Diagnostic value of needle aspiration cytology in the assessment of palpable axillary lymph nodes. A study of 336 cases

OBJECTIVE: To evaluate the diagnostic value of needle aspiration cytology (NAC) in the assessment of palpable axillary lymph nodes and determine whether ancillary procedures can be useful in enhancing the diagnosis. STUDY DESIGN: The material was analyzed in 336 cases with enlarged axillary lymph nodes in which NAC were performed by the conventional method. In all cases cytologic examination was done on site after staining the smears with the Papanicolaou method. In addition, air-dried smears, fixed smears, filter preparations from needle washings and cell blocks were studied. The NAC diagnosis was supported by examining cell blocks, which showed the reliability of histologic architecture; further support was obtained with tissue biopsy and/or comparison with the primary tumor in some of the cases. RESULTS: Twelve cases were diagnosed as inflammatory lesions, and 64 were unsatisfactory due to scanty/acellular samples (despite 2-3 repeat samplings). However, in 6 of these, malignant tumors were later found on a biopsy done due to persistent and continued enlargement of an axillary lymph node or nodes. One hundred twenty-two cases were regarded as negative (normal cellular elements, n = 52; reactive elements, n = 70), and 4 cases were suspicious for malignancy. In 124 cases a variety of metastatic tumors were diagnosed (breast, n = 63; melanoma, n = 22; others, n = 39), and in 10 cases a diagnosis of lymphoma was made. CONCLUSION: NAC of palpable axillary lymph nodes as a first-line of investigation is a cost-effective procedure and is not only useful in the diagnosis of various lesions but can also help in deciding on management. Also, histologic architecture from cell blocks can be correlated with cytology, and such material can be used for histochemical and immunomarker studies.     

Decisive role of intermediate filament typing of tumor cells in the differential diagnosis of difficult fine needle aspirates

Thirty-six diagnostically difficult fine needle aspirates from enlarged lymph nodes and malignant soft tissue tumors, containing tumor cells with scanty or no obvious light microscopic features indicative of their differentiation, were assessed by a panel of six cytopathologists. Their diagnoses were recorded and then compared with the definitive diagnosis established by combining the cytologic findings with the results of intermediate filament typing of tumor cells in the smears using monoclonal antibodies specific for each filament type. The results show that use of these antibodies can markedly improve the accuracy of the cytologic diagnosis of tumor type as well as revise or prevent erroneous cytologic diagnoses in difficult cases. This pertains especially to the differential diagnoses of carcinoma versus malignant lymphoma, carcinoma versus malignant melanoma, carcinoma versus sarcoma and squamous carcinoma versus carcinoma of simple epithelia. Intermediate filament typing of tumor cells in aspirates as an objective histogenetic criterium makes the differential diagnosis of the difficult aspirates much more reliable and reproducible, provided that appropriate questions are asked, monoclonal antibodies with well-defined specificities are used and the antigenicity of the intermediate filaments in smears is preserved.     

The diagnostic value of fine needle aspiration cytology (FNAC) in the assessment of palpable supraclavicular lymph nodes: a study of 218 cases

The aim of this study was to evaluate the diagnostic value of fine needle aspiration cytology (FNAC) in the assessment of palpable supraclavicular lymph nodes. The material was analysed in 218 cases with enlarged supraclavicular lymph nodes in which FNAC was performed by the conventional method. In all cases cytological examination was performed on-site after staining the smears by the Papanicolaou method. In addition, air-dried smears, fixed smears, filter preparations from needle washings and cell blocks were studied. The FNAC diagnosis was supported by examining cell blocks which added the reliability of histological architecture; further support was obtained by tissue biopsy and/or comparison with the primary tumour in some of the cases. Eleven cases were diagnosed as inflammatory lesions and 41 cases were unsatisfactory because of scanty/acellular samples (despite two to three repeat samplings). However, in five of these, malignant tumours were later found on biopsy, which was done for persistent enlargement of the supraclavicular lymph node(s). Fifty-three cases were diagnosed as negative for malignancy (normal cellular elements, n=15; reactive elements, n=38) and 12 cases were suspicious of malignancy. In 11 cases a diagnosis of lymphoma was made on histology and in 90 cases metastatic tumours were diagnosed. The overall sensitivity was 92.7%, specificity 98.5%, positive predictive value 97.3% and the negative predictive value was 94.8%. Based on our study we feel that FNAC of palpable supraclavicular lymph nodes as a first line of investigation is a cost-effective procedure and is not only useful in the diagnosis of various lesions but can also help in deciding on appropriate management. Furthermore, the histological architecture from cell blocks can be correlated with cytology, and such material can be used for appropriate histochemical and immunomarker studies, which can be useful in enhancing the diagnosis.     

Sediment cytology in bone biopsies

The cytologic examination of smears prepared from the sediment of biopsy specimen fixatives ("sediment cytology") was used to study 70 bone lesions biopsied with a suspicion of malignancy. The smears were adequately cellular in most cases and showed good morphologic preservation; some contained fragments of tissue. Cytology was able to identify the smears from the 47 malignant lesions as malignant, but was not always able to identify the histologic type. While the osteoclastomas, Ewing's sarcomas and metastatic carcinomas were accurately diagnosed, the osteogenic sarcomas could only be identified as sarcomas and the scanty smears from chondrosarcomas only permitted a diagnosis of malignancy. The latter was also true for soft tissue lesions and lymphoma involving the bones. The 12 benign lesions yielded less cellular specimens and were more difficult to cytologically diagnose. The 11 inflammatory lesions were identified as nonmalignant. While this simple technique of sediment cytology can provide an early diagnosis for bone lesions, the final diagnosis requires the histopathologic study of the actual biopsy specimen.     

Cell block as an adjunct to conventional Papanicolaou smear for diagnosis of cervical cancer in resource-limited settings

OBJECTIVE: To assess the utility of indigenously prepared cell blocks (CBs) as an adjunct to a conventional smear test in providing a reliable diagnosis of clinically suspicious cervical cancer in resource-limited settings. METHODS: Eighty-six clinically suspicious cervical cancer cases underwent a conventional smear test, CB preparation from residual cellular samples and biopsies at the same sitting. Correlations were performed between these modalities in order to derive the sensitivity and specificity of the CB technique to diagnose cervical cancer. OBSERVATION & RESULTS: Out of 86 clinically suspicious cervical cancers, 72 (83.7%), 70 (81.4%) and 67 (77.9%) cases were diagnosed as malignant on tissue biopsies, CBs and smears respectively. CB-biopsy agreement in the diagnosis of malignancy was feasible in 87.5% of the cases while CB-Pap smear agreement was feasible in 92.5% of the cases. Sensitivity and specificity of CB preparation to diagnose malignancy was 92.5% and 100%, respectively, when the smear was taken as the reference test (excluding the unsatisfactory smears). When biopsy was taken as the gold standard, the sensitivity and specificity of CBs were 87.5% and 100% respectively (excluding the unsatisfactory biopsies). In 8/19 cases where the smear diagnoses were either unsatisfactory or atypical squamous cells/atypical glandular cells, CBs picked up malignant lesions. CONCLUSION: CBs prepared from the residual cellular sample of conventional cervical scrapes augment the sensitivity of the smear test. When used as an adjunct to the smear, CBs aid in providing a reliable diagnosis of cervical cancer in the majority of the clinically suspected cases and thus the biopsy load can be reduced significantly in resource-poor settings.     

Fine needle aspiration cytology of well-differentiated liposarcoma. A report of two cases

BACKGROUND: Well-differentiated liposarcoma is difficult to diagnose on fine needle aspiration cytology (FNAC) smears and may create considerable diagnostic problems. CASES: Males aged 60 and 45 years presented with a swelling in the groin and retroperitoneal region, respectively. FNAC showed large cells with multilobulated nuclei and mature-looking fat tissue. A soft tissue tumor with bizarre cells was diagnosed cytologically in case 1 and liposarcoma in case 2. Histologically, both cases were diagnosed as well-differentiated sclerosing liposarcoma. CONCLUSION: The cytologic diagnosis of well-differentiated liposarcoma should be done with caution, and the sites should be taken into consideration. Deep-seated tumors with large, bizarre, giant cells should have wide excision as they recur more frequently.     

Nonaspiration-needle smear preparations of pulmonary lesions. A comparison of cytology and histology

Material for cytologic smears was obtained from pulmonary lesions in 146 patients at the Ohio State University between 1979 and 1984 using Rotex or Lee screw needles. Corresponding histologic specimens were available for comparison in 77 of these cases. Diagnoses of malignant neoplasms made by cytologic evaluation (55 cases) were confirmed by the corresponding histologic specimens in 93% of those cases. Possible explanations for the cytologic false-positive diagnoses of malignancy are presented. Correlations between the cytologic and histologic diagnoses of the morphologic type of tumor were 100% for adenocarcinoma, 75% for squamous-cell carcinoma and 20% for large-cell undifferentiated carcinoma. The correlation was 100% for small-cell carcinoma when the histology specimen represented the tumor. Nonneoplastic benign lesions diagnosed cytologically had corresponding benign histologic diagnoses in 94% of the cases. These results compare favorably with those reported for other fine needle aspiration studies of pulmonary lesions. The advantages of using Rotex needles as compared to fine needle aspiration are discussed.     

Negative predictive value of pulmonary fine needle aspiration cytology.

Percutaneous fine needle aspiration (FNA) for cytologic examination is an accepted and reliable technique for diagnosing neoplasia. It is less useful, however, in excluding that diagnosis. We performed a retrospective analysis of a consecutive series of pulmonary FNA specimens at Memorial Sloan-Kettering Cancer Center to determine the negative predictive value (NPV) of this technique in the setting of a large cancer hospital. Fifty-seven cases were studied. Six cases (10.5%) were initially diagnosed as negative but acellular and were not further analyzed, and another 6 were lost to follow-up; 24 cases (42.1%) were subsequently confirmed negative by tissue or clinical follow-up, and 21 of the cases (36.8%) were proven positive for malignancy by repeat aspiration, tissue diagnosis or clinical means. Of these 21 cases, 1 was misdiagnosed as negative, and review demonstrated malignant cells on the slide; 3 of the 21 cases should have been initially rejected as unsatisfactory, and 18 of the 21 contained material sufficient for a cytologic diagnosis but not representative of the lesion. On follow-up the false-negative cases showed primary adenocarcinoma, epidermoid carcinoma, lymphoma, metastatic breast carcinoma and metastatic sarcoma. Specific benign diagnoses were made on the initial cytologic preparation in three cases. No benign tumors were found. The NPV in our series was 53.3%, comparable to values in previous reports. The single largest factor contributing to false-negative diagnoses is sampling error, and we recommend repeat aspiration when no specific benign diagnosis is made. In addition, we suggest that the diagnoses of negative for malignant cells and insufficient for diagnosis or acellular be considered separate categories.     

Hydatid cyst in soft tissues mimicking malignant tumors. Diagnosis by fine needle aspiration cytology

OBJECTIVE: To evaluate the role of fine needle aspiration cytology in the diagnosis of soft tissue hydatid cysts. STUDY DESIGN: Five cases of soft tissue hydatid cyst were diagnosed primarily by fine needle aspiration cytology. RESULTS: In all cases, large fragments of acellular material, finely lamellated, were found. There were no complications related to fine needle aspiration, and histologic studies confirmed the diagnosis of hydatid cyst. CONCLUSION: When acellular, laminated fragments suggestive of a laminated layer are identified on smears, hydatid cyst should be considered in the differential diagnosis, even in atypical locations and in the absence of hooklets, protoscolices or both.     

Radial scar/complex sclerosing lesion—a problem in the diagnostic work-up of screen-detected breast lesions

During the first 7.5 years of breast cancer screening in South Australia, 88 radial scar/complex sclerosing lesions were among the mammographically detected abnormalities. A false-positive cytological diagnosis by fine needle biopsy was given in three of 69 such cases with satisfactory smears, a false-positive rate of 4.3% in this particular group. A review of the smears suggested that the false-positive diagnoses could have been avoided if a total or near total absence of a benign epithelial component had been included among the criteria for a malignant diagnosis. However, even after review, atypia was considered sufficiently worrying to be reported as a suspicion of malignancy in 7% of cases.     

Fine needle aspiration biopsy in the evaluation of lymphoreticular tumors of the thorax

The role of fine needle aspiration (FNA) biopsy in the evaluation of lymphoreticular disorders involving the lung and mediastinum was evaluated in a study of 16 cases from the authors' institutions. The cytologic material from these cases was reviewed, and the original cytologic interpretations were compared to the tissue diagnoses, with the overall accuracy of the cytologic interpretation evaluated. There were no false-positive diagnoses of malignancy in this series. A definite diagnosis of malignant lymphoma was most readily made in those cases in which the lymphoma was of the large-cell type. Small-cell and mixed large-cell and small-cell lymphoid proliferations were less able to be definitively interpreted, with pseudolymphoma presenting particular difficulty. The results support the conclusion that FNA biopsy can be useful in evaluating these lesions but also emphasize the fact that accurate diagnosis requires correlation of cytologic, clinical and laboratory data.     

Cytology of collagenous spherulosis of the breast: a diagnostic dilemma – report of three cases

Collagenous spherulosis is a rare incidental finding seen in association with benign breast lesions. Cytological findings in three cases of collagenous spherulosis diagnosed on fine needle aspiration are presented. The presence of hyaline pink globules surrounded by benign myoepithelial cells in Giemsa stained smears was a diagnostic feature. Associated lesions were atypical papillary hyperplasia (2) and fibroadenoma (1). Adenoid cystic carcinoma was the close differential diagnosis on cytology. Awareness of this entity is important to avoid a false positive diagnosis of malignancy.     

Cytopathological diagnosis of alveolar soft part sarcoma,a rare soft tissue neoplasm

S. Agarwal, R. Gupta, V. K. Iyer, S. R. Mathur and R. Ray Cytopathological diagnosis of alveolar soft part sarcoma, a rare soft tissue neoplasm Objective: Alveolar soft part sarcoma (ASPS) is a rare soft tissue neoplasm, having various morphological mimics, especially on fine needle aspiration cytology (FNAC). Because no definite immunohistochemical markers are available to aid a correct diagnosis, knowledge of the cytomorphological features is essential for correct patient management. Cytological features of five cases of ASPS are discussed, along with the ultrastructural findings available in one of them. Methods: Cytology records from 1997 to 2009 were reviewed for cases with a diagnosis of ASPS on cytology. The histology slides of the cases were also assessed for confirmation of the diagnosis. All the slides were reviewed by three pathologists. Results: There were five cases of ASPS diagnosed on FNAC. Their cytological features were noted in detail. The diagnoses in all the cases were confirmed on histology, and ultrastructural findings available in one of them were also assessed. Conclusions: The knowledge of cytological features may aid in diagnosing this rare tumour correctly on FNA smears, thus enabling correct patient management.     

The role of fine needle aspiration cytology in the diagnosis of lymphoma

The accuracy of fine needle aspiration (FNA) cytology for the diagnosis of lymphoma and other hematolymphoid malignancies was investigated by a review of 158 FNA specimens from 143 patients. Patients included in the study had either a diagnosis of a hematolymphoid malignancy by FNA cytology or a biopsy diagnosis of lymphoma that was preceded by FNA cytology. Biopsy specimens were obtained from 85% of the patients. Of the 158 needle aspirates, 118 (75%) were diagnosed as lymphoma, 13 (8%) as suspicious of lymphoma, 8 (5%) as myelomas, 3 (2%) as leukemias, 12 (8%) as positive for malignancy and 4 (2%) as negative for malignancy. Two of the 118 needle aspirates diagnosed as lymphoma were false positives while 3 of 13 diagnosed as suspicious for lymphoma were found to be benign. Overall, there were four false negatives. Morphologic subclassification of the lymphomas, originally attempted for 60 needle aspirates, was identical to the histologic subclassification in 51 cases (85%). FNA cytology provided the initial diagnosis of a hematolymphoid malignancy in 51% of the cases and allowed the documentation of recurrent disease in 49%. The results demonstrate the usefulness of FNA cytology for the diagnosis and management of patients with lymphoma.     

Transthoracic needle aspiration biopsy. Review of 233 cases

In 233 cases in which transthoracic needle aspiration was done at the Mayo Clinic from 1980 through 1983, the cytology slides, tissue fragments and patient histories were reviewed; the original and review diagnoses were compared and correlated with the subsequent clinical course. In most cases, the procedure was performed with an 18-gauge needle under fluoroscopic guidance, primarily in cases with suspected malignant masses that were considered to be not surgically resectable. In 70% of the cases, there was a history of malignancy, and 82% of the malignant lesions were of extrapulmonary origin. Correlation of the original diagnosis with the clinical course yielded 70% (164 cases) true positives, 6% (14 cases) true negatives, 16% (37 cases) false negatives, 0% false positives and 8% (18 cases) indeterminants. In none of the false-negative cases was the slide subsequently read as positive in a blind review. Of the true-positive cases, 12% had positive tissue fragments only, 37% had positive cytology smears only, and 51% had both positive smears and fragments. In 32% of the cases, there were radiologically demonstrable pneumothoraces, and in 12%, placement of a chest tube was required. Hemoptysis occurred in less than 5% of the cases. In summary, transthoracic needle biopsy provides an efficient way to accurately obtain diagnostic tissue, with acceptable minor complications.     

Primitive neuroectodermal tumor of the kidney. A report of two cases diagnosed by fine needle aspiration cytology

BACKGROUND: Primitive neurocetodermal tumors (PNETs) constitute a family of neoplasms of presumed neuroectrodermal origin most often presenting as bone or soft tissue masses. There are very few reported cases of PNET of the kidney and none diagnosed by fine needle aspiration cytology (FNAC), to the best of our knowledge, in the world literature. We present two cases of renal PNET diagnosed on cytology. CASES: Two patients with renal masses were diagnosed as having PNET on FNAC. Cytologically the tumors showed a dispersed population of malignant small round cells with focal rosette formation and perivascular arrangement of tumor cells. Immunohistochemistry on the cell blocks in both cases showed strong membrane positivity for CD99 (MIC2). Cytogenetic studies in both cases showed the characteristic t(11;22)(q24;q12) translocation, with additional chromosomal abnormalities in case 2. CONCLUSION: PNET of the kidney is a distinct entity and can be diagnosed on fine needle aspiration smears and confirmed with immunohistochemistry and cytogenetic studies. A diagnosis of PNET must be included in the differential diagnosis of renal masses in adolescents and young adults.     

Needle aspiration cytodiagnosis of the breast with abundant acellular calcific material mimicking soft tissue calcinosis

OBJECTIVE: To investigate calcific deposits in breast tissue by needle aspiration cytology (NAC). STUDY DESIGN: The aspirate was obtained using a disposable 10-mL syringe and 22-gauge needle. No smears were made, and material was collected as needle and syringe washings in a cytology container in which 30% ethyl alcohol in physiologic saline was present. From about half of this material, filter preparations were made on 3-microm Schleicher and Schuell filters and stained by the Papanicolaou method; the remainder of the aspirate was spun, and a cell block was made from the sediment and sections cut and stained with hematoxylin-eosin (H-E) stain. RESULTS: The filter preparations and sections of cell block in all the cases showed numerous amorphous, basophilic, deep-stained fragments of refractile material and some fragmented bod ies and concentric lamellations, which were diagnosed as calcium. No breast elements or malignant cells were found. The patients had no further treatment and on follow-up were clinically well, with no changes. CONCLUSION: The 9 cases described are interesting because the cytohistologic findings in the NAC sample mimicked soft tissue calcinosis.     

Adult-type rhabdomyoma of the palate. Cytologic presentation of two cases with histologic and immunologic study

The cytologic presentations of two adult-type rhabdomyomas of the soft palate are reported. Fine needle aspiration smears of the lesions contained globular tumor cells that had striations and intracytoplasmic rod-shaped inclusions. These inclusions, corresponding to hypertrophied Z bands, were pathognomonic of rhabdomyoma tissue. The cytologic diagnosis was confirmed by histologic and immunologic studies in both cases. The cytologic preparations fixed in alcohol or air dried did not show the "spiderweb cells" observed in the histologic sections of tissue fragments fixed in formaldehyde; this clearly illustrates that the morphology of the cells of this tumor depends primarily on the specimen preparation technique used. These cases suggest that aspiration cytology can establish the diagnosis of this benign tumor of striated muscle, for which total surgical removal is usually sufficient to effect a cure. The differential diagnosis is discussed in detail.     

FNAC of malignant lymphoma in an area with a high incidence of T-cell lymphoma. Correlation of accuracy of cytologic diagnosis with histologic subtype and immunophenotype

OBJECTIVE: To analyze the usefulness of fine needle aspiration cytology on malignant lymphoma in an area with a high incidence of T-cell lymphoma and to correlate the accuracy of cytologic diagnosis with histologic subtype and immunophenotype. STUDY DESIGN: We retrospectively studied the usefulness of fine needle aspiration cytology in the diagnosis of 49 cases of nodal and extranodal non-Hodgkin's lymphoma (NHL) and seven cases of Hodgkin's disease in a total of 56 patients in whom subsequent excisional biopsy revealed lymphoid malignancy. Slides showing the results of cytologic investigation were reviewed together with the information on which histologic diagnosis was based. On the basis of pathologic variables, such as prognostic groups based on the Working Formulation, so-called grade, cell size based on the modified Rappaport classification, and--in cases of NHL--immunophenotype, the accuracy of original and reviewed cytologic diagnoses was compared. RESULTS: Of the 49 cases of NHL, 8 (16.3%) were inadequate for cytologic diagnosis, and malignant lymphoma was diagnosed or suspected in 36 (73.5%), excluding inadequate specimens; the diagnostic accuracy for NHL was 87.8%. In high grade cases, malignant lymphoma was more easily diagnosed or suspected than in those that were low or intermediate grade. The rate of inadequate cases was highest in the "mixed small and large cell" category, and cases that were "false negative" were either composed entirely of small cells or contained a small cell component. Cytologic diagnosis or suspicion of malignant lymphoma was easily obtained in the "large cell" category, followed by mixed small and large cell and "small cell." Aspirates from non-B-cell type were more frequently acellular than those of B-cell type; with regard to diagnostic accuracy, however, there was no noticeable difference between the two immunophenotypes. CONCLUSION: In many cases in the mixed small and large cell category or where the immunophenotype was non-B, the aspirate was inadequate, and no definitive diagnosis was possible. Many of our cases of T-cell lymphoma were mixed small and large cell, and in Korea, where the incidence of extranodal and T-cell lymphoma is high, the usefulness of FNAC for the initial diagnosis of malignant lymphoma is limited. For a definitive diagnosis, biopsy is required.     

Hodgkin lymphoma: flow me?

Combining fine needle aspirate cytology with flow cytometry immunophenotyping for the rapid diagnosis of lymphoproliferative lesions is commonplace practice in many institutions. Yet, a definitive diagnosis of Hodgkin lymphoma in many cases remains elusive, requiring subsequent tissue biopsy confirmation. In this issue of CytoJournal, Hernandez et al explore the potential role of using the increased CD4/CD8 T-cell ratio in lymph node fine needle aspiration specimens as a specific feature in diagnosing Hodgkin lymphoma. CD4/CD8 T-cell ratio comparisons are made with cytomorphologic diagnoses of reactive, atypical, non-Hodgkin lymphoma, and Hodgkin lymphoma cases.