Cytological assessment of conventional transbronchial fine needle aspiration of lymph nodes

E. A. Rakha, V. Naik, Z. Chaudry, D. Baldwin and I. N. Soomro
Cytological assessment of conventional transbronchial fine needle aspiration of lymph nodes
Objectives:  Transbronchial fine needle aspiration (TBNA) is a minimally invasive bronchoscopic technique that allows pathological examination of mediastinal and hilar lymph nodes. The aim of this study was to assess the cytopathological outcome of TBNA.
Methods:  One hundred and eighty-seven patients who underwent TBNA of mediastinal and hilar lesions from May 2000 to June 2007 were reviewed.
Results:  TBNA results were considered to be adequate if the cytological material revealed a malignant lesion or sufficient number of benign lymphoid cells. In the current study, 40 cases (21.9%) were reported as inadequate. When inadequate tests were excluded, the overall sensitivity and accuracy of TBNA in the diagnosis of malignant lesions were 83.5% and 88.0% respectively. The lowest sensitivity was noted in lymph node involvement by lymphoma. Regarding the workload associated with TBNA cytology, we found that the average number of conventionally prepared cytological slides per case was high (17 slides per case).
Conclusion:  Our results confirm that conventional TBNA is a sensitive and useful technique but it is relatively expensive and the protocols should be adapted to allow appropriate material to be collected for ancillary diagnostic tests.     

Fine needle aspiration cytology (FNAC) of adrenal masses

Between 1992 and 1998 at the Pathology Section, Cytopathology Unit of the Department of Oncological and Surgical Sciences of the University of Padova, we performed one hundred and twelve FNACs of adrenal masses under radiological guidance and seven intraoperative scrape smears; histological follow-up was available in 55 cases. Immediate on-site assessment of smears revealed a satisfactory adequacy rate (92%). With a simple diagnostic tree, we have been able to classify all smears except one as benign or malignant correctly, (accuracy 97.6%), differentiation of primary tumours from metastatic depositions remaining the most difficult task. In our experience FNAC is a safe and accurate tool in the diagnostic characterization of adrenal masses.     

Fine needle aspiration cytology (FNAC) of mammary granular cell tumour: a report of three cases

This report describes the FNAC findings in three cases of granular cell tumour of the breast. The patients comprised two females aged 59 and 62 years and one male aged 28 years. All patients presented with a breast lump which was clinically and radiologically suspicious of malignancy. FNAs yielded moderately cellular specimens which on cytologic examipation consisted of groups of cells and single cells with small regular nuclei and abundant granular cytoplasm. Bare nuclei were also present but these did not have the characteristic bipolar appearance of myoepithelial cells. In two cases there was a granularity to the background. The aspirates were reported as equivocal or atypical, probably benign, and surgical biopsy was performed. Histological examination showed typical benign granular cell tumours with strong positive staining for S-100 protein. Pathologists should be aware that granular cell tumour may occur in or around the breast and should consider this diagnosis in aspirates containing a population of cells with regular nuclei and abundant granular cytoplasm. The main cytologic differential diagnoses are likely to be apocrine cells and histiocytes. The suspicion of a granular cell tumour should be heightened when these features are present in an aspirate from a clinically and radiologically suspicious mass. These cases highlight the role of the triple approach encompassing clinical, radiological and cytological features in the assessment of a breast lesion.     

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.     

Diagnostic value of lymph node fine needle aspiration cytology: an institutional experience of 387 cases observed over a 5-year period

Lymph node fine needle aspiration (LNFNA) cytology is valuable in solving the diagnostic problems of clinical adenopathy. The usefulness of the procedure in the staging and diagnosis of various malignant and lymphoproliferative tumours, as well as its role in distinguishing reactive hyperplastic lymph nodes from lymphoma, has been documented in the literature generally on an individual basis. We report our cumulative 5 year experience of LNFNA representing 387 cases. Approximately half (n = 182) were diagnosed as either metastatic carcinoma or melanoma; in 54 cases (30%) excisional biopsy or tissue study was performed to confirm the diagnosis; there was only one false-positive diagnosis of a metastatic squamous carcinoma rendered on a submandibular lymph node. Sixty-one lymphoma cases were successfully diagnosed via LNFNA with no false positives; concurrent flow cytometry was utilized in 51% (n = 31) of the 61 cases and supported the cytologic diagnosis of lymphoma in 27 of the 31 cases (87%). A benign or reactive lymph node process was also diagnosed via LNFNA alone or in combination with flow cytometry in 48 cases with only five false negatives, which included four cases of mantle cell lymphoma and one case of melanoma. Unsatisfactory cases accounted for 12%, and represented specimens obtained by 'Wang needle' or other emerging techniques. Our study demonstrates that LNFNA can be an accurate, economical and rapid diagnostic procedure.     

The role of fine needle aspiration cytology (FNAC) in the investigation of superficial lymphadenopathy; uses and limitations of the technique

Aspirates (n = 163) from 157 patients with enlarged superficial lymph nodes were obtained over a 5-year period in a combined surgical/FNAC clinic. A definitive diagnosis was achieved in over 77% of the cases: benign 52.7%, malignant 25.1%. The diagnostic accuracy was 94.4%, sensitivity 85.4%, and specificity 100%. The false-negative rate was 12.5% but decreased to 3.5% when lymphoma cases were excluded. There were 36 cases of metastatic disease, the majority of which were from a primary breast carcinoma. The main diagnostic difficulty was in distinguishing low-grade lymphoma from reactive hyperplasia. An added advantage was that aspirated material could be used in ancillary tests to help with the differential diagnosis. FNAC has a well-defined role in the investigation of superficial lymphadenopathy. Used in the proper setting it will provide a definitive diagnosis in the majority of cases, especially relating to recurrent malignancy or metastatic disease. Patients with a reactive cytological picture and no clinically suspicious symptoms could be spared unnecessary surgery and reviewed through follow up. This technique is cost-effective, of high diagnostic accuracy, and results in considerable resource savings.     

Role of fine needle aspiration cytology in diagnosis of pleomorphic adenomas

Role of fine needle aspiration cytology in diagnosis of pleomorphic adenomas This retrospective study was carried out to review the cases diagnosed as pleomorphic adenoma in major or minor salivary glands and determine the difficulties encountered on typing this tumour on fine needle aspiration cytology (FNAC). Over a 19‐year period (1982–2000) 488 pleomorphic adenomas were diagnosed on FNAC from different sites (parotid – 372 cases, submandibular – 95 cases; oral cavity – 21 cases). Histology was available in 232 cases. Twenty‐nine cases where a histological diagnosis of pleomorphic adenoma was made but the cytological diagnosis was variable were also reviewed. In 216 of the 232 cases a good cytohistological correlation was available. On review only 4 of the 16 cases initially diagnosed as pleomorphic adenoma on FNAC where the histology revealed a different tumour were categorized as pleomorphic adenoma, while 3 each were classified as adenoid cystic carcinoma and benign tumour ?type, and 2 each were diagnosed to be muco‐epidermoid carcinoma, monomorphic adenoma and acinic cell carcinoma. On review of the FNAC smears from 29 cases where a histological diagnosis of pleomorphic adenoma was available while the cytological diagnosis was variable, only 11 (38%) were categorized as pleomorphic adenoma. In the majority of the remaining cases the cytological diagnosis did not alter markedly, 7 of 10 cases where the tumour could not be typed on cytology initially could not be typed even on review. In conclusion, FNAC is an ideal, fairly accurate preoperative procedure for the diagnosis of pleomorphic adenomas. Certain diagnostic problems occur in differentiating pleomorphic adenomas from adenoid cystic carcinoma, monomorphic adenoma and mucoepidermoid carcinoma. Carcinoma ex‐pleomorphic adenoma is difficult to identify on FNAC and in our series all 4 such cases on histology were considered benign on cytology.     

Plasma cell tumours: cytomorphological features in a series of 12 cases diagnosed on fine needle aspiration cytology

U. Handa, S. Chhabra and H. Mohan
Plasma cell tumours: cytomorphological features in a series of 12 cases diagnosed on fine needle aspiration cytology Objective: Plasma cell tumours represent autonomous proliferation of plasma cells and can manifest as multiple myeloma, monoclonal gammopathy of undetermined significance, variants of plasma cell myeloma or plasmacytoma. Methods: We report 12 cases of plasma cell tumours, which were initially diagnosed as plasmacytoma on fine needle aspiration cytology (FNAC). The patients were further subjected to bone marrow examination, serum electrophoresis, urine examination for Bence–Jones proteins, and x‐ray examination of the skeleton. Results: The cytological smears from all cases were cellular and showed numerous plasma cells in varying degrees of maturity. Subsequent to investigations, five cases were labelled as multiple myeloma with secondary extramedullary plasmacytoma, three as solitary bone plasmacytoma and two as primary extramedullary plasmacytoma. In the remaining two cases, bone marrow and urine examination findings were not available, so a conclusive diagnosis of multiple myeloma or solitary plasmacytoma could not be made. Conclusion: The study highlights the role of FNAC in the diagnosis of plasma cell tumours. Subsequent work‐up and follow‐up of these patients is important to rule out the presence of multiple myeloma.     

Scrape cell-block technique for fine needle aspiration cytology smears

An inconclusive diagnosis on fine needle aspiration cytology (FNAC) may be due to poor spreading and presence of thick tissue fragments despite aspiration of adequate material. Repeat aspiration may not be possible especially when aspirates of deep seated organs have been obtained by image guided techniques. We have resorted to a 'scrape cell-block' (SCB) technique in such cases. In this technique the cellular material on the slides which had already been fixed and stained, was carefully removed by scraping following destaining and then processed as a cell block. SCB interpretation was then compared with the smear diagnosis and histological diagnosis, wherever available. A total of 27 cases were studied. In 12 cases SCB slides added information to the FNAC smears. In 14 cases SCB did not offer any additional information. SCB was inconclusive in one case. Final histological correlation was available in eight cases and the SCB diagnosis was confirmed in six cases, whereas in two cases SCB failed to identify the tumour. Immunocytochemistry (ICC) was done in one case. SCB is a useful technique to make the best use of the available material when reaspiration is difficult.     

Role of fine needle aspiration cytology in evaluation of paediatric lymphadenopathy

Fine needle aspiration cytology (FNAC) in children has been slow to gain acceptance as compared with its use in adults. The aim of this retrospective study is to determine the utility of FNAC in diagnosing paediatric lymphadenopathy. Six hundred and ninety-two paediatric lymph nodes were aspirated during the period from January 1996 to June 2001. Aspirated material in 32 cases (4.6%) was deemed inadequate for cytological diagnosis. In the remaining cases, 62.2% were reactive lymphadenopathy, 25.2% tuberculous lymphadenitis, 6.3% acute suppurative lymphadenitis, nine cases revealed malignancy (seven lymphoma, two metastatic deposits) and one case had Langerhan's cell histiocytosis. No significant complications were encountered in any of the cases. FNAC emerged as a safe and reliable diagnostic procedure in paediatric age group obviating the need for excision biopsy.     

Pitfalls in the diagnosis of Wegener''s granulomatosis on fine needle aspiration cytology

OBJECTIVE: To review the clinical and pathological findings in six suspected cases of Wegener's granulomatosis (WG) and highlight the diagnostic difficulties faced by the cytopathologist. METHODS: Retrospective review of records of the Cytopathology Department to identify patients who underwent image-guided transthoracic pulmonary fine needle aspiration cytology (FNAC) for pulmonary lesions of suspected WG and those who were subsequently confirmed to have WG. Detailed evaluation of cytomorphological features was carried out. RESULTS: A total of six cases were identified in whom the initial procedure to obtain a pathological diagnosis was transthoracic FNAC. In one case, atypical squamous cells on cytology initially suggested a diagnosis of squamous cell carcinoma while in another a diagnosis of WG was made on cytology; however, a subsequent lung biopsy revealed silicosis. CONCLUSION: Acute inflammation and necrosis are the most consistent cytopathological findings in WG. In selected cases FNAC can provide supportive pathological evidence to establish a diagnosis of WG.     

Micronucleus scoring in liver fine needle aspiration cytology

C.‐H. Wen, C.‐H. Lin, S.‐C. Tsao, Y.‐C. Su, M.‐H. Tsai and C.‐Y. Chai
Micronucleus scoring in liver fine needle aspiration cytology Objective: This study evaluated the role of the micronucleus (MN) in liver fine needle aspiration (FNA) cytology. Methods: Histological features of 75 cases of hepatocellular carcinoma (HCC), of which 25 were well differentiated, 37 moderately differentiated and 13 poorly differentiated, and 58 benign hepatic lesions (total, 133 cases) were correlated with MN expression observed in FNA smears reported as benign (n = 40), atypical (n = 14), suspicious (n = 30) and malignant (n = 49). Results: Stepwise increases in the MN score (0.4 ± 0.6, 1.2 ± 1.3, 6.3 ± 4.2 and 14.3 ± 8.8) correlated with the degree of cytological abnormality: benign, atypia, suspicious and malignant, respectively. The mean MN scores for well‐, moderately and poorly differentiated HCC were 5.4 ± 2.2, 11.5 ± 4.5 and 24.9 ± 9.1, respectively, which was significantly different between malignant and suspicious (P < 0.0001), between suspicious and atypical (P = 0.008) but not between atypical and benign. The MN scores differed significantly between all degrees of differentiation of HCC and between the HCC and benign hepatic lesions (P < 0.0001). High sensitivity, specificity and accuracy of liver FNA for diagnosing HCC (96%, 98%, and 96%, respectively) were obtained at a cutoff of three for the MN score. Conclusions: The MN score is an effective HCC biomarker and has a good potential use as an ancillary tool for diagnosing HCC using FNA cytology.     

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.     

UK national audit of breast fine needle aspiration cytology in 1990–91: diagnostic criteria

A survey into the practice of fine needle aspiration cytology of the breast amongst members of the British Society for Clinical Cytology in 1990 and 1991 was performed. This paper presents their reported use of diagnostic categories in reporting and the criteria found useful in the diagnosis of benign and malignant disease. A wide variety of diagnostic categories are in use. the criteria used in diagnosis largely follow recommendations found in standard textbooks, but some less well recognized features were also suggested.     

Fine needle aspiration (FNA) cytology of Rosai Dorfman disease

deshpande v and verma k. (1998) Cytopathology 9, 329–335
Fine needle aspiration (FNA) cytology of Rosai Dorfman disease
Rosai Dorfman disease (sinus histiocytosis with massive lymphadenopathy (SHML)) is a benign self-limiting disorder that commonly involves the lymph nodes. We reviewed eight cases of this entity aiming to document the cytomorphological features. Of the eight cases, a preoperative diagnosis was suggested in seven cases. Pertinent features included: numerous large histiocytes with prominent emperipolesis (documented by a halo around the cell), fine vacuoles in the cytoplasm and lymphocytes and plasma cells in the background. In some cases the histiocytes showed atypia. In one biopsy-proven case a diagnosis of Hodgkin's was suggested, emphasizing the pitfalls associated with the FNA diagnosis of this lesion.     

Fine needle aspiration cytology in a case of florid gynaecomastia

A case of gynaecomastia examined by fine needle aspiration cytology is reported. The pitfalls in trying to obtain a cytological diagnosis in the florid proliferative stage of the disease are detailed together with an account of the natural history.     

Improved fine needle aspiration (FNA) cytology results with a near patient diagnosis service for breast lesions

This study is a review of the quality of FNA cytology results for breast lesions approximately 18 months before and 10 months after a change from a rapid diagnosis FNA service with consultant pathologist aspirators to a conventional FNA service with clinician aspirators of varied experience. The setting was symptomatic breast clinic in a large hospital in rural New Zealand acting as a tertiary referral centre for a population of 550,000. The results were collected retrospectively and prospectively. The quality of results for pathologist aspirators (total 810) and clinician aspirators (total 403) was compared using the definitions of the NHS Breast Screening Program Guidelines for Cytology Procedures and Reporting in Breast Cancer Screening. There were statistically significant differences in specificity (biopsy cases only) with 73% for pathologists and 49% for clinicians, specificity (full) with 74% and 56%, inadequate rate with 23% and 37%, and complete sensitivity with 76% and 67%. The use of pathologist aspirators allowed the specimens to be reported in a few minutes. Specimens taken by clinicians took at least 30 min to report. The financial aspects of the two approaches are discussed. When compared with clinician aspirators, pathologist aspirators obtained better quality results and these were reported more quickly.