Papanicolaou society of cytopathology system for reporting pancreaticobiliary cytology: Risk stratification and cytology scope - 2.5-year study.

Objectives: Diagnosis of pancreatic lesions remains a clinical challenge. Early and accurate diagnosis is extremely important for improving the therapeutic usefulness of pancreatic cancers and Endoscopic ultrasonography - fine needle aspiration (EUS-FNA) cytology has come up with this advantage. For current study the authors evaluated the diagnostic accuracy of EUS-FNAC by applying PSC system for reporting pancreaticobiliary cytology and Calculated the malignancy risk associated with the diagnostic categories. Material and Methods: A retrospective study over the period of 2.5 years (April 2017 to Oct 2019) 60 patients in our cohort EUS-FNAC guided unstained fixed and unfixed slides received of pancreatic lesion and were stained with Papanicolau and Giemsa using standard technique and immunocytochemistry, where required Application of Papanicolaou Society of Cytopathology system for reporting pancreaticobiliary cytology Histopathological and clinical follow-up were retrieved. Results: Our study has comparable results with sensitivity, specificity, PPV, and NPV of 92.8%, 100%, 100%, and 92.59%, respectively. Fuurthermore, a diagnostic accuracy of 96.2%. Risk of malignancy is lower for benign and indeterminate category whereas it is higher for suspicious and malignant categories. Conclusion: The application of the new proposed terminology for pancreaticobiliary cytology brings standardization. Final diagnosis can be reached by the multidisciplinary approach of EUS-FNA cytology, cell block preparation, immunocytochemistry, and immunohistochemistry; if required, can be adopted as an alternative approach to biopsy. The present study showed high sensitivity and specificity for EUS-FNA in the diagnosis of pancreatic carcinoma, which may influence the treatment plans of both surgeons and oncologists.

Histomorphological analysis of gastric polyps.

INTRODUCTION: Incidence of gastric carcinoma and gastric polyps is on rise all over the world. Chronic atrophic gastritis to intestinal metaplasia progressing to adenocarcinoma has been documented pathway for gastric carcinogenesis. Another pathway for gastric carcinoma is adenoma carcinoma sequence similar to colon cancer. AIM: To study prevalence, endoscopic, and histomorphological features of gastric polyps. METHODS AND MATERIAL: This was retrospective analysis of gastric polyps from 2012 to 2019 in consecutive 10,800 upper gastrointestinal endoscopies. Demographic, endoscopic, and histopathological data were obtained from hospital records. All gastric polyps were classified as per standard histologic criteria. Additional histological features noted were presence of dysplasia, focus of adenoma, or malignancy. RESULTS: The prevalence of gastric polyps was 434 (4%) of 10,800 upper gastrointestinal endoscopies. Majority of polyps were found in the last 4 years (277: 63.8%). Mean age was 55.4 years with male to female ratio 1:1.2. Most of the polyps (94.9%) were less than 1 cm, located in gastric antrum. Multiple polyps were seen in 20.9% cases. On histopathology, fundic gland polyps were most common (147: 33.8%), followed by hyperplastic (128: 29.4%) polyps. Adenomatous polyps were nine (2%); of these, two cases of hyperplastic polyps and one each of fundic gland polyp and benign epithelial polyp showed adenomatous foci. CONCLUSION: Fundic gland polyps were the most common polyps. With rising incidence of gastric carcinoma, identification of gastric polyps on endoscopy with biopsy can prevent progression to carcinogenesis.

Utility of the Milan system for reporting salivary gland cytopathology: A retrospective 5 years study.

BACKGROUND: Fine-needle aspiration cytology (FNAC) is an established technique for preoperative diagnosis of salivary gland lesions; however, lack of a uniform reporting system has been a handicap. The main aims of this study were to evaluate the utility of the - "The Milan System for Reporting Salivary Gland Cytopathology" (MSRSGC) and ascertain the risk of malignancy (ROM) for each category. METHODS: All salivary gland FNACs over 5 years (January 2014-December 2018) were reviewed and assigned a diagnostic category from the MSRSGC. Clinical data were taken from Cytology records. Cytodiagnosis was correlated with histopathology wherever available and ROM was calculated. RESULTS: A total of 120 salivary gland FNACs were studied. Age ranged between 5 and 85 years, male:female ratio was 2:1 and parotid was the commonest gland aspirated. Cases were reclassified as I non-diagnostic (2.5%), II non-neoplastic (15%), III atypia of uncertain significance-AUS (1.7%), IV A neoplasm benign (50%), IV B neoplasm of uncertain malignant potential (12.5%), V suspicious for malignancy (5%), and VI malignant (13.3%). Follow-up was available in 70 (58.3%) cases. The sensitivity, specificity, negative predictive value, and positive predictive value were 92.3%, 100%, 100%, and 98.27% respectively. ROM was non-neoplastic (0%), AUS (50%), neoplasm benign (0%), neoplasm of uncertain malignant potential (28.6%), suspicious for malignancy (100%), and malignant (100%). CONCLUSION: Salivary gland FNAC is a reliable diagnostic tool and the "Milan system" will further increase FNA reliability, help risk stratification, and improve patient care.

Milan System for Reporting Salivary Gland Cytopathology- An Experience from Western Indian Population.

INTRODUCTION: Fine-needle aspiration cytology (FNAC) can be challenging to provide a precise diagnosis in salivary gland cytopathology due to diversity of lesions and cytomorphological convergence between the tumors and within the same tumor of salivary gland. The recently proposed Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) provides a risk stratification-based classification system with an intrinsic risk of malignancy (ROM) for each diagnostic category, which aims to furnish useful information to the clinicians. This study was undertaken to evaluate the diagnostic utility and validity of MSRSGC. METHODS AND MATERIAL: In this retrospective study, FNAC done for all salivary gland lesions over a period of two years were retrieved. All cases were categorized according to MSRSGC and correlated with histopathological follow-up, wherever available. ROM was calculated for each category. RESULTS: The cases belong to following categories: non-diagnostic (1.27%), non-neoplastic (30.38%), atypia of undetermined significance (5.06%), benign neoplasm (46.84%), salivary gland neoplasm of uncertain malignant potential (1.27%), suspicious for malignancy (1.27%), and malignant (13.92%). Out of 79 cases, 50.63% had follow-up. The ROM were 0% for category II and IVa, 50% for category III, and 100% for category IVb, V, and VI. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were recorded as 77.78%, 100%, 100%, 91.3%, and 93.33%, respectively. CONCLUSIONS: Application of MSRSGC has immense value for standardization of reporting of salivary gland FNAC. Our data corresponds to the studies done worldwide and recommends the use of MSRSGC for future diagnostic purposes.

Fibroadenoma versus phyllodes tumor: a vexing problem revisited!

BACKGROUND: Fibroepithelial lesions of the breast include fibroadenoma (FA) and phyllodes tumor (PT). Fibroadenomas are benign while phyllodes tumor range from benign, indolent neoplasms to malignant tumors capable of distant metastasis. Our study was to determine the select cytologic features that can accurately distinguish FA from PT. METHODS: A retrospective review was performed of patients who had histopathology follow up of FA or PT and on whom a pre-operative fine needle aspiration was performed. Cytologic criteria i.e. epithelial component, stromal component and background cellularity were assessed. RESULTS: 46 FA and 24 PT were specimens were reviewed. Median age and tumor size for FA and PT were 23.0 and 39.0 years, and 2.0 and 5.0 cm, respectively. Univariate analysis and regression models based on generalized estimating equations revealed that large opened out, folded epithelial sheets, frayed and irregular stromal fragment contours, spindle stromal cell nuclei, spindle cell nuclei in the background and background cell atypia are significant cytological predictors of PT. The GEE regression model achieved 78.9% diagnostic accuracy (p <  0.001) in identifying PT based on cytological features. Median epithelial: stromal ratio was 3.4 and 2.6 for FA and PT, respectively. CONCLUSION: Presence of large, opened out, folded epithelial sheets, frayed and irregular stromal contours with spindle nuclei, background spindle cells and atypia can help distinguish PT from FA.

Diagnostic utility of urine cytology in detection of decoy cells in renal transplant patients: Report of five cases and review of literature.

BK polyoma virus (PV) is one of the commonest post-transplant viral infections, affecting approximately 15% of renal transplantation recipients, leading to graft failure in more than half of cases. The epithelial cells with polyoma viral inclusions in urine cytology specimens are termed "decoy cells" to caution pathologists not to misdiagnose these cells as cancer cells. The infected cells in urinary sediments are characterized by enlarged nucleus, basophilic intranuclear homogenous inclusions, and ground glass chromatin, which may cause diagnostic error in urine cytology. We report five cases of renal transplant patients, in which urine sample was positive for decoy cells. Routine urine cytology of post renal transplant patients with worsening renal function is a useful screening procedure to rule out PV reactivation, before ascertaining transplant rejection. Its cost-effectiveness in addition to the short processing time makes it an invaluable tool in the evaluation of transplant recipients with symptoms suggestive of graft rejection.

This 'Rose' Has no Thorns-Diagnostic Utility of 'Rapid On-Site Evaluation' (ROSE) in Fine Needle Aspiration Cytology.

Fine needle aspiration (FNA) cytology is a basic diagnostic technique used to investigate superficial and deep swellings. Rapid on-site evaluation (ROSE) using toluidine blue (TB) is easily available, cheap, cost-effective, can be used both for testing adequacy and giving provisional diagnosis. To evaluate the role of ROSE using toluidine blue staining in arriving at a diagnosis in comparison to routine stains. A total of 1500 cases of FNA of palpable swellings from sites like salivary gland, breast, thyroid, lymph node, and soft tissue lesions [non-image guided] during a 9-month period were studied. All the cases were evaluated by ROSE using toluidine blue stain and routine Giemsa/PAP staining. The results were compared in each case. Only 2% cases proved inadequate on TB, Giemsa and PAP combination, commonest site of inadequacy being lymph node. Adequate sample was obtained within two passes in 92.5% cases. The turn-around time (TAT) was 1 day in 96.4% of cases. The average time for making a provisional diagnosis on TB was 3 minutes. There was 99.2% concordance between TB and final cyto-diagnosis. Validity parameters: sensitivity 98%, specificity 100%, positive predictive value 100%, negative predictive value 99.8%, efficacy 99.2% and false negative 1.94%. ROSE using toluidine blue is a reliable means of demonstrating sample adequacy, for making a provisional diagnosis and guiding collection of diagnostic material for microbiology, immunocytochemistry (ICC), cell block and molecular testing etc. The technique is easy enough for general laboratories to incorporate into their routine practice. ROSE can be called as the "frozen section of cytology".

Primary actinomycosis of anterior abdominal wall: A rare occurrence, diagnosed on fine needle aspiration cytology.

Actinomycosis, a chronic suppurative and granulomatous infection, is caused by Actinomyces israeli. The common clinical presentations are cervicofacial, abdominal, and thoracic regions. Abdominal wall actinomycosis following pelvic or intraperitoneal involvement is known, but isolated abdominal wall involvement is extremely rare and can mimic malignancy. We report a case of primary actinomycosis of anterior abdominal wall, diagnosed on fine needle aspiration cytology (FNAC). Identifying fluffy colonies and branching swirling filaments positive for fungal and Gram stain on cytology smears aid correct diagnosis. FNAC is an effective and reliable tool for early diagnosis of actinomycosis. The treatment is centered around antibiotics, and thus it is essential to diagnose accurately and avoid unnecessary surgery.

Cytologic diagnosis of unusual, large multiple cutaneous myxomas in a case of Carney complex.

Cutaneous myxomas are rare benign neoplasms which are frequently associated with Carney complex (CNC). Although more than 500 cases of CNC are reported, there is no literature on cytologic diagnosis of Cutaneous myxomas. An 18-year-old male, with no significant family history, presented with multiple cutaneous swellings, largest measuring 15 cm on the right cheek. He also had spotty skin pigmentations, raised adrenocorticotropic hormone levels and recurrent cardiac myxomas. Fine-needle aspiration cytology from the right cheek and suprapubic swellings revealed paucicellular smears with abundant myxoid material in the background, admixed with fragments of spindle and stellate cells with bland nuclear morphology, and vascular proliferation in few fragments. There was no mitosis, necrosis, or any epithelial element. Hence, diagnosis of cutaneous myxomas in CNC was made which was confirmed on histopathology. This is the first report of cytologic diagnosis of multiple cutaneous myxomas in CNC and the largest cutaneous myxoma reported in literature.

Endoscopic ultrasound guided brush/fine-needle aspiration cytology: A 15-month study.

BACKGROUND: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become increasingly popular for the diagnosis and staging of gastrointestinal diseases and peri-gastrointestinal lesions. The application of FNA/Brush has dramatically expanded the clinical utility of EUS. AIMS AND OBJECTIVE: To evaluate the diagnostic accuracy, study the spectrum of lesions encountered in EUS-FNAC/brush cytology of gastrointestinal and peri-gastrointestinal lesions. MATERIALS AND METHODS: Total of 124 patients during the period from August 2015 to November 2016 was included in the study. Routine staining was done. RESULTS: A total of 124 cases were studied with 86% (107 cases) being satisfactory for evaluation. M:F ratio was 1:1.03, mean age of 50.5 years. The most common site was common bile duct (CBD) (37%) followed by lymph node (21%), pancreas (17.7%), esophagus (17%), stomach (3.5%), liver (1.8%), gallbladder (1%), and spleen (1%). In total, 53.4% lesions were benign, in 6.5% atypical cells were seen, 12.1% were suspicious for malignancy, and 28% cases were positive for malignancy. Follow-up was available in 102 cases with cyto-histopathological concordance rate of 90%. CONCLUSION: EUS-FNA/Brush is a reliable, sensitive, specific and minimally invasive way to establish a diagnosis. It can be utilized as a pre-operative procedure for the management of many intra-abdominal lesions and prevent unnecessary invasive procedures.

Primary cutaneous aspergillosis, mimicking malignancy, a rare presentation in an immunocompetent patient.

Aspergillus species are ubiquitous opportunistic molds that cause both allergic and invasive syndromes. A 65-year-old female, farmer by occupation, presented with left upper limb and trunk swelling for one year, associated with pain, tightening of skin, and vesicles with watery discharge. Local examination showed a diffuse swelling extending from left arm to forearm and lateral chest wall associated with edema, induration, and raised temperature. The swelling was firm to hard with superficial skin ulcers and black eschar. Hematological investigations of the patient showed raised total WBC count and peripheral blood eosinophilia. Patient had no history suggesting immunosuppression. Clinico-radiological impression was left breast carcinoma with secondary skin involvement. fine-needle aspiration cytology (FNAC) from the swelling showed inflammatory cells, necrosis, epitheloid cell granulomas, and giant cells along with branching hyphae of variable thickness, confirmed on Gomori Methenamine Silver stain as fungal hyphae. Culture was advised which identified the species as Aspergillius fumigatus. Primary cutaneous infection by A. fumigatus in an immunocompetent patient is unheard of. FNAC has an important role in resolving diagnostic dilemma in primary cutaneous aspergillosis, which may mimic malignancy as in our case.

Anaplastic large cell lymphoma: A great mimic on cytology.

Anaplastic large cell lymphoma (ALCL) is a T-cell lymphoma, accounting for <5% of non-Hodgkin's lymphoma. Cutaneous involvement can be primary or secondary arising in systemic ALCL. The diagnostic feature in both is the presence of pleomorphic, CD30 positive hallmark cells. We present a case of ALCL in a 19-year-old male presenting as an ulcerated scalp swelling. Clinical impression was actinomycosis or scrofuloderma. Cytology smears showed large dispersed pleomorphic cells with hyperlobated nuclei and multinucleated giant cells. The differentials considered were ALCL, rhabdomyosarcoma, and poorly differentiated carcinoma. Immunocytochemistry (ICC) showed positivity for leukocyte common antigen (LCA) and CD30 while negativity for desmin, favoring ALCL. Computed tomography (CT) showed a lytic paravertebral lesion. Subsequently, both paraspinal and scalp lesions were biopsied and immunochemistry confirmed the diagnosis of ALCL. Thus, cutaneous involvement in ALCL can resemble inflammatory and other neoplastic lesions clinically and cytologically. Hence, a high index of suspicion and ICC can aid in the correct diagnosis on fine needle aspiration cytology (FNAC).

Utility of the Paris System in Reporting Urine Cytology.

OBJECTIVE: To find out the utility of The Paris System (TPS) in reporting urine cytology and to compare it with the reporting system currently used in our laboratory. STUDY DESIGN: This retrospective study was undertaken over a period of 1 year during which slides of all the urine specimens sent for cytological examination were retrieved from our laboratory filling system. They were blindly reviewed and reclassified according to TPS. Surgical follow-up was obtained from the uropathology services of our department. RESULTS: A total of 176 cases were meticulously reviewed. The mean age of the patients was 52 years, and 71% of cases presented with hematuria. Histopathological follow-up was available in 34 cases. Reporting by TPS detected 13.0% high-grade urothelial carcinoma (HGUC) and 5.1% atypical urothelial cells versus 7.3 and 11.9% by the current reporting system, respectively. The sensitivity and diagnostic accuracy for detecting HGUC of TPS were higher than those of our reporting system. CONCLUSION: TPS has increased the rate of detection of HGUC and reduced the rate of reporting "atypical" urothelial cells. TPS has also standardized the diagnostic criteria, thereby bringing uniformity and reproducibility into the system of reporting for urine cytology.

Evaluation of thyroid nodules classified as Bethesda category III on FNAC.

BACKGROUND: The Bethesda (BSRTC) category III has been ascribed a malignancy rate of 5-15%, however, the probability of malignancy remains variable. AIM: To evaluate category III with respect to its rate and risk of malignancy and substratify it. SETTINGS AND DESIGN: Atypia of undetermined significance/Follicular lesion of undetermined significance (AUS/FLUS) percentage, cytohistological correlation, and risk of malignancy were analyzed and substratification was done. MATERIAL AND METHODS: Category III cases over a 2-year period were analyzed retrospectively. STATISTICAL ANALYSIS: Two-tailed Fisher exact test, with a level of significance set at 0.05, was performed for data analysis. RESULTS: Of 1169 thyroid fine needle aspirations (FNAs), 76 (6.5%) were category III. A total of 48 patients had follow up; 24 patients underwent surgery, 12 repeat FNA, and 12 were clinically followed. Repeat FNA cytology was unsatisfactory in 8.3%, benign in 66.7%, AUS in 8.3%, and follicular neoplasm in 16.7%. Of the 24 operated, 8 (33.3%) were malignant (follicular variants of papillary thyroid carcinoma), 5 (20.8%) were follicular adenomas, and 11 (45.8%) were non-neoplastic. Among all AUS/FLUS nodules with follow-up, malignancy was confirmed in 16.7% (8/48) whereas with nodules triaged to surgery only, the malignancy rate was 33.3% (8/24). Substratification into categories of "cannot exclude PTC" and "favor benign" helped detect malignancy better, as 85.7% cases in the first subcategory (P < 0.001) and none (P < 0.02) in the last proved malignant. CONCLUSION: Though the rate of Category III in our study is in accordance to BSRTC, the risk of malignancy in AUS/FLUS nodules is higher. Substratification of AUS/FLUS may help better patient management.