The marked variability in the diagnostic reporting of

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1 Implementtion of the Bethesd System for Reporting Thyroid Cytopthology Observtions From the 2011 Thyroid Supplementl Questionnire of the College of Americn Pthologists Mnon Auger, MD; Ritu Nyr, MD; Wlid E. Khlbuss, MD, PhD; Güliz A. Brkn, MD; Cynthi C. Benedict, MD; Rosemry Tmbouret, MD; Mry R. Schwrtz, MD; Lydi P. Howell, MD; Rhon J. Souers, MS; Dvid A. Hrtley, CT; Nicole Thoms, CT; Ann T. Morirty, MD Context. Although informtion bout the Bethesd System for Reporting Thyroid Cytopthology (TBSRTC) hs been widely disseminted since its inception in 2007, the extent of its implementtion nd impct on dily prctice hs not been formlly evluted. Objectives. To ssess the extent of uptke of TBSRTC cross pthology lbortories nd to evlute its impct on dily prctice by collting prticipnt responses to the 2011 supplementl thyroid questionnire of the College of Americn Pthologists. Design. A questionnire ws designed to gther informtion bout vrious spects of TBSRTC nd miled in June 2011 to 2063 lbortories prticipting in the College of Americn Pthologists cytopthology interlbortory comprison progrm. The prticipting lbortories nswers were collted nd summrized. Results. Seven hundred nd seventy-seven lbortories Accepted for publiction Mrch 7, From the Deprtment of Pthology, McGill University nd McGill University Helth Center, Montrel, Quebec, Cnd (Dr Auger); the Deprtment of Pthology, Northwestern University nd Northwestern Memoril Hospitl, Chicgo, Illinois (Dr Nyr); the Deprtment of Pthology, University of Pittsburgh Medicl Center, Pittsburgh, Pennsylvni (Dr Khlbuss); the Deprtment of Pthology, Loyol University Medicl Center, Mywood, Illinois (Dr Brkn); DCL Pthology, LLC, Indinpolis, Indin (Dr Benedict); the Deprtment of Pthology, Hrvrd University nd Msschusetts Generl Hospitl, Boston (Dr Tmbouret); the Deprtment of Pthology nd Genomic Medicine, The Methodist Hospitl, Houston, Texs (Dr Schwrtz); the Deprtment of Pthology, University of Cliforni nd University of Cliforni Dvis School of Medicine, Scrmento (Dr Howell); Stff Biosttistics (Ms Souers); stff, College of Americn Pthologists, Northfield, Illinois (Ms Thoms nd Mr Hrtley); Esoteric Testing, AmeriPth Indin, Indinpolis, Indin (Dr Morirty). The uthors hve no relevnt finncil interest in the products or compnies described in this rticle. Reprints: Mnon Auger, MD, Deprtment of Pthology, McGill University, 3775 University St, Room 105, Montrel, QC H3A 2B4, Cnd (e-mil: mnon.uger@mcgill.c). The following re members of the College of Americn Pthologists Cytopthology Resource Committee: Drs Auger, Nyr, Khlbuss, Brkn, Benedict, Tmbouret, Schwrtz, Howell, nd Morirty (Pst Chir). (37.6%) returned the survey. Although 60.9% (n ¼ 451) nd 17.1% (n ¼ 127) of lbortories reported using TBSRTC or plnning to use it in the ner future, respectively, 22% (n ¼ 163) hd no plns to implement TBSRTC. Of the ltter, 32% (n ¼ 70) stted tht they were unwre of this clssifiction system. The mjority (78.3%, n ¼ 343) of the lbortories used TBSRTC s published in the Thyroid Bethesd System tls, wheres 21.7% (n ¼ 95) used it with minor modifictions. Most reported tht the use of TBSRTC hd cused either no chnge (n ¼ 67, 15.2%) or only minor chnges (n ¼ 353, 80.2%) in the terminology nd dignostic criteri previously used in their lbortories. Conclusions. According to the collected dt, TBSRTC is generlly well implemented in pthology lbortories. However, becuse pproximtely third of those not using this terminology re not wre of it, dditionl eductionl efforts regrding TBSRTC re wrrnted. (Arch Pthol Lb Med. 2013;137: ; doi: /rp CP) The mrked vribility in the dignostic reporting of thyroid cytopthology is best documented in Wng s 1 rticle published in 2006 in which she lists t lest 17 different reporting schemes found in reviewing the cytology literture. As response to the need for stndrdiztion, the Bethesd System for Reporting Thyroid Cytopthology (TBSRTC) ws proposed nd discussed t Stte of the Science consensus conference sponsored by the Ntionl Cncer Institute held in October 2007 in Bethesd, Mrylnd. Since then, the informtion relted to TBSRTC hs been widely disseminted through mny publictions in endocrine, pthology, nd cytopthology journls s well s vi vrious presenttions t scientific meetings. 2,3 The finl version of TBSRTC ws formlized with the publiction in December 2010 of n tls detiling the dignostic criteri of the min dignostic entities, ccompnied by mple illustrtions. 4 Despite the wide dissemintion of informtion bout TBSRTC, the extent of its uptke nd its impct on dily prctice is unknown. The purpose of the College of Americn Pthologists 2011 thyroid supplementl ques- Arch Pthol Lb Med Vol 137, November 2013 Implementtion of TBSRTC Auger et l 1555

2 Tble 1. Institution Type Voluntry, nonprofit hospitl Proprietry hospitl Regionl/locl independent lbortory City/county/stte hospitl University hospitl Ntionl/corporte hospitl Clinic, group or doctor-office lbortory Veterns hospitl Army/Air Force/Nvy hospitl Public helth, nonhospitl tionnire ws to document the extent of implementtion of TBSRTC nd its impct on dily prctice. MATERIALS AND METHODS A supplementl questionnire designed by the College of Americn Pthologists to gther dt concerning the extent of implementtion of TBSRTC nd the impct it hs hd on prctice ws miled in June 2011 to 2063 ntionl nd interntionl pthology lbortories. Prticipnts were sked questions relted to the yer of implementtion of TBSRTC, whether the integrl or modified version ws used, resons for not using TBSRTC, use of descriptive dignoses nd of sttement on risk of mlignncy in the report, the brekdown/percentge of the vrious cytologic dignostic ctegories with prticulr ttention to the typi of undetermined significnce (AUS)/folliculr lesion of undetermined significnce (FLUS) ctegory, nd the impct on clinicl mngement. Generl demogrphic informtionl questions nd generl questions bout thyroid fine-needle spirtion (FNA) were lso sked. All the prticipnts nswers were collted. Quntittive results were screened for outliers. This screen nd the summry were generted with Sttisticl Anlysis System v9.2 (SAS Institute Inc, Cry, North Crolin). The Wilcoxon rnk sum test ws used to determine the correltion between the use of TBSRTC nd the volume of thyroid FNAs received nnully, using P,.05 s the threshold for significnce. RESULTS Demogrphics Of the 2063 lbortories tht received the survey, 777 (37.6%) returned it; however, not ll lbortories provided n nswer to ll the questions. Of the 777 lbortory responses, 708 (91.1%) were from the United Sttes, 19 (2.5%) from Cnd, nd 50 (6.4%) from countries outside the United Sttes nd Cnd. The demogrphic dt of the lbortories tht responded to the survey cn be found in Tble 1. Becuse the number of responses from lbortories outside the United Sttes is very low, the response dt re presented s whole without breking them into US versus non-us responses. The men number of thyroid FNAs received per yer by the responding lbortories ws 326. There ws men of 3.7 pthologists interpreting thyroid FNA, of which there ws men of 1.2 pthologists with Added Qulifiction in Cytopthology from the Americn Bord of Pthology. Generl Survey Questions The following generl questions relted to thyroid FNA nd core biopsies were sked on the survey. Do you receive thyroid core biopsies? Thirty-seven percent (n ¼ 279) of the lbortories received thyroid core biopsies wheres 63% (n ¼ 476) did not. When further sked if they received touch preprtions of thyroid core biopsies for evlution, 19.5% (n ¼ 146) responded ffirmtively wheres 80.5% nswered tht they did not receive touch preprtions for interprettion. Who performs FNAs/core biopsies nd by which technique (multiple responses llowed)? Tble 2 gives the brekdown of who performed thyroid FNA nd/or core biopsies either by plption nd/or with ultrsound guidnce. For thyroid FNA, wht preprtory techniques do you use in your lbortory (multiple responses llowed)? Among totl of 738 responses, the brekdown of responses ws s follows: lcohol-fixed direct smers, 87% (n ¼ 642); cell blocks, 77.2% (n ¼ 570); ir-dried direct smers, 73.8% (n ¼ 545); nd liquid-bsed preprtions, 61.1% (n ¼ 451). Lbortories reported their primry method of FNA preprtion s follows: lcohol-fixed direct smers, 43.5% (n ¼ 312); irdried direct smers, 35.6% (n ¼ 255); liquid-bsed preprtions, 17.4% (n ¼ 125); nd cell blocks, 3.5% (n ¼ 25). Specific Survey Questions Relted to TBSRTC Are you currently using TBSRTC in your lbortory? Of the responding lbortories, 60.9% (n ¼ 451) stted tht they were using TBSRTC, 17.1% (n ¼ 127) were not using it currently but were plnning to use it in the ner future, nd 22% (n ¼ 163) responded tht they hd no plns to implement this terminology. Of the lbortories using TBSRTC, 15% (n ¼ 66) strted in 2007, 9.8% (n ¼ 43) in 2008, 16.2% (n ¼ 71) in 2009, 43.3% (n ¼ 190) in 2010, nd 15.7% (n ¼ 69) in Among those plnning to implement TBSRTC in the ner future, 73.1% nd 98.8% stted tht they would do so within 6 months nd 12 months respectively. The brekdown of the resons s to why certin lbortories were not plnning to implement TBSRTC ws s follows (multiple responses llowed; totl n ¼ 219): clients not supportive of/interested in receiving reports using this clssifiction system, 42.5% (n ¼ 93); pthologists nd/or lbortory director not supportive of this clssifiction system, 33.8% (n ¼ 74); nd lck of wreness of TBSRTC, 32% (n ¼ 70). Tble 2. Who Performs Thyroid Fine-Needle Aspirtion (FNA)/Biopsy nd by Which Technique? (n ¼ 723) Surgeon Rdiologist Pthologist Endocrinologist Primry Cre Other Helth Cre Professionl b FNA (n ¼ 709) Core biopsy (n ¼ 476) Ultrsound guided (n ¼ 683) By plption (n ¼ 556) Multiple responses llowed. b Medicl personnel other thn medicl doctors nd doctors of osteopthy Arch Pthol Lb Med Vol 137, November 2013 Implementtion of TBSRTC Auger et l

3 Of note, there is significnt ssocition between the use of TBSRTC nd the volume of thyroid FNAs received in the lbortories. Institutions using the terminology hd higher thyroid FNA volumes thn institutions not currently using the terminology, with medins of 115 nd 76 cses per yer, respectively (P,.001). The rnge for the lbortories using the terminology ws 0 to 3877, versus 0 to 2854 thyroid FNAs for those lbortories not using the terminology. Which of the following best reflects the use of TBSRTC in your lbortory? The mjority (78.3%, n ¼ 343) of lbortories used the TBSRTC s published in the thyroid Bethesd System (TBS) tls, wheres 21.7% (n ¼ 95) used it with minor modifictions. How much of chnge hs it been for your lbortory to use TBSRTC s compred to the terminology you previously used? The nswers were s follows: 15.2% (n ¼ 67) no chnge (ie, we used n equivlent terminology nd dignostic criteri s before), 80.2% (n ¼ 353) minor chnge in terminology (but dignostic criteri remined the sme), nd 4.5% (n ¼ 20) mjor chnge in terminology nd dignostic criteri, respectively. Is it obligtory tht the pthologists signing out thyroid FNA in your lbortory use TBSRTC? It ws obligtory to use TBSRTC in 51.5% (n ¼ 227) of the lbortories, nd it ws optionl in 48.5% (n ¼ 214). Wht hs the rection from clinicins been to the implementtion of TBSRTC in your institution? The clinicins response ws rted s indifferent by 40% (n ¼ 175), positive by 36.5% (n ¼ 160), unsure by 22.8% (n ¼ 100), nd negtive by 0.7% (n ¼ 3). Which of the following dignostic ctegories do you use? The responses re summrized in Tble 3. Of note, the dignostic ctegory tht ws the lest used ws nondignostic: cyst fluid only. For which of the following dignostic ctegories do you use further descriptive terminology? The responses re summrized in Tble 4. Suspicious for mlignncy, mlignnt, nd benign were the ctegories for which lbortories most commonly used further descriptive terminology. For which of the following dignostic ctegories do you include sttement bout the risk of mlignncy in the cytopthology report? The responses re summrized in Tble 5. Suspicious for folliculr neoplsm ws the dignostic ctegory for which lbortories most often used such sttement (in 70.6% of lbortories; 187 of 265). For which of the following dignostic ctegories do you include mngement recommendtions in the report? Tble 6 summrizes the responses; AUS nd its equivlent FLUS were the Tble 3. Which of the Following Dignostic Ctegories Do You Use? (n ¼ 435) Tble 4. For Which of the Following Dignostic Ctegories Do You Use Further Descriptive Terminology? (n ¼ 420) Suspicious for mlignncy Mlignnt Benign Suspicious for folliculr neoplsm Unstisfctory/nondignostic Atypi of undetermined significnce Folliculr lesion of undetermined significnce Folliculr neoplsm Cyst fluid only Multiple responses llowed. dignostic ctegories most often ssocited with mngement recommendtion. How do you report Hürthle cell neoplsm? Hürthle cell neoplsm ws reported s subtype of folliculr neoplsm by 55.7% (n ¼ 231) nd s n entity by itself by 41.2% (n ¼ 171); 3.1% (n ¼ 13) of lbortories chose other. Wht is the percentge of the vrious cytologic dignostic ctegories for thyroid FNA in your lbortory for the following ctegories? Tble 7 summrizes the dt relted to the percentges nd the relted percentile sttuses of the vrious cytologic dignostic ctegories for thyroid FNA. Wht is the usul follow-up in your prctice for thyroid FNA dignosed s AUS/FLUS for the first time? The most common response (41.8%; n ¼ 172) ws depends on the clinicin ; 32.1% (n ¼ 132) chose repet FNA, 19.2% (n ¼ 79) were unsure, nd 6.8% (n ¼ 28) chose surgicl excision. Is moleculr testing for predictive/prognostic purpose (BRAF/ RAS) done on thyroid needle spirtions received in your lbortory? Most lbortories, 95.3 (n ¼ 402), responded no; only 4.7 % (20) nswered yes. Specify which dignostic ctegories of thyroid FNA re submitted for moleculr testing (multiple responses llowed). The popultion of lbortories reporting moleculr testing ws smll. Among the 20 lbortories, 68.4% (n ¼ 13) nswered mlignnt, 57.9% (n ¼ 11) chose AUS/FLUS, 57.9% (n ¼ 11) chose folliculr neoplsm or suspicious for folliculr neoplsm, nd 57.9% (n ¼ 11) chose suspicious for mlignncy. For direct smers, how mny clusters of folliculr cells do you require for dequcy for noncystic, non colloid-rich, noninflm- Tble 5. For Which of the Following Dignostic Ctegories Do You Include Sttement About the Risk of Mlignncy in the Cytopthology Report? (n ¼ 265) Unstisfctory/nondignostic Benign Mlignnt Suspicious for mlignncy Suspicious for folliculr neoplsm Folliculr neoplsm Folliculr lesion of undetermined significnce Atypi of undetermined significnce Cyst fluid only Multiple responses llowed. Suspicious for folliculr neoplsm Folliculr lesion of undetermined significnce Suspicious for mlignncy Atypi of undetermined significnce Folliculr neoplsm Benign Mlignnt Cyst fluid only Unstisfctory/nondignostic Multiple responses llowed. Arch Pthol Lb Med Vol 137, November 2013 Implementtion of TBSRTC Auger et l 1557

4 Tble 6. For Which of the Following Dignostic Ctegories Do You Include Mngement Recommendtions in the Report? (n ¼ 295) Atypi of undetermined significnce Folliculr lesion of undetermined significnce Suspicious for folliculr neoplsm Suspicious for mlignncy Folliculr neoplsm Unstisfctory/nondignostic Mlignnt Cyst fluid only Benign Multiple responses llowed. mtory lesions in thyroid FNA? The most common definition of dequcy reflects TBSRTC; 80.6% (n ¼ 319) used 5 6 groups of folliculr cells, ech with 10 or more cells, 12.1% (n ¼ 48) 6 groups of folliculr cells, on t lest 2 slides, 4.8% (n ¼ 19) 10 groups of folliculr cells, ech with 20 or more cells, nd 2.5% (n ¼ 10) other. For liquid-bsed preprtions, how mny cells do you require for dequcy for noncystic, non colloid-rich, noninflmmtory lesions in thyroid FNA? 46.2% (n ¼ 128) chose no miniml requirement, 45.5% (n ¼ 126) 60 folliculr cells, 5.8% (n ¼ 16) 180 folliculr cells, nd 2.5% (n ¼ 7) other. COMMENT The Bethesd System for Reporting Thyroid Cytopthology ws proposed nd discussed t Stte of the Science consensus conference sponsored by the Ntionl Cncer Institute nd held in October 2007 in Bethesd, Mrylnd, mostly s response to the perceived nd documented lck of stndrdiztion of the dignostic reporting of thyroid FNA. 1 Although informtion bout TBSRTC hs been widely disseminted since October 2007, the sttus of its uptke in clinicl prctice is unknown. The current questionnire provides snpshot view, bsed on the collective dt of lbortory prticipnts, of the degree of implementtion of the TBSRTC nd its impct on dily prctice. Overll the dt show tht TBSRTC is well implemented. As of June 2011 (when the questionnire ws miled), 60% of the lbortory prticipnts were lredy using it, nd nother 17% were plnning to implement it by June Although the mjority (78.3%) of the centers use the originl TBSRTC version s published in the TBS tls, the reminder use it with minor modifictions. 4 For the institutions currently using TBSRTC, the doption ppers to hve been smooth for both pthologists nd clinicins. Indeed, 95% of the lbortories responded tht the new TBSRTC cused either no chnge or only minor chnge to their prctice, wheres the rection from clinicins ws listed s negtive by less thn 1% of the prticipnts. The dt revel severl interesting technicl points. First, the mjority of the thyroid FNA nd thyroid core biopsies re performed by surgeons, followed by rdiologists for both techniques. Although the mjority (63.3%) of thyroid FNAs done by plption re performed by surgeons, those done under ultrsound guidnce re mostly performed by rdiologists (76.3%). Of note, only 1.2% of the ultrsound-guided FNAs re performed by pthologists. Second, despite some ongoing debte in the literture s to wht constitutes the best preprtory technique, tht is, direct smers versus liquid-bsed cytology for thyroid FNA, it ppers tht lrge percentge of lbortories use both in combintion. 5,6 Nevertheless, the most prevlent primry preprtory method for thyroid FNA is still lcohol-fixed direct smers, s chosen by 43.5% of the lbortories in contrst to 17.4% for liquid-bsed cytology. Third, the use of thyroid core biopsies is not widespred, with only 37% of the lbortories nswering tht they receive them; this is ressuring becuse thyroid FNA is still considered the best dignostic pproch for thyroid nodule smpling, being t lest s ccurte s core biopsies with the dded dvntges of being esier to perform, being less expensive, nd hving fewer complictions thn core biopsy. 7,8 Added vlue for performing core biopsy in conjunction with FNA when FNA is unstisfctory hs, however, been described in the literture. 9 Fourth, lthough the use of moleculr testing hs been dvocted for thyroid FNA in mny recent publictions, the dt from this questionnire show tht very few institutions (4.7%) ctully perform such nlysis on thyroid FNA Survey results of interest concerning interprettion nd reporting of thyroid FNA center round specimen dequcy, the use of AUS/FLUS, nd the reporting of Hürthle cell nd folliculr neoplsms. First, it ppers tht there is still some confusion bout the recommended dequcy criteri for thyroid FNA, in prticulr for liquid-bsed cytology. Indeed, lthough most of the prticipnts use the TBS-recommended criterion (ie, 5 6 groups of folliculr cells, ech with 10 or more cells) for the evlution of direct smers of noncystic, non colloid-rich, noninflmmtory thyroid FNA, less thn 6% of the prticipnts use the TBS-recommended criterion (ie, 180 cells) for liquid-bsed cytology. 4 In ddition, the dt show tht nondignostic: cyst fluid only is the lest used of the dignostic ctegories, with only 61.8% of the prticipnts stting tht they use it. The questionnire did not specificlly sk how these specimens were being signed Tble 7. Wht is the Percentge of the Vrious Cytologic Dignostic Ctegories for Thyroid Fine-Needle Aspirtes in Your Lbortory for the Following Ctegories? Percentile No. Min Mx Men 10th 25th 50th 75th 90th Unstisfctory/nondignostic Cyst fluid only Benign negtive for mlignncy Atypi or folliculr lesion of undetermined significnce Folliculr neoplsm/suspicious for folliculr neoplsm Suspicious for mlignncy Mlignnt Abbrevitions: Mx, mximum; Min, minimum Arch Pthol Lb Med Vol 137, November 2013 Implementtion of TBSRTC Auger et l

5 out. Responses to the questionnire show tht the equivlent/synonymous terminologies AUS nd FLUS re eqully populr, ech being reportedly used by 77.2% nd 78.4% of the lbortories, respectively. Also, how Hürthle cell neoplsms re reported in the lbortories reflects the long debte on this subject t the Ntionl Cncer Institute consensus conference in Up to 41.2% of the respondents to this College of Americn Pthologists questionnire stted tht they reported Hürthle cell neoplsms s seprte entity insted of s subtype of the folliculr neoplsm ctegory s recommended by TBSRTC. Finlly, the ctegory folliculr neoplsm, which is synonymous with suspicious for folliculr neoplsm (s the 2 dignostic terminologies cn be used interchngebly), ws reported less frequently thn suspicious for folliculr neoplsm to require n dded sttement bout the risk of mlignncy (143 of 265 lbortories [54%] versus 187 of 265 lbortories [70.6%], respectively). An interesting spect of the dt is the fct tht the 50th percentile rte of reported AUS/FLUS lies t 5% (Tble 7), which implies tht, on verge, most lbortories responding to the survey re mintining the AUS/FLUS rte below the 7% rte recommended by the uthors of TBS. 4 The dt of the current questionnire could be used s counterrgument ginst the fer of potentil overuse of this controversil dignostic ctegory, which hs drwn criticisms nd even clls for its elimintion. According to the dt collected, 66% of the respondents use further descriptive terminology for the AUS/FLUS ctegory, prctice encourged by some in the literture. 13 Indeed, the AUS/FLUS ctegory is heterogeneous, being composite of different entities, nd is therefore lso likely heterogeneous in terms of risk of mlignncy. Folliculr lesion of undetermined significnce, cnnot exclude folliculr neoplsm, nd FLUS, cnnot exclude ppillry thyroid crcinom, hve been shown by some to be quite different with regrds to mlignncy risk, with FLUS, cnnot exclude ppillry thyroid crcinom, crrying prticulrly significnt higher risk. 14 The fct tht the AUS/FLUS ctegory is ssocited with high rte (69%) of mngement recommendtions in the survey results (Tble 6) suggests tht this ctegory is difficult for pthologists nd clinicins like. The dt derived from this questionnire hve some limittions. First, university-bsed centers ccount for only 5.7% of the prticipnts. Therefore, the results of this survey my not be representtive of prctices in most cdemic institutions nd my insted best reflect the sitution in nontrining fcilities. It is presumed tht the implementtion of TBSRTC is even more widespred in cdemic trining centers thn reflected in the nswers of this questionnire. Another limittion of this pper is tht the dt re self-reported nd not verified. Third, becuse the questionnire ws miled in June 2011, the dt my not reflect the current sitution (t the time of publiction of this rticle), t lest in certin spects. For instnce, ccording to the dt collected, only 1.2% of ultrsound-guided thyroid FNAs re performed by pthologists; the ctul current proportion is most likely higher in view of the incresing number nd populrity of courses offered for pthologists on this technique. Finlly, lthough informtion bout TBSRTC hs been widely disseminted, in prticulr in the cytopthology community, there is still need for eduction bout TBSRTC, most importntly for noncdemic institutions. Indeed, there were significnt number of prticipnts in the survey not using TBSRTC who stted tht they simply were unwre of this clssifiction system. Other spects of TBSRTC tht should be trgeted by eductionl ctivities include clrifiction of the terminologies nondignostic: cyst fluid only nd folliculr neoplsm versus suspicious for folliculr neoplsm, nd how Hürthle cell neoplsms should be reported. In conclusion, overll, TBSRTC hs been well received by both pthologists nd clinicins nd hs been widely implemented by pthology lbortories. However, ongoing eduction is still needed to optimize the continued implementtion of TBSRTC. References 1. Wng HH. Reporting thyroid FNA: literture review nd proposl. Dign Cytopthol. 2006;34(1): Abti A. The Ntionl Cncer Institute Thyroid FNA Stte of the Science Conference: wrpped up. Dign Cytopthol. 2008;36(6): Bloch ZW, LiVolsi VA, As SL, et l. Dignostic terminology nd morphologic criteri for cytologic dignosis of thyroid lesions: synopsis of the Ntionl Cncer Institute Thyroid FNA Stte of the Science Conference. Dign Cytopthol. 2008;36(6): Ali SZ, Cibs ES, eds. The Bethesd System for Reporting Thyroid Cytopthology: Definitions, Criteri nd Explntory Notes. New York, NY: Springer; Llung BM. Thyroid fine-needle spirtions: smers versus liquid-bsed preprtions. Cncer. 2008;114(3): Luu MH, Fischer AH, Pishrodi L, Owens CL. Improved preopertive definitive dignosis of ppillry thyroid crcinom in FNAs prepred with both ThinPrep nd conventionl smers compred with FNAs prepred with ThinPrep lone. Cncer Cytopthol. 2011;119(1): Bloch ZW, LiVolsi VA. Fine needle spirtion of thyroid nodules: pst, present nd future. Endocr Prct. 2004;10(3): Schmitt FC. Thyroid cytology: FNA is still the best dignostic pproch (letter). Cytopthology 2006;17(4): Zhng S, Ivnovic M, Nemcek AA Jr, DeFris DVS, Lucs E, Nyr R. Thin core needle biopsy crush preprtions in conjunction with fine-needle spirtion for the evlution of thyroid nodules: complementry pproch. Cncer Cytopthol. 2008; 114(6): Hssell LA, Gillies EM, Dunn T. Cytologic nd moleculr dignosis of thyroid cncers: is it time for routine reflex testing? Cncer Cytopthol. 2012; 120(1): Nikiforov YE. Moleculr dignostics of thyroid tumors. Arch Pthol Lb Med. 2011;135(5): Alexnder EK, Kennedy GC, Bloch ZW, et l. Preopertive dignosis of benign thyroid nodules with indeterminte cytology. N Engl J Med. 2012;367: Renshw A. Subclssifiction of typicl cells of undetermined significnce in direct smers of fine-needle spirtions of the thyroid: distinct ptterns nd ssocited risk of mlignncy. Cncer Cytopthol. 2011;119(5): Luu MH, Fischer AH, Stockl TJ, Pishrodi L, Owens CL. Atypicl folliculr cells with equivocl fetures of ppillry thyroid crcinom is not low-risk cytologic dignosis. Act Cytol. 2011;55(6): Arch Pthol Lb Med Vol 137, November 2013 Implementtion of TBSRTC Auger et l 1559