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BACKGROUND:The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) was created to establish a standard terminology regarding thyroid nodules that can be shared between endocrinologists, pathologists, radiologists, and surgeons. Since its inception and use in 2009, multiple large hospitals and academic institutions have performed retrospective studies to compare their classification rates, specifically those of atypia of undetermined significance (AUS) and follicular lesion of undetermined significance (FLUS), with the recommended rates created by the National Cancer Institute. The current study compared AUS/FLUS rates at a private suburban endocrine practice with those of previous publications from large institutions and the rates established by the National Cancer Institute. METHODS: Charts from 893 patients with fine-needle aspiration (FNA) performed in 2015 were reviewed. Data specific to thyroid aspirates classified as AUS/FLUS were organized into whether patients underwent surgery, underwent subsequent repeat FNA, or required continued observation. These results then were calculated to reveal the rate of malignancy in the AUS/FLUS category with surgical pathology in the study institution. RESULTS: A total of 893 patients underwent FNA, with 43 patients (4.82%) shown to have AUS/FLUS. A total of 21 patients proceeded to undergo thyroidectomy or lobectomy, with 7 patients (33.3%) found to have papillary or follicular thyroid carcinoma. CONCLUSIONS: The rate of use of the AUS/FLUS category for thyroid nodules examined at the study institution was found to be within the recommended range set forth by TBSRTC. However, the malignancy rates on histopathology in the study institution were found to be higher than the new proposed malignancy rates from TBSRTC published in 2017.This finding is comparable to those of multiple other community and academic institutions performed prior to and after institution of the new guidelines. Cancer Cytopathol 2018;126:881-888.We thank Richard Delgado, MD, who assisted with the review of surgical pathology slides from patients with a surgical diagnosis of papillary thyroid cancer to confirm the absence or presence of features consistent with noninvasive follicular thyroid neoplasm with papillary-like nuclear features. Shu Xian Lee, MBBS, is credited with the inception and creation of the figure used.

Background: Skeletal fluorosis (SF) is endemic in many places, especially where well water is rich in fluoride (F) from volcanic rock. SF is rare in the US, where it has unusual causes. The impact of F on the skeleton is conditioned by calcium and vitamin D sufficiency. Clinical Case: A 51-year-old obese man with chronic opiate use was referred for secondary hyperparathyroidism detected after right femoral neck and left proximal femur fractures, and displaced humeral fracture which healed poorly with radial nerve entrapment. Oncologic evaluation was negative, including intraoperative bone biopsy. He reported longstanding diffuse musculoskeletal pain, drank 72 oz of cola daily, and consumed little dietary calcium. Physical exam showed Ht 1.7 m, BMI 46, no dental abnormalities, deformed right humerus, diminished right wrist dorsiflexion, and an antalgic gait. DXA BMD Z-score was +7.4 at the spine and +0.4 at the “1/3” radius. At femur fracture, corrected serum calcium was 7.8 mg/dL (8.5-10.1) and alkaline phosphatase (ALP) 1080 U/L (46-116). After 5 months of calcium and vitamin D supplementation, calcium was 9.4 mg/dL, ALP 539 U/L, phosphorus 3.7 mg/dL (2.3-4.7), 25(OH)D 20.6 ng/mL (30-100), PTH 327 pg/mL (8.7-77.1), and creatinine 0.62 mg/dL (0.72-1.25). Hepatitis C Ab and PSA were normal. Elevated serum C-telopeptide 2513 pg/mL (87-345) and osteocalcin greater than 300 ng/mL (9-38) indicated rapid bone turnover. Bone scan showed increased uptake at the left hip fracture site, 2 ribs, and periarticular areas. Radiographic skeletal survey revealed diffuse osteosclerosis. Mutation analysis for high turnover sclerotic skeletal disease was negative, including examination of OPG, exon 1 of RANK and a NSG high bone mass panel. Initially, F exposure history was negative, however serum and urine F levels were elevated at 118 mcmol/L (0-4) and 42.6 mg/L (0.3-3.2), respectively. His mother confided that he had “huffed” difluoroethane containing computer cleaner for 2 years several times daily to control pain. Subsequently, right femur fracture required intramedullary fixation, several weeks rehabilitation, and generous doses of calcium and vitamin D3. Routine nondecalcified histology showed reactive bone with reticulin and collagen fibrosis. 24-hour urine of 3.43 liters contained calcium less than 68.6 mg and F 91.6 mg (0.2-3.2 mg/L). Conclusion: Inhalant abuse of fluorocarbons is known. However, literature concerning the skeletal effects is scant. Our patient’s positive bone balance together with low calcium intake could explain his secondary hyperparathyroidism. High phosphorus in colas may also have decreased gastrointestinal calcium absorption. Deposition of fluorohydroxyapatite in the skeleton likely explained our patient’s skeletal fragility.