Grading of follicular lymphoma in cytological samples.

OBJECTIVE: The treatment of follicular lymphoma (FL) depends on its grade. The current World Health Organization (WHO) 2008 Classification of Tumours of Haematopoietic and Lymphoid Tissues recommends the grading of FL on histological samples according to the Mann and Berard method, taking into consideration the number of centroblasts. There is no generally accepted method for the grading of FL in fine needle aspiration biopsy (FNAB) samples. The aim of the present study was to devise a grading system for FL in cytological samples. METHODS: Flow cytometry (FC) was performed on 60 FNAB samples of patients with primary FL. We assumed that FL cells larger than reactive T lymphocytes on FC histograms corresponded to centroblasts. The percentage of large cells was calculated and compared with histological grade, proliferative activity and number of centroblasts per high-power field (HPF) on histological slides, and with survival. RESULTS: The histological analysis of lymph nodes revealed 20 patients with high-grade and 40 patients with low-grade FL. The percentage of large cells in FNAB samples correlated significantly with histological grade (P = 0.02), MIB1 status (P < 0.001) and the number of centroblasts per HPF (P < 0.001). An age over 60 years and a percentage of large cells over 50% in FNAB samples were found to have a statistically significant impact on survival by univariate analysis (P = 0.001 and P = 0.006, respectively). CONCLUSIONS: The percentage of large lymphoma cells in FNAB samples of FL determined by FC can be used as a reliable method for FL grading, as it is comparable with the histological grading system.

Angiosarcoma in FNA smears: diagnostic accuracy, morphology, immunocytochemistry and differential diagnoses.

OBJECTIVE: The aim of our study was to analyse the diagnostic accuracy in recognizing angiosarcoma from fine needle aspiration (FNA) samples and to determine morphological features of angiosarcoma in cytology. METHODS: FNA samples from 18 histologically confirmed angiosarcomas obtained between 1985 and 2009 were included in the study. Original cytological diagnoses were retrieved, smears reviewed and morphological features analysed: cellularity, smear pattern, cell morphology, contents of background. Outcome of immunocytochemistry was noted and additional reactions performed if material was available. RESULTS: There were 13 primary angiosarcomas and five recurrent tumours; nine tumours were epithelioid. Twelve tumours were cytologically diagnosed as malignant, three as suspicious and three were judged unsatisfactory. Only two primary tumours were diagnosed as vascular. According to morphology, tumours were divided into those with predominantly epithelioid cells and those with predominantly spindle cells. Within these two groups were variations due to grade of tumour. Cytomorphology did not correlate well with histology in mixed and spindle cell types of angiosarcomas. Immunocytochemistry was applied in seven cases, specific vascular marker CD31 only twice at the time of diagnosis and three times retrospectively. CONCLUSIONS: Angiosarcomas are difficult to recognize on FNA smears when they lack the typical dual, spindle and epithelioid cell population and when they occur in internal organs where carcinomas are more common. Very few reliable data are available concerning specificity of CD31 on cytological material.

The role of breast FNAC in diagnosis and clinical management: a survey of current practice.

Most participating countries have now adopted a triple assessment approach, i.e. clinical,imaging and pathology, to breast diagnosis, with FNAC as the first-line pathological investigation in both screening and symptomatic populations, with the exception of microcalcifications. Pathologists specialized in cytopathology are best qualified to collect and interpret FNAC samples, but this is not always possible or practical. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out FNAC under all forms of image guidance. Best results are achieved by a combination of both techniques, as shown in the image-guided FNAC in the presence of the cytopathologist. The majority of European countries use similar reporting systems for breast FNAC (C1-C5), in keeping with European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis, although some still prefer descriptive reporting only. When triple assessment is concordant, final treatment may proceed on the basis of FNAC, without a tissue biopsy. ER and PR assessment can be done safely on FNAC material. However, not all institutions may have expertise in doing this. HER-2 protein expression on direct cytological preparations is insufficiently reliable for clinical use, although its use for FISH is possible, if expertise is available. The majority of participants practise a degree of one-stop diagnosis with a cytopathologist present in the out-patient clinic. Formal recognition of the importance of the time spent outside the laboratory, both for cytopathologist and cytotechnologist, is necessary in order to ensure appropriate resourcing. The use of core biopsy (CB) has increased, although not always for evidence-based reasons. CB and FNAC are not mutually exclusive. FNAC should be used in diagnosis of benign, symptomatic lesions and CB in microcalcifications, suspicious FNAC findings and malignancies where radiology cannot guarantee stromal invasion.

S-phase fraction determined on fine needle aspirates is an independent prognostic factor in breast cancer - a multivariate study of 770 patients.

BACKGROUND: The prognostic significance of DNA ploidy and the S-phase fraction (SPF) have been extensively studied in breast cancer, but their clinical utility remains controversial. The type of tumour material can substantially influence flow cytometric DNA measurements. Material obtained by fine needle aspiration (FNA) biopsy is very suitable for flow cytometric DNA analysis because it contains a low proportion of non-tumour cells and less debris than tissue samples. METHODS: The prognostic significance of DNA ploidy and SPF, determined on FNA samples, was analysed in 770 breast cancer patients, diagnosed between 1992 and 1997. DNA ploidy and SPF were determined at the time of diagnosis as part of the diagnostic work-up. The median follow-up was 90 months. Survival analysis included overall cancer specific survival (OS), disease free survival (DFS) and survival after recurrence (SAR). Other variables included in survival analyses were age, histological grade, histological type, lymph node status and tumour size. Disease free interval and the site of recurrence were also included in SAR analysis. RESULTS: DNA ploidy and SPF correlated with tumour type, size, lymph node involvement and, especially, tumour grade. In a univariate analysis, both aneuploidy and high SPF were associated with shorter OS, DFS and SAR, but only SPF retained its independent prognostic significance in multivariate analyses. Independent prognostic variables for OS were node status, histological grade, SPF and tumour size. Node status, histological grade and SPF were independent predictors of DFS, while the site of recurrence, SPF, histological grade, disease free interval and age were independent predictors of SAR. CONCLUSIONS: DNA ploidy and SPF can be efficiently and routinely determined on FNA samples. High SPF is independently associated with a worse clinical outcome of patients with breast cancer. Although SPF and histological grade share prognostic information to some degree, SPF provides additional, less subjective prognostic information. The prognostic value of SPF determined on FNA samples could be even more relevant in neoadjuvant settings and for patients not amenable for surgical treatment, when histological grade cannot be assessed.

Haemorrhagic cytology samples - how to get the best diagnostic results.

OBJECTIVE: To describe and evaluate the value of a simple filtration technique for use in processing haemorrhagic samples for cytomorphological evaluation and immunocytochemistry. METHODS: One hundred and sixty haemorrhagic cytological samples (133 FNAs, 27 effusions) received in our laboratory from August 2002 to September 2005 were included in this study. After preparing two smears for diagnostic evaluation, the residual sample was suspended in 2 ml of a cell medium prepared in our laboratory. These primary haemorrhagic suspensions were filtered through disposable nylon filter devices and the cells deposited on the upper membrane surface were transferred into 2 ml of fresh cell medium. From all three fractions - primary cell suspension, filter deposit and filtrate - cytospins were prepared and stained by Giemsa or Papanicolaou methods. Cytospins were examined under the microscope for the presence of diagnostic cells, red blood cells (RBCs) and debris. Additional cytospins for immunocytochemistry were prepared at the cytopathologist's request. RESULTS: RBCs and debris were successfully removed in 142 out of 160 haemorrhagic samples (88%) by using this new filtration technique. In all these cases the tumour cells were well presented and allowed substantially improved cytomorphological evaluation. Immunocytochemical staining was performed on 112 filtered samples with three different markers per case on average. Filtration did not improve the quality of cytospins in 18/160 haemorrhagic samples, mostly attributable to insufficient numbers of diagnostic cells in the original samples. CONCLUSION: The presented filtration technique is very simple and quick. It substantially improves the quality of haemorrhagic samples for cytomorphological evaluation; moreover, the samples are well suited for multiple immunocytochemical stainings.

BSCC, Bethesda or other? Terminology in cervical cytology European panel discussion.

The European panel agreed that reproducibility and translatability of terminology in cervical cytology were essential, arguing well for harmonization of reporting systems. The majority at this meeting use a modification of the Bethesda system (BS). Local modifications involved reporting subcategories within high grade and low grade lesions, which would not alter the overall translatability of their systems both with each other and BS. The majority agree that low grade lesions with and without koilocytosis should be managed similarly as should high grade lesions (moderate dysplasia/CIN2 or worse). Those systems linking moderate dysplasia with mild rather than severe dysplasia would need to define moderate dysplasia as such, if their results were to be translatable, which would be preferable to their using a different definition of low grade and high grade lesions. Translation between systems might anyway be facilitated by reporting moderate dysplasia as a subcategory within high grade, which was favoured by most of those present. Therefore, there is no need for exact agreement of terminology if broad principles are agreed. This useful discussion adds weight to the British Society for Clinical Cytology recommendation that the new classification should be adopted by the UK National Health Service Cervical Screening Programme. If the new classification is adopted, the UK would join the European consensus opinion on terminology.

Cytopathology in Slovenia.

Cytopathology started in Slovenia in the early 50s with exfoliative cytology, while fine needle aspiration biopsy (FNAB) was introduced some 10 years later. Today cytopathology is a well accepted diagnostic method in Slovenia and there are currently 20 cytopathological laboratories and 17 cytopathologists. The number of specimens examined in 2001 was 26 230 FNABs, 13 355 exfoliative non cervical and 323 888 cervical smears. FNABs are performed by cytopathologists, by clinical doctors and by radiologists. So far only the cytopathologists have a supervised training period in performing biopsies. In future the same requirement will be obligatory for non pathologists. In four laboratories immunocytochemistry is used as an ancillary technique to morphology and one laboratory is using also flow cytometry for immunophenotyping of lymphomas. The classification system used in Slovenia for reporting the findings in cervical cytology is a combination of Papanicolaou's classification and assessment of dyskariosis. In spite of a long tradition in opportunistic screening for cervical cancer (Cca) an organised screening programme was started late. A four year pilot study, which included one third of the women population of Slovenia, was concluded in 2002 and an organised screening programme was introduced to the whole country in 2003. The incidence rate of Cca in Slovenia has been rising slowly since 1994 and it reached 19.6/100 000 in the year 2000. The mortality rate has remained roughly constant at 5-7/100 000 for the last 20 years. During the last few years quality assurance measures have been taken for improving the performance in cervical cytology.

Acral myxoinflammatory fibroblastic sarcoma in FNAB samples: can we distinguish it from other myxoid lesions?

We analysed cytomorphological characteristics of three fine needle aspiration biopsy (FNAB) samples of acral myxoinflammatory fibroblastic sarcoma (AMIFS) as well as the features of a number of other benign and malignant myxoid lesions. The analysis showed that FNAB samples from two cases of AMIFS had similar cytomorphology, containing all the characteristic features described in surgical biopsies: myxoid material, spindle cells with bipolar cytoplasmic extensions, epithelioid cells with globules of extra-cellular material, ganglion-like and lipoblast-like giant cells. Only the inflammatory component was scarce. The third sample did not contain features typical of AMIFS. Samples from other myxoid tumours resembled AMIFS to some extent, however, none of them contained all three tumour components characteristic of AMIFS. Cytomorphology of AMIFS may be characteristic enough to enable a definitive diagnosis from FNAB, provided all the distinctive features are sampled.

Rhabdomyosarcoma. Cytomorphology, subtyping and differential diagnostic dilemmas.

OBJECTIVE: To identify morphologic characteristics and architectural patterns of rhabdomyosarcoma (RMS), to attempt a subclassification from fine needle aspiration biopsy (FNAB) smears and to point out some differential diagnostic problems. STUDY DESIGN: We reviewed all positive cytologic material from 53 patients with RMS whose diagnoses were histologically and/or immunocytochemically confirmed. We analyzed several morphologic features and identified architectural patterns of smears. RESULTS: Among alveolar RMS, we identified two major architectural patterns: one containing completely dissociated cells and one containing many chance formations. Among the embryonal type, the predominant architectural pattern contained large tissue fragments with abundant eosinophilic material and various numbers of dissociated cells. The pattern of only dissociated cells was similar to the one seen in the alveolar type. The relative proportion of poorly to better and well-differentiated rhabdomyoblasts varied in both types and in all patterns. CONCLUSION: RMS exhibits a variety of morphologic pictures regarding cellular morphology and architectural patterns, even within the same histologic subtype. Therefore, a reliable subclassification into alveolar and embryonal RMS cannot be made from FNAB smears. The embryonal type can be suggested in cases containing large tissue fragments with abundant eosinophilic material and small, tightly packed cells with oval nuclei. However, all cases suspected to be RMS must always be confirmed immunocytochemically since they could be confused with some benign and malignant tumors with similar morphology.

Desmin detection in FNAB samples of rhabdomyosarcoma: an immunocytochemical study.

We performed immunocytochemical (ICC) staining for desmin on 65 fine needle aspiration biopsies from 45 patients with rhabdomyosarcoma, using the avidin-biotin-peroxidase complex method (ABC), and two types of antibodies, D33 and DE-R-11. The material was fixed either in ether-alcohol or in Delaunay's solution. The ABC method was applied to Papanicolaou stained slides, without destaining. We compared the quality of staining on fresh, routinely prepared slides vs archival material and the quality of staining on smears vs cytospins. In 20 cases, D33 and DE-R-II were applied to a pair of slides from the same tumour sample in order to see if there was any difference in their ability to recognize desmin. Desmin was positive in all 18 cases in which ICC staining was performed at the same time diagnoses were given. Among the 27 cases where ICC staining was carried out on archival material, seven were negative. Slides from four of these cases were 20 or more years old and negative reaction could be attributed to heating of slides before coversliping and/or to uneven distribution of desmin immunoreactivity in tumours. The second reason was probably the cause of negative reactions in cases from 1985 and 87. The type of slide preparation had no influence on the quality of staining. However, results were easier to read on cytospins because cells were more evenly distributed. Finally, our results proved that there was no significant difference between D33 and DE-R-11 in their ability to recognize desmin.

Cytomorphology of Langerhans cell histiocytosis.

OBJECTIVE: To determine the diagnostic accuracy in recognizing Langerhans cell histiocytosis (LCH) in cytologic smears obtained between 1977 and 1994 and to analyze the composition of these smears and thus identify various cytomorphologic patterns. STUDY DESIGN: The study group consisted of 37 cytologic smears (34 patients) taken from 30 bone lesions, 5 lymph nodes, 1 parotid gland and 1 conjunctival lesion. We noted the presence of various components in each smear and estimated their abundance. Immunocytochemical staining for S-100 protein was performed in seven cases. RESULTS: LCH was recognized in 22 cases, suspected in 5 and unrecognized in 1; one case was suspected of malignancy. Six smears were nondiagnostic. Three reactive lesions were misinterpreted as LCH. Smears contained numerous Langerhans cells (LCs), eosinophils, neutrophils, lymphocytes, macrophages and multinucleated giant cells. Some capillary fragments were usually present. The morphology of smears varied somewhat in the percentage of individual constituents present as well as in the appearance of the LCs. Immunocytochemical staining for S-100 protein was positive in six cases and equivocal in one. CONCLUSION: The cytomorphologic pattern of LCHs in fine needle aspiration biopsy smears is usually characteristic, and a correct diagnosis is possible, especially with the aid of immunocytochemistry. One must be aware, however, of different morphologic patterns of LCHs and of unusual appearances of LCs, which may lead to diagnostic errors.

Hepatoblastoma in fine needle aspirates.

OBJECTIVE: To analyze cytomorphologic characteristics of hepatoblastoma (HB) and evaluate the feasibility of recognizing its histologic subtypes in smears. STUDY DESIGN: Fine needle aspirates from 14 primary and 1 metastatic HB were reexamined. The diagnosis of HB was confirmed by tissue examination (10 cases) and by clinical and laboratory findings alone (5 cases). RESULTS: In 12 samples, neoplastic cells resembled immature hepatocytes but were smaller and had a higher nuclear/cytoplasmic ratio. In nine of these smears the cells were rather uniform, while the other three presented with moderate pleomorphism. The cells were arranged in three-dimensional clusters, loose sheets, cords, rosettelike structures and occasional pseudopapillae and were dispersed. CONCLUSION: With knowledge of the cellular features and architectural patterns of HB, a reliable diagnosis could be obtained in 12/15 cases without the use of special techniques. In the remaining three aspirates the tumor cell population partly or entirely differed from normal hepatocytes, requiring ancillary techniques for proper diagnosis. On reexamination of the 10 cases with tissue diagnoses, 4/6 mixed HBs could be correctly subtyped, whereas the distinction between embryonal and fetal cells in four cases of epithelial HB seemed questionable.

Epithelioid sarcoma in FNAB smears.

FNAB smears of eleven epithelioid sarcomas were reviewed and analysed. Ten cases had a very similar cytomorphologic picture composed predominantly of dissociated epithelioid-like cells with eccentrically placed nuclei. These tumors were clearly malignant but difficult to differentiate morphologically from melanoma, epithelioid leiomiosarcoma, and Schwannoma or adenocarcinoma. One case was composed of spindle cells and was reminiscent of a fibrohistiocytic tumor. Immunocytochemical reactions to vimentin and cytokeratin were performed in six cases on the Papanicolaou stained smears. The reactions to both antigens were positive in all six cases. Ultrastructural characteristics of eight of the tumors are also described. It seems that epithelioid sarcoma has a rather distinct cytomorphologic picture. Taking into consideration clinical data and using also immunocytochemistry, a definitive diagnosis of epithelioid sarcoma can probably be given from FNAB smears.

Secretory breast carcinoma in a man diagnosed by fine needle aspiration biopsy. A case report.

Preoperative aspiration biopsy of a breast tumor in a 20-year-old male resulted in a diagnosis of secretory breast carcinoma. The material obtained from aspiration biopsy was also used for electron microscopic, immunocytochemical and flow cytometric analysis. The characteristic light microscopic features were numerous large secretory vacuoles containing proteinaceous material, which was also seen in the background of the smear. Electron microscopy revealed numerous intracellular lumina and some intercellular ones filled with secretory material as well as membrane-bound vacuoles. Immunoreactivity was positive for cytokeratin, epithelial membrane antigen, carcinoembryonic antigen, alpha-lactalbumin and vimentin. Flow cytometric analysis showed the tumor to be diploid. The affected breast and tumor were resected, and the cytologic diagnosis was confirmed histopathologically. The cytomorphologic features of secretory breast carcinoma seem to be alike in men and women and are sufficiently characteristic to permit a definitive preoperative diagnosis from fine needle aspiration biopsy smears. The differential diagnosis with other tumors is discussed briefly.

Primary carcinoid of the kidney.

A case of primary carcinoid tumour of the kidney in a 40-year-old man is reported. It was initially diagnosed as a Wilms' tumour monomorphic type. After total unresponsiveness to specific therapy, specimens were reexamined and immunohistochemical and electron microscopic examinations were also employed disclosing the real nature of the tumour which showed cytoplasmic positivity for neuron-specific enolase in tumour cells and presence of numerous electron dense core neuroscretory granules in their cytoplasm.

Chondroblastoma in fine needle aspirates.

The cytologic features of smears of fine needle aspirates from four chondroblastomas were studied. In an ideal fine needle aspiration biopsy sample of chondroblastoma, all the diagnostic details can be found: chondroid matrix surrounding individual round to oval mononuclear cells, calcifications among cells and multinucleate osteoclasts. Chondroid matrix, which we believe to be the decisive feature, and calcifications are seen better in Giemsa-than in Papanicolaou-stained smears.