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Atlas on Bethesda
system for reporting
Thyroid Cytology
Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
Images courtesy Papanicolaou society of cytopathology web atlas and Bethesda system for reporting thyroid cytology

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OVERVIEW
1.
2.
3.
4.
5.
6.
7.
8.
9.

Indications and goal of thyroid FNA

Contraindications
Procurement of cell sample
Staining methods
Limitations
Need for Bethesda terminology
Recommended diagnostic categories
Format of report
Diagnostic categories in detail
a. Non diagnostic or unsatisfactory
b. Benign
c. Atypia of undetermined significance or Follicular lesion of Undetermined
significance
d. Follicular neoplasm or suspicious for a follicular neoplasm
e. Suspicious for malignancy (suspicious of papillary/medullary/lymphoma/mets)
f. Malignant
10. Recommended management for diagnostic categories

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
Images courtesy Papanicolaou society of cytopathology web atlas and Bethesda system for reporting thyroid cytology

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* PROCUREMENT OF CELL SAMPLE

1. Nodule is identified by palpation
2. A 22G to 25 G needle is used to procure cell sample from atleast three different areas of
the nodule
3. If the nodule is difficult to palpate, FNA should be done under USG guidance
4. For cystic thyroid lesions, the cyst content should be evacuated first with a syringe
5. Since thyroid is rich in capillaries, needle aspirate usually contains large amount of
peripheral blood. This can be limited by a no aspiration technique and by limiting the
procedure to about five seconds

* STAINING METHODS
1. Parallel air dried (stained with romanowsky stains like Giemsa) and wet fixed smears
(stained with HE or Pap) are recommended
2. For Pap stained smears, quick fixation in 95% ethanol without drying is recommended, a
delay in fixation leads to air drying artefact
3. Nuclear details in Romanowsky stained smears are not well appretiated, but cytoplasmic
details are visualized nicely
4. In Pap stained smears, nuclear details are well visualized
5. Fixation of aspiration smears in Carnoys solution may be done to lyse red blood cells
prior to staining

* LIMITATIONS OF THYROID F.N.A.

1. overlap of cytological patterns of neoplastic and non neoplastic lesions
2. overlap of cytological features between various neoplasms
3. co existence of non neoplastic and neoplastic processes and multiple malignancies

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
Images courtesy Papanicolaou society of cytopathology web atlas and Bethesda system for reporting thyroid cytology

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* RECOMMENDED DIAGNOSTIC CATEGORIES

- Mucoepidermoid carcinoma of thyroid

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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Cyst fluid only

Blood and macrophages
Should be correlated with sonographic features

Cyst fluid only

Histiocytes and scant colloid on LBC smear
Should be correlated with sonographic features

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
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12

Non diagnostic due to extensive air drying

Blood only

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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17

Benign follicular cells (macrofollicle fragment)

Abundant colloid and scant benign follicular cells

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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23

Benign follicular cells in sheets.

Cellular portion of adenomatoid nodule (cellular colloid goiter)

Sheets of benign follicular cells.

Cellular portion of adenomatoid nodule. There is abundant colloid elsewhere

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
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31

Reactive Cyst Lining Cells with Hemosiderin Pigment

Graves Disease
Stimulated follicular cells and marginal eosinophilic cytoplasmic vacuoles with terminal frayed edges
Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
Images courtesy Papanicolaou society of cytopathology web atlas and Bethesda system for reporting thyroid cytology

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OVERVIEW
1.
2.
3.
4.
5.
6.
7.
8.
9.

Indications and goal of thyroid FNA

Contraindications
Procurement of cell sample
Staining methods
Limitations
Need for Bethesda terminology
Recommended diagnostic categories
Format of report
Diagnostic categories in detail
a. Non diagnostic or unsatisfactory
b. Benign
c. Atypia of undetermined significance or Follicular lesion of Undetermined
significance
d. Follicular neoplasm or suspicious for a follicular neoplasm
e. Suspicious for malignancy (suspicious of papillary/medullary/lymphoma/mets)
f. Malignant
10. Recommended management for diagnostic categories

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
Images courtesy Papanicolaou society of cytopathology web atlas and Bethesda system for reporting thyroid cytology

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33

Pure colloid

Colloid

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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39

Crowded follicular cell group with lymphoid background

Hurthle cells (oncocytic metaplasia)

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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40

Hurthle cells (oncocytic metaplasia) with reactive changes

Mixed lymphoid population without Hurthle cells

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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41

Lymphoid cells with crush artifact

Polymorphous population of lymphocytes and Hurthle cells

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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63

Cohesive fragment of Hurthle cells (oncocytes)

Hurthle cells (low magnification)

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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64

Hurthle cells (oncocytes).

Hurthle cells: single cells and fragments

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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103

Monolayered sheet

Intranuclear pseudoinclusions and focal oncocytic change

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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104

Monolayered sheet.

Intranuclear pseudoinclusions (INCIs).

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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105

Intranuclear pseudoinclusions (INCIs).

Monolayered sheet.

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
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106

Monolayered sheet with grooves and intranuclear pseudoinclusions

Intact papilla

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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137

anaplastic Carcinoma of Thyroid in liquid base prep

Cells with variation in size and shape. Because of tendency of cells to round up in liquid preparations, cells much
be evaluated in context of other cells present including inflammatory cells.

anaplastic Carcinoma of Thyroid in liquid base prep

Cells with variation in size and shape. Because of tendency of cells to round up in liquid preparations, cells much
be evaluated in context of other cells present including inflammatory cells.

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
Contact: pathologybasics@gmail.com Website: pathologybasics.wix.com/notes Facebook: facebook.com/pathologybasics
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18

Abundant thick colloid

Abundant thick colloid

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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19

Colloid mixed with blood

Abundant colloid with pavementing (cracking, windowpane) artifact

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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160

Metastatic Merkel cell carcinoma.

Metastatic bronchioloalveolar carcinoma.

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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161

Metastatic adenocarcinoma of the colon.

Malt Lymphoma

Color atlas - Bethesda system for reporting thyroid cytology By Dr. Ashish Jawarkar
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