On the utility and limitations of fine-needle aspiration of palpable lesions located in the hand

Various types of superficial and deep-seated lesions may occur in the hand, causing concern to the patient and posing diagnostic dilemmas to the clinician. A study was undertaken to evaluate the utility of fine-needle aspiration (FNA) or scraping for the diagnosis of palpable lesions located in the hand. From a clinico-cytologic point of view, lesions were classified as superficial (n = 41) or deep-seated (n = 66), and aspirates were categorized into five groups: benign without specific cytohistologic diagnosis, benign with specific cytohistologic diagnosis, atypical, malignant without specific cytohistologic diagnosis, and malignant with specific cytohistologic diagnosis. Out of 107 cases with aspirates adequate for cytologic evaluation, 85 had histologic correlation; in 22 cases, histologic confirmation was deemed unnecessary because of unequivocal cytologic findings and/or clinical workup. Sensitivity was 90.9%, specificity 100%, and efficacy 98%. Based on these findings, we believe that FNA or scraping may help in the clinical workup of patients with either superficial or deep-seated lesions located in this anatomic region.     

Fine-needle aspiration cytology findings in 214 cases of nonparotid lesions of the head

The use and limitations of fine-needle aspiration (FNA) of lesions of the parotid gland are known, but those of nonparotid lesions of the head have been described only sporadically. We conducted this study to evaluate the utility of FNA and to analyze the causes of diagnostic discrepancies for these lesions. A total of 6,898 FNAs of different sites was performed at our institutions between January 1991-August 1998, and 214 (3.1%) of the cases were FNAs of nonparotid lesions of the head. The most common diagnosis of nonparotid lesions was squamous-cell carcinoma, in 22% (n = 48), and the most common site aspirated was the scalp, in 34% (n = 73). Lipomas and keratinous cysts comprised 5% (n = 9) of the total. A statistical analysis was conducted on 98 paired cytology and histology (n = 83) and cytology and flow cytometry (n = 15) specimens (70 malignant and 28 benign). FNA recognized the malignant and benign nature of the lesion in 60 and 26 cases, respectively with 86% sensitivity 93% specificity and 88% accuracy. Causes of false-negative FNA diagnoses (n = 10) included sampling error (n = 6), bloody smears with scant cellularity (n = 3), and bland cytomorphology (n = 1). Florid granulation tissue and a mucocele of the tongue accounted for the two false-positive cases. We conclude that FNA is an effective tool for triage of surgery candidates with nonparotid lesions of the head. Adequate samples with sufficient cellularity are required for avoiding false-negative diagnoses. Occasionally, tissue biopsy is needed for diagnosis of equivocal cases.     

Pathologic observations of the duodenum in 615 consecutive duodenal specimens in a single Japanese hospital: II. malignant lesions

The author investigated histopathology of 615 consecutive duodenal specimens in our pathology laboratory in Japan. A computer review of the duodenal specimens was done. In cases of malignancy, histological slides were reviewed. The duodenal specimens were composed of 567 benign lesions (92%) and 48 malignant lesions (8%). The 48 malignant lesions were composed of 20 cases (42%) of primary adenocarcinoma, 10 cases (21%) of primary adenocarcinoma of ampulla Vater, 4 cases (8%) of primary squamous cell carcinoma, 1 (2%) cases of primary spindle cell carcinoma, 4 (8%) cases of carcinoid tumors, 1 (2%) case of malignant lymphoma, and 8 cases (17%) of secondary carcinoma from the pancreatic carcinoma or bile duct carcinoma. The primary adenocarcinoma (n=20) was composed of well differentiated adenocarcinoma (n=9), papillary adenocarcinoma (n=1), moderately differentiated adenocarcinoma (n=6), and poorly differentiated adenocarcinoma (n=4). The primary adenocarcinoma of the ampulla of Vater (n=10) was composed of well differentiated adenocarcinoma (n=7) and moderately differentiated adenocarcinoma (n=3). The primary squamous cell carcinoma (n=4) showed proliferation of malignant squamous cells with keratinization and intercellular bridges. The spindle cell carcinoma (n=1) consisted of only malignant spindle cells immunohistochemistry positive for various cytokeratins and vimentin. The carcinoid tumor (n=4) was typical carcinoid and showed organoid, trabecular, and ribbon-like arrangements. The carcinoid tumor was immunohistochemically positive for neuroendocrine markers such as CD56, neuron-specific enolase and synaptophysin. The malignant lymphoma (n=1) was diffuse large B-cell lymphoma immunohistochemically positive for CD10, CD20, and CD79α. The secondary carcinoma (n=8) was adenocarcinoma invaded from the pancreatic adenocarcinoma (n=6) and extrahepatic bile duct adenocarcinoma (n=2).     

Evaluation of aspiration cytology of the liver space occupying lesions by simultaneous examination of smears and cell blocks

This study was undertaken to compare the efficacy of cytologic smears and histological sections from cell blocks in diagnosis of space occupying lesions (SOLs) of the liver and to classify the lesions on the basis of combined cytohistologic diagnosis. The study was conducted on 50 patients who had radiologically detected SOL/SOLs in the liver and ultrasound‐guided fine needle aspiration of liver was done. In all the cases, both smears and cell blocks were made. Forty‐seven cases were diagnosed as malignant and three as benign on both cytologic smears and cell blocks. Hepatocellular carcinoma was diagnosed in 8 (16%) cases and metastasis in 39 (78%) cases. The subtyping of malignancy could not be done on 11 (22%) cytologic smears and 8 (16%) cell block sections. However, on combined cytohistologic correlation, 17 (34%) out of these 19 (38%) cases could be subtyped. Sensitivity of cytologic smears and cell blocks in subtyping of malignancy was 72.3% and 82.9%, respectively. Combined cytohistologic diagnosis was found to be significantly better than isolated cytologic and cell block diagnosis (P ≤ 0.05). To conclude, FNA of the SOLs of the liver is an effective procedure for diagnosing malignancy. However, cytological examination alone may fail to pinpoint the type of the tumor. Concomitant examination of cell block not only confirms the malignancy but also helps in subtyping it. Diagn. Cytopathol. 2009. © 2009 Wiley‐Liss, Inc.     

涎腺细针吸取细胞学分类诊断价值和存在问题

目的 分析涎腺疾病细针吸取细胞学（FNAC）形态学特点和准确分类,探讨涎腺FNAC的诊断价值和存在问题。方法 回顾113例涎腺FNAC形态学特征、免疫表型和分类诊断,并结合临床、组织病理学分析。结果 FNAC失败2例,诊断非肿瘤12例、肿瘤99例（良性肿瘤82例,恶性17例）。富于细胞多形性腺瘤、腺样囊性癌和基底细胞腺瘤相似,鉴别诊断困难。腮腺淋巴上皮癌与未分化型鼻咽型鳞状细胞癌转移完全一致,鉴别需结合临床分析。与组织学比较发现,FNAC误诊3例,分别为淋巴结反应性增生疑为非霍奇金淋巴瘤、黏液表皮样癌诊为“少量异型细胞”和淋巴上皮癌疑为良性淋巴上皮病变。FNAC区分良、恶性准确率97．4％（110／113）,良性病变99．0％（95／96）,恶性肿瘤88．2％（15／17）。总体分类准确率90．3％（102／113）,特异性91．9％（102／111）;良性病变准确率91．7％（88／96）,特异性92．6％（88／95）;恶性肿瘤准确率82．4％（14／17）,特异性87．5％（14／16）。结论 FNAC诊断涎腺良、恶性病变敏感、可靠,可提供准确的分类诊断,但诊断某些肿瘤仍有局限性,需要活检证实。     

The safety and efficiency of the ultrasound-guided large needle core biopsy of axilla lymph nodes

PURPOSE: To evaluate the safety and efficiency of the Ultrasound (US)-guided large needle core biopsy of axilla lymph nodes. MATERIALS AND METHODS: From March 2004 to September 2005, 31 patients underwent the US-guided core biopsy for axilla lymph nodes. Twenty five lesions out of 31 were detected during breast US, and 6 of 31 cases were palpable. Lymph nodes were classified based on their shape and cortical morphology. The core biopsy of axilla lymph nodes was performed on suspicious lymph nodes found during breast ultrasonography to find out whether the patients had a history of breast cancer or not. Among the 31 patients, 16 patients were associated with breast cancer. The lesion sizes varied from 0.6 cm to 3.3 cm (mean=1.59+/-0.76 cm). US-guided core biopsies were performed with 14 G needles with an automated biopsy gun. Total 3 or 5 specimens were obtained. RESULTS: Among the 31 cases of axilla lymph nodes core biopsies, 11 cases showed malignant pathology. Seven out of 11 cases were metastatic lymph nodes from breast cancer; 2 cases were from primary unknown and 2 cases from lymphomas. On the other hand, 20 histopathologic results of axilla lesions were benign: subacute necrotizing lymphadenitis (n=2), dermatopathic lymphadenitis (n=1), reactive hyperplasia (n=10) and free of carcinoma (n=7). CONCLUSION: The US-guided large needle core biopsy of axilla lesions is safe and effective for the pathological evaluation. The core biopsy is believed to be easy to perform if suspicious lymph nodes or mass lesions are found in the axilla.     

Group consensus review minimizes the diagnosis of "follicular lesion of undetermined significance" and improves cytohistologic concordance

We conducted a group consensus review of thyroid aspirates that were previously interpreted as “atypia of undetermined significance/follicular lesion of undetermined significance” (AUS/FLUS) and followed by surgical interventions. The study aimed to investigate if consensus review would minimize the diagnosis of AUS/FLUS with an optimal interobserver agreement and also promote a better cytohistologic concordance. A group of reviewers who were blinded to the corresponding histologic findings simultaneously evaluated a total of 50 aspirates at a multiheaded light microscope. Using the Bethesda System for Reporting Thyroid Cytopathology as a guideline, a consensus interpretation was reached upon review of each aspirate. Interobserver agreement was calculated and recorded. The cytohistologic correlation was then performed between the consensus interpretation and the corresponding histologic diagnosis. The consensus review reclassified 26 (52%) aspirates as non‐neoplasia/benign, 10 (20%) as follicular neoplasm/suspicious for a follicular neoplasm, 1 (2%) as papillary thyroid carcinoma, and 2 (4%) as nondiagnostic. Eleven (22%) aspirates remained AUS/FLUS. The interobserver agreement across the five diagnostic categories ranged from 71.6% to 100% with an average level of 88.8%. Cytohistologic concordance was achieved in 24 of 26 (92.3%) and 9 of 11 (81.8%) aspirates that were reclassified as non‐neoplasia/benign and neoplasia/malignancy, respectively. A diagnostic accuracy of 89.2% (33/37) was obtained in reclassified cases. In conclusion, the group consensus review minimized AUS/FLUS, offered an optimal level of interobserver agreement, and most importantly, promoted excellent cytohistologic concordance in reclassified cases and, therefore, could play a substantial role in the future in reducing reaspiration and/or unnecessary surgeries. Diagn. Cytopathol. 2012. © 2011 Wiley‐Liss, Inc     

Fine-needle aspiration cytodiagnosis of recurrent carcinoma of the breast in operative scars

Recurrence of carcinoma in scars following surgical treatment of breast carcinoma is a frequent problem. An early diagnosis of recurrent lesions is essential to enable timely management. In this study, the role of fine-needle aspiration cytology (FNAC) in the diagnosis of scar lesions was evaluated in 156 women seen over a period of 12½ yr. Ninety-eight of these on FNAC showed features of a recurrent carcinoma, and in six samples, the FNAC showed suspicious features. In all the six suspicious cases, a subsequent biopsy confirmed a recurrent breast carcinoma. The remaining 52 cases on repeated FNAC were diagnosed as benign, and this was confirmed on a subsequent biopsy. The sensitivity, specificity, and predictive value for cytologic findings were 94.2, 100, and 100%, respectively. It was concluded that FNAC clearly has a role as a first line of investigation for distinguishing between recurrent malignant and benign lesions in scars in women which have been surgically treated for a breast carcinoma. Diagn. Cytopathol. 16:14–16, 1997. © 1997 Wiley-Liss, Inc.     

Fine-needle aspiration cytology of recurrent and metastatic mixed mesodermal tumors

We report the cytological and clinical findings of 16 fine-needle aspirates (FNAs) performed on recurrent (n = 6) and metastatic (n = 10) mixed mesodermal tumors (MMMTs). The median interval between the primary diagnosis and FNA was 16 mo. Primary sites were the endometrium (n = 11), the ovary (n = 3), the cervix (n = 1), and pelvic soft tissue (n = 1). Primary tumors showed carcinoma with homologous mesenchymal components in 13 cases and focal heterologous elements in three (two chondrosarcomas and one rhabdomyosarcoma). The FNAs showed carcinoma in all 16 cases, with adenocarcinoma differentiation in three, Mesenchymal elements were identified in aspirates of three recurrent and two metastatic lesions. They were all homologous. No heterologous mesenchymal elements were identified in the aspirates. We conclude that mesenchymal components in FNAs of MMMTs are less likely to be seen in metastatic lesions, and that heterologous mesenchymal components are rarely seen in these aspirates even in recurrent disease. These findings confirm that the epithelial component is responsible for the malignant behavior of MMMTs, and suggest that these lesions may need to be classified as sarcomatoid carcinomas rather than true carcinosarcomas. Diagn Cytopathol 1994;11:328–332. © 1994 Wiley-Liss, Inc.     

Histopathologic study of the rectum in 1,464 consecutive rectal specimens in a single Japanese hospital: II. malignant lesions

The author investigated histopathology of 1,464 consecutive rectal specimens in of our pathology laboratory in Japan. A review of pathological reports was done by computer. Observation of histological slides was performed, when appropriate. The rectal specimens were composed of 1,041 benign lesions and 423 malignant lesions. The 423 malignant lesions were composed of 367 cases of primary rectal carcinoma, 41 cases of carcinoma in adenoma, 7 cases of neuroendocrine tumor, 3 cases of malignant lymphoma, 2 cases of gastrointestinal stromal tumors (GIST), and 3 cases of metastatic carcinoma. Of the 367 cases of primary rectal carcinoma, 37 cases were early carcinomas whose invasion was limited up to the submucosa (early rectal carcinoma). The remaining 330 cases were advanced carcinoma invading beyond the proper muscle layer. The histological types were well differentiated adenocarcinoma in 197 cases, moderately differentiated adenocarcinoma in 129 cases, poorly differentiated adenocarcinoma in 10 cases, mucinous adenocarcinoma in 24 cases, signet ring cell carcinoma in 6 cases, squamous cell carcinoma in 1 case In the 41 cases of carcinoma in adenoma, the carcinoma was well to moderately differentiated adenocarcinoma, and all cases were early carcinomas without invasion or with little invasions to subserosa. The size of carcinoma in adenoma was as follows: < 10 mm, 5 cases; 10-15 mm, 8 cases; 15-20 mm, 23 cases; > 20mm, 5 cases. The background adenoma was as follows: tubular adenoma (n=15), tubulo-villous adenoma (n=14), and villous adenoma (n=12). The 7 cases of neuroendocrine carcinoma consisted of 6 low grade neuroendocrine tumors (carcinoids) and 1 high grade neuroendocrine carcinoma (small cell carcinoma). All were submucosal lesions. Immunohistochemically, the tumor cells were positive for two or more of synaptophysin, chromogranin, neuron-specific enolase, CD56. In small cell carcinoma, KIT and PDGFRA were consistently positive. The 3 cases of malignant lymphoma were diffuse large B-cell lymphomas positive for CD20 and CD79a and negative for NK/T cell markers. The two cases of GIST was spindle cell type, and the risk was intermediate. Kit mutations were recognized in both GISTs. No PDGFRA mutations were seen. Of the 3 metastatic carcinomas, one was a metastasis from prostatic adenocarcinoma, and the remaining two was adenocarcinoma of unknown primary sites.     

Endoscopic ultrasound-guided real-time fine-needle aspiration: Clinicopathologic features of 60 patients

Diagnosis of lesions of the gastrointestinal tract and adjacent structures is possible using an imaging modality, endoscopic ultrasonography (EUS). Fine-needle aspiration (FNA) is a suitable and cost-effective technique for obtaining cytohistologic material to confirm the diagnosis. EUS is capable of both characterizing the lesion and then guiding the FNA under real-time (RT) ultrasound guidance using a through-the-scope needle aspiration system. The goal of this study was to determine the diagnostic accuracy of this technique and to describe the clinicopathologic features. Sixty patients underwent EUS-guided RTFNA of 64 lesions, including pancreas (n = 45), periluminal lymph nodes (n = 12), mediastinal and retroperitoneal masses (n = 4), and hepatobiliary masses (n = 3). Follow-up data were obtained by surgery, histopathology, or clinical course. Thirty-one lesions were malignant, eight were atypical/suspicious, 16 were non-neoplastic, and nine were non-diagnostic. Of the 55 lesions with sufficient material for interpretation, 54 had follow-up confirmation of the RTFNA diagnosis. The calculated sensitivity and specificity for malignancy was 90% and 100%, respectively. Diagnostic accuracy for malignancy was excellent for gastrointestinal associated lymph nodes (100%), mediastinal and retroperitoneal masses (100%), somewhat less so for pancreatic tumors (94%), and poor for hepatobiliary lesions (33%). EUS-guided RTFNA is accurate for sampling small gastrointestinal tract–associated lesions. EUS-guided RTFNA should be considered as a procedure of choice in selected patients when the results will influence management decisions. Diagn. Cytopathol. 1998; 18:98–109. © 1998 Wiley-Liss, Inc.     

Subcutaneous masses of the scalp and forehead: Diagnosis by fine-needle aspiration

We report our cytologic findings and clinical correlations in benign (N = 2) and malignant (N = 16) subcutaneous masses of the scalp (N = 15) and forehead (N = 3), studied by fine-needle aspiration (FNA). Diagnoses were divided in 3 groups: (1) Scalp plasmacytoma (as a manifestation of multiple myeloma) (6 cases) was the most frequent diagnosis. in one patient it was the presenting manifestation of the disease. (2) Miscellaneous malignancies included 8 carcinomas, 1 melanoma, and 1 malignant lymphoma. the scalp or forehead mass was the initial presentation and FNA was the initial diagnostic approach in five patients. (3) A single case each of pilar-type keratinous cyst and hematoma were the only benign masses encountered. in conclusion, a significant number of subcutaneous masses of the scalp or forehead represent metastatic or systemic malignancies, and they may be the initial manifestation of the disease. Rapid and accurate diagnosis by FNA provides guidelines for appropriate therapy, especially in those patients who present with advanced disease. © 1995 Wiley- Liss, Inc.     

Diagnostic efficiency of carcinoembryonic antigen and CA125 in the cytological evaluation of effusions.

In our previous study, the combination of the concentrations of carcinoembryonic antigen (CEA) and CA125 and the findings from cytological examination in 189 benign and malignant pleural and peritoneal effusions was useful in the diagnosis/classification of malignant effusions. Sensitivity of CEA (level, greater than 5 ng/mL) was 68%; specificity was 99% for the diagnosis of malignant effusions secondary to carcinoma of the lung, breast, gastrointestinal tract, and mucinous carcinoma of the ovary. Sensitivity of CA125 (level, greater than 5000 U/mL) was 85%; specificity was 96% for the diagnosis of malignant effusions in carcinoma of the ovary, fallopian tube, and endometrium. We now expanded the study to include 840 pleural and peritoneal effusions (benign, n = 520; malignant, n = 320) and analyzed the data by the statistical method of Rudolph and colleagues. Based on new cutoff values, ie, CEA level at 6.3 ng/mL and CA125 level at 3652 U/mL, the sensitivities for detection of malignant effusions secondary to carcinomas of the lung, breast, and gastrointestinal tract and mucinous carcinoma of the ovary varied between 75% and 100%; specificity was 98%. Sensitivity of CA125 for detection of malignant effusions from müllerian epithelial carcinoma was 71%; specificity was 99%. The elevated CEA fluid level alone helped to diagnose malignant effusions of the gastrointestinal tract in 54%, breast in 19%, and lung in 16%. The high CA125 fluid level was predictive of müllerian epithelial carcinoma. Adjunctive use of CEA and CA125 levels in fluid enhances the sensitivity of cytological diagnosis and may be predictive of the primary site in patients who present with carcinoma of an unknown primary source.     

Sacral and presacral lesions: cytopathologic analysis and clinical correlates

Although percutaneous biopsies of the spine at thoracolumbar levels have proven value, the benefit in the sacrococcygeal region has not been presented thoroughly in the literature. This region has unique anatomic and oncologic properties. The cytopathologic files at The Johns Hopkins Hospital over a 20-year-period were searched. Imaging studies and medical records were also reviewed. Ninety-one cases of sacral/presacral FNA were identified. There were 46 males and 45 females; 62% had a prior history of malignancy. The most common presentation was lower back pain (44%). Imaging revealed lytic and/or soft tissue lesions masses from 1 to 12 cm (mean = 5.0 cm). Of the 71 (78%) diagnostic cases, 19 (27%) were nonneoplastic, 2 (3%) were suspicious for neoplasm, while 50 (70%) cases were neoplastic. Of the nonneoplastic cases, 10 (53%) showed nonspecific inflammation. Two (4%) of the 50 neoplastic lesions were benign tumors (schwannoma and neurofibroma), and of the malignant cases, 11 (23%) were primary, and 37 (77%) were metastatic/secondary. The most common primary malignant tumor was chordoma (four cases, 36%). Of the 37 secondary tumors, the most common were colorectal carcinoma (8, 22%) and plasmacytic tumors (5/9, 56%). The overall accuracy, sensitivity and specificity of FNA were 96, 95, and 100%, respectively. Sacral and presacral lesions represent rare targets for FNA. Benign tumors are rare (2%). Most cancers are metastatic (41%), with colorectum being the most common primary site (9%). Primary malignancies are uncommon (14%), with chordomas being the most frequent of these entities (4%).     

Cutaneous and subcutaneous masses of the chest wall: A fine-needle aspiration study

Primary cutaneous and subcutaneous neoplasms of the chest wall are uncommon. However, metastatic tumors involving this region may be seen in local recurrence, widespread metastases, or as the first manifestation of an occult malignant neoplasm. We report a series of 81 fine-needle aspirations (FNA) of cutaneous and subcutaneous masses involving the chest wall of 45 males and 36 females (age range 32–89 yr, mean 63 yr). Sixty-nine patients (85%) have a previous history of malignancy. The most common sites of the primary malignancy are breast (n=32, 46%), lung (n=19, 26%), head and neck (n=6, 9%). Of these 69 aspirates, 65 (94%) are malignant and consistent with patients' primaries; two (3%) are benign aspirates, and two (3%) are unsatisfactory for cytologic evaluation. The remaining 12 (15%) aspirates from patients with no previous history of malignancy reveal 10 (84%) occult malignancies, and two (16%) benign entities. The malignant cases consist of nine (90%) metastatic epithelial neoplasms of unknown primary origin, and one (10%) primary soft-tissue sarcoma. In summary, this study demonstrates that the majority of cutaneous and subcutaneous masses of the chest wall subjected to FNA are neoplastic. FNA is an effective technique for primary assessment of these lesions. Diagn Cytopathol 1996;15:374–376. © 1996 Wiley-Liss, Inc.     

The significance of the diagnosis of atypia in breast fine-needle aspiration

The diagnosis of atypia in breast fine-needle aspiration (FNA) continues to be an area of debate in cytology practice. The aim of this study was to assess the clinical significance of this term and to evaluate potential morphological criteria, which would determine the patient's outcome. A computer-based search was carried out to retrieve breast FNAs performed between 1990 and 2000 that were diagnosed as atypical. Cases followed by surgical resection were reexamined for the presence of morphological features potentially differentiating benign and malignant lesions. Out of 1,568 breast FNAs, there were 64 cases (4%) with a diagnosis of atypia. Thirty-eight cases had surgical follow-up material that revealed malignancy in 14 cases (37%) and benign lesions in 24 cases (63%). The benign diagnostic categories included fibrocystic change (12/24), fibroadenoma (3/24), tubular adenoma (2/24), and nonspecific findings (7/24). The malignant diagnoses included ductal carcinoma (9/14), lobular carcinoma (3/14), ductal carcinoma in situ (DCIS; 1/14), and tubular carcinoma (1/14). The evaluation of cytological criteria used to differentiate benign from malignant lesions (i.e., cellularity, loss of cohesion, myoepithelial cells, nuclear enlargement, nuclear overlap, prominent nucleoli) revealed significant overlap between benign and malignant cases, particularly in cases of fibroadenoma, tubular adenoma, and proliferative breast disease. The surgical follow-up of four hypocellular cases revealed lobular carcinoma in two cases and ductal carcinoma in the remaining two cases. Our study confirmed that the diagnosis of atypia is clinically significant because it is associated with a high probability of malignancy. No morphological criterion is able to reliably differentiate benign and malignant lesions in cases diagnosed with atypia. Diagnosis of atypia is particularly significant in hypocellular cases. We recommended that breast FNAs with a diagnosis of atypia be evaluated further histologically.     

Stereotactic fine needle aspiration biopsy (SFNB) of breast: preliminary results in Perth with the TRC mammotest machine. Cytological aspects.

Stereotactic fine needle aspiration biopsy (SFNB) was carried out on 404 mammographically detected impalpable breast lesions from 389 women between October 1988 and January 1990. Seventy-three lesions were excised, and 38 were carcinomas. Thirty-six of the 38 carcinomas had been diagnosed as atypical, suspicious or malignant by cytology; in the remaining 2 only fat and fibrous tissue were present in smears. The sensitivity of cytological diagnosis in detecting malignancy was therefore 94.8% (36 of 38 cases). A cytological diagnosis of malignancy was made in 23 cases (5.7%) and in 5 (1.2%) the findings were suspicious of malignancy. All of these were confirmed as carcinoma histologically; the predictive value of a positive cytological diagnosis was therefore 100%. In 32 cases (7.9%) the cytological findings were atypical but inconclusive. Twenty-three of these lesions were excised, and 8 proved to be carcinoma (34.8%). No case assessed radiologically and cytologically as benign has subsequently proven to be malignant. Twenty-two of 28 cases of invasive carcinoma were given an unequivocal cytological diagnosis of malignancy; 2 were suspicious of malignancy, and in 3 the findings were atypical but inconclusive. Of the 10 pure duct carcinoma-in-situ (DCIS) lesions, (26.3% of the cancers) 1 was diagnosed cytologically as malignant, 3 as suspicious of malignancy, and 5 as atypical. The sensitivity of SFNB in detecting DCIS lesions was therefore similar to invasive carcinomas, but cases of DCIS were more likely to be given a suspicious or atypical diagnosis rather than a definite diagnosis of malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Fine-needle aspiration of scalp lesions

A variety of inflammatory and neoplastic scalp lesions are encountered in surgical pathology. However, the literature on fine-needle aspirations (FNAs) of the scalp is exceedingly rare. We report on a series of 70 FNAs involving cutaneous and subcutaneous lesions on the scalp. A total of 70 fine-needle aspirations of cutaneous and subcutaneous scalp lesions was reviewed to identify patterns of metastasis to the scalp and to demonstrate the effectiveness of FNA in diagnosing these lesions. There were 42 male and 28 female patients, ranging in age from 29-91 yr (mean, approximately 61 yr). Sixty-one patients had a previous history of malignancy. Of these aspirates, 59 were neoplastic, consistent with the patient's known primary. One case was an abscess, and the remaining case was unsatisfactorvy for cytologic evaluation. Follow-up biopsy revealed granulomatous inflammation. The most common primary tumor to metastasize to the scalp was lung carcinoma, which was seen in 18 cases, followed by hematopoietic malignancies in 14 cases. Melanoma was identified in 6 cases, head and neck tumors in 5 cases, renal malignancies in 4 cases, gastrointestinal tumors in 3 cases, sarcoma in 3 cases, breast and prostate malignancy in 2 cases each, and an olfactory neuroblastoma and meningioma in 1 case each. The remaining 9 aspirates were from patients who did not have a previous history of malignancy. These included 6 benign aspirates consisting of 3 epidermal inclusion cysts, 2 lipomas, and 1 neurofibroma. Two aspirates were malignant and included 1 primary squamous-cell carcinoma and 1 metastatic adenocarcinoma of unknown origin. The remaining case was unsatisfactory for cytologic evaluation. Follow-up biopsy of this lesion showed noncaseating granulomas. Of the aspirates from patients with a previous history of malignancy, 97% were neoplastic. Lung carcinoma and hematopoietic malignancies were the most common neoplasms that metastasized to the scalp. Since the scalp is a common site for metastasis, awareness of this fact is useful to both oncologists and dermatologists. It must be understood that FNA can provide a rapid and accurate diagnosis in the evaluation of scalp masses.     

The stereotaxic core breast biopsy using the Mammotome: an alternative to intraoperative examination

The aim of this work was to evaluate the accuracy of vacuum-assisted biopsy by comparing it with frozen biopsy. 141 stereotaxic biopsies were performed by Mammotome (Ethicon Endo-Surgery, Hamburg) from January 2000 to March 2001. Biopsies were performed for microcalcifications (n = 105, 74.5%), irregular opacities (n = 20, 14.2%), regular opacities (n = 6, 4.2%), stellate lesions (n = 10, 7.1%). Histological analysis showed 85 (60.3%) benign lesions, 46 (32.6%) malignant lesions including (21 cases of carcinoma in situ and 25 invasive carcinomas) and 10 (7.1%) atypical lesions. All malignant lesions were subjected to surgery. In three cases (1 in situ and 2 invasive), core biopsy was excisional and no residual lesion was observed. Two of the carcinomas in situ revealed invasive features on the surgical biopsy. One of the atypical lesions was underestimated and the final diagnosis was "well differentiated carcinoma in situ." Only three of benign lesions underwent surgery after Mammotome biopsy. Among the 55 frozen-section biopsies of mammographically detected breast lesions performed in the same period, were one false-positive and 3 false-negative cases, while in 4 cases the diagnosis was deferred after paraffin embedding. Our results confirmed Mammotome biopsy as an effective alternative and a more reliable method than frozen-section examination.     

Inverted urothelial papillomas with foamy or vacuolated cytoplasm

Inverted papillomas of the bladder are uncommon benign neoplasms characterized by endophytic growth of urothelial cells as anastomosing cords, displaying minimal cytologic atypia. Reports of inverted papilloma associated with urothelial carcinoma or urothelial carcinoma arising within inverted papilloma highlight the difficulties in evaluating urothelial lesions with inverted growth patterns. Within the spectrum of findings in inverted papilloma, vacuolization and foamy (xanthomatous-appearing) cytoplasmic changes have not been previously reported. In the current study, we present 5 novel cases of inverted papilloma involving 2 men and 3 women ranging in age from 48 to 88 years, who presented with microhematuria (n = 3) or irritative symptoms (n = 2). Cystoscopically, the lesions were polypoid (n = 3), pedunculated (n = 1), or solid (n = 1), measured between 0.7 and 2.5 cm, and were all located at the trigone or bladder neck. Morphologically, all cases had some component of usual inverted papilloma along with areas displaying foamy or vacuolated cytoplasm encompassing 30% to 90% of the lesion. These "clear cells" were seen both in distinct regions within the biopsy and, more frequently, intermingled with usual inverted papilloma cells. In 3 of 5 cases, these findings were sufficiently unusual to cause confusion with urothelial carcinoma. The diagnostic dilemma encountered in these cases of inverted papilloma with foamy or vacuolated cytoplasm warrants their distinction from other benign and malignant urothelial lesions with inverted growth and/or clear cell features.