Thyroid Nodule Biopsy/ Cytology 101: What you need to know and when to get outside opinions on the results.
DR. Guttler’s comments on the Bethesda reporting system. My comments follow the description of each category.
The most important is the ROM( risk of malignancy ) management recommendations.
- Bethesda 1 ND/UNS non-diagnostic unsatisfactory ROM 5-10% recommend repeat FNA with US guidance. I suggest you have expert FNA physicians who use of rapid adequacy assessment to decrease inadequate results. Radiologists are bad at adequacy because they use large needles and stay in the nodule too long obtaining bloody samples devoid of cells or cells clumped in fibrin resulting in an over diagnosis of complex 3 D follicular lesion.
- Bethesda 2 B benign 0-3 % Clinical and US follow up. A good quality FNA can result in a benign diagnosis that is strong evidence it is not cancer in 97-100 % of the cases. However, a benign diagnosis can be wrong. A recent case diagnosed as a Chronic thyroiditis with >3% ROM was a Warthin’s variant of papillary thyroid cancer. Extensive lymphocytes in the papillary fronds caused the missed diagnosis when reviewed by me.
3.Bethesda 3 AUS/FLUS atypia and or follicular lesion undetermined significance 6-18% Repeat FNA,molecular testing or lobectomy. The addition of NIFT-P a comment is added. ” rare atypical nuclear features in this follicular patterned lesion suggests the possibility of Follicular variant of Papillary cancer or NIFT-P. The key to this category is molecular marker testing. Several labs offer it.I use Interpace DX but there are several more. I do not use the ones with just classifiers.4
4.Bethesda 4 FN/SFN follicular neoplasm or suspicious for FN 10-40% molecular testing lobectomy. This can be a problem when bloody smears are called follicular neoplasms. Have expert review the smears and if they are distorted by blood and fibrin , a repeat should be done with molecular tests.
5. Bethesda 5 SM suspicious for maliganacy 45-60% near-total or lobectomy. There are things that can go wrong with both 5, and 6. Suspicious or diagnostic for cancer can be wrong. We have seen the wrong cancer diagnosed as 5, or 6. This resulted in the wrong surgery, and radiation therapy. The rare Medullary thyroid cancer can be miss-diagnosed as Hurthle cell or follicular cancers, and the chance to do the correct first surgery will be missed, and prevent unnecessary radiation surgery.
6.Bethesda 6 M malignant 94-96% near-total or lobectomy. I have seen biopsy proven stage 6 thyroid cancer at needle biopsy called benign at surgery. One was called Hashimoto’s instead of variant papillary with lymphocytes. Also a papillary thyroid cancer called benign.A follicular variant papillary thyroid cancer was called follicular adenoma.
What options do you have when a biopsy diagnosis causes your physician to recommend surgery?
- Get another opinion before you have the surgery.You may not need it.
- Consider non-invasive alternatives with small micropapillary thyroid cancer such as outpatient ethanol or radiofrequency ablation.
- Consider no therapy at all just active surveillance for lesion <1.5 cm.
- If you have thyroid cancer and it returns after thyroidectomy,neck dissection and radioiodine consider ethanol or radiofrequency ablation of the lymph nodes in the neck with cancer.
Richard Guttler MD,FACE,ECNU
Come to see me for outside opinions and re-biopsies with molecular marker testing.
Also for evaluation for alternative therapies with ethanol or radiofrequency ablation.
Call 310-393-8860 or firstname.lastname@example.org for details.