Pancreatic cytopathology practice has changed significantly in the last few decades, most notably in the preoperative diagnosis of pancreatic cysts. Evolving concepts include reporting terminology and classification, ancillary testing, and management guidelines. Also, use of next-generation biopsy devices for sampling the cyst wall. The World Health Organization (WHO) reporting system for pancreaticobiliary cytopathology was recently published and updates the Papanicolaou Society of Cytopathology reporting system. The categories of neoplastic: benign and neoplastic: other are replaced by the categories of pancreaticobiliary neoplasm low or high risk/grade to better classify the risk of progression in mucinous cysts. The WHO system emphasizes the need for correlation with radiological, clinical, and ancillary studies, and provides a risk of malignancy and management recommendations for each category. Preoperative diagnosis and prediction of risk of disease progression of pancreatic cystic neoplasms has improved with biochemical analysis and molecular testing. A complex issue for clinicians treating patients with pancreatic cysts is whether to resect, continue surveillance, or dismiss patients from surveillance. Management guidelines for the management of pancreatic cysts are designed to guide clinicians in making these decisions. The role of cytology has been refined to specify identification of features predictive of at least high-grade dysplasia. Finally, the tissue yield by endoscopic ultrasound-guided sampling of pancreatic masses has improved with the addition of next-generation biopsy devices. The use of these advanced needles promises to improve the yield of cytological material. This article summarizes these evolving concepts in pancreatic cytology.
Ultrasound-guided fine-needle aspiration (US-FNA) performed by cytopathologists represents prospects for expanding cytopathology practice. While there is a perceived need for further education and standardization to support future opportunities, this need remains insufficiently documented. The Product Innovation Committee of the American Society of Cytopathology conducted a survey to gather opinions and examine current practices in US-FNA. An online survey of 32 questions focused on US-FNA practice was open from December 19, 2022, to March 19, 2023, promoted through national and international cytopathology professional societies, using Qualtrics survey software. A total of 216 individuals accessed the survey, with 174 (68% from the USA) successfully completing a qualifying question. Data collected included information on certification, work setting, workload, and years of practice (mean: 16 years, range: 0-50 years). Fifty-nine percent (80/135) were certified in cytopathology by the American Board of Pathology or the International Academy of Cytology. Sixty-three percent (84/134) practiced in academia. Over one-half (70/123) worked in low-volume settings (0-50 US-FNA procedures/year), while 19% worked in medium-to-high volume settings (>300 US-FNA procedures/year). Responses showed variability in diagnostic practices and patient management. Nearly one-half (67/137) of respondents indicated that their pathologists performed US-FNA. Most, but not all, reported following standard procedures, including informed consent, site verification, procedure time-out, and documentation of both the procedure and ultrasound findings. Pathologist performed US-FNA represents an opportunity for growth, but there are significant barriers to adoption including: training, equipment, reimbursement, and procedural variability. This survey stands as an initial step to developing recommendations on best practices.
In June 2019, the World Health Organization Reporting System for Soft Tissue Cytopathology (WHORSSTC) was proposed at the European Congress of Cytology in Malmö, Sweden, for reporting soft tissue cytology. In this retrospective review, we evaluate the diagnostic categories of the proposed WHORSSTC. Five hundred ninety-two fine needle aspiration cytology and touch preparation specimens from core needle biopsies from musculoskeletal lesions were identified (2015-2021), of which 62 cases (10%) had an associated surgical resection. Of these cases, 15 cases with resection were diagnosed with fine needle aspiration, and 47 cases with resection were diagnosed with touch preparation samples. Cytology specimens were reclassified into the proposed WHORSSTC Categories: I) nondiagnostic/unsatisfactory, II) benign, III) atypical, IV) soft tissue neoplasm of uncertain malignant potential, V) suspicious for malignancy, and VI) malignant. The rate of malignancy was calculated based on corresponding surgical resections where a malignant resection diagnosis was considered a positive result. The observed rate of malignancy within the tested categories were as follows: Category I: nondiagnostic (5/17, 29%), Category II: benign (1/14, 7%), Category III: atypical (0/2, 0%), Category IV: soft tissue neoplasm of uncertain malignant potential (7/10, 70%), Category V: suspicious for malignancy (1/1, 100%), and Category VI: malignant (18/18, 100%). Our study showed a sensitivity of 96%, a specificity of 83%, a positive predictive value of 90%, and a negative predictive value of 94%. Our results support the potential utility of a standardized soft tissue reporting system for cytology to improve the clinical management of patients.
Clinically acquired cytopathology and small biopsy specimens provide essential diagnostic and predictive biomarker information that underlies precision medicine and patient care decisions. Biomarker testing using immunochemistry, in situ hybridization, and molecular analysis is routinely used to inform therapeutic decisions and monitor therapy. Cytopathology and small biopsy specimen collection, handling, and processing vary across different practices and are frequently determined by individual laboratory preference. Thus, clinical specimens are subject to different preanalytical variables that can impact downstream nucleic acid quality and protein antigenicity, compromising the reliability of the ancillary testing results. Based on a recent survey by the American Society of Cytopathology there is wide variation in current practices for specimen collection and processing, reflecting a lack of consensus and standardization among cytopathology laboratories. To address this need, the American Society of Cytopathology established a special task force comprising 18 members with expertise and/or interest in ancillary studies in cytopathology and small biopsy specimens. The task force conducted a survey of existing practices in cytopathology laboratories. A scoping review was performed to identify published literature for relevant evidence focusing on specific areas of interest. The existing literature on preanalytical variables in small specimens and their impact on ancillary studies were reviewed and data were compiled to draft best practice recommendations. The task force has developed these evidence-based best practice recommendations for optimizing and standardizing preanalytical variables in small specimens to ensure quality and reliability of ancillary studies.
Imaging informatics approaches have played a significant role in gynecologic cytology since the introduction of BD FocalPoint and the ThinPrep Imaging System at the dawn of the new millennium. Although rudimentary compared to modern artificial intelligence and machine learning (AI/ML) techniques, the development of these systems nearly 20 years ago led to increased diagnostic performance, with potential to address issues relating to speed, throughput and reliability of cytologic assessment. However, rather than ushering in an age of increasing automation and quantitative analysis, algorithmic advances in cytology (and pathology in general), stagnated for approximately a decade after its introduction. In the 2010's, the advent of AlexNet, coupled with plummeting storage and GPU costs, open-source development environments and the marketing of affordable, high throughput digital slide scanners accelerated progress and interest in digital pathology AI/ML applications. While the widespread adoption of large-scale consortium level datasets (e.g., The Cancer Genome Atlas) spurred the development of AI/ML methods for surgical pathology, large-scale collection, and algorithmic modeling of cytology specimens has lagged behind due to the varied nature of cytology preparations and assessment. However, increasing attention has been paid to cytopathology with a commensurate increase in publications and commercial applications in this area. Still, the applications of AI/ML to cytopathology and the herculean effort to implement fully digital pathology services remain in its nascent stages. This review explores the current state of research and commercial development in digital cytopathology, with a focus on AI/ML technologies.
The diagnostic accuracy of lymph node fine-needle aspiration cytology (LN-FNAC) relies on proper management of the diagnostic material and on ancillary techniques (AT). Despite the recognized utility of AT in LN-FNAC, their specific role on diagnostic accuracy remains underexplored. This study aims to analyze the impact of AT on the diagnostic accuracy of LN-FNAC. A retrospective review of 452 LN-FNAC samples (2021-2024; University Hospital of Salerno) was performed, identifying 187 cases in which AT were applied. Each case was classified according to the Sydney/WHO system. The impact of AT was assessed both on the first diagnostic level (L1 = inadequate/nondiagnostic, L2 = benign, L3 = atypical, L4 = suspicious for malignancy, and L5 = malignant) and on the second diagnostic level (specific diagnostic entity). Regarding the first level, the number of L3 and L4 diagnoses was reduced by the application of AT: n = 67/71 (94%) L3 cases were reclassified as L2 or L5; n = 26/26 (100%) L4 cases were reclassified as L5. Regarding the second level, it was reached only in 32/187 (17%) cases without AT and in 125/187 (67%) cases with AT. Finally, AT supported 19.8% of diagnoses, enhanced 36.4%, enabled 38.0%, and was noncontributory in only 5.9% of cases. This study shows that AT impacted on both the first and second level of the Sydney/WHO system and it had a positive impact on diagnoses in a significant proportion of cases. These findings highlight not only the importance of AT for LN-FNAC, but also the impact of strategic material management and the appropriate AT selection in achieving accurate diagnoses.
Ultrasound-guided fine needle aspiration (US-FNA) performed by cytopathologists is an expanding domain of effort; however, the clinical practice varies significantly across institutions and practitioners. To address this variability, a study group of the American Society of Cytopathology (ASC) Product Innovation Committee has initiated efforts to help bring consistency to US-FNA endeavors. In 2022, the ASC's Product Innovation Committee formed a study group as part of an initiative to standardize US-FNA practices. The group developed an online survey consisting of 32 questions related to US-FNA techniques and practices. The survey was distributed through the ASC and involved participation from several international cytopathology societies. The survey findings, combined with a literature review (spanning 50 articles over 36 years), on cytopathologist-performed US-FNA, served as the foundation for the group's recommendations. The literature review supports the contention that US-FNA performed by cytopathologists enhances diagnostic accuracy, specificity, and negative predictive value. The survey revealed significant variability in US-FNA activities (report in a separate manuscript entitled "Pathologist Performed Ultrasound Guided Fine Needle Aspiration: Current Status, Trends, and Insights from the American Society of Cytopathology Sponsored Survey"). Based on these findings, the ASC study group developed 10 key recommendations for cytopathologist-performed US-FNA regarding procedure, documentation, and quality control. These recommendations are intended to provide a basis for evolving discussion among cytopathologists with the aim of creating consensus-driven practices in US-FNA.
A World Health Organization (WHO) system has recently been introduced to standardize reporting of lymph node fine-needle aspiration biopsy (LN-FNAB) cytopathology. Herein, we analyze its diagnostic performance in a routine setting. We reviewed 2274 consecutive lymph node fine-needle aspiration biopsies categorized according to the WHO system. Corresponding histological material, radiological images, or uneventful clinical follow-up over 12 months were used as ground truths for classifying LNs as malignant or benign. The diagnostic accuracy of the WHO system was 91.8% without and 95.9% with ancillary techniques. The risk of malignancy (ROM) was 21.8% for the "Insufficient/Inadequate/Non-diagnostic", 6.6% for the "Benign", 29.7% for the "Atypical", 91.2% for the "Suspicious for malignancy", and 99.6% for the "Malignant" category. ROM increased with lymph node size, with a significant rise to 33.1% in the 10-14 mm size interval. The ratio of risk of lymphoma (ROL) to risk of metastasis (ROMet) was significantly lower in lymph nodes <15 mm and depended on the anatomical site with the highest ROL in abdominal/pelvic and the highest ROMet in axillary/mammary lymph nodes. The ROL-to-ROMet ratio was higher if the question was lymphoma (36.7%-8.0%) or unspecified (8.3%-8.3%) compared to any other question. The WHO system demonstrates high diagnostic accuracy, increasing with the use of ancillary techniques, particularly flow cytometry. The ROM, ROL, and ROMet depend on lymph node size, the anatomical site, and the clinical question. A lymph node size of 10 mm may be an appropriate threshold for further investigation, depending on the clinical context.
Minimally invasive biopsies are ideal for procuring tumor tissue for cancer patients at various stages. With an expanding array of therapeutic agents and variable response of tumors to these agents, these small samples can also be valuable during or after treatment to determine response, residual disease, or new diagnosis. In this narrative review, cytology and core biopsy cases mentioning therapy or treatment related changes were reviewed to look at different patterns that can arise with illustrative examples to provide morphologic clues to help when evaluating these specimens. The main patterns of morphological changes include epithelial atypia, epithelial and cellular degeneration, stromal changes, amorphous/foreign material, histiocytic and granulomatous inflammation, high-grade transformations, and immunophenotypic changes. Careful review of these cases with illustrative examples can help to maximize concordance between preliminary diagnoses at rapid on-site evaluation and final interpretations, in addition to providing guidance to the proceduralist during the procedure and helping to explain indeterminate imaging findings for cancer patients undergoing therapy. Given the increased use of novel therapies for cancer treatment and widespread use of imaging to follow-up cancer patients, cytopathology labs play an increasingly important role in evaluating specimens from these patients to exclude residual or recurrent tumor or to explain a mass lesion (eg, infection, new tumor, post-treatment changes). This review highlights the key patterns of changes that can be seen in tissue samples from patients who have had prior therapeutic intervention or are currently undergoing treatment, to demonstrate the impact of pathology review. Cytopathologists should be aware of these patterns and challenges when evaluating cytology and small biopsy specimens in the post-treatment setting to avoid overcalling malignancy and to understand clinical implications for the treating providers.
The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) established 6 categories with estimated risks of malignancy (ROM). The American College of Radiology developed the Thyroid Imaging and Reporting System (TIRADS) for ultrasound results. This system has 5 categories designated TIR1 to TIR5, demonstrating an increasing suspicion for malignancy. The present study investigates utility of the TIRADS designation in conjunction with each BSRTC category to see if the combination would improve the accuracy of the ROMs for each category. Cytology records were searched for all thyroid fine needle aspirates with surgical or longer than 2-year clinical follow-up. Available TIRADS results were correlated with BSRTC categories. ROMs for the combined TIRADS and BSRTC categories were calculated based on results of surgical and clinical follow-up. The search revealed 237 cases with adequate follow-up. BSRTC categorization was "benign" in 140, "atypia of undetermined significance" in 56, "follicular neoplasm" in 17, "suspicious for malignancy" in 10, and "malignant" in 14 cases. Cytologically benign cases designated as TIR5 had a ROM of 12%. The category of atypia of undetermined significance had 29% ROM when associated with a TIR5 designation. Combining the BSRTC and TIRADS appears to improve identification of cases with increased ROM. Specimens designated benign (category II) but showing a TIR5 category have a ROM of 12%, compared to 2%-7% when only the BSRTC is used. The combination of TIRADS with BSRTC improves the prediction of malignancy for BSRTC category V to 90%.
An "atypical" diagnosis is subjective in any cytologic specimen, and the interpretation is often problematic. To mitigate this issue, The Paris System for Reporting Urinary Cytology was released in 2016. Its goal was to standardize the criteria for urine cytology specimens. Atypical urothelial cells (AUC) can be a difficult diagnosis for clinicians to utilize, as it does not give a definitive answer as to whether a patient has a urothelial malignancy or not. However, a diagnosis of AUC is an acceptable option for a urine specimen that has characteristics that are clearly abnormal but fall short of malignancy. Voided urine specimens signed out as AUC in 2019 and 2020 from patients without a history of urothelial carcinoma were identified using the laboratory information system. Patient history, clinical history, and follow-up through April of 2024 were recorded. Selected cases were reviewed microscopically for the AUC diagnosis on the voided urine specimen. Of 151 cases identified, 50 (33.0%) cases included biopsy follow-up, and one case had follow-up of a ureteral brushing. Of those 51 cases, 33 (64.7%) cases had a positive follow-up, 12 (23.5%) cases had a negative follow-up, and 6 (11.8%) cases had a follow-up that showed a nonurothelial malignancy. Previous similar studies have evaluated the outcome of AUC diagnoses, but it is common for those patients to have had a prior history of urothelial carcinoma. In this study, the diagnosis of AUC correlates to an eventual diagnosis of malignancy in 63.0% of cases without a known history of urothelial carcinoma. Based upon these results and previous studies, AUC appears to be a beneficial diagnosis for the patient but may lead to variable outcomes in patient follow-up.
The World Health Organization (WHO), together with the International Academy of Cytology and the International Agency for Research on Cancer, has introduced a standardized framework for reporting lung cytopathology. This approach clarifies diagnostic tiers, provides malignancy risk estimates, and integrates with the latest WHO Tumour Classification. Derived partly from the Papanicolaou Society of Cytopathology model, it strengthens diagnostic reproducibility and clinical risk categorization. The aim of this study is to evaluate the diagnostic accuracy of fine-needle aspiration biopsy (FNAB) in lung lesions reported under the WHO system. A comprehensive search of Cochrane Library, PubMed, EMBASE, ClinicalTrials.gov and conference abstracts was carried out using predefined terms ("lung," "diagnostic accuracy," "FNAB"). Studies applying the WHO reporting scheme to lung FNAB were eligible, with histopathology or clinical follow-up as reference standards. Meta-analysis examined sensitivity and specificity at 3 thresholds: (1) malignant only, (2) suspicious or higher, and (3) atypical or higher. Pooled diagnostic odds ratios and summary receiver operating characteristic analyses were undertaken. Four studies met inclusion criteria. Risk of malignancy increased across WHO categories, from 27% in benign to 92% in malignant. Sensitivity and specificity differed by cut-off: malignant only (33%, 100%), suspicious or higher (73%, 96%), atypical or higher (83%, 84%). Aggregate diagnostic odds ratios and summary receiver operating characteristic curves supported the diagnostic robustness of the system. The WHO reporting system provides effective stratification of lung FNABs. Defining positivity at "suspicious" or higher offers the best diagnostic balance, while including "atypical" increases sensitivity with minimal loss of specificity, supporting its clinical utility.
The integration of digital whole slide imaging and artificial intelligence is poised to transform cytopathology practice. Our aim was to validate the Hologic Genius Digital Diagnostics System (GDDS) for clinical use in Papanicolaou (Pap) test interpretation by comparing digital interpretations using the GDDS to computer-assisted interpretations using the ThinPrep Imaging System (TIS). The study set consisted of 1748 Pap tests, including 53 unsatisfactory for evaluation cases, 1450 negative for intraepithelial lesion or malignancy (NILM) cases, and 245 atypical squamous cells of undetermined significance or worse cases. Each Pap test was reviewed either retrospectively or prospectively by one of 29 cytologists, and results of review on the GDDS were compared to review on the TIS for concordance. Cases requiring hierarchical review were reviewed by one of 23 pathologists. Concordance was calculated between each method. Diagnostic concordance of 95% was required for validation. The GDDS interpretation was concordant with the TIS interpretation in 1722/1748 cases (98.5%). Of the 26 discordant cases, most (20) were discordances between unsatisfactory and NILM, while 5 were attributed to interpretation error, and one was a low-cellularity low-grade squamous intraepithelial lesion containing rare diagnostic cells in the GDDS tiles that was originally interpreted as NILM on the TIS. Pap test interpretation using the GDDS showed high concordance with interpretations using the TIS, achieving the 95% threshold for clinical validation. Discordances were mainly attributable to the ability of the GDDS to quantify cellularity in low/borderline cellularity cases, or rarely to identify significant abnormalities missed by the TIS.
In recent years, social media (SoMe) has revolutionized medical education within the field of pathology; however, its performance in cytopathology has not been explored in detail. This systematic review aims to analyze SoMe trends, hashtag metrics, and online resources within cytopathology over the period of 7 years. A systematic review of 4 databases (PubMed, Medline, Embase, and Scopus) was conducted between January 1st, 2017, and December 22nd, 2022, in order to identify relevant English-language articles about SoMe and cytopathology. An index for online cytopathology (#cytopath) resources was created and posted on Knowledge In Knowledge Out on May 12, 2025. Sixteen studies were included for final analysis, dating from 2017 to 2023. The most commonly cited SoMe platforms used among cytopathologists were X (Twitter) (42%) and Facebook (26%) (P = 0.002). A variety of hashtags were used across posts: #Cytology (24%), #Cytopath (24%), #FNAFriday (24%), #Pathology (16%), and #Cytopathology (12%) (P = 0.865). Two studies discussed the use of SoMe in cytopathology during the COVID-19 pandemic, highlighting its role as a rapid communication tool in times of crisis. The most highly followed cytopathology accounts on X were @cytopathology (10,510), @IACytology (3639), and @britishcytology (3062). This systematic review shows how SoMe is enhancing networking, case discussion, and education in cytopathology. Although it could revolutionize professional communication, it still poses issues regarding privacy and possible misinformation. Future research and guidelines are necessary to optimize the use of SoMe in cytopathology.
The 2023 edition of the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) unified Category IV terminology by eliminating "suspicious for a follicular neoplasm," retaining only "follicular neoplasm (FN)." Given that nearly 30% of FN diagnoses on fine-needle aspiration (FNA) prove to be benign follicular nodular disease upon resection, concerns arose that the singular use of "FN" could lead cytopathologists to under-call FN and instead assign the atypia of undetermined significance (AUS) category. This study investigates whether the terminology change in 2023 TBSRTC influenced the distribution of FN and AUS diagnoses in thyroid FNA cases at The Johns Hopkins Hospital. A retrospective review of 3173 thyroid FNAs (May 2022-May 2025) at Johns Hopkins Hospital was conducted. Cases were divided into 2 groups: "Pre-2023 TBSRTC" (May 2022-April 2024) and "Post-2023 TBSRTC" (May 2024-May 2025). AUS and FN incidences were compared using Z-tests. Among 3173 FNAs, 491 (15.5%) were diagnosed as AUS. Overall AUS incidence showed no significant change post-2023 TBSRTC implementation (16.2% pre versus 14.2% post; P = 0.1554). Interestingly, the subcategory of AUS-nuclear atypia significantly increased (33.0%-50.3%, P = 0.0002), while AUS-Other (architectural or mixed atypia) significantly decreased (56.4%-41.0%, P = 0.0014). Contrary to concerns the unification, of 'suspicious for a follicular neoplasm' and 'FN' into 'FN' alone might prompt an increased use of the AUS-Other category, our findings show the opposite. For unexplained reasons, there has been a significant decrease in AUS-Other diagnoses. The updated nomenclature and subclassification framework of 2023 TBSRTC did not increase AUS incidence.
More than a century after Sister Mary Joseph first recognized the clinical significance of umbilical nodule, the umbilicus remains a diagnostic window into occult malignancy. Although prior studies demonstrate that most Sister Mary Joseph nodules (SMJNs) represent metastatic adenocarcinoma, our institutional review spanning February 2019 through October 2025 additionally identified rare presentations including melanoma, mesothelioma, and lymphoma. Fine-needle aspiration continues to provide a rapid, minimally invasive link between this superficial clinical finding and its association with underlying visceral primary. We performed a retrospective review of cytopathology and surgical pathology archives from February 2019 through October 2025 in the Epic Beaker database. All cases were retrieved and reviewed for cytopathologic and histopathologic features, and immunohistochemical (IHC) profiles. Additionally, clinical and imaging data were extracted from electronic records and correlated with the pathologic findings. Twenty-one patients with umbilical lesions were identified. Median age was 72 years (44-92), and 67% of the patients were female. Adenocarcinoma predominated (14/21, 67%), with primary origins confirmed as gastrointestinal (48%), gynecologic (24%), genitourinary (10%), and other (19%). IHC studies, available in 14 cases, supported primary site attribution using CK7, CK20, PAX8, WT1, GATA3, ER, CDX2, and other antibodies. The median interval from primary tumor diagnosis to presentation of SMJN was 8 months. In 4 patients, SMJN was the initial presentation. Six patients had documented survival data. SMJN in current practice remains predominantly metastatic adenocarcinoma, most often gastrointestinal or gynecologic in origin. However, rare entities-including mesothelioma, melanoma, and lymphoma-underscore the need for a broad diagnostic differential. Fine-needle aspiration offers a rapid, minimally invasive diagnostic bridge and reinforces that the umbilicus remains a valuable clinical marker of an often occult malignancy.
Molecular testing is increasingly integrated into the management of indeterminate thyroid fine-needle aspiration (FNA) diagnoses, particularly The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) category III. However, it remains unclear how increasing test availability has affected cytopathologists' use of this category and whether its expansion risks incorporating nodules that may not warrant surgery, particularly following the 2023 TBSRTC nomenclature updates. We retrospectively queried all in-house thyroid FNAs from 2018 to 2024, assessing temporal trends in TBSRTC category distribution, with focused analysis of TBSRTC III cases and associated parameters including ThyroSeq utilization, atypia of undetermined significance:malignant ratio, and risk of malignancy (ROM). From 2018 to 2024, TBSRTC III interpretations increased significantly (6%-26% of FNAs), accompanied by increased ThyroSeq utilization in this category (5%-75%) and atypia of undetermined significance:malignant ratios (1.0-4.5). Meanwhile, the proportion of TBSRTC III cases undergoing surgery declined (40%-26%). Surgical selection became strongly influenced by molecular results, with 71% of ThyroSeq-positive TBSRTC III nodules undergoing resection in 2024 compared with only 3% of ThyroSeq-negative nodules. Increased use of TBSRTC III occurred primarily at the expense of category II, while categories IV-VI remained stable. ROM was not statistically different with and without molecular testing. Molecular changes were consistent with published ThyroSeq cohorts. These findings suggest that increased ThyroSeq utilization is associated with increased use of TBSRTC III and more selective surgical management without altering ROM or increasing the inclusion of lesions less likely to require surgery.
This study retrospectively assessed the ultrasound parameters in Bethesda category III thyroid nodules accompanied by a diagnostic Afirma genomic sequencing classifier (GSC) testing result and surgical/clinical follow-up, and investigated whether combining ultrasound and GSC classifications could improve risk stratification of the atypia of undetermined significance (AUS) nodules. Data including radiologic Thyroid Imaging Report and Data System (TIRADS) score, concurrent GSC test results, and surgical/clinical follow-up were collected from patients with thyroid nodules meeting the study criteria. The distribution of TIRADS scores was compared between GSC-suspicious versus GSC-benign cohorts, as well as between malignant and benign nodules. The diagnostic performance of the GSC was compared between TIRADS 5 and TIRADS < 5 cohorts. The study consisted of 322 AUS nodules. Compared to the GSC-benign cohort, the GSC-suspicious cohort had a greater proportion of TIRADS 5 nodules (34% vs. 24%, P = 0.045), a lower proportion of TIRADS 1-3 nodules (20% vs. 30%, P = 0.048), and a higher average TIRADS score (4.12 vs. 3.92, P = 0.03). Compared to the benign cohort (histologically and/or clinically benign), the malignant cohort (histologically malignant) showed a higher proportion of TIRADS 5 nodules (52% vs. 24%, P = 0.004). The mean TIRADS score was also significantly higher in the malignant cohort compared to the benign cohort (4.36 vs. 3.92, P = 0.015). GSC testing demonstrated a significantly higher positive predictive value in the TIRADS 5 AUS nodules than that of TIRADS< 5 nodules (39% vs. 17%, P = 0.016). A GSC-suspicious result combined with TIRADS 5 significantly improved the positive predictive value, thereby enhancing risk stratification in AUS thyroid nodules, while other diagnostic parameters remained unchanged.
The cytology profession is experiencing a period of evolution marked by both workforce challenges and opportunities with new emerging roles and rapid integration of new technologies. The goal of this study was to comprehensively assess the current state of and trends in the cytotechnology practice to identify potential challenges for cytologists and areas of improvement. An online survey with 7 demographic-based questions and 14 questions assessing a range of practice patterns, evolving roles, and attitudes towards these shifts was developed by members of the American Society of Cytopathology Clinical Practice Committee and distributed to cytologists. Data were collected via SurveyMonkey which was later collated and analyzed. A total of 215 cytologists/cytologist supervisors participated with about half in practice for more than 20 years, from academic centers, and in practices with 5 or more cytologists. Most (85.5%) had experienced workforce shortages which had impacted their work. For most their responsibilities expanded beyond cytology slide review, with approximately three-quarters performing rapid on-site evaluation and/or quality control procedures. Roughly half of respondents were enthusiastic about how artificial intelligence and digital cytology could impact their practice. Most (64%) noted good/great overall job satisfaction; however, better compensation for their work, professional and career advancement opportunities, adequate staffing for workload, and more complex responsibilities were cited as factors that would most improve their job satisfaction. The results offer valuable insights and help find targetable areas for improvement including enhancing job satisfaction, retention, improving team dynamics, optimizing laboratory operations, and boosting targeted professional development.
The atypia of undetermined significance (AUS) category of the Bethesda System for Reporting Thyroid Cytopathology remains challenging due to its cytologic heterogeneity and variable risk of malignancy (ROM). This study assessed the frequency of AUS diagnoses, correlated cytologic and histologic outcomes, and compared ROM between AUS with nuclear atypia and with other atypia (AUS-Other) subcategories in a tertiary laboratory. A retrospective review of all thyroid fine needle aspiration cytology reported between 2016 and 2021 was performed using the National Health Laboratory Service database. AUS cases were subcategorized according to the third edition of the Bethesda System for Reporting Thyroid Cytopathology. ROM was calculated using histopathologic follow-up, excluding noninvasive follicular thyroid lesion with papillary-like nuclear features and other low-risk neoplasms from the malignant category. Clinical and demographic variables were analyzed using descriptive and comparative statistics, with significance set at P < 0.05. Of 1,703 thyroid fine needle aspiration cytology, 137 (8.0%) were categorized as AUS. Histologic follow-up was available for 40 cases (29.2%). The ROM among AUS cases that had surgical resections was 42.5% (17/40). AUS with nuclear atypia demonstrated a higher ROM than AUS-Other (50.0% versus 36.4%), although the difference was not statistically significant (P = 0.39). Malignant outcomes showed subtype-specific patterns: papillary thyroid carcinoma and follicular variant of papillary thyroid carcinoma predominated in AUS-Nuclear, while follicular thyroid carcinoma predominated in AUS-Other. Patient age showed no significant association with histologic outcome. The two-tier AUS subclassification provides functional stratification for identifying higher risk nodules in our setting. However, larger national multicentre studies integrating clinical and radiological data are needed to validate and refine AUS risk stratification and improve patient outcomes in our resource-limited environment.