Fine needle aspiration biopsy of hepatic lymphomas: cytomorphology and ancillary studies

Impact of flow cytometry in liver cytopathology

BACKGROUND

Fine needle aspiration (FNA) is commonly used as a diagnostic tool for the evaluation of lymphoproliferative diseases. Cytomorphology alone is often insufficient for the diagnosis and subclassification of lymphoma; therefore, flow cytometry (FC) plays an important role in the characterization of lymphoproliferative disorders. This study reviews our experience with FC on liver FNA at the Johns Hopkins Hospital.

METHODS

2,424 liver FNAs performed over a 21-year period were reviewed for clinical FC data (n=74) or a subsequent diagnosis of lymphoma in the liver without FC data (n=40).

RESULTS

In our study, 114 cases (4.7%) were included out of the 2,424 liver FNAs performed during the study period. Lymphoma was diagnosed 79 times. Cytomorphology alone was diagnostic of lymphoma in 45 cases, and in 33 cases both the cytomorphology and the FC were consistent with a diagnosis of lymphoma. Neither FC nor cytomorphology were diagnostic of lymphoma on 1 specimen. In 39 cases, FC had negative results on a lesion suspicious for lymphoma based on cytomorphology. In several nonlymphoma cases, FC provided information that allowed further subclassification of the neoplasm.

CONCLUSION

FC is a useful adjuvant diagnostic test for liver FNAs performed on patients with lymphoproliferative disorders.

Fine needle aspiration biopsy of the liver: Algorithmic approach and current issues in the diagnosis of hepatocellular carcinoma

The role of fine needle aspiration biopsy (FNAB) in the evaluation of focal liver lesions has evolved. Guided FNAB is still useful to procure a tissue diagnosis if clinical, biochemical and radiologic findings are inconclusive. Major diagnostic issues include: (i) Distinction of benign hepatocellular nodular lesions from reactive hepatocytes, (ii) Distinction of well-differentiated hepatocellular carcinoma (WD-HCC) from benign hepatocellular nodular lesions, (iii) Distinction of poorly differentiated HCC from cholangiocarcinoma and metastatic carcinomas, (iv) Determination of histogenesis of malignant tumor, and (v) Determination of primary site of origin of malignant tumor. This review gives a general overview of hepatic FNAB; outlines an algorithmic approach to cytodiagnosis with emphasis on HCC, its variants and their mimics; and addresses current diagnostic issues. Close radiologic surveillance of high-risk cirrhotic patients has resulted in the increasing detection of smaller lesions with many subjected to biopsy for tissue characterization. The need for tissue confirmation in clinically obvious HCC is questioned due to risk of malignant seeding. When a biopsy is indicated, core needle biopsy is favored over FNAB. The inherent difficulty of distinguishing small/early HCC from benign hepatocellular nodular lesions has resulted in indeterminate reports. Changing concepts in the understanding of the biological behavior and morphologic evolution of HCC and its precursors; and the current lack of agreement on the morphologic criteria for distinguishing high-grade dysplastic lesions (with small cell change) from WD-HCC, have profound impact on nomenclature, cytohistologic interpretation and management. Optimization of hepatic FNAB to enhance the yield and accuracy of diagnoses requires close clinicopathologic correlation; combined cytohistologic approach; judicious use of ancillary tests; and skilled healthcare teams.

Primary hepatic non-Hodgkin's lymphomas: case report and review of the literature

A 31-yr-old man presented with a 1-wk history of fever, chills, weakness, headaches, and a significant 20-lb weight loss over the preceding 2 months. His past medical history was relevant for liver amebiasis during childhood. Two days before admission, the patient noticed jaundice. He denied abdominal pain or other GI symptoms, and there was no history of alcohol intake, medications, or illicit drugs. His physical examination revealed generalized jaundice, hepatosplenomegaly, and bilateral leg edema. Neurologically, the patient was agitated, with periods of disorientation, and he had bilateral flapping. His blood tests revealed pancytopenia, renal failure, liver failure, and coagulopathy. Because the patient had a fever, hepatosplenomegaly, and pancytopenia, a further workup also included a bone marrow and liver biopsy. No conclusive diagnosis could be made from the above tests, and the patient died 5 days after admission. Postmortem evaluation, including flow cytometry and gene rearrangement in the tissue obtained from the liver, revealed large B cell lymphoma. This case illustrates an unusual presentation of hepatic non-Hodgkin's lymphoma. Current information regarding this entity is scant, mainly owing to its rarity. We present a review of the literature, including the incidence, presentation, treatment, and prognosis of primary hepatic lymphoma.

Mesenchymal tumors of the liver

Primary angiosarcoma of the liver accounts for up to 2% of all primary liver tumors and is the second most common primary malignant neoplasm of the liver. Approximately 10 to 20 new cases are diagnosed every year in the United States and the prevalence varies from 0.14 to 0.25 per million. In an autopsy series from Chicago, one hepatic angiosarcoma was noted for every 30 cases of hepatocellular carcinoma.

Fine-needle aspiration of extranodal and extramedullary hematopoietic malignancies

There is relatively little information concerning the use of fine-needle aspiration (FNA) to diagnose extranodal and extramedullary hematopoietic malignancies. Seventy-one such cases diagnosed by FNA form the basis of this study. Seventy-one cases of FNAs performed between 1988 and 1998 on extranodal and extramedullary hematopoietic malignancies were reviewed in order to evaluate the usefulness of this technique in diagnosing these entities as well as to assess patterns of relapse. There were 45 male and 26 female patients ranging in age from 29-86 years (mean, 68 years). Sixty-six patients had a previous history of a hematopoietic malignancy. Aspirates from 65 of these patients were consistent with the patient's known primary. One aspirate of a paravertebral mass from a multiple myeloma patient showed extramedullary hematopoiesis. The remaining five aspirates were cases of multiple myeloma that first presented as soft tissue masses. The most common malignancies were lymphoma: 52 cases (73%), 48 large cell lymphomas, four mixed small and large cell lymphoma; followed by multiple myeloma: 12 cases (17%); leukemia: four cases (5.4%); Hodgkin disease: two cases (2.8%); and one case of extramedullary hematopoiesis. The aspirate sites were soft tissue: 23 cases (32%); bone: 17 cases (24%); kidney: 14 cases (20%); liver: 11 cases (15%); lung: three cases (4%); adrenal: two cases (3%); and eye: one case. The interval between primary diagnosis and FNA was 1-36 months (mean, 13 months). In conclusion, 98% of the aspirates were neoplastic in patients with a known history of hematopoietic malignancies. The most common site of involvement was soft tissue in 23 (32%) cases. In five patients with multiple myeloma, the FNA diagnosis prompted a work-up to find the primary site of involvement. FNA is a useful technique in assessing extranodal and extramedullary hematopoietic malignancies.

Clinical utility of endoscopic ultrasound and endscopic ultrasound-guided fine needle aspiration in retroperitoneal neoplasms

OBJECTIVE

Nonpancreatic, retroperitoneal tumors are a relatively uncommon clinical problem. With the advent of endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration, gastroenterologists may be called upon to assist in the diagnosis and management of these lesions. This paper reviews the spectrum of upper retroperitoneal lesions encountered at a single institution using endoscopic ultrasound.

METHODS

We reviewed all cases of nonpancreaticobiliary or nonadrenal retroperitoneal lesions prospectively gathered from our endoscopic ultrasound database from April 1995 to September 1999.

RESULTS

Of 1120 upper endoscopic ultrasound examinations, 18 (1.6%) involved a retroperitoneal lesion; 16/18 lesions were neoplasms, nine were primary retroperitoneal tumors (four lymphomas, two leiomyosarcomas, two extraadrenal paraganglionomas, one leiomyoma), and seven were metastatic cancers. There was one fibrous mass and one mass-like abscess. Endoscopic ultrasound-guided fine needle aspiration was used in 15/18 cases. The management of 16 patients was significantly affected by the results of endoscopic ultrasound and biopsy.

CONCLUSIONS

Although it is not a frequent indication, assessing upper retroperitoneal tumors with endoscopic ultrasound and endoscopic ultrasound-guided fine needle aspiration can significantly affect the subsequent management of patients with these lesions.