Variable Impact of Qualifying Language on Clinical Management of Atypical Thyroid Fine Needle Aspirates
Marina Vivero, Andrew A Renshaw, Krane F Jeffrey. Brigham and Women's Hospital, Boston, MA; Baptist Hospital, Miami, FL
Background: The Bethesda System for Reporting Thyroid Cytopathology (TBS) category of atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS), is used to classify a variety of mild cytologic abnormalities in thyroid FNAs. Modifying terminology is often added in thyroid FNA reports for descriptive and risk assessment purposes, but it is not known whether specific phrases affect patient management. To answer this question, we correlated rates of excision and re-biopsy among patients with AUS/FLUS diagnoses from Baptist Hospital, Miami, FL (BH) and Brigham and Women's Hospital, Boston, MA (BWH) with the language used in thyroid FNA reports.
Design: We identified thyroid nodules with an initial FNA diagnosis of AUS/FLUS at both institutions. In total, we studied 314 FNAs from BH including 251 females and 63 males with a median age of 53 (21-79), and 300 FNAs from BWH including 241 females and 59 males with a median age of 66 (range 10-85). Pathology reports from all cases were evaluated for common descriptive phrases and language known to be associated with differences in risk of malignancy.
Results: Significantly more patients underwent excision at BH than at BWH (39% vs 8%, p<0.001), and significantly fewer had a repeat biopsy (15% vs 92%, p <0.001). AUS /FLUS qualifiers shown to be associated with different risks of malignancy (rule out papillary carcinoma, atypia NOS, cytologic atypia, architectural atypia) had no impact on rates of re-biopsy or excision (p >0.05 for all). A recommendation for repeat biopsy increased the rate of re-biopsy at BH (17% vs 4.8%, p = 0.02), but not at BWH (93% vs 91%, p =0.67). Use of the phrases “favor benign” or “likely benign” resulted in a decreased rate of excision at BH (14% vs 43 %; p=0.05), but were not used in BWH reports. Phrases suggesting uncertainty of malignancy, inadequate sampling, or any other phrase containing the word "benign" had no effect on treatment at BH or BWH (p>0.05 for all).
Conclusions: Management of patients with a diagnosis of AUS/FLUS in a thyroid FNA varies significantly. In a setting that closely adheres to proposed management guidelines of TBS, descriptive phrases do not modify clinical management of patients with an initial AUS/FLUS diagnosis. However, in a setting where most patients do not undergo repeat biopsy, the phrases “favor benign," “likely benign," and “recommend repeat biopsy” are more likely to affect patient management than descriptive qualifiers associated with different risks of malignancy.
Tuesday, March 5, 2013 8:15 AM
Proffered Papers: Section F, Tuesday Morning