Special Articles
Application of the Bethesda Classification for Thyroid
Fine-Needle Aspiration
Institutional Experience and Meta-analysis
Elliot A. Krauss, MD; Megan Mahon, BS; Jean M. Fede, DO; Lanjing Zhang, MD, MS
 Context.Fine-needle aspiration (FNA) biopsies have
been an important component in the preoperative evalu-
ation of thyroid nodules. Until the introduction of the
Bethesda System for Reporting Thyroid Cytopathology
(BSRTC) in 2008, individual institutions had developed
their own diagnostic categories. The BSRTC proposed 6
categories in an attempt to standardize reporting of thyroid
FNA.
Objective.To present a 15-year experience of thyroid
FNA at one institution, including data before and after
introduction of the BSRTC. The risk of malignancy is
compared with the meta-analysis of high-quality published
data.
Data Sources.Data sources were PubMed, a manual
search of references, and institutional data.
Conclusions.The diagnostic categories developed at
our institution were similar to those proposed by the
BSRTC, with best fit into the 6 categories easily accom-
plished and reported in the final 2 years of the study.
F ine-needle aspiration (FNA) of the thyroid gland has
proven to be an invaluable procedure for evaluating
patients with thyroid nodules. It has been in use for more
than 50 years, first advocated in Sweden.1 However, not
until the late 1970s was its use advocated in the United
States.2 As a method for triaging patients to distinguish
those who require surgery from those who do not,
institutions developed their own cytologic diagnostic
Accepted for publication February 12, 2016.
From the Department of Pathology, University Medical Center of
Princeton, Plainsboro, New Jersey (Drs Krauss, Fede, and Zhang); the
Department of Pathology, Rutgers Robert Wood Johnson Medical
School, New Brunswick, New Jersey (Drs Krauss, Fede, and Zhang,
and Ms Mahon); the Department of Chemical Biology, Rutgers Ernest
Mario School of Pharmacy, Piscataway, New Jersey (Dr Zhang); and
the Cancer Institute of New Jersey, Rutgers University, New
Brunswick, New Jersey (Dr Zhang). Drs Krauss and Zhang equally
supervised this work.
The authors have no relevant financial interest in the products or
companies described in this article.
Presented in part at the Princeton Integrated Pathology Sympo-
sium: Head and Neck Pathology; February 9, 2014; Princeton, New
Jersey.
Reprints: Elliot A. Krauss, MD, Department of Pathology, Univer-
sity Medical Center of Princeton, 1 Plainsboro Rd, Plainsboro, NJ
08536 (email: ekrauss@princetonhcs.org).
Arch Pathol Lab MedVol 140, October 2016
Significant differences were noted in the frequencies of
cases in diagnostic categories Benign (II; P .003),
Suspicious for follicular neoplasm/Follicular neoplasm
(IV; P , .001), and Malignant (VI; P .003) after the
introduction of the BSRTC. Eighteen published articles met
the criteria for inclusion in the meta-analysis. The risk of
malignancy in each category in our institution was similar
to that determined in the meta-analysis, except for
Insufficient for diagnosis (I; 20% versus 9%14%). Meta-
analysis showed an overlapping 95% CI of risk of
malignancy between Atypia of undetermined signifi-
cance/Follicular lesion of undetermined significance (III;
11%23%) and Suspicious for follicular neoplasm/Follic-
ular neoplasm (IV; 20%29%), suggesting similar risks of
malignancy. The use of newer molecular tests for these
indeterminate cases may further refine risk assessment.
(Arch Pathol Lab Med. 2016;140:11211131; doi:
10.5858/arpa.2015-0154-SA)
categories without consensus among reporting institutions.
Institutions reviewed their experiences with FNA of the
thyroid to determine its usefulness and predictive value for
malignancy.35 In 1996, the Papanicolaou Society of
Cytopathology proposed guidelines and 10 diagnostic
groups for the cytologic interpretation of thyroid FNA.6 In
2007, the National Cancer Institute hosted the NCI Thyroid
Fine Needle Aspiration State of the Science Conference. The
intention was to develop a system of classification of thyroid
FNA similar in scope to the Bethesda Classification for
gynecologic cervical cytology. By the publication and
acceptance of what has become known as the Bethesda
System for Reporting Thyroid Cytopathology (BSRTC), it
was hoped that there would be more effective communi-
cation among provider stakeholders, greater facilitation of
cytologic-histologic correlations, and the easy and reliable
sharing of data between different laboratories.7 Further, the
committee proposed morphologic criteria for each diagnos-
tic category.8 It was hoped that the proposed label of
Bethesda Classification would lend credibility to the
classification by reference and similarity to the gynecologic
cytology classification. The BSRTC has 6 diagnostic catego-
ries, including Nondiagnostic or Unsatisfactory (I); Benign
(II); Atypia of undetermined significance or follicular lesion
of undetermined significance (AUS/FLUS; III); Suspicious
Bethesda Classification for Thyroid FNAKrauss et al 1121
 Table 1. Distribution of Diagnoses Before and After Implementation of the Bethesda Classification
Diagnosis Bethesda Class 19992011, No. (%)a 20122013, No. (%) P Value
Total insufficient I 458 (10.3) 118 (10.4) .96b
Insufficient I 403 (9.1) 109 (9.6)
Cyst I 55 (1.2) 9 (0.8)
Total benign II 3211 (72.4) 875 (76.9) .003b
Chronic thyroiditis II 171 (3.9) 20 (1.8)
Benign nodule II 3040 (68.5) 855 (75.1)
Follicular lesion III 199 (4.5) 39 (3.4) .14b
Total class IV IV 322 (7.3) 21 (1.9) ,.001b
SuspFoll N IV 224 (5.0) 18 (1.6)
HCL/N IV 98 (2.2) 3 (0.3)
Total class V V 164 (3.7) 47 (4.1) .55b
Susp N/susp Malign V 55 (1.2) 43 (3.9)
Susp PTC V 109 (2.5) 4 (0.4)
Malignant (PTC and medullary carcinoma) VI 82 (1.8) 38 (3.3) .003b
Sum of Nodules 4436 1138 ,.001c
Abbreviations: HCL/N, Hurthle cell lesion/neoplasm; PTC, papillary thyroid carcinoma; SuspFoll N, Suspicious for follicular neoplasm; Susp N/susp
Malign, Suspicious for neoplasm/suspicious for malignancy.
a
Data through November 2011, when the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) was implemented.
b
Comparison of the frequencies of individual classifications in all cases before and after inclusion of BSRTC.
c
Comparison of the overall frequencies of major classifications before and after inclusion of BSRTC.

for follicular neoplasm or Follicular neoplasm (SFN/FN; IV);
Suspicious for malignancy (V); and Malignant (VI).
Beginning in 1999, our institution embarked on a program
of FNA sampling of thyroid nodules. The program was a
coordinated effort among a small group of physicians,
including a pathologist, interventional radiologists, endocri-
nologists, and thyroid surgeons. A system of classification
based on the Papanicolaou Societys report6 was agreed upon
by the providers. The system that developed was similar to
that later proposed by the BSRTC, which enabled a smooth
transition to that classification system. In this report, we have
summarized our 15-year experience, with comparison to the
BSRTC and an emphasis on the cytologic-histologic correla-
tion. We also conducted a meta-analysis of high-quality
published studies for comparison to our data. Our major aim
was to reappraise the value of BSRTC and seek areas of
potential improvement or update.
MATERIALS AND METHODS
Prospective Correlation Study
Beginning January 1, 1999, through December 31, 2013, all
results of thyroid FNA interpretations at the University Medical
Center of Princeton at Plainsboro, New Jersey (formerly University
Medical Center at Princeton, Princeton, New Jersey) were recorded
prospectively into a database. Thyroid nodules were localized with
palpation and ultrasound. The aspirates were prepared as direct
smears and were alcohol fixed. Excess material from the aspirates
was placed in Saccomanno or formalin (10%) fixative and a cell
block prepared, when possible. The smears were stained with the
standard Papanicolaou stain. Immediate diagnosis of adequacy was
not provided. The material was submitted by clinicians from their
office practice and from radiologists performing the procedure in
the hospital outpatient setting. Interpretation of the aspirates was
performed by pathologists only, not cytologists. During the 15
years of the study, 3735 of 5574 nodules (67%) were interpreted by
one pathologist, 1616 (29%) by another, and 223 (4%) by a third.
No retrospective review was performed on cases prior to analysis of
the data.
The cytologic diagnoses were classified into 9 categories with the
following criteria:
1. Unsatisfactory. Fewer than 6 groups containing at least 10 well-
preserved cells on each of at least 2 slides. Colloid only and
hypocellular aspirates from cysts were considered unsatisfactory
with a descriptive comment.
2. Benign thyroid nodule. Variable numbers of unremarkable
follicular cells in flat sheets, large clusters, and macrofollicles.

Table 2. Cytologic-Histologic Correlation 19992013

Surgical Diagnosis, No.
Cytologic Diagnosis Benign Cyst CT FA HCA FC HCC PTC Med Para SCC Totals
Insufficient 23 2 1 6 1 1 0 7 0 0 0 41
Benign 160 1 3 16 1 0 1 7 0 0 0 189
Follicular lesion 24 0 2 15 0 3 1 10 0 0 0 55
FN/Susp FN 47 0 1 38 0 3 0 15 0 0 0 104
HC lesion/neoplasm 15 0 1 1 6 3 12 0 0 0 0 38
Susp neoplasm/SuspMalig 11 0 0 10 0 9 1 34 1 3 1 70
Medullary carcinoma 0 0 0 0 0 0 0 0 1 0 0 1
Susp PTC 5 0 0 0 0 0 1 62 0 0 0 68
PTC 0 0 0 0 0 0 0 68 0 0 0 68
Total 634
Abbreviations: CT, chronic thyroiditis; FA, follicular adenoma; FC, follicular carcinoma; FN, follicular neoplasm; HC, Hurthle cell; HCA, Hurthle cell
adenoma; HCC, Hurthle cell carcinoma; Med, medullary carcinoma; Para, parathyroid gland; PTC, papillary thyroid carcinoma; SCC, squamous cell
carcinoma.
1122 Arch Pathol Lab MedVol 140, October 2016 Bethesda Classification for Thyroid FNAKrauss et al
 Table 3. Cytologic-Histologic Correlation Risk of Malignancy
Bethesda Risk of Risk of Malignancy,
Cytology Diagnosis, 19992013 Category Malignancy, % BSRTC, %a
Insufficient I 20 14
Benign II 4 03
Follicular lesion III 25 515
FN/Susp FN IV 17 1530
HC lesion/neoplasm IV 39
Susp neoplasm/Susp Malig V 66 6075
Susp PTC V 93
Medullary carcinoma VI 100
PTC VI 100 9799
Abbreviations: BSRTC, Bethesda System for Reporting Thyroid Cytopathology; FN, follicular neoplasm; HC, Hurthle cell; Malig, malignancy; PTC,
papillary thyroid carcinoma; Susp, suspicious for.
a
Risk of malignancy as reported in the BSRTC.8

Colloid and histiocytes were a common accompaniment. The
differential diagnosis for the group included hyperplastic
nodule, adenomatous follicular nodule, and macrofollicular
adenoma.
3. Chronic thyroiditis. Generally cellular specimens with abundant
lymphocytes or lymphoid tangles and follicular cells showing a
variety of changes in the same nodule, including variable
oxyphilic change, nuclear pleomorphism, and nuclear anisocy-
tosis. Histiocytes were common. Colloid was variable.
4. Follicular lesion. Hypercellular specimens with colloid and
variably sized follicles, predominantly microfollicles. Fewer
cellular specimens with atypical nuclei, including nuclear
enlargement, mild nuclear pleomorphism, and pale nuclei. The
differential diagnosis included a benign nodule, a follicular
neoplasm, and papillary carcinoma. Generally, the features of the
specimen were insufficient to reach a more definitive diagnosis.
5. Follicular neoplasm/suspicious for follicular neoplasm. Hyper-
cellular specimens with a predominance of microfollicles in 3-
dimensional, overlapping structures. Abundant isolated, intact,
individual cells with syncytial microbiopsies. Little colloid was
present. Cytologic nuclear changes of papillary thyroid carci-
noma were lacking. The differential diagnosis included benign

Figure 1. Forest plot of meta-analysis on the risk of malignancy of Bethesda classification I for thyroid fine-needle aspiration (I2 42.1%, P .04).
The reference numbers of the included articles are listed in the parentheses. Abbreviation: ES, estimated.
Arch Pathol Lab MedVol 140, October 2016 Bethesda Classification for Thyroid FNAKrauss et al 1123
Figure 2. Forest plot of meta-analysis on the risk of malignancy of Bethesda classification II for thyroid fine-needle aspiration (I2 93.6%, P , .001).
The reference numbers of the included articles are listed in the parentheses. Abbreviation: ES, estimated.
thyroid nodule, follicular adenoma, and well-differentiated
follicular carcinoma.
6. Hurthle cell lesion/suspicious for Hurthle cell neoplasm.
Variable cellularity with predominantly follicular cells showing
abundant granular and eosinophilic cytoplasm. Enlarged nuclei
with or without prominent nucleoli. Variably sized follicles or
sheets of follicular cells. Absence of lymphocytes. Colloid
variable, but generally scant. The differential diagnosis included
hyperplastic nodule, Hurthle cell adenoma, and Hurthle cell
carcinoma.
7. Suspicious for neoplasm. Generally hypercellular with cytologic
features suggestive of papillary carcinoma, such as enlarged
nuclei, atypical nuclei with irregular nuclear membranes,
nuclear grooves, overlapping and crowding of nuclei, nuclear
molding, and fine granular or powdery nuclear chromatin.
These features were quantitatively and qualitatively insufficient
for a more definitive diagnosis of malignancy. The differential
diagnosis included benign thyroid nodule and papillary thyroid
carcinoma.
8. Suspicious for papillary carcinoma. Generally hypercellular with
cytologic features suggestive of papillary carcinoma, such as
enlarged nuclei, atypical nuclei with irregular nuclear mem-
branes, nuclear grooves, overlapping and crowding of nuclei,
nuclear molding, fine granular or powdery nuclear chromatin,
and intranuclear pseudoinclusions. These specimens usually
lacked 1 or 2 of the cytologic features of papillary thyroid
carcinoma, preventing a definitive diagnosis. The differential
diagnosis included benign thyroid nodule and papillary thyroid
carcinoma.
1124 Arch Pathol Lab MedVol 140, October 2016
9. Malignant. Generally hypercellular with cytologic features
qualitatively and quantitatively definitive for papillary carcino-
ma as described in Suspicious for papillary carcinoma. This
category also would include anaplastic carcinoma, medullary
carcinoma, lymphoma, squamous cell carcinoma, and other
carcinomas, such as metastatic carcinoma.
In November 2011, our institution modified its reporting
categories to include the BSRTC category with a best fit to the
categories that had been in use.
This study has been approved by the Institutional Review Board
at our institution.
The Meta-analysis
We searched PubMed with the term cytology AND thyroid
AND Bethesda AND accuracy in May 2014. Additional articles
were also found or removed by manually reviewing the full text and
references of the matched articles. Two of the coauthors (M.M. and
L.Z.) cross-checked the accuracy and relevance of the articles. Only
studies meeting the following criteria were considered to have
high-quality data and to be relevant to the subject, and were
included: (1) the studies were indexed in PubMed; (2) the studies
reported correlations between thyroid cytology Bethesda classifi-
cation and respective surgical pathology diagnosis of thyroid
nodules; (3) the studies included both classes II and VI, and one
or more additional other categories, or included categories III, IV,
and V. The criterion 3 is particularly important for ensuring that the
included data represent a wide spectrum of pathology between
benign and malignant cases. This criterion in our view would
Bethesda Classification for Thyroid FNAKrauss et al
Figure 3. Forest plot of meta-analysis on the risk of malignancy of Bethesda classification III for thyroid fine-needle aspiration (I2 93.2%, P , .001).
The reference numbers of the included articles are listed in the parentheses. Abbreviation: ES, estimated.
significantly reduce the selection bias introduced by the studies that
included only one or two classes.
We used the best-fit approach to extract data and reclassify cases,
mostly for the works published prior to the publication of BSRTC.
Specifically, the acceptable alternative terminologies for AUS/FLUS
(III) category were indeterminate for neoplasm, indeterminate cells
of undetermined significance, atypical cellular lesion, atypical cells
of undetermined significance, atypical follicular cells, abnormal,
indeterminate, indeterminate follicular lesion, and inconclusive or
indeterminate. The acceptable alternative terminologies for SFN/
FN (IV) category were neoplasm, follicular/Hurthle cell neoplasm,
suspicious for neoplasm, suspicious for follicular or oncocytic
neoplasm, Hurthle cell, indeterminate Hurthle cell, and Hurthle
cell neoplasm.
The statistical analyses, including meta-analysis, were carried out
by using STATA version 12.0 (Stata Corp, College Station, Texas) as
described previously by Zhang et al.9 Random efforts were applied
to the meta-analysis. A random-effect model was used for meta-
analysis when I2 . 50% or P , .05 in the heterogeneity test;
otherwise, a fixed-effect model was used. P , .05 was considered
statistically significant.
RESULTS
Between January 1, 1999, and December 31, 2013, a total
of 5574 nodules were sampled during 4338 patient
encounters. Table 1 shows the distribution of diagnoses
before and after the inclusion of the BSRTC category, with
the descriptive diagnosis for each FNA. There was
significant frequency difference between before and after
Arch Pathol Lab MedVol 140, October 2016
inclusion of the BSRTC (P , .001), particularly within the
Benign (II) and Suspicious for malignancy (V) categories (P
, .001 for both). No frequency difference was found
between before and after inclusion of the BSRTC in the
categories Insufficient for diagnosis (I), AUS/FLUS (III),
SFN/FN (IV), and Malignant (VI; Table 1).
Of the 576 FNAs with Insufficient for diagnosis (which
included cysts), 193 patients (42%) had reaspirations, of
whom 165 (85%) resolved into a more specific category. Of
the 238 Follicular lesion diagnoses in 236 patients, only 6
patients (2.5%) had repeat aspirations of the nodules. All 6
(100%) had a diagnosis of Follicular lesion on the repeat
aspiration, which was separated from the first aspiration by
as much as 6 years. Of the 343 Suspicious for follicular
neoplasm/follicular neoplasm diagnoses, which included
those nodules with Hurthle cell features, in 324 patients,
only 6 patients (1.8%) had repeat aspirations of the nodules.
All 6 (100%) had a diagnosis of Suspicious for follicular
neoplasm/follicular neoplasm on the repeat aspiration,
which was separated from the first aspiration by as much as
7 years. Only 1 of these 6 patients (16.6%) had Hurthle cell
features, which was present on both the original as well as
the repeat aspiration.
According to the BSRTC, although Hurthle cell lesions/
neoplasms are included in the category SFN/FN (IV), it was
also recommended to specifically note the presence of
Hurthle cell changes. At our institution, Hurthle cell lesion/
Bethesda Classification for Thyroid FNAKrauss et al 1125
Figure 4. Forest plot of meta-analysis on the risk of malignancy of Bethesda classification IV for thyroid fine-needle aspiration (I2 91.0%, P ,
.001). The reference numbers of the included articles are listed in the parentheses. Abbreviation: ES, estimated.
neoplasm has always been considered a distinct category,
and although indicated as BSRTC SFN/FN (IV), it is
presented in Table 1 as a separate line category.
Similarly, Suspicious for papillary carcinoma had always
been considered by us as a separate category, and it is
presented as a BSRTC category V lesion, Suspicious for
malignancy.
The distribution of several diagnoses showed a significant
change after the introduction of the BSRTC classification.
Benign (II) showed a modest but significant increase in
percentage of cases, whereas SFN/FN (IV), Hurthle cell
lesion/neoplasm (IV), and Suspicious for papillary carcino-
ma (V) all showed significant decreases.
A total of 556 patients underwent a partial or total
thyroidectomy. Among them, 634 nodules were identifiable
based on the clinical or ultrasonographic description, and
were correlated with their cytologic diagnosis. The distri-
bution of the cytologic-histologic correlation of the nodules
within the excised thyroid glands is presented in Table 2.
The 2 diagnostic categories Hurthle cell lesion/Neoplasm
and Suspicious for papillary thyroid carcinoma are present-
ed as separate line categories.
There were 241 malignant nodules identified, of which 19
(7.9%) were follicular carcinoma, 16 (6.6%) Hurthle cell
carcinoma, 203 (84.2%) papillary thyroid carcinoma, 2
(0.8%) medullary carcinoma, and 1 (0.4%) squamous cell
1126 Arch Pathol Lab MedVol 140, October 2016
carcinoma. Within each category, except Hurthle cell lesion/
neoplasm, papillary thyroid carcinoma was the dominant
type of cancer identified, including 10 of the 14 cases
(71.4%) within the follicular lesion category and 15 of the 18
cases (83.3%) within the follicular neoplasm category.
Table 3 presents the cytologic-histologic correlations
charted in Table 2 as risk of malignancy (ROM) given the
cytologic diagnosis. Malignancy included follicular carcino-
ma, Hurthle cell carcinoma, papillary carcinoma, medullary
carcinoma, and squamous cell carcinoma. Although other
carcinomas can be seen in the thyroid gland, these were the
only malignancies identified in our patients. The ROM was
calculated by dividing the number of malignancies detected
by thyroidectomy, by the number of thyroidectomies, in a
diagnostic category, 3 100. The ROM was higher for
insufficient (I; 20%) and AUS/FLUS (III; 25%) than that
reported in the BSRTC.8 Of those insufficient cases which on
subsequent aspiration resolved into more definitive catego-
ries (n 165), 16 (10%) came to surgery. Of these 16, an
additional 5 (31%) malignancies were identified. If these
cases had surgery on the first Insufficient for diagnosis,
the ROM of Insufficient for diagnosis would have been
23%. In Table 3, these 16 cases were categorized in their
more definitive categories, not in the Insufficient for
diagnosis category.
Bethesda Classification for Thyroid FNAKrauss et al
Figure 5. Forest plot of meta-analysis on the risk of malignancy of Bethesda classifications III and IV (combined) for thyroid fine-needle aspiration (I2
94.2%, P , .001). The reference numbers of the included articles are listed in the parentheses. Abbreviation: ES, estimated.
Of the 628 articles identified in PubMed, 7 articles met the
inclusion criteria. An additional 11 qualified articles were
identified by searching the references of those articles and
personal article collections. A total of 18 articles therefore
were included for the meta-analysis and subject to the
heterogeneity test (Figures 1 through 7; Table 4). Our meta-
analysis found that AUS/FLUS (III) and SFN/FN (IV) had
similar ROMs, as shown by overlapping 95% CIs (average
[95% CI], 0.24 [0.160.32] and 0.25 [0.190.31], respectively;
Figures 3 and 5 and Table 5). The ROM of the combined
AUS/FLUS (III) and SFN/FN (IV) was 0.24 (0.190.30;
Figure 4 and Table 5) and did not overlap the 95% CIs of
Benign (II) or Suspicious for malignancy (V). The pooled
ROMs of categories Benign (II), Suspicious for malignancy
(V), and Malignant (VI) were significantly different from
each other, and from AUS/FLUS (III) and SFN/FN (IV) or
combined from AUS/FLUS (III) and SFN/FN (IV). Of note,
the pooled ROM from meta-analysis was slightly different
from the crude malignancy rate in cases combined because
weighted ROMs from the included studies were used for
calculation (Figures 1 through 7 and Table 4).
DISCUSSION
In the past 40 years, thyroid FNA has been recognized as
the most useful diagnostic tool in triaging those patients
most at risk of harboring a malignant lesion. We have
reported our 15 years of experience with the technique,
Arch Pathol Lab MedVol 140, October 2016
ROM in each diagnostic category, and comparison with the
pooled ROM through a meta-analysis on high-quality
published data.
The results of this thyroid FNA study confirm the
usefulness and comparability of this technique in our
institution to the experience at other institutions.1017 The
distribution of diagnoses is similar to that reported as
expected when using the BSRTC and our meta-analysis
results.8
After the implementation of the BSRTC, the distribution
of several diagnoses showed a significant change. Benign
(II) showed a modest but significant increase, whereas SFN/
FN (IV), Hurthle cell lesion/Neoplasm (IV), and Suspicious
for Papillary Carcinoma (V) all showed significant decreases.
The publication by Baloch et al8 of diagnostic criteria for
each category aided us in refining our interpretations and
may account for the change in distributions from 19992011
versus 20122013. However, our experience with reporting
the BSRTC encompassed only 2 years versus 13 years. The
distribution could regress to the results of the previous 13
years as time and the number of aspirates progresses
forward.
The recognition that the BSRTC category of Papillary
Carcinoma accepted a less than 100% ROM influenced us to
progressively eliminate the category of Suspicious for
papillary carcinoma, in which we had a 93% ROM, in favor
Bethesda Classification for Thyroid FNAKrauss et al 1127
Figure 6. Forest plot of meta-analysis on the risk of malignancy of Bethesda classification V for thyroid fine-needle aspiration (I2 93.3%, P , .001).
The reference numbers of the included articles are listed in the parentheses. Abbreviation: ES, estimated.
of the more definitive diagnostic category Papillary Carci-
noma.
Indeed, combining our Suspicious for papillary carcinoma
category, primarily used before the introduction of the
BSRTC, with our Papillary Thyroid Carcinoma category
would have produced a ROM of 96%, similar to that
reported in the BSRTC8 category Malignant (VI).
Of the 576 insufficient for diagnosis patients, 193 (34%)
had repeat aspirations, with 85% of them resolving into
more definitive diagnostic categories. A total of 41 patients
went on to have partial or total thyroidectomy, with 8 (20%)
of them showing malignancy. The meta-analysis also
identified a 12% (95% CI, 9%14%) ROM in this category.
The higher rate of malignancy in our series may reflect other
suspicious clinical features that prompted the election of
surgical excision. It is noteworthy to recognize that
insufficient for diagnosis does not mean negative for
malignancy, and these patients should have close clinical
follow-up.
The ROMs of our categories Suspicious for malignancy
(V) and Malignant (VI) are similar to that of the meta-
analysis. AUS/FLUS (III) is slightly higher (25%) and SFN/
FN (IV) is slightly lower (17%) than the ranges seen in the
meta-analysis (95% CIs, 11%23% and 20%29%, respec-
tively). This likely reflects subjective differences in how we
interpreted the criteria for these categories. This subjectivity
was mirrored as well by the wide 95% CIs seen in the meta-
analysis. It might be useful for laboratories to create a
standardized performance measure (such as ratio of AUS/
1128 Arch Pathol Lab MedVol 140, October 2016
FLUS to total thyroid FNAs) and incorporate a consensus
review for lesions falling into indeterminate categories
(AUS/FLUS [III] and SFN/FN [IV]). It is interesting to note
that there was a wide CI for the Suspicious for malignancy
(V) category in the meta-analysis, indicating significant
subjectivity here as well.
The usefulness of FNA of the thyroid is in its ability to aid
clinicians in their decision on how best to treat patients.
Thus, Benign (I), Suspicious for malignancy (V), and
Malignant (VI) categories have sufficient ROMs, in our
institution (4%, 66%, and 96%, respectively) and other
reports summarized by our meta-analysis, as to give
clinicians clear treatment directions.
The more problematic categories of AUS/FLUS (III), SFN/
FN (IV), and Hurthle cell lesion/Neoplasm (IV) have ROMs
that are in an indeterminate range, 17% to 39%, and
therefore do not give clinicians a clear direction. In our
series, very few of these cases had repeat aspirations, which
have been reported in other series to resolve the dilemma in
up to 50% of cases of AUS/FLUS (III).18 However, the ROM
for an AUS/FLUS (III) diagnosis with a subsequent Benign
(II) diagnosis on a follow-up FNA is not the same as a single
Benign (II) diagnosis, but rather falls somewhere in between
the two (15%29%).19,20 This would seem to preclude the
use of a second aspiration in cases of AUS/FLUS (III) for
additional risk stratification. The presented meta-analysis
shows overlapping ROMs for AUS/FLUS (III) and SFN/FN
(IV). On the surface, AUS/FLUS (III) and SFN/FN (IV) have
different diagnostic criteria, but the ROM is what drives a
Bethesda Classification for Thyroid FNAKrauss et al
Figure 7. Forest plot of meta-analysis on the risk of malignancy of Bethesda classification VI for thyroid fine-needle aspiration (I2 25.1%, P .24).
The reference numbers of the included articles are listed in the parentheses. Abbreviation: ES, estimated.
Table 4.
Source, y
Banks et al,24 2008
Blansfield et al,25 2002
Bohacek et al,26 2012
Bozhok et al,27 2009
Faquin and Baloch,28 2010
Jo et al,29 2010
Mufti and Molah,30 2012
Nayar and Ivanovic,31 2009
Oertel et al,32 2007
Poller et al,33 2000
Renshaw,34 2011
Sclabas et al,35 2003
Smith et al,36 2013
Theoharis et al,37 2009
Wu et al,15 2006
Wu et al,38 2012
Yang et al,39 2007
Yassa et al,40 2007
Arch Pathol Lab MedVol 140, October 2016
The List of the Studies Qualified and Included in the Meta-analysis
Article Title
A diagnostic predictor model for indeterminate or suspicious thyroid FNA samples
Recent experience with preoperative fine-needle aspiration biopsy of thyroid nodules in a
community hospital
Diagnostic accuracy of surgeon-performed ultrasound-guided fine-needle aspiration of thyroid
nodules
A cohort study of thyroid cancer and other thyroid diseases after the Chernobyl accident: Cyto-
histopathologic correlation and accuracy of fine needle aspiration biopsy in nodules detected
during the first screening in Ukraine
Fine-needle aspiration of follicular patterned lesions of the thyroid: Diagnosis, management, and
follow-up according to National Cancer Institute (NCI) recommendations
Malignancy risk for fine-needle aspiration of thyroid lesions according to the Bethesda System For
Reporting Thyroid Cytopathology
The Bethesda System for Reporting Thyroid Cytopathology: A five-year retrospective study of one
center experience
The indeterminate thyroid fine-needle aspiration
Value of repeated fine needle aspirations of the thyroid: An analysis of over ten thousand FNAs
Fine-needle aspiration of the thyroid: Importance of an indeterminate diagnostic category
Subclassification of atypical cells of undetermined significance in direct smears of fine-needle
aspirations of the thyroid
Fine-needle aspiration of the thyroid and correlation with histopathology in a contemporary series of
240 patients
Indeterminate pediatric thyroid fine needle aspirations: A study of 68 cases
The Bethesda Thyroid Fine-Needle Aspiration Classification System: Year 1 at an academic institution
Fine-needle aspiration cytology of the thyroid: Ten year experience in a community teaching hospital
The Bethesda System for Reporting Thyroid Cytopathology: An experience of 1,382 cases in a
community practice setting with the implication for risk of neoplasm and risk of malignancy
Fine-needle aspiration of thyroid nodules: A study of 4703 patients with histologic and clinical
correlations
Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation
Bethesda Classification for Thyroid FNAKrauss et al 1129
 Table 5. Meta-analysis of the Risk of Malignancy in the Bethesda Classes
Included Risk of Malignancy
Class Studies, No. (95% Cls)
I 10 0.12 (0.090.14)
II 11 0.05 (0.030.07)
III 10 0.17 (0.110.23)
III and IV 14 0.24 (0.180.29)
IV 14 0.25 (0.200.29)
V 12 0.72 (0.610.84)
VI 7 0.98 (0.970.99)
a
Some studies may be excluded in the meta-analysis.
b
Heterogeneity v2 P values.
clinicians decision, not the terminology. Newer molecular
tests have been developed and in particular assist in triaging
these indeterminate (AUS/FLUS [III] and SFN/FN [IV])
cases.21,22 These initial papers appear encouraging, but
further refinement and development of additional molecular
markers may enable an even more accurate categorization.
In its latest guidelines, the American Thyroid Association
indicates that investigations such as repeat FNA or
molecular testing may be used to supplement malignancy
risk assessment data, in lieu of proceeding directly with a
strategy of either surveillance or diagnostic surgery for
AUS/FLUS (III), and molecular testing may be used to
supplement malignancy risk assessment data, in lieu of
proceeding directly with surgery for SFN/FN (IV).23 The use
of these molecular markers as a reflex to initially indeter-
minate cytologic diagnoses may therefore lead to, in the
future, the collapse of the AUS/FLUS (III) and SFN/FN (IV)
categories into a single indeterminate category with a
consistent and unified set of management recommenda-
tions. However, prospective studies and high-quality data
are needed to validate our findings and proposals.
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