Background: The Bethesda System for Reporting Thyroid Cytopathology is the standard for interpreting fine needle aspiration (FNA) specimens. The ''atypia of undetermined significance/follicular lesion of undetermined significance'' (AUS/FLUS) category, known as Bethesda Category III, has been ascribed a malignancy risk of 5-15%, but the probability of malignancy in AUS/FLUS specimens remains unclear. Our objective was to determine the risk of malignancy in thyroid FNAs categorized as AUS/FLUS at a comprehensive cancer center. Methods: The management of 541 AUS/FLUS thyroid nodule patients treated at Memorial Sloan-Kettering Cancer Center between 2008 and 2011 was analyzed. Clinical and radiologic features were examined as predictors for surgery. Target AUS/FLUS nodules were correlated with surgical pathology. Results: Of patients with an FNA initially categorized as AUS/FLUS, 64.7% (350/541) underwent immediate surgery, 17.7% (96/541) had repeat FNA, and 17.6% (95/541) were observed. Repeat FNA cytology was unsatisfactory in 5.2% (5/96), benign in 42.7% (41/96), AUS/FLUS in 38.5% (37/96), suspicious for follicular neoplasm in 5.2% (5/96), suspicious for malignancy in 4.2% (4/96), and malignant in 4.2% (4/96). Of nodules with two consecutive AUS/FLUS diagnoses that were resected, 26.3% (5/19) were malignant. Among all index AUS/FLUS nodules (triaged to surgery, repeat FNA, or observation), malignancy was confirmed on surgical pathology in 26.6% . Among AUS/FLUS nodules triaged to surgery, the malignancy rate was 37.8% . Incidental cancers were found in 22.3% of patients. On univariate logistic regression analysis, factors associated with triage to surgery were younger patient age ( p < 0.0001), increasing nodule size ( p < 0.0001), and nodule hypervascularity ( p = 0.032). Conclusions: In patients presenting to a comprehensive cancer center, malignancy rates in nodules with AUS/ FLUS cytology are higher than previously estimated, with 26.6-37.8% of AUS/FLUS nodules harboring cancer. These data imply that Bethesda Category III nodules in some practice settings may have a higher risk of malignancy than traditionally believed, and that guidelines recommending repeat FNA or observation merit reconsideration.

Robotic surgery will likely become an integral part of otolaryngologic surgical practice. Training programs in robotic surgery need to be formally established in residency programs. We present a preliminary program for introducing robotic surgical skills in residency training.

Seven Otolaryngology residents at the UMDNJ residency program participated (all the PGY 2 -PGY 5 residents in the program except the first author who had previous experience using the dVSS). An interactive teaching module ( Figure 5) was designed and fabricated. This module tested the following tasks: 1) simultaneous bimanual carrying, 2) circular pin transfer, 3) precision bead drop, 4) suture tying, and 5) needle passing. Performance of these tasks was recorded and the proficiency of the resident rated based on time needed, and number of errors made. Prior to beginning the teaching module, each participant received a verbal explanation about the use of the dVSS and each specific task. No participants practiced any of the prearranged tasks. Five tasks were performed by each participant. Each task was completed three times. The performance was observed, video recorded and reviewed by one of the authors (J.M.), Each participant earned a composite score for each trial on each task.