ISSN: 2320-5407 Int. J. Adv. Res.

11(01), 693-697

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/16068

DOI URL: http://dx.doi.org/10.21474/IJAR01/16068

RESEARCH ARTICLE
THYROID DISORDERS IN NORTH INDIA AND THEIR REPORTING BY BETHESDA SYSTEM – “1
YEAR RETROSPECTIVE STUDY”

Dr. Rekha Rani1, Ishani Gupta1, Dr. Jyotsna Gupta2 and Anil Kumar3
1. Senior Resident Department of Pathology GMC Jammu.
2. Professor Postgraduate Department of Pathology GMC Jammu.
3. Senior Resident Department of Surgery GMC Jammu.
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Manuscript Info Abstract
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Manuscript History Background: Thyroid nodules are very common clinical problem and
Received: 25 November 2022 thyroid cancer is becoming more prevalent. Fine needle aspiration
Final Accepted: 27 December 2022 cytology (FNAC) has become a well established modality in the
Published: January 2023 diagnosis, staging and follow up of thyroid nodules. FNAC results are
routinely classified using the Bethesda system for reporting thyroid
Key words:-
FNAC, TBSRTC, Colloid, Follicular cytopathology. The Bethesda system for reporting thyroid
Neoplasm cytopathology is a significant step to standardize the thyroid FNA
reporting. It has high reproducibility, predictive value and improved
clinical significance.
Aims And Objectives: To determine the spectrum of thyroid disorders
in north India and to determine the accuracy and reliability of FNAC in
our center.
Material And Method: A retrospective study of FNAC thyroid
nodules was carried out on 133 patients referred to our Department
from July 2021 to August 2020. Slides were retrieved from the
cytopathology section of the Department of Pathology, GMCH,
reviewed and then classified as per the Bethesda system for reporting
thyroid cytopathology. Patients of all ages and gender were included in
the study.
Results: Total 133 FNAC procedures were performed during the study
period. 86 cases were females and 47 were males with male to female
ratio of 1:1.83. The nodules of 9 patients were classified as Bethesda
category-I, 74 patients as Bethesda category-II, 11 patients as Bethesda
category-III, 8 patients as Bethesda category-IV, 9 patients as Bethesda
category-V and 22 patients as Bethesda category VI. Out of 133
patients, only 36 patients underwent for surgery; among these 36 cases,
4 were classified as Bethesda category-IV , 9 as Bethesda category-V
and 22 as Bethesda category-VI on cytology which were further
confirmed as cases of thyroid malignancy on histopathology reports.
Conclusion: Our study substantiates greater reproducibility among
Pathologists using TBSRTC to arrive at a precise diagnosis with an
added advantage of predicting the risk of malignancy which enables the
clinician to plan for surgery, extent of surgery or follow-up of the
patients by repeating the FNA of thyroid nodules at specific intervals.

Corresponding Author:- Dr. Anil Kumar

Address:- Senior Resident Department Of Surgery Gmc Jammu. 693
ISSN: 2320-5407 Int. J. Adv. Res. 11(01), 693-697

Copy Right, IJAR, 2023,. All rights reserved.

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Introduction:-
Thyroid is one of the largest endocrine organ and both non-neoplastic and neoplastic abnormalities are frequent
source of specimens for surgical pathology laboratories. Thyroid nodules are very common clinical problem and
thyroid cancer is becoming more prevalent. Every patient with a palpable thyroid nodule is a candidate for FNAC.
Fine needle aspiration cytology (FNAC) is now a well-established modality in the diagnosis, staging and follow up
of thyroid nodules. Majority of thyroid nodules prove to be localized, non neoplastic. Benign neoplasms outnumber
the thyroid carcinomas by a ratio of 10:11. Less than 5% of all nodular swellings of thyroid are documented as
malignant2. The fifth most common cancer in women is thyroid cancer. The number of new cases in women in their
twenties is 5 times higher than for men in their twenties. Thyroid FNAC is very useful in identifying a substantial
proportion of thyroid nodules as benign and reducing unnecessary surgery for patients with benign diseases. FNAC
results of thyroid cytopathology are routinely classified using the Bethesda system. The Bethesda system for
reporting thyroid cytopathology has attempted to standardize the reporting and cytological criteria in aspiration
smears3. Proper communication among clinicians, radiologists, surgeons and pathologists along with
cytohistological correlation is essential for reporting of thyroid FNA. Hence, a diagnostic terminology which is
consistent is vital. TBSRTC is a six category scheme of thyroid cytopathology reporting. The categories and their
risk of malignancy for I-Non diagnostic, II- Benign, III- AUS/FLUS, IV- FN/SFN, V- Suscpicious for malignancy
(SM), VI- Malignant were 1-4%, 0-3%, 5-15%, 15-30%, 60-75% and 97-99% respectively4. The Bethesda system
for reporting thyroid cytopathology is a significant step to standardize the reporting of thyroid FNA. It has high
reproducibility, predictive value and improved clinical significance. Although FNAC is widely used in clinical
diagnosis, cytologically indeterminate thyroid nodules still present a diagnostic challenge for pathologists. This
makes reaching a definitive histologic diagnosis difficult in a large number (10-30%) of patients undergoing
thyroidectomy 5. The difficulty in defining the exact diagnosis of thyroid nodules is underlined by the fact that the
probability of malignancy in AUS/FLUS or FNAC specimens remains unclear 6, 7, 8. Some malignancy criteria such
as thyroidal or tumoral capsular and / or lymphovascular invasion are determinative, when establishing a cancer
diagnosis, which represents a significant limitation of the FNAC method.

Material And Methods:-

A retrospective study of FNAC thyroid nodules was carried out on 133 patients attending a tertiary care centre in
Jammu, J&K from July 2021 to August 2020 after taking clearance from the institutional ethical committee. Both
May Grunwald Giemsa (MGG) and Pap-stained slides were retrieved from the cytopathology section of the
Department of Pathology, GMCH, reviewed and then classified as per the Bethesda system for reporting thyroid
cytopathology into six categories. All the necessary clinical details, laboratory values of T3, T4, TSH and
ultrasonographic details were noted from the cytology forms. Patients of all ages and gender were included in the
study.

Results:-
Total of 133 FNAC procedures were performed on clinically significant thyroid nodules over a period of 1 year. Out
of 133 patients 86 were females and 47 were males with male to female ratio of 1:1.83. The youngest patient was a
female of 17 years with papillary carcinoma thyroid and oldest of 82 years with anaplastic carcinoma thyroid. The
nodules of 9 patients were classified as Bethesda category-1, 81 patients as Bethesda category-2, 11 patients as
Bethesda category-3, 8 patients as Bethesda category-4, 9 patients as Bethesda category-5 and 15 patients as
Bethesda category-6 respectively (TABLE-1). Further distribution of benign and malignant lesions is tabulated in
TABLE-2 and 3. Out of these, total 133 patients only 36 patients underwent for thyroid surgery. Out of these 36
cases, 4 were classified as Bethesda category-4, 9 patients as Bethesda category-5 and 22 patients as Bethesda
category-6 which were further confirmed as cases of thyroid malignancy on histopathology reports.

Table 1:- Distribution of cases as per Bethesda category system.

Bethesda category Number of cases (n) Percentage (%age)
I. Non-diagnostic 9 6.77
II. Benign 81 60.90
III. AUS/FLUS 11 8.27
IV. SFN 8 6.01
V. Suspicious for 9 6.77

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malignancy
VI. Malignant 15 11.28
Table 2:- Distribution of benign category cases.
Benign cases Number of cases (n) Percentage (%age)
Colloid goiter 47 58.02
Colloid cyst 7 8.64
Adenomatoid goiter with features of 8 9.88
hyperactivity
Lymphocytic thyroiditis 16 19.76
De Quervains thyroiditis 3 3.70
TOTAL 81 100

Table 3:- Spectrum of malignant lesions.

Malignant cases Number of cases (n) Percentage (%age)
PTC 8 53.34
Medullary carcinoma 5 33.33
Anaplastic carcinoma 2 13.33
TOTAL 15 100

Discussion:-
FNAC is a safe, rapid and relatively inexpensive procedure. Early diagnosis of thyroid nodules is important due to
their low malignant potential and slow progressive nature. Thyroid FNAC plays an important role in the diagnosis of
thyroid nodules.

This study shows the one year experience in reporting thyroid aspirations by TBSRTC in Government Medical
College Jammu. This system of reporting thyroid FNA improves the clarity of communication between
cytopathologists and treating clinicians, predicts the risk of cancer and reduces the unnecessary surgery of the
patients with benign thyroid lesions and appropriately triages patients with malignant lesions for timely surgical
interventions. TBSRTC does not recommend surgery for ND, Benign and AUS/FLUS category.

TBSRTC Category-I - Non diagnostic or unsatisfactory (ND/UNS)-

Non-diagnostic (ND) thyroid FNA results have major limitation in arriving at a definitive diagnosis and is a most
common cause of false negative reports9. Some of the studies stated that the operator experience and the number of
passes made during FNA correlate with the non diagnostic result 10,11. As per WHO Criteria, a thyroid FNA sample
is considered adequate for evaluation if it contains a minimum of 6 groups of follicular cells, with at least ten cells
per group on a single slide 12. The use of this WHO criteria for adequacy of thyroid FNA is helpful because they
improve the diagnostic efficiency of thyroid FNA and avoid unnecessary surgery for benign non neoplastic thyroid
lesions 13. In our study we have categorized 9 patients (6.76%) in category-I. This correlates with the studies
conducted by Bhat et al. and Mehra et al. 14, 3. When these patients came back to us for repeat FNAC after a month
then all these cases revealed features of benign thyroid lesions. Study carried out by Renshaw 15 shows that the
TBSRTC category –I had significantly lower risk of malignancy (0%) which is comparable to our study.

TBSRTC Category-II – Benign

Present study shows highest incidence of category-II lesions. In our study, 81 patients (60.90%) were reported as
TBSRTC category-II with colloid goiter being the predominant group followed by lymphocytic thyroiditis ,
adenomatoid goitre with features of hyperactivity and De Quervains thyroiditis respectively which is comparable
with the studies conducted by Mondal et al 16, Gupta et al17 and Nandedkar et al18. The risk of malignancy for
category-II is 0% to 3% with the recommended management being clinical follow-up of patients 19. Although
surgery is not recommended for category-II lesions still 6 out of 81 patients in categoery-II were underwent for
thyroid surgery for cosmetic purpose and pressure symptoms. 2 cases were diagnosed as a cases of follicular
adenoma, 3 were reported as colloid goiter and one as PTC on histopathology. Case of PTC was incidental finding
in thyroid specimen and was mural nodule in a cystic lesion.

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TBSRTC Category – III- atypia of undetermined significance or follicular lesion of undetermined

significance (AUS/FLUS)
Cases categorized as category – III are those for which cytological findings are not convincingly benign, but the
degree of architectural and cellular atypia is also not sufficient for a diagnosis of follicular neoplasm or suspicious
for malignancy. In our series, 11 patients (8.27%) were reported as category – III. Studies conducted by Jo et al 20
and Yassa et al21 have reported 3.4% and 4% lesions as AUS/FLUS, respectively. Out of these 11 patients, 5 were
underwent for thyroid surgery and 2 were reported as follicular adenoma, 1 was reported as PTC and 2 were
reported as granulomatous thyroiditis on histopathology.

TBSRTC category – IV – Follicular neoplasm or suspicious for follicular neoplasm (FN/SFN)

Based on cytology it is difficult to distinguish follicular carcinoma from follicular adenoma. Thyroid FNA with
cytomorphologic features of moderate to high cellularity, scant or absent colloid or microfollicular arrangement of
follicular cells in repetitive pattern were grouped under the category-IV. In our study, 8 patients (6.01%) were
categorized as category-IV. Out of 8 cases, 4 underwent for thyroid surgery. 3 were reported as follicular carcinoma
and 1 was reported as follicular adenoma on histopathology.

TBSRTC category – V- Suspicious for malignancy.

Most of the thyroid malignancies can be diagnosed with certainty by FNA. But the nuclear and architectural changes
of some PTCs are subtle and focal. This is especially true for the follicular variant of PTC which can be difficult to
distinguish from a benign follicular nodule. In the present study, 9 cases (6.76%) diagnosed as Suspicious for
malignancy on FNAC which showed only one or two characteristic features of PTC focally and the sample is
sparsely cellular. There was difficulty in giving them as truly malignant so we kept them in SFM category and
advised follow-up. Recent studies show that application of molecular techniques such as RET/PTC gene and
analysis of BRAF mutation are helpful and improve the differentiation of malignant from their benign counterparts
among the patients with category-V22, 23. On follow up, we have found that only 6 cases underwent for thyroid
surgery and 4 were diagnosed as PTC and 2 were diagnosed as follicular carcinoma on histopathology.

TBSRTC Category-VI- Malignant

This category is applied whenever the cytomorphologic features are conclusive for malignancy. In the present study
we reported 15 cases (%age) as category-VI, 8 cases were reported as papillary thyroid carcinomas, 5 cases were
reported as medullary carcinoma and 2 cases were reported as anaplastic carcinoma. Papillary carcinoma is the most
common malignancy of thyroid in our study which is similar to the findings of Laishram et al24 . All of these cases
were confirmed and correlated with histopathological diagnosis. Anaplastic carcinoma is a highly aggressive
malignancy of thyroid and accounts for less than 2% of thyroid malignancy, and characteristically occurs in older
adults.

The correlation of cytology and histopatholgy diagnosis is an important quality assurance method as it allows
cytopathologists to calculate their false positive and false negative results. In present study, only few cases were
available for HPE after their cytological diagnosis and there was not much discrepancy in cytological and
histopathological diagnosis.

References:-
1. The endocrine system. In: Kumar V, Abbas AK, Aster JC, editors. Robbins & Cotran Pathologic Basis of
Disease. 9th ed. Philadelphia: Elsevier; 2014. p. 1092.
2. Sukumaran R, Kattoor J, Pillai KR, Ramadas PT, Nayak N, Somanathan T, George NA, Sebastian P. Fine
needle aspiration cytology of thyroid lesions and its correlation with histopathology in a series of 248 patients.
Indian J Surg Oncol. 2014; 5(3):237-241.
3. Mehra P, Verma AK. Thyroid cytopathology reporting by the Bethesda system: a two year prospective study in
an academic institution. Patholog Res Int. 2015; 2015: 240505.
4. Cibas ES, Ali SZ, NCI Thyroid FNA State of the Science Conference. The Bethesda System for Reporting
Thyroid Cytopathology. Am J Clin Pathol. 2009;132(5):658-665
5. Broome JT, Cate F, Solorzano CC. Utilization and impact of repeat biopsy for follicular lesion/atypia of
undetermined significance. World J Surg. 2014; 38(3):628-633.
6. Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Am J Clin Pathol. 2009;
19(11):1159-1165.

696
ISSN: 2320-5407 Int. J. Adv. Res. 11(01), 693-697

7. Ho AS, Sarti EE, Jain KS, Wang H, Nixon IJ, Shaha AR, Shah JP, Kraus DH, Ghossein R, Fish SA, Wong RJ,
Lin O, Morris LGT. Malignancy rate in thyroid nodules classified as Bethesda category III (AUS/FLUS).
Thyroid:official journal of the American Thyroid Association. 2014; 24(5):832-839.
8. Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegedus L, Paschke R, Valcavi R, Vitti P.
AACE/ACE/AME task force on thyroid nodules. American association of clinical endocrinologists, American
college of endocrinology, and Associazione Medici Endocrinologi medical guidelines for clinical practice for
the diagnosis and management of thyroid Nodules-2016 update. Endocr Pract. 2016; 22(5):622-639.
9. Gunes P, Canberk S, Onenerk M, Erkan M, Gursan N, Kilinc E, Kilicoglu GZ. A different perspective on
evaluating the malignancy rate of the non-diagnostic category of the Bethesda System for reporting thyroid
cytopathology: a single institute experience and review of the literature. PLos One. 2016; 11(9):e0162745.
10. Hall TL, Layfield LJ, Philippe A, Rosenthal DL. Sources of diagnostic error in fine needle aspiration of the
thyroid. Cancer. 1989; 63(4): 718-725.
11. Hamburger JI, Husain M, Nishiyama R, Nunez C, Solomon D. Increasing the accuracy of fine-needle biopsy
for thyroid nodules. Arch Pathol Lab Med. 1989; 113(9):1035-1041.
12. Crothers BA, Henry MR, Firat P, Hamper UM. Chapter 2; non diagnostic/unsatisfactory. In: Ali SZ, Cibas ES,
editors. The Bethesda System for Reporting Thyroid Cytopathology. New York, NY: Springer;2010. Pp.5-7 .
13. Haider AS, Rakha EA, Dunkley C, Zaitoun AM. The impact of using defined criteria for adequacy of fine
needle aspiration cytology of the thyroid in routine practice. Diagn Cytopathol. 2011; 39(2):81-86.
14. Bhat S. Bhat N, Bashir H, Farooq S, Reshi R, Nazeir MJ, Niyaz I. The Bethesda system for reporting thyroid
cytopathology: a two year institutional audit. Int J Cur Res Rev. 2016; 8(6):5-11.
15. Renshaw AA. Significance of repeatedly nondiagnostic thyroid fine-needle aspirations. Am J Clin Pathol. 2011;
135(5):750-752.
16. Mondal SK, Sinha S, Basak B, Roy DN, Sinha SK. The Bethesda system for reporting thyroid fine needle
aspirates: a cytologic study with histologic follow-up. J Cytol. 2013; 30(2):94-99.
17. Gupta C, Bhardwaj S, Sharma S. Diagnostic utility of thyroid fine needle aspiration cytology using the
Bethesda system for reporting thyroid cytopathology : a one year prospective study. IP J Diagn Pathol Oncol.
2019; 4(4):320-326.
18. Nandedkar SS, Dixit M, Malukani K, Varma AV, Gambhir S. Evaluation of thyroid lesions by fine-needle
aspiration cytology according to Bethesda system and its histopathological correlation. Int J Appl Basic Med
Res. 2018 8(2):76-82.
19. Cibas ES, Ali SZ. The Bethesda system for reporting thyroid cytopathology. Am J Clin Pathol. 2009;
132(5):658-665.
20. Jo VY, Stelow EB, Dustin SM, Hanley KZ. Malignancy risk for fine-needle aspiration of thyroid lesions
according to the Bethesda system for reporting thyroid cytopathology. Am J Clin Pathol. 2010; 134(3):450-456.
21. Yassa L, Cibas ES, Benson CB, Frates MC, Doubilet PM, Gawande AA, Moore FD Jr, Kim BW, Nose V,
Marqusee E, Larsen PR, Alexander EK. Long-term assessment of a multidisciplinary approach to thyroid
nodule diagnostic evaluation. Cancer. 2007; 111(6):508-516.
22. Letsas KP, Andrikoula M, Tsatsoulis A. Fine needle aspiration biopsy-RT-PCR molecular analysis of thyroid
nodules: a useful preoperative diagnostic tool. Minerva Endocrinol. 2006; 31(2):179-182.
23. Cheung CC, Carydis B, Ezzat S, Bedard YC, Asa SL. Analysis of ret/PTC gene rearrangements refines the fine
needle aspiration diagnosis of thyroid cancer. J Clin Endocrinol Metab. 2001; 86(5):2187-2190.
24. Laishram RS, Zothanmawii T, Joute Z, Yasung P, Debnath K. The Bethesda system of reporting thyroid fine
needle aspirates: a 2-year cytologic study in a tertiary care institute. J Med Soc. 2017; 31(1):3-7.

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