Flow cytometric DNA analysis on fine needle aspiration biopsies of liver lesions

Flow cytometric DNA analysis on fine needle aspiration biopsies of liver lesions The DNA cell content of 39 fine needle aspiration biopsies (FNAs) from five benign liver lesions, nine hepatocellular carcinomas (HCCs), and 25 metastatic tumours was analysed in a prospective fashion by flow cytometry (FCM). All benign lesions were diploid. Aneuploidy was found in five (55.6%) HCCs and in nine (36%) metastatic tumours. DNA index (DI) differences were not significant. The S-phase fraction (SPF) was higher in the malignant tumours, both combined (P < 0.02) and separated primary and metastatic (P < 0.05). We could not demonstrate an association between diploidy and percentage of benign hepatocytes in the smears of malignant tumours. The serum alpha-fetoprotein (AFP) level did not correlate with ploidy, DI, or SPF in the HCCs. In conclusion, ploidy and DI do not discriminate between benign and malignant liver lesions, but the SPF is higher in malignant tumours. DNA analysis does not help to distinguish primary from metastatic liver tumours. The presence of benign hepatocytes in samples from malignant tumours does not seem to influence the analysis of ploidy by FCM.     

Quantitative image analysis of estrogen receptors in breast fine needle aspiration biopsies

OBJECTIVE: To establish whether the results of quantitative evaluation of estrogen receptors (ERs) in cytologic fine needle aspiration (FNA) biopsies of the breast are comparable to the results obtained on excised breast tumors and therefore suitable for making a clinical decision on tamoxifen treatment in women who are not candidates for surgery. STUDY DESIGN: We performed a retrospective review of 118 breast FNA specimens that were positive for adenocarcinoma cells, had adequate cell block cellularity and provided subsequent surgical resection tissue. Quantification of ERs was performed on cell block material and follow-up tissue sections by the Chromavision Automated Imaging System, San Juan Capistrano, California, U.S.A. RESULTS: Quantitative image analysis provided consistently reliable, comparable results when evaluating for the presence or absence of ERs (at a 5% staining cutoff level), with 98.3% agreement between FNA cytology and histology specimens. Quantitative measurements of FNA samples showed the best agreement with the values derived from the subsequent surgical specimens at high-end (> 85% staining) and low-end (< 10% staining) values. However, a direct linear correlation of values was not observed. In the great majority of parallel measures, ERs were either strongly positive (> 75% staining) or had a zero value, particularly in the surgical specimens, with more "in-between" values identified in FNA specimens. CONCLUSION: Quantitative image analysis of FNA of ER results are comparable to those of surgical excision specimens and can be used for therapeutic decision making. The utility and advantages of quantitative ERs by image analysis include providing the patient and physician with important early prognostic and diagnostic information before planning a surgical approach. Additionally, FNA ERs are useful in determining therapy alternatives in patients who are not surgical candidates and in evaluating the preoperative hormone status of patients receiving chemotherapy prior to surgery.     

Morphologic spectrum of hepatocellular carcinoma in fine needle aspiration biopsies

The light microscopic features of fine needle aspiration smears from 52 primary hepatocellular carcinomas were reviewed. Cytologic grading of these tumors, which indicated three grade I, 29 grade II and 20 grade III carcinomas, was compatible with grading done by histologic examination. In addition to the general cellular characteristics, other cytologic features observed in the smears included bile (48% of the cases), large cytoplasmic vacuoles (23%), small cytoplasmic vacuoles (46%), eosinophilic cytoplasmic inclusions (8%), basophilic cytoplasmic inclusions (48%) and intranuclear cytoplasmic inclusions (71%). The significance of these features is briefly discussed.     

Telecytologic diagnosis of breast fine needle aspiration biopsies. Intraobserver concordance

OBJECTIVE: To determine the intraobserver concordance between telecytologic and glass slide diagnosis of breast fine needle aspirates. STUDY DESIGN: Twenty-five cases, originally received in consultation, were each examined by three cytopathologists. An average of seven compressed digital images per case were presented, together with a brief clinical history, using the http protocol and an internet browser. RESULTS: Agreement between the telecytologic and glass slide diagnosis ranged from 80% to 96%. Nevertheless, two cases that had been unequivocally diagnosed as malignant based upon video images were considered to be benign by the same pathologist when reviewing the glass slides. Both diagnostic confidence and self-concordance were higher for one pathologist having significant previous video microscopy experience. CONCLUSION: Although intraobserver concordance between telecytologic and glass slide diagnoses of breast fine needle aspirates is high, refinement of existing criteria for diagnosis of malignancy, taking account of the particular limitations associated with telecytologic diagnosis, may be prudent prior to widespread use of telecytology for fine needle aspiration evaluation.     

Nucleolar morphometry in fine needle aspiration biopsies of the prostate.

OBJECTIVE: To find efficient morphometric nucleolar features for distinguishing different prostatic atypia groups in fine needle aspiration biopsies. STUDY DESIGN: A computerized interactive morphometry program was used to outline nucleoli of prostate cells. The samples were divided into three groups: group 1 (definitely benign [n = 10] and atypical but benign [n = 13]), group 2 (moderately atypical [n = 11] or highly suspicious [n = 13]) and group 3 (definitely malignant [n = 17]). RESULTS: The analysis revealed a difference in the number of nucleoli between definitely benign samples and other atypia groups but not between the latter. Nucleolar size features were best in distinguishing between atypia groups. The sample-associated mean size features were more powerful than cell group-associated size features. CONCLUSION: The sample-associated mean area, defined from cells selected by an experienced cytologist, if larger than 2 micron 2, was strongly associated with definitely malignant samples. The same was true for the largest nucleolar area if larger than 5.0 micron 2. Morphometric nucleolar size features appeared efficient in distinguishing between definitely malignant and other samples.     

Value of rapid staining and assessment of ultrasound-guided fine needle aspiration biopsies

In a series of 160 ultrasonically guided fine needle aspiration (FNA) biopsies, immediate cytologic evaluation of each specimen's adequacy was performed using a rapid staining method. The number of passes was thus limited to what was strictly necessary in order to obtain sufficient material; the average number of passes was only 1.27 per patient. The total series of FNA biopsies had a sensitivity of 95.6%, a specificity of 100% and an overall accuracy of 97.3%. In addition, the cumulative accuracy after each pass was calculated. A significant increase in diagnostic accuracy was found only after the second pass; the third and the fourth passes gave little further improvement. The results indicate that a rapid evaluation of the aspirated material during ultrasound-guided FNA biopsy can reduce the number of punctures needed per case, resulting in less discomfort and, probably, a reduced likelihood of complications for the patient. The results also suggest that a maximum of two punctures will probably yield adequate diagnostic material in most cases.     

Electron microscopy of fine needle aspiration biopsies of mediastinal and paramediastinal lesions

The ultrastructural cytologic study of fine needle aspiration (FNA) biopsies from eight cases with mediastinal and paramediastinal lesions is reported. In these cases, electron microscopy (EM) was essential in cytologically determining the correct type of the cancer cells. The results in these cases suggest that portions of FNA biopsies from deep sites, where aspiration is difficult or requires computed tomographic scanning, should be routinely processed for plastic embedding, so that EM examination can be performed if the cells are undifferentiated, scanty or poorly preserved by light microscopic examination. The proper cytologic identification of the cell might, in fact, have a major bearing on the therapeutic choices and on the prognosis.     

Paratesticular adenomatoid tumors. The cytologic presentation in fine needle aspiration biopsies

Adenomatoid tumors are the most common tumors of male paratesticular tissues (epididymis, tunica or spermatic cord) and have also been described in females (uterus, fallopian tube, ovary and paraovarian tissues); fine needle aspiration (FNA) of masses in these locations is increasingly utilized as an alternative to surgical exploration in order to establish a tissue diagnosis. This paper describes the FNA cytodiagnosis of seven cases of paratesticular adenomatoid tumors. The main cytologic criteria included epithelioid sheets and multilayered clusters of monotonous cells with round or ovoid, eccentric nuclei containing small, central nucleoli. Paranuclear clearing with a pink coloration (Giemsa stain) or a clear vacuolelike area (Papanicolaou stain) and abundant cellularity with a background of naked nuclei and stromal fragments were noted. The clinical presentation and clinicohistologic follow-up of these seven cases is also described in detail. A discussion of the differential diagnosis and the expected FNA findings is provided.     

Flow cytometric DNA analysis of renal-cell carcinoma. A study of fine needle aspiration biopsies in comparison with multiple surgical samples

The flow cytometric (FCM) DNA analysis of fine needle aspiration (FNA) biopsy material was compared with the DNA analysis of multiple surgical biopsy material from 44 renal-cell carcinomas. Twenty tumors were heterogeneous with respect to their DNA content. Eleven of the 17 tumors that had both diploid and aneuploid tumor cell clones in the surgical specimens gave a diploid DNA content in the aspiration biopsies; the other 6 cases showed aneuploidy in the aspirate. The fine needle aspirates from 18 homogeneously diploid tumors and 9 tumors with an aneuploid DNA content in all eight surgical samples revealed DNA indices similar to those found in the surgical samples. These findings show that aneuploid clones of renal-cell carcinoma can remain undetected by the use of FNA biopsy as a method for obtaining samples for FCM DNA analysis.     

Diagnostic efficacy of immunocytochemistry on fine needle aspiration biopsies processed by thin-layer cytology

OBJECTIVE: To evaluate the efficacy of immunocytochemistry (ICC) performed on smears processed by thin-layer cytology (TLC). STUDY DESIGN: During the period January 2001-September 2003, 3,573 consecutive fine needle aspiration biopsies were processed with both conventional smears (CSs) and TLC diagnosed by a single pathologist; 113 required immunocytochemical study. CSs were fixed in ethanol whereas TLC slides were processed with the ThinPrep 2000 method (Cytyc Co., Marlborough, Massachusetts, U.S.A); both were stained with Papanicolaou stain. ICC staining was carried out on only TLC slides. RESULTS: The 113 cytologic cases were grouped as follows: 32 thyroid nodules with 16 histologic controls (HCs), 24 lymph nodes (regardless of location) with 15 HCs, 18 liver and pancreatic lesions (3 HCs), 11 lung nodules (6 HCs), 5 kidney and adrenal gland lesions (1 HC), 6 abdominal (2 HCs) and 4 mediastinal masses (1 HC), 6 salivary gland tumors (3 HCs), 4 bone masses (2 HCs) and 3 subcutaneous lesions (1 HC). ICC contributed to the diagnosis in 104 cases (92%), whereas it was inconclusive in 9. The cytologic diagnoses were histologically confirmed in 46 of 50 cases (92%). CONCLUSION: ICC can be successfully applied on TLC slides with better results than on CSs, and its yield can be useful in making the correct diagnosis on fine needle aspiration biopsy.     

Nuclear changes in cytologic specimens obtained by CT-guided fine needle aspiration biopsies.

A light and electron microscopic study was conducted to investigate nuclear changes observed in specimens obtained from various sites by computed tomographic (CT)-guided fine needle aspiration (FNA) biopsy. These changes, which consisted of a disappearance of the nuclear chromatin and a disruption of the nuclear membrane, were found in 70% of 10 FNA specimens obtained with CT guidance, in 26% of 15 specimens obtained with fluoroscopic guidance and in 0% of 10 specimens obtained without x-ray imaging techniques. Although the number of cases studied was small and the mechanisms responsible for these changes are not clear, cytopathologists should be aware of alterations in evaluating FNA specimens obtained with the guidance of x-ray imaging techniques.     

Renal fine needle aspiration cytology

OBJECTIVE: To audit and evaluate the pitfalls in renal fine needle aspiration (FNA) cytology. STUDY DESIGN: A retrospective analysis of 180 renal FNAs from 163 patients, encountered at Canberra Hospital, Australian Capital Territory, between June 1989 and July 1997 was undertaken. The FNA procedures had been performed by radiologists under computed tomography (CT) or ultrasound (US) guidance. The study correlated the FNA results with biopsy findings and clinical outcome. RESULTS: The initial cytologic diagnoses included 84 (47%) benign, 6 (3%) atypical, 7 (4%) suspicious, 70 (39%) malignant and 13 (7%) inadequate. Six of the 13 cytologically inadequate group, on further investigation, had malignant histology. The benign cytologic categories contained 79 benign conditions and 5 cases with a malignant outcome. The atypical cytologic group contained 5 benign and 1 malignant case. All nine cytologically suspicious cases had malignant histology. The cytologically malignant group contained 62 malignant, 7 benign and 1 patient lost to follow-up. The sensitivity was 92.5%, specificity was 91.9%, positive predictive value was 89.9%, negative predictive value was 94.0%, and efficacy of the test was 92.2%. CONCLUSION: Renal FNA can provide an accurate diagnosis in most instances; however, aspiration cytology of the kidney has limitations and pitfalls. Low grade renal cell carcinoma has to be differentiated from oncocytoma, angiomyolipoma, renal infarct and reactive conditions. Renal FNA has a high negative predictive value, which is useful in reassuring patients with radiologically and cytologically benign lesions. Negative FNA does not exclude malignancy in the presence of a radiologic suspicion.     

Endoscopic fine needle aspiration biopsy

A catheter assembly that can be passed through the biopsy channel of a standard fiberoptic gastroduodenoscope was devised to permit fine needle aspiration biopsy of gastrointestinal neoplasms under direct vision of the endoscope. This technique for endoscopic aspiration biopsy was performed in ten consecutive patients with esophageal and gastric carcinomas, along with the conventional endoscopic brushing and biopsy. Endoscopic aspiration biopsy gave a positive diagnosis in all ten cases while the other two techniques gave inconclusive results in one patient with an ulcerative growth. We feel that endoscopic aspiration biopsy can be used to obtain representative samples from gastrointestinal neoplasms, and it may add to the diagnostic accuracy of endoscopic biopsy and brushing cytology.     

Triple test approach to inadequate fine needle aspiration biopsies of palpable breast lesions.

OBJECTIVE: To perform a retrospective study evaluating the triple test for inadequate fine needle aspiration (FNA) biopsies of palpable breast lesions with a two-year clinical follow-up. STUDY DESIGN: All aspirates were reviewed and assessed for cellular adequacy in a one-year period. Specimen adequacy was based on the most stringent criteria, the presence of six or more epithelial cell clusters composed of at least six cells each. In all cases, clinical and radiologic results were reviewed and compared with the histologic outcome. RESULTS: Aspirates from 61 of 263 (23%) patients with palpable breast lesions that yielded nondiagnostic results were examined. The study showed a misdirected FNA rate of 21% and a misinterpreted rate of 1.6%. The other 77% of cases had benign surgical biopsies and/or clinical follow-up. Three of 61 (4.9%) cases with nondiagnostic smears were found to have cancer; two were inadequate due to misdirected aspirates, and one was misinterpreted microscopically. All cancer cases underwent surgical removal of the mass as a result of clinical or radiologic suspicion. CONCLUSION: We recommend utilizing the three diagnostic parameters of cytology, clinical findings and radiology, the "triple test," to achieve the best diagnostic accuracy in breast FNAs and to enhance patient management.     

Comparison of diagnostic results obtained by fine needle aspiration cytology and tru-cut or open biopsies

In seven cases fine needle aspiration (FNA) cytology provided a diagnosis of neoplasm when the Tru-Cut (TC) tissue biopsies (four cases) and open biopsies (three cases) were negative. The specimens consisted of two breast carcinomas, two metastatic neoplasms in the liver, one metastatic melanoma in inguinal lymph nodes, a retroperitoneal mass and a pelvic mass. In the two cases of mammary carcinoma, TC biopsies were negative and FNAs were diagnostic of carcinoma. TC biopsies in the two cases of questionable hepatic metastasis were negative, but FNAs demonstrated a malignant neoplasm. Open biopsy of a retroperitoneal mass failed to diagnose a neoplasm however, subsequent ultrasound-directed FNA demonstrated a neoplasm, possibly seminoma. FNA cytology of inguinal lymph nodes in one case was diagnostic of melanoma; open biopsy showed no neoplasm. Because of the FNA diagnosis, additional sections were made and the presence of melanoma was confirmed. This series demonstrates that FNA cytology should be considered the initial diagnostic procedure more often.     

Actinomycosis in fine needle aspiration cytology

Four cases of actinomycosis were diagnosed by fine needle aspiration (FNA) cytology and eight more cases were detected during a review of FNA smears reported as inflammatory. the age of these 12 cases ranged from 20 to 61 years with a median of 35 years. the male to female ratio was 3:1. the common regions of involvement were cervicofacial in seven cases (58.3%), thoracic in three (25.0%) and abdominal in two (16.7%). Four of the seven cervicofacial cases presented with intra-oral masses; the thoracic lesions were pulmonary in location, and the abdominal lesions presented as bowel masses. the possibility of actinomycosis was not considered clinically in any case. the main reason for missed cytodiagnosis in two thirds of the cases appeared to be observer error. It is suggested that when the aspiration smear from a mass is found to be an inflammatory exudate rich in neutrophils, special efforts must be made to look for this microorganism.     

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.     

Wilms' tumor. Role of fine needle aspiration and DNA ploidy by image analysis in prognostication

OBJECTIVE: To evaluate the utility of cytomorphologic features and DNA ploidy estimation in fine needle aspirates (FNAs), from Wilms' tumors for prognostication. STUDY DESIGN: Twenty-three cases of Wilms' tumor having FNA and follow-up data were selected. Cytomorphology was analyzed by two observers. DNA ploidy was determined in 19 cases by image cytometry by destaining Papanicolaou-stained slides and restaining with Feulgen stain. Various parameters and patient outcomes were compared, and statistical evaluation was done. RESULTS: Poor outcome (12/23 cases) was associated with age < 2 years (P = .01), severe pleomorphism of blastemal cells (4/23 cases, P < .05), very large nucleoli (5/23 cases, P = .075), atypical mitosis (6/23 cases, P = .032) and aneuploidy/tetraploidy of tumor cells (6/29 cases, P = .005). Term unfavorable cytology is proposed when a combination of severe pleomorphism, very large nucleoli and atypical mitosis is seen in FNA smears. Four Wilms' tumor FNAs were characterized as showing unfavorable cytology, and all had a poor outcome (P = .0351). Three of the six cases with aneuploid/tetraploid features also showed unfavorable cytology. CONCLUSION: Unfavorable cytology and aneuploidy/tetraploidy in FNA smears of Wilms' tumor are associated with a poor prognosis.