, and contains a component (M) that can be evaluated by histopathologic correlation. (26) However, additional studies will be needed to test these proposed performance measures and determine the appropriate recommended range.

CONCLUSION

Although challenges remain with the AUS/FLUS category, an understanding of how each individual laboratory uses this category is imperative. Although the ultimate goal of the BSRTC is to eventually develop a unified system that is standardized among all laboratories, it will be important to understand how each laboratory performs compared with the recommendations of the BSRTC and to continue accumulating published data. However, when used appropriately, the AUS/FLUS category does indicate a reduced risk compared with cases categorized as "suspicious" and warrants the current recommendation of a repeat aspirate in 3 to 6 months, followed by surgery for those nodules with a subsequent AUS/FLUS or worse diagnosis.

References

(1.) Cibas ES, Alexander EK, Benson CB, de Agustin PP, Doherty GM, Faquin WC, et al. Indications for thyroid FNA and pre-FNA requirements: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol. 2008;36(6):390-399.

(2.) Ljung BM, Langer J, Mazzaferri EL, Oertel YC, Wells SA, Waisman J. 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. Diagn Cytopathol. 2008;36(6):400-406.

(3.) Pitman MB, Abele J, Ali SZ, Duick D, Elsheikh TM, Jeffrey RB, et al. Techniques for thyroid FNA: a synopsis of the National Cancer Institute Thyroid Fine-Needle Aspiration State of the Science Conference. Diagn Cytopathol. 2008; 36(6):407-424.

(4.) Baloch ZW, LiVolsi VA, Asa SL, Rosai J, Merino MJ, Randolph G, et al. 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(6):425 437.

(5.) Filie AC, Asa SL, Geisinger KR, Logani S, Merino M, Nikiforov YE, et al. 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. Diagn Cytopathol. 2008;36(6):438-441.

(6.) Layfield LJ, Abrams J, Cochand-Priollet B, Evans D, Gharib H, Greenspan F, et al. Post-thyroid FNA testing and treatment options: a synopsis of the National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. Diagn Cytopathol. 2008;36(6):442-448.

(7.) Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference. The Bethesda System for Reporting Thyroid Cytopathology. Am J Clin Pathol. 2009; 132(5):658-665.

(8.) Ali SZ, Cibas ES, eds. The Bethesda System for Reporting Thyroid Cytopathology: Definitions, Criteria and Explanatory Notes. 1st ed. New York, NY: Springer; 2010.

(9.) Nayar R, Ivanovic M. The indeterminate thyroid fine-needle aspiration: experience from an academic center using terminology similar to that proposed in the 2007 National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. Cancer. 2009;117(3):195-202.

(10.) 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(11):1215-1223.

(11.) Marchevsky AM, Walts AE, Bose S, Gupta R, Fan X, Frishberg D, et al. Evidence-based evaluation of the risks of malignancy predicted by thyroid fine- needle aspiration biopsies. Diagn Cytopathol. 2010;38(4):252-259.

(12.) Jo VY, Stelow EB, Dustin SM, Hanley KZ. Malignancy risk for fine-needle aspiration of thyroid lesions according to the Bethesda system for reporting thyroid cytopathology. Am J Clin Pathol. 2010;134(3):450-456.

(13.) Renshaw AA. Subclassification of atypical cells of undetermined significance in direct smears of fine-needle aspirations of the thyroid: distinct patterns and associated risk of malignancy. Cancer Cytopathol. 2011;119(5):322-327.

(14.) Luu MH, Fischer AH, Pisharodi L, Owens CL. Improved preoperative definitive diagnosis of papillary thyroid carcinoma in FNAs prepared with both ThinPrep and conventional smears compared with FNAs prepared with ThinPrep alone. Cancer Cytopathol. 2011;119(1):68-73.

(15.) 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(10):710-714.

(16.) Shi Y, Ding X, Klein M, Sugrue C, Matano S, Edelman M, et al. Thyroid fine-needle aspiration with atypia of undetermined significance: a necessary or optional category? Cancer. 2009;117(5):298-304.

(17.) 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(2):123-131.

(18.) Vanderlaan PA, Krane JF, Cibas ES. The frequency of 'atypia of undetermined significance' interpretations for thyroid fine-needle aspirations is negatively correlated with histologically proven malignant outcomes. Acta Cytol. 2011;55(6):512-517.

(19.) Renshaw AA. Should "atypical follicular cells" in thyroid fine-needle aspirates be subclassified? Cancer Cytopathol. 2010;118(5):186-189.

(20.) Raparia K, Min SK, Mody DR, Anton R, Amrikachi M. Clinical outcomes for "suspicious" category in thyroid fine-needle aspiration biopsy: patient's sex and nodule size are possible predictors of malignancy. Arch Pathol Lab Med. 2009;133(5):787-790.

(21.) VanderLaan PA, Marqusee E, Krane JF. Clinical outcome for atypia of undetermined significance in thyroid fine-needle aspirations: should repeated fna be the preferred initial approach? Am J Clin Pathol. 2011;135(5):770-775.

(22.) VanderLaan PA, Marqusee E, Krane JF. Features associated with locoregional spread of papillary carcinoma correlate with diagnostic category in the Bethesda System for Reporting Thyroid Cytopathology. Cancer Cytopathol. 2012; 120(4):245-253.

(23.) Jing X, Knoepp SM, Roh MH, Hookim K, Placido J, Davenport R, et al. Group consensus review minimizes the diagnosis of "follicular lesion of undetermined significance" and improves cytohistologic concordance. Diagn Cytopathol. 2011;40(12):1037-1042.

(24.) Jing X, Roh MH, Knoepp SM, Zhao L, Michael CW. Minimizing the diagnosis of "follicular lesion of undetermined significance" and identifying predictive features for neoplasia. Diagn Cytopathol. 2011;39(10):737-742.

(25.) Ohori NP, Schoedel KE. Variability in the atypia of undetermined significance/follicular lesion of undetermined significance diagnosis in the Bethesda system for reporting thyroid cytopathology: sources and recommendations. Acta Cytol. 2011;55(6):492-498.

(26.) Krane JF, Vanderlaan PA, Faquin WC, Renshaw AA. 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. Cancer Cytopathol. 2012;120(2):111-116.

Aaron M. Harvey, MD; Dina R. Mody, MD; Mojgan Amrikachi, MD

Accepted for publication December 14, 2012.

From the Department of Pathology and Genomic Medicine, The Methodist Hospital, Weill Medical College of Cornell University, Houston, Texas.

Dr Harvey is now with the Department of Pathology, Christus Health System, Corpus Christi, Texas.

The authors have no relevant financial interest in the products or companies described in this article.

Presented in abstract/poster form at the 2011 American Society of Cytopathology annual meeting; November 4-8, 2011; Baltimore, Maryland; and the 2012 Texas Society of Pathologists annual meeting; January 13-14, 2012; Dallas, Texas.

Reprints: Mojgan Amrikachi, MD, Department of Pathology and Genomic Medicine, The Methodist Hospital, 6565 Fannin St, Main 227, Houston, TX 77030 (e-mail: mamrikachi@tmhs.org).
Table 1. Thyroid Fine-Needle Aspiration Biopsy Reporting Rates by
Diagnostic Category Before and After Bethesda Implementation

                                                         Suspicious
                 Unsatisfactory, Negative,    AUS/FLUS,    for FN,
Time Frame         No. (%)       No. (%)      No. (%)     No. (%)

2002-2005          72 (2.2)     2797 (84.7)     NA       309 (9.4)(a)
2009-2011          61 (1.8)     3047 (88.8)  72 (2.1)    79 (2.3)

                 Suspicious  Suspicious    Positive
                 for HN,    Malignancy,    Malignancy, Total Cases,
Time Frame       No. (%)      No. (%)       No. (%)     No. (%)

2002-2005                                  124 (3.8)   3302 (100.0)
2009-2011        27 (0.8)     36 (1.0)     110 (3.2)   3432 (100.0)

Abbreviations: AUS/FLUS, atypia of undetermined significance or
follicular lesion of undetermined significance; FN, Follicular
neoplasm; HN, Hurthle cell neoplasm; NA, not available in published
study.

(a) Calculated total of all suspicious for follicular neoplasm,
suspicious for Hurthle cell neoplasm, and suspicious for malignancy.

Table 2. Comparison of Histologic Outcomes for Suspicious
and Atypia of Undetermined Significance or Follicular Lesion
of Undetermined Significance (AUS/FLUS) Thyroid Fine-Needle
Aspiration Biopsies (FNABs) Before and After Bethesda
Implementation
                                              2009-2011

                                      Cases With       Cases With
                                      Histologic        Malignant
                        Total         Follow-up,        Outcomes,
Cytology Diagnosis      Cases,         No. (%)           No. (%)
                        No.

AUS/FLUS                 72           31 (43.0) (b)      6 (19)
Total suspicious (d)    142           60 (42.3)         23 (38.3)
  Suspicious for         79           33 (41.8)          7 (21.2)
    follicular
    neoplasm
  Suspicious for         27           11 (40.7)          3 (27)
    Hurthle cell
    neoplasm
  Suspicious for         36           16 (44.4)         13 (81.3)
    malignancy

                                       2000-2005 (a)

                                  Cases With    Cases With
                                  Histologic     Malignant
                                  Follow-up,     Outcomes,
Cytology Diagnosis      Total,        No.         No. (%)
                          No.

AUS/FLUS                            DNE (c)
Total suspicious (d)      309         180        70 (38.9)
  Suspicious for          NA          108        26 (24.1)
    follicular
    neoplasm
  Suspicious for          NA           37        15 (40.5)
    Hurthle cell
    neoplasm
  Suspicious for          NA           35        29 (82.9)
    malignancy

Abbreviations: DNE, did not exist; NA, not available in
published study.

(a) Data derived from Raparia et al. (20)

(b) The 31 cases include 18 surgical resections, 11 repeat
FNABs, and 2 with both repeat FNAB and surgical resection.

(c) AUS/FLUS category did not exist prior to 2008.

(d) Total suspicious category includes suspicious for
follicular neoplasm, suspicious for Hurthle cell neoplasm,
and suspicious for malignancy.

Table 3. Incidence of Reported BSRTC Categories From Literature, (%)

               Nayar
                and       Theoharis     Marchevsky    Jo
Diagnostic   Ivanovic,(9) et al,(10)    et al,(11)    et al,(12)
Category        2009         2009          2010       2010

UNS/ND               5         11.1           12.9         18.6
Benign              64         73.8           71.6           59
AUS/FLUS            18            3            9.8          3.4
FN/SFN               6          5.5            1.5          9.7
SuspM                2          1.3            2.3          2.3
Malignant            5          5.2              2            7

                             Luu                Somma     Layfield
Diagnostic   Renshaw,(13)et al,(14) Current    et al,(17) et al,(15)
Category       2011         2011    Study        2010       2009

UNS/ND             24        8.7        1.8       16.1         NA
Benign             54       71.1         89       64.4         NA
AUS/FLUS            8        3.8        2.1       15.8       12.1
FN/SFN              9        9.2        3.1        1.8         NA
SuspM               2        2.9          1                    NA
Malignant           4        4.4        3.2        1.9         NA

                        Vanderlaan
               Shi      et al,(18); 2011;
Diagnostic   et al,(16) VanderLaan
Category       2009     et al,(22) 2012

UNS/ND            NA        12.9
Benign            NA        62.8
AUS/FLUS         2.1        11.2
FN/SFN            NA         3.9
SuspM             NA         4.2
Malignant         NA         4.9

Abbreviations: AUS/FLUS, atypia of undetermined significance or
follicular lesion of undetermined significance; FN/SFN, follicular
neoplasm/suspicious for follicular neoplasm; NA, not available in
published study; SuspM, suspicious for malignancy; UNS/ND,
unsatisfactory/non-diagnostic.

Table 4. Malignant Outcome by Cytologic-Histologic Correlation for
BSRTC Diagnostic Categories From Literature, (%)

              Nayar
               and       Theoharis    Marchevsky   Jo
Diagnostic  Ivanovic,(9) et al,(10)   et al,(11)   et al,(12)
Category       2009         2009         2010        2010

UNS/ND              9        32       75           8.9
Benign              2       9.8       32.2         1.1
AUS/FLUS            6        48       37.9         17
FN/SFN             14        34       27.3         25.4
SuspM              53        87       100          70
Malignant          97       100       100          98.1

                            Luu                    Somma     Layfield
Diagnostic  Renshaw,(13) et al,(14)   Current    et al,(17) et al,(15)
Category       2011        2011        Study       2010        2009

UNS/ND      20           33.3        n/c         NA             NA
Benign      2            6.9         n/c         NA             NA
AUS/FLUS    25           21.7        19          26            28.3
FN/SFN      28           23.1        20.5        NA             NA
SuspM       97           78.6        81.3        NA             NA
Malignant   100          98.8        n/c         NA             NA

                         Vanderlaan
               Shi      et al,(18); 2011;
Diagnostic  et al,(16)   VanderLaan
Category      2009      et al,(22) 2012

UNS/ND         NA       NA
Benign         NA       NA
AUS/FLUS       35       33
FN/SFN         NA       45
SuspM          NA       81
Malignant      NA       98.9

Abbreviations: AUS/FLUS, atypia of undetermined significance or
follicular lesion of undetermined significance; FN/SFN, follicular
neoplasm/suspicious for follicular neoplasm; NA, not available in
published study; n/c, not calculated in current study; SuspM,
suspicious for malignancy; UNS/ND, unsatisfactory/non-diagnostic.
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Author:Harvey, Aaron M.; Mody, Dina R.; Amrikachi, Mojgan
Publication:Archives of Pathology & Laboratory Medicine
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2013
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