Intraoperative evaluation of sentinel lymph nodes in breast cancer: comparison of frozen sections,imprint cytology and immunocytochemistry

M. Francz, K. Egervari and Z. Szollosi
Intraoperative evaluation of sentinel lymph nodes in breast cancer: comparison of frozen sections, imprint cytology and immunocytochemistry Objective: We analysed the utility of imprint cytology with rapid immunocytochemistry and frozen section analysis for the evaluation of sentinel lymph nodes in breast cancer patients. Methods: The sensitivity, specificity, and positive and negative predictive values have been calculated for each method individually, each pair and all three together. We compared these results with those of routinely processed paraffin sections. Results: The sensitivity and specificity of each of the three methods for detection of metastatic carcinoma were as follows: 69.4% and 97.8% for touch imprint cytology; 58.3% and 100% for frozen sections; 68.5% and 98.9% for rapid immunocytochemistry. When the methods were combined, the highest accuracy was achieved by touch imprint cytology, frozen sections, touch imprint cytology plus rapid immunocytochemistry, or touch imprint cytology frozen section analysis and rapid immunocytochemistry, each of these having identical sensitivity and specificity of 72.2% and 97.8%, respectively. Conclusions: In our study the combined accuracy of the three methods was the same as combining touch imprint cytology and frozen sections or touch imprint cytology plus rapid immunocytochemistry. Rapid immunocytochemistry provides an additional parameter and preserves tissue for permanent sections.     

Intraoperative cytologic diagnosis of sentinel node metastases in breast cancer

OBJECTIVE: To clarify the usefulness of imprint cytology for intraoperative investigations of sentinel lymph nodes in breast cancer, comparing the results with those of examinations using frozen and permanent sections. STUDY DESIGN: The material consisted of 303 sentinel lymph nodes from 124 cases of clinically node negative breast cancer. Touch imprint cytologic slides and frozen sections were obtained from the same cut surface of the sentinel nodes. Correlations with the final histopathologic results in paraffin sections were evaluated. RESULTS: The sensitivity, specificity and accuracy of imprint cytology were 70.3%, 99.6% and 96.0%, and those of frozen sections were 83.8%, 100%, 98.0%, respectively. The values were improved when the 2 methods were combined (89.2%, 99.6%, 98.3%), though the concordance between imprint cytology and frozen section was 91.9%. CONCLUSION: Both imprint cytology and frozen section are useful for evaluating sentinel lymph node status in breast cancer. However, the 2 techniques should be combined to improve the diagnostic sensitivity.     

Fine needle aspiration (FNA) cytology in the diagnosis of recurrent soft tissue sarcoma

trovik c. s., bauer h. c. f., brosjö o., skoog l. and söderlund v. (1998) Cytopathology 9, 320–328
Fine needle aspiration (FNA) cytology in the diagnosis of recurrent soft tissue sarcoma
We have used FNA cytology to diagnose suspected local recurrences of soft tissue sarcoma. Since 1991, a total of 95 FNA cytologies were performed on 86 patients. There were 47 local recurrences, of which 44 were diagnosed correctly by FNA cytology; one biopsy was inconclusive, and two lesions were incorrectly assessed as benign. Thirty-nine patients proved to have benign lesions in the scar area examined cytologically on 50 occasions. None of the specimens was regarded as malignant, but in four cases FNA cytology was inconclusive. Overall, there were 5% inconclusive cytological biopsies, 0% falsely malignant and 5% falsely benign. The inconclusive and false-negative cytological diagnoses had no important clinical consequences. FNA biopsy provides a simple means of diagnosing local recurrence of soft tissue sarcoma.     

Cytological diagnosis of basal cell carcinoma and actinic keratosis, using Papanicolaou and May–Grünwald–Giemsa stained cutaneous tissue smear

Objective:  Cytology may become the diagnostic method of choice with the advent of new non-invasive treatments for non-melanoma skin cancer, as the sampling technique for cytology entails little tissue disfiguration. The aim of this study was to compare and evaluate the diagnostic performance of scrape cytology using two different cytological staining techniques, and to evaluate additional touch imprint cytology, with that of histopathology of basal cell carcinoma (BCC) and actinic keratosis (AK).
Methods:  We investigated 50 BCC and 28 AK histologically verified lesions, from 41 and 25 patients, respectively. Two separate skin scrape samples and one touch imprint sample were taken from each lesion. The smears were stained with Papanicolaou (Pap) or May–Grünwald–Giemsa (MGG) stains. All cytological specimens were examined in random order by pathologists without knowledge of the histology. Cytodiagnostic results were compared with the histopathological report.
Results:  Scrape cytodiagnosis agreed with histopathology in 48 (Pap) and 47 (MGG) of the 50 BCC cases, and in 26 of 28 (Pap) and 21 of 26 (MGG) AK cases, yielding sensitivities of 96%, 94%, 93% and 81%, respectively. No significant difference in sensitivity between the two staining methods was found but a trend towards higher Pap sensitivity for AK was noted ( P  =   0.10). Touch imprint cytology confirmed histopathology in 38 of the 77 cases of BCC and AK.
Conclusion:  Cytological diagnosis with either Pap or MGG stain for BCC and AK is reliable, and differentiates well between BCC and AK. Imprint cytology proved to be non-diagnostic in half of the examined cases.     

Fine needle aspiration cytology of palatine tonsils: a study of 112 consecutive adult tonsillectomies

M. J. Ashraf, N. Azarpira, B. Nowroozizadeh, M. Shishegar, B. Khademi, A. Faramarzi, S. B. Hashemi, A. Hakimzadeh and E. Abedi
Fine needle aspiration cytology of palatine tonsils: a study of 112 consecutive adult tonsillectomies Objective: To study fine needle aspiration cytology (FNAC) findings of tonsillar lesions with histological controls and to assess its role in the diagnostic evaluation of tonsillectomy specimens. Methods: This study consisted of 112 cases that required tonsillectomy, comprising 55 (49.1%) men and 57 (50.9%) women. The ages ranged between 20 and 62 years. The clinical diagnosis in 101 cases was chronic tonsillitis, whereas 11 were suspected of neoplasia. FNAC was performed before tonsillectomy under general or local anaesthesia or on fresh specimens using a 21‐G needle. The smears were stained using Wright–Giemsa and Papanicolaou methods. Histological examination was carried out on surgical specimens of all cases and, when required, immunohistochemistry was performed on histological sections. The diagnostic outcomes between FNAC and surgical biopsy were compared. Results: In this study, 106 cases were diagnosed as chronic tonsillitis/follicular hyperplasia, four cases as non‐Hodgkin’s lymphoma, one as Hodgkin’s lymphoma and one as monophasic synovial sarcoma. All malignant cases were diagnosed by FNAC, but synovial sarcoma was incorrectly diagnosed as squamous cell carcinoma. Five cases clinically suspected of neoplasia were correctly diagnosed as chronic tonsillitis on cytology. Conclusion: Tonsillar aspiration is a safe procedure and is useful in the evaluation of tonsillectomy specimens. However, ancillary tests on cytological material are often needed when neoplasia is suspected and would help clinical management and allow histological examination of cases diagnosed cytologically as lymphoma.     

Scrape cytology assessment of margins of lumpectomy specimens in breast cancer

In cases of breast carcinoma in which only lumpectomy is performed, it is necessary to ascertain that the surgical margins were adequate, i.e., free of tumor. Since the histologic methods used for this purpose are either unreliable or very cumbersome, scrape cytology was evaluated as a method for the examination of lumpectomy margins. In 30 cases examined both cytologically and histologically, a very good correlation was found between the two methods. The scrape cytology method has the advantage of being much easier and quicker and is thus recommended for routine use.     

Accuracy of touch imprint cytology in diagnosing lung cancer.

A 3-year study assessed the diagnostic accuracy of touch imprint smears in the diagnosis of lung cancer. Touch imprint smears were prepared from 90 computerized tomographic-guided core needle lung biopsies. Cytological diagnosis of touch imprint smears were correlated with the histological diagnosis of the corresponding core needle biopsy specimen, which was taken as the gold standard. The sensitivity, specificity, positive predictive value and negative predictive value of imprint smear results were 89%, 100%, 100% and 68%, respectively. There were no false positives, and all patients with small cell lung cancer were correctly diagnosed with this technique. Imprint cytology can be used to provide a rapid, preliminary diagnosis of lung cancer.     

Comparison of cytohistologic techniques in diagnosis of gastroesophageal malignancy

OBJECTIVE: To evaluate the diagnostic performance of various endoscopic cytologic techniques, namely, brushing cytology, touch smear cytology and crush cytology, and comparison with concurrent biopsy results in diagnosis of gastroesophageal malignancy. STUDY DESIGN: This prospective study was conducted on 100 patients, with 78 clinically suspected cases of esophageal malignancy and 22 cases of gastric malignancy. RESULTS: The diagnostic accuracy of touch smear in esophageal malignancy was significantly higher (94.12%) than brushing and crush smears (89.71% each), and endoscopic biopsy had the diagnostic accuracy of 88.24%. The diagnostic accuracy of combined brushing and biopsy was 100%; it was 97.06% for touch smears combined with biopsy. In comparison, the diagnostic accuracy in gastric malignancy was 75% for brushing alone, which was significantly lower than touch smear (87.5%) and endoscopic biopsy (87.5%). The diagnostic yield for crush smear was 81.25%. A combination of touch smears and biopsy had a diagnostic yield of 100%; it was 93.75% for combined brushings and biopsy. CONCLUSION: A combination of cytohistologic techniques resulted in a statistically significant increase in the diagnostic yield of gastroesophageal malignancies and thus cytologic techniques may act as adjunct to biopsy histology to increase the diagnostic efficiency.     

Ultrasound Guided Optoacoustic Tomography in Assessment of Tumor Margins for Lumpectomies

PURPOSE: To determine the accuracy of a handheld ultrasound-guided optoacoustic tomography (US-OT) probe developed for human deep-tissue imaging in ex vivo assessment of tumor margins postlumpectomy. METHODS: A custom-built two-dimensional (2D) US-OT–handheld probe was used to scan 15 lumpectomy breast specimens. Optoacoustic signals acquired at multiple wavelengths between 700 and 1100 nm were reconstructed using model linear algorithm, followed by spectral unmixing for lipid and deoxyhemoglobin (Hb). Distribution maps of lipid and Hb on the anterior, posterior, superior, inferior, medial, and lateral margins of the specimens were inspected for margin involvement, and results were correlated with histopathologic findings. The agreement in tumor margin assessment between US-OT and histopathology was determined using the Bland–Altman plot. Accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of margin assessment using US-OT were calculated. RESULTS: Ninety margins (6 × 15 specimens) were assessed. The US-OT probe resolved blood vessels and lipid up to a depth of 6 mm. Negative and positive margins were discriminated by marked differences in the distribution patterns of lipid and Hb. US-OT assessments were concordant with histopathologic findings in 87 of 89 margins assessed (one margin was uninterpretable and excluded), with diagnostic accuracy of 97.9% (kappa = 0.79). The sensitivity, specificity, PPV, and NPV were 100% (4/4), 97.6% (83/85), 66.7% (4/6), and 100% (83/83), respectively. CONCLUSION: US-OT was capable of providing distribution maps of lipid and Hb in lumpectomy specimens that predicted tumor margins with high sensitivity and specificity, making it a potential tool for intraoperative tumor margin assessment.     

Diagnostic value of unusual gross appearance of aspirated material from endoscopic ultrasound-guided fine needle aspiration of pancreatic and peripancreatic cystic lesions

OBJECTIVE: To evaluate the diagnostic value of the gross appearance of aspirated material from endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of pancreatic orperipancreatic cystic lesions. STUDY DESIGN: This study focuses on nonneoplastic (peri)-pancreatic cystic lesions on EUS-FNA. Eight cases were identified with distinct gross appearances of aspirated material by the authors' experience and by computerized review. Gross observations are evaluated together with clinical data, radiologic findings, laboratory markers and cytologic and surgical microscopy findings. RESULTS: Aspiration of cystic lesions often results in nonspecific cytologic findings. Gross and microscopic appearance of aspirated material can provide valuable information. We divide findings of 8 cystic lesions into 3 different patterns according to their gross appearance at on-site EUS-FNA: Pattern 1, 2 cases of biloma; Pattern 2, 1 case of lymphoepithelial cyst with sebaceous differentiation; Pattern 3, 3 cases of regular lymphoepithelial cysts and 2 cases ofpancreatic pseudocyst. CONCLUSION: The full value of FNA is achieved only with the integrated approach, including the gross appearance of the cytology specimens. Certain unusual gross appearances of the aspirated material can add valuable information toward a pathologic diagnosis.     

Prediction of recurrence using exfoliative cytology and melanoma‐associated antigen‐A mRNA analysis following wide excision of oral squamous cell carcinoma: short report

N. Mollaoglu, P. Metzler, J. Zenk, E. Nkenke, F. W. Neukam and J. Ries
Prediction of recurrence using exfoliative cytology and melanoma‐associated antigen‐A mRNA analysis following wide excision of oral squamous cell carcinoma: short report Background: Oral squamous cell carcinoma (OSCC) is the sixth most common cancer. The local recurrence of OSSC might result from the existence of occult cancer cells around tumour margins. Exfoliative cytology has lately gained great importance as a method for obtaining RNA samples from suspicious oral mucosal lesions in order to carry out molecular diagnosis. In addition, melanoma associated‐A antigens (MAGE‐A) are expressed in various tumours and their detection is a highly accurate sign that cancer cells are present. Objective: The prediction of a recurrence using MAGE‐A mRNA expression analysis to follow‐up OSCC cases using a newly established molecular diagnostic technique applied to cytological materials. Methods: RNA was extracted from three recurrent OSCC cases and from 20 healthy volunteers as a control group using a cytobrush. The expression of MAGE‐A3, A4, A6, A10 and A12 was investigated in these specimens using quantitative real‐time (RT‐PCR). Results: There was no expression of MAGE‐A in the specimens of normal oral mucosa. However, the expression analysis of five different MAGE‐A genes indicated a high potential for malignant change in biopsy‐proven recurrent OSCC cases. Except for MAGE‐A10, the rest of the genes were expressed in different ratios by the three recurrent cases, which had been determined on histopathology to be OSCC or carcinoma in situ. Conclusion: It is suggested that analysis of MAGE‐A expression may be used as a risk prediction method in the diagnosis of recurrence after wide excision of OSCC to enhance the accuracy of exfoliative cytology, which has limitations due to false negative and false positive results.     

A method of assessing the adequacy of trucut biopsy specimens obtained with a 19-gauge trucut core biopsy needle

OBJECTIVE: To develop a simple and accurate method of evaluating trucut biopsy (TCB) specimen. STUDY DESIGN: We performed 40 ex vivo TCBs of surgical specimens under direct visual guidance with the Quick-Core needle (Wilson-Cook, Winston-Salem, North Carolina, U.S.A). Touch preparations were made using 4 methods. Slides were stained with a modified Wright-Giemsa stain, and biopsies were processed for histology. Slides were blindly classified as malignant, suspicious, atypical, benign or inadequate. The ease of the 4 touch preparation methods was compared. RESULTS: There were 20 TCBs of benign tissue and 20 of malignant tissue. Cytologic interpretation could be made in 34 of 40 cases and was correct in 25 of 34 cases. Touching the biopsy to a glass slide was significantly easier than the 3 other methods tested. CONCLUSION: Touch preparations can be made easily with TCB samples and can provide information about specimen adequacy and diagnosis.     

Semiquantitative assessment of c-erbB-2 (HER-2) status in cytology specimens and tissue sections from breast carcinoma

OBJECTIVE: To determine whether various methods of fixation of surgical pathology specimens from breast carcinomas would influence the outcome of evaluation of the expression levels of c-erbB-2 (HER-2). For this, comparisons were made between (1) alcohol-fixed (95%) and air-dried smears from fresh surgical pathology specimens of breast carcinomas, and (2) formalin-fixed, paraffin-embedded tissue sections of the same specimens. STUDY DESIGN: Alcohol-fixed and air-dried smears or touch preparations were made from 30 fresh mastectomy/lumpectomy surgical pathology specimens from breast carcinomas. Immunohistochemistry was performed using the c-erbB-2 primary antibody against the extracellular domain of the c-erbB-2 gene product. Staining was simultaneously performed on formalin-fixed, paraffin-embedded tissue sections of the same specimens. A semiquantitative approach was used for evaluation of immunostaining by three independent investigators, and a consensus was reached. RESULTS: A total of 30 cases were reviewed. Tissue positivity was determined for c-erbB-2 in: 73% of alcohol-fixed specimens (n = 13 [3+] and n = 9 [2+]), 67% of air-dried smears (n = 9 [+3] and n = 11 [+2]) and 47% (n = 8 [+3]) and n = 6 [+2]) of formalin-fixed, paraffin-embedded tissue specimens. All formalin-fixed tissue specimens that were determined to positively express c-erbB-2 were also found to be positive on the alcohol-fixed smears. CONCLUSION: The incidence of c-erbB-2 expression in fresh cytologic material is significantly higher (P < .05) than in formalin-fixed, paraffin-embedded tissue. Alcohol-fixed smears demonstrate a slightly higher percentage of cell staining and stronger intensity of c-erbB-2 expression than the matched, air-dried smears. This is a sensitive and simple processing method that can be routinely applied in surgical pathology or fine needle aspiration biopsy specimens for the detection of c-erbB-2 (HER-2), with clinical implications.     

False "false-positive" results in diagnostic cytology

With the introduction of transbronchial brushings and fine needle aspiration biopsy, which enable us to obtain samples directly from lesions, the diagnostic potential of cytology for the detection of malignancy, including early cancer, has been greatly enhanced. From 1976 to 1982, five positive cytology reports were initially considered to be "false positives" on the basis of negative gross findings, benign operative biopsies or negative histologic findings in the resected surgical specimens. However, these proved to be false "false positives," based upon the clinical follow-up or further examination of the surgical specimens. Presentation is made of three of these cases with positive cytologic findings and initially negative histologic diagnoses, with an analysis of the causes of the latter. From our experience, four types of cancerous lesions seem prone to being missed during gross examination, namely: any small cancer with a consistency similar to that of the parenchyma of the organ in which the tumor is located, superficially invasive carcinoma, scar cancer and a radiologically occult lung cancer in the presence of a coexisting radiologically demonstrable lesion. With more clinical application of these cytologic methods, false "false positives" are expected to occur more often.     

Increasing diagnostic accuracy with a cell block preparation from thin-layer endometrial cytology: a feasibility study

OBJECTIVE: To investigate (1) the feasibility of preparing cell blocks by inverted filter sedimentation (IFS-CB) from endometrial samplings processed by the ThinPrep (TP) technique (Cytyc Corp., Boxborough, Massachusetts, U.S.A.), and (2) the possibility of increasing the diagnostic accuracy of TP endometrial cytology by examining the tissue architecture as an adjunctive method of detecting endometrial lesions. STUDY DESIGN: Three hundred one endometrial samplings were obtained, using the Endogyn endometrial device (Biogyn S. n.c., Italy), from perimenopausal and postmenopausal women. The endometrial samplings were collected in a vial with liquid fixative for the TP processing. One TP slide was prepared from each case. If adequate material remained in the vial after the TP slide preparation, it was processed for IFS-CB preparation. RESULTS: IFS-CB preparation was processed in 263 cases (87%) with adequate material. Diagnoses on IFS-CB preparations obtained by endometrial sampling matched those of the hysterectomy specimens. The addition of IFS-CB histology to the cytologic diagnosis by TP increased the diagnostic accuracy of endometrial cytology to 96.3% and 100% for benign/atrophic endometrium and adenocarcinoma, respectively (p = 0.39 and 0.46). In hyperplasia without atypia and hyperplasia with atypia, the diagnostic accuracy increased significantly, to 96% and 95.3%, respectively (p = 0.037 and < 0.001). CONCLUSION: This study illustrates the merit of linking TP cytology with direct endometrial sampling, including small tissue fragments and material adequate for IFS-CB preparation. TP cytology provides an accurate cytologic diagnosis and the possibility of IFS-CB preparation, which could be a valuable diagnostic adjunct to TP cytology.     

Fine needle aspiration cytology of ovarian lesions

OBJECTIVE: To assess the diagnostic value of fine needle aspiration cytology (FNAC) in ovarian lesions. STUDY DESIGN: Sixty-two fine needle aspirations of varied ovarian masses were performed between January 2000 and February 2003. Aspiration material was obtained from fresh tissues at the time of frozen section before dissection of the specimens. The slides were evaluated by a pathologist who was blinded to the gross findings and histopathologic diagnosis. RESULTS: A total of 62.9% of cases were assessed as malignant and 30.6% as benign. Two false positive and 2 false negative cases occurred. In our series the overall sensitivity and specificity were 95.1% and 90.4%, respectively. Seven benign and 15 malignant lesions could be subclassified specifically. CONCLUSION: We studied excised specimens, but since ovarian masses are reachable by laparoscopically and ultrasonographically guided aspiration, FNAC can be used for diagnoses of these lesions. If a multidisciplinary approach can be carried out in patients with ovarian lesions, cytopathologic interpretation can provide optimum benefits.     

The utility of assessing the gross appearances of FNA specimens

F. Mayall, A. Cormack, S. Slater and K. McAnulty The utility of assessing the gross appearances of FNA specimens Objective: Ideally, fine needle aspiration (FNA) cytology should be performed with near‐patient assessment of the adequacy of the specimen by a cytopathologist. However, this is often not feasible. A cruder alternative is for the FNA practitioner to examine the gross appearances of the specimen and to try to predict the its quality. This study set out to determine the value of this approach. Methods: The study was conducted in tertiary public hospitals in New Zealand and the UK. FNA gross material grading was performed by a variety of pathologists on FNA samples taken using manual guidance and image guidance. The FNA gross material grade was compared with the findings on microscopic examination. Results: Nine out of 123 FNA samples were assessed as Grade 1 (unlikely to contain diagnostic material). All were subsequently reported as having insufficient diagnostic tissue on microscopic examination. Forty‐two of the FNA samples were assessed as Grade 2 (possibly contains diagnostic material) and 46 as Grade 3 (probably contains diagnostic material). None from either of these grades was reported as showing insufficient diagnostic material on microscopic examination. Twenty‐six cases were reported as Grade 4 (material suggesting a specific diagnosis). None of these was reported as showing insufficient diagnostic material on microscopic examination. The most common Grade 4 provisional diagnosis was that of a colloid cyst or colloid nodule of the thyroid (seven cases). Only two cases had misleading Grade 4 provisional diagnoses. Both were thought to be pus on gross examination but showed necrotic carcinoma on microscopic examination. Conclusions: The gross appearances of FNA samples can usually predict the adequacy of the samples and sometimes predict the final microscopic diagnosis. However, near‐patient microscopic assessment of FNA specimens is preferable if available.     

Diagnosis of bronchial carcinoma on sections of paraffin-embedded sputum. Sensitivity and specificity of an alternative to routine cytology.

The diagnostic accuracy of sputum cytology for the diagnosis of bronchial carcinoma using paraffin-embedded, serially sectioned and hematoxylin and eosin-stained specimens was tested in 4,297 sputum samples from 1,889 patients, 219 of whom had bronchial carcinoma. The diagnostic sensitivity depended mainly on the number of investigated samples and was 85.4% with three sufficient sputa. The sensitivity was not influenced by the histologic types, location or TNM stage of the tumor. The specificity of the method was 99.5%. In three cases localization of sputum cytologically diagnosed bronchial carcinomas was not possible immediately (occult carcinomas, pTx); in two of these cases the bronchial carcinomas were located during follow-up. The third patient died without verification of the cytologic diagnosis. According to our results, sputum cytology on serial sections is a valuable instrument for mass screening of high-risk groups for the early detection of bronchial carcinoma. Lower sensitivities of sputum cytology in mass screening programs for the early diagnosis of lung cancer are discussed critically.     

Usefulness of bile cytology in the diagnostic management of patients with biliary tract obstruction

Eighteen patients with evidence of biliary tract obstruction had a total of 29 satisfactory bile samples submitted for diagnostic cytology during a two-year period. These 29 specimens were reviewed in order to determine if bile cytology is useful in the diagnostic management of patients with obstructive biliary tract disease. Twenty-one of the bile specimens were from patients with malignant biliary stricture, and eight were from patients with benign biliary obstruction. Bile cytology was positive for carcinoma in eight samples from patients with malignant stricture and was inconclusive for malignancy in two. There were no false positives. The diagnostic specificity of bile cytology was 100%, the diagnostic sensitivity was 48%, and the diagnostic accuracy was 62%. When carefully collected and promptly processed, bile proved an excellent specimen for cytologic evaluation and was a valuable adjunct to other diagnostic procedures for the detection of carcinoma causing biliary tract obstruction.