ARTICLE

The Bethesda System for Reporting Thyroid Cytopathology

Edmund S. Cibas
1
and Syed Z. Ali
2
Objective: To address terminology and other issues related to thyroid ne-needle aspiration (FNA), the National
Cancer Institute (NCI) hosted The NCI Thyroid FNA State of the Science Conference. The conclusions regarding
terminology and morphologic criteria from the NCI meeting led to the Bethesda Thyroid Atlas Project and form
the framework for the Bethesda System for Reporting Thyroid Cytopathology.
Design: Participants of the Atlas Project were selected from among the committee members of the NCI FNA State
of the Science Conference and other participants at the live conference. The terminology framework was based
on a literature search of English language publications dating back to 1995 using PubMed as the search engine;
online forum discussions (http:==thyroidfna.cancer.gov=forums=default.aspx); and formal interdisciplinary dis-
cussions held on October 22 and 23, 2007, in Bethesda, MD.
Main Outcome: For clarity of communication, the Bethesda System for Reporting Thyroid Cytopathology rec-
ommends that each report begin with one of the six general diagnostic categories. Each of the categories has an
implied cancer risk that links it to an appropriate clinical management guideline.
Conclusions: The project participants hope that the adoption of this framework will facilitate communication
among cytopathologists, endocrinologists, surgeons, and radiologists; facilitate cytologichistologic correlation
for thyroid diseases; facilitate research into the understanding of thyroid diseases; and allow easy and reliable
sharing of data from different laboratories for national and international collaborative studies.
Introduction
F
ine-needle aspiration (FNA) plays an essential role in
the evaluation of the euthyroid patient with a thyroid
nodule. It reduces the rate of unnecessary thyroid surgery for
patients with benign nodules and appropriately triages pa-
tients with thyroid cancer to appropriate surgery. Before the
routine use of thyroid FNA, the percentage of surgically re-
sected thyroid nodules that were malignant was 14%(1). With
current thyroid FNA practice, the percentage of resected
nodules that are malignant surpasses 50% (2).
It is critical that the cytopathologist communicate thyroid
FNA interpretations to the referring physician in terms that
are succinct, unambiguous, and clinically helpful. Histori-
cally, terminology for thyroid FNA has varied signicantly
from one laboratory to another, creating confusion in some
instances and hindering the sharing of clinically meaningful
data among multiple institutions.
To address terminology and other issues related to thyroid
FNA, the National Cancer Institute (NCI) hosted The NCI
Thyroid Fine Needle Aspiration State of the Science Con-
ference. The meeting was organized by Andrea Abati, M.D.,
and took place on October 22 and 23, 2007, in Bethesda, MD.
Edmund S. Cibas, M.D., and Susan J. Mandel, M.D., M.P.H.,
served as moderators. Zubair W. Baloch, M.D., Ph.D., served
as Chair of the Terminology and Morphologic Criteria com-
mittee. Preparations for the conference began 18 months
earlier with the designation of a steering committee, coordi-
nation with cosponsoring organizations, and the establish-
ment of a dedicated, permanent Web site.
Literature reviews were limited to English language pub-
lications dating back to 1995, using PubMed as the search
engine, with key words determined by the committee mem-
bers. The rst draft of the committees summary documents
was posted on the Web site and open for online discussion
from May 1 to June 30, 2007. There were several subsequent
drafts and online discussion periods (August 15September
30, 2007, and November 30December 15, 2007). The docu-
ments underwent revision after each comment period before
reposting on the Web. The 2-day live conference in October
2007, attended by 154 registrants comprised of pathologists,
endocrinologists, surgeons, and radiologists, gave the com-
mittees an in-depth opportunity to present their conclusions
and debate controversial areas.
By mutual agreement among the authors and editors of their respective journals, this work is being published jointly in Thyroid and the
American Journal of Clinical Pathology.
1
Department of Pathology, Brigham and Womens Hospital and Harvard Medical School, Boston, Massachusetts.
2
Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, Maryland.
THYROID
Volume 19, Number 11, 2009
Mary Ann Liebert, Inc.
DOI: 10.1089=thy.2009.0274
1159
The Bethesda System for Reporting
Thyroid Cytopathology
The NCI conference participants acknowledged the im-
portance of developing an uniform terminology for reporting
thyroid FNA results. An inspiration for the thyroid proposal
was the Bethesda System for reporting cervical cytology in-
terpretations, rst developed at an NCI workshop in 1988 and
widely adopted in the United States for reporting Pap test
results. It is expected that the many benets, clinical and in-
vestigational, of the Bethesda cervical terminology will also
apply to the Bethesda thyroid terminology. A uniform re-
porting system for thyroid FNA will

facilitate effective communication among cytopatholo-

gists, endocrinologists, surgeons, radiologists, and other
health care providers;

facilitate cytologichistologic correlation for thyroid

diseases;

facilitate research into the epidemiology, molecular

biology, pathology, and diagnosis of thyroid diseases,
particularly neoplasia;

allow easy and reliable sharing of data from different

laboratories for national and international collaborative
studies.
An online atlas of illustrations of the Bethesda diagnostic
categories is currently being assembled on the Papanicolaou
Society Web site under the direction of Syed Ali, M.D., Chair
of the Online Atlas Committee. A print atlas, with over 40
contributing authors (see end of text), is in press (3).
It was apparent from the discussions at the conference and
the Web postings that the primary purpose of terminology is
clarity of communication. The interpretation should provide
clinically relevant information that will assist the referring
physician in the management of the patient. The terms for
reporting results should have an implied (or explicit) risk of
malignancy upon which recommendations for patient man-
agement (e.g., annual follow-up, repeat FNA, surgical lobec-
tomy, and near total thyroidectomy) can be based.
The discussions and conclusions regarding terminology
and morphologic criteria from the NCI meeting, summarized
in the publications by Baloch et al. (4,5), form the framework
for the terminology presented here and in atlas form (3). It is
intended as a exible framework that can be modied to suit
the needs of the particular laboratory andthe patients it serves.
Format of the Report
For clarity of communication, the Bethesda System for
Reporting Thyroid Cytopathology recommends that each
report begin with a general diagnostic category. The six
general diagnostic categories are shown in upper case in
Table 1. Some categories have two alternative names; a con-
sensus was not reached at the NCI conference on a single
name for these categories. Each of the categories has an im-
plied cancer risk (ranging from 0% to 3% for the Benign cat-
egory to virtually 100% for the Malignant category) that links
it to a rational clinical management guideline (Table 2).
For some of the general categories, some degree of sub-
categorization can be informative and is often appropriate;
recommended terminology is shown in Table 1. Additional
descriptive comments (beyond such subcategorization) are
optional and left to the discretion of the cytopathologist.
Notes and recommendations are not required but can be
useful in certain circumstances. Some laboratories, for exam-
ple, may wish to state the risk of malignancy associated with
the general category, based on its own data or that found in
the literature (Table 2).
Nondiagnostic or unsatisfactory
Every thyroid FNA must be evaluated for adequacy. In-
adequate samples are reported as Nondiagnostic (ND) or
Unsatisfactory (UNS). This category applies to specimens
that are unsatisfactory due to obscuring blood, overly thick
smears, air drying of alcohol-xed smears, or an inadequate
number of follicular cells. For a thyroid FNA specimen to be
satisfactory for evaluation (and benign), at least six groups of
benign follicular cells are required, each group composed of at
least 10 cells (6,7). The minimum size requirement for the
groups allows one to determine (by the evenness of the nu-
clear spacing) whether or not they represent fragments of
macrofollicles.
There are several exceptions to the numerical requirement
of benignfollicular cells. Any specimen that contains abundant
Table 1. The Bethesda System
for Reporting Thyroid Cytopathology:
Recommended Diagnostic Categories
I. NONDIAGNOSTIC or UNSATISFACTORY
Cyst uid only
Virtually acellular specimen
Other (obscuring blood, clotting artifact, etc.)
II. BENIGN
Consistent with a benign follicular nodule (includes
adenomatoid nodule, colloid nodule, etc.)
Consistent with lymphocytic (Hashimoto) thyroiditis
in the proper clinical context
Consistent with granulomatous (subacute) thyroiditis
Other
III. ATYPIA OF UNDETERMINED SIGNIFICANCE
or FOLLICULAR LESION OF UNDETERMINED
SIGNIFICANCE
IV. FOLLICULAR NEOPLASM or SUSPICIOUS
FOR A FOLLICULAR NEOPLASM
Specify if Hu rthle cell (oncocytic) type
V. SUSPICIOUS FOR MALIGNANCY
Suspicious for papillary carcinoma
Suspicious for medullary carcinoma
Suspicious for metastatic carcinoma
Suspicious for lymphoma
Other
VI. MALIGNANT
Papillary thyroid carcinoma
Poorly differentiated carcinoma
Medullary thyroid carcinoma
Undifferentiated (anaplastic) carcinoma
Squamous cell carcinoma
Carcinoma with mixed features (specify)
Metastatic carcinoma
Non-Hodgkins lymphoma
Other
From Ali and Cibas (3). With kind permission from Springer
Science and Business Media.
1160 CIBAS AND ALI
colloid is considered adequate (and benign), even if six groups
of follicular cells are not identied: a sparsely cellular speci-
men with abundant colloid is, by implication, a predominantly
macrofollicular nodule and therefore almost certainly benign.
Whenever a specic diagnosis (e.g., lymphocytic thyroiditis)
can be rendered, and whenever there is any atypia, the spec-
imen is, by denition, adequate for evaluation. ND=UNS re-
sults occur in 220% of cases but ideally should be limited to
no more than 10% of thyroid FNAs, excluding samples com-
prised exclusively of macrophages (810).
Specimens that consist only of cyst contents (macrophages)
are problematic. Many laboratories have traditionally consid-
ered a macrophages-only sample unsatisfactory and included
them in the ND=UNS category, with the understanding that,
because the parenchyma of the nodule has not been sampled,
one cannot exclude a cystic papillary carcinoma. In such lab-
oratories, macrophages-only often constituted the great
majority of ND=UNS cases, with rates that ranged from15%to
30% (2,9,11,12). Other laboratories considered the risk of a
false-negative result negligible and reported macrophages-
only as benign (10,11). At the 2007 NCI Conference, it was
decided that cyst uidonly (CFO) cases should be considered
a clearly identied subset of ND=UNS. The signicance (and
clinical value) of a CFO result depends in large part on sono-
graphic correlation. If the nodule is almost entirely cystic, with
no worrisome sonographic features, an endocrinologist might
proceed as if the CFOwere a benign result. On the other hand,
it might be clinically equivalent to an ND result if the sono-
graphic features are worrisome and the endocrinologist is not
convinced that the sample is representative. In a study that
segregated CFO cases and analyzed them separately, the risk
of malignancy for a CFO sample was 4% (9). The risk of ma-
lignancy for ND=UNS (not including CFO) was 14% (810).
A repeat aspiration with ultrasound guidance is re-
commended for ND=UNS and clinically=sonographically
worrisome CFOcases and is diagnostic in 5088%of the cases
(2,6,9,11,13,14), but some nodules remain persistently
ND=UNS. Excision is considered for persistently ND=UNS
nodules because about 10% prove to be malignant (13).
Unless specied as ND=UNS, the FNA is considered ade-
quate for evaluation. An explicit statement of adequacy is
optional.
Benign
The benet of thyroid FNA derives in large part from the
ability to make a reliably benign interpretation that avoids
unnecessary surgery. A BENIGN result is obtained in
6070% of the thyroid FNAs. Descriptive comments that fol-
low are used to subclassify the benign interpretation. The
term benign follicular nodule (BFN) applies to the most
common benign pattern: an adequately cellular specimen
comprised of varying proportions of colloid and benign fol-
licular cells arranged as macrofollicles and macrofollicle
fragments. If resected, virtually all BFNs turn out to be either
nodules of a multinodular goiter or follicular adenomas (FAs).
This distinction cannot be made by FNA and is of no conse-
quence to the patient. The false-negative rate of a benign in-
terpretation is low (03%) (2,12), but patients are nevertheless
followed with repeat assessment by palpation or ultrasound
at 618 month intervals (15). If the nodule shows signicant
growth or suspicious sonographic changes, a repeat FNA is
considered.
Other benign subcategories include consistent with lym-
phocytic (Hashimoto) thyroiditis inthe proper clinical context
and consistent with granulomatous (subacute) thyroiditis.
This is a partial list and does not include a variety of other
benign conditions like infections and amyloid goiter that are
occasionally sampled by FNA. Additional benign ndings
(e.g., black thyroid, reactive changes, radiation changes, and
cyst-lining cells) can be mentioned as descriptive diagnoses at
the discretion of the cytopathologist.
Atypia of undetermined signicance or
Follicular lesion of undetermined signicance
Some thyroid FNAs are not easily classied into the be-
nign, suspicious, or malignant categories. Such cases repre-
sent a minority of thyroid FNAs and in the Bethesda System
are reported as Atypia of Undetermined Signicance (AUS)
or Follicular Lesion of Undetermined Signicance. The
necessity for this category was debated at the NCI confer-
ence, after which a vote (limited to the clinicians in atten-
dance) was taken, and the majority voted in favor of this
category.
Table 2. The Bethesda System for Reporting Thyroid Cytopathology:
Implied Risk of Malignancy and Recommended Clinical Management
Diagnostic category Risk of malignancy (%) Usual management
a
Nondiagnostic or unsatisfactory 14 Repeat FNA with ultrasound guidance
Benign 03 Clinical follow-up
Atypia of undetermined signicance or
follicular lesion of undetermined
signicance
*515
b
Repeat FNA
Follicular neoplasm or suspicious for a
follicular neoplasm
1530 Surgical lobectomy
Suspicious for malignancy 6075 Near-total thyroidectomy or surgical
lobectomy
c
Malignant 9799 Near-total thyroidectomy
c
Modied from Ali and Cibas (3). With kind permission from Springer Science and Business Media.
a
Actual management may depend on other factors (e.g., clinical and sonographic) besides the FNA interpretation.
b
Estimate extrapolated from histopathologic data from patients with repeated atypicals.
c
In the case of suspicious for metastatic tumor or a malignant interpretation indicating metastatic tumor rather than a primary thyroid
malignancy, surgery may not be indicated.
THE BETHESDA SYSTEM FOR THYROID CYTOPATHOLOGY 1161
The heterogeneity of this category precludes outlining all
scenarios for which an AUS interpretation is appropriate. The
most common scenarios can be described as follows:
A. There is a prominent population of microfollicles in an
aspirate that does not otherwise fulll the criteria for
Follicular Neoplasm=Suspicious for Follicular Neo-
plasm. This situation may arise when a predominance
of microfollicles are seen in a sparsely cellular aspirate
with scant colloid. Alternatively, a more prominent
than usual population of microfollicles may occur (and
may be disproportionately apparent on a minority of
smears) in a moderately or markedly cellular sample,
but the overall proportion of microfollicles is not suf-
cient for the diagnosis of Follicular Neoplasm=
Suspicious for Follicular Neoplasm.
B. There is a predominance of Hu rthle cells in a sparsely
cellular aspirate with scant colloid.
C. The interpretation of follicular cell atypia is hindered by
sample preparation artifact, for example,
a. air-drying artifact with slight nuclear and cytoplas-
mic enlargement, pale and slightly smudgy chro-
matin, and=or mildly irregular nuclear contours,
b. clotting artifact with crowding.
D. A moderately or markedly cellular sample is composed
of a virtually exclusive population of Hu rthle cells, yet
the clinical setting suggests a benign Hu rthle cell
nodule, for example,
a. lymphocytic (Hashimoto) thyroiditis,
b. multinodular goiter
E. There are focal features suggestive of papillary carci-
noma, including nuclear grooves, enlarged nuclei with
pale chromatin, and alterations in nuclear contour and
shape in an otherwise predominantly benign-appear-
ing sample (especially in patients with Hashimoto
thyroiditis or those with abundant colloid and other
benign-appearing follicular cells).
F. There are cyst-lining cells that may appear atypical due
to the presence of nuclear grooves, prominent nucleoli,
elongated nuclei and cytoplasm, and=or intranuclear
cytoplasmic inclusions in an otherwise predominantly
benign-appearing sample (16).
G. A minor population of follicular cells show nuclear
enlargement, often accompanied by prominent nucle-
oli, for example,
a. specimens from patients with history of radioactive
iodine, carbimazole, or other pharmaceutical agents,
b. repair due to involutional changes such as cystic
degeneration and or hemorrhage
H. There is an atypical lymphoid inltrate (in which a
repeat aspirate for ow cytometry is desirable), but the
degree of atypia is insufcient for the general category
suspicious for malignancy.
I. Not otherwise categorized.
Importantly, only nodules with atypia of undetermined
signicance should be placed in the AUS category. Re-
cognizably benign cellular changes (e.g., typical cyst-lining
cells, focal Hurthle cell change, changes ascribed to radio-
iodine therapy, and black thyroid) should not be interpreted
as AUS. A moderately or even highly cellular specimen by
itself (without signicant nuclear or architectural atypia) does
not qualify a nodule for an AUS interpretation.
An AUS result is obtained in 36% of thyroid FNAs (2,10).
Higher rates likely represent an overuse of this category
when other interpretations are more appropriate. The re-
commended management is clinical correlation and a repeat
FNA at an appropriate interval (2,15). In most cases, a repeat
FNA results in a more denitive interpretation; only about
20% of the nodules are repeatedly AUS (2). In some cases,
however, the physician may choose not to repeat the FNAbut
follow the nodule clinically, or, alternatively, to refer the pa-
tient for surgery because of concerning clinical and=or sono-
graphic features.
The risk of malignancy for an AUS nodule is difcult to
ascertain because only a minority of cases in this category
have surgical follow-up. Those that are resected represent a
selected population of patients with repeatedly AUS results or
patients with worrisome clinical or sonographic ndings. In
this selected population, 2025% of the patients with AUS
prove to have cancer after surgery, but this is undoubtedly an
overestimate of the risk for all AUS interpretations (2,10). The
risk of malignancy is certainly lower and probably closer to
515%. An effort should be made to use this category as a last
resort and limit its use to approximately 7% or fewer of all
thyroid FNAs.
Follicular neoplasm or
Suspicious for a follicular neoplasm
The purpose of this diagnostic category is to identify a
nodule that might be a follicular carcinoma (FC) and triage it
for surgical lobectomy. FNA is diagnostic of many thyroid
conditions (e.g., papillary carcinoma and lymphocytic thy-
roiditis), but, with regard to FC, it is better considered a
screening test. FCs have cytomorphologic features that dis-
tinguish them from BFNs. Although these cytomorphologic
features do not permit distinction from FA, they are report-
able as FOLLICULAR NEOPLASM or SUSPICIOUS FOR
A FOLLICULAR NEOPLASM, leading to a denitive diag-
nostic procedure, usually lobectomy (12,15,17). The term
suspicious for a follicular neoplasm is preferred by some
laboratories over follicular neoplasm for this category be-
cause a signicant proportion of cases (up to 35%) prove not
to be neoplasms but rather hyperplastic proliferations of fol-
licular cells, most commonly those of multinodular goiter
(10,1821). About 1530%of the cases called FN=SFNprove to
be malignant (2,10,19,22). The majority of SFN cases turn out
to be FAs or adenomatoid nodules of multinodular goiter,
both of which are more common than FC. Of those that prove
to be malignant, many are FCs, but a signicant proportion
are follicular variants of papillary carcinoma (2,8,11,19).
Cytologic preparations typically have high cellularity, and
colloid is scant or absent. The hallmark of this diagnostic
category is a disturbed cytoarchitecture: follicular cells are
arranged predominantly in microfollicular or trabecular ar-
rangements. Cases that demonstrate the nuclear features of
papillary carcinoma are excluded from this category. Cellular
crowding and overlapping are conspicuous, and the follicu-
lar cells are usually larger than normal. Nuclear atypia=
pleomorphism and mitoses are uncommon. A minor popu-
lation of macrofollicles (intact spheres and fragments) can be
present. Conspicuous cellularity alone does not qualify the
nodule for a suspicious interpretation (23). If the sample is
cellular but mostly macrofollicular (intact spheres and at
1162 CIBAS AND ALI
fragments of evenly spaced follicular cells), a benign inter-
pretation is appropriate. BFNs often have a small population
of microfollicles and crowded groups. If these comprise the
minority of the follicular cells, they have little signicance and
the FNA can be interpreted as benign. A suspicious inter-
pretation is rendered only when the majority of the follicular
cells are arranged in abnormal architectural groupings (mi-
crofollicles, crowded trabeculae).
The general category FN=SFN is a self-sufcient interpre-
tation; narrative comments that follow are optional.
In the World Health Organization classication, Hu rthle
cell adenoma and Hu rthle cell carcinoma (HC) are considered
oncocytic variants of FA and FC, respectively (24). Studies
suggest, however, that follicular and Hu rthle cell tumors have
different underlying genetics (4,25). For this reason, and be-
cause they have such distinctive morphologic features, it is
helpful to specify that a sample raises the possibility of a
Hu rthle cell rather than a FN. This interpretation applies to
cellular samples that are composed exclusively (or almost
exclusively) of Hu rthle cells. Oncocytic cells with nuclear
features of papillary carcinoma are excluded from this inter-
pretation. A signicant proportion of these cases (1625%)
prove not to be neoplasms but rather hyperplastic prolifera-
tions of Hu rthle cells in nodular goiter or lymphocytic thy-
roiditis (26,27). About 1545%nodules are malignant, and the
remainder of the neoplasms prove to be Hu rthle cell adeno-
mas (22,26,27).
Suspicious for malignancy
Many thyroid cancers, most especially papillary thyroid
carcinoma (PTC), can be diagnosed with certainty by FNA.
But the nuclear and architectural changes of some PTCs are
subtle and focal. This is particularly true of the follicular
variant of PTC, which can be difcult to distinguish from a
BFN(28). Other PTCs may be incompletely sampled and yield
only a small number of abnormal cells (29). If only one or two
characteristic features of PTCare present, if they are only focal
and not widespread throughout the follicular cell population,
or if the sample is sparsely cellular, a malignant diagnosis
cannot be made with certainty. Such cases occur with some
regularity, and they are best classied as SUSPICIOUS FOR
MALIGNANCY, qualied as Suspicious for papillary car-
cinoma. Nodules called suspicious for papillary carcinoma
are resected, either by lobectomy or thyroidectomy. Most
(6075%) prove to be papillary carcinomas and the rest are
usually FAs (2,10,12,30).
The same general principle applies to other thyroid ma-
lignancies like medullary carcinoma and lymphoma, but
these are encountered less frequently than PTC. Ancillary
testing (e.g., immunohistochemistry and ow cytometry) in
borderline cases is usually more helpful with medullary car-
cinoma and lymphoma than PTC.
Malignant
The general category MALIGNANT is used whenever
the cytomorphologic features are conclusive for malignancy.
Descriptive comments that follow are used to subclassify the
malignancy and summarize the results of special studies, if
any. Approximately 37% of the thyroid FNAs have conclu-
sive features of malignancy, and most are papillary carcino-
mas (2,1012). Malignant nodules are usually removed by
thyroidectomy, with some exceptions (e.g., metastatic tumors,
non-Hodgkin lymphomas, and undifferentiated carcinomas).
The positive predictive value of a malignant FNA interpre-
tation is 9799%.
Summary
This document summarizes several years of work, begun as
a Web-based discussion, followed by a live conference, and
culminating in the production of a print and online atlas. It is
the hope of all the contributors to this project that this ter-
minology proposal will be a valuable rst step toward uni-
formity and consensus in the reporting of thyroid FNA
interpretations. As with the Bethesda System for cervical cy-
tology, it is expected that subsequent workshops will lead to
further renements to this framework.
List of Bethesda Thyroid Atlas Contributors
Pedro Patricio de Agustin, M.D., Ph.D., Department of Pathology,
University Hospital 12 de Octubre, Madrid, Spain
Erik K. Alexander, M.D., Department of Medicine, Brigham and
Womens Hospital, Boston, MA
Sylvia L. Asa, M.D., Ph.D., Department of Pathology and La-
boratory Medicine, University of Toronto; University Health
Network and Toronto Medical Laboratories; Ontario Cancer
Institute, Toronto, Ontario, Canada
Kristen A. Atkins, M.D., Department of Pathology, University of
Virginia Health System, Charlottesville, VA
Manon Auger, M.D., Department of Pathology, McGill Uni-
versity Health Center and McGill University, Montreal, Que-
bec, Canada
Zubair W. Baloch, M.D., Ph.D., Department of Pathology and
Laboratory Medicine, University of Pennsylvania Medical
Center, Philadelphia, PA
Katherine Berezowski, M.D., Department of Pathology, Virginia
Hospital Center, Arlington, VA
Massimo Bongiovanni, M.D., Department of Pathology, Geneva
University Hospital, Geneva, Switzerland
Douglas P. Clark, M.D., Department of Pathology, The Johns
Hopkins Medical Institutions, Baltimore, MD
Beatrix Cochand-Priollet, M.D., Ph.D., Department of Pathology,
Lariboisie`re Hospital, University of Paris 7, Paris, France
Barbara A. Crothers, D.O., Department of Pathology, Walter Reed
Army Medical Center, Springeld, VA
Richard M. DeMay, M.D., Department of Pathology, University
of Chicago, Chicago, IL
Tarik M. Elsheikh, M.D., Ball Memorial Hospital=PA Labs,
Muncie, IN
William C. Faquin, M.D., Ph.D., Department of Pathology, Mas-
sachusetts General Hospital, Boston, MA
Armando C. Filie, M.D., Laboratory of Pathology, National Can-
cer Institute, Bethesda, MD
Pinar Firat, M.D., Department of Pathology, Hacettepe Uni-
versity, Ankara, Turkey
William J. Frable, M.D., Department of Pathology, Medical Col-
lege of Virginia Hospitals, Virginia Commonwealth Uni-
versity Medical Center, Richmond, VA
Kim R. Geisinger, M.D., Department of Pathology, Wake Forest
University School of Medicine, Winston-Salem, NC
Hossein Gharib, M.D., Department of Endocrinology, Mayo
Clinic College of Medicine, Rochester, MN
Ulrike M. Hamper, M.D., Department of Radiology and Radi-
ological Sciences, The Johns Hopkins Medical Institutions,
Baltimore, MD
THE BETHESDA SYSTEM FOR THYROID CYTOPATHOLOGY 1163
Michael R. Henry, M.D., Department of Laboratory Medicine
and Pathology, Mayo Clinic and Foundation, Rochester, MN
Jeffrey F. Krane, M.D., Ph.D., Department of Pathology, Brigham
and Womens Hospital, Boston, MA
Lester J. Layeld, M.D., Department of Pathology, University of
Utah Hospital and Clinics, Salt Lake City, UT
Virginia A. LiVolsi, M.D., Department of Pathology and La-
boratory Medicine, University of Pennsylvania Medical Cen-
ter, Philadelphia, PA
Britt-Marie E. Ljung, M.D., Department of Pathology, University
of California San Francisco, San Francisco, CA
Claire W. Michael, M.D., Department of Pathology, University of
Michigan Medical Center, Ann Arbor, MI
Ritu Nayar, M.D., Department of Pathology, Northwestern
University, Feinberg School of Medicine, Chicago, IL
Yolanda C. Oertel, M.D., Department of Pathology, Washington
Hospital Center, Washington, DC
Martha B. Pitman, M.D., Department of Pathology, Massachu-
setts General Hospital, Boston, MA
Celeste N. Powers, M.D., Ph.D., Department of Pathology, Medi-
cal College of Virginia Hospitals, Virginia Commonwealth
University Medical Center, Richmond, VA
Stephen S. Raab, M.D., Department of Pathology, University of
Colorado at Denver, UCDHSC Anschutz Medical Campus,
Aurora, CO
Andrew A. Renshaw, M.D., Department of Pathology, Baptist
Hospital of Miami, Miami, FL
Juan Rosai, M.D., Dipartimento di Patologia, Instituto Nazionale
Tumori, Milano, Italy
Miguel A. Sanchez, M.D., Department of Pathology, Englewood
Hospital and Medical Center, Englewood, NJ
Vinod Shidham, M.D., Department of Pathology, Medical College
of Wisconsin, Milwaukee, WI
Mary K. Sidawy, M.D., Department of Pathology, Georgetown
University Medical Center, Washington, DC
Gregg A. Staerkel, M.D., Department of Pathology, The Uni-
versity of Texas M.D. Anderson Cancer Center, Houston, TX
Edward B. Stelow, M.D., Department of Pathology, University of
Virginia Health System, Charlottesville, VA
Jerry Waisman, M.D., Department of Pathology, New York Uni-
versity of Medicine, New York, NY
Helen H. Wang, M.D., Dr.P.H., Department of Pathology, Beth
Israel-Deaconess Medical Center, Boston, MA
Philippe Vielh, M.D., Ph.D., Department of Pathology, Institue de
Cancerologie Gustave Roussy, France
Grace C. H. Yang, M.D., Department of Pathology, Weill Medical
College of Cornell University, New York, NY
Matthew A. Zarka, M.D., Department of Laboratory Medicine
and Pathology, Mayo Clinic Arizona, Scottsdale, AZ
Acknowledgment
The authors thank Dr. Diane Solomon for her review of the
manuscript and helpful comments.
Disclosure Statement
The authors declare that no competing nancial interests
exist.
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Address correspondence to:
Edmund S. Cibas, M.D.
Department of Pathology
Brigham and Womens Hospital
75 Francis St.
Boston, MA 02115
E-mail: ecibas@partners.org
THE BETHESDA SYSTEM FOR THYROID CYTOPATHOLOGY 1165
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