sparsely cellular specimen sparsely cellular specimen

Nikiforov YE, Ohori NP, Hodak SP, Carty SE, LeBeau SO, Ferris RL, Yip L, Seethala RR, Tublin ME, Stang MT, et al. The authors of the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) recommended that the DC III (AUS/FLUS) category should not exceed 7% of the thyroid FNA diagnoses, and the risk of malignancy in this category should be in the range of 5% to 15%[23]. Nuclear grooves become an important diagnostic feature when associated with an oval, enlarged nucleus with fine chromatin[41]. Loose cellular material can be held together to make into a cell block in all of the following EXCEPT a. agar b. albumin c. blood clot d. resin resin A slide of breast fluid has the cells washing off during staining. Yassa Centrifuge the specimen again and decant the entire supernatant. Flat sheets showing enlarged, pale nuclei with finely granular chromatin of a papillary Ca case ( 40 pap stain on ThinPrep slide) (diagnostic categories VI). LiVolsi JA EK Inadequate cellularity is defined as the presence of less than 6 groups of well-preserved follicular cells on each of at least two slides; (2) DC II Benign (Figure (Figure1).1). Inadequate cellularity is defined as the presence of less than 6 groups of well-preserved follicular cells on each of at least two slides; (2) DC II Benign (Figure (Figure1).1). These can be highly useful when a core biopsy is suboptimal, demonstrates marked myelofibrosis, is a dry tap, or otherwise fails to provide adequate visual data for morphology, architecture, cellularity, and hematopoietic lineage assessments. Different cell types of neurons form complicated circuits in the brain. PG What is the hematopathologist looking for when assembling all the parts to report back in consultation with you? These cells constitute more than 50% of tumor volume[44]. Horn RC. FCs have cytomorphologic features that distinguish them from benign follicular nodules. Centrifuge each specimen, and resuspend the cell concentrate in about 5 mL balanced electrolyte solution. In some cases more diffuse but mild nuclear changes may exist with nuclear enlargement, crowding, and pallor, but without other characteristics, such as nuclear contour irregularities, grooves and nuclear pseudoinclusions, suggestive of a PTC. Historically, terminology for thyroid FNA has varied significantly from one laboratory to another, creating confusion in some cases and hindering the sharing of clinically meaningful data among multiple institutions. However, some three dimensional structures that resemble the epithelial tips of papillae without the fibrovascular cores can be seen[35]. There is a predominance of Hrthle cells in a sparsely cellular aspirate with scant colloid. This resulted in diagnostic inconsistencies among different laboratories and difficulty in communicating the implications of thyroid fine-needle aspiration (FNA) results both to clinicians (endocrinologists and endocrine surgeons) and laboratory doctors (pathologists and radiologists)[6]. Due to the fact that the nuclei of this variant are darker than those of the regular PTC, the neoplastic cells of this variant may be mistaken for benign respiratory epithelial cells, or a colorectal neoplasm. The FNA specimen of this neoplasm is usually cellular and shows neoplastic cells arranged in papillary groups, or clusters, or as single cells in a background of thick colloid, nuclear or calcific debris, macrophages and stromal fragments[41] (Figure (Figure44). The individual tumor cells are enlarged, oval in shape with eosinophilic cytoplasm; the nuclei show elongation, oval shape, membrane thickening, chromatin clearing, grooves, and inclusions. In: Ali SZ, Cibas ES, editors. One nucleus has an apparent intranuclear pseudoinclusion (arrow). This category applies to specimens that are unsatisfactory owing to obscuring blood, overly thick smears, air drying of alcohol-fixed smears, or an inadequate number of follicular cells. CellMapper is a crowd-sourced cellular tower and coverage mapping service. CA However, this requires additional FNA passes or residual cellular material from the cytologic sample. Help . After this therapy the patients serum thyroglobulin levels should fall to undetectable levels. "Sparse" is not a medical term. Several systems have been proposed for the cyropathologic diagnosis of the thyroid nodules. Additional descriptive comments (beyond such subcategorization) are optional and left to the discretion of the cytopathologist. Deshpande AH, Munshi MM, Bobhate SK. ES Cytological diagnosis of paucicellular variant of anaplastic carcinoma of thyroid: report of two cases. Furthermore, the clot section, like the core biopsy, can be used for immunohistochemical stains. Anderson Cancer Center, Houston, Edward B. Stelow, MD, Department of Pathology, University of Virginia Health System, Charlottesville, Jerry Waisman, MD, Department of Pathology, New York University of Medicine, New York, Helen H. Wang, MD, DrPH, Department of Pathology, Beth Israel-Deaconess Medical Center, Boston, MA, Philippe Vielh, MD, PhD, Department of Pathology, Institut de Cancerologie Gustave Roussy, Villejuif, France, Grace C. H. Yang, MD, Department of Pathology, Weill Medical College of Cornell University, New York, NY, Matthew A. Zarka, MD, Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale. This category is reserved for aspirates with borderline cellularity and is subdivided into two subcategories. It is a point of great significance that Ohori et al[56] found a greater percentage of BRAF-mutated (V600E, K601E, and others) cases in the AUS/FLUS and SFN/SFN categories, rendering BRAF mutational testing a useful predictor of PTC diagnosis in these indeterminate cases. The Bethesda System for Reporting Thyroid cytopathology. Carcinoma of the thyroid. VA JR The standard management of PTCs greater than 1 cm is total, or near-total thyroidectomy followed by radioactive iodine (131I) therapy to ablate residual thyroid tissue. Seventeen . S Recognizably benign cellular changes (eg, typical cyst lining cells, focal Hrthle cell change, changes ascribed to radioiodine therapy, black thyroid) should not be interpreted as AUS. Marchevsky AM, Walts AE, Bose S, Gupta R, Fan X, Frishberg D, Scharre K, Zhai J. Evidence-based evaluation of the risks of malignancy predicted by thyroid fine-needle aspiration biopsies. If the nodule is almost entirely cystic, with no worrisome sonographic features, an endocrinologist might proceed as if the CFO were a benign result. VA This technique is conclusive for the majority of cases suspicious for PTC, lymphoma, or follicular neoplasm after previous incomplete FNA results. Role of repeat fine-needle aspiration biopsy (FNAB) in the management of thyroid nodules. The main purpose of thyroid FNA is to stratify higher risk patients for surgery, and to prevent unnecessary surgeries for benign conditions. The bone marrow aspirate smear. Ravetto Highly cellular specimens are ideal for smeared preparations, whereas sparsely cellular specimens will require multiple centrifugation steps and special cell consolidation processing. Before The six-tier diagnostic approach includes the following six categories[8,15]: (1) Disctrict of columbia (DC)INondiagnostic or Unsatisfactory. The 2-day live conference in October 2007, attended by 154 registrants including pathologists, endocrinologists, surgeons, and radiologists, gave the committees an in-depth opportunity to present their conclusions and debate controversial areas. The clinical and diagnostic impact of using standard criteria of adequacy assessment and diagnostic terminology on thyroid nodule fine needle aspiration. This category includes specimens with features characteristic of a malignant neoplasm, which are quantitatively or qualitatively insufficient to make a definitive diagnosis of malignancy (Figure (Figure4).4). An AUS result is obtained in 3% to 6% of thyroid FNAs.2,10 Higher rates likely represent overuse of this category when other interpretations are more appropriate. The FNA specimens show enlarged follicular cells arranged in monolayer sheets and follicular groups in a background of thin and thick colloid (Figure (Figure6).6). Suspicious for medullary thyroid carcinoma, Suspicious for papillary thyroid carcinoma, Vote for your favorite image from the PathologyOutlines.com Directory. Gupta KH Specifically, the ultrasound image of the malignant nodule, as well as the patients general condition and age and other comorbidities should be taken into account when planning surgery. Single neurons, as the basic unit of the brain, consist of a cell body and processes, including dendrites and axons. Go to: . Cases that demonstrate the nuclear features of papillary carcinoma are excluded from this category. The four components of a routine bone marrow analysis. The 6 general diagnostic categories are shown in bold type in Table 1. See more. Nuclear atypia or pleomorphism and mitoses are uncommon. In order to establish a standardized diagnostic terminology/classification system for reporting thyroid FNAC results, the National Cancer Institute (NCI) in the United States sponsored the NCI Thyroid FNA State of the Science Conference with a group of experts at Bethesda, MD, in October 2007[7]. The rate of malignancy in FNA-BRAF positive nodules has been shown to be 99.8%[55]. A) 20 view of the bone marrow aspirate reveals a deeply basophilic smear of cells. . These indeterminate results imply surgeons to consider alternative therapies (e.g., thyroid lobectomy with intraoperative frozen section). The Bethesda System for Reporting Thyroid Cytopathology is the most preferred system for the diagnosis of FNA specimens, which also contains guidelines for the diagnosis and treatment of indeterminate cases. The morphology is similar to that seen on the core biopsy. On the other hand, these polarized spermatids also align across the plane of seminiferous epithelium, mimicking planar cell polarity (PCP . 36.3-50 mL); all 3 scantly cellular specimens had volumes below this median value. Incidence of malignancy in thyroid nodules determined to be follicular lesions of undetermined significance on fine-needle aspiration. Because of the mixture of oncocytes with lymphocytes on smears, this tumor should be distinguished from Hashimoto thyroiditis or a follicular lesion with oncocytic changes[44]. Does Hrthle cell lesion/neoplasm predict malignancy more than follicular lesion/neoplasm on thyroid fine-needle aspiration? The nuclear chromatin appears as salt and pepper type in a medullary carcinoma case ( 40 pap stain on ThinPrep slide) (diagnostic categories VI). The most common scenarios can be described as follows: There is a prominent population of microfollicles in an aspirate that does not otherwise fulfill the criteria for follicular neoplasm/suspicious for follicular neoplasm. This situation may arise when a predominance of microfollicles is seen in a sparsely cellular aspirate with scant colloid. Thyroid FNA is a well established procedure used in the preoperative diagnosis of thyroid nodules. ME Warthin's tumor : the presence of oncocytic epithelium. According to the Bethesda system for reporting thyroid cytopathology, a specimen . The prepared core biopsy slides can be used for immunohistochemical (IHC) investigations (phenotyping the cells using IHC stains), and an initial standard hematoxylin and eosin stain is done to assess baseline histology. Based on the findings (MRI, gross and histopathology) cysticercosis was confirmed. Diagnostic terminology for reporting thyroid fine needle aspiration cytology: European Federation of Cytology Societies thyroid working party symposium, Lisbon 2009. A serum protein electrophoresis might have even shown a monotypic expansion. Renshaw AA. In addition, Ohori et al[61] investigated the utility of the above panel in specimens classified as FLUS. R Schnadig The difficulties in securing diagnosis of a diffuse large B-cell lymphoma derive from the inadequate sampling technique and/or insufficient preservation of the specimen. moc.oohay@sokaisime. Baloch Z, LiVolsi VA, Jain P, Jain R, Aljada I, Mandel S, Langer JE, Gupta PK. The remaining 10% of cases represent a significant subset of thyroid specimens with some form of AUS/FLUS. The Bethesda System for Reporting Thyroid Cytopathology: Definitions, Criteria and Explanatory Notes. A malignant thyroid FNA diagnosis accounts for 4%-8% of all thyroid FNAs, the majority of which are PTCs, and these patients will require thyroidectomy[53]. The nuclei are enlarged, with usually an oval or irregular shape, and include intense nuclear grooves and inclusions. The reason is that in approximately 10%-30% of cases, cytology is indeterminate and nondiagnostic[4]. Piana S, Frasoldati A, Ferrari M, Valcavi R, Froio E, Barbieri V, Pedroni C, Gardini G. Is a five-category reporting scheme for thyroid fine needle aspiration cytology accurate? Liquid-based preparation can also be made after a FNA pass, with the needle been rinsed in normal saline or ThinPrep solutions. The Bethesda System for Reporting Thyroid Cytopathology is the most widely used system for the diagnosis of thyroid FNA specimens. Report of the Thyroid Cancer Guidelines Update Group. Pu The many faces and mimics of papillary thyroid carcinoma. ES In some cases psammoma bodies may be present[35,44]. PTC accounts for 80% of all thyroid malignancies and occurs more often in women with a 3:1 female-to-male ratio, with a mean age at presentation 30-40 years. This conference established the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), a 6-tiered diagnostic classification system based on a probabilistic approach[8,9]. Gharib (General, Ortho . The spindle-shaped morphology of these cells is helpful in distinguishing these cells from PTC[24,34]. Moreover, large, atypical, histiocytoid cells with enlarged nuclei and abundant vacuolated cytoplasm usually coexist. Moreover, a lower percentage of cases in the European system was placed into the TIR 4 and TIR 5 categories as well, compared with the American system. Gupta Fine-needle aspiration in the work-up of thyroid nodules. Vimentin immunoexpression is also a common finding[52]. Highly cellular specimens are ideal for smeared preparations, whereas sparsely cellular specimens will require multiple centrifugation steps and special cell concentration methods. G Moses et al[60] also examined the clinical utility of the above panel in thyroid FNA biopsies. View an interactive bone marrow clot specimen online. One nucleus has an apparent intranuclear pseudoinclusion ( arrow ). endstream endobj 93 0 obj <>>> endobj 94 0 obj <>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/Thumb 35 0 R/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 95 0 obj <>stream D The core biopsy is useful for assessing overall marrow cellularity, trilineage hematopoiesis, and marrow architecture. Federal government websites often end in .gov or .mil. The discussions and conclusions regarding terminology and morphologic criteria from the NCI meeting, summarized in the publications by Baloch et al,4,5 form the framework for the terminology presented here and in atlas form.3 It is intended as a flexible framework that can be modified to suit the needs of the particular laboratory and the patients it serves. Psammoma bodies are occasionally seen in some aspirates, most possibly arising from calcification of epithelial tips. The cytological diagnosis of PTC is based mainly on the characteristic nuclear morphology. Therefore, in the majority of patients in the AUS/FLUS category (72%-80%) the diagnosis will be resolved by repeat FNA, although 20%-28% of them will have AUS/FLUS on the repeat aspirate and thus require surgery. Gough The same general principle applies to other thyroid malignancies like medullary carcinoma and lymphoma, but these are encountered less frequently than PTC. Baloch Additionally an immunohistochemical panel, including thyroglobulin, TTF1, and CDX2 may help in the differential diagnosis of such difficult cases. The purpose of this diagnostic category is to identify a nodule that might be a follicular carcinoma (FC) and triage it for surgical lobectomy. Thyroid aspiration cytology: current status. The interpretation of follicular cell atypia is hindered by sample preparation artifact, eg, Air-drying artifact with slight nuclear and cytoplasmic enlargement, pale and slightly smudgy chromatin, and/or mildly irregular nuclear contours. Note extensive red blood cells in the background. However, we cannot answer medical or research questions or give advice. The recommended management is clinical correlation and a repeated FNA at an appropriate interval.2,15 In most cases, a repeated FNA results in a more definitive interpretation; only about 20% of nodules are repeatedly AUS.2 In some cases, however, the physician may choose not to repeat the FNA but observe the nodule clinically or, alternatively, to refer the patient for surgery because of concerning clinical and/or sonographic features. Yang J, Schnadig V, Logrono R, Wasserman PG. a. crush method b. cytocentrifuge c. fine needle aspiration d. liquid-based b. cytocentrifuge cytocentrifugation is the most common method of handling sparsely cellular specimens such as urine or spinal fluid A cellular specimen composed of Hrthle cells arranged in loosely cohesive sheets or isolated in a case diagnosed as Hrthle cell adenoma ( 40 pap stain on ThinPrep slide) (diagnostic categories IV). Utilization of ancillary studies in thyroid fine needle aspirates: a synopsis of the National Cancer Institute Thyroid Fine Needle Aspiration State of the Science Conference. It also predicted cancer in the majority of indeterminate samples, as well as of the suspicious for cancer samples. Consequently it is essential to distinguish this form of atypical calcification from true psammomatous calcifications with their concentrically laminated microscopic appearance[35]. Most (60%75%) prove to be papillary carcinomas, and the rest are usually FAs.2,10,12,30. )TEgX>T|*Q0%K5P- HVe t Such cases represent a minority of thyroid FNAs and in the Bethesda System are reported as atypia of undetermined significance (AUS) or follicular lesion of undetermined significance. The necessity for this category was debated at the NCI conference, after which a vote (limited to the clinicians in attendance) was taken, and the majority voted in favor of this category. Patients with the sporadic forms of MTC or the familial MTC are most often middle-aged (mean age 50 years old), except in familial cases, in which they are relatively younger. To collect as many cells as possible from sparsely cellular urine, the specimen should have which of the following techniques applied? LiVolsi The false-negative rate of a benign interpretation is low (0%3%),2,12 but patients are nevertheless followed up with repeated assessment by palpation or ultrasound at 6- to 18-month intervals.15 If the nodule shows significant growth or suspicious sonographic changes, a repeated FNA is considered. It generally affects elderly patients presenting as a firm mass rapidly growing in the neck infiltrating extrathyroidal tissues, such as muscle, trachea, esophagus, skin, bone and cartilage[49]. Employing genetic markers to improve diagnosis of thyroid tumor fine needle biopsy. The nuclei have conventional PTC nuclear features that distinguish it from Hurthle cell neoplasms[35]. Accessibility 2nd ed. Oncocytic cells with nuclear features of papillary carcinoma are excluded from this interpretation. After patient preparation, sedation, and the procedure itself, a bone marrow investigation provides four specimen types for pathologist review (Figure 1): the bone marrow core biopsy, the bone marrow touch imprint, the bone marrow aspirate smear, and the bone marrow clot particle. However, nuclear grooves can be seen also in several thyroid diseases such, as Hashimotos thyroiditis, multinodular goiter, Hurthle cell tumors and medullary carcinoma[42,43]. van Hoeven The site is secure. H These specimens are differentially used to study morphology, assess lineage, perform cell counts and differentials, triage and send for appropriate immunohistochemical stains, perform flow cytometry, and send ancillary cytogenetic and molecular genetic studies. Giorgadze The .gov means its official. On the other hand, it might be clinically equivalent to an ND result if the sonographic features are worrisome and the endocrinologist is not convinced that the sample is representative. For a thyroid FNA specimen to be satisfactory for evaluation (and benign), 6 . Theoharis CG, Schofield KM, Hammers L, Udelsman R, Chhieng DC. It allows classification of nodules as benign or malignant, and patients with malignant nodules are scheduled for surgery. PU Once obtained, the core biopsy is used to make touch preps (discussed below) and then is transferred into a container with appropriate fixative (usually formalin) and sent to the laboratory for processing. Some laboratories, for example, may want to state the risk of malignancy associated with the general category, based on their own data or that found in the literature (Table 2). The significance and clinical value of a CFO result depend in large part on sonographic correlation. Preparation Methods As a result they may be not diagnosed through the FNA test, resulting in a false-negative test[44]. The cystic lining showed outer cellular and inner sparsely cellular areas [Table/Fig-8]. Occasionally FNAC results can be inconsistent and can be a source of dispute among clinicians. %PDF-1.6 % A full molecular panel of BRAF, RAS, RET/PTC and PAX8PPAR offer additional diagnostic value[58]. In this review we analyze all literature regarding Thyroid Cytopathology Reporting systems trying to identify the most suitable methodology to use in clinical practice for the preoperative diagnosis of thyroid nodules. Yang A clinicopathologic study of 121 cases. Papaparaskeva K, Nagel H, Droese M. Cytologic diagnosis of medullary carcinoma of the thyroid gland. It is expected that the many benefits, clinical and investigational, of the Bethesda cervical terminology will also apply to the Bethesda thyroid terminology. Evangelos P Misiakos, Dimitrios Schizas, Konstantinos Petropoulos, Anastasios Machairas, 3, Niki Margari, Christos Meristoudis, Aris Spathis, Petros Karakitsos, Department of Cytopathology, Attikon University Hospital, University of Athens School of Medicine, Attica, 12462 Athens, Greece. $AJ !b``3iK Your patients cytopenias remain unexplained. hbbd``b`$Ks ^ Faquin WC, Cibas ES, Renshaw AA. Among thyroid malignancies, PTC has the highest propensity to appear cystic, as 10% of the PTC specimens are entirely cystic. Low and high power of clot particle. In FNA specimens of this variant, the cancer cells appear more profuse, granular or vacuolated compared to regular PTC. Renshaw AA. Since the malignancy rate of this category is quite high, TBSRTC recommends that most patients undergo a repeat thyroid FNA within 3 to 6 mo, in order to define the nature of atypia[24,26]. Renshaw G However, in almost 20% to 28% of AUS/FLUS cases, a repeat thyroid FNA will again be characterized as AUS/FLUS[27,28]. The differential diagnosis for the latter includes hyperplastic adenomatoid nodule with Hurthle cell change, Hurthle cell adenoma, and Hurthle cell carcinoma; (5) DC V Suspicious for malignancy. . In adult mammalian testes, spermatids, most notably step 17-19 spermatids in stage IV-VIII tubules, are aligned with their heads pointing toward the basement membrane and their tails toward the tubule lumen. . %%EOF Such changes may represent atypical but benign cyst lining cells, but a papillary carcinoma cannot be entirely excluded (ThinPrep, Papanicolaou stain). A benign result is obtained in 60% to 70% of thyroid FNAs. For a thyroid FNA specimen to be satisfactory for evaluation (and benign), at least 6 groups of benign follicular cells are required, each group composed of at least 10 cells.6,7 The minimum size requirement for the groups allows one to determine (by the evenness of the nuclear spacing) whether they represent fragments of macrofollicles. endstream endobj startxref Does the fine-needle aspiration diagnosis of Hrthle-cell neoplasm/follicular neoplasm with oncocytic features denote increased risk of malignancy? Touch preps can be imprinted, rolled, or crushed between glass to provide similar information. . O First Time Setup Tested phones Android App Settings Estimated Band FAQ Translate . Weber D, Brainard J, Chen L. Atypical epithelial cells, cannot exclude papillary carcinoma, in fine needle aspiration of the thyroid. Various diagnostic terminologies, including indeterminate, atypical, and suspicious for malignancy, were used to describe these challenging cases[5]. The positive predictive value of a malignant FNA interpretation is 97% to 99%. A: No. Wu HH, Rose C, Elsheikh TM. Bone core biopsy. The interpretation should provide clinically relevant information that will assist referring physicians in the management of patients. Even neurons of the same type show various subtle process characteristics to fit into the diverse neural circuits. 4';KiRQ5S&. Any specimen that contains abundant colloid is considered adequate (and benign), even if 6 groups of follicular cells are not identified: A sparsely cellular specimen with abundant colloid is, by implication, a predominantly macrofollicular nodule and, therefore, almost certainly benign. As such, the redundancies in place discussed here and the compound output of the four major components have synergistic effects on diagnostic evaluation. Its clinical utilization is significant, as it can define whether a recently emerged thyroid nodule should be managed expectantly or surgically, and can assist in selecting the appropriate surgical procedure when necessary[3]. An explicit statement of adequacy is optional. Melton Author contributions: Misiakos EP, Margari N, Meristoudis C, Petropoulos K, and Spathis A contributed significantly in preparation, collection of data, writing and critically revising the manuscript; Machairas N, Schizas D, Karakitsos P and Machairas A contributed in data analysis, and writing the manuscript. A moderately or even highly cellular specimen by itself (without significant nuclear or architectural atypia) does not qualify a nodule for an AUS interpretation. Descriptive comments that follow are used to subclassify the malignancy and summarize the results of special studies, if any. How does one separate cellular follicular lesions of the thyroid by fine-needle aspiration biopsy? 0