Revised Bethesda System for Reporting Thyroid Cytology: Lessons learned from an appraisal of 5 years of experience in a central hospital.

OBJECTIVE: The Bethesda System for Reporting Thyroid Cytology (BSFRTC) is widely adopted in the management of thyroid nodules. The system was updated in 2017, and its impact is the subject of this paper. METHODS: All thyroid fine needle aspirations from 2016-2020 using the BSFRTC, with follow-up surgical pathology, were reviewed. The risk of neoplasia (RON), risk of malignancy (ROM), RON/ROM ratio, and surgical follow-up rate were determined for each diagnostic category with cytohistological correlation. ROM was calculated in two separate manners, with non-invasive follicular tumours with papillary-like nuclear features (NIFTP) counted as malignant or non-malignant. Sensitivity, specificity, negative and positive predictive values were determined for indeterminate categories: atypia of undetermined significance (AUS), suspicious for follicular neoplasm (SFN), and suspicious for malignancy (SFM). RESULTS: RON, ROM, and the surgical follow-up rate increased steadily from the benign through intermediate to malignant categories. The omission of NIFTP from malignant lesions reduced the calculated ROM in indeterminate categories and improved the stratification between AUS and SFN. ROM in AUS was distinct from SFN. AUS has a well-balanced sensitivity and specificity favouring a screening rather than a diagnostic category. The calculated RON/ROM was significantly higher in AUS (1.56), compared to SFN (1.03) and SM (1.05), in agreement with current BSRTC management recommendations. CONCLUSIONS: AUS is an important screening category and should remain with the addition of subcategorisation. RON and surgical follow-up rates are essential quality indicators. The RON/ROM ratio could be utilised to determine appropriate management for each diagnostic category on an institutional basis.

Child With Extranodal Marginal Zone B-cell Lymphoma of Mucosa-associated Lymphoid Tissue.

Many patients present to our clinic with Helicobacter pylori (H. pylori) infection. Most have nonspecific symptoms that cannot be immediately attributed to H. pylori. The joint European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)/North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines recommend upper gastroscopy to detect the cause of such symptoms. Herein, we present the case of a 9-year-old girl diagnosed with gastric mucosa-associated lymphoid tissue lymphoma associated with H. pylori infection using upper gastroscopy. We believe that a patient of such a young age with this serious condition secondary to H. pylori will highlight the importance of upper gastrointestinal endoscopy in such cases.

Breast diseases in the Northern region of Saudi Arabia.

OBJECTIVE: The incidence and pattern of breast diseases varies within countries. There is virtually no information on breast diseases found in the Northern region, Kingdom of Saudi Arabia (KSA). This study hopes to provide data in this area. METHODS: We reviewed the histological and clinical records of 708 patients who presented to General Surgery in Prince Abdul-Rahman Al-Sudairy Central Hospital, Sakaka, Al-Jouf, KSA, with breast complaints over an 8-year period (June 1994 and June 2002). Breast findings were categorized in terms of benign, inflammatory, malignant, congenital and functional. Benign diseases were also evaluated in terms of their proliferative status and cancer risk. RESULTS: The findings in order were benign breast disease in 245 (48.9%) were most common, inflammatory disease, 213 (42.5%), and finally cancer of the breast in 43 (8.6%). Fibroadenoma was the most common benign disease. Twenty-seven (5.4%) of benign breast disease were lesions with a cancer relative risk ranging from 1.6-4.4. Breast abscess was the most common inflammatory disease. Ductal carcinoma was the most common breast cancer. Breast cancer was bulky and presented late in mostly premenopausal women. CONCLUSION: Breast diseases are common among our patients. Although benign disease is the most common, some patients have lesions that have a small but definite cancer risk. Of concern is the pattern of advanced breast cancer, which presents mostly in young premenopausal women. A concerted educational program is needed to acquaint the patients with the significance of breast masses.

Cytological clues in the distinction between phyllodes tumor and fibroadenoma.

BACKGROUND: Fine-needle aspiration (FNA) sensitivity in discriminating between phyllodes tumor and its benign mimicker fibroadenoma (FA) remains low. Because a preoperative categorization of phyllodes tumor is crucial for their appropriate management, the authors undertook this study in an effort to improve the outcome of FNA by identifying reliable distinguishing features. METHODS: FNA smears from 15 and 12 histologically proven cases of phyllodes tumor and FA, respectively, were reviewed. The stromal and epithelial components were qualitatively and quantitatively analyzed. A group of cytological features that may distinguish between phyllodes tumor and FA were identified. Their value and reproducibility in categorizing phyllodes tumor cases were tested. RESULTS: Three major cytological features were exclusively seen in all of, or the vast majority of, the phyllodes tumor cases; fibromyxoid stromal fragments with spindle nuclei (90%), fibroblastic pavements (93%), and appreciable number of spindles cells of fibroblastic nature among dispersed cell population (100%). The identification of these features improved the pick-up rate of phyllodes tumor from 40% to 100% and had substantial (kappa = 0.56-0.73) interobserver and almost perfect (kappa = 0.83) intraobserver reproducibility. There was no significant difference in the epithelial component characteristics between phyllodes tumor and FA. The frequency and degree of atypia in the dispersed cell population correlated well to the histological grade of phyllodes tumor. CONCLUSIONS: FNA has proven to be a reliable test in differentiating between phyllodes tumor and FA with high sensitivity and good reproducibility. The importance of training and continuing education is emphasized.

Esophageal trachealization: a feature of eosinophilic esophagitis.

Eosinophilic esophagitis (EE) is an inflammatory condition characterized by intense eosinophilic infiltration of the esophagus. EE is frequently misdiagnosed as gastroesophageal reflux disease. Here, we present a child with EE and a characteristic endoscopic finding, "ringed esophagus". An 11-year-old Saudi boy presented with dysphagia for 1 year. He had experienced an intermittent sensation of solid food sticking in his chest, which was relieved by drinking liquids. A barium swallow excluded anatomical causes of dysphagia, but revealed multiple-ringed esophagus. Endoscopy showed a furrowing and trachealizing appearance of the entire esophagus. Hisologically, extensive eosinophilic infiltration was a feature in biopsies obtained from the esophagus. The child responded well to a 2-month course of inhaled fluticasone. Symptoms recurred 3 months after discontinuation of therapy, which necessitated resumption of inhaled fluticasone. The endoscopic appearance of multiple esophageal rings should raise suspicion of EE and be confirmed by esophageal biopsies.

Pattern and incidence of cancer in Northern Saudi Arabia.

OBJECTIVE: To study the pattern and incidence of cancer in the Al-Jouf region of Saudi Arabia. METHODS: The record of all confirmed cancer cases were retrieved and studied from the files of the Histopathology and Cytology Department, Prince Abdulrahman Al-Sudairy Central Hospital, Al-Jouf, Kingdom of Saudi Arabia (KSA) during the period 1994 to 2001. The major types of cancer were ranked in order of relative frequency. The crude incidence rate and age standardized rate were then calculated. RESULTS: The age standardized rate in Al-Jouf was 38.5 per 100,000, a figure lower than the Saudi Arabian national average of 71.7 per 100,000 and lower than the lowest published international figure of 39.6 from Gambia. The most common cancers in the whole population irrespective of sex were carcinoma of the breast, lymphoma and leukemia combined and colorectal cancer. The most common cancers in females in Al Jouf were those of the breast, thyroid, and lymphomas and leukemia combined. Comparative findings for males were lymphomas and leukemias combined, colorectal and skin cancers. CONCLUSION: The incidence of cancer in Al Jouf region appears to be the lowest incidence published to date. The over all pattern of cancer is however similar to the findings in other regions of KSA. Carcinoma of breast, lymphomas and leukemias, and colorectal cancers are the leading cancers in the region.