Ultrasound-guided fine needle aspiration cytology of parathyroid lesions. A review of 72 cases

OBJECTIVE: To elucidate the specific cytomorphologic patterns and diagnostic pitfalls in fine needle aspiration cytology (FNAC) of parathyroid lesions. STUDY DESIGN: Seventy-two cases of surgically excised and pathologically verified hyperparathyroidism (20 cases of parathyroid hyperplasia, 51 of parathyroid adenoma and one of parathyroid carcinoma) received preoperative, ultrasound-guided FNAC examination for enlarged parathyroid glands. The smears were reviewed and analyzed. RESULTS: Parathyroid lesions were diagnosed cytologically in 60 cases (83.3%). The presence of colloidlike substance, macrophages or follicular structures in smears led to six cases (8.3%) being misinterpreted as thyroid lesions. The cellularity of the smears was insufficient for interpretation in six cases (8.3%); however, two of these cases were diagnosed by determination of parathyroid hormone (PTH) levels in the fluid. Parathyroid hyperplasia had more tightly cohesive cell clusters with monomorphism, while parathyroid adenoma had more dispersed or loosely cohesive cells with pleomorphism and anisokaryosis. High PTH concentration in an aspirate was noted in all four cases of cystic lesions.     

Utility of fine needle aspiration cytology in mediastinal lesions: a clinicopathologic study of 1617 cases from a single institution

OBJECTIVE: To study the distribution, prevalence and cytomorphologic features of mediastinal lesions and assess the utility of fine needle aspiration cytology (FNAC) in such lesions by correlating with clinical, laboratory and imageologic parameters. STUDY DESIGN: A retrospective study was performed of mediastinal lesions that were referred for ultrasonographic/computed tomography-guided FNAC during the years 2001-2006. Correlation was done wherever possible using the following parameters: histology, bone marrow, imageology, tumor markers, cytology, immunohistochemistry, antecedent history and regression after therapy. RESULTS: A total of 161 patients underwent 182 aspirates. Diagnosis was possible in 130 (80.7%) patients, and, in 31 cases (19.3%), aspirates were unsatisfactory. In 71 (54.6%) correlation was done, and in 70 (98.5%) positive correlation was found. CONCLUSION: FNAC in correlation with clinical, imageologic and hematologic features proved to be an excellent diagnostic tool in diagnosing as well as classifying mediastinal lesions and can be used as a substitute to core biopsy.     

Transthoracic fine needle aspiration biopsy in pulmonary lesions. Updated results

An investigation was carried out on 271 patients who underwent transthoracic fine needle aspiration biopsy ( FNAB ) for suspected pulmonary lesions in a four-year period; 80% of them had a malignant tumor. The histologic control of the cytologic diagnoses made on the transthoracic FNAB was possible in over 50% of the cases. The sensitivity and predictive value for positive results were, respectively, 0.890 and 0.995, whereas the typing accuracy verified in 58 cases on the surgical specimen was 0.76. The comparison of the data obtained from the most recent case material with that of early observations confirmed the high sensitivity of transthoracic FNAB in the detection and characterization of malignant lesions in the lungs. The sensitivity was almost identical for primary tumors, 0.90, and metastatic disease, 0.88. Furthermore, over the years the data showed an improvement in the results due to the experience gained, the combined use of cytology and histology and the application of histochemical methods. More sophisticated methods, such as immunocytochemistry and electron microscopy, were essential to the final diagnosis in only a few cases.     

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.     

Comparative study of fine needle aspiration and fine needle capillary sampling of thyroid lesions

OBJECTIVE: To investigate whether fine needle capillary (FNC) sampling gives quantitatively and qualitatively superior cytologic material as compared to the conventional technique of fine needle aspiration (FNA) when performed by a single aspirator. STUDY DESIGN: Cross-sectional diagnostic test evaluation study. FNA and FNC were performed by a single operator on 200 diffuse and nodular thyroid lesions. RESULTS: A statistically significant difference in favor of FNC was observed for the parameter amount of cellular material. For the rest of the parameters--background blood or clot, degree of cellular degeneration, degree of cellular trauma and retention of architecture--the average score favored FNC but was not statistically significant--i.e., smears prepared from FNC displayed cellular material that was more concentrated, less damaged and less likely to be obscured by blood. CONCLUSION: Although FNC sampling was diagnostic in a greater number of cases than FNA sampling, this study did not prove a clear superiority of FNC over FNA. Until greater experience shows clear sampling superiority of FNC alone, rather than performing only FNA in diffuse or nodular thyroid lesions, incorporating FNC into the second puncture will definitely improve the quality and quantity of material at the patient's first visit.     

Value of fine needle aspiration in the diagnosis of breast lesions.

OBJECTIVE: To evaluate the accuracy values of 276 fine needle aspriations (FNA) of breast lesions with a subsequent excisional biopsy diagnosis and to make a comparison between 25 studies of the literature using the same criteria to calculate those values. STUDY DESIGN: Cytologic findings were compared with the histologic diagnosis of each mass. The correlation of results was analyzed by a decision-analysis approach, and the following values concerning diagnostic accuracy were calculated in the present study and in 25 other reports: sensitivity, specificity, positive predictive value, negative predictive value, false positive fraction and false negative fraction. To calculate those values, we eliminated unsatisfactory results and assumed that suspicious and positive cytologic findings represented carcinoma of the breast. RESULTS: Comparing our results with the means in the literature (numbers in parenthesis), FNA detected cancer with a sensitivity of 92.1% (87.7%), specificity of 98.6% (94.7%), positive predictive value of 99.4% (92.8%), negative predictive value of 82.1% (90.7%), false positive fraction of 0.6% (7.1%) and false negative fraction of 17.9% (13.4%); in 6.2% of cases the material was unsatisfactory (13.4%). CONCLUSION: All the rates varied enormously between the studies and during the past 13 years. It seems that false positive and false negative fractions tended to diminish and stabilize in more recent years, and specificity and sensitivity underwent a slight increase. The differences between the rates of those studies suggest that FNA of the breast has some unavoidable limitations.     

Utility of CD34 reactivity in evaluating focal nodular hepatocellular lesions sampled by fine needle aspiration biopsy

OBJECTIVE: To determine the patterns of CD34 reactivity in hepatocellular adenoma and focal nodular hyperplasia and to evaluate the utility of CD34 reactivity in the diagnosis of hepatocellular carcinoma. STUDY DESIGN: Seventeen cases of well-differentiated hepatocellular carcinoma, 14 cases of cirrhosis, 9 cases of focal nodular hyperplasia and 7 cases of hepatocellular adenoma were stained with immunoperoxidase antibodies to CD34. The slides were scored according to the degree of lesional reactivity. RESULTS: Fourteen of 17 cell blocks with hepatocellular carcinoma showed unequivocal sinusoidal or peripheral reactivity for CD34. Five of seven cases of hepatocellular adenoma and four of nine cases of focal nodular hyperplasia showed > 50% sinusoidal reactivity for CD34. All 14 cases of cirrhosis showed peripheral to no sinusoidal reactivity. CONCLUSION: CD34 reactivity in a diffuse sinusoidal pattern can be helpful in the diagnosis of hepatocellular carcinoma. However, consideration should be given to the possibility of hepatocellular adenoma and focal nodular hyperplasia, which can also exhibit significant diffuse CD34 reactivity. In these cases, a reticulin stain may be helpful with the differential diagnosis.     

Three-dimensional cytomorphology in fine needle aspiration biopsy of parathyroid lesions

OBJECTIVE: To elucidate three-dimensional (3-D) cytomorphology in fine needle aspiration biopsy (FNAB) of parathyroid lesions. STUDY DESIGN: Ultrasound-guided FNAB was performed on parathyroid lesions from 10 patients with hyperparathyroidism. The aspirates were stained and observed under a light microscope (LM). The aspirates were also fixed, dehydrated, critical point dried, spattered with gold ions and observed with a scanning electron microscope (SEM). Findings under SEM were correlated with the appearances under LM as well as with serum parathyroid hormone (PTH) concentrations. RESULTS: Under LM, nine cases displayed isokaryosis and one case, anisokaryosis. These appearances corresponded to isocytosis or anisocytosis under SEM. Under SEM, 3-D cytomorphology of parathyroid lesions displayed isocytotic, scattered cells in five cases, uniform cellular arrangements in four cases and anisocytotic, scattered cells in one case. The cell surface was rather smooth in five cases. The other five cases had significant granules on the cell surfaces; these all had serum PTH concentrations > or = 268 pg/mL. CONCLUSION: 3-D cytomorphology in FNAB of parathyroid lesions was a rather smooth cell surface in cases with low serum PTH and a granular cell surface in cases with significantly increased serum PTH. These characteristics and the absence of microvilli might be helpful in the differential diagnosis between parathyroid and follicular thyroid lesions.     

Use of fine needle aspiration cytology in leprotic lesions: a report of 4 cases

BACKGROUND: Although a few studies have shown fine needle aspiration cytology (FNAC) to be a sensitive diagnostic tool in the detection of nerve involvement, its role as an initial diagnostic procedure in pure neuritic leprosy (PNL) and in the detection of skeletal lesions with unusual findings has not been documented before. CASES: Three patients who presented with thickened nerves and a fourth with biopsy-proven lepromatous leprosy with lesions in hand bones underwent FNAC. Of the 3 patients with nerve thickening, 2 had a clinical suspicion or diagnosis of neuritic leprosy, whereas in the third patient a clinical differential diagnosis of a soft tissue tumor or parasitic cyst was considered. FNAC in all 3 cases revealed epithelioid cell granulomas, Langhans giant cells and caseous necrosis. Fites and Ziehl-Neelsen stains were negative for acid-fast bacilli. Cytologic diagnosis of pure neuritic leprosy was made in all 3 cases and confirmed by histopathologic examination. FNAC of skeletal lesions from the fourth patient confirmed involvement of bone with unusual cytologic findings of epithelioid cell granulomas and giant cells along with a significant proportion of foamy macrophages and strong Fites stain positivity. CONCLUSION: FNAC is a simple, useful, minimally traumatic and routinely applicable procedure in the diagnosis of pure neuritic leprosy and leprous osteitis.     

Endoscopically directed fine needle aspiration biopsy of gastric and esophageal lesions.

Endoscopically directed fine needle aspiration (FNA) has been reported to be a valuable adjunct to forceps biopsy in the evaluation of gastric and esophageal lesions. In our series of 38 cases with endoscopically detected mucosal and submucosal abnormalities, FNAs were obtained with a Stifcor transbronchial aspiration needle. Four cases were reported as insufficient. Five aspirates correctly documented the presence of a neoplasm, but three failed to identify a subsequently histologically confirmed adenocarcinoma. Two cases were falsely suspicious for adenocarcinoma. FNA correctly excluded lymphoma in 12 patients with thick gastric folds clinically suspicious for lymphoma. FNA is a useful adjunct to forceps biopsy of neoplastic and inflammatory lesions in both mucosal and submucosal locations within the upper gastrointestinal tract.     

Transvaginal fine needle aspiration biopsy.

OBJECTIVE: To assess the role of transvaginal fine needle aspiration biopsy (FNAB) in the evaluation of palpable gynecologic masses. STUDY DESIGN: Transvaginal FNABs from 1994 to 1999 were identified from the files of Barnes-Jewish Hospital. Histologic correlation was obtained using the Pathology Department's computer database. Two pathologists reviewed the pathologic samples. Pertinent clinical information was obtained by reviewing the medical records. RESULTS: Twenty-two transvaginal FNABs from 22 patients were studied. The patients' mean age was 59 years (range, 29-84). Most patients (77%) had a previous history of a gynecologic malignancy, and 73% had a previous total abdominal hysterectomy and bilateral salpingo-oophorectomy. The size of the lesion sampled was provided in 15 cases and ranged from <1 to 5.4 cm in diameter. The location of the mass was reported as follows: vaginal (10 cases), vaginal cuff (5), rectovaginal septum (2), cul-de-sac (1), fornix (1), vaginal apex (1), right side of pelvis (1), and not specified (1). The cytologic diagnoses were: negative for malignancy (10 cases), positive for malignancy (9) and unsatisfactory (3). Most cases (77%) had histologic correlation or clinical follow-up. There was one false negative and no false positive cytologic diagnosis. CONCLUSION: Cytologic interpretation of transvaginal FNAB is an effective toolfor the evaluation of palpable pelvic and vaginal masses. Its specificity and sensitivity are 100% and 88%, respectively.     

Audit of fine needle aspiration cytology of 120 renal lesions

Solid renal masses in 120 patients were assessed by percutaneous fine needle aspiration cytology, performed under radiographic guidance. Follow-up was obtained in all but seven cases. Diagnostic sensitivity for 83 tumours in the series was 91.6%, while two false positive reports resulted in a specificity of 93.8%. Positive and negative predictive values were 97.4% and 81.1% respectively. One advantage of the procedure was the ability to cell type neoplasms accurately, which enabled administration of pre-operative chemotherapy in childhood tumours, and selection of appropriate surgical procedures in adults. The technique offered a non-surgical means of confirming primary renal tumours in patients presenting initially with distant metastases, and documenting renal secondaries in cases with malignancy at other sites. The diagnosis of benign or inflammatory lesions permitted institution of definitive therapy.     

Pitfalls in fine needle aspiration cytology.

A review of pitfalls encountered in fine needle aspiration cytology (FNAC) of all organs and tissues and based mainly on the author's 35-year experience of diagnostic FNAC in clinical practice is presented. Diagnostic difficulties are usually related to deviations from common cytological criteria that may occur in some lesions. Others are due to the effects of the sampling procedure or of the preparation of samples. A few basic rules are proposed, which may help to avoid some of the diagnostic pitfalls.     

Chordoma. Cytomorphologic findings in 14 cases diagnosed by fine needle aspiration

OBJECTIVE: To review the clinical and cytomorphologic features of 14 chordomas diagnosed by fine needle aspiration biopsy (FNAB) at our institution. STUDY DESIGN: The cytology files from January 1985 to February 2000 at Mayo Clinic, Rochester, Minnesota, U.S.A., were searched for all cases diagnosed as chordoma by FNAB. Clinical, radiographic and cytomorphologic findings of each case were reviewed. RESULTS: Ten males and four females (mean age, 55 years; range, 14-78) had tumors involving the sacrum (8), clivus (3) and vertebrae (lumbar, 2; cervical, 1). Pain was the presenting symptom in 11 patients. Most smears (82%) were cellular with a fibrillary background. Chondroid matrix was recognized in nine cases. Small, epitheliallike cells constituted the predominant cellular component in nine cases. Cells with clear, vacuolated cytoplasm were seen in almost 'every case; however, true physaliferous cells were rare. Mitotic figures were seen in four cases, binucleation in six and multinucleated giant cells in seven. Needle biopsies contained diagnostic material in all cases. Of the nine patients with follow-up (mean, 57 months; range, 3-184 months), three patients were alive and free of disease, five were alive with disease, and one was dead of disease at this writing. CONCLUSION: Because various cytologic presentations and overlapping cytologic features occur between chordoma, chondrosarcoma and metastatic clear cell carcinoma, it is important to recognize the various appearances of chordoma in FNAB.     

Computed tomography-guided fine needle aspiration biopsy of deep-seated lesions. A four-year experience

With the increased sophistication of radiologic imaging techniques, the sensitivity of detecting nonpalpable, deep-seated lesions has greatly improved. Coupling these techniques with fine needle aspiration biopsy (FNAB) provides a cost-effective, minimum-risk, highly sensitive and specific method of diagnostically evaluating the lesions. Over a four-year period (1985-1989) a total of 2,229 FNABs were performed at Loyola University Medical Center, Chicago; 539 of these biopsies were computed tomographically guided. The geographic computed tomographic biopsy sites were: thorax, 267 (49.54%); abdomen, 175 (32.47%); and retroperitoneum, 97 (18%). Four hundred eighty FNAB cases were diagnostic, with subsequent histologic follow-up in 284 (58%) cases. Fifty-nine (10.9%) FNABs were unsatisfactory; of them, 31 had subsequent diagnostic histology, and 9 remained unsatisfactory. A good correlation between FNAB and histology was observed, with an overall sensitivity of 93.2%, specificity of 98.8%, false-negative rate of 6.8% and false-positive rate of 1.2%. Diagnostic pitfalls and biopsy adequacy in computed tomographically guided FNABs are discussed.     

Positive predictive value of fine needle aspiration cytology of breast lesions

The predictive value of fine needle aspiration (FNA) was assessed in 1,181 consecutive cases of breast lesions in which cytologic abnormalities were reported. The positive predictive value (PPV) of an FNA cytologic report of atypia, suspicious or positive was 0.49, 0.95 or 0.996, respectively. In the presence of a suspicious/positive report by both physical examination and mammography, the PPV of a cytologic report of suspicious was 0.99. The PPV was directly correlated with age, partly due to the incidence of fibroadenomas among younger patients; fibroadenomas were present in 53 of 146 cases with a false FNA report of atypia, in 10 of 19 cases with a false FNA report of suspicious and in 2 of 2 cases with a false FNA report of positive. Overall, 93 cases reported as benign by physical examination and mammography were biopsied on the basis of the FNA cytologic report; cancers were diagnosed in 33 of these 93 cases (6 cancers among 42 women less than 40 years old and 27 cancers among 51 women greater than 39 years old). The widespread use of FNA cytology to study breast lesions is thus recommended, without regard to patient age and even in the presence of clinically benign findings, since the increase in the rate of cancer detection is worth the excess of unnecessary biopsies. The predictive value of a positive report of FNA cytology, or even of a suspicious report in the presence of clinical suspicion, is so high that an intraoperative frozen section biopsy might be spared in such cases.