Atypical Thyroid Diagnoses-Potential for Overuse?

Papillary Carcinoma of the Thyroid This illust...

Papillary Carcinoma of the Thyroid This illustrative cell group shows cardinal features of papillary carcinoma: nuclear grooves and pseudoinclusion. Scrape cytology from cut surface of tumor in thyroidectomy specimen, rapid H&E, 1000X. (Photo credit: Wikipedia)

In a recent editorial published in Cancer Cytopathology, Vol. 120:2, April 25, 2012, Dr. Michael Henry discusses the potential for overuse of atypical thyroid diagnoses according to The Bethesda System for Reporting  Thyroid Cytopathology (TBSRTC). This journal also includes other articles related to thyroid FNA, interpretation and quality tools (to be discussed in a subsequent blog post). The articles included in this journal center around the AUS/FLUS categories, and suggestions for keeping these nebulous categories in check.

Just as the ASC:SIL ratio has been useful in cervicovaginal cytology, Dr. Henry describes the proposed use by Krane et. al of an AUS:Malignant (M) ratio as a quality tool to monitor the overcalling of AUS or undercalling of M. The authors suggest that this ratio should fall between 1.0 and 3.0 in most laboratories. In addition to following this ratio, the actual rate of AUS/FLUS cases, which TBSRTC recommends should not exceed 7%, is another metric to be monitored. Krane, et. al. reviewed data collected in 8 series of thyroid FNAs in institutions using TBSRTC,  with a range of AUS/FLUS cases from 3.0% to 17.8%, and a combined rate of 9.7%. Bongiovanni discuss the role of molecular testing on AUS/FLUS cases, with cases with positive molecular markers having a high probability for a cancer outcome. However, they also suggest that currently available molecular markers “…are not as useful for the difficult thyroid FNA lesions…”. Recently, “…microarray data from >200 genes have been used to produce a “benign thyroid fingerprint” that has the potential for use in guiding management of patients with an AUS/FLUS interpretation.”

Dr. Henry discusses that

“…the objective of thyroid cancer diagnosis is not so much achieving a reduction in mortality as the prevention of morbidity.”

And, as a result of the American Cancer Society’s 2010 data indicating low mortality rates from thyroid cancer,

“…the goal of the cytopathologist in thyroid FNA should not necessarily be the elimination of all false-negative cases[,]…[but should be on] ways to improve the [quality] performance of their laboratories.”

In summary, laboratories should establish a quality assessment program to monitor the results of their thyroid FNA program. This program would include monitoring of:

  • overall diagnostic rates
  • cyto-histo correlation and followup on surgically excised lesions
  • rates of malignant outcomes according to FNA diagnostic categories and comparison with published benchmarks
  • AUS:M ratio for overall laboratory and individual pathologists

(via Henry, M. (2012), The potential for overuse of atypical thyroid diagnoses. Cancer Cytopathology, 120: 108–110. doi: 10.1002/cncy.20191)

About Jana Sullinger

GYN Pathologist and Cytopathologist. Special interest in quality assessment and use of online social media in sharing educational information about cytology and quality.


  1. […] the articles on thyroid cytology listed below, you may want to read my previous blog post regarding atypical thyroid diagnoses, based on the editorial article listed […]

  2. […] in the improvement of thyroid cytology quality was the advent of TBSRTC, which I recently discussed here and here. Not only does this system attempt to standardize terminology, it also provides an […]

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