Diagnostic criteria and risk-adapted approach to indeterminate thyroid cytodiagnosis
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Diagnostic Criteria and Risk-Adapted Approach to Indeterminate Thyroid Cytodiagnosis I read the commentary on a risk-adapted approach to an indeterminate thyroid cytodiagnosis written by Drs. Abele and Levine 1 and would like to comment. I agree with the authors that thyroid lesions are excessively diagnosed and that the risk-adapted approach should be adopted in the cytologic evalua- tion of thyroid lesions. Unfortunately, in most cases of thyroid lesions, many of the suspicious clinical and radiological characteristics described by the authors are not immediately disclosed to patholo- gists. Although it is essential for pathologists to pro- actively communicate with clinicians to obtain this crucial information, I believe it is also important that physicians who possess integrated information on their patients use fine-needle aspiration (FNA) judi- ciously, so that the nodules with low-risk clinical and radiological features, such as case 1 in the article, are not aspirated but carefully followed instead. Other- wise, given the inherent inability of cytology to assess features associated with encapsulation and the increased use of ultrasonography-guided FNA, which can precisely target smaller solid thyroid nod- ules, indeterminate cytodiagnoses may increase. The authors suggested that the 15% national rate of an indeterminate thyroid cytodiagnosis (which actually appears to be 22% in the cited abstract 2 ) was in large part from overdiagnosis, compared with their rate of 5%. This result is difficult to evaluate given that the authors’ sensitivity was accounted for by a set of legal criteria as opposed to a quality assurance pro- tocol, such as subsequent cytohistologic correlation. It would be an important addition to the literature if the authors could demonstrate the malignancy risk in each of their cytodiagnostic categories and compare them to those in the Bethesda System. 3 In addition, I believe that the term ‘‘microfollicular neoplasm’’ does not necessarily add significant clarification to ‘‘follicular neoplasm’’ which, in the Bethesda System, refers to a cellular aspirate comprising follicular cells arranged in an altered architectural pattern characterized by signifi- cant cell crowding and/or a microfollicle formation with scant or no colloid. 4 The adopted Bethesda term emphasizes but does not limit the use of the diagnostic entity to those lesions with a microfollicular pattern, given that some follicular neoplasms (especially those proven to be follicular carcinomas on histological ex- amination) may present as syncytial clusters and single cells without obvious microfollicles. 5 Hypercellular smears of macrofollicles are not considered to be an altered architectural pattern and, therefore, should not be of concern as long as there are no nuclear features of papillary thyroid carcinoma identified. FUNDING SOURCES No specific funding was disclosed. CONFLICT OF INTEREST DISCLOSURES The author made no disclosures. REFERENCES 1. Abele JS, Levine RA. Diagnostic criteria and risk- adapted approach to indeterminate thyroid cytodiag- nosis. Cancer Cytopathol. 2010;118:415-422. 2. Lanman RB, Kennedy GC, Olchanski N, Mathews C, Wang C, Ladenson PW. Economic impact of a novel molecular diagnostic test in evaluation of thy- roid nodules with indeterminate FNA cytology results. Endocr Rev. 2010;31(suppl 1):S617. 3. Baloch ZW, Alexander EK, Gharib H, Raab SS. Overview of diagnostic terminology and reporting. In: Ali SZ, Cibas ES, eds. The Bethesda System for Reporting Thyroid Cytopathology. New York, NY: Springer; 2010:1-3. 4. Henry MR, DeMay RM, Berezowski K. Follicular neoplasm/suspicious for a follicular neoplasm. In: Ali SZ, Cibas ES, eds. The Bethesda System for Report- ing Thyroid Cytopathology. New York, NY: Springer; 2010:51-58. 5. Kini SR. Follicular adenoma and follicular carcinoma. In: Kini SR. Thyroid Cytopathology: an Atlas and Text. 1st ed. Philadelphia, PA: Lippincott Williams Wilkins; 2008:53-99. Jack Yang, MD Department of Pathology Medical University of South Carolina Charleston, South Carolina DOI: 10.1002/cncy.20144 Published online: March 25, 2011 in Wiley Online Library (wileyonlinelibrary.com) Cancer Cytopathology June 25, 2011 215 Correspondence
Transcript of Diagnostic criteria and risk-adapted approach to indeterminate thyroid cytodiagnosis
Diagnostic Criteria andRisk-Adapted Approach toIndeterminate ThyroidCytodiagnosis
I read the commentary on a risk-adapted approachto an indeterminate thyroid cytodiagnosis writtenby Drs. Abele and Levine1 and would like tocomment.
I agree with the authors that thyroid lesions areexcessively diagnosed and that the risk-adaptedapproach should be adopted in the cytologic evalua-tion of thyroid lesions. Unfortunately, in most casesof thyroid lesions, many of the suspicious clinicaland radiological characteristics described by theauthors are not immediately disclosed to patholo-gists. Although it is essential for pathologists to pro-actively communicate with clinicians to obtain thiscrucial information, I believe it is also important thatphysicians who possess integrated information ontheir patients use fine-needle aspiration (FNA) judi-ciously, so that the nodules with low-risk clinical andradiological features, such as case 1 in the article, arenot aspirated but carefully followed instead. Other-wise, given the inherent inability of cytology to assessfeatures associated with encapsulation and theincreased use of ultrasonography-guided FNA,which can precisely target smaller solid thyroid nod-ules, indeterminate cytodiagnoses may increase.
The authors suggested that the 15% nationalrate of an indeterminate thyroid cytodiagnosis (whichactually appears to be 22% in the cited abstract2) wasin large part from overdiagnosis, compared with theirrate of 5%. This result is difficult to evaluate giventhat the authors’ sensitivity was accounted for by a setof legal criteria as opposed to a quality assurance pro-tocol, such as subsequent cytohistologic correlation. Itwould be an important addition to the literature if theauthors could demonstrate the malignancy risk in eachof their cytodiagnostic categories and compare themto those in the Bethesda System.3 In addition, I believethat the term ‘‘microfollicular neoplasm’’ does notnecessarily add significant clarification to ‘‘follicularneoplasm’’ which, in the Bethesda System, refers to acellular aspirate comprising follicular cells arranged in
an altered architectural pattern characterized by signifi-cant cell crowding and/or a microfollicle formationwith scant or no colloid.4 The adopted Bethesda termemphasizes but does not limit the use of the diagnosticentity to those lesions with a microfollicular pattern,given that some follicular neoplasms (especially thoseproven to be follicular carcinomas on histological ex-amination) may present as syncytial clusters and singlecells without obvious microfollicles.5 Hypercellularsmears of macrofollicles are not considered to be analtered architectural pattern and, therefore, should notbe of concern as long as there are no nuclear featuresof papillary thyroid carcinoma identified.
FUNDING SOURCESNo specific funding was disclosed.
CONFLICTOF INTERESTDISCLOSURESThe author made no disclosures.
REFERENCES1. Abele JS, Levine RA. Diagnostic criteria and risk-
adapted approach to indeterminate thyroid cytodiag-nosis. Cancer Cytopathol. 2010;118:415-422.
2. Lanman RB, Kennedy GC, Olchanski N, MathewsC, Wang C, Ladenson PW. Economic impact of anovel molecular diagnostic test in evaluation of thy-roid nodules with indeterminate FNA cytologyresults. Endocr Rev. 2010;31(suppl 1):S617.
3. Baloch ZW, Alexander EK, Gharib H, Raab SS.Overview of diagnostic terminology and reporting. In:Ali SZ, Cibas ES, eds. The Bethesda System forReporting Thyroid Cytopathology. New York, NY:Springer; 2010:1-3.
4. Henry MR, DeMay RM, Berezowski K. Follicularneoplasm/suspicious for a follicular neoplasm. In: AliSZ, Cibas ES, eds. The Bethesda System for Report-ing Thyroid Cytopathology. New York, NY: Springer;2010:51-58.
5. Kini SR. Follicular adenoma and follicular carcinoma.In: Kini SR. Thyroid Cytopathology: an Atlas andText. 1st ed. Philadelphia, PA: Lippincott WilliamsWilkins; 2008:53-99.
Jack Yang, MDDepartment of Pathology
Medical University of South Carolina
Charleston, South Carolina
DOI: 10.1002/cncy.20144Published online: March 25, 2011 in Wiley Online Library
(wileyonlinelibrary.com)
Cancer Cytopathology June 25, 2011 215
Correspondence
