Cost Effectiveness of A Fine Needle Aspiration Clinic

The resource implications of a Fine Needle Aspiration (FNA) Clinic at Northampton General Hospital have been evaluated over a 12 month period using a patient management questionnaire. A total of 490 cases from which fine needle aspirates were taken from superficial sites have been assessed (breast 381, thyroid 46, lymph node 44, salivary gland 9, soft tissue 10). Total resource savings (135,544 pounds) exceeded the expenses of the FNA clinic (27,290 pounds). Potential cost savings per case were the greatest for thyroid aspirates. The FNA clinic where the pathologist takes, stains and reports optimally prepared specimens, provides a high quality and accurate service on which clinicians can confidently base clinical management decisions. Unnecessary investigations and operations are avoided, allowing scant resources to be released for other procedures.     

Fine needle aspiration cytology of lymph node: experience of 2 university hospitals with conventional smears and liquid-based cytology

OBJECTIVE: To compare 2 different series of fine needle aspirations (FNA) performed by conventional smears (CS) and liquid-based cytology (TriPath PREP). STUDY DESIGN: From January 1, 2001, to December 31, 2005, we selected 139 FNA samples of lymph node, if the diagnosis was histologically proven after the initial cytologic diagnosis. Samples came from 2 university hospitals from Brussels: UZ-Brussel (n=96) using liquid-based cytology (LBC) and Hospital Erasme ULB (n=43) using CS. RESULTS: The number of inadequate samples was greater for LBC than CS, but there was no statistical difference (17.7% vs. 4.7%, p = 0.059). No differences were found between LBC and CS in sensitivity (respectively, 85.0% vs. 85.2%), specificity (84.2% vs. 85.7%) and efficiency (84.8% vs. 85.4%). CONCLUSION: Despite the cost, the efficiency of lymph node FNA cytology is identical between the CS and LBC performed by the TriPath PREP system. The quality of the smears, both LBC and CS, depends mainly on practitioner dexterity. Nevertheless, one advantage of LBC is that it provides an ancillary technique to improve FNAC diagnosis. In the future, a combination of these technologies with FNAC alone could in some cases take the place of surgical lymph node excision.     

Fine needle aspiration cytology of head and neck masses. Seven years' experience in a secondary care hospital

OBJECTIVE: To study the value of fine needle aspiration (FNA) in the diagnosis of head and neck masses in a secondary care hospital. STUDY DESIGN: FNA from 225 patients with head and neck masses were reviewed. The results were analyzed, according to anatomic location, into 3 groups: inflammatory, congenital and neoplastic. FNA diagnoses were retrospectively correlated with available histologic findings or with the outcome of treatment. Accuracy, sensitivity, specificity, positive predictive value and negative predictive value in the diagnosis were computed. The numbers of lymph node biopsies performed before and after introduction of the procedure were compared. RESULTS: The most common diagnoses were reactive/nonspecific lymphadenitis and tuberculous (TB) lymphadenitis (33% and 21%, respectively). Sensitivity and negative predictive value for TB were 97% and 93%, respectively. The next most common masses were malignant neoplasms, cysts, benign neoplasms and sialadenitis, in 13%, 11%, 9% and 5%, respectively. Carcinomas metastatic to the lymph node were the most common type of cancer, followed by lymphoma and salivary gland carcinoma. The primary site of metastatic carcinomas were nasopharynx (44%) and thyroid (22%). The sensitivity and negative predictive values for the diagnosis of cancer were 95% and 96%, respectively, but reached 100% when lymphoma was excluded. The introduction of FNA reduced the number of lymph node biopsies performed in this hospital by 90%. CONCLUSION: FNA of head and neck masses proved to be a very useful diagnostic tool in separating inflammatory lesions (no surgical excision required) from cystic and neoplastic lesions. It enhanced surgical planning for malignant diseases, allowing rapid referral of lymphomas and cancer cases to tertiary care centers for management. FNA is simple, cost effective and suitable for developing countries and small, secondary care hospitals with limited resources. Skilled personnel and routine audits are the keys to success.     

Diagnostic value of fine needle aspirates processed by ThinPrep® for the assessment of axillary lymph node status in patients with invasive carcinoma of the breast

X. Jing, E. Wey and C. W. Michael Diagnostic value of fine needle aspirates processed by ThinPrep® for the assessment of axillary lymph node status in patients with invasive carcinoma of the breast Objective: To evaluate the utility of ThinPrep® as an optional specimen processing method for the detection of axillary lymph node metastasis of invasive breast carcinoma. Methods: A computer SNOMED search from the file at our institution between January 2003 and August 2011 retrieved a total of 209 fine needle aspiration (FNA) specimens of axillary lymph nodes prepared by ThinPrep and followed by axillary lymph node biopsy and/or dissection. Original cytological diagnoses and corresponding histological diagnoses were documented. Using the histological diagnoses as the gold standard, the diagnostic parameters including sensitivity, specificity, positive (PPV) and negative predictive values (NPV) and diagnostic accuracy were calculated. Both cytology and histology slides from cyto‐histologically discrepant cases were reviewed. Results: Out of a total of 209 specimens, 193 (92%) had adequate diagnostic material while the remaining 16 specimens (8%) were inadequate for cytological assessment. The diagnostic specimens included 168 invasive ductal carcinomas (IDC), 15 invasive lobular carcinomas (ILC) and 10 mixed carcinomas (IDC and ILC). Excluding 19 cases with malignant cells on FNA in which no residual tumour was found in fibrotic lymph nodes after neoadjuvant therapy (cytology and histology confirmed on review) ThinPrep detected nodal metastasis with an overall sensitivity of 77.5%, specificity of 100%, PPV of 100% and NPV of 53.7%. Diagnostic accuracy was 82.2%. There was no difference in Bloom–Richardson grade or the number or size of metastases between tumours with true‐positive and false‐negative cytology. Sampling error was the sole factor contributing to cyto‐histological discrepancy. Conclusions: ThinPrep is a good alternative to the conventional smear for cytological assessment of axillary lymph node status in patients with invasive breast carcinoma, particularly when specimens are collected at remote sites or when cytologists are not available for assistance during FNA.     

Cystic Lymph Nodes in the Lateral Neck As Indicators of Metastatic Papillary Thyroid Cancer

ObjectiveTo determine whether radiographic findings portend to metastatic disease in patients with papillary thyroid carcinoma (PTC) and whether cystic lymph node metastasis can be recognized by preoperative, ultrasound-guided fine-needle aspiration (FNA).MethodsWe performed a retrospective review of patients with cystic lymph nodes in the lateral neck identified on preoperative ultrasonography between March 1996 and December 2009. Factors examined included demographic information; stage; cytologic and final pathologic findings; and imaging characteristics including location, size, and presence of vascularity and calcifications. Time of cystic node identification in relationship to initial diagnosis was also recorded.ResultsThirty patients had cystic lymph nodes in the lateral neck on cervical ultrasonography during the study period. Among this group, 28 (93%) had PTC, 1 (3%) had papillary serous carcinoma of the ovary, and 1 (3%) had poorly differentiated thyroid cancer. Median age at initial cancer diagnosis was 41 years (range, 16-64 years). Twenty-one patients (70%) were women, and median lymph node size was 1.8 cm (range, 0.6-4.8 cm). Twenty-three patients (77%) had a solitary cystic lymph node, and the remainder had more than 1 cystic lymph node. Cystic lymph nodes were identified at initial presentation in 11 patients (37%), while cystic lymph nodes were discovered in 19 patients (63%) after the initial operation. FNA was performed on the cystic lymph nodes of 23 patients (77%). Cytologic findings were positive for metastatic disease in 18 of 23 patients (78%). Among the 5 of 23 patients with negative cytologic findings, thyroglobulin aspirate was obtained in 1 patient, confirming metastatic PTC. Final pathologic review after surgical resection of cystic lymph nodes with negative cytologic findings from FNA was consistent with metastatic disease in 4 of 5 patients (80%).ConclusionsIn patients with PTC, the presence of a cystic lymph node by ultrasonographic examination is highly suggestive of locally metastatic disease. Confirmation of metastatic PTC may sometimes be achieved with thyroglobulin aspirate from cystic lymph nodes when cytologic findings are negative. Clinicians should strongly consider surgical lymph node resection of cystic lymph nodes regardless of the preoperative cytologic findings by FNA. (Endocr Pract. 2011;17:240-244)     

Diagnosing Kikuchi disease on fine needle aspiration biopsy: a retrospective study of 44 cases diagnosed by cytology and 8 by histopathology.

OBJECTIVE: To study the accuracy of fine needle aspiration (FNA) diagnosis of Kikuchi lymphadenitis (KL). STUDY DESIGN: Retrospective review of all cases of FNA biopsy of lymph nodes in which KL was diagnosed or suggested. False positive cases were studied. Cases of KL diagnosed by histopathology were examined for the false negative rate of FNA diagnosis. RESULTS: Forty-four cases of KL diagnosed or suggested by FNA were found. Five of eight cases were confirmed on lymph node excision. The false positive rate was 37.5%. One case was nonspecific reactive changes. Two cases were proven to be tuberculous lymphadenitis by culture. Eight cases of KL diagnosed by lymph node excisional biopsy had prior FNA. Four were diagnosed as or suspected to be KL. The false negative rate was 50%. CONCLUSION: The overall accuracy of FNA diagnosis of KL was 56.25%. Detailed study offalse positive cases and knowledge of other conditions suggested that overreliance on certain cytologic features and the morphologic erlap between KL and tuberculous lymphadenitis could have been the reasons for the inaccuracies.     

Fine needle aspiration of follicular variant of papillary thyroid carcinoma presenting with pleural effusion: a case report

BACKGROUND: Malignant pleural effusion in association with mesothelioma, bronchogenic carcinoma and breast carcinoma is common, although less frequently reported with other malignancies. We report a follicular variant of papillary thyroid carcinoma (FVPTC), diagnosed on fine needle aspiration cytology (FNAC) of thyroid and lymph nodes and subsequently proved to have metastasized to the pleural cavity. CASE: A 46-year-old man presented with history of breathlessness, thyroid swelling, pleural effusion and bilateral cervical lymphadenopathy. FNAC of the thyroid swelling and the lymph nodes showed features of FVPTC with cervical lymph node metastasis. Pleural fluid examination led to suspicion of pleural involvement by metastatic deposit, confirmed by subsequent pleural biopsy. CONCLUSION: Thyroid malignancies presenting with pleural effusion are rare. In this case, although pleural fluid cytology suggested involvement of pleura, a definitive diagnosis could be rendered only on pleural biopsy. An ancillary aid, such as immunocytochemistry, could have helped establish pleural involvement on routine pleural fluid cytology alone. This case emphasizes the possible existence of rare cases of FVPTC that may be associated with a dismal prognosis. In our case, initial diagnosis of FVPTC could be made only on correlating FNA features of thyroid aspirate with those of lymph node aspirate.     

Lymph node examination by fine needle aspiration in patients with known or suspected malignancy

In a series of more than 2,500 fine needle aspirates from multiple body sites, over 200 were clinically identified as lymph nodes from patients with known or suspected malignancy. The material was obtained using the easily manipulated Aspir-Gun with a 21-gauge or 22-gauge needle and syringe. Of the 200 lymph node specimens, 100 (50%) were cytologically reported as positive for malignancy. Ninety cases had surgical pathology specimens available for comparison with the fine needle aspiration (FNA) specimens. For the 88 of these cases with satisfactory FNA specimens, evaluation of the FNA results showed a predictive value of a positive result of 96.8%. These results compare favorably with those of surgical biopsy. The malignancies present in the lymph nodes included numerous adenocarcinomas from the breast, melanoma and pulmonary small-cell carcinoma. Six cases are briefly presented in which the FNA diagnosis was more problematic. While histologic examination of tissues or organs remains the desirable benchmark of comparison, the appropriate utilization of FNA cytology to guide therapy, particularly in a patient with previously diagnosed malignancy, may obviate the need for an open biopsy. The technique is convenient for patient and physician, useful for outpatients, relatively painless and provides good correlation between cytologic morphology and histopathology.     

Papillary carcinoma of the thyroid occurring during pregnancy. Report of a case diagnosed by fine needle aspiration cytology

A case of papillary carcinoma of the thyroid gland occurring during pregnancy in a 29-year-old woman is described. The enlarged thyroid nodule was first detected at 10 weeks of gestation; fine needle aspiration (FNA) of the nodule showed no cytologic evidence of malignancy. Repeat FNA at 30 weeks of gestation produced inadequate material for diagnosis. A final FNA at 38 weeks of gestation showed classic cytologic features of papillary carcinoma, including papillary structures, grooved nuclei and intranuclear cytoplasmic inclusions. After delivery, the patient was treated with total thyroidectomy and cervical lymph node dissection. The enlargement of the nodule in this case during the course of the pregnancy suggests a relationship between pregnancy and the malignant development of thyroid nodules; this is discussed along with the utility of FNA cytology for diagnosing thyroid cancers during pregnancy.     

An unusual presentation of fine needle aspiration (FNA) cytology from the syncytial variant of nodular sclerosing Hodgkin's disease

Introduction
Open access breast clinics are now widely available and immediate reporting of FNAs of the breast has become an established part of the triple approach to the management of breast disease ¹ .
We report the unexpected findings of a case of Hodgkin's disease at such a clinic. The patient was a young woman who initially was thought by both her general practitioner and surgeon to have a fibroadenoma in the axillary tail region of her right breast. The FNA of this lump showed the features of Hodgkin's disease but with widespread necrosis, which was unusual and potentially misleading and which we wish to highlight. A lymph node biopsy confirmed the diagnosis and showed that the patient was suffering from the syncytial variant of nodular sclerosing Hodgkin's disease (NSHD).
This variant probably accounts for about 5% of cases of Hodgkin's disease ² . Necrosis is a common feature of NSHD; it can range from minute scattered foci to more extensive necrosis of nodules or even involve the entire lymph node.     

Should FNA be Performed in Patients with a Multinodular Goiter and Compressive Symptoms?

Objective: In this study, we aimed to determine whether preoperative thyroid fine-needle aspiration (FNA) in patients with multinodular goiter (MNG) and compressive symptoms influences the type of thyroid surgery performed, the incidence of recurrent thyroid cancer, or the need for successive surgery.Methods: We retrospectively reviewed the charts of 431 patients who underwent thyroidectomy at our institution from 2008 to 2011. Patients who presented with compressive symptoms and no prior FNA at initial presentation were included in this study.Results: Eighty patients met the criteria for our study, of which 46 (57.5%) underwent FNA prior to surgery and 34 (42.5%) were referred to surgery without FNA. The prevalence rates of malignancy (>1 cm) on surgical pathology in the FNA and non-FNA groups were 41% (n = 19) and 38% (n = 13), respectively. There was no statistically significant difference between the rate of total/subtotal thyroidectomies (71.7% in FNA vs. 79.4% in non-FNA, P = .31), lobectomies/partial thyroidectomies (28.3% in FNA vs. 20.5% in non-FNA, P = .43), neck lymph node dissections (P = .89) or subsequent surgeries (P = .72) between the 2 groups.Conclusion: Our findings show that preoperative FNA in patients with an MNG and compressive symptoms does not influence the type of surgery performed, short-term outcomes, or the need for subsequent surgeries. Further studies are needed to validate the need for preoperative FNA in such patients.Abbreviations:FNA = fine-needle aspirationMNG = multinodular goiterWHO = World Health Organization     

Fine needle aspiration biopsy in the diagnosis of thyroid nodules

The fine needle aspiration (FNA) biopsies performed on thyroid nodules at Turku University Central Hospital from 1983 to 1988 were reviewed. Of the 1,054 total aspirated nodules, 194 were investigated histologically after thyroid surgery (191 cases) or at autopsy (3 cases). Two cases with an insufficient FNA sample, 4 with an incidental occult papillary carcinoma and 2 cases with carcinoma outside the nodule investigated by FNA biopsy were excluded from the series, leaving 186 histologically confirmed nodules in the final analysis. Three (3%) of the 107 cases with an FNA biopsy diagnosis of benign, 4 (8%) of the 52 with an FNA diagnosis of equivocal, 3 (20%) of the 15 with an FNA diagnosis of suspicious and all 12 (100%) with an FNA diagnosis of malignant were histologically malignant. If only an unequivocally malignant cytologic finding is considered positive, FNA biopsy had a diagnostic specificity of 100%, a sensitivity of 55% and an accuracy of 95% among the histologically confirmed cases. Follow-up revealed no cases of cancer among the 863 thyroids that were not explored surgically. It is concluded that FNA biopsy is a practical method with considerable diagnostic value in the evaluation of thyroid nodules.     

Clinicopathologic analysis of fine needle aspiration cytology of the thyroid. A review of 1,613 cases and correlation with histopathologic diagnoses

OBJECTIVE: To evaluate the accuracy of fine needle aspiration (FNA) of thyroid lesions at our institution and to ascertain its usefulness in determining the therapeutic approach. STUDY DESIGN: The authors reviewed the results of 1,613 cases of FNA cytology of thyroid nodules performed from 1999 to 2001 at the Department of Pathology, Chonnam National University Hospital. Cytologic diagnoses were compared with histologic diagnoses in 207 cases that included both FNA and thyroid surgery. RESULTS: The sensitivity for the detection of neoplasms (carcinoma and follicular adenoma) was 78.4% and the specificity 98.2%. A false positive diagnosis was made in 1 case (1.8%) and false negative ones in 28 cases (21.5%). The diagnostic accuracy was 84.4%, with a positive predictive value of 99.0% and negative predictive value of 66.3%. The predictive value of a cytologic diagnosis was 100% in papillary carcinoma. CONCLUSION: FNA is a useful test in determining the therapeutic approach of thyroid lesions.     

Fas 相关死亡结构域蛋白在乳腺癌中表达的临床病理研究

目的:探讨Fas相关死亡结构域蛋白(Fas-associated death domain protein,FADD)在乳腺癌中表达的临床病理学意义。方法:收集乳腺癌病例及相应的临床资料包括随访资料,应用免疫组织化学技术检测乳腺良性病变,有/无淋巴结转移的乳腺癌及配对淋巴结转移灶中FADD的表达,观察分析FADD表达与乳腺癌患者年龄、肿块大小、临床分期、组织学类型和分级、雌孕激素受体水平等临床病理指标间的关系。结果:免疫组化检测结果显示良性乳腺病变组中FADD的阳性表达率(85.1%,40/47)与无淋巴结转移的乳腺癌组(45.8%,38/83),伴有淋巴结转移的乳腺癌组(67.3%72/107)和淋巴结转移灶(45.8%,49/107)组织中FADD阳性表率均有显著性差异(P值分别0.001,=0.022和0.001);此外,伴有淋巴结转移的乳腺癌组中FADD阳性表达率也均与其它三组中FADD阳性表达率之间具有显著性差异(P值分别为0.003,0.001和0.022)。FADD与患者的确诊年龄(P=0.049)和淋巴结转移有显著性相关(P=0.003),与肿瘤大小、临床分期、组织学类型、组织学分级、雌孕激素受体及cerb B-2的表达情况和月经史无明显相关性(P0.05)。生存分析显示FADD阳性表达的患者较FADD阴性患者的生存期更短。结论:FADD与乳腺癌淋巴结转移和预后有关。     

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.     

Posters. P17 Accuracy of fine needle aspiration cytology in diagnosis of thyroid swellings

Introduction Fine needle aspiration cytology is regarded as the gold standard investigation in diagnosis of thyroid swellings. Published data suggest an overall accuracy rate of 75% 1 in the detection of thyroid malignancy. The aim of this study was to determine the accuracy of FNA cytology in detection of thyroid malignancy in our surgical unit. Methods Between 1989–2002, 144 patients who underwent thyroid resection by single consultant surgeon and who had pre‐operative FNA were enrolled in this retrospective study. The pre‐operative FNA results were compared with definitive histological diagnosis following thyroid resection. Fine needle aspiration cytology was performed using aspirate and non‐aspirate techniques on each thyroid swelling. The cytological sample was assessed by a single cytopathologist and was classified as inadequate, non‐neoplastic, neoplastic, suspicious or indeterminate. The histology was classified as non‐neoplastic (benign) and neoplastic (malignant). Results Fine needle aspiration cytology analysis revealed 94 (13.88%) non‐neoplastic, six (65.27%) neoplastic and 20 (4.16%) suspicious aspirates. Twenty (13.88%) samples were inadequate and four (2.77%) samples were indeterminate. Histological analysis showed 118 (81.94%) benign, 26 (18.05%) malignant specimens. Fine needle aspiration cytology had a sensitivity, specificity and accuracy rate of 52.6%, 86.6% and 79.1%, respectively for diagnosing thyroid malignancy. Conclusion The results are comparable with the current published data and demonstrate that FNA cytology in our hands is accurate investigation for pre‐operative diagnosis for the detection of thyroid malignancy.     

Value of fine needle aspiration cytology in the initial diagnosis of Hodgkin's disease. Analysis of 188 cases with an emphasis on diagnostic pitfalls

OBJECTIVE: To evaluate the diagnostic accuracy and pitfalls of fine needle aspiration (FNA) cytology in the initial evaluation of Hodgkin's disease (HD) and to assess the influence of the pathologist's experience by comparing the results during two periods. STUDY DESIGN: A total of 170 cytodiagnoses of HD were reviewed and compared with those on the final histopathologic report. Thirty-three cases of HD with a previous, different cytologic diagnosis were also selected. In all the cases under study, FNA was performed as part of the initial diagnostic approach. From a practical perspective, diagnostic errors were divided into major or minor according to the consequences on patient management. RESULTS: Fifteen cytologic diagnoses of HD were followed by a different histologic diagnosis after lymph node biopsy. In 33 cases of HD an erroneous cytologic diagnosis was given prior to biopsy. The sensitivity of the series was 82.4% (86.1% excluding nonrepresentative cases). The positive predictive value reached 91.2%. Sensitivity varied from 79.3% in the first period (1982-1990) to 84.9% in the second (1991-1999) (83.3% and 88.2%, respectively, excluding nonrepresentative cases). Similarly, the positive predictive value increased from 89% to 92.8%. Diagnostic errors with important consequences for patient management diminished from 14 in the first period to 5 in the second. CONCLUSION: Cytology offers a rapid and accurate approach not only for the diagnosis of recurrent HD but also for its initial recognition. These results increase the capacity of FNA as a first-level diagnostic technique in the screening of lymphadenopathies.     

Metaplastic breast carcinoma. A diagnostic problem in fine needle aspiration biopsy.

Fine needle aspiration (FNA) was used to evaluate a breast lump and enlarged lymph nodes in a woman with a prior history of lumpectomy on the contralateral breast and a recent negative mammogram. The FNA cytologic findings included markedly atypical fibroblast-like cells lying singly and in groups in a myxoid background, highly atypical multinucleated cells and numerous mitoses, features that were interpreted as a high-grade malignant mesenchymal tumor. The carcinomatous cells in the aspirates were only fully appreciated after histologic examination of the mastectomy specimen and the axillary lymph node metastases showed a dual differentiation consisting of both epithelial and mesenchymal components, leading to a final diagnosis of metaplastic carcinoma. Electron microscopic study of histologic samples confirmed the dual differentiation, and both keratin and vimentin intermediate filaments were recognized by immunohistochemical staining. The regional lymph node metastases were predominantly sarcomatous, which apparently is a rare event. The entity of metaplastic carcinoma is discussed in relation to other mixed epithelial-mesenchymal lesions of the breast, and the previous literature on this entity is briefly reviewed.