XIII CONGRESSO NAZIONALE Roma, 7-9 novembre NODULO TIROIDEO: Agoaspirato o Core Needle Biopsy?

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1 XIII CONGRESSO NAZIONALE NODULO TIROIDEO: Agoaspirato o Core Needle Biopsy? Anna Crescenzi Policlinico Universitario Campus Bio-Medico Roma

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3 Indeterminate lesions are heterogeneous

4 The gray zone

5 CONSERVATIVE SURGERY RISK VERY LOW < 3% LOW 10% INTERMEDIATE HIGH 15-30% 60-80% VERY HIGH >95% ACTION CLASS TIR 2 Thy2 Benign Control TIR 3A Thy3a AUS FLUS Repeat FNA TIR 3B Thy3f FN Surgery/ rigorous follow up TIR 4 Thy4 Suspicious Surgery with intraoperative biopsy TIR 5 Thy5 Malignant Surgery, total resection

6 TIR 3 B Non follicular patterned lesions 7-9 novembre 2014 Nuclear altera*ons, such as nuclear grooves and clearing, too mild or focal to be included in TIR 4 Bethesda AUS/FLUS category Expected risk of malignancy: 15-30% E.Focal features suggestive of papillary carcinoma, including nuclear grooves, enlarged nuclei with pale chromatin and alteration in nuclear and contour and shape in otherwise predominantly benign appearing sample. Expected risk of malignancy: 5-15%

7 .dark gray zone HURTHLE CELL LESIONS AUS/FLUS B. There is a predominance of Hurthle cells in a sparsely cellular aspirate with scant colloid. AUS/FLUS D.A moderately or markedly cellular sample is composed of a virtually exclusive population of Hurthle cells yet the clinical setting suggest a benign Hurthle cell nodule (thyroiditis, goiter) FN Hurthle cell type This interpretation applies to cellular samples that are composed exclusively (or almost exclusively) of Hurthle cells

8 Italian Consensus 2014 HURTHLE CELL LESIONS TIR2 A minor component of Hurthle cells may be present and does not exclude the diagnosis of benign nodule TIR3A Sparsely cellular samples containing predominantly microfollicular groups, also with oxyphilic features in a background of scant colloid can fulfill the criteria for inclusion in TIR3A category. TIR3B Samples composed exclusively or almost exclusively of Hurthle cells are also included here and the report should mention the cell type.

9 . gray zone

10 NON DIAGNOSTIC TIR1 The inadequate reports should not exceed 10% Excision is considered for persistently ND nodules because about 10% prove to be malignant (McHenry CR et al Am. Surg. 1993)

11 TIR1 Principale indicazione alla Core Biopsy sono i noduli non diagnostici per marcata fibrosi/calcificazioni ed i noduli ipervascolarizzati.

12 TIR1C Samples obtained from a cystic lesion containing erythrocytes, macrophages, cellular debris without abundant colloid which do not meet the criteria of cell adequacy These samples should be subclassified as TIR 1C (Cystic)

13 TIR2?

14 Atypical cystic lesions AUS/FLUS Bethesda F. There are cyst-lining cells that may appear atypical owing to the presence of nuclear grooves, prominent nucleoli elongated nuclei and cytoplasm, and/or nuclear cytoplasmic inclusions in an otherwise predominantly benign-appearing sample.

15 Atypical cyst-lining cells There are cyst-lining cells that may appear atypical owing to the presence of nuclear grooves, prominent nucleoli, elongated nuclei and cytoplasm in an otherwise predominantly benign appearing sample

16 TIR3 TIR3A This category also includes partially compromised specimens (because of preparation artifacts or blood contamination), with cytologic or architectural alterations that cannot be confidently classified as benign nor otherwise categorized. TIR3B This subcategory also includes samples characterized by nuclear alterations suggestive of papillary carcinoma, which do not permit to reliably exclude malignancy, but are too mild or focal to be included in the TIR 4 category.

17 Atypical cyst-lining cells EE CK19

18 . gray zone

19 MEDULLARY CARCINOMA Medullary thyroid carcinoma account for approximately 5-10% of thyroid malignancy 56% of histologically proven MTCs are correctly detected by cytological evaluation Medullary carcinoma cells are very heterogeneous and any size or shape may be present DD include Hurthle cell nodules, PTC and other follicular lesions Interpretation pitfall may be due to poorly cellular specimens and entrapped normal follicular cells and colloid

20 MEDULLARY CARCINOMA icytology.wordpress.com

21 MEDULLARY CARCINOMA

22 REAL PRACTICE Inadequate specimens (Sampling, Fibrin, Technical artefacts, Fibrosis, amyloid) FNA > TL > CNB Follicular lesions (Cytology > Molecular markers > CNB) Atypia of Unknown Significance (Cytology > Mutational analysis) Lesions of non-follicular origin (FNA > Washout > Ct )

23 Integrated Genomic Characterization of Papillary Thyroid Carcinoma We demonstrate striking signaling differences in RAS- and BRAFV600Edriven PTCs. In particular, BVL-PTCs signal preferentially through MAPK while RL-PTCs signal through both MAPK and PI3K. Cell 159, , October 23, 2014 The Cancer Genome Atlas Research Network,*The Cancer Genome Atlas Program Office, National Cancer Institute at NIH, 31 Center Drive, Bldg. 31, Suite 3A20, Bethesda,MD 20892, USA

24 Gray areas