Diagnosis of deep‐seated lymphomas by endoscopic ultrasound‐guided fine needle aspiration combined with flow cytometry

A. Stacchini, P. Carucci, D. Pacchioni, G. Accinelli, A. Demurtas, S. Aliberti, M. Bosco, M. Bruno, A. Balbo Mussetto, M. Rizzetto, G. Bussolati and C. De Angelis
Diagnosis of deep‐seated lymphomas by endoscopic ultrasound‐guided fine needle aspiration combined with flow cytometry Objective: Although endoscopic ultrasound combined with fine needle aspiration (EUS‐FNA) is rapidly becoming the preferred diagnostic approach for the sampling and diagnosis of gastrointestinal and mediastinal malignancies, there are limited data as to its use in the diagnosis of lymphoproliferative disorders. Therefore, we carried out a retrospective evaluation of the performance of EUS‐guided FNA combined with flow cytometry (FC) as a tool to improve overall sensitivity and specificity in the diagnosis of lymphoma. Methods: Of 1560 patients having EUS‐guided FNA during the period of the study, a total of 56 patients were evaluated by cytology with FC after EUS‐FNA. There was adequate material to perform FC analysis for all but one case. Results: EUS‐FNA‐FC gave a diagnosis of lymphoma in 11 cases and of reactive lymphadenopathy in 20. A specific histological type was defined by FC alone in eight cases. The remaining cases were diagnosed later by cytology and cell block sections: 13 carcinomas, nine granulomatous lymphadenopathies and one mediastinal extramedullary haematopoiesis. One case was considered only suspicious for lymphoma on cytology and FC but was not confirmed on molecular analysis and one had insufficient material for FC. Conclusions: Our results show that a combination of EUS‐FNA‐FC is a feasible and highly accurate method, which may be used for the diagnosis and subtyping of deep‐seated lymphoma, providing a significant improvement to cytomorphology alone both for diagnosis and treatment planning, as long as immunocytochemistry is available for non‐lymphoma cases.     

Effect of ultrasound transmission gel on ultrasound‐guided fine needle aspiration cytological specimens of thyroid

A. Lalzad, D. Ristitsch, W. Downey, A. F. Little and M. E. Schneider‐Kolsky
Effect of ultrasound transmission gel on ultrasound‐guided fine needle aspiration cytological specimens of thyroid Objective: To investigate prospectively the diagnostic impact of ultrasound coupling gel on thyroid specimens obtained under ultrasound guidance. Methods: Patients presenting for ultrasound‐guided fine needle aspiration (USG‐FNA) of the thyroid were invited to participate in the study. Four specimens per nodule were collected: two using chlorhexdine wash and two using sterile, colourless ultrasound gel as couplant according to routine protocol. All slides were analysed in a blinded fashion by two senior cytologists for the presence or absence of ultrasound gel‐induced artefacts. The presence of gel‐induced artefacts between the two groups was analyzed using Pearson’s chi‐square test. Kappa statistics were used to measure the inter‐rater agreement between the cytologists. Results: Twenty thyroid nodules comprising 80 specimen slides were collected. On slides collected with gel, cytological artefacts were detected in 60–65% of cases compared with 10–15% of cases without gel (P < 0.001). The inter‐rater agreement between the two observers was very good (κ = 0.84). Two of the 14 patients required repeat FNA due to non‐diagnostic cytology results caused by inadequate sampling and gel‐induced artefacts. Conclusions: Clinical cytopathologists, radiologists and sonographers should be aware of the potential for ultrasound gel to cause significant artefacts on cytological specimens. Our findings suggest that staff involved in USG‐FNA cytology should remove the gel carefully before taking the aspirate.     

Endoscopic ultrasound-guided fine needle aspiration cytology of pancreatic neuroendocrine tumours: cytomorphological and immunocytochemical evaluation

OBJECTIVES: Endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) is increasingly used in preoperative localization and diagnosis of pancreatic neoplasms including neuroendocrine tumours (NETs). The objective of the present study was to identify the cytological features of pancreatic NETs obtained by EUS-FNA. METHODS: The study group consisted of nine cases of pancreatic tumours correctly diagnosed or strongly suggestive of NETs based on EUS-FNA. Cytological smears were retrospectively reviewed. The clinical data and immunocytochemical stains applied to the cell block preparations were also reviewed and examined. RESULTS: All cases except one showed characteristic cytomorphological features sufficient for their recognition and separation from pancreatic adenocarcinoma and other lesions. The most helpful cytological features that facilitated the cytological diagnosis of NET were a richly cellular aspirate with a monotonous, poorly cohesive population of small cells with a speckled or dusty chromatin pattern and plasmacytoid morphology. The neuroendocrine differentiation of these tumours was further confirmed by immunocytochemistry. CONCLUSION: EUS-FNA is a valuable method in the recognition of pancreatic NETs. By adherence to the characteristic cytomorphological criteria of pancreatic NET together with collection of suitable material for ancillary immunocytochemical stains, cytopathologists could reach a correct diagnosis in most instances.     

Endoscopic ultrasound‐guided fine needle aspiration of the pancreas: cytomorphological evaluation with emphasis on adequacy assessment,diagnostic criteria and contamination from the gastrointestinal tract1

Objective: Endoscopic ultrasound (EUS)‐guided fine needle aspiration (FNA) has been proved to be safe, efficient and reliable in the diagnosis of pancreatic lesions. This study evaluated specimen adequacy, diagnostic criteria of various pancreatic neoplasms and contamination from the gastrointestinal (GI) tract. Methods: EUS‐guided FNA of the pancreas and subsequent surgical resections performed at the University of California Irvine Medical Center during February 1996–October 2000 were retrospectively selected. Modified Papanicolaou staining method was used for immediate evaluation and cell block prepared. Results: A total of 267 cases were available for review, including 147 (55.1%) positive/suspicious, 10 (3.7%) atypical, 96 (36.0%) negative and 14 (5.2%) unsatisfactory cases. Eighty‐six (58.5%) positive/suspicious cases had histological confirmation and 12 (8.3%) had lymph node or distant metastases by cytology. Three atypical, two negative, and two unsatisfactory cases proved to have adenocarcinoma. Contamination from duodenum, stomach or pancreas was found in 77 positive/suspicious, three atypical and 90 negative cases. The sensitivity, specificity, diagnostic accuracy, positive and negative predictive values were 94.6%, 100%, 95.6%, 100%, 82% respectively. Conclusions: EUS FNA is efficient and accurate in the diagnosis of pancreatic neoplasms in adequate samples. Contamination from the GI tract should be well recognized to avoid misinterpretation.     

Optimizing specimen collection and laboratory procedures reduces the non‐diagnostic rate for endoscopic ultrasound‐guided fine‐needle aspiration of solid lesions of the pancreas

Objectives: Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) is a routine technique to assess solid pancreatic lesions. The aim of this study was to analyse the effect of optimizing laboratory procedures for specimen preparation on the rate and accuracy of the procedure. Methods: All EUS‐FNAs of solid pancreatic lesions performed during the year 2000 (Period 1) and from May 2003 to May 2004 (Period 2) were analysed. During Period 1, one experienced gastroenterologist performed all EUS‐FNAs, making direct smears and retrieving small fragments if present on the smear for histology. In Period 2, two endoscopists performed the EUS‐FNAs and all the material was emptied into a vial containing a fixative. Slide preparation was carried out in the pathology laboratory: one slide was processed using cytocentrifugation and cell blocks were made from left‐over material. Neither period utilized rapid on‐site evaluation. Results: During the two periods, 67 and 102 FNAs were analysed and showed significantly different (P < 0.001) non‐diagnostic rates of 22.8% and 4.2%, respectively. The increased diagnostic yield can be explained by the modified laboratory procedures and to a lesser extent by the increased experience of the gastroenterologists. Sensitivity, specificity, PPV, NPV and accuracy in the second time period were, respectively, 90.6%, 100%, 100%, 81.8% and 93.4%, not significantly different from the first time period. Conclusion: This study shows that accurate EUS‐FNA results may be obtained with a low non‐diagnostic rate comparable to those reported for rapid on‐site evaluation by optimizing laboratory specimen processing in a setting of solid pancreatic lesions.     

Initial axillary staging of breast cancer using ultrasound‐guided fine needle aspiration: a liquid‐based cytology study

A. Schiettecatte, C. Bourgain, C. Breucq, N. Buls, V. De Wilde and J. de Mey
Initial axillary staging of breast cancer using ultrasound‐guided fine needle aspiration: a liquid‐based cytology study Objective: To evaluate the preoperative detection of axillary metastasis combining ultrasound (US)‐guided fine needle aspiration cytology (FNAC) and liquid‐based cytology (Surepath^®) to reduce sentinel node procedures. Methods: In total, 148 patients with clinically negative lymph nodes and no preoperative therapy were included. All patients underwent preoperative ultrasound of the axilla with FNAC if suspicious lymph nodes were found. Complete axillary lymph node dissection was performed at primary surgery when FNAC was positive. All other patients underwent a sentinel node procedure. Results: US‐guided FNAC of the axilla revealed metastasis in 34 (23.0%) of the 148 patients. These 34 patients were 53.1% of all patients (n = 64) with proven axillary lymph node involvement. In 66 patients (44.6%), both ultrasound and histopathology were negative. Overall sensitivity of US‐guided FNAC was 50.0%, specificity 100%, positive predictive value 100% and negative predictive value 70.2%. In T1 tumours, all patients referred for sentinel node procedure were node‐negative. The correlation between malignant FNAC and histopathology was 100%. US‐guided liquid‐based FNAC in patients with no clinically positive lymph nodes reduced the necessity for a sentinel node procedure by 23.0%. Conclusions: We advocate that US‐guided fine needle aspiration (FNA) combined with liquid‐based cytology of axillary lymph nodes should be included in the preoperative staging of breast cancer.     

Single slide assessment: A highly effective cytological rapid on‐site evaluation technique for endobronchial and endoscopic ultrasound‐guided fine needle aspiration

No standardised, comprehensive approach to rapid on‐site evaluation (ROSE) of cytology samples currently exists. Recent meta‐analysis indicates variation in the effectiveness of ROSE, however, reviews commonly omit the details of how ROSE is conducted. This review demonstrates the clinical effectiveness of single slide assessment (SSA) for ROSE of cytology samples, providing a highly effective, standardised methodology, maximising cell yield and the diagnostic potential of samples obtained via endobronchial or endoscopic ultrasound. Advances in molecular testing and immunotherapy now allow patients to access sophisticated, targeted cancer treatments and, consequently, obtaining diagnostic material alone is no longer sufficient. SSA uses specific criteria, based on the morphological presentation, to ensure sufficient material is obtained through one procedure, allowing for all the molecular profiling and tumour expression testing required to provide the patient and clinicians with the optimal treatment options. In total, 450 endobronchial or endoscopic ultrasound procedures were conducted with ROSE SSA performed by a biomedical scientist between 2010 and 2017. In 97% of cases, ROSE SSA matched the final report (inadequate vs adequate—benign material vs malignancy). ROSE SSA provided sufficient material for immunocytochemistry in 200/208 cases (96%) and for additional molecular testing/tumour profiling in 92% (85/92) of cases. The median number of needle passes was three. ROSE SSA streamlines diagnostic pathways; minimising risk of complications to patients, reducing cost and delays to treatment associated with repeat or more invasive procedures. Using SSA, sufficient material for a comprehensive diagnosis can be obtained in one procedure.     

Endoscopic ultrasound-guided fine needle aspiration cytology of the pancreas: a morphological and multimodal approach to the diagnosis of solid and cystic mass lesions

Cytological evaluation of pancreatic masses and cysts is the preferred pre-operative diagnostic modality and is increasingly being performed by endoscopic ultrasound. This review focuses on the multimodal approach at the Massachusetts General Hospital that utilizes clinical, cytological, radiological and ancillary studies in rendering a final cytological diagnosis.