Fine needle aspiration cytology in the diagnosis of uncommon types of lymphoma

Uses and limitations of small-volume biopsies for the diagnosis of lymphoma

Although surgical biopsy remains the gold standard for the diagnosis of lymphoma, small-volume biopsies including fine-needle aspiration and core needle biopsy are increasingly being used as a first line diagnostic tool. Small-volume biopsies are safe, rapid and cost effective; however, diagnostic utility varies by lymphoma subtype. It is important for pathologists and clinicians to recognize both the strengths and limitations of such biopsies.

Role of FNA with core biopsy or cell block in patients with nodular lymphocyte-predominant Hodgkin lymphoma

BACKGROUND

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL) represents a diagnostic challenge on surgical excisional or incisional biopsy. Classification is further challenging on fine needle aspiration (FNA) material accompanied by needle core and/or cell block biopsy (FNA+core/CB).

METHODS

The authors studied all FNA+core/CB and surgical excisional or incisional biopsies to evaluate for lymphoma in patients who had a prior history of NLPHL or subsequent diagnosis of NLPHL over a 5-year period from 2012 through 2016.

RESULTS

Patients who ultimately were diagnosed with NLPHL represented <0.5% of those who underwent FNA+core/CB for an initial suspicion of lymphoma. FNA+core/CB resulted in a definitive diagnosis in 7 of 13 cases, and surgical excisional or incisional biopsy specimens resulted in a definitive diagnosis in 13 of 13 cases (chi-square statistic, 9.6; P = .002). At initial diagnosis, FNA+core/CB was negative in 2 cases and atypical or suspicious in 3 cases; all 5 of those patients required surgical excisional or incisional biopsy for a definitive lymphoma diagnosis. By contrast, patients who underwent FNA+core/CB for recurrent lymphoma required surgical excisional or incisional biopsy in only 1 of 8 cases (chi-square statistic, 9.5; P = .002). Flow cytometry was positive for a light-chain-restricted B-cell population in only 1 of 11 biopsies that were involved by lymphoma.

CONCLUSIONS

Surgical excisional or incisional biopsy remains the gold standard for NLPHL diagnosis and for distinguishing progression to a T-cell/histiocyte-rich large B-cell lymphoma pattern. At a tertiary cancer center with routine collaborative diagnosis of lymphoma on FNA+core/CB by cytopathologists and hematopathologists, FNA+core/CB performs well to assess for recurrent or transformed NLPHL, rarely requiring subsequent surgical excisional or incisional biopsy. FNA+core/CB has limited sensitivity in the initial diagnosis setting.

Limited Tissue Biopsies and Hematolymphoid Neoplasms

OBJECTIVES

Use of fine-needle aspiration/needle core biopsy (FNA/CNB) in evaluating hematolymphoid processes has been debated. We investigate its applicability in various clinicopathologic settings.

METHODS

We retrospectively analyzed 152 cases of FNA/CNB.

RESULTS

Of 152 FNA/CNBs, 124 (81.6%) resulted in diagnoses without excisional biopsies, while 28 required subsequent excisional biopsies. Of these, 43 FNA/CNBs performed for suspected lymphoma relapse demonstrated 95.4% diagnostic rate (41/43), which was significantly better than those without history of lymphoma (77/109, 71%; odds ratio [OR], 8.5; confidence interval, 1.9-37.4). Patients with immunodeficiency also showed a high rate of diagnosis by FNA/CNB (100%). When stratified by types of disease, diffuse large B-cell lymphoma/high-grade B-cell lymphoma demonstrated a higher success rate (92.7%) than small B-cell lymphoma (79.2%), though the difference was not statistically significant (OR, 3.3; P value = .07). A subsequent excisional biopsy was required in 28 cases, 23 of which resulted in diagnoses concordant with the FNA/CNB. Five cases showed diagnostic discordance, reflecting pitfalls of FNA/CNB in unusual cases with complex pathology.

CONCLUSIONS

FNA/CNB is practical in evaluating most hematolymphoid lesions, with high efficacy in recurrent disease and some primary neoplasms with homogeneous/ aggressive histology, or characteristic immunophenotype.

Cytology and the cell block method in diagnostic characterization of canine lymphadenopathy and in the immunophenotyping of nodal lymphoma

Minimally invasive techniques used to evaluate canine peripheral lymphadenopathy (PLN), including fine needle aspiration biopsy with cytological evaluation (FNAB-C) and flow cytometry (FC), have benefits and limitations. The cell block (CB) method is an alternate processing technique in which fine needle aspirate biopsy samples are concentrated, fixed, and embedded in paraffin for routine histological processing/staining. Utilizing three observers, we determined the diagnostic value of the CB in evaluating canine PLN across six categories (non-diagnostic, reactive, inflammatory/infectious, probable lymphoma and lymphoma, metastatic neoplasia) and correlated findings to immunophenotypic and clonal antigen receptor rearrangement results in canine nodal lymphoma. Eighty-five paired FNAB-C and CB samples were evaluated from canine patients presenting to the University of Minnesota Veterinary Oncology or Internal Medicine services. Diagnostic quality samples were obtained in 55/85 (65%) CB and 81/85 (95%) FNAB-C samples, respectively, and nodal pathology impacted CB diagnostic yield. Overall percent agreement between diagnostic-quality FNAB-C and CB samples was 86%, but increased to 95% if the categories of lymphoma and probable lymphoma were combined. There was 100% agreement for both the diagnoses of metastatic neoplasia and reactive lymph nodes and 92% agreement for the diagnosis of lymphoma/probable lymphoma. Using immunohistochemistry (IHC), CB samples correctly immunophenotyped 22/23 (96%) cases of B-cell lymphoma, but only 1/6 (17%) cases of T-cell lymphoma. IHC was not completed on nine cases of lymphoproliferative disease because of insufficient cellularity. When the CB method (CBM) yielded diagnostic quality samples there was good to excellent agreement with FNAB-C samples and CB samples were suitable for some IHC tests.

Bifocal primary pancreatic Burkitt's lymphoma in a 4-year-old child

Pancreatic tumors are uncommon in children and rarely result in biliary obstruction. Primary pancreatic Burkitt's lymphoma is an exceptionally rare entity with only a few cases described in the literature. We present a case of a bifocal primary pancreatic Burkitt's lymphoma in a 4-year-old child presenting with jaundice. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:171-174, 2017.

Extranodal Lymphoproliferative Processes and Flow Cytometry

OBJECTIVE

Fine-needle aspiration (FNA) cytology is a safe and cost-effective technique for the diagnosis of lymphoproliferative processes, especially when correlated with clinical and imaging studies. However, cytology alone may be unable to detect a lymphoid neoplastic process, as architectural features are less obvious than in histologic preparations and, in certain cases, reactive processes may mimic lymphoma. Flow cytometry (FC) has been recognized as an important ancillary technique in the diagnosis of lymphoid neoplasms and it can be used in conjunction with FNA in the evaluation of lymphoproliferative processes.

STUDY DESIGN

We performed a review of the published literature concerning FC applied to the detection of salivary glands and thyroid lymphoproliferative processes, which are frequently related to autoimmune diseases and difficult to diagnose by cytomorphology alone.

RESULTS

FC is able to detect and subtype non-Hodgkin lymphomas and may contribute to the exclusion of a neoplastic process in cytologically unclear cases.

CONCLUSIONS

FC can be successfully applied in the differential diagnosis of lymphoproliferative processes in the head and neck region. The FNA-FC combined approach can reduce time to therapy and may prevent unnecessary surgical biopsies.

Mantle cell lymphoma: a report of 31 nodal and extranodal fine-needle aspirates

INTRODUCTION

This study reports our experience using aspiration cytopathology coupled with various auxiliary tests in achieving diagnostic accuracy in cases of mantle cell lymphoma (MtCL) from both nodal and extranodal sites.

MATERIALS AND METHODS

Specimens retrieved from our cytology database used search codes for MtCL. Tissue files were searched for any cases of MtCL that had corresponding fine-needle aspiration biopsy (FNAB) cytopathology. FNAB was performed using the standard technique.

RESULTS

Thirty-one aspirates of MtCL were recovered: 11 primary and 20 recurrent examples over a wide age range (x = 63 years). All had histologic confirmation. Nearly one-half were from extranodal sites (14; 45%), mostly representing skin/soft tissue masses. Microscopic examination showed a monotonous proliferation of small-medium lymphocytes in a dispersed pattern with dendritic cells and rarely tingible-body macrophages. Flow cytometry (FCM) performed on all but 6 aspirates demonstrated light chain clonality. In 12 aspirates, ancillary testing in addition to FCM consisted of fluorescence in situ hybridization only (6 cases), fluorescence in situ hybridization plus immunohistochemical (IHC) (2), and IHC only (4). One case had cell block IHC alone without FCM. A specific diagnosis of MtCL was made from 45% of primary and 89% of recurrent MtCL cases. No examples of a correct, specific FNAB diagnosis of MtCL were made without the use of some form of auxiliary testing.

CONCLUSIONS

Aspirates of MtCL are characterized by nonspecific relatively uniform small-sized to medium-sized lymphocytes. A specific diagnosis of MtCL is achievable in nodal/extranodal sites, but only when a combination of auxiliary studies is judiciously employed.

MRT letter: 3D culture of isolated cells: a fast and efficient method for optimizing their histochemical and immunocytochemical analyses

The rapid development of three-dimensional (3D) culture systems and engineered cell-based tissue models gave rise to an increasing need of new techniques, allowing the microscopic observation of cell behavior/morphology in tissue-like structures, as clearly signalled by several authors during the last decennium. With samples consisting of small aggregates of isolated cells grown in suspension, it is often difficult to produce an optimal embedded preparation that can be further successfully processed for classical histochemical investigations. In this work, we describe a new, easy to use, efficient method that enables to embed an enriched "preparation" of isolated cells/small 3D cell aggregates, without any cell stress or damage. As for after tissue-embedding procedures, the cellular blocks can be further suitably processed for efficient histochemical as well as immunohistochemical analyses, rendering more informative-and attractive-studies onto 3D cell-based culture of neo-tissues.

Role of the pulmonologist in ordering post-procedure molecular markers in non-small-cell lung cancer: implications for personalized medicine

In the growing era of personalized medicine for the treatment of non-small-cell lung cancer (NSCLC), it is becoming increasingly important that sufficient quality and quantity of tumor tissue are available for morphologic diagnosis and molecular analysis. As new treatment options emerge that might require more frequent and possibly higher volume biopsies, the role of the pulmonologist will expand, and it will be important for pulmonologists to work within a multidisciplinary team to provide optimal therapeutic management for patients with NSCLC. In this review, we discuss the rationale for individualized treatment decisions for patients with NSCLC, molecular pathways and specific molecular predictors relevant to personalized NSCLC therapy, assay technologies for molecular marker analysis, and specifics regarding tumor specimen selection, acquisition, and handling. Moreover, we briefly address issues regarding racial and socioeconomic disparities as they relate to molecular testing and treatment decisions, and cost considerations for molecular testing and targeted therapies in NSCLC. We also propose a model for an institution-based multidisciplinary team, including oncologists, pathologists, pulmonologists, interventional radiologists, and thoracic surgeons, to ensure adequate material is available for cytological and histological studies and to standardize methods of tumor specimen handling and processing in an effort to provide beneficial, individualized therapy for patients with NSCLC.

Cytopathology in the diagnosis of lymphoma

FNA is a simple, safe, and an inexpensive sampling technique that plays an important role in the evaluation of lymphadenopathy. The key to enhancing the accuracy of FNA diagnosis of lymphoma is the multi parameter approach in which the cytomorphologic features are evaluated in correlation with the results of ancillary studies and clinical context. A full understanding of the current lymphoma classification, clinical features associated with each lymphoma subtype and the impact of the diagnosis on patient management is essential in FNA diagnosis of lymphoma. It is also important to recognize the limitations of FNA in the primary diagnosis of some subtypes of lymphoma, and tissue biopsy should be recommended for a definitive diagnosis and subclassification in such cases.

Nodular lymphocyte-predominant Hodgkin lymphoma: cytopathologic correlates on fine-needle aspiration

BACKGROUND

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL), a rare subtype of Hodgkin lymphoma, is an indolent tumor with frequent instances of disease recurrence but a favorable prognosis. To the best of the authors' knowledge, there are only limited descriptions of NLPHL in the cytology literature because it was only formally recognized as a distinct entity in 1994.

METHODS

In the current study, all cases of NLPHL diagnosed on excisional biopsy (n = 6 cases) at the study institution between 2000 and 2011 that had undergone previous fine-needle aspiration (FNA) were reviewed, with a focus on cytomorphologic features.

RESULTS

Four of 6 cases were termed benign on FNA; however, there was retrospective recognition of characteristic LP cells in all cases. Unlike classical Hodgkin lymphoma, the tumor cells of NLPHL were often found to be mononucleate and presented in a background of small lymphocytes. Other features identified included epithelioid histiocytes and numerous bare atypical nuclei.

CONCLUSIONS

Cases of NLPHL are commonly misdiagnosed as benign reactive lymphoid tissue and therefore a careful search using high magnification for LP cells is recommended in the evaluation of lymph node FNAs.

[Primary lymphomas of the urinary in the urological service of the Yaounde Central Hospital]

OBJECTIVE

The objective of this study were to recruit and present epidemiological, clinical, histological and therapeutic aspects of primary lymphomas of the urogenital tract in Cameroon.

MATERIAL AND METHOD

This was a retrospective study over a 10-year period (1999-2008) done on clinical records of the Urological Unit of the Yaounde Central Hospital. From these records, we noted the age and the sex of the patients, their clinical presentation and histological aspect. The patients were treated by surgical resection and chemotherapy.

RESULTS

Twenty cases were recruited between this period of the study. The age of the patients varied from 6 to 60 years with a mean age of 35 years. There were 19 men and one woman. Eighteen cases involved the testis, one case the kidney and one penile involvement. On histology, there were 19 cases of Burkitt's lymphoma and one case of large B cell lymphoma involving the penis. Three patients had positive syphilis serology and two other were HIV positive. All the patients in this series had a complete remission after treatment but the tumour recurs after 6 to 9 months.

CONCLUSION

Burkitt's lymphoma is the first malignant tumour of the testis in Cameroonian. Unfortunately, patients consult late, there are no supports for the treatment and this will lead to a poor prognosis.

The Poor Man's Cell Block

The authors describe a simple method for making formalin or isopropyl alcohol vapour fixed cell blocks from fine needle aspiration cytology specimens that we refer to as ‘The Poor Man's Cell Block.’

The additional value of EUS-guided Tru-cut biopsy to EUS-guided FNA in patients with mediastinal lesions

BACKGROUND AND OBJECTIVE

EUS-guided FNA is a sensitive method to obtain cytologic specimens from solid lesions in close proximity to the GI tract. Although FNA provides cells for analysis, large-caliber Tru-cut biopsy (EUS-TCB) needles obtain samples that can be used for additional histopathologic analysis. We assessed the additional diagnostic yield of EUS-TCB in patients with solid mediastinal lesions in whom EUS-FNA was performed.

PATIENTS AND DESIGN

In the period from July 2003 to July 2007, all patients with mediastinal lesions accessible to EUS-FNA and EUS-TCB were evaluated. In all patients, a mean of 3 passes of EUS-FNA was followed by EUS-TCB. Cytologic and histologic specimens were evaluated by 2 pathologists blinded for patient condition. A final diagnosis was obtained by combining all information present (EUS-FNA and EUS-TCB results, mediastinoscopy, bronchoscopy [if performed], and other investigations).

RESULTS

The diagnostic accuracy of EUS-FNA, EUS-TCB, and the combination of both techniques was 93%, 90%, and 98%, respectively (not significant). In EUS-FNA-negative patients, EUS-TCB provided a final diagnosis in an additional 3 patients (5%). Malignant disease found by EUS-FNA could be specified by EUS-TCB in 15 patients (25% of patients). The granulomatous disease established by cytologic samples of clinically suspected tuberculosis could be specified by EUS-TCB in 2 patients (3%). In 1 patient (2%), both FNA and TCB were inconclusive.

LIMITATIONS

Retrospective study.

CONCLUSIONS

The diagnostic yield of EUS-FNA and EUS-TCB is comparable. We recommend limiting the use of EUS-TCB to specific cases in which EUS-FNA is not conclusive.

Clinical utility of fine-needle aspiration for diagnosis of head and neck lymphoma

BACKGROUND

Although fine-needle aspiration (FNA) is currently used for the diagnosis of lymphoma, its diagnostic utility in patients with head and neck (HN) lymphoma is unclear. We therefore assessed the utility of initial clinical and FNA diagnoses for HN lymphoma in a clinician's perspective.

METHODS

We conducted a retrospective study of total 109 patients with HN lymphoma underwent both FNA and tissue diagnoses from January 2000 through December 2005. The diagnostic sensitivity of FNA was compared with that of histopathology. FNA diagnosis was based on cytomorphology alone in 69 patients and on immunophenotyping plus morphology in 40.

RESULTS

On clinical diagnosis, lymphoma was suspected in 54 patients, nonlymphoma/metastatic malignancy in 31, and benign disease in 24. FNA diagnosed lymphoma in 41 patients; suspicious of lymphoma in 23; atypical lymphoma in 20; benign disease in 19; and was nondiagnostic in 6 patients. Diagnostic accuracy of FNA was not significantly improved by repeat core needle biopsy and immunophenotyping. Delay from FNA to tissue diagnosis was significant in the benign FNA-diagnostic group, with a mean 49 days.

CONCLUSIONS

The clinical and FNA diagnoses of HN lymphoma may be incomplete and include the potential pitfall of significant diagnostic delay.

Diagnosis of Burkitt lymphoma in pediatric patients by thoracentesis

The diagnosis of Burkitt lymphoma by thoracentesis has been rarely reported in the literature, particularly in children. From 1995 to 2004, we diagnosed six pediatric patients with mature B-cell neoplasms using thoracentesis as the initial diagnostic procedure. The cytology, immunophenotyping, and cytogenetic results of the pleural fluid cells were consistent with mature B-cell malignancies. We conclude that thoracentesis for the diagnosis of Burkitt lymphoma in children is safe, fast, and accurate. It should be strongly considered as an initial diagnostic procedure for pediatric patients with pleural effusions who are suspected of having B-cell malignancies.

Monitoring diagnostic accuracy and complications. A report from the Children's Oncology Group Hodgkin lymphoma study

BACKGROUND/PURPOSE

Cancer studies mandate quality assurance programs for clinical trials. Surgeons consistently play 2 roles early in the management of Hodgkin lymphoma in children and adolescents: obtaining a specimen for pathologic diagnosis and placing a central venous catheter to assist with therapy delivery. A surgical quality assurance program was embedded as part of the of the Hodgkin lymphoma study (AHODOOO31) to assess diagnostic accuracy and complications.

METHODS

Surgical checklists and operative and pathology reports were reviewed concurrently. Diagnostic technique, success rate, location of biopsy, combined procedures under one anesthetic, and complications are reported.

RESULTS

One hundred eighty-five cases were reviewed, with 169 having complete data. Diagnostic techniques included open biopsy (n = 148), computed tomography-guided core biopsy (n = 5), thoracoscopic/laparoscopic biopsy (n = 10) and fine-needle aspirations (n = 4). No staging laparotomies were performed. Biopsy sites included cervical (133), mediastinal (18), axillary (7), and others (11). Diagnostic accuracy was 145 of 148 (98.5%) for the open biopsy; 4 of 5, core biopsy (80%); 6 of 10 (60%), thoracoscopic/laparoscopic biopsy; and 1 of 4, fine-needle aspiration (25%). Eighteen had mediastinal disease only, 9 of whom had a thoracoscopic biopsy with a 55% diagnostic accuracy. Inadequate sample was the only reason for a lack of diagnosis. A second open operation was required in these cases for diagnosis. At biopsy, frozen section confirmed a malignancy in 68. In 38 of these 68 children, a central line was placed during the same anesthetic. The most common complication was inadequate sampling. Three wound infections were reported.

CONCLUSIONS

With an appropriate surgical approach to obtain an adequate tissue specimen, diagnostic accuracy is high and surgical complications are low in children with Hodgkin lymphoma. Diagnostic technique should ensure adequate tissue sampling especially when not using an open procedure. When possible, central line insertion should be performed under the same anesthetic. Fine-needle aspiration was not used enough to assess its role in the diagnosis of children with Hodgkin lymphoma.

Value of CT-guided core-needle biopsy in diagnosis and classification of malignant lymphomas using automated biopsy gun

AIM: To evaluate the value of CT-guided core-needle biopsy in diagnosis and classification of malignant lymphomas.

METHODS: From January 1999 to October 2004, CT-guided core-needle biopsies were performed in 80 patients with suspected malignant lymphoma. Biopsies were performed with an 18-20 G biopsy-cut (CR Bard, Inc., Covington, GA, USA) needle driven by a spring-loaded Bard biopsy gun.

RESULTS: A definite diagnosis and accurate histological subtype were obtained in 61 patients with a success rate of 76.25% (61/80). Surgical sampling was performed in 19 patients (23.75%) with non-diagnostic core-needle biopsies. The success rate of CT-guided core-needle biopsy varied with the histopathologic subtypes in our group. The relatively high success rates of core-needle biopsy were noted in diffuse large B-cell non-Hodgkin’s lymphoma (NHL, 88.89%) and peripheral T-cell NHL (90%). However, the success rates were relatively low in anaplastic large cell (T/null cell) lymphoma (ALCL, 44.44%) and Hodgkin’s disease (HD, 28.57%) in our group.

CONCLUSION: CT-guided core-needle biopsy is a reliable means of diagnosing and classifying malignant lymphomas, and can be widely applied in the management of patients with suspected malignant lymphoma.

Cytologic diagnosis of Burkitt lymphoma

BACKGROUND

The diagnosis and classification of lymphoma require correlation of morphologic, immunophenotypic, and molecular-cytogenetic studies. Fine-needle aspiration biopsy (FNAB) is a valuable diagnostic technique that allows material to be collected for these ancillary studies, and for morphologic evaluation.

METHODS

The authors report a series of seven cases clinically or morphologically suspicious for Burkitt lymphoma. Fluorescence in situ hybridization studies (FISH) for c-myc were performed on FNAB material and correlated with cytologic and immunophenotypic data.

RESULTS

Six of seven specimens were positive for c-myc rearrangement by FISH. However, only three of these cases represented Burkitt lymphoma, with one additional case of atypical Burkitt lymphoma. The other cases included diffuse large B-cell lymphoma, monomorphic posttransplant B-cell lymphoma, and an aggressive B-cell lymphoma, with the latter case negative for c-myc rearrangement by FISH. Of 2 non-Burkitt lymphoma specimens tested, 1 was positive for the immunoglobulin H/bcl-2 rearrangement, in addition to the c-myc rearrangement, suggesting transformation from a lower grade lymphoma.

CONCLUSIONS

These cases illustrated the value of FNAB in the diagnosis of Burkitt lymphoma, as well as the importance of obtaining material for, and integrating results of, ancillary studies for the final diagnosis.