Anatomic Pathology/ Cytotechnologist On-Site Adequacy Evaluation of Thyroid FNA
Cytotechnologist-Attended On-Site Adequacy Evaluation
of Thyroid Fine-Needle Aspiration
Comparison With Cytopathologists and Correlation With
the Final Interpretation
Matthew T. Olson, MD,1 Armanda D. Tatsas, MD,1 and Syed Z. Ali, MD1,2
Key Words: On-site evaluation for adequacy; Thyroid FNA; Cytotechnologist; Cytopathologist
DOI: 10.1309/AJCP84AXSRABZCTZ
Abstract
Recent increases in the number of thyroid fineneedle aspiration (FNAs) biopsies and the popularity of
on-site evaluation for adequacy (OSEA) have led many
practices, including ours, to rely on cytotechnologists
for performing OSEA. We retrospectively analyzed
the accuracy of a cytotechnologist against that of
a cytopathologist in performing OSEA and making
the final diagnosis. Of 2,261 thyroid FNA specimens
evaluated over a 33-month period under ultrasound
guidance with OSEA, the cytotechnologist attended
64.7% (1,462/2,261) of the procedures whereas
the cytopathologist attended 35.3% (799/2,261).
There was no difference in the adequacy downgrade
rate for cytotechnologists compared with that for
cytopathologists during this study period (4.1% vs
5.0% downgrade rate, P = .33). Regardless of who
rendered the OSEA, subadequate specimens had a
higher rate of indeterminate diagnosis (25.2%) than
those specimens deemed adequate at the time of OSEA
(11.9%, P = .00001). These results indicate that the
accuracy of cytotechnologists is comparable with that
of cytopathologists in conducting OSEA of the thyroid.
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DOI: 10.1309/AJCP84AXSRABZCTZ
Fine-needle aspiration (FNA) biopsy of the thyroid is a
valuable and time-proven diagnostic modality for the assessment of thyroid nodules.1-3 Despite its widespread use, the
procedure has the potential for yielding material that is inadequate or suboptimal for rendering a diagnosis. A shortage of
cellularity is a common factor leading to the inability to make
a definitively malignant or benign diagnosis. For this reason,
adequacy evaluation is a key component of cytopathologic
evaluation of thyroid FNA and is included as a component of
The Bethesda System for Reporting Thyroid Cytopathology
(TBSRTC).4-7
Pathologists and clinical investigators have tested multiple strategies to minimize the frequency of inadequate thyroid
FNA specimens. These have included gross examination of
the direct smear,8-10 universal increase in the number of passes
and slides,11,12 standardization of techniques for noncytologist specimen handling,13 and microscopic on-site evaluation
of adequacy (OSEA) of a direct smear. Of these, most of the
attention in the literature has focused on OSEA by cytopathologists. The investigations to date that have focused on
thyroid OSEA have had mixed results, including a decrease in
the inadequacy rate,14,15 no change in the inadequacy rate,16 or
a small change in the inadequacy rate that does not justify the
increased procedure time and expense.12
Even if the decrease in the inadequacy rate is modest, the
benefits of OSEA are clear when they are viewed on a large
institutional scale.17 An on-site cytologist brings other advantages such as a preliminary impression of the disease process
and the ability to process material appropriately for special
studies. For these reasons, the demand for OSEA is expected
© American Society for Clinical Pathology
Anatomic Pathology / Original Article
to increase, and this will lead to increased demand for cytologists. Cytotechnologists appear ideally placed to address the
rising demand caused by OSEA, so there is a need to evaluate
their performance in this evolving role. However, the literature to date on this subject has been limited. One article demonstrated excellent accuracy in OSEA when cytotechnologists
attended the OSEA instead of cytopathologists.18 Another
study demonstrated agreement between the cytopathologists
and cytotechnologists in a paired analysis.19 The number
of thyroid FNAs in both of these series is relatively small
because of the lack of these investigators’ experience with
cytotechnologist-attended OSEA. By contrast, our institution
has several years of experience with cytotechnologist-attended OSEA. Our current analysis focuses on our institution’s
experience with a large number of cytotechnologist-attended
OSEA. Because cytopathologists also performed OSEA in the
same period, we also compared the performance of cytotechnologists and cytopathologists in this role.
Materials and Methods
Patients and Specimens
All cases of thyroid cytopathology were retrieved from
the computerized record system between January 2009 and
September 2011. Of all cases, 99.4% were performed with
ultrasound guidance and OSEA (2,261/2,275). These were
chosen for analysis. The FNA procedures were performed by
a combination of endocrinologists and interventional radiologists. Smears evaluated on site were prepared in duplicate and
included at least 1 air-dried slide for Romanowsky staining
and on-site evaluation and an alcohol-fixed slide for Papanicolaou staining for each pass. Each procedure was given a
final adequacy evaluation of “adequate,” “less than optimal,”
or “inadequate.” Preliminary diagnostic impressions are not
routinely given at our institution. After the procedure, both
the Romanowsky- and Papanicolaou-stained slides were
previewed by a cytotechnologist and signed out by a boardcertified cytopathologist by strict application of TBSRTC
guidelines. If the OSEA was attended by a cytopathologist,
the same cytopathologist rendered the final diagnosis and
adequacy evaluation. As required under TBSRTC, the final
diagnosis included an evaluation of adequacy with the same 3
choices available during on-site evaluation.
Data Analysis and Statistics
The retrieved data were queried for the cytologist performing the OSEA, the OSEA verdict, the final adequacy,
and the final TBSRTC diagnosis. A Perl script automated
this process, and each case underwent a rapid visual inspection with a Filemaker (Santa Clara, CA)–based graphical user
interface that allowed for the corrections of any errors, such as
typographical irregularities, made by the automated analysis.
Nodule sizes were obtained from the pathology report when
they were recorded. When they were not recorded in the
pathology report, the size was obtained from the ultrasound
guidance procedure note or radiologic report. After this process, it was confirmed that 24 aspirates (1.1%) were collected
in the absence of any identifiable nodule. The adequacies and
diagnoses from these aspirates were counted for statistical
purposes but excluded from calculation of the metrics regarding the nodule size.
Half of the diagnostic material was unavailable to the
cytologist at the time of OSEA, therefore accuracy was
defined as either complete agreement or an upgrade of adequacy in the final diagnosis. Inaccuracy was defined as any
downgrade in adequacy. While the total number of needle
passes is not tracked explicitly in the pathology database, the
number of smears is documented and was used to approximate
the number of needle passes (needle passes = integer [(smears
+ 1)/2]). The differences of sex distribution for patients with
cytopathologists vs cytotechnologists attending the OSEA
were assessed with the Fisher exact test. Differences in age,
nodule size, and number of passes for these patient groups
were evaluated with the Student t test. Differences involving
accuracy and adequacy were evaluated with the χ2 test. All
statistical tests, calculations, and graphs were performed using
R scripts executed in the R console (http://cran.r-project.org).
Results
Over the past 10 years, the number of thyroid FNAs
at our institution underwent a median annual growth rate
of 2.0% in the number of patients and 2.5% in the number
of thyroid FNA procedures, from 422 FNAs (357 patients)
in 2002 to 821 FNAs (647 patients) in 2011. Our analysis
began in 2009 for several reasons. First, the universal implementation of TBSRTC began at this time in our institution,
and the standardized accuracy reporting that accompanied
this change allowed for the data consistency required for
such analyses. Second, the standardized diagnostic categories allow for a simultaneous analysis of the effect of specimen adequacy on the rates of the indeterminate categories.
Third, although on-site evaluation has been practiced for
longer than this period, it was not universal until this time.
During the study period, only 17 thyroid FNAs—comprising
0.6% of all thyroid FNAs at our institution—were excluded
from the study for lack of OSEA.
Monthly counts of cytotechnologist- and cytopathologist-attended OSEA are shown in ❚Figure 1❚. Overall, cytotechnologists attended 64.7% of the thyroid FNAs during
© American Society for Clinical Pathology
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DOI: 10.1309/AJCP84AXSRABZCTZ
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Olson et al / Cytotechnologist On-Site Adequacy Evaluation of Thyroid FNA
100
T
T
FNA OSEA Count
T
T
80
T
T
60
T
C
T
C
C
C
40
20
C
TT
T
M
M
M
C
T
C
M
T
M
MM
M
C
M
C
C
M
C
M
M
M
C
C
M
MM M
CM
MC
M M
C
T
C
C
CCC
Gender (M/F)
Age (y)
Nodule cize (cm)
T
C
M
C
M
M
M
M
M
11/2009
10/2010
M
09/2011
❚Figure 1❚ On-site evaluation of adequacy (OSEA) statistics
for cytotechnologists (C) and cytopathologists (M) over the
study period. The total number of fine-needle aspirates for
the month is shown (T).
the study period, with a range of 34.0% to 97.7%. The
monthly FNA counts varied from 43 to 101, with most of the
increased volume being met by increased allocation of cytotechnologist time to attending thyroid FNA. The dramatic
shift at the end of the study period reflects a change in our
clinical practice; cytotechnologists are now sent to almost all
thyroid OSEA. ❚Table 1❚ shows a demographic comparison
of patients who had a cytotechnologist- vs cytopathologistattended OSEA. The demographics of these 2 patient groups
did not differ significantly.
The on-site adequacy determinations are compared with
the final adequacy determinations for both cytotechnologists
❚Table 2❚ and cytopathologists ❚Table 3❚, and the individual
breakdowns for the 3 most active cytopathologists and 5
most active cytopathologists are shown in ❚Figure 2❚. Cytopathologists and cytotechnologists had similar accuracy
rates of 96% and 95%, respectively (P = .33). The on-site
adequacy rate was also comparable for cytotechnologists
and cytopathologists (61.6% vs 65.6%; P = .0693); our
study found no correlation between the experience of the
cytotechnologist and the accuracy rate (P = .11). Interestingly, the final adequacy was higher than the on-site adequacy in more cytotechnologist-attended cases (26%) than
in cytopathologist-attended cases (17%), and this difference
is significant (P = .000001). In addition, the percentage of
cases that were ultimately signed out as adequate was also
significantly higher for the cases in which a cytotechnologist
was present for the OSEA (81.0% vs 77.2%; P = .038). The
adequacy underestimation is possibly related to the finding that cytotechnologists had access to fewer passes than
cytopathologists at the time of OSEA. The median number
of passes in a cytotechnologist-attended OSEA is 3 whereas
cytopathologist-attended OSEAs have a median of 5 passes
(P < . 000001).
Am J Clin Pathol 2012;138:90-95
DOI: 10.1309/AJCP84AXSRABZCTZ
Cytopathologist
OSEA
P
1/3.7
54.3 ± 14.9
2.2 ± 1.2
1/3.6
54.7 ± 14.8
2.1 ± 1.2
.51
.55
.53
M
Month
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Cytotechnologist
OSEA
OSEA, on-site evaluation of adequacy.
* Data are given as mean ± SD.
M
0
01/2009
T
C
T
CC
T
T
MCC
CM
M
CT
T
T
T
T
T
T
T
T
C
C
T
T
T
❚Table 1❚
Comparison of Patients With Cytotechnologist OSEA vs
Cytopathologist OSEA*
T
C
T
❚Table 2❚
On-Site vs Final Adequacy for Cytotechnologist-Attended
OSEA*
Final Adequacy
OSEA (N = 1,462)
Inadequate (n = 161)
Less than optimal
(n = 400)
Adequate (n = 901)
Inadequate
(n = 79)
Less Than
Optimal (n = 199)
Adequate
(n = 1,184)
59 (36.7)
15 (3.75)
57 (35.4)
103 (25.8)
45 (28.0)
282 (70.5)
5 (0.55)
39 (4.33)
857 (95.1)
OSEA, on-site evaluation of adequacy.
* The numbers as a percentage of the OSEA determination are given in parentheses.
Boldface data indicate inaccurate OSEA determinations; all others indicate accuracy.
❚Table 3❚
On-Site vs Final Adequacy for Cytopathologist-Attended OSEA*
Final Adequacy
OSEA (N = 799)
Inadequate (n = 93)
Less than optimal
(n = 182)
Adequate (n = 524)
Inadequate
(n = 68)
Less Than
Adequate
Optimal (n = 114) (n = 617)
52 (55.9)
15 (8.24)
19 (20.4)
71 (39.0)
22 (23.7)
96 (52.8)
1 (0.19)
24 (4.58)
499 (95.2)
OSEA, on-site evaluation of adequacy.
* The numbers as a percentage of the OSEA determination are given in parentheses.
Boldface data indicate inaccurate OSEA determinations; all others indicate accuracy.
The relationships between the on-site and final adequacy
determinations and TBSRTC diagnoses are shown in ❚Figure
3❚. Figure 3A demonstrates that when cases are upgraded
from the inadequate category, they have a higher proportion
of the indeterminate categories than cases that are deemed
to be adequate on site (25.2% vs 11.9%; P = .00001). This
finding holds when the cases deemed less than optimal and
inadequate on site are included, even though the indeterminate
rate is slightly lower (19.9% vs 11.9%; P = .000002). The
final indeterminate diagnosis rate was comparable regardless
of whether a cytotechnologist (20.7%) or cytopathologist
(17.8%) rendered the OSEA (P = .43). Regardless of the
OSEA, it is clear from Figure 3B that the final adequacy is
© American Society for Clinical Pathology
72.5% (129/178)
25.3% (45/178)
2.2% (4/178)
79.2% (99/125)
16.0% (20/125)
4.8% (6/125)
82.4% (89/108)
15.7% (17/108)
1.9% (2/108)
90.4% (47/52)
1.9% (1/52)
7.7% (4/52)
9.5% (23/243)
8.6% (21/243)
100
1.5% (12/793)
200
76.1% (140/184)
16.8% (31/184)
7.1% (13/184)
300
74.6% (334/448)
400
33.5% (266/793)
FNA OSEA Count
500
81.9% (199/243)
Complete agreement with OSEA
OSEA upgraded
OSEA downgraded
18.5% (83/448)
6.9% (31/448)
600
64.9% (515/793)
Anatomic Pathology / Original Article
MD2
MD3
MD4
MD5
0
CT1
CT2
CT3
MD1
❚Figure 2❚ Follow-up of on-site evaluations of adequacy (OSEA) for cytotechnologists (CT) and cytopathologists (MD).
associated with indeterminate TBSRTC diagnoses. Specimens with a final less-than-optimal adequacy account for only
13.8% of all thyroid FNAs but contribute 30.0% of all the
indeterminate diagnoses. The indeterminate diagnosis rate for
cases with a final adequacy of less-than-optimal specimens is
29.4% compared with 11.9% for cases deemed adequate at
sign out (P < .0000001).
Discussion
The results of our study demonstrate an acceptable
interchangeability of cytotechnologists and cytopathologists
for OSEA of the thyroid. For the analysis here, accuracy is
defined as both complete agreement and adequacy upgrade,
and inaccuracy is defined as an adequacy downgrade. Others have defined accuracy in this context as the percentage
of cases that are called adequate on site and are subsequently
found to be adequate and unequivocally benign or malignant.18 Although this definition may make sense for other
types of cytology specimens, it is too stringent for thyroid
cytology. The rates of indeterminate diagnoses are widely
known and outlined by TBSRTC, so it is possible for a thyroid FNA specimen to be both adequate and indeterminate.
In addition, because half of the material is unstained at the
time of OSEA, adequacy upgrades should not be considered
an inaccuracy. For the purposes of this article as well as our
practice, the only unacceptable discordance between on-site
and final adequacy determinations is an adequacy downgrade.
While the adequacy downgrade rate is the same for both
cytology providers, adequacy evaluations by a cytotechnologist are more likely to be upgraded than those made by a cytopathologist. This is of no concern given that patients receiving
cytotechnologist-attended OSEA do not undergo more passes.
However, it is a feature of the data that warrants some discussion because it may reflect a limitation of this retrospective
study. At our institution, cytotechnologists had less exposure
to inexperienced operators given the days and clinics they
served during the study period. Based on other reports,20
one would expect this to explain both the lower number of
passes and higher final adequacy rates for patients who had
a cytotechnologist at their on-site evaluation. Records are not
available about which or how many passes are performed
by trainees, so it is impossible to fully quantify the contribution of operator experience to the adequacy upgrade rates.
However, if the increased adequacy upgrade rate were purely
because of a different combination of aspirators and trainees,
one would expect that the on-site adequacy rate would also
be higher. This is not the case; the on-site adequacy rate
is comparable for both cytotechnologists and cytopathologists. There appears to be a tendency for cytotechnologists
to underestimate adequacy on site. This behavior is probably
unavoidable given that cytotechnologists do not sign out their
own aspiration cases and cytopathologists do.
© American Society for Clinical Pathology
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6.5% (93/1,425)
0.9% (5/582)
0.8% (2/254)
1.0% (14/1,425)
1.2% (3/254)
0.7% (4/582)
4.2% (60/1,425)
3.8% (22/582)
0.8% (2/254)
13.1% (76/582)
5.2% (30/582)
20
0.42% (6/1,425)
40
6.7% (95/1,425)
60
40.9% (104/254)
43.7% (111/254)
% Cases
80
Inadequate
Less than optimal
Adequate
11.8% (30/254)
100
75.9% (442/582)
A
81.0% (1,154/1,425)
Olson et al / Cytotechnologist On-Site Adequacy Evaluation of Thyroid FNA
0
SFM
0
Inadequate
Benign
AUS
SFN/SHCN
SFM
5.5% (100/1,802)
0.8% (15/1,802)
20
1.9% (6/313)
40
4.3% (78/1,802)
60
Malignant
Inadequate
Less than optimal
Adequate
25.6% (80/313)
% Cases
80
SFN/SHCN
1.9% (6/313)
100
6.8% (122/1,802)
70.6% (221/313)
B
AUS
0% (0/313)
Benign
82.5% (1,487/1,802)
Inadequate
Malignant
❚Figure 3❚ A, Relationship between on-site adequacy evaluation and sign-out diagnosis. B, Relationship between sign-out
adequacy and diagnosis. AUS, atypia of undetermined significance; SFM, suspicious for malignancy; SFN, suspicious for
follicular neoplasm; SHCN, suspicious for Hürthle cell neoplasm.
The ultimate goal of adequacy evaluations is to reduce
the need for repeat procedures and ambiguous final diagnoses. By this measure, cytotechnologists and cytopathologists
perform similarly. As expected, specimens identified as suboptimal at the time of OSEA have a significantly higher rate
of indeterminate classifications, and this is true regardless of
the type of cytologist performing the OSEA. This finding suggests that both cytopathologists and cytotechnologists are able
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to recognize quantitatively compromised aspirates. Because
our institution does not provide on-site preliminary diagnoses,
the data here cannot be used to determine if cytotechnologists and cytopathologists are equally capable at identifying
qualitatively compromised specimens on site at our institution. This will be an area for future inquiry at our institution
and elsewhere because parity on this skill is necessary in the
setting of new molecular tests such as Afirma21 (Veracyte,
© American Society for Clinical Pathology
Anatomic Pathology / Original Article
South San Francisco, CA), which requires a dedicated pass
and storage in a specific medium.
There is currently no mechanism for laboratories to bill
for cytotechnologist services rendered during OSEA.18,22
In the absence of any revenue generation, the financial
justifications for cytotechnologist-attended OSEA currently
involve savings from a decreased rebiopsy rate on an institutional level or savings vis-à-vis cytopathologist time.19
The economics of cytotechnologist-attended OSEA for our
institution are beyond the scope of this article. However,
there is clearly a need for billing codes that will allow for
all laboratories to recuperate the personnel costs involved in
cytopathologist OSEA. More studies such as ours are needed
to demonstrate the suitability of cytopathologists to perform
OSEA and to formulate a fee that is commensurate with the
value of this service.
The data presented here demonstrate that cytotechnologists can perform OSEA for thyroid FNA with a level of accuracy similar to that of cytopathologists. At our institution, we
noted a slight tendency for underestimating adequacy, but the
number of passes was not greater. Specimens deemed to be
suboptimal on site were more likely than adequate ones to be
placed in the indeterminate categories on final diagnosis. This
was true regardless of the type of cytologist who performed
the OSEA.
From the 1Departments of Pathology and 2Radiology, The Johns
Hopkins Hospital, Baltimore, MD.
Address reprint requests to Dr Ali: Department of Pathology,
The Johns Hopkins Hospital, Path 406, 600 N Wolfe St, Baltimore,
MD 21287; sali@jhmi.edu.
References
1. Wong CK, Wheeler MH. Thyroid nodules: rational
management. World J Surg. 2000;24:934-941.
2. Hamberger B, Gharib H, Melton LJ, et al. Fine-needle
aspiration biopsy of thyroid nodules: impact on thyroid
practice and cost of care. Am J Med. 1982;73:381-384.
3. Silverman JF, West RL, Finley JL, et al. Fine-needle aspiration
versus large-needle biopsy or cutting biopsy in evaluation of
thyroid nodules. Diagn Cytopathol. 1986;2:25-30.
4. Cibas ES, Ali SZ, Conference NTFSotS. The Bethesda
System for Reporting Thyroid Cytopathology. Am J Clin
Pathol. 2009;132:658-665.
5. Cibas ES, Ali SZ. The Bethesda System for Reporting
Thyroid Cytopathology. Thyroid. 2009;19:1159-1165.
6. Cibas ES, Sanchez MA. The National Cancer Institute
thyroid fine-needle aspiration state-of-the-science
conference: inspiration for a uniform terminology linked
to management guidelines. Cancer. 2008;114:71-73.
7. Baloch ZW, Cibas ES, Clark DP, et al. The National Cancer
Institute thyroid fine needle aspiration state of the science
conference: a summation. Cytojournal. 2008;5:6.
8. Mayall F, Cormack A, Slater S, et al. The utility of assessing
the gross appearances of FNA specimens. Cytopathology.
2010;21:395-397.
9. Prayaga AK, Vijaya K. Role of unstained smears in
determining sample adequacy. Acta Cytol. 2004;48:321-324.
10. Nguyen YP, Maple JT, Zhang Q, et al. Reliability of gross
visual assessment of specimen adequacy during EUS-guided
FNA of pancreatic masses. Gastrointest Endosc. 2009;69:12641270.
11. Rossi ED, Morassi F, Santeusanio G, et al. Thyroid fine
needle aspiration cytology processed by ThinPrep: an
additional slide decreased the number of inadequate results.
Cytopathology. 2010;21:97-102.
12. Eedes CR, Wang HH. Cost-effectiveness of immediate
specimen adequacy assessment of thyroid fine-needle
aspirations. Am J Clin Pathol. 2004;121:64-69.
13. Sidiropoulos N, Dumont LJ, Golding AC, et al. Quality
improvement by standardization of procurement and
processing of thyroid fine-needle aspirates in the absence of
on-site cytological evaluation. Thyroid. 2009;19:1049-1052.
14. Zhu W, Michael CW. How important is on-site adequacy
assessment for thyroid FNA? An evaluation of 883 cases.
Diagn Cytopathol. 2007;35:183-186.
15. Redman R, Zalaznick H, Mazzaferri EL, et al. The impact
of assessing specimen adequacy and number of needle passes
for fine-needle aspiration biopsy of thyroid nodules. Thyroid.
2006;16:55-60.
16. O’Malley ME, Weir MM, Hahn PF, et al. US-guided fineneedle aspiration biopsy of thyroid nodules: adequacy of
cytologic material and procedure time with and without
immediate cytologic analysis. Radiology. 2002;222:383-387.
17. Nasuti JF, Gupta PK, Baloch ZW. Diagnostic value and
cost-effectiveness of on-site evaluation of fine-needle
aspiration specimens: review of 5,688 cases. Diagn Cytopathol.
2002;27:1-4.
18. Burlingame OO, Kessé KO, Silverman SG, et al. On-site
adequacy evaluations performed by cytotechnologists:
correlation with final interpretations of 5241 image-guided
fine needle aspiration biopsies [published online ahead
of print August 21, 2011]. Cancer Cytopathol. 2011.
19. Wotruba AL, Stewart J, Scheberl T, et al. Added value,
decreased cost: The evolving role of the cytotechnologist for
preliminary screening and triage
of thyroid aspirates. Diagn Cytopathol. 2011;39:896-899.
20. Ghofrani M, Beckman D, Rimm DL. The value of onsite
adequacy assessment of thyroid fine-needle aspirations is a
function of operator experience. Cancer. 2006;108:110-113.
21. Chudova D, Wilde JI, Wang ET, et al. Molecular
classification of thyroid nodules using high-dimensionality
genomic data. J Clin Endocrinol Metab. 2010;95:5296-5304.
22. Dhillon I, Pitman MB, Demay RM, et al. Compensation
crisis related to the onsite adequacy evaluation during FNA
procedures: urgent proactive input from cytopathology
community is critical to establish appropriate reimbursement
for CPT code 88172 (or its new counterpart if introduced in
the future). Cytojournal. 2010;7:23.
© American Society for Clinical Pathology
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