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1 PREVIEW ONLY 1 Atlas on Bethesda system for reporting Thyroid Cytology
2 PREVIEW ONLY 2 OVERVIEW 1. Indications and goal of thyroid FNA 2. Contraindications 3. Procurement of cell sample 4. Staining methods 5. Limitations 6. Need for Bethesda terminology 7. Recommended diagnostic categories 8. Format of report 9. Diagnostic categories in detail a. Non diagnostic or unsatisfactory b. Benign c. Atypia of undetermined significance or Follicular lesion of Undetermined significance d. Follicular neoplasm or suspicious for a follicular neoplasm e. Suspicious for malignancy (suspicious of papillary/medullary/lymphoma/mets) f. Malignant 10. Recommended management for diagnostic categories
3 * PROCUREMENT OF CELL SAMPLE PREVIEW ONLY 4 1. Nodule is identified by palpation 2. A 22G to 25 G needle is used to procure cell sample from atleast three different areas of the nodule 3. If the nodule is difficult to palpate, FNA should be done under USG guidance 4. For cystic thyroid lesions, the cyst content should be evacuated first with a syringe 5. Since thyroid is rich in capillaries, needle aspirate usually contains large amount of peripheral blood. This can be limited by a no aspiration technique and by limiting the procedure to about five seconds * STAINING METHODS 1. Parallel air dried (stained with romanowsky stains like Giemsa) and wet fixed smears (stained with HE or Pap) are recommended 2. For Pap stained smears, quick fixation in 95% ethanol without drying is recommended, a delay in fixation leads to air drying artefact 3. Nuclear details in Romanowsky stained smears are not well appretiated, but cytoplasmic details are visualized nicely 4. In Pap stained smears, nuclear details are well visualized 5. Fixation of aspiration smears in Carnoy s solution may be done to lyse red blood cells prior to staining * LIMITATIONS OF THYROID F.N.A. 1. overlap of cytological patterns of neoplastic and non neoplastic lesions 2. overlap of cytological features between various neoplasms 3. co existence of non neoplastic and neoplastic processes and multiple malignancies
4 * RECOMMENDED DIAGNOSTIC CATEGORIES PREVIEW ONLY 6 - Mucoepidermoid carcinoma of thyroid
5 PREVIEW ONLY 8 Cyst fluid only Blood and macrophages Should be correlated with sonographic features Cyst fluid only Histiocytes and scant colloid on LBC smear Should be correlated with sonographic features
6 PREVIEW ONLY 12 Non diagnostic due to extensive air drying Blood only
7 PREVIEW ONLY 17 Benign follicular cells (macrofollicle fragment) Abundant colloid and scant benign follicular cells
8 PREVIEW ONLY 23 Benign follicular cells in sheets. Cellular portion of adenomatoid nodule (cellular colloid goiter) Sheets of benign follicular cells. Cellular portion of adenomatoid nodule. There is abundant colloid elsewhere
9 PREVIEW ONLY 31 Reactive Cyst Lining Cells with Hemosiderin Pigment Graves Disease Stimulated follicular cells and marginal eosinophilic cytoplasmic vacuoles with terminal frayed edges
10 PREVIEW ONLY 2 OVERVIEW 1. Indications and goal of thyroid FNA 2. Contraindications 3. Procurement of cell sample 4. Staining methods 5. Limitations 6. Need for Bethesda terminology 7. Recommended diagnostic categories 8. Format of report 9. Diagnostic categories in detail a. Non diagnostic or unsatisfactory b. Benign c. Atypia of undetermined significance or Follicular lesion of Undetermined significance d. Follicular neoplasm or suspicious for a follicular neoplasm e. Suspicious for malignancy (suspicious of papillary/medullary/lymphoma/mets) f. Malignant 10. Recommended management for diagnostic categories
11 PREVIEW ONLY 33 Pure colloid Colloid
12 PREVIEW ONLY 39 Crowded follicular cell group with lymphoid background Hurthle cells (oncocytic metaplasia)
13 PREVIEW ONLY 40 Hurthle cells (oncocytic metaplasia) with reactive changes Mixed lymphoid population without Hurthle cells
14 PREVIEW ONLY 41 Lymphoid cells with crush artifact Polymorphous population of lymphocytes and Hurthle cells
15 PREVIEW ONLY 63 Cohesive fragment of Hurthle cells (oncocytes) Hurthle cells (low magnification)
16 PREVIEW ONLY 64 Hurthle cells (oncocytes). Hurthle cells: single cells and fragments
17 PREVIEW ONLY 103 Monolayered sheet Intranuclear pseudoinclusions and focal oncocytic change
18 PREVIEW ONLY 104 Monolayered sheet. Intranuclear pseudoinclusions (INCIs).
19 PREVIEW ONLY 105 Intranuclear pseudoinclusions (INCIs). Monolayered sheet.
20 PREVIEW ONLY 106 Monolayered sheet with grooves and intranuclear pseudoinclusions Intact papilla
21 PREVIEW ONLY 137 anaplastic Carcinoma of Thyroid in liquid base prep Cells with variation in size and shape. Because of tendency of cells to round up in liquid preparations, cells much be evaluated in context of other cells present including inflammatory cells. anaplastic Carcinoma of Thyroid in liquid base prep Cells with variation in size and shape. Because of tendency of cells to round up in liquid preparations, cells much be evaluated in context of other cells present including inflammatory cells.
22 PREVIEW ONLY 18 Abundant thick colloid Abundant thick colloid
23 PREVIEW ONLY 19 Colloid mixed with blood Abundant colloid with pavementing ( cracking, windowpane ) artifact
24 PREVIEW ONLY 160 Metastatic Merkel cell carcinoma. Metastatic bronchioloalveolar carcinoma.
25 PREVIEW ONLY 161 Metastatic adenocarcinoma of the colon. Malt Lymphoma
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