Bethesda system for reporting thyroid malignancy
- 1. BETHESDA SYSTEM FOR REPORTING THYROID CYTOPATHOLOGY Guide : Dr Sharada Rane PG : Dr Gourav Agrawal
- 2. Introduction ☛Bethesda System for Reporting Thyroid Cytopathology (BSRTC) recommends that each thyroid FNA report should begin with a general diagnostic category. ☛The motive behind is to bring clarity of communication amongst pathologists and amongst pathologist and clinicians.
- 3. 1. Nondiagnostic or Unsatisfactory 2. Benign 3. Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance 4. Follicular Neoplasm or Suspicious for a Follicular Neoplasm 5. Suspicious for Malignancy 6. Malignant
- 5. ☛Fewer than six groups of well- preserved, well-stained follicular cell groups with ten cells each ☛Poorly prepared, poorly stained, or obscured follicular cells ☛Cyst fluid, with or without histiocytes, and fewer than six groups of ten benign follicular cells
- 6. Nondiagnostic (cyst fluid only). Abundant hemosiderin-laden macrophages
- 7. Nondiagnostic. The smear shows abundant red cells, with rare lymphocytes
- 8. Nondiagnostic. Extensive air-drying artifact in this alcohol-fixed smear
- 9. Exceptions 1. Solid nodules with cytologic atypia • Any significant atypia has to be reported • Minimum number of cells not required 2. Solid nodules with inflammation • Thyroiditis may show only infammatory cells • Minimum number of cells not required 3. Colloid nodules • Minimum number of cells is not required if easily-identifiable colloid
- 11. Benign Follicular Nodules (BFNs) ● nodules in nodular goiter (NG) ● hyperplastic (adenomatoid) nodules ● colloid nodules ● nodules in Graves’ disease ● subset of follicular adenomas (those of macrofollicular type) Thyroiditis ● Lymphocytic, Acute, Sub-acute, Riedel’s
- 12. Benign Follicular Nodule ☛ Colloid ● dark blue-violet-magenta with Romanowsky ● green to orange-pink with Papanicolaou ● Thin colloid - “thin membrane/cellophane” or “crazy pavement” or “chicken wire” or mosaic appearance ● Dense colloid - hyaline quality and shows cracks ☛ Follicular cells - arranged predominantly in monolayered sheets and are evenly spaced
- 13. BFN : Watery colloid has a light green-pink color and shows a “thin membrane/cellophane coating” appearance
- 14. Benign follicular nodule: Thick colloid demonstrates a “stained glass cracking” appearance
- 15. BFN : Predominantly monolayered sheets of follicular cells are admixed with occasional pigment-laden macrophages
- 16. Grave’s Disease ☛ Lymphocytes may be seen in the background. ☛ Follicular cells are arranged in flat sheets and loosely cohesive groups, with abundant delicate, foamy cytoplasm. ☛ Nuclei are often enlarged, vesicular, and show prominent nucleoli. ☛ Few microfollicles may be observed. ☛ Distinctive flame cells may be prominent, and are represented by marginal cytoplasmic vacuoles with red to pink
- 17. Large monolayered sheets of cells have abundant cytoplasm. Flame cells are distinctive, with marginal cytoplasmic vacuoles with red to pink
- 18. Hashimoto’s Thyroiditis ☛ Usually hypercellular, but does not require a minimum number of follicular/Hürthle cells for adequacy. ☛ The lymphoid population is polymorphic, including small mature lymphocytes, larger reactive lymphoid cells, and occasional plasma cells. ☛ Hürthle cells (oncocytes), when present, are arranged in sheets or as isolated cells. They have abundant granular cytoplasm, large nuclei, and prominent nucleoli
- 19. Lymphocytic (Hashimoto’s) thyroiditis. There is a mixed population of Hürthle cells and polymorphic lymphocytes
- 20. Granulomatous/de Quervain’s thyroiditis ☛ Clusters of epithelioid histiocytes, i.e., granulomas, are present along with many multinucleated giant cells. ☛ Early stage - many neutrophils and eosinophils, similar to acute thyroiditis. ☛ Late stages - smears are hypocellular. They show giant cells surrounding and engulfing colloid, epithelioid cells, lymphocytes, macrophages, and scant degenerated follicular cells
- 21. Granulomatous (de Quervains) thyroiditis. Epithelioid granulomas, mixed inflammatory cells, and benign follicular cells are present. Macrophage with
- 22. Acute thyroiditis ☛ Numerous neutrophils are associated with necrosis, fibrin, macrophages and blood. ☛ There are scant reactive follicular cells and limited to absent colloid. ☛ Bacterial or fungal organisms are occasionally seen in the background especially in immunocompromised patients.
- 23. Acute thyroiditis. There are numerous neutrophils, macrophages, and inflammatory debris
- 24. Riedel’s Thyroiditis ☛The thyroid gland feels stony hard on palpation. ☛The preparations are often acellular. ☛Collagen strands and bland spindle cells may be present. ☛There are rare chronic inflammatory cells. ☛Colloid and follicular cells are usually absent
- 25. Riedel´s thyroiditis. The hypocellular smear contains scattered bland spindle cells and rare chronic inflammatory cells
- 26. Category III Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance
- 27. ☛ specimens that contain cells (follicular, lymphoid, or other) with architectural and/or nuclear atypia that is not sufficient to be classified as suspicious for a follicular neoplasm, suspicious for malignancy or malignant ☛ On the other hand, the atypia is more marked than can be ascribed confidently to benign changes
- 28. Examples : ☛ Predominance of Hürthle cells in a sparsely cellular aspirate with scant colloid ☛Focal features suggestive of papillary carcinoma in an otherwise predominantly benign-appearing sample ☛Cyst-lining cells which may appear atypical due to nuclear features in an otherwise predominantly benign-appearing sample. ☛Atypical lymphoid infiltrate but the degree of atypia is insufficient for the general category “suspicious for malignancy.”
- 29. AUS. Sparsely cellular specimen with a predominance of microfollicles. Inset : high magnification of a microfollicle
- 30. AUS (a) heterogeneous infiltrate of lymphoid cells, including occasional atypical
- 31. Category IV Follicular Neoplasm/Suspicious for a Follicular Neoplasm Follicular Neoplasm, Hürthle Cell Type/Suspicious for a Follicular Neoplasm, Hürthle Cell Type
- 32. ☛ Significant alteration in the follicular cell architecture, characterized by cell crowding, microfollicles, and dispersed isolated cells. ☛ Follicular cells are normal-sized or enlarged and relatively uniform, with scant or moderate amounts of cytoplasm. ☛ Nuclei are round and slightly hyperchromatic, with inconspicuous nucleoli ☛ Colloid is scant or absent. Follicular Neoplasm/Suspicious for a Follicular Neoplasm
- 33. Highly cellular aspirate composed of uniform follicular cells arranged in crowded clusters and microfollicles
- 34. Follicular neoplasm/Suspicious for a follicular neoplasm. Microfollicles may contain small amounts of colloid
- 35. Follicular Neoplasm, Hürthle Cell Type/Suspicious for a Follicular Neoplasm, Hürthle Cell Type ☛ Exclusively (or almost exclusively) Hurthle cells ☛ abundant finely granular cytoplasm ☛ enlarged, central or eccentrically located, round nucleus with prominent nucleolus
- 36. The aspirate is very cellular and consists of Hürthle cells of variable size arranged as isolated cells and in crowded groups; colloid is absent
- 37. The aspirate consists of a population of loosely cohesive Hürthle cells. The cells are highly variable in size and amount of cytoplasm
- 39. Sub-categories ☛ Suspicious for Papillary Carcinoma • Pattern A - Patchy nuclear changes pattern • Pattern B - Incomplete nuclear changes pattern • Pattern C - Sparsely cellular specimen pattern • Pattern D - Cystic Degeneration pattern ☛ Suspicious for Medullary Carcinoma ☛ Suspicious for Lymphoma ☛ Suspicious for malignancy, not
- 40. The aspirate consists of a population of loosely cohesive Hürthle cells. The cells are highly variable in size and amount of cytoplasm
- 41. The aspirate consists of a population of loosely cohesive Hürthle cells. The cells are highly variable in size and amount of cytoplasm
- 43. Sub-categories ☛ Papillary Thyroid Carcinoma ☛ Medullary Thyroid Carcinoma ☛ Poorly differentiated Thyroid Carcinoma ☛ Undifferentiated (Anaplastic) Carcinoma and Squamous Cell Carcinoma of the Thyroid ☛ Metastatic tumors and lymphoma
- 44. Papillary Carcinoma Thyroid ☛ Follicular cells are arranged in papillae and/or syncytial-like monolayers. ☛ Swirling sheets (“onion-skin”) sometimes seen. ☛ Characteristic nuclear features: • Enlarged nuclei • Oval or irregularly shaped, with marked overlapping. • Longitudinal nuclear grooves • Intranuclear cytoplasmic pseudoinclusions (INCI) • Pale nuclei with powdery chromatin (“Orphan
- 45. Papillary Carcinoma Thyroid ☛ Psammoma bodies are sometimes present. ☛ Multinucleated giant cells are common. ☛ The amount of colloid is variable and may be stringy, ropy, or “bubble-gum” like. ☛ Hürthle cell (oncocytic) metaplasia is sometimes seen.
- 46. Papillary Thyroid Carcinoma. There is a mix of flat sheets and rounded, papillary-like fragments without fibrovascular cores
- 47. Papillary thyroid carcinoma. There is marked crowding of the neoplastic
- 48. PTC. Large sheet of tumor cells with crowded, “Orphan Annie eye” nuclei.
- 49. Medullary Thyroid Carcinoma ☛ Moderate to marked cellularity. ☛ Numerous isolated cells alternate with syncytial-like clusters in variable proportions from case to case. ☛ Cells are plasmacytoid, polygonal, round, and/or spindle-shaped, with moderate to abundant cytoplasm, eccentric nucleus and smudged chromatin ☛ The neoplastic cells usually show only mild to moderate pleomorphism. ☛ Fragments of amorphous material - colloid versus amyloid.
- 50. Predominantly dispersed, uniform plasmacytoid or polygonal cells have granular (“salt and pepper”) chromatin and small but distinct
- 51. Medullary thyroid carcinoma. Amyloid is abundant and readily appreciated in some cases
- 52. Poorly Differentiated Thyroid Carcinoma ☛ Cellular preparations display an insular, solid, or trabecular cytoarchitecture ☛ There is a uniform population of follicular cells with scant cytoplasm (sometimes plasmacytoid) ☛ The malignant cells have a high nuclear/cytoplasmic (N/C) ratio with variable nuclear atypia ☛ Apoptosis and mitotic activity are present
- 53. Poorly differentiated thyroid carcinoma. Aspirates show marked pleomorphism which are mitotically active.
- 54. Poorly differentiated thyroid carcinoma. Aspirates exhibit marked nuclear atypia with impressive
- 55. Undifferentiated (Anaplastic) Carcinoma and Squamous Cell Carcinoma of the Thyroid Undifferentiated (Anaplastic) Carcinoma ☛ Neoplastic cells are arranged as isolated cells and/or in variably sized groups. ☛ Neoplastic cells are epithelioid (round to polygonal) and/or spindle-shaped and range in size from small to giant-sized. “Plasmacytoid” and “rhabdoid” cell shapes
- 56. ☛ Nuclei show enlargement, irregularity, pleomorphism, clumping of chromatin with parachromatin clearing, prominent irregular nucleoli, intranuclear inclusions, eccentric nuclear placement, and multinucleation. ☛ Necrosis, extensive inflammation (predominantly neutrophils, “abscess-like”) and/or fibrous connective tissue may be present. ☛ Osteoclast-like giant cells (non-neoplastic) are conspicuous in some cases. ☛ Neutrophilic infiltration of tumor cell cytoplasm can be seen.
- 57. Cells are epithelioid (polygonal) in appearance. Variation in cell and nuclear size is evident.
- 58. Squamous Cell Carcinoma ☛ Cytologic samples are composed almost exclusively of large, pleomorphic keratinized cells. ☛ Necrosis may be present.
- 59. Large pleomorphic cells with dense cytoplasm. There is abundant necrosis, and nuclei show degenerative changes
- 60. Sample Reports – Nondiagnostic or Unsatisfactory
- 61. Sample Reports – Benign
- 62. Sample Reports – Atypia of Undetermined Significance
- 63. Sample Reports – Follicular Neoplasm/ Suspicious for a Follicular Neoplasm
- 64. Sample Reports – Suspicious for a Malignancy
- 65. Sample Reports – Malignant
- 66. 1. Nondiagnostic or Unsatisfactory 2. Benign 3. Atypia of Undetermined Significance or Follicular Lesion of Undetermined Significance 4. Follicular Neoplasm or Suspicious for a Follicular Neoplasm 5. Suspicious for Malignancy 6. Malignant THANK U BSRTC