Reproducibility of atypia of undetermined significance/follicular lesion of undetermined significance category using the bethesda system for reporting thyroid cytology when reviewing slides from different institutions: A study of interobserver variability among cytopathologists

Diagn Cytopathol. 2017 May;45(5):399-405. doi: 10.1002/dc.23681. Epub 2017 Feb 20.


Background: The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) offers a six-tiered diagnostic scheme for thyroid Fine Needle Aspiration (FNA): Benign, Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance (AUS/FLUS), suspicious for follicular neoplasm, suspicious for malignancy, malignant, and unsatisfactory with an aim to standardize diagnostic criteria. Reported rate of AUS/FLUS category in the literature has varied from 3% to 20.5%.

Methods: The aim of this study was to assess interobserver variability among cytopathologists to assess reproducibility of the AUS/FLUS category. Seven cytopathologists brought FNA cases (a mixture of atypical and non-atypical FNA diagnosis) diagnosed using TBSRTC from their respective institutions which were reviewed and diagnosed by the participants. The analysis assessed interobserver variability among 7 cytopathologists and determined characteristics on the slides which were associated with concordance to the institutional diagnosis.

Results: Seventy eight of 125 (62.4%) benign cases were classified as benign by the reviewers and 26 (21%) were called AUS/FLUS on review. A third of the AUS/FLUS cases were called benign on review and 28.2% were classified as suspicious for neoplasia/malignancy. Roughly a third each of the suspicious for follicular neoplasm/suspicious for malignancy cases were classified as AUS/FLUS.

Discussion: When pathologists from different institutions shared their slides, concordance was high for specimens with adequate cellularity and those that were clearly benign but thresholds varied for the other indeterminate categories. Most definite categorization of the AUS/FLUS category was seen on review. Diagn. Cytopathol. 2017;45:399-405. © 2017 Wiley Periodicals, Inc.

Keywords: atypical; cytology; interobserver; the Bethesda system; thyroid; variability.

MeSH terms

  • Adenocarcinoma, Follicular / diagnosis*
  • Adenocarcinoma, Follicular / pathology
  • Biopsy, Fine-Needle
  • Carcinoma / diagnosis*
  • Carcinoma / pathology
  • Carcinoma, Papillary
  • Diagnosis, Differential
  • Histocytochemistry / statistics & numerical data*
  • Humans
  • Neoplasm Grading
  • Neoplasm Staging
  • Neoplasms / diagnosis*
  • Neoplasms / pathology
  • Observer Variation
  • Pathology, Clinical
  • Reproducibility of Results
  • Thyroid Cancer, Papillary
  • Thyroid Gland / pathology
  • Thyroid Neoplasms / diagnosis*
  • Thyroid Neoplasms / pathology
  • Thyroid Nodule / diagnosis*
  • Thyroid Nodule / pathology
  • Workforce