Cytopathologic analysis of paraspinal masses: a study of 59 cases with clinicoradiologic correlation

Paraspinal masses (PSM) are uncommon and present a wide spectrum of differential diagnoses on fine-needle aspiration (FNA). We analyzed 59 cases of PSM on FNA in a 15-yr period, in the context of clinicoradiologic correlation. Radiologic findings, clinical data, and tissue biopsies were reviewed. Patients were 14-83 yr of age (mean 54.7) with a M:F ratio of 1.36:1. Of the 59 cases, 39 (66%) were deemed diagnostic. Of these, 8 (21%) revealed nonneoplastic lesions and 31 (79%) yielded neoplasms: 2 (6%) benign and 29 (94%) malignant. Of the malignant cases, 22 (76%) were metastatic tumors from various sites, while 7 (24%) were cancers from local spread, which included non-Hodgkin's lymphoma (NHL, 5) and myeloma (2). Benign neoplasms were nerve sheath tumors. Metastatic tumors consisted of adenocarcinoma, 9; squamous-cell carcinoma, 3; renal-cell carcinoma, 1; and non-small-cell carcinoma/not otherwise specified (NOS), 9. Twenty-four (41%) cases received further studies: immunoperoxidase (IPOX) alone, 17 (71%); special stains for microorganisms, 2 (8%); IPOX/other special stains, 4 (17%); and flow cytometry analysis, 1 (4%). Eight (14%) cases received follow-up biopsies. Half of these biopsies added information to previously "nondiagnostic" FNAs. Of the previously "diagnostic" FNAs, tissue biopsy yielded no additional information. Cytopathologic diagnoses were consistent with the pre-FNA radiology analyses in 13 (39%) cases. In instances of radiologic and cytopathologic discrepancy (4 cases, 12%), diagnoses made by FNA reversed the initial radiologic impression of neoplasm to infection, and vice versa. PSMs are rare lesions (0.26% of total FNAs done in 15 yr at our institution). The most common lesion encountered is metastatic adenocarcinoma, followed by NHL. Ancillary studies are helpful in difficult cases. In cases of radiologic/cytopathologic discrepancy, FNA diagnoses are more accurate and decisive for patient management. The sensitivity and specificity of a PSM FNA are 88% and 75% respectively.     

Breast masses in males: multi-institutional experience on fine-needle aspiration

Male breast masses are uncommon pathologic findings. They are rarely aspirated, resulting in limited cytopathologic experience. The following study describes the cytopathology of male breast lesions from data collected for a period of 10 yr from three large institutions. A total of 14,026 breast aspirations were performed of which 614 were from male patients. All cases were reviewed and correlated with the appropriate clinicopathologic follow-up. The FNA diagnoses were as follows: benign, 427 cases (gynecomastia 353, fat necrosis 21, miscellaneous 53); malignant, 32 cases (ductal carcinoma nos 15, metastatic tumors 17); and atypical/suspicious, 61 cases. Ninety-four cases were nondiagnostic due to scant cellularity. Male breast aspirates accounted for 4.3% of the total breast FNAs performed. The clinicopathologic follow-up in both the benign and malignant categories showed 100% correlation. The overall sensitivity was 95.3%, specificity was 100%, and diagnostic accuracy was 98%. A relatively high specimen unsatisfactory rate was seen (>15%). The commonest cytopathologic diagnosis was gynecomastia, followed by ductal carcinoma. Florid duct atypia in gynecomastia may mimic adenocarcinoma, necessitating a higher threshold for cytopathologic interpretation for malignancy in males.     

Comparison of ThinPrep and conventional preparations in pancreatic fine-needle aspiration biopsy

Use of ThinPrep preparation for fine-needle aspiration biopsy (FNA) is gaining popularity. However, there may be a difference in the morphology and the operating characteristics between ThinPrep and conventional methods. The objective of this study was to compare the accuracy of the two methods and to address the pitfalls of ThinPrep preparation in pancreatic FNA. A computer search identified 67 pancreatic FNAs with both conventional smears and ThinPrep preparation during a 19-mo period. These cases, obtained under endoscopic ultrasound-guidance, consisted of 47 malignant neoplasms (44 ductal carcinomas, two mucinous neoplasms, and one islet cell tumor) and 20 benign lesions. Direct smears were prepared first and the remaining material was then put into PreservCyt Solution for ThinPrep slides. All slides were reviewed and the cytologic diagnoses were correlated with histologic and clinical follow-up. Five conventional and 16 ThinPrep specimens were unsatisfactory due to insufficient cellularity. These cases were excluded from the analysis. Among the 62 cases evaluated by conventional preparation, 77% (34) were diagnosed as positive and 14% (seven) atypical/suspicious by conventional smears. For the 51 ThinPrep specimens, 58% (22) were interpreted as positive and 31% (12) atypical/suspicious. The sensitivity, specificity, and accuracy of diagnosing a malignancy were 77%, 100%, and 84% for conventional smears and 58%, 100%, and 67% for ThinPrep preparation, respectively. There were no false positives with either method. However, three benign lesions were interpreted as atypical/suspicious with ThinPrep preparation because of the presence of single atypical cells with distinct nucleoli. One of the two mucinous neoplasms was incorrectly diagnosed with ThinPrep preparation because of lack of mucin. The diagnostic accuracy of pancreatic FNA using ThinPrep is inferior to that of conventional smears. This may be partly due to the use of split sample technique resulting in scant cellularity in ThinPrep preparation and partly due to the differences in morphology between the two preparations. Therefore, the current morphologic criteria may need modification for ThinPrep preparation in pancreatic FNA.     

Cytopathologic analysis of thyroid lesions in the pediatric population

Fine-needle aspiration (FNA) of the thyroid is seldom performed in the pediatric population. Therefore, the clinical utility of thyroid FNA in this patient group has not been adequately addressed. A 15 yr retrospective review of the cytopathology archives at the participating institutions was performed to identify cases of thyroid FNA performed in pediatric patients. The medical records of these cases were reviewed, including the surgical pathology reports of those patients who had subsequently undergone surgical resection. One hundred one specimens from 82 patients were identified. Of these, 40 had a cytopathologic diagnosis of carcinoma, "suspicious" for carcinoma, neoplasm, or atypia, 48 were benign, and 13 were unsatisfactory. Of the 82 patients, 45 underwent partial or total thyroidectomy. Twenty-two (49%) of these were found to harbor a malignant neoplasm (18 papillary carcinomas). The diagnostic sensitivity for identifying a lesion was 87% (26/30) and the diagnostic specificity was 92% (47/51). There were four false-positives and four false-negatives in the review, yielding a positive predictive value of 87% and a negative predictive value of 92%. We conclude that FNA is a useful adjunct to the management of thyroid lesions in the pediatric population, with good diagnostic accuracy. Although thyroid neoplasms are relatively rare in children, our experience demonstrated that 40% of thyroid masses referred for FNA had an interpretation that caused concern, ranging from "atypical" to carcinoma. Additionally, a benign diagnosis by FNA may avoid unnecessary surgery with its potential complications, a significant consideration for this age group.     

Transthoracic fine-needle aspiration vs concurrent core needle biopsy in diagnosis of intrathoracic lesions: a retrospective comparison of diagnostic accuracy

To assess the value and limitations of fine-needle aspiration (FNA) and core needle biopsy (CNB) in the diagnosis of intrathoracic lesions, we retrospectively compared the diagnostic accuracy of 362 FNA and concurrent CNB procedures performed on 350 patients. Based on the final diagnoses that were determined based on combined information from biopsy, resection, clinical, radiologic, and microbiologic findings, the study cases were grouped into 188 malignant, 161 benign, and 13 inconclusive lesions. FNA and CNB yielded similar diagnostic accuracy for malignant tumors (85.1% vs 86.7%) and epithelial malignant neoplasms (86.4% vs 85.2%), whereas CNB yielded better diagnostic accuracy (96%) than FNA (77%) for nonepithelial malignant neoplasms. Combined FNA and CNB substantially improved the rate of malignancy diagnosis (95.2%). Of 161 benign cases, 50 were proven to be benign-specific lesions; FNA provided specific diagnosis in 20 (40%) and CNB in 46 (92%). The remaining 111 benign lesions yielded benign-nonspecific findings on both specimens. These results indicate that CNB should be obtained when clinical or radiologic findings do not match the cytologic findings or nonepithelial lesions and benign lesions are considered likely.     

Equivocal diagnoses in breast aspiration biopsy cytology: sources of uncertainty and the role of "atypical/indeterminate" terminology.

In 1996, a National Cancer Institute committee recommended four categories as uniform terminology for breast fine-needle aspirations (FNAs): benign, malignant, suspicious/probably malignant, and atypical/indeterminate. The latter is a controversial category. This study evaluates the usefulness of the atypical/indeterminate term, and examines sources of diagnostic equivocation in breast FNA. Eight hundred and twenty-two consecutive breast FNAs were previously classified as benign, malignant, suspicious, or unsatisfactory. Two hundred and thirteen (25.9%) cases had surgical follow-up and were classified as true positive (TP), false positive (FP), true negative (TN), false negative (FN), true suspicious (TS), or false suspicious (FS). Slides from FN, FP, TS, and FS were reviewed for interpretative error, poor clarity or preservation, obscuring material, sampling error, or insufficient malignant criteria. Cases were also evaluated as to whether classification as "atypical/indeterminate" would have improved patient care. There were 21/822 (2.6%) FN, 37/822 (4.5%) TS + FS, and 0 FP diagnoses. Seventy percent of suspicious diagnoses showed cancer on follow-up. The majority of FN and suspicious cases were due to sampling problems and insufficient criteria of malignancy. None were deemed more appropriately classified as "atypical/indeterminate" All required surgical confirmation for treatment. All equivocal breast diagnoses are due to similar problems. Splitting them into "suspicious/probably malignant" and "atypical/indeterminate" would not lower the biopsy rate. A simpler three-part terminology of benign, malignant, and suspicious/equivocal, without qualification of the latter favoring benign or malignant, would provide more effective communication and appropriate follow-up. Diagn. Cytopathol. 1999;21:217-222.     

Fine‐needle aspiration in pediatric patients 12 years of age and younger

Fine‐needle aspiration (FNA) is a well‐established diagnostic tool in adult patients, and while in recent years it has gained popularity in the pediatric population, it is still far less universally accepted in children than in adults. A computerized search of our tertiary medical center's laboratory information system was performed for the 20‐year period from 1992 to 2012. All FNAs in children 12 years of age and younger and all related surgical pathology reports were identified. Cytologic and histologic diagnoses were stratified into six diagnostic categories—benign, atypical, suspicious, malignant, cyst contents, and nondiagnostic—and then compared to determine the utility of FNA in this patient population. Four hundred and three FNAs in 389 patients were included in this study, of which there were 288 benign (71.5%), 8 atypical (2.0%), 10 suspicious (2.5%), 42 malignant (10.4%), 12 cyst contents (3.0%), and 43 nondiagnostic (10.6%) cases. The most common benign diagnoses were reactive lymph node and inflammatory infiltrate/abscess, while the most common malignant diagnoses were leukemia/lymphoma, rhabdomyosarcoma, and neuroblastoma. Of the 127 FNAs (31.5%) with histologic follow‐up, we identified just one false positive and one false negative case. Like FNA in adults, this study shows that the technique is both sensitive (97.2%) and specific (98.5%), and has high positive predictive (97.2%) and negative predictive (98.5%) values for diagnosing malignancy in childhood. As FNA is a simpler, less invasive, and more cost‐effective procedure when compared with surgical biopsy, it represents a valuable diagnostic tool in the pediatric population. Diagn. Cytopathol. 2014;42:600–605. © 2013 Wiley Periodicals, Inc.     

Fine-needle aspiration of cystic lesions of the kidney. Morphologic spectrum and diagnostic problems in 41 cases

Although imaging studies show the nature of most cystic lesions of the kidney (RCs), many RCs require fine-needle aspiration (FNA) for accurate diagnosis. Interpretation of the FNAs remains challenging. The FNA specimens of 41 RCs were reviewed and correlated with imaging studies. Final diagnoses for 30 cytologically benign lesions were simple cyst (28), acquired cystic kidney (1), and cystic renal carcinoma (1). The fluid from the benign cysts displayed macrophages, epithelial cells from the cyst lining, tubular cells, neutrophils, and Liesegang rings. Fluid from the acquired cystic kidney and the cystic renal cell carcinoma showed features similar to those of the benign cysts. The 9 cases with "suspicious" cytology included 5 complex cystic lesions displaying rare but atypical epithelial cell clusters, 3 low-grade renal cell carcinomas with many mildly atypical papillary clusters of epithelial cells, and 1 simple benign cyst with many tubular cells. The 2 cytologically malignant lesions were cystic renal cell carcinomas with abundant tumor cells with partially clear cytoplasm and atypical nuclei admixed with abundant macrophages and lymphocytes; 1 case developed in a kidney with acquired cystic disease. Simple cysts remain the most frequently aspirated RCs, but complex cystic lesions are increasingly recognized. Since many RCs are composed of independent loculi, a nonrepresentative sample is a potential problem, and cytologic-radiologic correlation becomes mandatory. The "suspicious" patterns identified in this study should serve as diagnostic guidelines and set the foundation for future validation.     

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.     

Utility of fine-needle aspiration in the diagnosis of salivary gland lesions in patients infected with human immunodeficiency virus.

Fine-needle aspiration (FNA) has been increasingly utilized as a diagnostic tool in evaluating salivary gland masses, primarily to differentiate nonneoplastic from neoplastic lesions. Patients infected with human immunodeficiency virus (HIV) frequently present with salivary gland lesions. In this study, we reviewed the cytology of salivary gland lesions in HIV-infected patients and assessed the value of FNA in the diagnosis of salivary gland lesions in HIV-infected patients. One hundred and three FNAs of salivary gland lesions from 78 HIV-infected patients (63 males and 15 females) were included in our study. The patients' ages ranged from 7-65 yr, with a mean age of 40.9 yr. FNAs were classified into three categories: benign lymphoepithelial lesions (BLL) (77 cases or 74.8%), inflammatory processes (14 cases or 13.6%), including 3 reactive lymphoid hyperplasia, and neoplastic lesions (6 cases or 5.8%). The latter included three malignant lymphomas, a multiple myeloma, a metastatic adenocarcinoma from a lung primary, and a direct extension of basal-cell carcinoma. Six (5.8%) aspirates were nondiagnostic. No false-positive or false-negative cases were noted during follow-up of these patients. In conclusion, FNA is a simple and cost-effective procedure for the diagnosis of HIV-related salivary gland lesions. The majority of these lesions are cystic BLL and can be managed conservatively. Malignant lesions are rarely encountered and are readily recognized by FNA. Diagn. Cytopathol. 1999;21:260-264.     

Fine-needle aspiration cytology of Hürthle cell carcinoma of the thyroid

Specific criteria for the diagnosis of fine-needle aspiration (FNA) of Hürthle Cell Carcinoma (HCC) have rarely been discussed in the literature. A retrospective review of 35 FNA cases with the diagnosis of Hürthle cell lesion or Hürthle cell neoplasm was performed. In each case, there was a subsequent surgical excision. The FNA specimens were divided according to histologic diagnoses as HCC (12 cases), Hürthle cell adenoma (HCA) (14 cases), and benign nonneoplastic Hürthle cell lesions (BNHCL) (9 cases). Each case was examined using a semiquantitative scoring system for the following 11 features: presence or absence of colloid, lymphocytes, and transgressed blood vessels (each scored 0 or 1); the percentage of nuclear enlargement, small cell dysplasia, large cell dysplasia, nuclear crowding, and cellular dyshesion (each scored 0-3); and age, gender, and size of lesion. When diagnosed by FNA as either Hürthle cell neoplasm or Hürthle cell lesion, males were much more likely to have malignant tumors than females. Statistically significant cytologic features that favored malignant (HCC) over benign lesions (HCA and BNHCL) included small cell dysplasia, large cell dysplasia, nuclear crowding, and cellular dyshesion. The presence of colloid and lymphocytes favored a benign lesion. Nuclear enlargement and large tumor size are significantly more common in neoplasms than BNHCL.     

Pediatric fine-needle aspiration biopsy.

A total of 135 fine-needle aspiration (FNA) biopsies from varying sites were performed in 123 children (mean, 10.5 years; range, one day to 18 years) over a five-year period. One hundred thirty (96.3%) biopsy specimens were satisfactory for evaluation. Seventy-nine cases were nonneoplastic (60.8%); among these cases, a specific diagnosis of infectious disease was made in 17 (13.1%). A diagnosis of neoplastic disease was made in 50 (38.5%) cases, of which 14 (10.8%) were benign, 28 (21.5%) were malignant, and 8 (6.2%) were neoplasms of uncertain biologic potential. The sensitivity of pediatric FNA biopsies was 90.6%, specificity 100%, positive predictive value 100%, negative predictive value 94.7%, and efficiency of the test 96.5%. There were no false-positive diagnoses and there were four false-negative diagnoses, three of which involved aspirates of the central nervous system (CNS). Ancillary studies, including immunocytochemistry (20 cases), electron microscopic examination (18 cases), microbiologic culture (8 cases), cytogenetic studies (7 cases), and flow cytometry (3 cases), were performed on the aspirated material, enabling a more specific diagnosis or supplying additional information in many cases. Definitive diagnosis by FNA biopsy enabled radiation therapy and/or chemotherapy to be administered for unresectable malignant neoplasms, provided material for culture of infectious lesions, identified benign lesions not needing surgery, and aided the surgeon in planning the extent of surgery in resectable malignant neoplasms. These results support the greater use of FNA biopsy in the pediatric population.     

Diagnosis and subclassification of primary and recurrent lymphoma. The usefulness and limitations of combined fine-needle aspiration cytomorphology and flow cytometry

The primary diagnosis of non-Hodgkin lymphoma/leukemia by fine-needle aspiration (FNA) is still controversial and relatively underused. We evaluated our FNA experience with lymphomas using the revised European-American classification of lymphoid neoplasms to determine the reliability of FNA when combined with flow cytometry in the diagnosis of lymphoma, the types of diagnoses made, and the limitations of this technique. Slides and reports from all lymph node and extranodal FNAs performed during the period January 1, 1993, to December 31, 1998, with a diagnosis of lymphoma or benign lymphoid process were reviewed. There were 290 aspirates from 275 patients. These included 158 cases of lymphoma, of which 86 (54.4%) were primary and 72 (45.6%) were recurrent. There were 44 aspirates suggestive of lymphoma and 81 benign/reactive diagnoses. With diagnoses suggestive of lymphoma considered as positive for lymphoma, levels of diagnostic sensitivity and specificity were 95% and 85%, respectively. Specificity was 100% when only definitive diagnoses of lymphoma were considered. Clearly, FNA and immunophenotyping by flow cytometry are complementary and obviate a more invasive open biopsy for many patients with lymphadenopathy.     

Fine-needle aspiration of the thyroid: rate and causes of cytohistopathologic discordance

Fine-needle aspiration (FNA) of the thyroid gland is a widely utilized, sensitive, specific, and cost-effective method for the evaluation of thyroid nodules. The purpose of this study was to evaluate the accuracy of thyroid FNA and causes of cytohistological discordance in our institution. Six hundred twenty-five thyroid FNAs obtained from 503 females (mean age, 54) and 122 males (mean age, 51) in whom histopathologic follow-up material was available for review, were analyzed. FNAs were classified as: nondiagnostic, negative, intermediate, and positive for malignancy, and the histopathologic material was categorized as benign or malignant. The review revealed 93% sensitivity and 96% specificity for the FNA diagnoses. The FNA results were diagnostic in 87%, indeterminate in 6%, and nondiagnostic in 7% of the cases. Cytohistologic correlation was achieved in 88% of the cases. The false-negative rate was 4% and the false-positive rate was 8%. The most common pitfalls for false-negative diagnoses consisted of suboptimal material and underdiagnosis of papillary carcinoma due to cystic degeneration. The most common pitfall for false-positive cases was overdiagnosis of follicular neoplasms. Our study confirmed that FNA of thyroid nodules can be performed with high sensitivity and specificity by experienced clinicians or pathologists. The application of strict specimen adequacy rules for FNA interpretation is likely to decrease the rate of false-negative and false-positive diagnoses.     

A retrospective study of the diagnostic accuracy of fine-needle aspiration for breast lesions and implications for future use

In recent years, the use of fine-needle aspiration (FNA) in the diagnosis of breast lesions has declined in many institutions. We sought to evaluate the role of FNA for breast lesions and the annual rate of the procedure at our institution over a 4(1/2) year period (May 2002-October 2006). A total of 831 FNAs were performed, with 258 (31%) having histologic follow-up. The number of FNAs obtained was 159 from 5/02 to 4/03, 192 from 5/03 to 4/04, 194 from 5/04 to 4/05, 191 from 5/05 to 4/06, and 95 from 5/06 to 10/06. Each case was placed into one of four categories: nondiagnostic (9%), benign (77.5%), atypical/suspicious (5.5%), or malignant (8%). Surgical tissue was available for 37% of nondiagnostic cases, 22% of benign cases, 80% of atypical/suspicious cases, and 72% of malignant cases. The overall sensitivity and specificity for FNA was 83 and 92% respectively. The overall positive and negative predictive values were 83 and 92% respectively. There were no false-positive cases, indicating a positive predictive value of 100% for a Dx of malignancy. For cases with surgical follow-up, the false-negative rate was 5.4%. Although there is a national trend away from FNAs of breast lesion, this has not been the experience at our institution. Although FNA may not be ideal in the initial evaluation of suspicious lesions, we argue that FNA for clinically benign palpable lesions and recurrent carcinomas has significant value.     

Intraoperative consultation in ovarian lesions: A comparison between cytology and frozen section

Little information is available on the relative value of intraoperative cytology (IOC) and frozen section (FS) in evaluation of ovarian lesions. We compared the two methods in 63 histologically proven cases of resected ovaries studied by imprints (40 cases), FNAs (38 cases), and scrapes (5 cases). Diagnoses were: 10 non-neoplastic cysts, 46 neoplasms (benign, 19; borderline, 8; and malignant, 19) and 7 tumors comprised of small blue cells (SBC): granulosa cell (3), lymphoma (1), small cell carcinoma (1), and sarcoma (2). There were no false-positive diagnoses by IOC or FS among the benign and borderline conditions. Five benign lesions, however, had FS deferred because of architectural complexity, this in contrast to only one case reported as atypical by IOC. Borderline tumors were recognized as such in 3 cases examined by FS, but no such diagnosis was possible by IOC due to the inability to assess invasion. The diagnosis in borderline neoplasms of surface epithelial origin was deferred in 4 cases by FS and reported as atypical in 5 cases examined by IOC due to the spectrum of architectural and nuclear atypia in borderline tumors. Of the 19 malignant cases, five were deferred because of uncertainty of invasion by FS, whereas two were called atypical by IOC. Five of 7 SBC tumors were recognized as such by FS and 6 of 7 by IOC, but none could be unequivocally subclassified by either method. Intraoperative FNAs and scrapes were superior to imprints, which tended to be bloodier and thicker. In contrast to FNAs, scrapes were easier to direct and yielded greater cellularity, although both methods were comparable in diagnostic accuracy. Even though the diagnostic yield of IOC was only slightly better than that of FS, it provided much better cytologic detail, and afforded a more representative sampling. Diagn Cytopathol 1996;15:387–394. © 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.     

Fine-needle aspiration cytology of hematopoietic lesions from multiple sites

We reviewed 130 fine-needle aspiration (FNA) biopsies from 118 patients with a variety of benign and malignant hematopoietic lesions. There were 74 (57%) malignant, 45 (35%) benign, and 11 (8%) atypical diagnoses. Immunocytochemistry of the aspirated material was performed in 47 (36%) and electron microscopy in 4 (3%) of the cases. FNA cytology was utilized to make a primary hematopoietic malignant diagnosis in approximately half of the cases and to confirm recurrence in the remainder. The malignant cases included non-Hodgkin's lymphoma. Hodgkin's disease, medullary and extramedullary plasmacytoma, and granulocytic sarcoma. Forty-two malignant cases had either previous or follow-up surgical biopsy with no false-positive diagnoses. Of the 11 atypical cases, seven had surgical confirmation with five malignant and two benign diagnoses. The benign hematopoietic lesions correctly identified included acute and chronic lymphadenitis, granulomatous processes, and eosinophilic granuloma. Only 5 of the 45 benign FNA biopsies had surgical pathology follow-up, with no false-negative diagnoses. The most commonly aspirated sites were lymph nodes (71%), although hematopoietic lesions were correctly identified in a number of extranodal locations, including soft tissue (8%), abdominal viscera (6%), lungs (5%), mediastinum (2.5%), bone (3%), and thyroid, salivary gland, and breast (1.5% each). This study demonstrates the clinical utility and diagnostic accuracy of FNA cytology in the evaluation of benign and malignant hematopoietic disorders from multiple sites. Ancillary studies performed on the aspirated material aided in making a specific and accurate diagnosis.     

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%).     

Utilization of fine-needle aspiration in the diagnosis of metastatic tumors to the kidney.

Renal masses secondary to metastases are not common. Few comprehensive reviews exist, which consist primarily of autopsy and radiologic reports. The purpose of this study was to review the types and incidences of various neoplasms which metastasize to the kidney and to determine the usefulness of fine-needle aspiration (FNA) in diagnosing them. Two hundred and sixty-one radiologically guided FNAs of renal lesions over a 9-yr period were reviewed. The diagnoses of the 261 renal FNAs were as follows: 136 (52%) were malignant, 111 (43%) were benign, and 14 (5%) were unsatisfactory. Of the 136 positive FNAs, 28 (21%) revealed metastatic tumors. The overall incidence of renal FNAs displaying metastatic tumors was 11%. Among the 28 patients with metastases to the kidney, 23 patients were men and 5 were women, with the mean age being 58 yr. Twenty-five patients (89%) had prior history of a primary malignancy, including lung carcinoma (11 cases, 39%), lymphoma (8 cases, 29%), hepatocellular carcinoma (3 cases, 11%), and one case each of breast, pancreatic, and cervical cancer. In the remaining 3 patients (11%), with metastatic adenocarcinoma (2 cases) and squamous-cell carcinoma (1 case), the primary tumor site remained unknown despite an extensive clinical workup. Overall survival after FNA was poor, with a mean of 9.8 mo. FNA is useful in the diagnosis of masses in the kidney secondary to metastatic disease. This information is of clinical importance, principally in the exclusion of a primary malignancy, but also to avoid unnecessary surgery and to plan for subsequent patient care.