Fine needle aspiration cytodiagnosis of liver tumors

OBJECTIVE: To present our experience with liver fine needle aspiration (FNA) diagnosis and the adjunctive use of cell blocks with reticulin stain. STUDY DESIGN: The authors reviewed the results of cytopathologic diagnosis obtained by FNA biopsy over a 1-year period, from January 2000 to December 2000, in patients who presented primarily with ultrasonographically suspected liver nodules. FNA smears from 936 patients and cell blocks from 796 patients were reviewed. RESULTS: Among the 936 aspirates studied, the most common malignancy was hepatocellular carcinoma (HCC), which was diagnosed in 427 cases (45.6%), followed by metastatic adenocarcinoma, with 52 cases (5.6%). The concurrent cell block was available in 796 cases. Among them, 574 (72.1%) contained sufficient tissue for diagnosis. Combining analysis of cytologic and histologic specimens, the sensitivity of ultrasound-guided FNA for diagnosis of liver tumors was 85.1% and the specificity 98.7%. The results were better than isolated cytologic analysis, which gave a sensitivity of 78.4% and specificity of 97.4%. The lower diagnostic accuracy of cytology resulted mainly from its lower ability to distinguish well-differentiated HCC from benign lesions. In the cell block sections with reticulin stain, all HCCs showed a decreased or absent reticulin pattern, whereas all the benign hepatocellular lesions usually had a normal trabecular reticulin framework. CONCLUSION: FNA cytology assisted by cell block examination can be an accurate and minimally invasive method for the definitive pathologic diagnosis of primary benign and malignant liver masses and for confirmation of tumors metastatic to the liver. In addition, reticulin staining should be part of the routine assessment of cell blocks. It enhances diagnostic accuracy, particularly for well-differentiated HCC.     

Application of the immunoperoxidase technique to cell block preparations from fine needle aspirates

Immunocytochemistry on fine needle aspiration (FNA) material has been mainly performed on cytologic preparations; there have been few reports on the use of FNA cell blocks. This study compared the intensity scores of immunoperoxidase staining on FNA cell block preparations from 21 breast, 12 thyroid and 10 lymph node aspirates with the scores on the corresponding surgically excised specimens. FNA materials for cell blocks were fixed in formalin and embedded in agar. Ten commercially available antibodies forming three panels were studied using standard peroxidase-antiperoxidase and avidin-biotin complex techniques. In general, the staining results on the FNA cell block sections agreed with those on the surgical specimens; in addition, there were fewer aberrant positive staining results and much less background staining in the cell block sections. These phenomena were most striking with the cytokeratin antibodies. It is concluded that immunoperoxidase staining on FNA cell block preparations is reliable; the advantages of the use of cell block sections as opposed to smears are discussed.     

Papanicolaou stain: Is it economical to switch to rapid, economical, acetic acid, papanicolaou stain?

OBJECTIVE: To standardize an inexpensive and rapid Papanicolaou staining technique with limited ethanol usage. STUDY DESIGN: Smears from 200 patients were collected (2 per patient) and fixed in methanol. Half were subjected to conventional Papanicolaou and half to stain ing with rapid, economical, acetic acid Papanicolaou (REAP) stain. In REAP, pre-OG6 and post-OG6 and post-EA36 ethanol baths were replaced by 1% acetic acid and Scott's tap water with tap water. Hematoxylin was preheated to 60 degrees C. Final dehydration was with methanol. REAP smears were compared with Papanicolaou smears for optimal cytoplasmic and nuclear staining, stain preservation, cost and turnaround time. RESULTS: With the REAP method, cytoplasmic and nuclear staining was optimal in 181 and 192 cases, respectively. The staining time was considerably reduced, to 3 minutes, and the cost per smear was reduced to one fourth. The staining quality remained good in all the smears for > 2 years. CONCLUSION: REAP is a rapid, cost-effective alternative to Papanicolaou stain. Though low stain penetration in large cell clusters is a limitation, final interpretation was not compromised.     

Hepatocellular carcinoma versus carcinoma metastatic to the liver. Value of stains for carcinoembryonic antigen and naphthylamidase in fine needle aspiration biopsy material

Staining for amino acid naphthylamidase and carcinoembryonic antigen (CEA) was examined as an ancillary technique to improve the accuracy of differentiating hepatocellular carcinoma from metastatic carcinoma to the liver in fine needle aspiration (FNA) biopsy specimens. Twenty-four cases of FNA specimens from the liver, in which air-dried smears and/or cell blocks were available, were examined. Naphthylamidase-positive bile canalicular structures were present in 2 cases of hepatocellular carcinoma and absent in 8 cases of metastatic carcinoma studied. Ninety percent of the hepatocellular carcinomas were immunoreactive with the antibody to CEA, showing a predominantly bile canalicular pattern. Ninety percent of the cases of metastatic carcinoma were positive with the antibody to CEA, showing a diffuse cytoplasmic pattern. These findings indicate that both staining techniques may be useful in differentiating hepatocellular carcinoma from metastatic carcinoma. Since the naphthylamidase stain requires air-dried smears, which may not be available, whereas immunocytochemistry can be done on fixed material, the latter technique is more practical.     

Species-specific immunocytochemical localization of Mycobacterium tuberculosis complex in fine needle aspirates of tuberculous lymphadenitis using antibody to 38 kDa immunodominant protein antigen

OBJECTIVE: To examine immunocytochemical localization of Mycobacterium tuberculosis (MTB) complex antigen in fine needle aspiration (FNA) smears of tuberculous lymphadenitis (TBLN) using species-specific monoclonal antibody MTSS to 38-kDa immnunodominant protein antigen as a diagnostic adjunct to conventional cytomorphology and its advantage over Ziehl-Neelsen (ZN) microscopy. Study Design FNA smears from 340 cases-174 TBLN; 34 negative controls from nontuberculous, positive controls of 13 known acid-fast bacilli (AFB)-positive sputum smears; 50 blind controls; and 69 other controls (smears from stock cultures of bacterial, atypical mycobacteria and fungal species) were subjected to ZN and immunocytochemical staining using MTSS by the streptavidin-biotin method. RESULTS: Immunocytochemical staining was positive in 59 of 61 (96.7%) archival and 110 of 113 (97.3%) fresh FNA smears; ZN positivity for AFB was observed in 27 of 61 (44.2%) archival and 48 of 113 (42.4%) fresh FNA smears of TBLN. CONCLUSION: The immunostaining using MTSS showed a definite advantage over conventional ZN staining for detection and specific diagnosis of TBLN in FNA smears with 0% false positive results. Immunostaining of cytosmears with species specific antibody to MTB would prove to be a good diagnostic adjunct to morphologic diagnosis.     

Nucleic acid amplification of Mycobacterium tuberculosis complex DNA from archival fine needle aspiration smear scrapings vs. fresh fine needle aspirates of tuberculous lymphadenitis

OBJECTIVE: To assess the efficacy of the nucleic acid amplification (NAA) technique for Mycobacterium tuberculosis (MTB) complex from archival fine needle aspirate (FNA) smear scrapings of confirmed cases of extrapulmonary tuberculosis (EPTB) for a retrospective diagnosis of EPTB as compared to NAA from fresh FNA material from the same cases. STUDY DESIGN: Smear scrapings from 51 cases; 33 cases of tuberculous lymphadenitis (from patients who had undergone NAA 1 year before for MTB from fresh FNA material); 13 negative controls from nontuberculous, archival FNA smears; and 5 known acid-fast bacilli (AFB)-positive sputum smears, were subjected to NAA using the IS6110 primer sequence of M tuberculosis. Ziehl-Neelsen staining was done in all the smears. RESULTS: Of the 33 cases of tuberculous lymphadenitis, 15 (45.4%) were AFB positive and 18 (64.5%) AFB negative. MTB NAA was positive in 73.3% (11 of 15 AFB-positive cases) in the freshly aspirated material and was observed in 60% (9 of 15 AFB-positive cases) when done on DNA extracted from the archival smear scrapings of the same cases. Similarly, in the 18 AFB-negative cases, MTB NAA positivity was 72.2% (13 of 18) on fresh material and 44.4% (8 of 18) on archival smear scrapings from the same AFB-negative cases. Overall NAA positivity was 51.5% for archival smear scrapings as compared to 71% for fresh FNA of the same cases. CONCLUSION: Low NAA sensitivity of MTB DNA in archival material of known tuberculous cases limits the routine use of NAA based retrospective molecular diagnosis of MTB complex.     

Galectin-3 is not useful in thyroid FNA

INTRODUCTION: Previous studies have suggested that galectin-3 immunohistochemistry may be useful in the fine needle aspiration (FNA) diagnosis of thyroid carcinoma as it has been reported to selectively stain carcinomas and not adenomas or goitres. METHODS: Fifty-one patients were included in a prospective study of galectin-3 in thyroid FNA; 88.2% were female and 11.8% male, mean age 53 years, range 25-87 years. Cell blocks were prepared and stained for galectin-3 if any cells were present in needle washings from the respective FNAs. RESULTS: Twelve of 51 (23.5%) of cell blocks contained epithelial cells. One benign and one inadequate FNA were negative for galectin-3 staining. One of five non-diagnostic FNA cases, a papillary carcinoma on final histology showed positive staining. Four follicular neoplasm/suspicious of carcinoma cases showed negative staining. One malignant FNA case, a papillary carcinoma showed positive staining with galectin-3 but three further carcinomas, two papillary and one follicular were galectin-3 negative. CONCLUSION: Galectin-3 immunohistochemistry does not appear to be a useful adjunct to diagnosis in thyroid FNA as it does not reliably distinguish malignant and benign lesions. Many thyroid aspirates are of low cellularity and are not suitable for cell block immunohistochemistry.     

Effect of fixation on the antigenicity of human lactoferrin in paraffin-embedded tissues and cytocentrifuged cell smears.

Immunoperoxidase techniques were used to study the preservation of the antigenicity of human lactoferrin (LF) of polymorphonuclear neutrophils (PMN) and various exocrine glandular cells in paraffin-embedded tissue blocks and cytocentrifuged cell smears. Tissues fixed in Carnoy's fluid in contrast to other fixatives used, showed good preservation of LF antigenicity irrespective of the fixation time. Cell smears fixed in Carnoy's fluid showed diffuse nuclear and cytoplasmic staining for LF, although morphologic integrity was poorly preserved. Granular cytoplasmic staining for LF with no staining of nuclei was seen in cell smears fixed in buffered formol acetone for 2--10 min. The nature of nuclear LF staining and future applications of the present methods are discussed.     

Diagnosis of acute bacterial osteomyelitis of the pubis by means of fine needle aspiration

Fine needle aspiration (FNA) was used to make a definitive diagnosis of osteomyelitis of the pubis with negligible trauma to an elderly patient. The material obtained was adequate to resolve the differential diagnosis of osteomyelitis versus osteitis pubis occurring after urologic surgery. The three basic components of acute bacterial osteomyelitis, an acute inflammatory cell exudate of neutrophils, necrotic bone and bacteria in cells, were present in the FNA smears and cell blocks; the presence of bacteria was shown by Gram staining of FNA smears and culture of part of the FNA specimen.     

Effect of fixation on the antigenicity of human lactoferrin in paraffin-embedded tissues and cytocentrifuged cell smears

Summary Immunoperoxidase techniques were used to study the preservation of the antigenicity of human lactoferrin (LF) of polymorphonuclear neutrophils (PMN) and various exocrine glandular cells in paraffin-embedded tissue blocks and cytocentrifuged cell smears. Tissues fixed in Carnoy's fluid in contrast to other fixatives used, showed good preservation of LF antigenicity irrespective of the fixation time. Cell smears fixed in Carnoy's fluid showed diffuse nuclear and cytoplasmic staining for LF, although morphologic intergrity was poorly preserved. Granular cytoplasmic staining for LF with no staining of nuclei was seen in cell smears fixed in buffered formol acetone for 2–10 min. The nature of nuclear LF staining and future applications of the present methods are discussed.     

Comparison of smears and cell blocks in the fine needle aspiration diagnosis of recurrent gynecologic malignancies.

A retrospective, seven-year study was conducted to evaluate the value of cell blocks as an adjunct to smears in the fine needle aspiration (FNA) diagnosis of recurrent gynecologic malignancies. Eighty-four FNAs were performed on patients with previously diagnosed malignancies of the cervix (39 cases), ovary (27), uterus (14), vulva (2) and vagina (2). Material for the preparation of cell blocks was available in all cases. Smears and cell blocks were reviewed separately, and the findings were categorized as positive, negative, suspicious or unsatisfactory. Identical smear and cell block results were reported in 71 (84.5%) of the 84 cases (45 positive, 20 negative, 1 suspicious and 5 unsatisfactory). In 12 cases (14.3%) the smear was superior to the cell block in detecting malignant cells; while all 12 smears were positive, 8 cell blocks were negative, and 4 were suspicious. In no case was the cell block positive with a negative smear; in one (1.2%) the cell block was positive and the smear suspicious. The results of this study indicate that the additional study of cell blocks is of little benefit in the FNA cytodiagnosis of recurrent disease in patients with documented gynecologic malignancies.     

Fine needle aspiration cytology of the testis as the first-line diagnostic modality in azoospermia: a comparative study of cytology and histology

Objectives:  Male factors are responsible for about half of all infertility cases. Until recently, testicular biopsy was the standard method to ascertain the aetiology of azoospermia. Fine needle aspiration cytology has gained increasing popularity as a simple and minimally invasive procedure that can help in assessing testicular function accurately. This study was aimed at addressing the question whether testicular fine needle aspiration (FNA) may be used as a first-line diagnostic modality in azoospermia and to assess its usefulness in the diagnostic protocol.
Methods:  The FNA was performed in 78 consecutive azoospermic patients. To obviate sampling errors both testes were aspirated, except when contraindicated. Routine haematoxylin and eosin as well as Romanowsky staining was performed on the smears.
Results:  The smears were categorized on cytological examination into normal spermatogenesis in 35 (50%) patients, Sertoli cells only syndrome in 22 (31.4%) and maturation arrest at the spermatocyte/spermatid level was seen in 13 (18.4%) patients. There were eight (10.2%) cases with scant smears where cytological diagnosis could not be made. A good correlation between cytological smears and histological sections was found in 54 of 58 testes (93.1%) in which histopathological confirmation was available.
Conclusions:  Testicular FNA may be utilized as a first-line investigative modality in patients with azoospermia, provided the procedure is performed and interpreted by experts.     

Acid-fast bacilli in aspiration smears from tuberculous lymph nodes. An analysis of 255 cases

An analysis of fine needle aspiration (FNA) smears from 255 patients with tuberculous lymphadenopathy was done. The aspirates were either purulent, cheesy or mixed with blood. A total of 56.4% of all cases aspirated showed acid-fast bacilli. Of the cases in which purulent material was aspirated, 66% were positive for acid-fast bacilli. These findings stress the importance of doing Ziehl-Neelsen staining in smears of all cases suspected of being tuberculous in etiology, particularly when purulent material is aspirated.     

Immunohistochemical studies with monoclonal antibodies B72.3 and MA5 on histologic and cytologic specimens from benign and malignant breast lesions

Monoclonal antibodies B72.3 and MA5 were tested by the avidin-biotin immunoperoxidase method in histologic sections of 38 benign, 22 precancerous and 22 cancerous breast lesions, as well as in fine needle aspiration (FNA) smears and cell blocks of 25 breast carcinomas. Neither B72.3 nor MA5 was specific for breast cancer cells: both also reacted with cells from benign and precancerous conditions. B72.3 as a "detector" of malignant cells or their precursors was superior to MA5, however: it was not reactive to cells in most benign breast lesions (mammary duct ectasia, fibroadenoma and ductal hyperplasia, with and without atypia). Cancerous cells had heterogeneous immunostaining with B72.3, which may lead to false-negative results in relatively hypocellular FNA samples. FNA samples prepared as both smears and cell blocks provided the most abundant cellular samples and the lowest false-negative immunostaining reaction of cancerous cells with B72.3.     

Fine needle aspiration cytodiagnosis of sialadenitis with crystalloids.

OBJECTIVE: To assess the utility of fine needle aspiration cytology in the diagnosis of sialadenitis with crystalloid formation in four patients that presented with a swelling of the parotid gland. STUDY DESIGN: The swelling was aspirated in all the cases using a 22-gauge needle, and aspirates were submitted as needle and syringe washings in a cytology fixative (30% ethyl alcohol in physiologic saline). From these washings filter preparations were made on Sartorius or Gelman filters (pore size, 3 microns) and stained by the Papanicolaou method. Additionally, cell block preparations were made from the aspirate. After processing, sections were cut and stained by hematoxylin-eosin, Prussian blue, alcian blue, mucicarmine, and Von Kossa and congo red stain. No air-dried smears were made, and no electron microscopic studies were done. RESULTS: Stained cytologic preparations and cell blocks showed numerous nonbirefringent crystalloids of varying sizes and shapes appearing as rectangles, needles, squares and rods mixed with neutrophils and rare multinucleated giant cells. No salivary gland components were seen, and all special staining was negative. CONCLUSION: Fine needle aspiration cytology not only provided an accurate diagnosis of sialadenitis with crystalloids but also resulted in adopting conservative management and avoiding unnecessary surgery.     

Cytologic features of clear cell carcinoma of the female genital tract. Diagnostic value of the "raspberry body" in nonexfoliative cytologic specimens

OBJECTIVE: To evaluate the presence of basement membrane stromal material in fine needle aspiration (FNA) and scrape cytologic specimens from patients with clear cell carcinoma (CCC) of the female genital tract. STUDY DESIGN: The study group consisted of 6 patients with CCC (5 ovarian and 1 cervical). Four samples corresponded to FNA specimens and 3 to scrape material obtained during intraoperative consultation for ovarian tumors. FNA was performed on a pelvic recurrence and on liver, pulmonary and lymph node metastases. The 6 cases had a complete histopathologic study. RESULTS: In addition to large, clear cells, all cases showed basement membrane stromal material that assumed several forms. The most common was globular, hyaline structures, either naked or surrounded by neoplastic epithelial cells ("raspberry bodies"). Other fragments were larger, with several spherules and elongated prolongations. Scrape material showed stromal material resembling reduplicated basement membrane material. In Diff-Quik-stained smears (QCA, Tarragana, Spain) it showed metachromatic staining with a pink to purple color. Its recognition on Papanicolaou-stained smears was more difficult since it did not stain or was gray. CONCLUSION: Basement membrane stromal material and, more precisely, "raspberry bodies," are a characteristic cytologic feature of CCC of the female genital tract. The combination of clear, atypical cells and basement membrane stroma is highly specific to this neoplasm and can be observed not only in exfoliative specimens but also in FNA and scrape samples.     

Immunocytochemistry on scrape cytology in breast cancer: will it unearth the weaker positives?

OBJECTIVE: To standardize the technique of immunocytochemical (ICC) assessment of estrogen (ER) and progesterone receptor (PR) status in breast cancer by scrape cytology and to compare the results with immunohistochemistry on paraffin blocks. STUDY DESIGN: ICC assessment for ER and PR was done on scrape smears from tissue samples in 200 cases of primary breast cancer. The results were compared to those obtained from immunohistochemical (IHC) evaluation of formalin-fixed paraffin same tissue samples. RESULTS: ER/PR positivity rates as well as staining scores were compared between the scrape smears and tissue sections. The concordance between cytology and histology was 84% for ER and 90% for PR. Both the positivity rates and the staining intensity scores were higher for cytochemistry than for histochemistry. CONCLUSION: The ICC method on scrape smears is a simple test with rapid turnaround time. The sample required is small, and antigen loss due to fixation and processing is minimal. This new method gives a higher yield of hormone receptor positivity and, when used in conjunction with the IHC method, may improve the pickup rate of ER-positive cases, thereby playing an important role in risk stratification and therapeutic decision making in patients with breast cancer.     

Wilms' tumor. Role of fine needle aspiration and DNA ploidy by image analysis in prognostication

OBJECTIVE: To evaluate the utility of cytomorphologic features and DNA ploidy estimation in fine needle aspirates (FNAs), from Wilms' tumors for prognostication. STUDY DESIGN: Twenty-three cases of Wilms' tumor having FNA and follow-up data were selected. Cytomorphology was analyzed by two observers. DNA ploidy was determined in 19 cases by image cytometry by destaining Papanicolaou-stained slides and restaining with Feulgen stain. Various parameters and patient outcomes were compared, and statistical evaluation was done. RESULTS: Poor outcome (12/23 cases) was associated with age < 2 years (P = .01), severe pleomorphism of blastemal cells (4/23 cases, P < .05), very large nucleoli (5/23 cases, P = .075), atypical mitosis (6/23 cases, P = .032) and aneuploidy/tetraploidy of tumor cells (6/29 cases, P = .005). Term unfavorable cytology is proposed when a combination of severe pleomorphism, very large nucleoli and atypical mitosis is seen in FNA smears. Four Wilms' tumor FNAs were characterized as showing unfavorable cytology, and all had a poor outcome (P = .0351). Three of the six cases with aneuploid/tetraploid features also showed unfavorable cytology. CONCLUSION: Unfavorable cytology and aneuploidy/tetraploidy in FNA smears of Wilms' tumor are associated with a poor prognosis.     

Analysis of KIT mutation and protein expression in fine needle aspirates of gastrointestinal stromal/smooth muscle tumors

OBJECTIVE: To determine if sequencing the KIT gene could facilitate more definitive FNA diagnosis. STUDY DESIGN: Sixteen cases of gastrointestinal stromal/smooth muscle tumor (GIST) in which fine needle aspiration (FNA) was performed (mean age, 67; M/F = 12/4) were studied. DNA was extracted from cytologic preparations from all patients (15 cell blocks, 1 alcohol-fixed smear) and seven subsequent resection specimens. DNA was amplified by polymerase chain reaction, using primers designed to amplify a segment of the KIT gene exon 11 and sequenced on an ABI Prism 377 DNA sequence analyzer (Applied Biosystems, Indianapolis, Indiana, U.S.A.). Immunocytochemical staining for CD 117 (the KIT gene product) was performed on sections from 12 cell blocks and 7 surgical resections. RESULTS: In-frame deletion of exon 11 was detected in eight cases (7 monoalleic, 1 bialleic); a point mutation was found in one case. Mutation was found only in histologically malignant (6 of 10 cases) and borderline GISTs (3 of 4 cases). No mutation was identified in benign tumors. In three cases, scant cellularity or blood precluded sequencing. CD 117 was expressed in 12 of 15 cases. CONCLUSION: Immunocytochemical staining for CD 117 is useful in confirming a cytologic diagnosis of GIST but does not facilitate diagnosis of malignancy. FNA biopsy specimens are suitable for KIT gene sequencing; detection of a KIT mutation favors a malignant diagnosis, though absence of mutation does not preclude malignancy.     

Fine needle aspiration biopsy in the diagnosis of tuberculosis

Bacteriologic data and aspiration smears obtained by fine needle aspiration (FNA) biopsy for a series of 39 cases of tuberculosis were reviewed. Based on the morphologic features of the aspiration smears, the cases were divided into two groups: 18 cases in which distinct epithelioid granulomas were present and 21 in which no granulomas were found but large amounts of necrotic debris with variable numbers of polymorphonuclear cells, histiocytes and lymphocytes were present. Material from the FNA biopsy specimen was submitted for culture and fluorescence studies in 34 cases (15 with and 19 without granulomas). In the first group, auramine-rhodamine staining of smears was positive in 4 of 15 cases and Mycobacterium tuberculosis was isolated in 12 of 15 cases. In the second group, auramine-rhodamine staining was positive in 9 of 19 cases and culture was positive for M. tuberculosis in 16 of 19 cases. The results indicate that studying FNA smears by light microscopy and bacteriologic culture is an effective way of diagnosing tuberculosis.