Techniques for cytologic sampling of pancreatic and bile duct lesions: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreatobiliary cytology, including indications for endoscopic ultrasound guided fine-needle aspiration biopsy, techniques of the endoscopic retrograde cholangiopancreatography, terminology and nomenclature of pancreatobiliary disease, ancillary testing, and postbiopsy management. All documents are based on the expertise of the authors, a review of literature, discussions of the draft document at several national and international meetings over an 18 month period and synthesis of online comments of the draft document on the Papanicolaou Society of Cytopathology website [www.papsociety.org]. This document presents the results of these discussions regarding the use of sampling techniques in the cytological diagnosis of biliary and pancreatic lesions. This document summarizes the current state of the art for techniques in acquiring cytology specimens from the biliary tree as well as solid and cystic lesions of the pancreas.

Clinical evaluation, imaging studies, indications for cytologic study and preprocedural requirements for duct brushing studies and pancreatic fine-needle aspiration: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing and postbiopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.

Utilization of ancillary studies in the cytologic diagnosis of biliary and pancreatic lesions: The Papanicolaou Society of Cytopathology Guidelines

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreatobiliary cytology including indications for endoscopic ultrasound guided fine needle aspiration, terminology and nomenclature of pancreatobiliary disease, ancillary testing and post-biopsy management. All documents are based on the expertise of the authors, a review of the literature, discussion of the draft document at several national and international meetings and synthesis of selected online comments of the draft document. This document presents the results of these discussions regarding the use of ancillary testing in the cytologic diagnosis of biliary and pancreatic lesions. Currently, fluorescence in-situ hybridization (FISH) appears to be the most clinically relevant ancillary technique for cytology of bile duct strictures. The addition of FISH analysis to routine cytologic evaluation appears to yield the highest sensitivity without loss in specificity. Loss of immunohistochemical staining for the protein product of the SMAD4 gene and positive staining for mesothelin support a diagnosis of ductal adenocarcinoma. Immunohistochemical markers for endocrine and exocrine differentiation are sufficient for a diagnosis of endocrine and acinar tumors. Nuclear staining for beta-catenin supports a diagnosis of solid-pseudopapillary neoplasm. Cyst fluid analysis for amylase and carcinoembryonic antigen aids in the pre-operative classification of pancreatic cysts. A number of gene mutations (KRAS, GNAS, von Hippel-Lindau, RNF43 and CTNNB1) may be of aid in the diagnosis of cystic neoplasms. Other ancillary techniques do not appear to improve diagnostic sensitivity sufficiently to justify their increased costs.

Defining the outcome of patients with delayed diagnosis of differentiated thyroid cancer

OBJECTIVES/HYPOTHESIS

In the present study we sought to define the outcome of patients with delay in diagnosis and treatment (>1 year) of well-differentiated thyroid carcinoma (WDTC) due to initial benign cytology (IBC).

STUDY DESIGN

Retrospective medical record review and analysis of survival outcomes.

METHODS

The records of 47 patients with delayed diagnosis of thyroid cancer were reviewed. In 38, surgery was performed for growing nodules and in nine due to malignant cytology during follow-up. Median time to delayed surgery was 52 months (range, 13-205 months). Multivariate analysis was performed to assess variables associated with outcome.

RESULTS

Most patients (32/47) underwent total thyroidectomy, whereas 15/47 had hemithyroidectomy. With a median follow-up of 96 months (range, 12-184 months), the 5-year disease-free survival of these patients was 96%. Multivariate analysis showed that the outcome of these patients was not statistically different than that of patients (n = 162) who underwent immediate surgery for similar disease.

CONCLUSIONS

We show that patients with delayed diagnosis and treatment for WDTC due to IBC have excellent outcome.

LEVEL OF EVIDENCE

4.

Risk stratification in follicular neoplasm: a cytological assessment using the modified Bethesda classification

BACKGROUND

The 2007 Bethesda classification for thyroid cytology defines follicular neoplasm as a category of cases with cellular specimens demonstrating abundant follicular cells arranged in a microfollicular pattern with little or no colloid. The current recommendation for the management of these cases is diagnostic lobectomy. There has been great difficulty and variability in triaging and reporting follicular neoplasm. To increase diagnostic accuracy, at the study institution, this category is subclassified further into 3 categories: 1) microfollicular-patterned neoplasm (MN); 2) Hürthle cell neoplasm (HN); and 3) follicular lesion with some features suggestive of but not diagnostic of the follicular variant of papillary thyroid carcinoma (FL). The authors reviewed the cases of follicular neoplasm observed over a period of 5 years to document the follow-up trend using this modified classification.

METHODS

A search of the cytology records was performed for the period between January 2008 and December 2012. All thyroid fine-needle aspiration cases were reviewed and those with a diagnosis of follicular neoplasm (including Hürthle cell neoplasm) were identified. Correlating follow-up surgical pathology reports were reviewed.

RESULTS

A total of 399 cases of follicular neoplasm with surgical follow-up were identified. Malignancy was identified in 32% of all cases of follicular neoplasm and was found to be disproportionately higher in the FL category (73%). A cytological diagnosis of FL is more likely to be called malignant (73%) than benign neoplastic (9%) or benign nonneoplastic (18%). A cytological diagnosis of MN or HN is more likely to be benign neoplastic (46% and 46%, respectively) than malignant (29% and 26%, respectively) or benign nonneoplastic (25% and 28%, respectively). Of the cytological features examined, 2 (nuclear enlargement and nuclear grooves) were significantly associated with the follicular variant of papillary thyroid carcinoma.

CONCLUSIONS

The results of the current study clearly indicate that follicular lesions with even subtle nuclear atypia have a high positive predictive value for malignancy and therefore should be distinguished from other follicular lesions because these cases require more aggressive surgical management. The current study also raises an important issue concerning the current thyroid classification based on the 2007 Bethesda classification for thyroid cytology. Future thyroid fine-needle aspiration classification schemes should consider subclassifying follicular neoplasms for the purpose of risk stratification.

Verification bias in diagnostic accuracy studies for fine- and core needle biopsy of salivary gland lesions in otolaryngology journals: a systematic review and analysis

BACKGROUND

Diagnostic test accuracy (DTA) studies for needle biopsy are frequently published in otolaryngology journals, but this body of literature has not been assessed for verification bias.

METHODS

We conducted a systematic review of DTA studies on needle biopsy of salivary gland lesions appearing in otolaryngology journals. Studies were assessed by 2 reviewers for verification bias.

RESULTS

We identified 95 DTA studies for needle biopsy of salivary gland lesions. Eighty-one studies (84%) had verification bias. Five of the biased studies provided sufficient data to estimate the extent of bias. Verification bias was associated with an overestimate of sensitivity and an underestimate of specificity. Studies on core needle biopsy (CNB) had a lower rate of verification bias than fine-needle aspiration (FNA) studies.

CONCLUSION

Verification bias is common in DTA studies of needle biopsy for salivary gland lesions published in ear, nose, and throat (ENT) journals. Such studies overestimated sensitivity and underestimated specificity.

Utilization of ancillary studies in the cytologic diagnosis of biliary and pancreatic lesions: the Papanicolaou Society of Cytopathology guidelines for pancreatobiliary cytology

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreatobiliary cytology including indications for endoscopic ultrasound-guided fine-needle aspiration, terminology and nomenclature of pancreatobiliary disease, ancillary testing, and post-biopsy management. All documents are based on the expertise of the authors, a review of the literature, discussions of the draft document at several national and international meetings, and synthesis of selected online comments of the draft document. This document presents the results of these discussions regarding the use of ancillary testing in the cytologic diagnosis of biliary and pancreatic lesions. Currently, fluorescence in situ hybridization (FISH) appears to be the most clinically relevant ancillary technique for cytology of bile duct strictures. The addition of FISH analysis to routine cytologic evaluation appears to yield the highest sensitivity without loss in specificity. Loss of immunohistochemical staining for the protein product of the SMAD4 gene and positive staining for mesothelin support a diagnosis of ductal adenocarcinoma. Immunohistochemical markers for endocrine and exocrine differentiation are sufficient for a diagnosis of endocrine and acinar tumors. Nuclear staining for beta-catenin supports a diagnosis of solid-pseudopapilary neoplasm. Cyst fluid analysis for amylase and carcinoembryonic antigen aids in the preoperative classification of pancreatic cysts. Many gene mutations (KRAS, GNAS, VHL, RNF43, and CTNNB1) may be of aid in the diagnosis of cystic neoplasms. Other ancillary techniques do not appear to improve diagnostic sensitivity sufficiently to justify their increased costs.

The role of core needle biopsy in the preoperative diagnosis of follicular neoplasm of the thyroid

Follicular neoplasm/suspicious for follicular neoplasm (FN/SFN) can often be challenging to diagnose using core needle biopsy (CNB) specimens. We have developed the histologic criteria for the CNB diagnosis of FN and validated the usefulness of CNB. We retrospectively reviewed 184 CNBs and 224 FNACs diagnosed with FN/SFN. CNBs were histologically classified into four subgroups, based on the histologic features of follicular proliferation, fibrous capsulation, and surrounding parenchyma. Among 184 CNBs, 103 (55.9%) had previous FNAC results of non-diagnostic or indeterminate. Overall malignancy rates in FNAC (48%) and CNB (46%) were nearly identical (p > 0.05), and the neoplasm rate was higher in CNB (88%) than FNAC (74%) (p = 0.007). There was no significant difference in the malignancy rates among the four histologic subgroups. Among the 40 nodules with simultaneous CNB and FNAC, only nine had the FNAC diagnosis of FN/SFN, and others were non-diagnostic, benign, or atypia of undetermined significance. Overall, CNB improved specimen adequacy and achieved better sensitivity of the FN/SFN diagnosis in thyroid nodules that were inconclusive by FNAC. In the preoperative diagnosis of FN/SFN, CNB has no advantage over FNAC in predicting the likelihood of malignancy, but helps to reduce the need for repeat biopsy.

Fine-needle aspiration cytology of Merkel cell carcinoma-a review of 69 cases

This study reviewed the clinical presentation, cytologic findings, and the immunophenotype of 69 Merkel cell carcinoma (MCC) cases sampled by fine-needle aspiration (FNA).  Demographic and clinical data, the cytology findings, and results of ancillary testing were reviewed.  Median patient age was 78 years (37-104) with a 1:1.8 female to male ratio. The most common FNA sites sampled included lymph nodes in the neck, the axillary region, the inguinal region and the parotid gland. Most patients had a history of MCC (68%) and/or non-MCC malignancy (70%).  The common cytologic pattern was a cellular smear with malignant cells arranged in a dispersed pattern with variable numbers of disorganized groups of cells. Cytoplasm was scant or absent and nuclei showed mild to moderate anisokaryosis, stippled chromatin, inconspicuous nucleoli, and nuclear molding. Numerous apoptotic bodies were often present.  Cell block samples (28 cases) were usually positive for cytokeratins in a perinuclear dot pattern, including 88% of cases with CK20 positivity. CD56 was the most sensitive (95%) neuroendocrine marker on cell blocks and was also positive with flow cytometry in nine cases tested.  MCC is most commonly seen in FNA specimens from the head and neck of elderly patients, often with a history of previous skin lesions. Occasional cases present in younger patients and some may be mistaken for other round blue cell tumors, such as lymphoma. CD 56 may be a useful marker in cell block preparations and in flow cytometric analysis of MCC.

Putting an eye on cytological specimens: an audit of the clinical impact of thyroid fine-needle aspiration in different health care settings

There is published evidence showing less cost-benefit approaches in the evaluation of thyroid nodules. We performed an institutional audit of the cytologic diagnosis of thyroid fine-needle aspiration (FNA) in an attempt to perceive the clinical impact of this technique on the management of thyroid nodules and to compare it in two different types of health care: Primary Care Medicine and Endocrinology. We performed a retrospective analysis to the electronic records of patients referred from General Practitioners (GP) and Endocrinologists (E) for thyroid FNA between 2010 and 2012. Request forms for cytological reports where retrieved for analysis of clinical and cytological data. The database search retrieved 1655 patients (female gender: 88.2%; GP references: 51.8%). Preprocedure clinical information was available from 157 out of 2005 nodules (7.8%). Significant differences in cytological diagnosis were seen in "Nondiagnostic" (GP: 11.6%; E: 7.5%, χ(2)  = 0.002) and "Benign" categories (GP: 75%; E: 81.8%, χ(2)  < 0.001). The main potential cause of "Nondiagnostic" samples was nodules smaller than one centimeter (total: 14 cases; GP: 7; E: 7). Reasons to request FNA for these nodules were provided in 6 out of 27 cases (GP: 0/16; E: 6/11, P < 0.001). The rate of insufficient samples was inversely correlated with nodule size (τ = -0.242, P = 0.001). When evaluating thyroid nodules, clinicians should take into account the limitations of FNA, the international recommendations for better cost-benefit approaches and the importance of a well-informed cytopathologist for better cytological diagnostic results.

Aggressive variants of follicular cell-derived thyroid carcinomas: a cytopathologist's perspective

Follicular cell-derived carcinomas of the thyroid gland comprise a heterogeneous group of malignant neoplasms of the thyroid gland with varied histologic appearance and molecular profiles. In most patients, these tumors represent relatively indolent neoplasms; however, certain subtypes/variants behave in an aggressive manner, and the recognition of this subset of tumors is essential because of their variable response to therapy and significant morbidity and mortality. Fine-needle aspiration is considered an essential tool for the diagnosis of suspicious thyroid nodules. In this review, the authors discuss the clinical, histologic, and molecular findings and the prognostic implications of aggressive thyroid neoplasms with emphasis on the characteristic cytomorphologic features on fine-needle aspiration smears.

The state of cell block variation and satisfaction in the era of molecular diagnostics and personalized medicine

BACKGROUND

In the recent past, algorithms and recommendations to standardize the morphological, immunohistochemical and molecular classification of lung cancers on cytology specimens have been proposed, and several organizations have recommended cell blocks (CBs) as the preferred modality for molecular testing. Based on the literature, there are several different techniques available for CB preparation-suggesting that there is no standard. The aim of this study was to conduct a survey of CB preparation techniques utilized in various practice settings and analyze current issues, if any.

MATERIALS AND METHODS

A single E-mail with a link to an electronic survey was distributed to members of the American Society of Cytopathology and other pathologists. Questions pertaining to the participants' practice setting and CBs-volume, method, quality and satisfaction-were included.

RESULTS

Of 95 respondents, 90/95 (94%) completed the survey and comprise the study group. Most participants practice in a community hospital/private practice (44%) or academic center (41%). On average, 14 CBs (range 0-50; median 10) are prepared by a laboratory daily. Over 10 methods are utilized: Plasma thrombin (33%), HistoGel (27%), Cellient automated cell block system (8%) and others (31%) respectively. Forty of 90 (44%) respondents are either unsatisfied or sometimes satisfied with their CB quality, with low-cellular yield being the leading cause of dissatisfaction. There was no statistical significance between the three most common CB preparation methods and satisfaction with quality.

DISCUSSION

Many are dissatisfied with their current method of CB preparation, and there is no consistent method to prepare CBs. In today's era of personalized medicine with an increasing array of molecular tests being applied to cytological specimens, there is a need for a standardized protocol for CB optimization to enhance cellularity.

Fine-needle aspiration in desmoplastic small round cell tumor: a report of 10 new tumors in 8 patients with clinicopathological and molecular correlations with review of the literature

BACKGROUND

Desmoplastic small round cell tumor (DSRCT) is a rare round cell sarcoma entity characterized by a specific t(11;22)(p13;q12) translocation, usually intra-abdominal localization and an aggressive clinical outcome. To date, only 35 DSRCT cases diagnosed by fine-needle aspiration have been described.

METHODS

This study reports the cytological diagnosis of DSRCT. Ten tumors from 8 patients were sampled for diagnosis and analyzed to search the characteristic translocation using fluorescence in situ hybridization or reverse transcription polymerase chain reaction methods.

RESULTS

Smears were always hypercellular and consisted of nonspecific round cell sarcoma. Nuclei were polymorphic round, kidney-, or heart-shaped. Nuclear molding was usually present. Paranuclear cytoplasmic densities were obvious and noted in 7 cases. Cytonuclear atypia, mitotic figures, numerous crushed nuclei, and apoptosis were frequently seen. Purple-stained stroma was present in 8 cases (ranging from few connective tissue fragments to large hyalinized deposits). Molecular studies based on cytological aspirates were performed in 8 patients. The presence of the fusion gene EWSR1-WT 1 transcript was identified in all, which confirmed the diagnosis of DSRCT.

CONCLUSIONS

Smears showing poorly differentiated round cells associated with cytoplasmic densities and connective stoma, in a specific clinical context, young adult age, intra-abdominal localization, suggestive immunocytochemical profile, and a unique cytogenetic abnormality are highly specific and allow an accurate diagnosis of DSRCT.

Liquid-based cytologic findings of solitary extramedullary plasmacytoma in thyroid: a case report identified with fine-needle aspiration cytology

Preoperative cytologic diagnosis of solitary extramedullary plasmacytoma (SEP) presents a challenge to cytopathologists because this tumor rarely occurs as a primary thyroid malignant neoplasm. In this report, we provide the first description of liquid-based cytomorphologic findings of SEP observed on fine-needle aspiration biopsy (FNAB) of the thyroid. A 56-year-old woman with a history of Hashimoto thyroiditis presented with a growing nodule in the thyroid. The liquid-based preparation obtained from FNAB showed numerous dispersed plasmacytoid cells with occasional loosely cohesive aggregates of tumor cells. Cells were round to oval in shape, with eccentrically located nuclei. Hyalinized perinuclear vacuoles were found in the cytoplasm of the tumor cells. Initial cytological findings, including those of immunochemistry using a cell block preparation, were consistent with plasmacytoma. Histopathological examination subsequent to thyroidectomy revealed a plasmacytoma in the thyroid. Plasma cell neoplasms were not concurrently detected in tissues other than the thyroid. On the basis of preoperative FNAB findings, a specific diagnosis of SEP in the thyroid can be difficult because this tumor is rare. Moreover, diagnosis is impeded because SEP in the thyroid resembles other, more common thyroid lesions, including both benign and malignant neoplasms. Careful cytomorphologic examination and supportive studies may be required to fully confirm a diagnosis of SEP.

Thyroid "atypia of undetermined significance" with nuclear atypia has high rates of malignancy and BRAF mutation

BACKGROUND

"Atypia of undetermined significance" (AUS) in the Bethesda System for Reporting Thyroid Cytopathology is a heterogeneous category for cases that cannot be easily classified into benign, suspicious, or malignant. This study evaluated whether cytomorphology-based subcategorization could better predict the malignancy risk in cases designated as AUS, and how the subcategories correlated with BRAF mutation status in thyroid fine-needle aspirates (FNA).

METHODS

Of 3589 cases of thyroid FNA diagnosed at the authors' institution in Seongnam, Korea, from January 2010 to December 2011, 331 cases of AUS were reviewed and subcategorized based on cytomorphological features, including nuclear atypia (NA), microfollicle formation (MF), Hürthle cell change (HC), and others (O). The malignancy rate of each subcategory was calculated using cases with histologic follow-up. Pyrosequencing was conducted to detect BRAF mutations.

RESULTS

Malignancy was histologically proven in 23.3% (77 of 331) of cases diagnosed as AUS. In cytomorphology-based subcategories, the rate of malignancy was 30.8% (66 of 214) for AUS-NA, 14.5% (8 of 55) for AUS-O, 4.8% (2 of 42) for AUS-MF, and 5% (1 of 20) for AUS-HC. The BRAF V600E mutation was found in 40% (48 of 120) of AUS-NA, 30.8% (4 of 13) of AUS-HC, 6.7% (1 of 15) of AUS-O, and 2.8% (1 of 35) of AUS-MF.

CONCLUSIONS

The AUS-NA subcategory was associated with the highest risk of malignancy and the greatest frequency of BRAF V600E (substitution of valine to glutamic acid at position 600) mutation. These findings suggest that subcategorization of AUS by cytomorphology and BRAF V600E mutation status is important for predicting the risk of malignancy.

Fine-needle aspiration biopsy of alveolar rhabdomyosarcoma of Stensen's duct: a case report and review of the literature

The cytologic features of an alveolar rhabdomyosarcoma arising within Stensen's duct of the parotid gland are described. These malignancies and sarcomas in general are not usually included in the differential diagnosis of a parotid lesion as they rarely present as primary parotid malignancies. In addition, these neoplasms are even rarer outside of the pediatric and adolescent populations. Due to the difficulty of this diagnosis, we present this case to increase awareness of the diagnosis in the salivary glands and to highlight the cytomorphologic features that can aid in the correct diagnosis.

Significance of the diagnostic categories "atypical" and "suspicious for malignancy" in the cytologic diagnosis of solid pancreatic masses

Endoscopic ultrasound guided (EUS) fine-needle aspiration (FNA) investigation of solid pancreatic lesions has been shown to have good sensitivity and specificity. Many lesions can be definitely classified as benign or malignant but some can only be cytologically classified as "atypical" or "suspicious for malignancy". Risk for malignancy in these indeterminate categories has not been well categorized. The cytology records of four University Medical centers were searched for all EUS guided FNAs of solid pancreatic lesions. All cases with a diagnosis of "atypical", or "suspicious for malignancy" were selected for analysis when histologic biopsy or over 18 months clinical follow-up was available. Two hundred and ninety-two cases with a diagnosis of "atypical" or "suspicious for malignancy" and adequate follow-up were obtained from the combined data of the four institutions. The percentage malignant for the categories "atypical" and "suspicious for malignancy" were 79.2 and 96.3%, respectively. If the category "atypical" was classified as benign and "suspicious for malignancy" was classified as malignant, the resulting positive predictive value was 96.3 (95% CI: 92.6-98.5) and the negative predictive value 20.8 (95% CI: 13.4-30.0). The categories of "atypical" and "suspicious for malignancy" stratify risk for malignancy in a fashion, which may aid in patient counseling and selection of follow-up protocols. Classification of "suspicious for malignancy" as malignant optimizes diagnostic sensitivity and specificity.

Clinical evaluation, imaging studies, indications for cytologic study, and preprocedural requirements for duct brushing studies and pancreatic FNA: the Papanicolaou Society of Cytopathology recommendations for pancreatic and biliary cytology

The Papanicolaou Society of Cytopathology has developed a set of guidelines for pancreaticobiliary cytology including indications for endoscopic ultrasound (EUS) and fine-needle aspiration (FNA) biopsy, techniques for EUS-FNA, terminology and nomenclature to be used for pancreaticobiliary disease, ancillary testing, and post-biopsy management. All documents are based on expertise of the authors, literature review, discussions of the draft document at national and international meetings, and synthesis of online comments of the draft document. This document selectively presents the results of these discussions. This document summarizes recommendations for the clinical and imaging work-up of pancreatic and biliary tract lesions along with indications for cytologic study of these lesions. Prebrushing and FNA requirements are also discussed.

Cytotechnologist screening of fine-needle aspiration specimens: impact on turnaround time and diagnostic accuracy

Fine-needle aspiration (FNA) is widely utilized due to its short turnaround time (TAT), diagnostic accuracy, and low cost. Controversy exists as to what role cytotechnologists should play in evaluation of FNAs. Some authorities believe all FNAs should be screened by cytotechnologists while others believe that cytotechnologist review is unnecessary. Sixty sequentially performed FNAs without initial review by cytotechnologists were selected from the files of the University of Utah, Department of Pathology. The slides were obtained along with the associated final diagnoses. The slides were reviewed by cytotechnologists given patient history and specimen site but were blinded to the initial pathologist's diagnoses. The initial cytopathologist's diagnoses and subsequent cytotechnologists' diagnoses were recorded and correlated. TATs for these cases were calculated and compared with TATs in a second set of randomly selected FNAs where cytotechnologists had initially screened the cases. Correlation of initial cytopathologists' diagnoses with those of cytotechnologists' revealed no instances where cytotechnologists identified diagnostically significant findings not noted by the original pathologist. TAT for the FNAs reviewed only by a cytopathologist averaged 25.9 hours with a mode of 6 hours. TATs for cases with initial cytotechnologist screening averaged 44.1 hours with a mode of 25 hours. Pre-sign-out screening of FNA specimens by cytotechnologists does not appear to increase detection of cytologic abnormalities. Cytotechnologist screening does substantially increased TAT from a mean of 26 hours to approximately 44 hours. Such an extensive delay may reduce the overall clinical utility of the FNA technique.

Granulomatous inflammation and organizing pneumonia: Role of computed tomography-guided lung fine needle aspirations, touch preparations and core biopsies in the evaluation of common non-neoplastic diagnoses

Background:

Fine-needle aspirations (FNAs) and core biopsies (CBs), with or without touch preparations (TPs), are performed to characterize pulmonary lesions. Although a positive (P) or suspicious report is sufficient for further management, the significance of unsatisfactory (U), negative (N) and atypical (A) cytological diagnoses remains uncertain. The aims of the study were to correlate U, N and A cytological diagnoses with histological and/or clinical/radiological follow-up and evaluate the utility of FNAs, TPs and CBs.

Materials and Methods:

We performed a retrospective search and examined 30 consecutive computed tomography-guided transthoracic U, N and A lung FNAs (n = 23) and TPs (n = 7) with surgical pathology (SP) (n = 17) and/or clinical/radiological follow-up (n = 13) and compared them to 10 SP-confirmed P FNAs, which served as controls.

Results:

The 30 FNAs and TPs were from 29 patients. All 6 U specimens were scantly cellular. Granulomas, the most common specific benign cytological diagnosis, were evident in 8 (of 13) and 7 (of 11) N and A cytology cases, respectively. Histology corroborated the presence of granulomas identified on cytology. Organizing pneumonia was the second leading benign specific diagnosis (5/17), but it was rendered on histology (n = 5) and not FNAs or TPs. Evaluation of the A cases revealed that type II pneumocytes were the source of “atypical”, diagnoses often associated with granulomas or organizing pneumonia and lacked 3-D clusters evident in all P cases.

Discussion:

U, N and A FNAs and TPs lacked 3-D clusters seen in carcinomas and were negative on follow-up. Granulomas and organizing pneumonia were the most common specific benign diagnoses, but the latter was recognized on histology only. In the absence of a definitive FNA result at the time of on-site assessment, a CB with a TP containing type II pneumocytes increases the likelihood of a specific benign diagnosis.

Case of malignant transformation of vagus nerve schwannoma to angiosarcoma

BACKGROUND

It is known that benign tumors have the potential for malignant transformation. Malignant transformation of vagus nerve schwannoma to angiosarcoma is very rare.

METHODS

We report a case of malignant transformation in which the initial diagnosis was subsequently altered to angiosarcoma originating from the vagus nerve. We compared the findings of MRI and fine-needle aspiration (FNA) at initial diagnosis with those after malignant transformation.

RESULTS

MRI revealed that the mass property had been changed from the initial tumor; also the FNA findings were significantly different from those in the previous ones. The patient had significant clinical progression with multiple cranial neuropathies and died.

CONCLUSION

Schwannomas sometimes undergo malignant transformation; therefore, surgery should be recommended. If follow-up observation is chosen, MRI and FNA should be regular and patients should sign a statement acknowledging awareness of the potential for malignant transformation.

Comparison of fine-needle aspiration and fine-needle capillary sampling of thyroid nodules: a prospective study with emphasis on the influence of nodule size

BACKGROUND

The objective of this study was to compare the sampling efficiency of ultrasound-guided fine-needle aspiration (FNA) and fine-needle capillary (FNC) sampling in thyroid nodules, in which the authors specifically analyzed the influence of nodule size.

METHODS

This study included 280 thyroid nodules in 275 consecutive patients. The nodules were divided into 4 size subgroups: ≤5.0 mm, from 5.1 to 10.0 mm, from 10.1 to 20.0 mm, and >20.0 mm. Each nodule was sampled by both FNA and FNC. The final cytopathologic findings were reported. The smears were scored and then categorized as diagnostically inadequate, adequate, or superior on the basis of 4 parameters, which included background clot or blood, the number of obtained cells, preserved tissue architecture, and cellular degeneration.

RESULTS

The κ scores for agreement of the cytopathologic results between FNA and FNC sampling in the 4 size subgroups were 0.377, 0.455, 0.751, and 0.352 for nodules that measured ≤5.0 mm, from 5.1 to 10.0 mm, from 10.1 to 20.0 mm, and >20.0 mm, respectively. The proportion of nondiagnostic of FNAs was significantly lower than the proportion of nondiagnostic FNC samples in nodules that measured >20.0 mm (P = .037). Scores for the 4 diagnostic parameters were significantly greater in FNAs than in FNC samples in nodules that measured from 5.1 to 10.0 mm and >20.0 mm (all P < .05); however, similar results were not observed in the nodules that measured ≤5.0 mm or from 10.1 to 20.0 mm (all P > .05). Also, FNA yielded significantly more diagnostically superior specimens than FNC sampling in nodules that measured from 5.1 to 10.0 mm and >20.0 mm (P < .05 for both).

CONCLUSIONS

The current findings indicated that FNA may be more suitable than FNC for sampling nodules that measure from 5.1 to 10.0 mm and >20.0 mm; whereas, for nodules that measure ≤5.0 mm and from 10.1 to 20.0 mm, the 2 techniques could yield specimens with similar quality.

Cytomorphology of intraductal oncocytic papillary neoplasm of the liver

We describe the first cytology case report of an intraductal oncocytic papillary neoplasm (IOPN) of the liver. A 51-year-old male presented with recurrent cholangitis. Magnetic resonance imaging and endoscopic retrograde cholangiopancreatogram revealed a 1.1 × 0.9 cm polypoid lesion within the left intrahepatic bile duct. Fine-needle aspiration and needle core biopsy (NCB) revealed nests, 3-dimensional or papillary clusters of columnar or cuboidal cells with loss of polarity. The nuclei were uniform with even chromatin, and cytoplasm was granular or vacuolated. No mitosis or necrosis was seen. The cytologic and histologic diagnosis was "consistent with Intraductal Oncocytic Papillary Neoplasm (IOPN), intermediate grade (borderline)." The patient then underwent a left lateral liver segmentectomy. Microscopic examination showed histology similar to the NCB with no stromal invasion identified. Hepatic IOPN poses a diagnostic challenge due to its broad differential diagnoses. Both malignant and non-malignant IOPNs may present with similar clinical symptoms, pathology, histology, cytomorphology, and immunohistochemistry. Hepatic IOPN should be excised as it is a precursor lesion of adenocarcinoma.

Performance of the Roche cobas 4800 high-risk human papillomavirus test in cytologic preparations of squamous cell carcinoma of the head and neck

BACKGROUND

Determining high-risk human papillomavirus (HR-HPV) status of head and neck squamous cell carcinoma (HNSCC) defines a tumor subset with important clinical implications. Cytologic sampling often provides the sentinel or sole diagnostic specimen. The authors assessed the performance characteristics for the Roche cobas 4800 HPV real-time polymerase chain reaction (PCR)-based system (cobas) on cytologic specimens of HNSCC compared with standard methods of in situ hybridization (ISH) for HR-HPV and immunohistochemistry (IHC) for p16 on formalin-fixed, paraffin-embedded (FFPE) tissue.

METHODS

Samples of HNSCC were collected by fine-needle aspiration and from surgical biopsies or resections, fixed, and processed with the cobas system. Available corresponding FFPE samples were synchronously evaluated for HR-HPV using ISH and IHC. Discrepant cases underwent additional PCR studies for adjudication.

RESULTS

Thirty-six samples from 33 patients were analyzed. Forty-two percent (n = 15) of tumors were positive for HR-HPV according to cobas. Corresponding histology with ISH (n = 30) was concordant in 91% of samples. Compared with the adjudication PCR standard, there were 3 false-positive cases according to cobas. Ninety-two percent (n = 12) of cases were the HPV16 subtype. The overall sensitivity for the cobas system was 100%, and the specificity was 86%.

CONCLUSIONS

Concordance in HNSCC HR-HPV status between cobas and ISH/IHC was > 90%, and cobas demonstrated a sensitivity of 100% and a specificity of 86%, broadening options for HR-HPV testing of fine-needle aspiration samples. Advantages for this system include subtyping of HR-HPV and the ability to discern HR-HPV status earlier in a patient's treatment course.

Immunocytochemical detection of mycobacterial antigen in extrapulmonary tuberculosis

The aim of the study is to determine whether immunostaining for mycobacterial antigen can contribute to the cytological diagnosis of extrapulmonary tuberculosis (EPTB). The study was carried out on aspirated material of lymph nodes, and other accessible sites, from 65 patients with clinical diagnosis of tuberculosis (TB). Twenty patients, diagnosed by fine-needle aspiration, with non-tuberculous granulomas served as controls. The diagnosis of TB was based on the demonstration of acid-fast bacilli (AFB), culture positivity for Mycobacterium tuberculosis (M. tuberculosis), or response to treatment with standard anti-tubercular therapy. Immunostaining was done using polyclonal antibody to mycobacteria. AFB positivity by Ziehl Neelsen (ZN) staining was 21%, 65.38%, and 68% respectively in Pattern 1 (granulomas alone), in Pattern 2 (granulomas with necrosis), and in Pattern 3 (necrosis alone). Overall AFB positivity was 56.92%. Twenty-eight of 65 cases were negative for AFB on direct smear. Culture was positive in 46% (13/28). Sensitivity and specificity of immunostaining were 96.92% (63/65) and 95%, respectively. Immunoreactivity was seen in 26 (92.8%) of 28 cases which were negative by ZN staining. Except in the case of leprosy, in which cross reactivity was seen, there was no immunoreactivity in the control group. Immunocytochemistry (ICC) had high sensitivity (96.2%) and specificity (95%) in the diagnosis of EPTB. ICC may be a useful adjunct to evaluation of cytomorphology and ZN staining.

Fine-needle aspiration cytology of primary renal angiosarcoma with histopathologic and immunocytochemical correlation: a case report

Primary renal angiosarcoma is an extremely rare neoplasm, with fewer than 28 cases reported thus far in the English literature. We report for the first time the cytomorphology and immunocytochemistry of this tumor in liquid-based (ThinPrep) fine-needle aspiration (FNA) samples in correlation with the conventional cytologic and histopathologic findings. Conventional smears showed pleomorphic tumor cells focally arranged in structures suggesting anastomosing vascular channels, while ThinPrep smears were less cellular with fewer and smaller tumor cells arranged in clusters or rosette-like formations. Immunocytochemical staining demonstrated positive results for vimentin, CD31, and CD34 and negative staining for epithelial markers, thus supporting the diagnosis of a mesenchymal tumor of vascular origin. The diagnosis of primary renal angiosarcoma was established after histopathologic evaluation of a metastatic liver nodule. The cytological differential diagnosis of this neoplasm and the utility of the ThinPrep method as a diagnostic adjunct to conventional FNA cytology are further discussed.

Diagnostic value of B-RAF(V600E) in difficult-to-diagnose thyroid nodules using fine-needle aspiration: systematic review and meta-analysis

Fine-needle aspiration (FNA) is routinely used in the preoperative evaluation of thyroid nodules. However, approximately 5-20% of thyroid nodules are considered indeterminate or suspicious cases that do not meet clinical standards. The B-RAF(V600E) mutation has been reported in FNA specimens. We conducted a systematic review to evaluate the diagnostic value of testing for B-RAF(V600E) in thyroid nodules that are difficult to diagnose by FNA. A systematic literature search was performed from January 1, 2002 to June 30, 2012. Articles were obtained by searching two electronic databases (MEDLINE and EMBASE), hand searching selected journals, and contacting authors. Article quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Sensitivity, specificity, and other measures of accuracy were pooled using random effects models. Summary receiver operating characteristic (SROC) curves were used to summarize overall diagnostic accuracy. A total of 16 studies incorporating 1131 patients were included in a meta-analysis on diagnostic accuracy of B-RAF(V600E) tests. Pooled sensitivity was 0.60 (95% confidence interval [CI]: 0.556-0.634), pooled specificity was 0.99 (95% CI 0.976-0.997), and the area under the curve of the SROC curve was 0.8376. Q index value was 0.7696. Our data suggest a potentially useful adjunct to evaluating thyroid nodules that are difficult to diagnose. The B-RAF(V600E) test has a high positive predictive value and could help clinicians formulate a more individualized treatment schedule. When supplemented with other noninvasive test methods, the B-RAF(V600E) test could be a powerful adjunct with extensive clinical applications.

Prognostic significance of a positive axillary lymph node fine-needle aspirate in patients with invasive breast carcinoma

BACKGROUND

Image-guided axillary lymph node fine-needle aspirates (FNAs) correlate well with pathologic lymph node staging in cases of invasive breast carcinoma. The objective of this study was to determine the prognostic significance of a positive lymph node.

METHODS

Consecutive cases of nonmetastatic (M0) invasive breast carcinoma evaluated by image-guided FNA were identified (4-year period, median follow-up of 51 months). "Positive" and "nonpositive" groups were compared using Kaplan-Meier survival analysis. Multivariate Cox regression was used to correct for clinicopathologic and treatment factors. A total of 142 cases was included, 70 with positive axillary FNA and 72 with a nonpositive result.

RESULTS

FNA-positive and nonpositive cases did not differ in patient age, tumor subtype, or hormone receptor status. Positive FNA was significantly associated with advanced T and N pathologic stage, and with HER2 (human epidermal growth factor receptor 2) positivity. FNA-positive patients were more likely to undergo mastectomy and to receive chemotherapy. Kaplan-Meier analysis showed that positive FNA is associated with poor prognosis, both with respect to disease-free survival (89% nonpositive versus 73% positive at 5 years, P < .001) and overall survival (94% versus 81%, respectively, at 5 years, P = .01). Multivariate analysis showed that when correcting for other variables, FNA positivity was not independently significant.

CONCLUSIONS

Positive axillary lymph node FNA is associated with poor prognosis on univariate analysis. By contrast, overall nodal staging is independently significant on multivariate analysis. The prognostic significance of axillary FNA likely results from its ability to predict for nodal status. Axillary FNA has utility as a preoperative staging procedure.

Preprocedural considerations in gastrointestinal endoscopy

The current practice of open-access endoscopy allows primary care and other non-gastroenterology physicians to directly refer patients for routine gastrointestinal endoscopic procedures. Open-access endoscopy is considered to be more cost-effective and time efficient than the traditional practice of referring patients for preprocedural consultation with a gastrointestinal endoscopist. Several studies have evaluated the performance of endoscopic procedures in an open-access environment and the utility of structured referral mechanisms to ensure safe and appropriately indicated procedures. This review focuses on 4 common preprocedural issues in gastrointestinal endoscopy encountered by primary care physicians: management of anticoagulation and antiplatelet therapy, indication for prophylactic antibiotic drug therapy, need for anesthesia-assisted sedation, and management of poor bowel preparation. We summarize the current guidelines that address these 4 common preprocedural issues to facilitate safe and clinically appropriate procedures in open-access endoscopy.

Fine-needle aspiration diagnosis of lymphomas with signet ring cell features: potential pitfalls and solutions

BACKGROUND

Lymphoma with signet ring cell features (LSF) is a rare morphologic variant of non-Hodgkin lymphoma. Although it has been well documented in the surgical pathology literature, to the best of the authors's knowledge, the features of LSF in fine-needle aspiration (FNA) samples have rarely been reported. An accurate cytologic diagnosis of LSF is of important therapeutic significance.

METHODS

The authors retrospectively reviewed 7 FNA cases of LSF for cytologic features, ancillary studies, corresponding histologic findings, and the patients' clinical and radiologic information to illustrate the diagnostic clues and potential pitfalls.

RESULTS

The final diagnoses, based on a multidisciplinary approach, were follicular lymphoma (5 patients), large B-cell lymphoma of follicular center cell origin (1 patient), and low-grade B-cell lymphoma with plasmacytoid features (1 patient). FNAs were obtained from both lymph node and extranodal sites. Common cytologic features included various percentages of signet ring cells in a background of nonvacuolated lymphomatous cells, lymphoglandular bodies, and cytoplasmic rings. The majority of signet ring cells contained a single, large, clear intracytoplasmic vacuole that pushed the nucleus laterally whereas fewer cells contained ≥ 2 vacuoles that indented the nucleus into a scalloped or stellate configuration. These cells resemble, to some degree, other lesions with signet ring cell features. One of the diagnostic clues of LSF was the similarity in nuclear details between signet ring cells and surrounding nonvacuolated lymphoid cells.

CONCLUSIONS

Familiarity with cytologic features, correlation with clinical/radiologic information, and ancillary studies are important for an accurate diagnosis of LSF and for distinguishing it from other lesions with signet ring cell features in FNA samples.

Contribution of the BRAF oncogene in the pre-operative phase of thyroid carcinoma

Numerous experiments have been conducted over the last few years aiming to identify molecular markers that show the diagnostic accuracy of fine-needle aspiration (FNA), particularly in thyroid lesions that are considered indeterminate. Using certain search arguments and previously defined criteria, 37 studies reporting experiments with the BRAF mutation in pre-operative FNA of the thyroid were selected from the electronic databases PUBMED, MEDLINE, SCOPUS and LILACS, in order to gather evidence with regard to the possible contribution of BRAF in the management of thyroid carcinoma. There were no cases positive for BRAF in follicular carcinomas (FTCs), Hürthle cell carcinomas (HCCs) or medullary thyroid carcinomas (MTCs). Among the 11 cases of anaplastic thyroid carcinomas (ATC), three showed positive results for the BRAF mutation. The number of cases positive for BRAF among the benign lesions was not significant. The average prevalence of BRAF-positive cases in papillary carcinomas (PTC) was 58.6%, while in follicular variants of papillary carcinoma (FVPTC), the average prevalence was 29.6%. For lesions diagnosed as indeterminate or suspicious, the average prevalence of BRAF positivity in PTC was 48.5%. The experiments included in the present study indicated a specificity of almost 100% and a high predominance of the BRAF mutation in PTC, distinguishing the marker in the planning and medical management of papillary carcinoma of the thyroid.

Cytological criteria of high-grade epithelial atypia in the cyst fluid of pancreatic intraductal papillary mucinous neoplasms

BACKGROUND

The recognition of epithelial cells with high-grade atypia (HGA) in the cyst fluid of an intraductal papillary mucinous neoplasm (IPMN) identifies a cyst at high risk of invasive carcinoma. To the best of the authors' knowledge, the cytological features of HGA have not been systematically analyzed to define diagnostic criteria.

METHODS

Cell groups from patients with histologically confirmed branch-duct IPMNs were evaluated by 2 cytopathologists with expertise in pancreatic cytology. A consensus interpretation categorized the cell groups as having either low-grade (LG) or high-grade (HG) morphology. Characteristics regarding cell size and architecture, nuclear and cytoplasmic features, and background necrosis were analyzed. Performance characteristics were assessed using the Fisher exact test at 95% confidence intervals.

RESULTS

Sixty cell groups yielded 27 LG and 25 HG morphological groups. No consensus was reached for 8 groups, which were excluded from statistical analysis. Five features that were found to be significantly different between the LG and HG groups included: 1) cell size <  a 12-μm duodenal enterocyte for HG and size equal for LG; 2) an increased nuclear-to-cytoplasmic (N/C) ratio; 3) marked nuclear membrane abnormalities; 4) abnormal chromatin pattern; and 5) background necrosis. The 3 most accurate features for the identification of HGA were background necrosis (88%), abnormal chromatin pattern (84%), and an increased N/C ratio (82%).

CONCLUSIONS

IPMN cyst fluid at high-risk of malignancy can be recognized most accurately by the presence of epithelial cells with HGA showing an increased N/C ratio, an abnormal chromatin pattern, and background necrosis.

Optimal indication of thyroglobulin measurement in fine-needle aspiration for detecting lateral metastatic lymph nodes in patients with papillary thyroid carcinoma

BACKGROUND

The purpose of this study was to evaluate optimal indication of thyroglobulin (Tg) measurement in fine-needle aspiration (FNA) for detecting lateral metastatic lymph nodes in patients with papillary thyroid carcinoma (PTC).

METHODS

We performed a retrospective study of 241 lymph nodes of 220 patients who underwent ultrasound-guided FNA with Tg in FNA (FNA-Tg) washout fluid measurements for suspicious lymph nodes.

RESULTS

On multivariate analysis, hyperechogenicity, cystic change, presence of calcifications, and peripheral vascularity were independent factors predictive of lymph node metastasis. After adding FNA-Tg, sensitivity and accuracy were significantly increased when the lymph node had 1 or 2 suspicious ultrasound features. However, sensitivity and accuracy were not significantly increased when the lymph node had multiple suspicious ultrasound features.

CONCLUSION

Additional FNA-Tg can help diagnose a metastatic lymph node with 1 or 2 suspicious ultrasound features. However, additional FNA-Tg is not beneficial in lymph nodes with highly suspicious ultrasound features, in which FNA alone is sufficient for diagnosis of predictive of lymph node.

Cytomorphologic and molecular features of hobnail variant of papillary thyroid carcinoma: case series and literature review

Recent reports indicate that hobnail papillary thyroid carcinoma (HPTC) is a rare, but very aggressive variant of papillary thyroid carcinoma. The authors describe the cytological features of five HPTC on fine-needle aspiration biopsies (FNAB). Moreover, their immunophenotype and the presence of B-RAF mutation by pyrosequencing were investigated. The patients' (three females and two males) age ranged from 27 to 86 (mean 65) years. Tumor size ranged from 2 to 9 cm (mean 4.2 cm). FNAB were highly cellular with a bloody background and scant colloid. The cells were arranged in papillary-like clusters or in micropapillary groups. The cell population consisted of medium-sized cells with "tear-drop" cytoplasm, apically placed nuclei that produced a surface bulge leading to a hobnail appearance. At higher magnification, nuclei showed variable degrees of atypia, occasional pink intranuclear pseudoinclusions, and grooves. Nuclear stratification and atypical mitotic figures were usually present. Immunocytochemistry revealed positive staining for thyroglobulin, thyroid transcriptor factor-1, Hector Battifora Mesothelial Antigen-1, partial loss of E-cadherin expression, and nuclear expression of p53 protein. B-RAF mutation was present in three out of five cytological cases. Immunohistochemical and molecular results were confirmed on histological sections. Recognizing the unique cytological features of HPTC should help to avoid misdiagnosis of this rare variant.

Artificial neural network analysis for evaluating cancer risk in multinodular goiter

BACKGROUND

The aim of this study was to create a diagnostic model using the artificial neural networks (ANNs) to predict malignancy in multinodular goiter patients with an indeterminate cytology.

MATERIALS AND METHODS

Out of 623 patients, 411 evaluated for multinodular goiter between July 2004 and March 2010 had a fine-needle aspiration biopsy. All patients underwent total thyroidectomy. The interpretation was consistent with an indeterminate lesion in 116 (18.6%) patients. Patient's medical records including age, sex, dominant nodule size, pre-operative serum thyroid-stimulating hormone level, thyroid hormone therapy and final pathologic diagnosis were collected retrospectively.

RESULTS

The mean age of the patients was 44.6 years (range, 17-78 years). About 104 (89.7%) were female and 12 (10.3%) were male patients. Final pathology revealed 24 malignant diseases (20.7%) and 92 (79.3%) benign diseases. After the completion of training, the ANN model was able to predict diagnosis of malignancy with a high degree of accuracy. The area under the curve of ANNs was 0.824.

CONCLUSION

The ANNs technique is a useful aid in diagnosing malignancy and may help reduce unnecessary thyroidectomies in multinodular goiter patients with an indeterminate cytology. Further studies are needed to construct the optimal diagnostic model and to apply it in the clinical practice.

Appropriate and accurate diagnosis of thyroid nodules: a review of thyroid fine-needle aspiration

Thyroid nodules are clinically palpable in 4-7% of adults in the United States. With ultrasound examination, thyroid nodules are identified in up to 70% of adults. In asymptomatic individuals, the potential for malignancy underlies the clinical importance of investigating thyroid nodules. Increased diagnostic accuracy has improved non-operative management of benign thyroid lesions. Appropriate management of thyroid microcarcinoma and large nodules remains a topic of debate. False-negative FNA cytology remains a concern for clinicians treating patients with thyroid nodules. Due to the challenge of interpreting FNA cytology and recent changes to the cytopathologic classification system, we reviewed the current literature on diagnosis of thyroid nodules using the recent Bethesda criteria.

The changing face of percutaneous image-guided biopsy: molecular profiling and genomic analysis in current practice

Oncology is undergoing a revolutionary change. Image-guided biopsy is expected to play an increasingly important role in this radical transformation. Current concepts of disease and treatment are based on an established set of physical signs and symptoms and laboratory tests broken down by organ system. However, soon diseases will be categorized and treated based on much more specific and detailed molecular and genetic information. This transformation in how disease is categorized and treated will depend on the ability to harvest tissue from tumors and analyze it appropriately.

Endoscopic ultrasonography for pancreatic cancer: current and future perspectives

A suspected pancreatic lesion can be a difficult challenge for the clinician. In the last years we have witnessed tumultuous technological improvements of the radiological and nuclear medicine imaging. Taking this into account, we will try to delineate the new role of endoscopic ultrasound (EUS) in pancreatic imaging and to place it in a shareable diagnostic and staging algorithm of pancreatic cancer (PC). To date the most accurate imaging techniques for the PC remain contrast-enhanced computed tomography (CT) and EUS. The latter has the highest accuracy in detecting small lesions, in assessing tumor size and lymph nodes involvement, but helical CT or an up-to-date magnetic resonance imaging (MRI) must be the first choice in patients with a suspected pancreatic lesion. After this first step there is place for EUS as a second diagnostic level in several cases: negative results on CT/MRI scans and persistent strong clinical suspicion of PC, doubtful results on CT/MRI scans or need for cyto-histological confirmation. In the near future there will be great opportunities for the development of diagnostic and therapeutic EUS and pancreatic pathology could be the best testing bench.

Case report: different metastatic components from anaplastic thyroid carcinoma in mediastinal and neck lymph nodes simultaneously diagnosed by FNA

Anaplastic thyroid carcinoma (ATC) is a rare but aggressive form of undifferentiated thyroid carcinoma which arises from previously well-differentiated thyroid carcinomas, such as papillary carcinoma or follicular carcinoma. We report on an interesting case of ATC found in an enlarging neck mass with metastatic papillary carcinoma found in mediastinal lymph nodes sampled by endoscopic bronchial-ultrasound guided- fine-needle aspiration, due to the incidental finding of a lung mass by CT scan. Divergent morphologies on cytology preparations were resolved by immunohistochemistry, which aided in the identification of both sites of malignancy and the common thread between them. The eventual palliative resection demonstrated the various components including undifferentiated thyroid carcinoma, papillary carcinoma, and background lymphocytic thyroiditis.

Health resource utilization and multidisciplinary impact of endoscopic ultrasonography in a tertiary referral medical center

BACKGROUND

Endoscopic ultrasound (EUS) is a resource-intensive endoscopic procedure, but may result in high downstream health resource utilization and multispecialty impact. Our aim was to examine the downstream impact of EUS by specialty and by indication.

METHODS

A retrospective chart review was performed at an academic medical center for patients for whom EUS represented the first point of contact at the study institution within a 20-month period.

RESULTS

A total of 552 EUS procedures were reviewed and 208 represented the first point of contact. The most common principle indication involved the pancreas (n = 117, 56%). Downstream health utilization was calculated for an average of 313 days postprocedure (range: 35-632 days). Following unique referral for endoscopic ultrasound, 52% of the patients in the study were retained within the institution for further management and, of these, 34% had a major intervention in the form of surgery or chemoradiotherapy. Compared with other indications, patients presenting with a pancreatic mass were significantly more likely to remain in the study institution for further management (62% versus 39%, p = 0.005), were more likely to have a downstream surgery (29% versus 14%, p = 0.020) and were more likely to have downstream chemo-radiotherapy (11% versus 3%, p = 0.012).

CONCLUSIONS

EUS represents a unique portal of entry into tertiary referral medical centers. First point of contact EUS referrals are associated with major downstream health resource utilization and significantly increased utilization for mass lesions of the pancreas.

Fine-needle aspiration of metanephric adenoma of the kidney with clinical, radiographic and histopathologic correlation: a review

Metanephric adenoma of the kidney is an uncommon benign epithelial neoplasm with only a small number of reports that describe its cytologic features. We describe two additional cases of metanephric adenoma diagnosed on fine-needle aspiration biopsy and review the available literature. Our cases showed similar cytology and were composed of cellular smears with numerous clusters of small, oval to round cells arranged in a microfollicular pattern and papillary configurations. The tumor cells had scant cytoplasm, fine chromatin and absent nucleoli. Psamomma bodies, nuclear atypia, cellular cpleomorphism, necrosis, and mitoses were absent. Because of the rarity of this tumor and the common cytologic features it shares with other lesions, including malignant tumors such as Wilms' tumor and papillary renal cell carcinoma, awareness of the cytologic features of metanephric adenoma may aid in avoiding a diagnosis of malignancy, especially preoperatively, and in guiding the proper management for the patients.

Spontaneous cutaneous endometriosis in the mons pubis region: a case report diagnosed by fine-needle aspiration biopsy

Most cutaneous endometriosis develops at the site of an abdominal surgical scar. Spontaneous cutaneous endometriosis is extremely rare. We report a case of spontaneous cutaneous endometriosis in the mons pubis region. A 41-year-old woman presented with a mass in the right mons pubis, causing cyclic pain associated with menses. Fine-needle aspiration (FNA) biopsy was performed. The smears contained three cellular components: honeycombed sheets of glandular epithelial cells, fragments of ovoid-to-spindle shaped stromal cells, and background inflammatory cells, including hemosiderin-laden macrophages, histiocytes, and neutrophils. Biphasic clusters of glandular epithelial cells and stromal cells were identified. FNA cytology is a safe and useful adjunctive tool for diagnosing cutaneous endometriosis.

Increased diagnostic yield of endoscopic ultrasound-guided fine needle aspirates with flow cytometry and immunohistochemistry

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is the most sensitive and specific test for establishing a tissue diagnosis for many gastrointestinal malignancies; however, cytologic morphology alone may not be definitive for subsets of tumors. Our aim was to quantify the impact of the broad application of flow cytometry (FC) and immunohistochemistry (IHC) on EUS-FNA diagnostic yield. A retrospective chart review was performed on EUS procedures at a tertiary referral, academic medical center. All EUS-FNA cases performed over a 21-month period were examined. Of 606 EUS procedures reviewed during the period of study, 264 utilized FNA. After pancreatic cyst cases were excluded, 235 EUS-FNA cases for 221 patients were selected for analysis. For cases with subsequent histological evaluation, including the subset utilizing FC/IHC, the sensitivity of EUS-FNA was 89%, specificity was 100%, and accuracy was 91%. One quarter (58/235, 25%) of the tissue specimens underwent further testing by FC/IHC. There were 48 definitive diagnoses made in the subset utilizing FC/IHC. In 20 of the 48 diagnoses (42%), FC/IHC was deemed critical to the diagnosis, and without FC/IHC testing in those cases, the overall sensitivity and accuracy of EUS-FNA would be reduced to 74 and 77%, respectively. FC/IHC allowed for six diagnoses rarely or not previously described by EUS-FNA. Application of FC/IHC improves characterization predominantly for nonadenocarcinoma tumor subtypes and may lead to a diagnostic result for tumors not previously characterized by EUS-FNA. With an adequate tissue sample, broad application of FC/IHC increases the diagnostic yield of EUS-FNA.

Isolated splenic metastasis from carcinoma of the breast: a case report

Breast carcinoma with visceral metastasis to the lungs, liver, and bone is common. However, isolated splenic metastases from breast carcinoma are rare. This has been rarely described in the medical literature. This case report presents a 48-year-old woman with newly diagnosed breast cancer and an isolated splenic metastasis diagnosed by ultrasound-guided fine-needle aspiration (FNA). Radiologic staging revealed no involvement of other organs, such as lungs, liver, or bone. The pathogenesis of rare single splenic metastasis and the diagnostic role of FNA on the spleen lesion are discussed. This case is being reported due to its rare metastatic initial presentation and the role of FNA in achieving the diagnosis.

Endoscopic ultrasound and endobronchial ultrasound-guided fine-needle aspiration of deep-seated lymphadenopathy: Analysis of 1338 cases

Background:

We retrospectively studied 1338 samples of lymph nodes obtained by endoscopic and endobronchial ultrasound-guided fine needle aspiration biopsy (EUS and EBUS-FNAB) with an objective of characterizing the utility of this diagnostic modality in the assessment of deep-seated lymphadenopathy. The secondary aims were to establish the utility in the diagnosis of lymphoma and to determine the number of passes required to obtain adequate cellularity for flow cytometric analysis.

Materials and Methods:

On-site assessment was performed by a cytopathologist using Diff-Quik (American Scientific Products, McGraw Park, IL) stain. In addition, Papanicolaou and immunohistochemical stains were performed and additional samples were sent for flow cytometric analyses (n = 145). The final cytologic diagnosis was correlated with surgical pathology diagnosis and/or clinical follow-up. In select cases, fluorescence in situ hybridization analysis with specific probes was performed on Diff-Quik smears.

Results:

Both morphology as well as ancillary studies (flow cytometry or immunohistochemical stain and/or fluorescence in situ hybridization) show that EUS and EBUS-FNA are effective techniques to detect and stage intrathoracic and intra-abdominal tumors. Operating characteristics show that these are highly sensitive (89%) and specific (100%) techniques for the diagnosis of lymphoma. At least two passes provided an average of 5.66 million cells (range, 0.12-62.32 million) for lymphoma cases.

Conclusions:

EUS and EBUS-FNA are powerful modalities to stage malignancies and at least two passes can provide adequate cells for flow cytometric analysis. We also demonstrate that fluorescence in situ hybridization analysis can be performed on Diff-Quik-stained and mounted smears.

Transrectal ultrasound - Techniques and outcomes in the management of intestinal endometriosis

The widespread use of endoscopic ultrasound has facilitated the evaluation of subepithelial and surrounding lesions of the gastrointestinal tract. Deep pelvic endometriosis, with or without infiltration of the intestinal wall, is a frequent disease that can be observed in women in their fertile age. Patients of this disease may present nonspecific signs and symptoms or be completely asymptomatic. Laparoscopic surgical resection of endometriotic lesions is the treatment of choice in symptomatic patients. An accurate preoperative evaluation is indispensable for therapeutic decisions mainly in the suspicion of intestinal wall and/or urinary tract infiltration, and also in cases where we need to establish histological diagnosis or to rule out malignant disease. Diagnostic tools, including transrectal ultrasound, magnetic resonance image, transvaginal ultrasound, barium enema, and colonoscopy, play significant roles in determining the presence, depth, histology, and other relevant data about the extension of the disease. Diagnostic algorithm depends on the clinical presentation, the expertise of the medical team, and the technology available at each institution. This article reviews and discusses relevant clinical points in endometriosis, including techniques and outcomes of the study of the disease through transrectal ultrasound and fine-needle aspiration.

Thyroid cyst wall atypia in a patient with a history of malignant melanoma: a pitfall in fine-needle aspiration cytology

We present an interesting case report from a patient with a history of desmoplastic malignant melanoma (MM), who presented with a thyroid nodule. The patient's clinical diagnosis included a benign thyroid nodule versus a primary thyroid malignancy or metastatic MM. Fine-needle aspiration biopsy showed highly atypical spindle cells suspicious for metastatic MM. The acellular cell block prevented further studies such as immunohistochemical analysis. The patient underwent surgical excision of the mass, which showed a benign cystic thyroid nodule with an atypical cyst lining. Here, we report the presence of atypical cyst-lining cells in a patient with diagnosis of MM. The atypical cytology of the cyst-lining cells has been reported in the English literature; however, presence of significant cytological atypia, especially in a patient with a history of another malignancy, can be problematic. The cytopathologist should be aware of this entity and its diagnostic pitfalls.

ALK-negative anaplastic large cell lymphoma mimicking a soft tissue sarcoma

Anaplastic lymphoma kinase protein (ALK)-negative anaplastic large cell lymphoma (ALCL) has a vast morphologic spectrum and may mimic many other types of malignancies both cytologically and histologically. There are only a few published case reports/series describing the cytomorphologic features of ALCL on fine-needle aspiration (FNA) biopsy specimens. We describe a case of ALK-negative ALCL mimicking a high-grade soft tissue sarcoma of the thigh in a 62-year-old man. The characteristic morphologic findings on FNA and core biopsy along with the immunophenotypic profile are described and reviewed. The diagnosis of ALCL on FNA biopsy may be difficult, but can be done successfully with the use of ancillary tests. Therefore, it must be considered in the differential diagnosis of lesions with pleomorphism, anaplasia, and wreath-like or horseshoe-shaped nuclei to ensure that adequate material is obtained for ancillary studies.