color atlas on bethesda system for reporting thyroid cytology

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Atlas on Bethesda
system for reporting
Thyroid Cytology
Color atlas - Bethesda system for reporting thyroid cytology… By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
Images courtesy Papanicolaou society of cytopathology web atlas and Bethesda system for reporting thyroid cytology

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OVERVIEW
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9.

Indications and goal of thyroid FNA
Contraindications
Procurement of cell sample
Staining methods
Limitations
Need for Bethesda terminology
Recommended diagnostic categories
Format of report
Diagnostic categories in detail
a. Non diagnostic or unsatisfactory
b. Benign
c. Atypia of undetermined significance or Follicular lesion of Undetermined
significance
d. Follicular neoplasm or suspicious for a follicular neoplasm
e. Suspicious for malignancy (suspicious of papillary/medullary/lymphoma/mets)
f. Malignant
10. Recommended management for diagnostic categories



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* PROCUREMENT OF CELL SAMPLE
1. Nodule is identified by palpation
2. A 22G to 25 G needle is used to procure cell sample from atleast three different areas of
the nodule
3. If the nodule is difficult to palpate, FNA should be done under USG guidance
4. For cystic thyroid lesions, the cyst content should be evacuated first with a syringe
5. Since thyroid is rich in capillaries, needle aspirate usually contains large amount of
peripheral blood. This can be limited by a no aspiration technique and by limiting the
procedure to about five seconds

* STAINING METHODS
1. Parallel air dried (stained with romanowsky stains like Giemsa) and wet fixed smears
(stained with HE or Pap) are recommended
2. For Pap stained smears, quick fixation in 95% ethanol without drying is recommended, a
delay in fixation leads to air drying artefact
3. Nuclear details in Romanowsky stained smears are not well appretiated, but cytoplasmic
details are visualized nicely
4. In Pap stained smears, nuclear details are well visualized
5. Fixation of aspiration smears in Carnoy’s solution may be done to lyse red blood cells
prior to staining

* LIMITATIONS OF THYROID F.N.A.
1. overlap of cytological patterns of neoplastic and non neoplastic lesions
2. overlap of cytological features between various neoplasms
3. co existence of non neoplastic and neoplastic processes and multiple malignancies



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* RECOMMENDED DIAGNOSTIC CATEGORIES

- Mucoepidermoid carcinoma of thyroid



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Cyst fluid only
Blood and macrophages
Should be correlated with sonographic features

Cyst fluid only
Histiocytes and scant colloid on LBC smear
Should be correlated with sonographic features



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Non diagnostic due to extensive air drying

Blood only



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Benign follicular cells (macrofollicle fragment)

Abundant colloid and scant benign follicular cells



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Benign follicular cells in sheets.
Cellular portion of adenomatoid nodule (cellular colloid goiter)

Sheets of benign follicular cells.
Cellular portion of adenomatoid nodule. There is abundant colloid elsewhere



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Reactive Cyst Lining Cells with Hemosiderin Pigment

Graves Disease
Stimulated follicular cells and marginal eosinophilic cytoplasmic vacuoles with terminal frayed edges


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Pure colloid

Colloid



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Crowded follicular cell group with lymphoid background

Hurthle cells (oncocytic metaplasia)


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Hurthle cells (oncocytic metaplasia) with reactive changes

Mixed lymphoid population without Hurthle cells



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Lymphoid cells with crush artifact

Polymorphous population of lymphocytes and Hurthle cells



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Cohesive fragment of Hurthle cells (oncocytes)

Hurthle cells (low magnification)



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Hurthle cells (oncocytes).

Hurthle cells: single cells and fragments



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Monolayered sheet

Intranuclear pseudoinclusions and focal oncocytic change



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Monolayered sheet.

Intranuclear pseudoinclusions (INCIs).



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Intranuclear pseudoinclusions (INCIs).

Monolayered sheet.



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Monolayered sheet with grooves and intranuclear pseudoinclusions

Intact papilla



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anaplastic Carcinoma of Thyroid in liquid base prep
Cells with variation in size and shape. Because of tendency of cells to round up in liquid preparations, cells much
be evaluated in context of other cells present including inflammatory cells.

anaplastic Carcinoma of Thyroid in liquid base prep
Cells with variation in size and shape. Because of tendency of cells to round up in liquid preparations, cells much
be evaluated in context of other cells present including inflammatory cells.



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Abundant thick colloid

Abundant thick colloid


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Colloid mixed with blood

Abundant colloid with “pavementing” (“cracking,” “windowpane”) artifact



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Metastatic Merkel cell carcinoma.

Metastatic bronchioloalveolar carcinoma.



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Metastatic adenocarcinoma of the colon.

Malt Lymphoma



color atlas on bethesda system for reporting thyroid cytology

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color atlas on bethesda system for reporting thyroid cytology