BSCC Code of Practice – fine needle aspiration cytology

The British Society for Clinical Cytology Code of Practice on fine needle aspiration cytology complements that on exfoliative cytopathology, which was published in the last issue ( Cytopathology 2009; 20 :211–23). Both have been prepared with wide consultation within and outside the BSCC and have been endorsed by the Royal College of Pathologists. A separate code of practice for gynaecological cytopathology is in preparation. Fine needle aspiration (FNA) cytology is an accepted first line investigation for mass lesions, which may be targeted by palpation or a variety of imaging methods. Although FNA cytology has been shown to be a cost-effective, reliable technique its accurate interpretation depends on obtaining adequately cellular samples prepared to a high standard. Its accuracy and cost-effectiveness can be seriously compromised by inadequate samples. Although cytopathologists, radiologists, nurses or clinicians may take FNAs, they must be adequately trained, experienced and subject to regular audit. The best results are obtained when a pathologist or an experienced and trained biomedical scientist (cytotechnologist) provides immediate on-site assessment of sample adequacy whether or not the FNA requires image-guidance. This COP provides evidence-based recommendations for setting up FNA services, managing the patients, taking the samples, preparing the slides, collecting material for ancillary tests, providing rapid on-site assessment, classifying the diagnosis and providing a final report. Costs, cost-effectiveness and rare complications are taken into account as well as the time and resources required for quality control, audit and correlation of cytology with histology and outcome. Laboratories are expected to have an effective quality management system conforming to the requirements of a recognised accreditation scheme such as Clinical Pathology Accreditation (UK) Ltd.     

Fine needle aspiration at a Regional Head and Neck Clinic: A clinically beneficial and cost-effective service

Background:  Fine needle aspiration (FNA) is an important adjuvant to the diagnosis of a palpable lesion which often permits the complete assessment of patients. The main objective of this study was to determine the clinical benefit of a dedicated FNA service at a tertiary referral Head and Neck Clinic and to assess if such a service is cost effective.
Methods:  All patients attending the Head and Neck Clinic during 2004 were prospectively assessed in this study. Patient records were analysed regarding investigative modalities including FNA, the subsequent cytology result and the requirement for further histopathological investigations. A cost analysis for all investigative procedures was performed.
Results:  A total of 135 patients (36 males) had FNAs performed during the study period. The median age was 51.5 years (range 17–92). Patients presented with lesions of lymph nodes ( n  = 46), thyroid ( n  = 41), salivary, parotid or submandibular glands ( n  = 22) and other cutaneous or cystic lesions ( n  = 26). Cytological grading results were; C1 = 26, C2 = 93, C3 = 8, C4 = 2 and C5 = 6. Patients with lesions C3 or above normally proceeded to further investigations. The overall cost of the FNA per episode in the out-patient clinic was £114 per episode compared to day case open biopsy per patient of £333 and an in-patient stay per patient was £2371. FNA provided sufficient pathological diagnosis to avoid day case surgery in 57 patients (42.2%), and inpatient surgery in 65 patients (48.1%) resulting in a total saving of £158 372 in 2004.
Conclusion:  This study demonstrates the clinical benefit and cost-effectiveness of FNA services in a dedicated Head and Neck clinic.     

Renal FNA-based typing of renal masses remains a useful adjunctive modality: evaluation of 31 renal masses with correlative histology

Objectives:  Given the advances in renal imaging modalities in the recent years, a greater number of renal cell carcinomas (RCCs) with tumour size of <3 cm are being detected radiologically. Consequently, there is a pressing need for accurate typing of RCCs which, in turn, will aid in selection of cases of nephron-sparing surgery.
Methods:  A total of 31 cases of renal masses with available fine needle aspiration (FNA) material and concomitant histopathology details were retrieved. They included 27 RCCs (17 clear cells, eight papillary and two chromophobe), one oncocytoma, one liposarcoma and two benign lesions – one xanthogranulomatous pyelonephritis (XPN) and one benign cyst. Two investigators reviewed all FNA material. The degree of concordance between cytological typing and histological typing was assessed.
Results:  There was excellent agreement between the FNA typing and the final diagnosis, with correct classification in 28 of 31 cases. Among the three discordant cases, two were RCCs. The first was a papillary RCC (PRCC) that was misdiagnosed on FNA as clear cell RCC. Another case that was typed as a PRCC on final histopathology was diagnosed 'suspicious cells' on FNA. The third case was an XPN that was misdiagnosed on FNA as RCC with necrosis.
Conclusions:  There is an excellent concordance (90.3%) between the FNA diagnosis and the final histological diagnosis, especially in RCCs. There is a tendency for misdiagnosis with PRCC. Lesions with extensive necrosis and relatively insufficient diagnostic material on FNA specimens must be interpreted with caution. Better concordance might be observed with more extensive sampling.     

Collapse of an avifauna: climate change appears to exacerbate habitat loss and degradation

Aim  We characterized changes in reporting rates and abundances of bird species over a period of severe rainfall deficiency and increasing average temperatures. We also measured flowering in eucalypts, which support large numbers of nectarivores characteristic of the region.
Location  A 30,000-km² region of northern Victoria, Australia, consisting of limited amounts of remnant native woodlands embedded in largely agricultural landscapes.
Methods  There were three sets of monitoring studies, pitched at regional (survey programmes in 1995–97, 2004–05 and 2006–08), landscape (2002–03 and 2006–07) and site (1997–2008 continuously) scales. Bird survey techniques used a standard 2-ha, 20-min count method. We used Bayesian analyses of reporting rates to document statistically changes in the avifauna through time at each spatial scale.
Results  Bird populations in the largest remnants of native vegetation (up to 40,000 ha), some of which have been declared as national parks in the past decade, experienced similar declines to those in heavily cleared landscapes. All categories of birds (guilds based on foraging substrate, diet, nest site; relative mobility; geographical distributions) were affected similarly. We detected virtually no bird breeding in the latest survey periods. Eucalypt flowering has declined significantly over the past 12 years of drought.
Main conclusions  Declines in the largest woodland remnants commensurate with those in cleared landscapes suggest that reserve systems may not be relied upon to sustain species under climate change. We attribute population declines to low breeding success due to reduced food. Resilience of bird populations in this woodland system might be increased by active management to enhance habitat quality in existing vegetation and restoration of woodland in the more fertile parts of landscapes.     

Fine needle aspiration (FNA) cytology of the breast: the influence of unsatisfactory samples on patient management

FNA continues to play an important role in the management of patients with breast lesions. However, the reliability and efficiency of the FNA service depends heavily on the quality of the specimens. We have audited the rate of 'inadequate FNAs' at intervals over the last 5 years and related our findings to the clinical expertise of the aspirator. We have also correlated the rate of inadequate FNAs with the percentage of patients who had an FNA preceding a definitive diagnosis of cancer. We report trends in the rate of inadequate samples, and subsequent diagnosis of cancer, over a 5‐year period. The percentage of breast FNA samples reported as inadequate was 46.8% in 1988–89, falling to 20% in 1991–92 with the introduction of an FNA clinic, and rising to 30.6% in 1993. The rates of cancer following inadequate FNA were 15.7%, 16.1% and 4.2%, respectively, and the percentage of patients with cancer having a preceding inadequate FNA were 37.5%, 13.2% and 7.1%. Possible explanations for the apparent paradox between increasing numbers of inadequate FNA specimens and a falling breast cancer rate are discussed.     

Fine needle aspiration (FNA) cytology of Rosai Dorfman disease

deshpande v and verma k. (1998) Cytopathology 9, 329–335
Fine needle aspiration (FNA) cytology of Rosai Dorfman disease
Rosai Dorfman disease (sinus histiocytosis with massive lymphadenopathy (SHML)) is a benign self-limiting disorder that commonly involves the lymph nodes. We reviewed eight cases of this entity aiming to document the cytomorphological features. Of the eight cases, a preoperative diagnosis was suggested in seven cases. Pertinent features included: numerous large histiocytes with prominent emperipolesis (documented by a halo around the cell), fine vacuoles in the cytoplasm and lymphocytes and plasma cells in the background. In some cases the histiocytes showed atypia. In one biopsy-proven case a diagnosis of Hodgkin's was suggested, emphasizing the pitfalls associated with the FNA diagnosis of this lesion.     

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.     

Molecular pathology and thyroid FNA

This review summarises molecular pathological techniques applicable to thyroid FNA. The molecular pathology of thyroid tumours is now fairly well understood. Molecular methods may be used as a rule‐in test for diagnosis of malignancy in thyroid nodules, eg BRAF V600E point mutation, use of a seven‐gene mutational panel (BRAF V600E, RAS genes, RET/PTC or PAX8/PPARG rearrangement), or as a comprehensive multigene next‐generation sequencing panel, eg ThyroSeq v2. Molecular methods can also be applied as rule‐out tests for malignancy in thyroid nodules, eg Afirma or ThyroSeq v2 or as markers of prognosis, eg TERT promoter mutation or other gene mutations including BRAF V600E, TP53 and AKT1, and as tests for newly defined tumour entities such as non‐invasive follicular thyroid neoplasm with papillary like nuclei, or as a molecular marker(s) for targeted therapies. This review describes practical examples of molecular techniques as applied to thyroid FNA in routine clinical practice and the value of molecular diagnostics in thyroid FNA. It describes the range of molecular abnormalities identified in thyroid nodules and thyroid cancers with some practical applications of molecular methods to diagnosis and prognosis of thyroid nodules and thyroid cancer.     

Predicting the impact of climate change on Australia's most endangered snake, Hoplocephalus bungaroides

Aim  To predict how the bioclimatic envelope of the broad-headed snake (BHS) ( Hoplocephalus bungaroides ) may be redistributed under future climate warming scenarios.
Location  South-eastern New South Wales, Australia.
Methods  We used 159 independent locations for the species and 35 climatic variables to model the bioclimatic envelope for the BHS using two modelling approaches – B ioclim and M axent . Predictions were made under current climatic conditions and we also predicted the species distribution under low and high climate change scenarios for 2030 and 2070.
Results  Broad-headed snakes currently encompass their entire bioclimatic envelope. Both modelling approaches predict that suitable climate space for BHS will be lost to varying degrees under both climate warming scenarios, and under the worst case, only 14% of known snake populations may persist.
Main conclusions  Areas of higher elevation within the current range will be most important for persistence of this species because they will remain relatively moist and cool even under climate change and will match the current climate envelope. Conservation efforts should focus on areas where suitable climate space may persist under climate warming scenarios. Long-term monitoring programs should be established both in these areas and where populations are predicted to become extirpated, so that we can accurately determine changes in the distribution of this species throughout its range.     

Temperature, oxygen and heat-budgets of six small western Irish lakes

SUMMARY. 1. Temperature and oxygen were examined in six small western Irish lakes (areas 2–110 ha) in 1981, 1982 and 1984.
2. The four deeper lakes (= 6–11m) stratify stably in the same manner as some well-known stratifying lakes in Britain. Windiness (due to proximity to the ocean) seems generally to be reflected in the lakes by the presence of a sharp thermo clinic. Considerable variation in the pattern of stratification occurs from year to year.
3. Two shallow lakes (= 4.1 and 2.7m) stratify only in periods of warm, calm weather.
4. Annual heat-budgets range from 4.1 kcal cm⁻² to 13.7 kcal cm⁻². There is a strong linear relationship between mean-depth and annual heat-budget.
5. Oxygen depletion is severe in the more productive lakes.     

Book Reviews

Book reviewed in this article:
Trees of Ireland. Native and Naturalized. E. Charles Nelson and Wendy F. Walsh. 256 pp., 30 colour plates.
A man who can speak of plants. Dr Thomas Coulter (1793–1843) of Dundalk in Ireland, Mexico and Alta California. E. Charles Nelson & Alan Probert. 192 pp., 52 figures & photographs and 8 colour plates.
Siebold's Florilegium of Japanese Plants: Florilegium Plantarum Japonicarum Sieboldii. Yojiro Kimura and Valerii I. Grubov (eds.). Vol. 1, 2 parts (Colour plates); Vol. 2 (Articles and Catalogue).     

Metaplastic carcinomas of the breast—fine needle aspiration (FNA) cytology findings

nogueira m., andré s. and mendonça e. . (1998) Cytopathology 9, 291–300
Metaplastic carcinomas of the breast—fine needle aspiration (FNA) cytology findings
Metaplastic carcinomas of the breast are defined by mesenchymal and/or squamous cell components associated with ductal carcinoma and may raise diagnostic problems in FNA cytology. We reviewed FNA smears of a series of nine cases; seven were compared with histological sections and two with cell-block sections. The cytological pattern was diagnostic of carcinoma in six cases; in two cases a diagnosis of sarcoma/phyllodes tumour was considered, as cells were predominantly spindle-shaped. One case had a pleomorphic adenoma type pattern. The cytological findings suggesting a diagnosis of metaplastic carcinoma include a liquid aspirate, a proteinaceous or chondromyxoid background and a poorly differentiated tumour with multinucleated giant cells, neoplastic or histiocytic. A definite diagnosis requires the presence of both carcinomatous and metaplastic (squamous/mesenchymal) components.     

Posters

Introduction  Fine needle aspiration (FNA) cytology of the thyroid is a well-established test in the clinical work-up of patients with solitary nodules of the thyroid. Thyroid FNA does however have limitations and audit of diagnostic performance is important.
Methods  The histopathology archives of the Royal Victoria Hospital were searched for all thyroid resections and the histopathological diagnosis was correlated with the pre-operative cytological diagnosis, where available. Special emphasis was placed on the accuracy of tumour diagnosis.
Results  A total of 173 cases were identified during the 2-year period, of these 93 had available pre-operative FNA. A total of 57 tumours were identified. A small number (six of 57) of significant discrepancies were identified. These included a malignant lymphoma diagnosed as Hashimoto's thyroiditis, a metastasis which the FNA had suggested was a medullary carcinoma and an insular carcinoma diagnosed as medullary carcinoma on FNA. False positives included a colloid cyst diagnosed as suspicious of malignancy and a cytological diagnosis of papillary carcinoma not confirmed on histology.
Discussion  At present, the majority of thyroid FNAs in our clinics are performed by surgeons and material is not routinely available for immunocytochemistry. In spite of these limitations, there were few major discrepancies. These might be reduced if pathologist aspirators were able to perform FNAs and collect material for further studies, where necessary. This would allow identification of medullary carcinomas and malignant lymphomas.
Conclusion  FNA of thyroid lesions is a useful investigation in our clinical setting, however, some areas of potential for improvement have been identified.     

Fine needle aspiration (FNA) of testicular germ cell tumours; a 10-year experience in a community hospital

garcía-solano j., sánchez-sánchez c., montalbán-romero s., sola-pérez j. and pérez-guillermo m. (1998) Cytopathology 9, 248–262
Fine needle aspiration (FNA) of testicular germ cell tumours; a 10-year experience in a community hospital
A retrospective reappraisal is made of the smears of 29 testicular germ cell tumours (TGCT) studied by FNA in which both orchiectomy specimens and histologic diagnoses were available. In 22 cases (75.86%) the yield was sufficient and contained cells suitable for cytologic diagnosis; in these 22 cases a diagnosis of malignancy was reached. In four cases (13.79%) the yield was sparse and diagnostic cells were partially obscured by haemorrhage and necrosis; these cases were categorized as suspicious of malignancy. In three cases (10.34%) the yield was not suitable for cytologic evaluation because haemorrhage and necrosis hampered evaluation of diagnostic cells. The cytologic findings that enable a reliable diagnosis of TGCT are described and those cytologic features that may lead the less experienced cytopathologist into an erroneous diagnosis are discussed. Pure TGCT can be confidently diagnosed with FNA and mixed TGCT can be successfully diagnosed, although it is difficult to recognize every cytologic subtype observed in the histologic sections. Despite the advantages of FNA for the prompt diagnosis of TGCT, FNA can not fully replace the histologic diagnosis and should rather be considered as a helpful tool in the work-up of testicular tumours.     

Interactive effects of diet and thermal regime on growth of the midge Pseudochironomus richardsoni Malloch

1. Larvae of Pseudochironomus richardsoni were reared to pupation in individual enclosures, in one of three thermal habitats in a northern California stream. The average temperature range in cold seeps was 15–21 °C, while the main channel ranged from 20 to 27 °C, and side pools ranged from 18 to 33 °C. Diet consisted of either diatoms or algal detritus.
2. Specific growth rate ranged from 0.057 to 0.267 day^–1. Specific growth and developmental rates were highest on a diatom diet, and increased with temperature. Regressions of growth rate on mean microsite temperature were also significantly altered by diet. Differences in specific growth rate due to diet are magnified at higher temperatures.
3. Pupae reared on diatoms were larger than those reared on detritus. The mass of pupae reared on detritus decreased with increasing temperature. However, there was no significant relationship between pupal mass and temperature for larvae reared on diatoms.
4. The combined effects of food quality and thermal environment on growth of the midge P. richardsoni are significantly different from the independent effects of diet and temperature. Interactive effects of food quality and temperature may influence the contribution of certain aquatic habitats (algal mats) to invertebrate secondary production.     

P-3THE VALUE OF PERITONEAL WASHING CYTOLOGY IN THE STAGING OF GYNAECOLOGICAL MALIGNANCY

Introduction:  Current protocols for staging gynaecological cancers include cytopathological examination of peritoneal washings taken at the time of definitive surgery. We investigated the clinical usefulness of this procedure.
Methods:  During 2004 and 2005, 140 peritoneal washings were submitted for cytopathological examination in our institutions for staging of 36 ovarian, 101 endometrial and 3 synchronous ovarian/endometrial cancers.
Results:  The washings contained malignant cells in 39 cases (28%). 35 of these cases had high stage disease – not confined to the organ of origin (i.e. stage 2 or more for ovary and stage 3 or more for endometrial). The other 4 were stage 1C ovarian cancers where there was either rupture or tumour involvement of the capsule. In only 2 of the 39 positive cases the cancer was marginally upstaged by the positive washings – these were ovarian cancers upstaged from 2A /B to 2C.
Discussion:  These findings suggest that peritoneal washing cytology as a routine procedure for staging ovarian and endometrial cancer is of limited clinical value. A larger study is needed to determine whether this procedure should continue to be included in staging protocols for gynaecological cancer.     

The optimal shape of avian eggs

1. The shape of avian eggs is often explained by involving the mechanical properties of eggshell such as resistance to breakage or invoking physiological forces operating during egg development.
2. Here we take a different approach and investigate the efficient use of space. According to this approach the optimal egg shape is the one that produces the most compact fit under the incubating parent.
3. We extend the model of Andersson (1978) and use a numerical technique to investigate egg shapes in clutches of 1 to 10 eggs. In our model the shape of eggs is described by four parameters in a two-dimensional space. These parameters are free to vary – but eggs cannot be concave.
4. The optimal egg shape for each clutch size was found by a genetic algorithm.
5. The model predicts that egg shape should depend on clutch size. In particular, if the clutch consists of one egg then this egg should be spherical; whereas in clutches of two or three eggs the eggs should be biconical. In clutches of four the eggs should be pointed. The model also predicts that in clutches of over seven eggs the optimal egg shape should be approximately spherical.
6. These predictions are valuable because they point out that some of the variation in avian egg shapes may be explained solely by the efficient use of the brood patch area of the incubating parent.     

Mortality during dispersal and the cost of host-specificity in parasites: how many aphids find hosts?

1. For a full assessment of explanations for the evolution of host-specificity it is necessary to estimate the probability that a dispersing parasite finds a host. We develop a method of estimating this success rate from samples of dispersing parasites and populations resident on hosts.
2. Applying this method to data on the bird cherry-oat aphid, Rhopalosiphum padi (L.), from southern Scotland in 1984–92, we estimate that 0·6% of the autumn migrants find hosts.
3. With such a low success rate, there should be selection for a broadening of host range, to include any host on which the colonist's fitness is more than about 0·6% of that on the normal hosts. We argue that neither nutrition nor the need for 'enemy-free space' are sufficient explanations of the host-specificity of this animal, and propose instead that it is the host's role as a rendezvous for mating that constrains the migrants to their costly host-specificity.
4. We also discuss the implications of this low success rate for the hypothesis that aphids speciate sympatrically through the formation of host races.     

What do dung beetles eat?

Abstract.  1. Most adult coprophagous beetles feed on fresh dung of mammalian herbivores, confining ingestion to small particles with measured maximum diameters from 2–5 to 130 μm, according to body size and kind of beetle. This study explores benefits and costs of selective feeding in a 'typical' dung beetle with a maximum diameter of ingested particles (MDIP) of 20 μm.
2. Examined dung types (from Danish domestic sheep, cattle and horse, and African wild buffalo, white rhino and elephant) contained 76–89% water. Costs of a 20 μm MDIP were often low, since 69–87% of the total nitrogen in bulk dung other than that of elephant and rhino (40–58%) was available to selective feeders.
3. Nitrogen concentrations were high – and C/N ratios low – in most types of bulk dung compared with the average food of terrestrial detritivores or herbivores. Exceptions were elephant and rhino dung with low nitrogen concentrations and high C/N ratios.
4. Estimated C/N ratios of 13–39 in bulk dung (sheep–elephant) were decreased by selective feeding to 7.3–12.6 in the ingested material. In assimilated food, ratios are probably only 5–7, as most assimilable nitrogen and carbon may be of microbial origin. If so, the assimilable food contains a surplus of nitrogen relative to carbon.
5. The primary advantage of selective feeding, particularly in dung with a high C/N ratio, may be to concentrate assimilable carbon in the ingested food. Effects of changing the MDIP within 20–106 μm are modest, especially in dung with a low C/N ratio.