Differential diagnosis of malignant intrahepatic tumors by ultrasonically guided fine needle aspiration biopsy and by laparoscopic/intraoperative biopsy. A comparative study

Thirty-six cases of ultrasonographically detected liver tumors (28 malignant and 8 benign lesions) were investigated by both fine needle aspiration (FNA) biopsy and laparoscopic or intraoperative tissue biopsy. The sensitivity of FNA biopsy in detecting a neoplasm was 85.7% while that of tissue biopsy was 82.1%. Specificity was 100% in both methods. A correct histologic diagnosis of the neoplasm could be made on the cytologic smear in only 14 cases (50.0%) due to technical and methodologic difficulties. Endoscopic and intraoperative tissue biopsy yielded sufficient material to make a definite histologic tumor diagnosis in 23 of 28 cases. Additional information on tumor spread and sequelae of liver infiltration was obtained by macroscopic tissue observations in nine cases. These results indicate that FNA biopsy is less sensitive in the classification of primary or secondary liver tumors and that tissue biopsies obtained during laparoscopy or laparotomy are required if a suspected hepatic neoplasm needs to be classified exactly to plan therapy and to establish a prognosis.     

Fine needle aspiration biopsy in uveal melanoma

Fine needle aspiration (FNA) biopsies were performed in a series of patients with uveal tumors. Cytopathologic examination established the correct diagnosis in 26 of 29 uveal melanomas. FNA biopsy was able to exclude the diagnosis of a malignant neoplasm in five nonmelanoma tumefactions. Histologic and FNA cytologic typing of melanomas as epithelioid or predominantly spindle cell showed good agreement, with the same classifications made in 14 of 18 cases. FNA biopsy specimens also proved to be adequate for DNA-content and cell-cycling studies. The cessation of cell cycling in successfully irradiated melanomas may be useful in establishing the postradiation status of tumors that have questionable growths after therapy, as was shown using FNA samples in three such cases in this study. The results of this study show that FNA biopsy is a useful diagnostic adjunct in patients with atypical lesions that require therapy.     

Fine needle aspiration diagnosis of a nasopharyngeal teratoma

A newborn presented with airway obstruction due to a large nasopharyngeal mass extending into the oropharynx. A diagnosis of teratoma was made by transoral fine needle aspiration (FNA) biopsy and confirmed by subsequent histologic studies. The cytologic features of nasopharyngeal teratoma are presented, and the diagnostic utility of FNA biopsy in evaluating such lesions is discussed.     

Percutaneous core needle biopsy vs. fine needle aspiration in diagnosing benign lung lesions.

OBJECTIVE: To determine the diagnostic value of percutaneous core needle biopsy (PCNB) in comparison with fine needle aspiration (FNA) in patients with benign pulmonary lesions. STUDY DESIGN: A retrospective review was undertaken of computed tomography-guided PCNBs and FNAs performed between 1988 and 1997. Both FNA and PCNB biopsies were carried out sequentially at the same visit in every patient. RESULTS: A specific benign diagnosis was made in 10/60 cases (16.7%) by FNA and in 49/60 (81.7%) by PCNB. PCNB findings resulted in significant modification of the diagnosis established by FNA. The only significant complication encountered was pneumothorax, at a rate of 11.7%, which is compatible with that reported in the literature for complications induced by FNA alone. CONCLUSION: Radiologically guided PCNB is a safe procedure, can provide sufficient histologic material for a specific diagnosis of peripheral lung disease and can avoid more-invasive surgical procedures in many cases. Our experience demonstrated that the histologic analysis provided by PCNB can greatly increase the diagnostic accuracy in benign pulmonary diseases as compared with the yield of FNA.     

Conclusive diagnosis of hepatic and pancreatic malignancies by fine needle aspiration

A study of the diagnosis of hepatic and pancreatic malignancies by fine needle aspiration (FNA) was made, based on 221 aspirates obtained from 209 patients with histologic or clinical confirmation: 159 with hepatic and 50 with pancreatic lesions. The values of sensitivity, specificity and predictivity for positive FNA results were, respectively, 0.84, 0.96 and 1.0 for the liver and 0.76, 1.0 and 1.0 for the pancreas. The composition of the case material showed an incidence of malignant tumors of the liver and pancreas of 84% and 60%, respectively (among which the primary malignancies were 39% and 48%), while nonneoplastic lesions had incidences of 14% and 40%. However, conclusive FNA diagnoses of the histologic type of the primary and the site of origin of metastatic tumors were made in 60% of the hepatic lesions but in only 9% of the pancreatic lesions. Primary hepatocellular carcinoma was diagnosed by FNA of the liver in 95% of the cases; FNA specifically diagnosed 42% of intrahepatic bile duct carcinomas and 40% of hepatic metastases. These findings correlate with the unique cytologic features of primary hepatocellular carcinoma of intrahepatic rather nonspecific morphology of carcinoma of intrahepatic and extrahepatic origin, as well as of pancreatic ductal origin.     

Fine needle aspiration biopsy in the diagnosis of intrathoracic masses.

During a 3.5-year period (January 1, 1987, to June 30, 1990) 420 percutaneous fine needle aspiration (FNA) biopsies were performed on 390 patients (309 males, 81 females) suffering from one or more intrathoracic, radiologically visible lesions. Aspirations were carried out using 21- or 23-gauge Chiba needles under fluoroscopic or computed tomographic control. The aspirates were used to make minibiopsies and cytologic smears. Diagnosis was possible in 373 cases (95.64%): on the first pass in 344 cases, on the second in 28 cases and on the third in 1. In 17 cases (4.36%) the aspirate was inadequate for diagnosis. There were complications in 10 cases (2.56%) (9 pneumothorax and 1 hemophtysis) requiring intensive care. The 373 percutaneous FNA biopsy diagnoses included 256 malignant tumors (68.63%), of which 234 were primary and 22 were secondary, and 117 benign lesions (31.37%), 5 of them neoplastic and 112 nonneoplastic. Three hundred two of 373 percutaneous FNA biopsy diagnoses were followed (80.96%). One hundred twenty-three follow-ups were histologic (40.73%), including secondary tumors, which could be compared with the primary histotype. Twenty-eight follow-ups were cytologic (9.27%), and 151 were clinical (50.00%), using progression of the disease or the beginning of chemoradiotherapy as a criterion for malignancy and a stable condition or regression of the lesion with nononcologic medical treatment as a criterion for benignity. Percutaneous FNA biopsy diagnoses were confirmed in 288 cases (221 true positives and 67 true negatives) and unconfirmed in 14 (1 false positive and 13 false negatives). Specificity, sensitivity, negative predictive value, positive predictive value and total diagnostic accuracy were, respectively, 98.52, 94.44, 83.75, 99.54 and 95.36%. The histologic typing accuracy of percutaneous FNA biopsy on 70 specimens of surgically removed malignant epithelial neoplasias was 70.00%. These results confirm that percutaneous FNA biopsy is a reliable method of diagnosing intrathoracic masses and reduces the need for diagnostic thoracotomy.     

Fine needle aspiration cytology of soft tissue tumors

OBJECTIVE: To review of the value of fine needle aspiration (FNA) cytology in the diagnosis of soft tissue tumors (STT). STUDY DESIGN: A review of the literature was coupled with the authors' experience with indications, diagnostic specificity and pitfalls; clinical information; and the final cytology report. RESULTS: Over the last few years, FNA has come to be considered a valuable tool in the management of STT in that it affords a specificity of > 90%. FNA is of particular value in any subcutaneous lesion > 5 cm, in all pediatric tumors and whenever direct incision biopsy is particularly contraindicated. Material from aspirates can be used to obtain cytologic smears for conventional staining, special pigment identification, histochemical techniques, cell blocks for paraffin embedding and ancillary techniques (immunocytochemistry, electron microscopy, and densitometric and cytogenetic analyses). The cytologic diagnosis, like its histologic counterpart, should be based on a correct evaluation of clinical data (age, localization, size, effect on bone, nerve and vessel involvement), radiologic information, cytologic findings (architectural pattern, cell and stroma characteristics) and results of special staining techniques. The final cytology report should place the tumor in one of three basic categories: benign, malignant, and inconclusive or undetermined. Wherever possible, a histopathologic diagnosis should also be provided, either based on purely cytologic criteria or aided by ancillary techniques. CONCLUSION: FNA does not present major complications and permits a swift, preliminary diagnosis in a large number of cases. The method is most effective when the aspiration is performed by an experienced pathologist.     

Fine needle aspiration biopsy of azoospermic testes. Could it replace histologic biopsy?

OBJECTIVE: To evaluate the possibility of replacing histologic biopsy of azoospermic testes by fine needle aspiration (FNA) for diagnostic and management purposes. STUDY DESIGN: Twenty-seven patients were examined under general anesthesia, and 53 testes were biopsied by FNA. Fifty-four testes were biopsied for histologic examination. Histology and cytology of each testis were compared to assess the discrepancy or concordance between the diagnoses. RESULTS: Twenty-seven testes showed complete concordance of cytology and histology, and 13 testes showed a mild degree of discrepancy. A severe degree of discrepancy was seen in 13 testes. In the majority of discrepant cases, FNA biopsy diagnosis was more sensitive in detecting evidence of full or advanced maturation. In one case of discrepancy, the histologic finding was Sertoli cells only, and cytology revealed focal full maturation. In vitro fertilization using sperm from this case was successful. CONCLUSION: FNA biopsy of testes in azoospermia is a fast, reliable and minimally traumatic method. The prospects for utilizing FNA biopsy material in assisted and microassisted fertilization are promising.     

Diagnostic pitfalls in the fine needle aspiration of thyroid nodules. A study of 555 cases in Chinese patients

The diagnostic value and limitations of fine needle aspiration (FNA) were determined by examining 555 palpable thyroid nodules in Chinese patients who had a definitive diagnosis established by thyroidectomy (529 cases) or large-needle biopsy (26 cases). Of the aspirates, 97.8% were satisfactory for cytologic examination. The overall malignancy rate was 20%. FNA detected 73 (74.5%) of 98 primary malignant tumors and 9 (90%) of 10 metastatic tumors. Diagnostic errors were most commonly due to inadequate specimens and cystic lesions. Cystic fluid, present in one-third of all lesions, was associated with a malignant nodule in 13% of the cases. FNA was most valuable for detecting papillary carcinomas; it may at times suggest the likelihood of a follicular carcinoma.     

Lipomatous lesions of the parotid gland. Potential pitfalls in fine needle aspiration biopsy diagnosis

Nine cases of benign fatty tumors of the parotid studied initially by fine needle aspiration (FNA) biopsy and subsequently diagnosed by open biopsy were reviewed. All lesions presented as enlargements of the parotid gland. The cytologic diagnoses were correct in only five of the nine cases. While four of six FNA samples from lipomas were correctly diagnosed by cytology, the other two samples were classified as inadequate. Three cases of diffuse infiltration of the parotid by mature-appearing adipose tissue were cytologically characterized as "no diagnostic change" in two cases and sialosis in one case. The clinical, radiologic, cytologic and histologic features of these tumors are described to increase the familiarity of cytologists with these lesions, which may prevent unnecessary surgical intervention in some patients.     

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.     

Fine needle aspiration cytology of focal nodular hyperplasia of the liver

In five cases, the fine needle aspiration (FNA) cytologic study of ultrasonically detected solitary liver tumors yielded a diagnosis of focal nodular hyperplasia. Cytomorphologically, the lesions were characterized by the presence of both abundant normal hepatocytes and numerous epithelial cells in ductal formations, clusters or tightly packed groups in the FNA samples. In two of the five cases, the cytologic diagnosis was confirmed by subsequent histologic studies; in the remaining three cases, the clinical data were consistent with focal nodular hyperplasia of the liver. All five patients were women, four of whom had used oral contraceptives for long periods of time (5 to 15 years), which has previously been linked to the development of focal nodular hyperplasia of the liver. Based on the findings in this study, FNA cytology should be adequate for making the differential diagnosis of focal nodular hyperplasia versus liver-cell adenoma when solitary liver tumors are detected in such cases; it can yield a morphologic diagnosis and facilitate the decision as to whether surgical intervention is required.     

Testicular germ cell tumors. Classification based on fine needle aspiration biopsy

Fine needle aspiration (FNA) biopsy was performed preoperatively on 13 patients with testicular germ cell tumors. The cytologic typing of the tumors was based on the presence or absence of seminoma, embryonal carcinoma, yolk-sac tumor, choriocarcinoma and teratoma in the aspirate. The cytologic findings showed good agreement with the histologic findings. Only four cases showed a single type of tumor; the other nine cases showed as many as four different tumor components. A few characteristic cytologic features proved to be sufficient for tumor typing; this suggests that FNA biopsy cytology can also be useful in identifying metastatic germ cell tumors in extra-gonadal sites.     

Fine needle aspiration of breast lesions in women aged 30 and under

Fine needle aspiration (FNA) biopsies of 1,598 breast masses were performed between 1983 and 1989, and of them, 48 were from women aged 30 and under for whom a cytologic diagnosis was made by FNA and histologic follow-up was available. In 37 (77%) of the cases, both the cytologic and histologic diagnoses were benign. Fibroadenoma (20/37) and fibrocystic changes (14/37) were the most common benign lesions aspirated. Eight (17%) FNAs showed cytologic atypia. Four of these atypical lesions proved to be benign (two fibroadenomas, two fibrocystic changes). Epithelial proliferation in fibroadenomas and fibrocystic changes and cellular stroma in a fibroadenoma mimicking phylloides tumor were the causes of atypia in these biopsies. Four of the eight atypical lesions were shown to be carcinoma at biopsy (three infiltrating duct, one atypical medullary). Low cellularity, epithelial cohesiveness mimicking a fibroadenoma and background lactational changes in a pregnant patient were the causes of the atypical, rather than unequivocally malignant, diagnoses in these cases. In three patients (6%), a diagnosis of carcinoma was made by FNA and confirmed histologically (all were infiltrating duct carcinoma). Although most breast masses in women aged 30 and under are benign, cytologic atypia in a breast fine needle aspirate in this age group warrants a surgical biopsy. Clinical follow-up alone may be appropriate for young women with clinically nonsuspicious breast masses without cytologic atypia.     

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 biopsy versus sputum and bronchial material in the diagnosis of lung cancer. A comparative study of 168 patients

A group of 168 consecutive lung cancer patients in whom a definitive diagnosis of primary lung cancer was established either in a conventional cytologic specimen of sputum or bronchial material or in a specimen obtained by fine needle aspiration (FNA) biopsy was reviewed to compare the relative accuracies between the modalities of sputum and bronchial material on one hand versus FNA cytology on the other in the diagnosis of lung cancer. The patients included in the study were selected from a total of 1,093 patients who had been diagnosed and treated for lung cancer at Duke University Medical Center over the five-year period of January 1, 1980, through December 31, 1984. In 325 (29.8%) of the 1,093 patients, a definitive cancer diagnosis was established from histopathologic study alone, without any cytologic diagnoses. In 420 patients (38.4%), both histologic and cytologic material had been interpreted as being conclusively diagnostic for lung cancer. In 348 patients (31.8%), a cytologic diagnosis of lung cancer was made without a histologic confirmation. Thus, in a total of 768 (70.3%) of the 1,093 cases, a definitive cytologic diagnosis of cancer had been made. Of these 768 patients, 168 had been evaluated by both conventional respiratory cytologic methods (examination of sputum and bronchial material) and with FNA biopsy cytology. In 9 patients (5.4%), only conventional respiratory cytologic specimens were conclusively diagnostic for cancer. In 122 patients (72.6%), only the FNA biopsy specimen was diagnostic. In 37 patients (22.0%), both conventional respiratory specimens and FNA specimens yielded a definitive lung cancer diagnosis. The FNA specimen was the only positive cytologic specimen in 90.2% of large cell undifferentiated carcinomas, 79.5% of adenocarcinomas, 66.7% of small cell undifferentiated carcinomas and 58.2% of squamous cell carcinomas. In 26.5% of the patients, a diagnosis of cancer could have been established on conventional cytologic specimens, without the necessity of proceeding to percutaneous FNA biopsy. From this study, it is concluded that the techniques of conventional respiratory cytology and FNA biopsy cytology are complementary in the diagnosis of lung cancer. While the percentage of lung cancers diagnosed by FNA biopsy cytology alone is much greater than that obtained by conventional respiratory cytology alone, more than one-fourth of these cancers could be detected by the less invasive techniques of sputum collection and bronchoscopy.     

Cytomorphometry of uveal melanoma. Comparison of fine needle aspiration biopsy samples with histologic sections.

A number of approaches are being investigated to increase the prognostic accuracy for uveal melanoma patients; the standard deviation of nucleolar area measurements and the DNA content appear to correlate better with survival than do classic histologic parameters. The utility of performing cytomorphometric measurements on fine needle aspiration (FNA) biopsy samples was prospectively analyzed for 24 eyes containing uveal melanomas that were examined with both 25-gauge FNA biopsy and standard histologic techniques. "Masked" analysis of the cellular composition of the 24 cases showed the presence or absence of epithelioid cells to be accurately predicted on the FNA samples in all cases. Image analysis cytomorphometric measurements of nucleolar area showed marked variability (with r less than 0.4) when FNA and histologic samples from the same case were compared. The relationship between these measurements was affected by cell type, sampling, specimen processing and investigator experience.     

Endometriosis in an inguinal crural hernia. Diagnosis by fine needle aspiration biopsy.

The fine needle aspiration (FNA) biopsy findings of endometriosis is an inguinal crural hernia in a 40-year-old woman are presented. The cytologic findings were similar to those previously reported in aspirates of solid endometriosis in other sites: nonatypical, small, epithelial groups in an inflammatory and proteinaceous background. The cytologic diagnosis of a benign epithelial lesion, possibly endometriosis, was confirmed by histologic study of the extirpated mass. This case shows that endometriosis must be included in the differential diagnosis of FNA samples of palpable lesions of the groin in women of reproductive age.     

Fine needle aspiration biopsy diagnosis of giant-cell tumor of bone. An experience with nine cases

The cytologic findings in nine cases of giant-cell tumor (osteoclastoma) of bone diagnosed by fine needle aspiration (FNA) biopsy are described. The aspirates contained a dual population of cells, consisting of mononucleated tumor cells and multinucleated giant cells (osteoclasts). The tumor cells were usually evident in the FNA smears as cohesive perivascular clusters; some were present as sheets or single cells. The most striking feature, which may best suggest the diagnosis of giant-cell tumor in an FNA smear, was the attachment of the osteoclasts to the cohesive groups of tumor cells. Even when the cells were more dissociated, there was a rather regular distribution of the two types of cells. This series further demonstrates that FNA biopsy permits an accurate cytopathologic diagnosis of giant-cell tumor and that its use can clarify the clinical and radiologic impressions of these bony lesions preoperatively. The differential diagnosis between osteoclastoma and other giant-cell containing bone lesions is discussed in detail.