Measures to reduce diagnostic error and improve clinical decision making in thyroid FNA aspiration cytology: A proposed framework

• Published in: Cancer cytopathology 2020-12, Vol.128 (12), p.917-927
• Main Authors: Poller, David N., Johnson, Sarah J., Bongiovanni, Massimo
• Format: Article
• Language: English
• Subjects: Biopsy, Fine-Needle; Cellular biology; Clinical decision making; Clinical Decision-Making - methods; Cytodiagnosis - methods; cytology; Decision making; diagnostic error; Diagnostic Errors - prevention & control; Histopathology; Humans; pathology; Terminology; thyroid; Thyroid gland; Thyroid Gland - pathology; Thyroid Gland - surgery; Thyroid Neoplasms - diagnosis; Thyroid Neoplasms - surgery; Thyroid Nodule - diagnosis; Thyroid Nodule - surgery
• ISSN: 1934-662X; 1934-6638
• DOI: 10.1002/cncy.22309

Thyroid fine‐needle aspiration cytology (FNA) and histopathology can be subjective areas of medical diagnosis and subject to different interpretations. On the basis of the authors' personal experience, 12 recommendations with potential to improve clinical decision making, ensure quality, and reduce diagnostic error in thyroid FNAC and histopathology are presented. 1) use a standardized reporting terminology for thyroid FNAC; 2) understand and explain to service users the limitations of cytology and the standardized thyroid FNAC reporting terminology used; 3) the cytopathologist should review all relevant clinical and ultrasound findings, if feasible; 4) include the risk of malignancy in all FNAC reports if feasible; 5) collect data to calculate the local institutional risk of malignancy for FNAC if feasible; 6) accept that nondiagnostic FNAC will include small numbers of carcinomas; 7) use rapid on‐site evaluation and/or educational sessions for aspirators if the nondiagnostic aspiration rate is high; 8) know the diagnostic pitfalls of both cytology and histopathology; 9) use special immunohistochemical and molecular techniques that are evidence‐based; 10) make use of second opinions, either in‐house or interinstitutional; 11) multidisciplinary discussion of cases before surgery or therapy is invaluable; and, finally, 12) manage patient and clinician expectations of thyroid cytology and histopathology. These 12 recommendations may assist in quality‐improvement initiatives and may reduce diagnostic errors in thyroid cytology and histopathology. Thyroid multidisciplinary case discussion remains the principal, overarching method for error reduction and for providing high‐quality clinical decision making. This review discusses the reasons for diagnostic error in thyroid cytology and histopathology and provides 12 recommendations for cytology and histopathology to improve quality and reduce the likelihood of clinical diagnostic errors. For each of the 12 recommendations, the rationale is explained together with the overarching requirement for multidisciplinary case discussion if there is clinical or diagnostic uncertainty.