BETHESDA THYROID 2023 updates only .pptx

New updates of Bethesda Thyroid 2023

1. BETHESDA THYROID 2023

2. BETHESDA THYROID 2017

3. 3. Risk of malignancy (ROM) estimates have been refined. (incorporating more extensive published data since the second edition of TBSRTC) 4. More formalized subcategorization of AUS (based on ROM: AUS with nuclear atypia vs. AUS-other

4. 5. All high-grade follicular-derived carcinomas, including poorly differentiated thyroid carcinoma (PDTC) and differentiated high-grade thyroid carcinoma (DHGTC).. Included in the chapters

5. ROM PEDIATRIC POPULATION

6. I. NON-DIAGNOSTIC Cyst fluid only Virtually acellular specimen Other (obscuring blood, clotting artifact, drying artifact, etc.)

7. DEFINITION A specimen is considered “nondiagnostic” if it fails to meet the adequacy criteria.

8. ADEQUACY CRITERIA At least six groups of well-visualized (i.e., well stained, undistorted, and unobstructed) benign follicular cells Each group composed of at least 10 cells These six groups of ten follicular cells could be either on one slide or distributed among several for adequacy determination

9. EXCEPTIONS Colloid nodules: Any specimen that contains abundant colloid is adequate (and benign) Solid nodules with inflammation: Whenever a specific diagnosis (e.g., lymphocytic thyroiditis, thyroid abscess, granulomatous thyroiditis) can be rendered Solid nodules with cytologic atypia : whenever there is any significant atypia

10. II. BENIGN Consistent with a follicular nodular disease (includes adenomatoid nodule, colloid nodule, etc.) Consistent with chronic lymphocytic (Hashimoto) thyroiditis in the proper clinical context Consistent with granulomatous (subacute) thyroiditis

11. Cytologic sample that is adequate for evaluation and consists of colloid and benign-appearing follicular cells in varying proportions .

12. III. ATYPIA OF UNDETERMINED SIGNIFICANCE TBSRTC 2023 discontinues the term ‘‘follicular lesion of undetermined significance’’ AUS is one of the three ‘‘indeterminate’’ cytopathologic interpretations that convey a diagnosis that is not definitively benign or malignant.

13. “Atypia of Undetermined Significance” (AUS) is reserved for - one or more of a heterogeneous group of findings. That raise concern for neoplasm/malignancy but are insufficient to be classified as a follicular neoplasm, suspicious for malignancy, or malignant.

14. An important change in this category • Atypia in AUS has been categorised as: nuclear and other (which includes architectural, oncocytic , lymphoid and NOS categories) • The term cytologic atypia is no longer used. AUS aspirates with nuclear atypia: twofold higher ROM

15. AUS are now subclassified into two broad subcategories • AUS with nuclear atypia: raises a low level of concern for papillary carcinoma or NIFTP • AUS—Other: in which other (non-nuclear) features result in AUS interpretation are Architectural atypia, Oncocytic atypia, Atypical lymphoid cells, Atypia NOS

16. Architectural atypia a). -Scantly cellular specimen with rare clusters of follicular cells, Almost entirely in microfollicles or crowded three-dimensional groups and with scant colloid Focally prominent microfollicles with minimal nuclear atypia ( Intrathyroid Parathyroid adenoma)

17. Moderately to markedly cellular specimen Exhibits architectural atypia in most follicular cells but without a marked predominance (at least 70% of follicular cells) that would warrant a FN diagnosis.

18. ATYPIA, NOT OTHERWISE SPECIFIED (NOS) A minor population of follicular cells shows nuclear enlargement, often accompanied by prominent nucleoli Does not raise concern for papillary carcinoma

19. A). Graves’ disease treated with methimazole show marked nuclear enlargement and anisonucleosis (b) Atypical follicular cells from a patient with a history of ionizing radiation to the neck

20. AUS/FLUS is an interpretation of last resort and should be used judiciously. Mixed, but predominantly macrofollicular, architectural patterns are best classified as benign Some Hürthle cells or cyst-lining cells, with mild nuclear alterations (e.g., nuclear grooves, finely granular or pale chromatin) Does not warrant an AUS/FLUS designation if there is ample evidence of benign follicular cells and abundant colloid

21. IV. FOLLICULAR NEOPLASM TBSRTC 2023 recommends discontinuing the use of term ‘‘suspicious for a follicular neoplasm I ntended for those aspirates that are at least moderately cellular and composed of follicular cells M ost of which show significant architectural abnormality in the form of microfollicles and/or crowding, trabeculae, or single cells.

22. Overlapping cytologic features between various follicular-patterned lesions • Follicular nodular disease • Follicular adenoma • FVPTC • Follicular thyroid carcinoma • NIFTP

23. NIFTP cases in thyroid FNAs is important to avoid overdiagnosing them as‘‘malignant —papillary thyroid carcinoma’’ or ‘‘suspicious for malignancy. S uspicious for papillary thyroid carcinoma, ’’diagnostic categories that could unnecessarily result in aggressive surgical procedures T he recommended treatment for NIFTP is conservative surgery.

24. F ollicular-patterned aspirates with only mild nuclear changes (i.e., mild degree of enlargement, contour irregularity, and/or chromatin clearing) are best classified as follicular neoplasm I f true papillae are absent and intranuclear pseudoinclusions are either absent or very rare. Because the reporting category name is now simply ‘‘follicular neoplasm’’ and not ‘‘suspicious for a follicular neoplasm. The recommended management of follicular neoplasm is surgical excision of the nodule, most often hemithyroidectomy or lobectomy.

25. “ MICROFOLLICLE” designation must be limited to crowded, flat or 3 dimensional groups of less than 15 follicular cells Arranged in a circle that is at least two-thirds complete An important defining feature of the microfollicle is the crowding and overlapping of the follicular cell

26. A virtually exclusive population of oncocytes usually scant to absent colloid, R are to absent background lymphocytes O ften, with the presence of nuclear and cellular size variations. All comes under follicular neoplasm.

27. V. SUSPICIOUS FOR MALIGNANCY C ytomorphologic features of a thyroid FNA are worrisome for papillary thyroid carcinoma, medullary thyroid carcinoma, lymphoma, or another malignant neoplasm B ut are quantitatively and/or qualitatively insufficient for a definitive malignant

28. S ample is moderately or highly cellular. F ollicular cells (arranged predominantly in sheets and/or macrofollicular fragments) A dmixed with cells that have nuclear enlargement, nuclear pallor, limited nuclear grooves, nuclear membrane irregularity, and/or nuclear molding. Intranuclear pseudoinclusions (INPIs) are very few or absent, and psammoma bodies and papillary architecture are absent.

29. S heet of follicular cells including nuclear enlargement, powdery chromatin, nuclear membrane irregularity, nuclear grooves and molding, and small nucleoli.

30. VI. MALIGNANT T he cytomorphologic features are conclusive for malignancy.

31. SWIRLING

32. PSAMMOMA BODIES