Comparison of conventional Papanicolaou smears and fluid-based, thin-layer cytology with colposcopic biopsy control in central Italy: a consecutive sampling study of 461 cases

The aim of this study was to compare the cytologic diagnosis and specimen adequacy of conventional Papanicolaou (CP) and fluid-based, thin-layer [ThinPrep (TP), Cytyc, Boxborough, MA] cervical cytology in a population from central Italy. CP and TP samples were collected simultaneously using a consecutive sampling method on women presenting for cervical screening. Colposcopy was performed as clinically indicated, and biopsy results were compared with cytologic diagnoses. Among the 461 patients included in the study, 413 were negative at both CP and TP, 9 had unsatisfactory results at both tests and 39 patients presented abnormal results at CP, TP or both. Cohen's Kappa was 0.77 showing good agreement between CP and TP test results. Histological data were available for 20 (51.28%) of the 39 patients with at least one positive test. Among the 13 patients with HSIL at histology, 7 had HSIL at CP (sensitivity 53.85%) and 5 at TP (sensitivity 38.46%). For all three patients with squamous cell carcinoma (SCC) at histology, CP and TP had shown the same diagnosis (sensitivity 100%). The positive predictive values were 33.33% for CP and 25.0% for TP regarding the LSIL diagnosis and 100% for both CP and TP regarding HSIL and SCC diagnoses. Our results may be influenced by the consecutive sampling procedure.     

Conventional and liquid-based cervicovaginal cytology: a comparison study with clinical and histologic follow-up

Increased rates of squamous intraepithelial lesion (SIL) diagnosis with liquid-based cervicovaginal cytology (CVC) methods are well documented. This retrospective study compares the ability of the ThinPrep Pap Test (TP) and the conventional Pap smear (CP) to detect biopsy-proven SIL and to exclude nonneoplastic disease. All CVC reports from January 1999 through December 2000 from seven community Family Medicine clinics affiliated with the University of Nebraska were reviewed. For women with at least one CVC diagnosis of epithelial cell abnormality (ECA), follow-up histology, cytology, and clinical data were obtained. Statistical analysis was performed using the chi-square method. SIL was diagnosed in 166 of 3,286 patients by TP (5.1%) and in 169 of 4,872 patients by CP (3.5%) (P < 0.001); 32 of the TP diagnoses (1.0%) and 34 of the CP diagnoses (0.7%) were high-grade SIL (HSIL). Atypical squamous or glandular cells of undetermined significance (ASCUS/AGUS) was the most severe abnormality diagnosed by TP in 218 patients (6.6%) and by CP in 279 patients (5.7%). Follow-up histology data on CVC SIL diagnoses showed evidence of cervical intraepithelial neoplasia in 94 patients screened by TP (2.9%) and in 79 patients screened by CP (1.6%) (P < 0.001); the biopsy diagnoses were CIN 2 or CIN 3 in 34 patients in the TP group (1.0%) and in 28 patients in the CP group (0.6%) (P < 0.025). Follow-up of patients in whom the first ECA CVC diagnosis was ASCUS or AGUS disclosed a positive predictive value for CIN of 22.8% for TP ASCUS/AGUS diagnoses and 11.9% for CP ASCUS/AGUS diagnoses (P < 0.005). In this population, TP was significantly better than CP in detecting biopsy- proven disease and in screening out benign abnormalities.     

Technical evaluation of the new thin layer device CellSlide (Menarini Diagnostics)

The CellSlide Processor (Menarini Diagnostics) is an automatic computer-controlled instrument, designed to prepare standardized, thin-layer cytological preparations using a filtration process. In this report, this new processor has been tested in a multicentric investigation, designed to evaluate cell recovery, cellular morphology and possible time saved in reading the slide. The results of this study show that the CellSlide processing system is suitable for use in the preparation of liquid-based gynaecology samples. Furthermore, the high-quality smear produced by the CellSlide decreases the reading time by approximately 20-25%.     

Cytodiagnosis of primary lymphoma of bone on fine-needle aspiration cytology specimens: review of 25 cases

Diagnosis of nodal lymphomas on fine-needle aspiration (FNA) cytologic specimens has been well established. However, cytodiagnosis of primary lymphoma of bone has not been well documented because of its rarity. We undertook a retrospective study of 25 cases of FNA cytologic specimens of primary lymphoma of bone. The slides were available for review in 20 cases; each case was evaluated with 15 cytologic features in conjunction with immunophenotyping and available surgical materials. Three diagnostic categories were assigned, including nondiagnostic (4/16%), suspicious (3/12%), and malignant (18/72%). Among the 18 malignant lymphoma, all were diagnosed on the basis of cytologic materials together with immunocytochemistry, except that two cases also relied on the cell blocks. The nondiagnostic and suspicious cases were subsequently confirmed to be malignant lymphoma on the surgical core biopsies. Of the 25 cases, 23 cases were large B-cell lymphoma, one follicular lymphoma large cell type, and one small lymphocytic lymphoma. False-positive or false-negative cases were not present in this study series. In conclusion, the vast majority of primary lymphoma of bone can be accurately diagnosed and classified on FNA cytologic specimens in conjunction with immunocytochemistry. The nondiagnostic and suspicious categories can be further reduced or eliminated by improving FNA techniques or by recommendation of surgical core biopsies together with other techniques such as flow cytometry and molecular analysis.     

Diagnostic accuracy and safety of fine-needle aspiration biopsy of the parapharyngeal space

Fine-needle aspiration (FNA) biopsy of the parapharyngeal space (PPS) is a diagnostic challenge and sampling is often done without image guidance, often trans-orally. Primary PPS tumors are rare, and there is a broad differential diagnosis. The accuracy of PPS FNA, in particular without CT-guidance and using liquid-based cytology (LBC), has not been well studied. Pathology records from our institution (a 1,100 bed Canadian academic tertiary care centre) were searched to identify all patients who underwent PPS FNA from September 1991 to August 2009. The FNA diagnosis was compared to the gold standard of subsequent histopathology or long-term clinical follow-up. Of 36 FNAs, 3 employed image guidance. Eleven (31%) FNAs were nondiagnostic. In the 25 diagnostic FNAs, there was sensitivity 89%, specificity 94%, PPV 89%, NPV 94%, and accuracy 92% for the diagnosis of positive or negative for malignancy. A correct specific diagnosis was made in 9/25 (36%) cases. The nondiagnostic rate was significantly higher (P < 0.025) in FNAs prepared as conventional smears (9/17 = 53%) versus LBC (2/19 = 11%). A specific diagnosis was made significantly more often (P < 0.05) with LBC (8/19 = 43%) versus conventional smear (1/17 = 5.9%). One minor complication from FNA occurred. In conclusion, PPS FNA is safe and accurate for the diagnosis of malignancy. The rate of reporting a specific diagnosis is low. Nondiagnostic FNAs are common. There are more specific diagnoses and fewer nondiagnostic tests with LBC than with conventional smears. Improved specimen quality with LBC is likely a factor.     

Diagnostic value of GLUT-1 immunoreactivity to distinguish benign from malignant cystic squamous lesions of the head and neck in fine-needle aspiration biopsy material

The distinction of cystic squamous-cell carcinoma (SCC) from benign cystic squamous lesions (BCSLs) of the head and neck can be problematic on fine-needle aspiration biopsy (FNAB) material, particularly when BCSLs display epithelial reactive atypia or when SCC is well differentiated. Glucose transporter 1 (GLUT-1), a facilitative cell surface glucose transport protein, is aberrantly expressed in many cancers including oral and hypopharyngeal SCC. We evaluated the expression of GLUT-1 by immunochemistry on FNAB material to determine its value in distinguishing cystic SCC from BCSL of the head and neck. A 5-yr retrospective review of all head and neck cystic squamous lesions having FNAB specimens with cell block material, radiological studies, and histological confirmation was performed at our institution. Cell block material from 24 cystic squamous lesions, including 8 (33%) BCSL (7 branchial cleft cysts and 1 thyroglossal duct cyst[TDC]) and 16 (67%) metastatic SCCs with cystic/liquefactive degeneration, was retrieved and immunostained with anti-GLUT-1. GLUT-1 expression was considered positive when at least 10% of squamous cells exhibited distinct cell membrane reactivity. Positive GLUT-1 immunostaining was detected in all 16 SCCs and in none of the 8 BCSLs. In the carcinoma cases, the majority of malignant cells exhibited GLUT-1 reactivity; only a minor population of well-differentiated SCC cells displaying keratinization and arranged as squamous pearls did not express GLUT-1. GLUT-1 expression in cell block material can help to distinguish cystic SCCs from BCSLs of the head and neck. In conjunction with clinical and radiological correlation, GLUT-1 immunoreactivity can be an important diagnostic aid when the cytological findings are ambiguous.     

Primary pure squamous cell carcinoma of the breast diagnosed by fine-needle aspiration cytology: a case study using liquid-based cytology

Pure primary squamous cell carcinoma (SCC) is an extremely rare type of breast tumor. We report one of such cases in a 32-year-old woman, diagnosed by fine-needle aspiration cytology (FNAC). Aspiration smears were characterized by squamous cells, both isolated and in aggregates, at various stages of maturation. The tumor was excised, and the histologic sections confirmed the cytologic diagnosis. Pure primary SCC of the breast has a distinctive cytomorphologic appearance, and diagnosis of this tumor by FNAC is possible. For its diagnosis, the exclusion of SCC of local cutaneous structures and metastasis of distant squamous carcinoma are mandatory.     

Evaluation of RNA and DNA extraction from liquid‐based cytology specimens

Molecular diagnosis using DNA and RNA derived from malignant tumors and molecular biological tools such as the quantitative polymerase‐chain‐reaction (qPCR) is a commonly used technique in clinical pathology. In this report, we compared the qualitative extraction of RNA and DNA from cancer cells fixed using several liquid‐based cytology (LBC) kits. Ten to 1,000 cells from the T24 urinary bladder cancer cell line and SKG‐II cervical cancer cell line were fixed with 55% methanol and three different methanol‐based LBC solutions. The mRNA levels of CD44 in T24 cells and E7 in SKG‐II cells and DNA levels of p53 in T24 cells and E7 in SKG‐II cells were analyzed by qPCR. mRNA and DNA extracted from T24 and/or SKG‐II cells fixed with methanol‐based LBC solutions were efficiently detected, but to differing degrees, by qPCR. mRNA, and DNA from cells fixed with a formaldehyde‐containing fixative liquid were detected at significantly low copy numbers by qPCR. Our results demonstrate that LBC systems are powerful tools for cytopathology and immunocytochemistry applications. However, the appropriate fixative must be selected for cell preservation when a small number of LBC samples is used for molecular testing, particularly in RNA‐based molecular analyses. Diagn. Cytopathol. 2016;44:833–840. © 2016 Wiley Periodicals, Inc.     

Comparative evaluation of different DNA extraction methods for HPV genotyping by linear array and INNO-LiPA

In order to investigate the influence of DNA extraction on two PCR-based HPV genotyping tests (Linear Array, Roche and INNO-LiPA Extra, Innogenetics), three different procedures were used to purify DNA from 28 cervico-vaginal samples tested previously by the Hybrid Capture 2: the AmpliLute Liquid Media Extraction kit (Roche), the QIAamp DNA Blood mini kit (QIAGEN), and the NucliSENS EasyMAG automated platform (bioMérieux). All HC2-positive samples were found positive by both assays, independently of the extract used. Type-specific concordance (i.e., identical HPV type-specific profile in all the extracts of the same sample) was observed in 55% and 75% of the cases testing samples by the Linear Array and the INNO-LiPA, respectively. Using the DNA extracted with the two manual methods the results were concordant in 75% of the cases both for the Linear Array and the INNO-LiPA. When comparing the Linear Array results obtained on either of the two manual extracts with those obtained following automated extraction, 65% of the samples showed type-specific concordance in both cases. The INNO-LiPA results were concordant in 80% of the cases comparing the AmpliLute versus the automated extract, while concordant results were observed in 90% of the cases when comparing the QIAGEN versus the automated extract. In conclusion, the Linear Array and INNO-LiPA results are affected by the method of DNA extraction. Consequently, different HPV type-specific profiles may be observed using different extracts of the same sample. The use of consistent protocols for DNA purification is a priority to guarantee intra-assay reproducibility over time.     

Resolving ASCUS without recourse to HPV testing: manual reprocessing of residual automated liquid-based cytology (ALBC) material using manual liquid-based cytology (MLBC)

We show that residual cell material from ThinPrep PapTest (Cytyc Corporation, Boxborough, MA) atypical squamous-cells of undetermined significance (ASCUS) cases may be manually reprocessed to triage women into actionable diagnostic categories (HSIL, LSIL, and Negative). Material remaining from each of 358 ThinPrep ASCUS cases was manually reprocessed as two slides, labeled "A" and "B." Interobserver agreement between case contributors (CCs) and three sequential reviewers (SRs) was analyzed with 186 cases (Study 1), and diagnostic reproducibility between SRs was examined with an additional 172 cases (Study 2). In Study 1, CCs classified 33% of cases as LSIL or greater, SRs classified 60% as LSIL or greater, and there was 58% diagnostic agreement between CCs and SRs. No "Negative" case assignment by one group afforded an "HSIL" assignment by the complementary group. In Study 2, there was 95% agreement between SRs A slide and B slide diagnoses with 54% of A slides and 55% of B slides classified as LISL or greater. Again, no "Negative" case assignment to one slide afforded an "HSIL" assignment to the complementary slide. Overall, 12.6% of the 358 cases showed HSIL, and all HSILs by one observer group were ASCUS or greater by the complementary observer group. Using manual reprocessing beyond the 21-day specimen outdate for HPV testing by the Hybrid Capture II High Risk HPV test (HR-HCII; Digene Corporation, Beltsville, MD), many ThinPrep ASCUS cases were reclassified as LSIL or HSIL. The 12.6% HSIL proportion of this study approximated the 11.5% CIN 2 or greater proportion of the ALTS ASCUS arm. Similar to ALTS, manual liquid-based cytology (MLBC) would have referred nearly 60% of women to colposcopy for a definitive diagnosis of HSIL or LSIL without resorting to HPV testing. These data demonstrate that many cases of automated liquid-based cytology (ALBC)-diagnosed ASCUS represent unrecognized SIL, which is present in the ALBC specimen vial at the time the ASCUS diagnosis is rendered.     

Fine-needle aspiration of rheumatoid nodule: a case report with review of diagnostic features and difficulties

Patients with rheumatoid arthritis may develop extra-articular subcutaneous nodules as part of the systemic disease or as initial manifestation. These lesions may represent significant diagnostic dilemmas in patients with clinical suspicion of malignancy. In this setting, fine-needle aspiration (FNA) of the nodules may be the simplest and most appropriate diagnostic approach. In the literature, however, there are only sporadic reports describing FNA cytology of a rheumatoid nodule. In this report, we present a case of a 67-year-old male with a history of rheumatoid arthritis and squamous-cell carcinoma of the larynx who developed a subcutaneous neck nodule in the immediate proximity of the surgical scar. Clinically, because of the history of squamous-cell carcinoma and location of the lesion, the nodule was suspected to be metastatic cancer, but was proven by FNA biopsy to represent rheumatoid disease. Cytological criteria of rheumatoid nodule and diagnostic difficulties are discussed.     

PREPmate automated processor: comparison of automated and manual methods of liquid-based gynecologic sample preparation

The development of procedures for fully automated processing of liquid-based gynecologic samples has been the focus of considerable interest to the cytology laboratory. Liquid-based collection and processing technology has been shown to improve sample adequacy, resulting in an overall improvement in quality of sample preparations. PREPmate, an accessory to the PrepStain slide processor, automates the initial enrichment process of mixing and dispensing the specimen over a density gradient. This report describes a study evaluating cellularity and diagnostic reproducibility in SurePath samples processed using the PREPmate accessory compared to samples processed using a manual technique. Samples processed using the PREPmate accessory contained 8.3% more squamous cells. Exact diagnostic reproducibility between preparation types was 83.3%; when considering negative vs. abnormal (ASCUS+), in adequate samples, reproducibility was 100%.     

Vaginal Enterobius vermicularis diagnosed on liquid‐based cytology during Papanicolaou test cervical cancer screening: A report of two cases and a review of the literature

Enterobiasis is one of the most common human parasitic infections. It is considered an intestinal parasite, but cases of extra‐intestinal affections exist, notably infections of the female genital tract. Enterobius vermicularis (EV) eggs (or ova) have been found in the cervical smears of two patients in our institute during the last 16 years. No gynaecological or gastrointestinal symptoms were reported, and there was no known intestinal infection in these two cases. A review of the available literature revealed rare cases of vaginal enterobiasis, with a wide range of clinical presentations, many patients being asymptomatic. The diagnosis may sometimes be difficult, mainly because of the lack of clinical suspicion. However, cytological identification of EV in cervico‐vaginal smears is important, especially when considering the risk of ascending infections of the genital tract associated with severe complications.     

Prevalence and typing of HPV DNA by hybrid capture II in women with ASCUS, ASC-H, LSIL, and AGC on ThinPrep Pap tests

Testing for human papillomavirus (HPV) DNA is now a viable option for the management of women with atypical squamous cells of undetermined significance (ASCUS). The utility of reflexive HPV DNA testing for women with a cytologic diagnosis of atypical glandular cells-not otherwise specified (AGC-NOS), ASCUS subtypes, and low-grade squamous intraepithelial lesion (LSIL) has not been well established. In the present investigation, reflex Hybrid Capture II HPV DNA testing results were evaluated for HPV prevalence and type in 371 women with abnormal cytologic diagnoses of ASCUS-not otherwise specified (ASCUS-NOS), ASCUS-suspicious for low-grade squamous intraepithelial lesion (ASCUS-L), atypical squamous cells-cannot exclude high-grade squamous intraepithelial lesion (ASC-H), AGC-NOS, and LSIL on ThinPrep Pap tests. Positive high-risk HPV DNA was identified in 53.6% of the study samples, including ASCUS-NOS 40.2% ASCUS-L 71.4%, ASC-H 37.5%, LSIL 88.6%, and AGC-NOS 0%. We conclude that reflex HPV DNA testing appears to not be useful for colposcopy triage for cytologic diagnoses of LSIL or AGC-NOS.     

Cytologic features of small-cell carcinoma on ThinPrep

The use of ThinPrep (TP) technology for fine-needle aspiration (FNA) cytology has become widely accepted. However, some literature suggests that small-cell carcinoma may present a diagnostic pitfall due to morphologic alterations. In this study, we retrospectively compared 14 FNA of small-cell carcinoma prepared using TP with corresponding conventional smears (CS). We also examined the TP appearance of 23 other small round-cell lesions in order to determine if differential diagnostic features were preserved. TP and CS were evaluated semiquantitatively for background, architecture, chromatin quality, nuclear molding, nuclear smearing, nucleolar prominence, amount of cytoplasm, nuclear size, and single-cell necrosis. The data were analyzed using the McNemar chi(2) test. TP slides of small-cell carcinoma showed a cleaner background than CS (P < 0.005). Although some degree of nuclear molding was preserved, it was decreased in amount (P < 0.025) and subtler in quality. Similarly, nuclear smearing was present but decreased in amount (P < 0.05), and less prominent qualitatively. The amount of discernible cytoplasm was greater on TP (P < 0.005). No significant differences were found for any of the other parameters studied. The presence of nuclear molding was the single most useful feature in differentiating small-cell carcinoma from other small round-cell tumors on TP. Small-cell carcinoma may be diagnosed with confidence by FNA using TP. However, pathologists should be aware of certain morphologic alterations in order to avoid diagnostic pitfalls.     

Cervical biopsy-based comparison of a new liquid-based thin-layer preparation with conventional Pap smears

The objective of this study is to compare the diagnostic efficacy of universal collection medium (UCM) liquid-based cytology (LBC) (Digene Corp., MD) and the conventional Pap smear in a comparative study, using histologic results as the gold standard. This was a cross-sectional study. Conventional Pap smears and UCM LBC specimens, obtained from women in a low socioeconomic outpatient population referred to a tertiary center for gynecologic care, were compared. For the purpose of this study, when cervical specimens were collected for cytology, all women underwent colposcopy and biopsy was done if a cervical abnormality was observed. Cytologic evaluation of UCM LBC and conventional Pap smears were carried out separately, masked to the results of the other method. Agreement beyond chance between the two cytologic methods was ascertained by means of the unweighted kappa statistic. Sensitivity, specificity, and predictive values with 95% confidence intervals were calculated for both methods. McNemar's test was used to determine the level of association between the two cytology procedures. A total of 800 women were evaluated. Assessment of the overall agreement between the two cytologic methods yielded a kappa of 0.777 (P < 0.0001). After adjustment for histologic diagnosis, the computed kappa in each stratum was as follows: normal = 0.733; CIN 1 = 0.631; CIN 2/3 = 0.735; cancer = 0.652. The sensitivity and specificity of UCM LBC for detection of cervical intraepithelial lesions and cancer were 75.3% and 86.4%, respectively, not statistically different from the 81.8% and 85.2% seen with the conventional method. This study demonstrates that the UCM LBC method is as accurate as the conventional Pap smear cytology in detecting cervical intraepithelial lesions and cancer even so the UCM samples were systematically prepared from a second sampling of the cervix.