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The evaluation of miRNAs on thyroid FNAC: the promising role of miR-375 in follicular neoplasms

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Esther Diana Rossi
Esther Diana Rossi
Esther Diana Rossi
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Tommaso Bizzarro
Tommaso Bizzarro
Tommaso Bizzarro
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Maurizio Martini at Università degli Studi di Messina
Maurizio Martini
Sara Capodimonti
Sara Capodimonti
Sara Capodimonti
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Abstract and Figures

Fine needle aspiration cytology (FNAC) plays an essential role in the evaluation of thyroid nodules especially for the category of follicular neoplasms (FN) representing 25 % of all thyroid cases including different neoplastic entities. Hence, one of the most promising areas is the application of molecular tests to FNAC. Among them, microRNAs (miRNA),identified as negative (post-transcriptional) gene expression regulators involved in tumor development, are likely to discriminate among FNs. Limited data explored the use of miRNAs on FNAC as well as their role in the malignant risk stratification. We aimed to define whether liquid-based cytology (LBC) is a valid method for miRNA evaluation. From June 2014 to March 2015, we enrolled 27FNs with histological follow-up. In the same reference period, 13 benign nodules (BN) and 20 positive for malignancy (PM) were selected as controls. Histologically, FNs resulted in 14 malignancies (3 papillary thyroid carcinoma-PTC and 11 follicular variant of PTC-FVPC) and 13 follicular adenomas (FA). The 20 PMs included two FVPC, 16 PTC and two medullary thyroid carcinoma (MTC). Five miRNAs (10b, 92a, 221/222 cluster, and 375) were studied on LBC and quantified by real-time PCR. Only miR-375 was over-expressed in the FNs diagnosed as carcinomas and in the PMs. A cut-off of 12 miR-375/U6 relative ratio recognized all BNs and 95 % PMs. Specifically, in each category, FVPCs and PTCs did not show any difference while MTCs had the highest value. miR-375 shows 97.1 % sensitivity, 100 % specificity, 96.3 % negative predictive value (NPV), 100 % positive predictive value (PPV), and 98.3 % diagnostic accuracy. LBC is suitable for miRNAs evaluation. miR-375 resulted over-expressed in all malignant FNs and 95 % PMs. It may represent a valid aid in ruling out BNs and supporting PTCs and/or FVPCs.
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ORIGINAL ARTICLE
The evaluation of miRNAs on thyroid FNAC: the promising role
of miR-375 in follicular neoplasms
Esther Diana Rossi
1
•Tommaso Bizzarro
1
•Maurizio Martini
1
•Sara Capodimonti
1
•
Diletta Sarti
1
•Tonia Cenci
1
•Mirna Bilotta
1
•Guido Fadda
1
•Luigi Maria Larocca
1
Received: 29 September 2015 / Accepted: 11 January 2016 / Published online: 27 January 2016
ÓSpringer Science+Business Media New York 2016
Abstract Fine needle aspiration cytology (FNAC) plays
an essential role in the evaluation of thyroid nodules
especially for the category of follicular neoplasms (FN)
representing 25 % of all thyroid cases including different
neoplastic entities. Hence, one of the most promising areas
is the application of molecular tests to FNAC. Among
them, microRNAs (miRNA),identified as negative (post-
transcriptional) gene expression regulators involved in
tumor development, are likely to discriminate among FNs.
Limited data explored the use of miRNAs on FNAC as
well as their role in the malignant risk stratification. We
aimed to define whether liquid-based cytology (LBC) is a
valid method for miRNA evaluation. From June 2014 to
March 2015, we enrolled 27FNs with histological follow-
up. In the same reference period, 13 benign nodules (BN)
and 20 positive for malignancy (PM) were selected as
controls. Histologically, FNs resulted in 14 malignancies (3
papillary thyroid carcinoma-PTC and 11 follicular variant
of PTC-FVPC) and 13 follicular adenomas (FA). The 20
PMs included two FVPC, 16 PTC and two medullary
thyroid carcinoma (MTC). Five miRNAs (10b, 92a,
221/222 cluster, and 375) were studied on LBC and
quantified by real-time PCR. Only miR-375 was over-
expressed in the FNs diagnosed as carcinomas and in the
PMs. A cut-off of 12 miR-375/U6 relative ratio recognized
all BNs and 95 % PMs. Specifically, in each category,
FVPCs and PTCs did not show any difference while MTCs
had the highest value. miR-375 shows 97.1 % sensitivity,
100 % specificity, 96.3 % negative predictive value
(NPV), 100 % positive predictive value (PPV), and 98.3 %
diagnostic accuracy. LBC is suitable for miRNAs evalua-
tion. miR-375 resulted over-expressed in all malignant FNs
and 95 % PMs. It may represent a valid aid in ruling out
BNs and supporting PTCs and/or FVPCs.
Keywords Thyroid lesions Liquid-based cytology
PTC Follicular neoplasms miRNAs
Introduction
Fine needle aspiration cytology (FNAC) is the first ‘‘gold
standard approach’’ in the evaluation and diagnosis of
thyroid nodules [1–4]. Numerous studies reported that
more than 70 % of the thyroid FNACs are benign, 5–10 %
are ‘‘malignant,’’ and the remaining 20–25 % of them
represent the so-called ‘‘grey zone’’ of follicular neoplasms
(FN) in which different neoplastic entities are included [5–
10]. However, FN category encompasses also some cases
in which an objective and consistent morphological diag-
nosis is not always straightforward [1–10]. In fact, deciding
on both the FN nature and the consequent management
(clinical and/or surgical) remains a vexing issue in several
cases. In this regard, the recognized evidence that upward
of 75 % of the FNs are found to be histological benign do
not warrant the useless risk, costs of surgery and thyroid
hormone replacement therapy. The remaining 25 %
includes also cases of follicular variant of papillary thyroid
The preliminary data of this project were presented as a poster at the
104th USCAP meeting in Boston, 21–27 March 2015.
The abstract was prized as the best oral presentation during the 39th
European congress of cytology held in Milan September 2015.
&Esther Diana Rossi
esther.rossi@rm.unicatt.it
1
Division of Anatomic Pathology and Histology, ‘‘Agostino
Gemelli’’ School of Medicine, Universita
`Cattolica del Sacro
Cuore, Largo Francesco Vito, 1, 00168 Rome, Italy
123
Endocrine (2016) 54:723–732
DOI 10.1007/s12020-016-0866-0
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... In these last decades, different authors highlighted that specific somatic mutations, gene rearrangements, and/or microRNA (miRNA) expression profiles are supported by a high specificity and predictive value for malignant thyroid disease [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37]40,[61][62][63][64][65][66][67][68][69][70][71][72][73]. Nonetheless, apart from the validation of single mutation, Nikiforov et al. encouraged the adoption of a broad next-generation sequencing (NGS) panel, leading to a more comprehensive genetic analysis in the diagnosis of indeterminate lesions including nodules with AUS/FLUS and FN/SFN cytology for their best and tailored management [35,36]. ...
... Significantly relevant, also in this paper, the authors confirmed the high specificity of point mutations such as BRAF V600E , TERT, TP53, PIK3CA, and any gene fusion in 100% of malignant cases [35]. Additionally, the high PPV and NPV obtained from their studies, assesses that ThyroSeq v2 may perform as both a "rule-out" and "rule-in" test for FN/SFN, representing a valid additional test in selecting those patients eligible for total thyroidectomy [35,[65][66][67][68][69][70][71][72][73][74][75][76][96][97][98][99][100][101][102][103][104][105][106][107][108][109][110]. A marginal role is played in the evaluation of Hürthle cell nodules. ...
... That found, Interpace Diagnostics suggested that ThyraMIR (from Interpace Diagnostics, Parsippany, NJ) might be a valid additional reflex test, for those cases with wild type/negative ThyGenX result that are not BRAFV600E or RET/PTC1-3 mutated 94). In fact, different papers studied the performance of miRNAs on indeterminate thyroid lesions, as some specific miRNAs (e.g., miR-146, 221, 222) are a clue to thyroid well differentiated carcinomas [65][66][67][68][69][70][71][72][73][74][75][76]. In fact, ThyraMIR is defined as a thyroid microRNA (miRNA) classifier that is able to divide results into "positive" or "negative" categories. ...
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View
... The clinical relevance of different miRNAs was investigated in two studies focusing on follicular-patterned lesions. miRNAs were assessed by RT-PCR on retrospective and prospective FNAs [28,29]. Rossi et al. showed that, among five potential miRNAs candidates, only miR-375 was overexpressed in the majority of malignant lesions [29]. ...
... miRNAs were assessed by RT-PCR on retrospective and prospective FNAs [28,29]. Rossi et al. showed that, among five potential miRNAs candidates, only miR-375 was overexpressed in the majority of malignant lesions [29]. Conversely, Stokowy et al. adopted a minimal classifier that included only two miR-NAs, miR-484 and miR-148b-3p. ...
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Molecular testing has acquired a relevant role for diagnostic and prognostic stratification of indeterminate thyroid nodules. Besides the available commercial solutions marketed in the United States, various local testing strategies have been developed in the last decade. In this setting, the modern interventional cytopathologist, the physician who performs the both aspirate and the morphologic interpretation plays a key role in the correct handling of fine-needle aspiration (FNA) samples not only for microscopy but also for molecular techniques. This review summarizes experiences with local approaches to the molecular testing of thyroid FNA, highlighting the role of the modern interventional cytopathologist.
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... Sample size justification was never reported. Whether the participation rate of eligible persons was at least 50%, it was unclear in 16 studies [16,17,19,24,26,28,30,33,35,37,[41][42][43][44][45][46]. A loss to follow-up after baseline below 20% was reported in 16 studies [16-20, 22, 23, 27, 30, 31, 34-36, 40, 43, 45]. ...
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  • ENDOCR PATHOL
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View
... To support the false negative rate of ThyGenX, the Interpace Diagnostics proposes the adjunct of ThyraMIR (from Interpace Diagnostics, Parsippany, NJ) as a reflex test, to improve the diagnostic accuracy in those cases that are not BRAFV600E or RET/PTC1-3 positive (23). Different papers demonstrated that the evaluation of miRNAs has been successfully carried out on different cytological material, including indeterminate thyroid lesions, and that aberrant expression of specific miRNAs (e.g., miR-146, 221, and 222) is a clue to thyroid well-differentiated carcinomas (43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54). In fact, ThyraMIR is a thyroid microRNA (miRNA) classifier that is able to divide results into "positive" or "negative" categories. ...
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It is unequivocally recognized that thyroid nodules are frequently detected in the adult population and mostly characterized by benign lesions (up to 70% of them), with only 5%–15% malignant lesions. The evaluation of thyroid lesions with fine-needle aspiration cytology (FNAC) represents one of the first and most useful diagnostic tools in the definition of their nature. Despite the fact that the majority of thyroid lesions are correctly diagnosed as either benign (70%–75%) or malignant (5%–10%) entities, the remaining nodules (20%–25%) represent the “gray zone” of follicular lesions, which belong to indeterminate categories, according to the different classification systems. This indeterminate group of lesions includes both benign and malignant entities, which cannot be easily discriminate with morphology alone. In these last decades, the increasing role of molecular testings, feasibly performed on cytological material combined with the discoveries of specific genetic alterations in the field of thyroid pathology, has opened the pace to their more accurate and specific contribution on cytology. In fact, in 2015, in the revised management guidelines for patients with thyroid nodules and well-differentiated thyroid cancers (WDTCs), the American Thyroid Association (ATA) confirmed the performance of molecular testing in thyroid indeterminate cytology, and the same performance was addressed in recent update of the management of thyroid nodules in the second edition of the Bethesda system for reporting thyroid cytopathology (TBSRTC). In the current review, we discuss the role of molecular tests for the different thyroid diagnostic categories of the Bethesda system for reporting thyroid cytopathology, mostly focusing our attention on the follicular and indeterminate lesions.
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... Unsurprisingly, alterations in miRNA expression are associated with cancer development, progression, and metastasis in different cancer types [116], making them useful clinical indicators. What makes them even more exploitable is that high quality miRNAs can be obtained from various sources including histological, cytological, and liquid biopsy specimens [116][117][118]. For instance, in the experience of Gasparini et al., the expression level of three miRNAs (miR-1253, miR-504 and miR-26a-5p) was adopted to classify NSCLC cases as ALK rearranged, EGFR or KRAS mutants versus wild-type [119]. ...
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... 28 miRNAs may be extracted from biological samples, including liquid specimens such as plasma, saliva, and serous effusions. 29 However, the usefulness of miRNA profiling in effusions as a biomarker of MPM remains unknown. 30 The aim of this study, therefore, was to conduct a systematic review to assess published evidence for the diagnostic accuracy of the aforementioned diagnostic biomarkers for the diagnosis of MPM in pleural effusion cytological materials. ...
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View
... The different transcriptional profiles of benign and malignant thyroid tumors offer an additional opportunity for risk-stratifying cytologically indeterminate nodules on FNA samples. In contrast to specific driver mutations and gene fusions, gene [46][47][48] and microRNA [49][50][51][52] expression profiles can be understood as readouts of the cumulative and complex genetic, epigenetic, and possibly environmental influences on cells. Largescale gene expression analysis can currently be performed using high-throughput RNA sequencing technology. ...
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... 74,81 It is foreseeable, however, that in the near future even more studies with better design and focused on pleural effusion material will be performed, given that miRNAs are highly persistent and well preserved in cytology specimens. [81][82][83] It is also possible to retrieve miRNAs from cytology samples even 10 years after slide preparation and to isolate miRNAs from the exosome in the acellular component of a pleural effusion. For such tests to be successful, it is of great importance to assure optimal handling of the cytology material from collection to slide or cell block preparation to storage for future analysis. ...
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Full-text available
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The British system (Thy1-5), the Bethesda system for reporting thyroid cytopathology (BSRTC) and the Italian Society of Anatomic Pathology and Cytology (SIAPEC) classification represent the most important international classifications for thyroid cytopathology. Irrespective of the system used, the 'indeterminate' categories are still debated among cytopathologists, particularly with regard to diagnostic criteria, clinical impact of subclassification and role of molecular techniques. We aimed to find answers to the following questions: Are there shared criteria in cytological preparations that allow the division of indeterminate follicular lesions into subcategories? What is the true clinical impact of this possible subclassification? Among 1150 consecutive thyroid fine needle aspiration (FNA) specimens, 80 patients had nodules with a final cytological report of Tir3 (SIAPEC)/Thy3. These 80 cases were re-evaluated and subclassified according to morphological criteria into three groups: pure follicular proliferations, Hürthle cell follicular lesions and atypical proliferations. Sixteen (20%) cases were categorized as pure follicular proliferations, 40 (50%) as Hürthle cell follicular lesions and 24 (30%) as atypical proliferations. Surgery was performed in 57 cases (71%). Cyto-histological correlation showed that follicular adenoma was the most frequent final diagnosis in the cases treated by surgery (24/57, 42%). The overall malignancy rate in the Tir3 category was 28% (16/57). Atypical proliferations were more often malignant than either of the follicular groups (53% versus 19%, P = 0.019). A five-tiered classification, subdividing the 'indeterminate for malignancy' class into 'follicular proliferations' and 'atypical lesions' could be adopted. As a result of their higher risk of malignancy, surgical management of the atypical lesions would be justified. In future, the introduction of a genetic panel might contribute to their stratification, to the determination of a more accurate risk of malignancy of the atypical lesions and to the verification of follicular proliferations that are benign.
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Fine-Needle Aspiration Diagnoses of Noninvasive Follicular Variant of Papillary Thyroid Carcinoma
Article
  • Dec 2015
Objectives: Endocrine pathologists are reconsidering whether tumors characterized as noninvasive follicular variant of papillary thyroid carcinoma (NFVPTC) warrant a diagnosis of carcinoma. A change in terminology would affect cytology diagnoses; thus, our aim was to study the preceding fine-needle aspiration (FNA) diagnoses of this group of tumors. Methods: We evaluated the FNA diagnoses of a primary cohort of 72 consecutively resected NFVPTCs and the cytologic and molecular features of an additional cohort of 39 tumors that included both NFVPTCs and classical papillary thyroid carcinomas (cPTCs). Results: For our primary cohort, the preceding FNA diagnosis associated with the highest risk of malignancy was suspicious for PTC in nearly half (48.6%) of cases. In contrast to the majority of cPTCs, no NFVPTCs in our second cohort had papillae or pseudoinclusions on cytologic evaluation of the FNA specimens, and none harbored a BRAF V600E mutation. Conclusions: If NFVPTCs were no longer termed carcinomas, this would affect the rate of malignancy of FNA diagnostic categories. Cytologic and molecular features could aid in identifying NFVPTCs at the time of FNA diagnosis.
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Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance
Article
  • May 2015
  • Pathol Case Rev
Atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) is the most controversial category in The Bethesda System for Reporting Thyroid Cytopathology. The intent of this category is to recognize a heterogeneous group of cytologic findings that exceed what is acceptable in a benign aspirate while being insufficient to warrant any of the diagnoses associated with a higher risk of malignancy. An AUS/FLUS diagnosis may be prompted by quantitatively or qualitatively restricted features that raise concern for a follicular neoplasm (including a Hürthle cell neoplasm), papillary carcinoma, or other less common malignancies. These aspirates are often limited by factors such as sparse cellularity or preparation artifact. The AUS/FLUS category is anticipated to have a 5% to 15% risk of malignancy, but in practice has been shown to often pose a greater risk, particularly when the atypia is due to cytologic features that raise concern for papillary carcinoma. Recommended initial management for an AUS/FLUS diagnosis is typically repeat fine-needle aspiration with molecular testing presenting a potentially viable alternative for determining whether surgery is appropriate. The AUS/FLUS rate is recommended to not exceed 7%, but this target has proved difficult to achieve for many practitioners. A concerted effort to use alternative diagnostic categories wherever possible may help minimize overuse of AUS/FLUS.
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Follicular variant of papillary thyroid carcinoma (FVPTC): histological features, BRAF V600E mutation, and lymph node status
Article
  • Feb 2015
  • J CANCER RES CLIN
Follicular variant of papillary thyroid carcinoma (FVPTC) is currently treated like conventional papillary thyroid carcinoma (cPTC). Recent reports indicate that encapsulated FVPTC behaves like follicular adenomas, while infiltrative FVPTC behaves like cPTC. This raises the possibility that histology and/or mutation status might help personalize management of FVPTC regarding extent of surgery, intensity of follow-up, and targeted therapy. This study correlates histological features, immunoreactivity for CK19, HBME, and Gal, and BRAF V600E mutation with lymph node (LN) metastasis and follow-up in FVPTC. Forty-eight FVPTC (21 with regional lymph node metastasis [LN+] and 27 with negative lymph nodes [LN-]) were reviewed. Demographics, tumor focality, size, circumscription, follicular architecture, lymphovascular invasion, extrathyroidal extension (ETE), and margin status were charted. Macrodissected formalin-fixed paraffin-embedded sections from 47 (21 LN+ and 26 LN-) cases were analyzed for BRAF V600E (1799T>A) mutation using real-time PCR. Correlations between the variables and LN status were calculated. Sixty-two percent of cases with ETE demonstrated LN metastasis, while 59 % of cases with circumscribed tumors were LN-. In multivariable analysis, ETE and tumor size ≥1 cm were the best predictors of LN+ status, whereas in cases without ETE, the infiltrative pattern and tumor size provided the "best fit." Immunostains and BRAF mutation status were not helpful. All four tumors that recurred were LN+, with infiltrative borders, and lacked the BRAF mutation. Tumor circumscription, extrathyroidal extension, and tumor size ≥ 1.0 cm are predictors of lymph node status in FVPTC.
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Recent Advances in Follicular Variant of Papillary Thyroid Carcinoma
Article
  • Jan 2012
  • N A J Med Sci
The follicular variant of papillary thyroid carcinoma (FVPTC) constitutes a distinct class of papillary thyroid carcinoma (PTC), presenting unique challenges to the clinician and pathologist regarding its diagnosis, prognosis and treatment. Fifty years since its identification as a unique class of thyroid neoplasms, controversies still exist with respect to the histologic diagnosis and categorization of FVPTC. While agreement exists among experts as to its generic place within PTC, FVPTC exhibits biologic and molecular properties that distinguish it from conventional PTC. Many studies and proposals utilizing histopathologic criteria, immunohistochemical and molecular techniques have been brought to bear on the problems posed by these set of tumors with varying degrees of success. Here we examine the clinical and pathologic features of FVPTC, highlighting diagnostic controversies and recent molecular findings that attempt to provide clues to the proper classification of this unique group of thyroid tumors. [N A J Med Sci. 2012;5(4):212-216.]
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Diagnostic value of microRNAs in discriminating malignant thyroid nodules from benign ones on fine-needle aspiration samples
Article
  • Jun 2014
Many studies have suggested that microRNAs (miRNAs) might serve as novel diagnostic indicators of thyroid cancer (TC). However, inconsistent results have also been reported. This meta-analysis was conducted to assess the diagnostic value of miRNAs in discriminating malignant thyroid nodules from benign ones on fine-needle aspiration samples. A systematic literature search for relevant literature published up to April 5, 2014 was conducted in PubMed, Embase, Chinese National Knowledge Infrastructure (CNKI), and Chinese Biological Medicine (CBM) databases. Data from different studies were pooled to estimate the summary sensitivity (SEN), specificity (SPE), positive likelihood ratios (PLR), negative likelihood ratios (NLR), diagnostic odds ratio (DOR), using the random-effect model. Summary receiver operator characteristic curves (SROCs) were plotted and areas under the SROC curve (AUC) were calculated to evaluate the overall test performance. Between-study heterogeneity was tested using the Q tests and the I 2 statistics. Potential sources of heterogeneity were analyzed through subgroup analyses and meta-regression. Deeks’ funnel plot asymmetry test was performed to evaluate publication bias. All analyses were performed using STATA 12.0 software. Eighteen studies from 7 articles, including 543 patients with malignant thyroid nodules (n = 266) and benign ones (n = 277), were included in this meta-analysis. The pooled SEN was 0.77 (95 % CI: 0.70–0.83), SPN was 0.75 (95 % CI: 0.68–0.81), PLR was 3.1 (95 % CI: 2.4–4.0), NLR was 0.30 (95 % CI: 0.23–0.39), DOR was 10 (95 % CI: 7–16), and AUC was 0.83 (95 %CI: 0.79–0.86). Subgroup analyses indicated that multiple miRNAs assays showed a higher diagnostic accuracy than single miRNA assays. In conclusion, this meta-analysis suggests that miRNAs analysis can significantly improve diagnostic accuracy for differentiating malignant thyroid nodules from benign indeterminate ones on fine-needle aspiration (FNA) samples. With further confirmation, multiple miRNAs assays may play a critical role as a complement to fine-needle aspiration biopsy (FNAB).
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The Bethesda System for Reporting Thyroid Cytopathology: A Single-Center Experience over 5 Years
Article
  • May 2014
  • ANN SURG ONCOL
The Bethesda System for Reporting Thyroid Cytopathology (BSRTC) was developed to refine fine-needle aspiration (FNA) cytology definitions and improve clinical management. This study evaluates the impact of the BSRTC 5 years after its adoption at a single institution. A total of 1,625 patients undergoing thyroidectomy in the pre-BSRTC (Group 1: July 2007-January 2009) and post-BSRTC (Group 2: February 2009-September 2013) periods were reviewed. Cytologic diagnoses in Group 1 included non-diagnostic, benign, follicular neoplasm, suspicious for malignancy and malignant. Atypia/follicular lesion of undetermined significance (AUS/FLUS) was included in Group 2. The proportions of each FNA category and malignancy rate per cytologic diagnosis were compared. Fifty-four percent (187/347) of Group 1 patients had a preoperative FNA versus 61 % (777/1278) in Group 2 (p = 0.02). Group 1 FNA results included 3 % non-diagnostic, 48 % benign, 17 % follicular, 13 % suspicious for cancer, and 19 % cancer. Group 2 results included 3 % non-diagnostic, 36 % benign, 9 % follicular, 8 % suspicious for malignancy, 18 % malignant and 26 % AUS/FLUS. In Group 2, the proportions of benign, follicular and suspicious for malignancy FNAs decreased significantly (p < 0.05). In Group 2, there were more indeterminate FNA diagnoses overall (30 vs. 43 %; p < 0.001). The rate of cancer in suspicious for cancer FNA lesions increased from 44 to 65 % (p = 0.07). The AUS/FLUS malignancy rate was 15 %. Since the adoption of the BSRTC at our institution, the proportion of indeterminate FNAs has increased; however, the diagnostic accuracy of the suspicious for cancer category improved. We recommend periodic review of the utilization and malignancy rates per cytologic category at each institution to help tailor clinical management.
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