Original article
Efficiency of the Bethesda System for Thyroid Cytopathology
Rendimiento del sistema Bethesda en el diagnóstico citopatológico del nódulo tiroideo
Ismael Mora-Guzmána, José Luis Muñoz de Novaa,b,
, Cristina Marín-Camposa, José Antonio Jiménez-Heffernanc, Juan Julián Cuesta Pérezd, Marcos Lahera Vargase, Emma Torres Míngueza, Elena Martín-Péreza,b
Corresponding author
a Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de La Princesa, Madrid, Spain
b Departamento de Cirugía, Universidad Autónoma de Madrid, Madrid, Spain
c Servicio de Anatomía Patológica, Hospital Universitario de La Princesa, Madrid, Spain
d Servicio de Radiodiagnóstico, Hospital Universitario de La Princesa, Madrid, Spain
e Servicio de Endocrinología, Hospital Universitario de La Princesa, Madrid, Spain
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"identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "José Antonio" "apellidos" => "Jiménez-Heffernan" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Juan Julián" "apellidos" => "Cuesta Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "Marcos" "apellidos" => "Lahera Vargas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 6 => array:3 [ "nombre" => "Emma" "apellidos" => "Torres Mínguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Elena" "apellidos" => "Martín-Pérez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirugía, Universidad Autónoma de Madrid, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Radiodiagnóstico, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Endocrinología, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rendimiento del sistema Bethesda en el diagnóstico citopatológico del nódulo tiroideo" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 749 "Ancho" => 1333 "Tamanyo" => 140422 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Nodular thyroid disease is very common in the population, especially in women and seniors, affecting up to 60%.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1,2</span></a> In recent decades, there has been a significant increase in the incidence of thyroid cancer, especially at the expense of microcarcinomas.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,4</span></a> Thus, the annual incidence of thyroid cancer in the United States has tripled, with 40% for microcarcinomas.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> One of the factors that has been associated with this fact is the constant increase in the use of cervical imaging tests, mainly thyroid ultrasound, which resulted in the identification of an increasing number of thyroid nodules (TN) susceptible to being biopsied using fine needle aspiration (FNA).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> In order to standardize the terminology used for the description of thyroid cytology, in 2007 consensus recommendations were issued, known as the Bethesda system (BS).<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> This system was based on the creation of six categories associated with a certain risk of malignancy in each. Subsequent studies have described the results after adopting BS recommendations, with high agreement in the categorization of FNA samples.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> However, there is a limitation inherent to the BS, which is the intra- and interobserver variability in the cytopathology study of TN.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> Furthermore, the most frequent context in the general population is the presentation of multinodular goiter: a single patient may present several nodules that are able to be biopsied by FNA due to their ultrasound characteristics, which increases the complexity of the diagnostic-therapeutic process. The aim of the study is to evaluate the validity of BS in nodular thyroid disease to diagnose malignancy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">The study population consisted of consecutive patients who had undergone thyroid surgery between June 1, 2010 and June 30, 2017. Only those patients treated with a first thyroid intervention whose preoperative FNA had been performed at our hospital were included. Excluded from the study were patients with FNA performed at other centers, patients who underwent surgery without preoperative FNA or those with FNA not in accordance with the BS (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). For all patients, the diagnostic-therapeutic protocol included anamnesis, physical examination, thyroid function work-up and a cervical ultrasound. In patients who met the criteria for FNA in accordance with the international guidelines of the American Thyroid Association,<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10,11</span></a> this procedure was performed under ultrasound guidance by a radiologist assisted by an expert cytologist.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The samples were classified following the BS<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> recommendations, grouped into the six originally described categories: (I) unsatisfactory/non-diagnostic; (II) benign; (III) atypia of uncertain significance/follicular lesion of uncertain significance; (IV) follicular neoplasm/suspicion of follicular neoplasm; (V) suspected malignancy and (VI) malignant. The indication to repeat a needle-aspiration was limited to those cases with diagnostic categories I and III, and to benign punctures, but with a high degree of clinical-radiological suspicion. Once the needle-aspiration was done, surgery was indicated: in patients with categories IV, V and VI; in patients with persistent category I after repeated aspiration who presented a high degree of clinical-radiological suspicion; in patients with persistent category III after repeating needle-aspiration or after the initial aspiration if there was a high degree of suspicion; and in patients with category II, but who presented symptoms attributable to thyroid nodularity, hyperfunction, progressive growth of the TN or if any of the TN was >4<span class="elsevierStyleHsp" style=""></span>cm. The surgical technique used in each case was based on the individual characteristics of the patient, the BS categories and the location of the TN. In general, hemithyroidectomy was performed in the presence of unilateral nodules or millimetric contralateral nodules in categories I–IV. In the presence of symptomatic bilateral multinodular goiter, Graves’ disease or categories V–VI, total thyroidectomy was selected.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient follow-up data and the final histological correlation were only available in patients with surgical management. If a patient had several FNA samples from different TN, the results of each aspiration and the corresponding histological results were analyzed separately. A thorough review of each evaluated TN was performed, carefully correlating the description of the ultrasound that guided the FNA (size and location) with the findings of the surgical piece to confirm the agreement between the biopsied TN with its respective definitive pathology diagnosis. Regarding the study design, a prospectively maintained database was analyzed that collected the diagnostic-therapeutic data of all the patients, particularly demographic data, size and ultrasound localization of the TN, BS diagnostic category (in cases of multiple aspirations in the same patient, only the highest BS risk category was included), operative data and pathology data. This study was approved by the Clinical Research Ethics Committee at our hospital.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical Analysis</span><p id="par0025" class="elsevierStylePara elsevierViewall">The statistical analysis was carried out using the SPSS<span class="elsevierStyleSup">®</span> 23.0 program for Windows (SPSS Inc., Chicago, Illinois, USA). The results were expressed as percentages for categorical variables, and as mean and standard deviation for continuous variables, using the median and interquartile range for variables with asymmetrical distribution.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The correlation between the different diagnostic categories was assessed by comparing them with the final histological result, for which a linear logarithmic model (likelihood ratio) and a chi-squared model were applied, using symmetrical measures of association. The malignancy data used were calculated by assigning to each biopsied nodule its corresponding final histological diagnosis. Statistically significant differences were considered bilaterally with <span class="elsevierStyleItalic">P</span> values <.05. The phi correlation was used as a measure of the degree of association between categorical variables, whose values oscillate between +1 and −1. According to the strength of association: −1 indicates a strong negative association, +1 indicates a strong positive association and 0 indicates absence of association.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnostic test parameters calculated were sensitivity, specificity, predictive values (positive predictive value [PPV], negative predictive value [NPV]) and diagnostic accuracy to detect malignancy by means of two analyses. In the analysis as a screening test (analysis I), the FNA results were considered an indication for surgery for suspected malignancy (BS II vs IV, V, VI categories). According to this analysis, the terms “positive” or “negative” constituted the existence or not of surgical indication for the statistical analysis. Categories I and III were excluded from this analysis because they may involve the repetition of FNA. A second analysis was performed, which measured the ability of the test to detect malignancy (analysis II) in the case of highly suspicious aspirations (categories V and VI) compared to patients with benign puncture (category II).</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">In the study period, 631 patients were treated. Excluded from the study were 67 patients with FNA performed at another hospital, 25 patients without preoperative FNA, and 17 patients in whom the FNA report was not done in accordance with the BS (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Thus, out of the 522 patients included, 433 (83%) were women, with a mean age of 51.8±16 years. The median TN size evaluated preoperatively was 2.5<span class="elsevierStyleHsp" style=""></span>cm (1.6–4). The most frequent cytology among the operated patients was category II (49%), with very similar percentages of patients operated on with categories III, IV, V and VI (14.9, 13.6, 7.1 and 11.5%, respectively). In 316 cases (60.5%), total thyroidectomy was performed; the remainder had hemithyroidectomies with isthmectomies (39.5%). Dissection of the central compartment was associated in 66 cases (12.6%). Regarding histological results, 184 malignancies (35.2%) were identified; papillary carcinoma was the most frequent tumor with 155 cases (84.2%), 42 of which were incidental microcarcinomas (27.1% of the total papillary carcinomas and 8% of the total number of patients treated surgically). The remaining neoplasms identified were 19 follicular carcinomas (10.3%), right medullary carcinomas (4.3%), an anaplastic carcinoma (0.5%) and a thyroid lymphoma (0.5%).</p><p id="par0045" class="elsevierStylePara elsevierViewall">As for the percentages of malignancy in the different BS categories, after excluding incidental microcarcinomas, malignancy rates for category II, III, IV, V and VI were 4.6%, 11.5%, 33.8%, 86.5% and 100%, respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In category I, the rate of malignancy was 35.3%, but in no case was this due to the preoperatively biopsied nodule, while in the overall series 86.4% of patients presented the tumor on the nodule that had been biopsied preoperatively. Thus, the rates of malignancy attributable to the biopsied nodule for categories II, III, IV, V and VI were 1.5%, 6.4%, 31%, 86.5% and 100%, respectively. By analyzing the differences between the percentages of malignancy in each of the different categories, we found a strong correlation in practically all of the comparisons (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Only statistically significant differences were not detected between categories I and II (<span class="elsevierStyleItalic">P</span>=1.000) and between categories I and III (<span class="elsevierStyleItalic">P</span>=.581).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Regarding the performance of BS, when we analyzed its utility as a screening test (analysis I: category II vs IV+V+VI), we found a sensitivity for detecting malignancy of 98.9%, with a specificity of 84.4%, a PPV of 69.6%, a NPV of 99.5% and an overall diagnostic accuracy of 88.2% (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). In highly suspicious aspirations (analysis II: category II vs V+VI), this analysis increased the overall accuracy of the test up to 97.9% (sensitivity 98.6%, specificity 97.6%, 93.5 PPV% and NPV 99.5%).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">The most commonly used method for the description and categorization of thyroid FNA samples is the BS.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8,10</span></a> It is based on six categories, for each of which there is an estimated risk of thyroid cancer.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a> Our study seeks to review this risk, comparing cytology findings with the only possible gold standard: the definitive histological study of patients who have undergone thyroid surgery. The malignancy rates on which the statistical study has been based do not take incidental microcarcinomas into account, since most of them will have an indolent clinical course. In addition, we have considered only the existence of malignancy on the biopsied nodule, since we sought to define the capacity of the cytology study to identify the malignancy, not that of the ultrasound selection of the nodule to be biopsied. Despite this, we would like to point out that only 20 patients (3.8%) had a tumor >1<span class="elsevierStyleHsp" style=""></span>cm in one of the non-biopsied nodules. For identifying malignancy, our analysis shows the existence of a strong correlation for each of the BS categories, with differences between almost all of them (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). This could justify maintaining the six categories, as occurred in the recent revision of the BS.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a> The percentages of malignancy observed for each category were, in general, within the limits described.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Only 3.3% of the patients who underwent surgery had category I, a figure well below reports of other authors (7–26%).<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8,14</span></a> We believe that this figure is based on the fact that all FNA were guided by ultrasound, avoiding other aspirations, while a cytologist evaluated the quality of the material obtained in situ. The percentage of malignancy for the nodule biopsied within this category was 0%, which represents an ideal percentage if we take into account that the results of this category affect the importance of obtaining satisfactory material for cytological analysis.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The malignancy rate associated with category III was 6.4%, similar to the originally proposed rate.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> Although subsequent studies presented rates of up to 48% for this category, this can be attributed to the selection of surgical patients and the inclusion of incidental neoplasms in the analysis.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> To try to assess this wide variation of malignancy within category III, it is recommended to assess the quotient between category III and category VI patients,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a> whose ideal value should be between 1 and 3. Values above 3 would indicate an overuse of category III, while values lower than 1 would be due to a low use of this category, with the consequent risk of loss of sensitivity for detecting malignancy. In our series, this quotient was 1.3, which brings us closer to the most efficient part of the recommended range.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding the diagnostic test parameters of the BS (when assessed as a screening test, that is), needle-aspirations indicating a surgical intervention (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) had an observed sensitivity of 98.9% and an NPV of 99.5%. These data are similar to the Bongiovanni et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> study in terms of sensitivity, although our NPV greatly improves the average indicated in this study (99.5 vs 47%). This last datum is of special importance, since the main objective of preoperative FNAP is to rule out the existence of malignancy in order to reduce the number of unnecessary surgeries for this reason. In the second part of the analysis of the diagnostic test parameters of the BS, we have considered their capacity to ensure the existence of malignancy (categories V and VI), obtaining in this case a specificity of 97.6% and a PPV of 93.5%, with an overall accuracy of 97.9%. These data allow the BS to be defined as a very reliable tool when it comes to confirming the existence of malignancy. One of the limitations of the present study is those inherent to cytological analyses. Pathologists should be alert to the possibility of more errors in the analysis of cystic lesions, multinodular goiter or overlapping lesions with similar cytomorphological characteristics, such as the presence of reactive follicular cells or lesions with Hürthle cells. These findings mainly appear in the context of categories I and III, precisely those involved in the only comparisons between BS categories that did not show significant differences. However, we believe that the small number of patients that made up category I limits the ability to detect differences.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of Interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1060481" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres1060482" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1009276" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres1060483" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1009277" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical Analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of Interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-29" "fechaAceptado" => "2018-02-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1009276" "palabras" => array:4 [ 0 => "Thyroid cancer" 1 => "Bethesda" 2 => "Fine-needle aspiration" 3 => "Cytology" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1009277" "palabras" => array:4 [ 0 => "Cáncer de tiroides" 1 => "Bethesda" 2 => "Punción-aspiración con aguja fina" 3 => "Citología" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Fine-needle aspiration biopsies are a key tool for preoperative assessment of thyroid nodules, and the Bethesda system is the preferred method to report cytological analysis. The purpose of this study is to assess the efficiency of the Bethesda system to identify the malignancy risk of thyroid nodules.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patients who underwent thyroid surgery between June 2010 and June 2017 were included. Samples were classified into six categories according to rates of malignancy associated with each diagnostic category. In order to investigate the correlation between categories, a statistical analysis compared the categories with pathology reports. Diagnostic indicators were calculated as a screening test (categories IV, V, VI as true-positive) and as a method to identify malignancy (V, VI as true-positive).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In a series of 522 patients, we found 184 (35.2%) malignant tumors, papillary carcinoma being the most prevalent with 155 cases (84.2%). Malignant rates for diagnostic categories were: I, 0%; II, 1.5%; III, 6.4%; IV, 31%; V, 86.5%; VI, 100%. A robust correlation was identified between categories on statistical analysis. For the “screening test” analysis, sensitivity was 98.9%, specificity 84.4%, positive predictive value 69.6%, negative predictive value 99.5%, and diagnostic accuracy 88.2%. Analysing the accuracy to detect malignancy, values were: sensitivity 98.6%, specificity 97.6%, positive predictive value 93.5%, negative predictive value 99.5%, diagnostic accuracy 97.9%.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The Bethesda system is a clear and reliable approach to report thyroid cytology and therefore is an effective tool to identify malignancy risk and guide clinical management.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La punción-aspiración con aguja fina es una pieza clave en la evaluación preoperatoria del nódulo tiroideo y el sistema Bethesda es el más aceptado para categorizar el análisis citológico. El objetivo del estudio es evaluar la validez del sistema Bethesda en la enfermedad nodular tiroidea para diagnosticar malignidad.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Métodos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluye a los pacientes intervenidos de tiroides consecutivamente entre junio de 2010 y junio de 2017. Se realizó el análisis de la punción preoperatoria según el sistema Bethesda, correlacionando este dato con la histología definitiva para cada nódulo biopsiado. Los parámetros de prueba diagnóstica se calcularon como prueba de <span class="elsevierStyleItalic">screening</span> (verdadero positivo: categorías IV, V, VI) y como método para identificar malignidad (verdadero positivo: categorías V, VI).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se incluyó a 522 pacientes, de los que 184 (35,2%) presentaron un carcinoma en la histología definitiva; siendo el carcinoma papilar el más frecuente (84,2%). Los porcentajes de malignidad en el nódulo biopsiado para cada categoría Bethesda fueron: I, 0%; II, 1,5%; III, 6,4%; IV, 31%; V, 86,5% y VI, 100%. En el análisis como prueba de <span class="elsevierStyleItalic">screening</span>, se identificó una sensibilidad del 98,9%, especificidad del 84,4%, valor predictivo positivo del 69,6%, valor predictivo negativo del 99,5% y precisión diagnóstica global del 88,2%. En el análisis para detectar malignidad, los parámetros fueron: sensibilidad 98,6%, especificidad 97,6%, valor predictivo positivo 93,5%, valor predictivo negativo 99,5% y precisión diagnóstica global 97,9%.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El sistema Bethesda es un método sencillo y reproducible en la categorización citológica del nódulo tiroideo, una herramienta útil en el manejo y eficaz para identificar el riesgo de malignidad.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as: Mora-Guzmán I, Muñoz de Nova JL, Marín-Campos C, Jiménez-Heffernan JA, Cuesta Pérez JJ, Lahera Vargas M, et al. Rendimiento del sistema Bethesda en el diagnóstico citopatológico del nódulo tiroideo. Cir Esp. 2018;96:363–368.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1257 "Ancho" => 1586 "Tamanyo" => 83196 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Diagram of patients included in the study.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">miCPin: incidental papillary microcarcinoma (<span class="elsevierStyleItalic">n</span>=42).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic category \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No. of cases (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Risk of malignancy, No. of cases (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Risk of malignancy in TN excluding miCPin, No. of cases (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Risk of malignancy in TN evaluated, No. of cases (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (3.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (35.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (35.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">259 (49.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (14.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 (4.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (1.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78 (14.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 (23.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (11.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (6.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 (13.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 (42.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 (33.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (31) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">37 (7.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 (89.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (86.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (86.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (11.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1804886.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Percentage of Malignancy in the Diagnostic Categories.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">DC: diagnostic category; DF: degrees of freedom; LR: likelihood ratio.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comparison of diagnostic categories \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Chi-squared<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">phi<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">LR<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">DF \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC I vs DC II vs DC III vs DC IV vs DC V vs DC VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">365.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">374.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC II vs DC III vs DC IV vs DC V vs DC VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">352.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">365.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC II vs DC VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">294.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">278.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC II vs DC V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">218.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">148.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC II vs DC IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC II vs DC III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.034 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC II vs DC I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC III vs DC VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">119.22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">153.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC III vs DC V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">78.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC III vs DC IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC III vs DC I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.03 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.581 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC IV vs DC VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66.15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC IV vs DC V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC IV vs DC I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.005 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC V vs DC VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.08 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.007 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC V vs DC I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DC VI vs DC I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−1.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1804887.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Chi-squared model to evaluate the association between categorical variables.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Phi correlation coefficient used to evaluate the strength of association in categorical variables.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Likelihood ratio (log-linear model) used to evaluate association in categorical variables.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Statistical Analysis of the Categories of the Bethesda System.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Parameter \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Analysis I (%)<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Analysis II (%)<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sensitivity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.9 (87/88) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.6 (72/73) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Specificity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84.4 (205/243) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.6 (205/210) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPV in DC VI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (43/43) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 (43/43) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPV in DC V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.3 (29/34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85.3 (29/34) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPV in DC IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.3 (15/48) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.6 (87/125) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.5 (72/77) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.5 (205/206) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">99.5 (205/206) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rate of false negatives \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 (1/88) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4 (1/73) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rate of false positives \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15.6 (38/243) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.4 (5/210) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnostic accuracy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.2 (292/331) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.9 (277/283) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1804888.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Considers cases in DC IV+V+VI true positives and cases in DC II true negatives.</p>" ] 1 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Considers cases in DC V+VI true positives and cases in DC II true negatives.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Test Parameters of the Bethesda System.</p>" ] ] 4 => array:5 [ "identificador" => "fig0010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 749 "Ancho" => 1333 "Tamanyo" => 140422 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical practice. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 46 | 4 | 50 |
| 2024 September | 83 | 8 | 91 |
| 2024 August | 87 | 3 | 90 |
| 2024 July | 79 | 11 | 90 |
| 2024 June | 77 | 9 | 86 |
| 2024 May | 85 | 8 | 93 |
| 2024 April | 64 | 9 | 73 |
| 2024 March | 93 | 6 | 99 |
| 2024 February | 92 | 6 | 98 |
| 2024 January | 94 | 7 | 101 |
| 2023 December | 90 | 2 | 92 |
| 2023 November | 142 | 6 | 148 |
| 2023 October | 188 | 12 | 200 |
| 2023 September | 77 | 5 | 82 |
| 2023 August | 81 | 3 | 84 |
| 2023 July | 131 | 12 | 143 |
| 2023 June | 143 | 7 | 150 |
| 2023 May | 197 | 16 | 213 |
| 2023 April | 167 | 4 | 171 |
| 2023 March | 130 | 12 | 142 |
| 2023 February | 136 | 19 | 155 |
| 2023 January | 130 | 17 | 147 |
| 2022 December | 110 | 6 | 116 |
| 2022 November | 91 | 8 | 99 |
| 2022 October | 88 | 10 | 98 |
| 2022 September | 114 | 13 | 127 |
| 2022 August | 89 | 6 | 95 |
| 2022 July | 94 | 22 | 116 |
| 2022 June | 76 | 7 | 83 |
| 2022 May | 97 | 11 | 108 |
| 2022 April | 79 | 11 | 90 |
| 2022 March | 78 | 11 | 89 |
| 2022 February | 101 | 13 | 114 |
| 2022 January | 108 | 12 | 120 |
| 2021 December | 87 | 20 | 107 |
| 2021 November | 76 | 10 | 86 |
| 2021 October | 90 | 10 | 100 |
| 2021 September | 68 | 12 | 80 |
| 2021 August | 77 | 6 | 83 |
| 2021 July | 72 | 10 | 82 |
| 2021 June | 42 | 9 | 51 |
| 2021 May | 50 | 9 | 59 |
| 2021 April | 101 | 11 | 112 |
| 2021 March | 112 | 11 | 123 |
| 2021 February | 102 | 8 | 110 |
| 2021 January | 80 | 23 | 103 |
| 2020 December | 59 | 6 | 65 |
| 2020 November | 58 | 14 | 72 |
| 2020 October | 36 | 10 | 46 |
| 2020 September | 50 | 14 | 64 |
| 2020 August | 55 | 7 | 62 |
| 2020 July | 54 | 7 | 61 |
| 2020 June | 31 | 10 | 41 |
| 2020 May | 49 | 11 | 60 |
| 2020 April | 53 | 7 | 60 |
| 2020 March | 51 | 4 | 55 |
| 2020 February | 68 | 7 | 75 |
| 2020 January | 42 | 6 | 48 |
| 2019 December | 65 | 15 | 80 |
| 2019 November | 35 | 8 | 43 |
| 2019 October | 43 | 13 | 56 |
| 2019 September | 51 | 8 | 59 |
| 2019 August | 17 | 5 | 22 |
| 2019 July | 45 | 14 | 59 |
| 2019 June | 78 | 18 | 96 |
| 2019 May | 195 | 36 | 231 |
| 2019 April | 86 | 24 | 110 |
| 2019 March | 16 | 8 | 24 |
| 2019 February | 14 | 4 | 18 |
| 2019 January | 11 | 6 | 17 |
| 2018 December | 5 | 2 | 7 |
| 2018 November | 11 | 5 | 16 |
| 2018 October | 11 | 1 | 12 |
| 2018 September | 6 | 6 | 12 |
| 2018 July | 0 | 1 | 1 |
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