Thyroid FNA reporting

[levels x3]

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How does everyone report thyroid FNA? How many of you are using a tiered system a la Bethesda/NCI? We've been having some spirited discussions lately about switching to a tiered reporting system, with me in favor and my 4 partners largely opposed. The objections range from believing there's no difference between the lower categories to complaining that thyroid FNA is a "diagnostic" procedure, not a "screening or risk-stratification" procedure like a Pap. I maintain that it is very much like a Pap, that we're assessing the risk of malignancy and guiding appropriate follow-up and/or surgical approach. Honestly I don't know how reproducible some of the new categories are, particularly the "atypia of undertermined significance/FLUS" category, but I am very much in favor of standard diagnostic categories for use across the country. As much as possible, I want to report everything the same as everyone else.

 

[earmuff]

Tiered system here... Out of curiosity, how do you do it? no atypical/suspicious categories or what?

 

[levels x3]

I try to stick to a the tiered system because that's how I learned it as a resident. In my first few months here (this is my first year out) I used some of the more descriptive, favor X, language of my partners because they were reviewing my cases (I'm not fellowship trained in cytopathology). Now that I'm more on my own, I've gone back to the tiered system. Rarely, I will use the "atypia of undertermined significance" category, once I think.

Some of my partners want to use the term "follicular lesion, favor X" for a lot of cases. The one's who do that are essentially saying that they might favor a hyperplastic nodule, but they really can't exclude a follicular neoplasm. They are essentially unwilling to commit to a benign diagnosis and that drives some of our clinicians crazy. They think the FNA is diagnostic and since they can't truly make a definitive diagnosis, they aren't going to give a likelihood of it being benign. I think that there are reliable features (eg. macro vs. microfollicles) that allow you to assign a risk category.

Again, I'm inexperienced and not boarded in cyto, so I'm still working this out in my head too.

 

[lipomas]

Thyroid FNAs are not diagnostic studies. They are screening studies for neoplasms. That is the whole purpose of the Bethesda system, to try to stratify risk based on morphology. Just because it is a screening test does not mean it cannot be diagnostic on occasion. Just like Pap smears and urine cytology.

The simple fact that many neoplasms cannot be diagnosed until you see the entire thing on slides means that FNA can't always be a diagnostic procedure.

I sign things out as "follicular lesion, favor colloid nodule" all the time. **** them if they don't like it. I don't like it either! But I'm not going to put my ass on the legal line just so they put it between them and the blood sucking lawyer. Especially when they do a ****ty biopsy because the patient says it hurts!

I am not cyto boarded either. We don't really use the "Atypical of uncertain significance" category, although I suppose we might eventually. There are clinical guidelines as to how to utilize atypical biopsies. Even things that are called "colloid nodule" are not supposed to be ignored by clinciians, they are supposed to be followed up and monitored for change. Why? because FNA IS A SCREENING TEST!!

 

[levels x3]

So then, Lipomas, am I correct in understanding that you do not use a specific tiered system like Bethesda? If I remember some of your previous posts correctly, you're in a community setting, as am I. Have any of your clinicians requested the tiered reporting system. Some of our endocrinologists are pushing us that way now (I'm all for it of course), I think specifically because of these "follicular lesion, favor X" diagnoses.

 

[yaah]

My group might be similar to lipomas in this fashion, not entirely sure but it sounds similar. We don't have a tiered system - we just give our impression. We try to be as definitive as possible but sometimes you can't be. Our clinicians seem to understand that and they follow-up and repeat biopsies as necessary.

I don't really think FNAs are diagnostic unless you get PTC or maybe a really good colloid nodule. Especially because the whole "minimally invasive follicular carcinoma" keeps getting more common. But you can be pretty confident most of the time. Basically, our terminology ends up similar to bethesda - Non-diagnostic, clearly benign, probably benign, unclear cannot rule out neoplasm, neoplasm.

 

[lipomas]

So then, Lipomas, am I correct in understanding that you do not use a specific tiered system like Bethesda? If I remember some of your previous posts correctly, you're in a community setting, as am I. Have any of your clinicians requested the tiered reporting system. Some of our endocrinologists are pushing us that way now (I'm all for it of course), I think specifically because of these "follicular lesion, favor X" diagnoses.

We have not had the system requested. I am unsure why. I think the way we sign things out essentially conforms to such a system, just not with the specific language. We do tend to use "favor" or "probable" a lot more, but they generally treat them the same way whether we say "favor" or we just outright call it. Unless of course it's a question of PTC or not, then they will do a frozen if we call it suspicious for PTC.

If they wanted to go ahead and ask us to use bethesda I would not have a big problem with it. I think the bethesda terminology is a bit overly cumbersome and doesn't help stratify things a ton, but it may help organize things better in many practices.

 

[levels x3]

I appreciate the responses. Whether consciously or not, it seems that most people's diagnoses essentially correspond to the proposed systems anyway. Still, I like standardized terminology wherever possible. And since yesterday one of our endocrinologists emailed us 6 articles, all of them referencing the NCI/Bethesda system, I think we'll be officially moving that way soon.

 

[coomasie blue]

The Bethesda System for Reporting Thyroid Cytopathology. Cibas ES, Ali SZ. Thyroid. 2009 Nov;19(11):1159-65.

Fine-needle aspiration of follicular patterned lesions of the thyroid: Diagnosis, management, and follow-up according to National Cancer Institute (NCI) recommendations. Faquin WC, Baloch ZW. Diagn Cytopathol. 2010 Jan 4.

The Bethesda System For Reporting Thyroid Cytopathology. Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference Am J Clin Pathol. 2009 Nov;132(5):658-65. Review.

The Bethesda thyroid fine-needle aspiration classification system: year 1 at an academic institution. Theoharis CG, Schofield KM, Hammers L, Udelsman R, Chhieng DC. Thyroid. 2009 Nov;19(11):1215-23.


We use it at our institution and surgeons/endocrinologists prefer the 6 tier system:

1. UNSAT
2. NEGATIVE
3. FLUS/INDETERMINATE
--------------------------
4. FN
5. SUSPICIOUS
6. POSITIVE

Everything from FN on up is a surgical case.

 

[yaah]

At many institutions anything from 3 and up is a surgical case. Part of the problem with bethesda and why some resist using it.

 

[coomasie blue]

At many institutions anything from 3 and up is a surgical case. Part of the problem with bethesda and why some resist using it.

FLUS/INDETERMINATE should not lead to surgery DIRECTLY if there is good relationship with the surgeons and endocrinologist. There should be a repeat FNA and or more stringent clinical workup first...

FLUS/ INDETERMINATE should either have nuclear features that are not characteristic of benign lesions or be cellular with minimal to zero colloid.

One issue is that FNA's can be performed in a sub-optimal way and institutions might use H/E staining instead of PAP for nuclear features and DIFF QUICK for extra nuclear features including colloid.

If done correctly thyroid FNA's are an exceedingly useful modality. Unfortunately too many unqualified individuals signout cyto and perform FNA's

Their experience is added to the pool of data for total thyroid FNA's etc making things seem much more tentative than they actually are.

This would less likely happen with other boarded specialties.

Hopefully as older pathologists that were grandfathered into cyto retire and criteria, training, and requirements become more stringent for signing out cytology and/or performing FNA's, the field will represent its true potential.

Consensus is usually a good thing.

Maybe that is why the heme and derm subspecialty board pass rates are reaching 100%

If a system trains competent professionals to use evidence based medicine and build consensus we will have less of an eminence based sausage fest.

 

[2121115]

Unfortunately too many unqualified individuals signout cyto and perform FNA's.

Not to derail the thread, but every academic attending in every subspecialty says this about their specialty.

 

[coomasie blue]

Not to derail the thread, but every academic attending in every subspecialty says this about their specialty.

They are saying it because it holds truth. It is academic institutions that aid in the development of consensus and evidence based medicine.

Consensus is not a bad thing. It might
be frustrating sometimes but it is a step toward evidence rather than eminence and CYA based pathology.