Diagnostic pitfalls in fine-needle aspiration cytology of temporomandibular chondroblastoma: report of two cases.

Chondroblastoma is a benign bone neoplasm, which usually presents in the epiphysis of long bones, but can occur in unusual locations. This report describes the clinical, radiologic, and cytologic features on FNA of two chondroblastomas of the temporomandibular region that were only recognized by histopathologic study. This emphasizes the diagnostic pitfalls of this entity and expands the cytologic differential diagnosis of tumors of the parotid region.

Fine needle aspiration biopsy. Applications in the diagnosis of lymphoproliferative diseases.

A review of fine needle aspiration biopsies of lymph nodes was performed to determine accuracy and reproducibility among observers for the diagnosis of malignant lymphomas and lymphoproliferative diseases and to identify problem areas in the diagnosis of lymphomas and lymphoproliferative diseases by this biopsy method. Not including cases of carcinoma, 85% of the lymphomas and lymphoproliferative processes were correctly identified by seven of eight observations from a blind review without clinical information. Four problem areas in diagnosis from aspirates were identified: (a) distinction of lymphoid hyperplasia from non-Hodgkin's lymphoma by relying significantly on polymorphism versus monomorphism of the smear pattern; (b) separating undifferentiated carcinoma from large cell lymphoma; (c) overinterpreting extensive lymphoid polymorphism as Hodgkin's disease; and (d) diagnosing some aspirates of granulomatous lymphadenopathy, viral infection, or nodes with extensive necrosis as Hodgkin's disease. From the analysis of this series, a programmed approach was developed for diagnosing lymph node aspirates. History, physical examination, correct performance of the aspiration biopsy, and proper handling of the specimen are the four basic elements. Microscopic evaluation includes assessment of overall cellularity, pattern of cell arrangement, identification of predominant cell type, and background elements.

Needle aspiration biopsy: past, present, and future.

Since its inception more than 50 years ago at Memorial Hospital for Cancer (New York), needle aspiration biopsy has traveled to its present popularity over a torturous road. The early influence of Stewart on the interpretation of aspiration smears and the use of this biopsy method is still worthy of review, particularly the importance of close cooperation between clinician and pathologist. While cytology has been profoundly influenced by individual cell interpretation as practiced by Papanicolaou, it is really pattern recognition that dominates successful diagnosis by the aspiration biopsy smear method. Present concerns over technical variation in procurement of the biopsy and staining methods should be of less importance than identification of the aspiration methodology that produces the best-quality microscopic image. Reliability of diagnosis by aspiration smear must also be judged by a suitable and reproducible standard, something that is not necessarily fulfilled by tissue pathology, although many would believe otherwise. The author proposes that aspiration may also now be judged, like tissue pathology, by clinical outcome. The application and ease of procuring cell samples from tumors for cell image analysis, for flow cytometry and ploidy studies, and for gene rearrangement place this biopsy method in the forefront of the integration of biologic research and clinical medicine. Aspiration biopsy has caused us to explore how the human eye and brain analyze microscopic images and may even assist in the design of useful artificial intelligence diagnostic systems in the future.

Metachronous soft-tissue masses in children and young adults with cancer: correlation of histology and aspiration cytology.

We describe a series of 28 fine needle aspiration biopsies (FNAB) of soft tissue from 22 patients. Four patients had two separate FNABs, and one had three aspiration procedures. The patient population was limited to children and young adults (age range, 2 months to 29 years; mean, 16 years) who were known to have diverse forms of cancer, and who subsequently developed a mass in the peripheral soft tissues (including breast). The interval between the time of diagnosis of the primary malignant neoplasm and FNAB ranged from 1 day to 17 years (mean, 39 months). All FNAB diagnoses were confirmed by subsequent surgical open biopsy or clinical follow-up greater than 1 year. No complications occurred from the procedure. The cytomorphology is presented in selected cases and correlated with the patient's original tissue histopathology. Twenty aspirates were diagnosed as cytologically malignant, one as suspicious for malignancy. Seven were considered benign. None were unsatisfactory. One false-positive and no false-negative cytologic diagnoses were obtained. The overall accuracy of FNAB diagnoses was 96%, while sensitivity was 100% and specificity 88%. Sites of aspiration included soft tissues of the head and neck (seven cases), trunk (eight cases), breast (four cases), and extremities (nine cases). Malignant cytologic diagnoses included sarcoma (thirteen), seminoma (two), lymphoma/leukemia (two), melanoma (one), undifferentiated neoplasm (one), and neuroblastoma (one). Electron microscopy of aspirated cells was used to confirm the diagnosis in two cases. Fine needle aspiration biopsy of soft tissue masses from children and young adults with cancer demonstrates a high diagnostic accuracy, and its use is justified in this population.

Application of fine needle aspiration biopsy to pediatrics.

Fine needle aspiration (FNA) biopsy cytology is a technique rarely used in children, although it is increasingly used in a routine fashion for the evaluation of masses in adults. We reviewed our experience with FNA in patients 16 years of age and younger from the period 1973 to 1987. FNA diagnoses were confirmed either by subsequent surgical biopsy, autopsy, or clinical follow-up for a minimum period of 1 year. One-hundred twelve FNA procedures were performed in 107 patients. Patient age distribution was as follows: newborn to 5 years of age, 37 aspirates; 6 to 11 years of age, 39 aspirates; and 12 to 16 years of age, 36 aspirates. Fifty-five patients were female. Of the 112 aspirates, 70 were diagnosed as benign disorders, 39 were diagnosed as malignant, one was diagnosed as unsatisfactory, and two were considered suspicious for malignancy. The most common sites of involvement for benign lesions were lymph node (31 sites), soft tissue (13 sites), and thyroid (12 sites). The most common sites for malignancies were lymph node (12 sites), bone (eight sites), and soft tissue (eight sites). Of the malignant aspirates, 20 were from primary neoplasms, three were from locally recurrent neoplasms, and 16 were from metastatic neoplasms. Two false-positive and one false-negative diagnoses yielded sensitivity and specificity rates of 97%, and a predictive value of a positive FNA of 95%. Our experience indicates that selective application of FNA is a useful and important step in the evaluation and management of mass lesions throughout the entire age range of infancy and childhood.

Role of intraoperative cytopathology in pediatric surgical pathology.

Studies regarding the efficacy of intraoperative cytopathology (IOC) of surgical specimens in the pediatric population are almost non-existent, despite their recent popularity in adults. To determine the utility of IOC in children, we examined 58 cases from 54 pediatric patients (neonate to 18 years of age) who had cytologic smears performed in addition to or instead of frozen section (FS) examination during their surgical procedure. Knowing only the patient's age, sex, anatomic site, and any pertinent radiographic or historic data, three pathologists independently reviewed and issued a diagnosis using only the IOC smears. Subsequently, in 28 cases that also had accompanying FS examination, both IOC and FS analysis were interpreted for a composite final diagnosis. Three cases were judged unsatisfactory because of sparse cellularity of smears. Correct classification of the smears as being benign or malignant for each pathologist was 98%, 94%, and 94% using IOC alone and 98%, 94%, and 96% using combined IOC and FS examination. The most frequent anatomic sites were bone (15 cases) and lymph node (14 cases). The most common diagnoses were malignant small round cell tumor (22 cases) and benign lymphoid tissue (10 cases). The records of all 55 cases were reviewed in the second phase of our study. Twenty-seven cases (49%) were found in which IOC diagnoses were rendered without a concurrent FS examination. These were correctly interpreted in 26 of 27 cases (96%) in the determination of a benign versus malignant disease process. The tissue sample measured < or = 2 cm in 15 of 27 cases (56%) in this latter group. Intraoperative cytopathology diagnoses in this group were rendered by various faculty members on call for FS examination and, in some cases, by fifth-year residents with faculty supervision. Without minimizing the degree of difficulty in the interpretation of pediatric IOC, we conclude that it serves as a useful supplement in FS diagnosis and, in some situations (particularly when tissue is limited), can replace histologic FS examination.

Distribution of human papillomavirus types in genital lesions from two temporally distinct populations determined by in situ hybridization.

We examined 341 paraffin-embedded cervical tissues for human papillomavirus (HPV) DNA by in situ hybridization. The genital lesions examined represented tissue biopsies from two temporally distinct populations (1964 to 1965 and 1988 to 1989). Biotinylated probes to 14 different HPV types were used in our analysis: HPV types 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56. The number of HPV DNA-positive specimens and the distributions of HPV types were similar for these two populations. Human papillomavirus DNA sequences were detected in approximately 50% of the tissues from each time period. Of the low-grade lesions (condyloma/cervical intraepithelial neoplasia 1 [CIN 1]) 52% (1964 to 1965) and 35% (1988 to 1989) were positive for HPV DNA by in situ hybridization. Among the high-grade lesions (CIN 2/CIN 3), 41% (1964 to 1965) and 67% (1988 to 1989) had detectable HPV sequences. Approximately 15% of the tissues with minimal histopathologic changes also contained HPV DNA. Human papillomavirus types 16 and/or 18 were the most common viral types in lesions from both time periods, followed by types 31/33/35; 6/11, 51/52; and 42/43/44, 45/46. Types 16 and/or 18 were strongly associated with high-grade lesions. Five percent of the HPV-positive lesions demonstrated evidence of multiple infections. Our results indicate that HPV DNA sequences can be detected readily by in situ hybridization in archival materials, even those prepared more than 25 years ago. In addition, analysis of HPV type distributions demonstrates that recently isolated HPV types (42, 43, 44, 45, 51, 52, and 56) were equally represented in tissues from both time periods.

Thin-needle aspiration biopsy. A personal experience with 469 cases.

The thin-needle aspiration biopsy technic was used in 469 cases to diagnose benign and malignant tumors. The success of the technic depends upon careful examination of the lesion to be biopsied and attention to the details outlined in procuring the aspiration material and preparing the smears. The most important technical consideration is creating a simulated tissue pattern in the preparation of the smears. Routine Papanicolaou, May-Grünwald-Giemsa, metachrome B, and hematoxylin and eosin stains are all useful. Special stains may provide additional evidence for specific diagnoses. Lymph nodes were the most common tissue examined by aspiration biopsy in this series. It was possible to identify the primary tumor site from the aspiration smear in most of the cases. Forty-seven breast cancers were identified from 127 aspiration biopsies of breast lumps. Breast aspirations are the most difficult to interpret, and no deviation from classic malignant smears should be attempted. The false-negative rate for breast aspirations was 7.0%. No delay in treatment occurred because of a false-negative report. Patient acceptance of the procedure was excellent.

History of the Association of Directors of Anatomic and Surgical Pathology.

The Association of Director of Anatomic and Surgical Pathology formed its earliest roots in 1989. It has now grown to nearly 200 members. The history of that growth and the activities of the associations are herein described.

Fine-needle aspiration biopsy cytology of giant-cell tumor of tendon sheath.

Localized nodular tenosynovitis, better known as giant-cell tumor of tendon sheath (GCTTS), is a common neoplasm that has a peak incidence in the fourth to sixth decades of life. Few reports exist elucidating the cytologic features of this lesion obtained by fine-needle aspiration biopsy (FNAB). The authors describe five patients, aged 8-50 years, in whom GCTTS was diagnosed by FNAB cytology. In four of the patients, the lesion was excised, and the FNAB diagnosis of GCTTS was confirmed; surgical excision is pending in one patient. A diagnosis of malignancy was not suggested in any of the patients. The tumors were .7-5 cm in greatest dimension. In two patients, GCTTS affected the ankle; the hand was affected in the other three. Aspiration smears were cellular in four cases. All but one case contained several multinucleate osteoclast-type giant cells; in addition, binucleate cells were common. The nongiant cell population was dispersed principally as single cells that had a cytologic appearance mimicking histiocytes and osteoblasts. Anisonucleosis was minimal, and nuclear pleomorphism was distinctly absent in both single and multinucleate cells. Mitotic figures were infrequent, except in one case. The diagnosis of GCTTS can be made or at least strongly suggested using FNAB when the cytologic and clinical features are combined.

Breast carcinoma with osseous metaplasia: an electron microscopic study.

A breast carcinoma containing osseous metaplasia was examined with electron microscopy. The heterologous components were intermingled closely with the usual infiltrating ductal type of a breast carcinoma. Ultrastructurally, carcinoma cells were distinguished clearly from the various mesenchymal cells composed of active fibroblasts, osteoblasts, and osteoclasts. No intermediate cells were present between the two distinct cell populations. Our findings are consistent with the stromal cell origin of the heterologous components and are discussed with relation to their histogenesis in breast carcinoma.

"Tree-barking" of the ascending aorta. Syphilis or systemic lupus erythematosus?

A case of unsuspected classical aortitis with "tree-barking" of the ascending aorta in a young woman with systemic lupus erythematosus and inconclusive syphilitic serologic results is presented. At autopsy, no definite diagnostic clues as to syphilitic or lupic aortitis could be obtained. Although infrequent today, the possibility of complicated cardiovascular syphilis still should be considered. Involvement of the ascending aorta by other systemic diseases is well known and can imitate syphilitic aortitis. Although the possibility of two concomitant diseases cannot be ruled out, the young age of the patient, the weak syphilitic serologic result, and active systemic lupus erythematosus demonstrated in other organs favor a diagnosis of lupic aortitis of the ascending aorta.

Cryptococcal endophthalmitis: diagnostic vitreous aspiration cytology.

A case of cryptococcal endophthalmitis diagnosed by vitreous aspiration membrane filtration cytology is presented. Interest lies in its being the first such diagnosis reported by vitreous aspiration. This case also illustrates the usefulness of combining membrane filtration cytology with the mucicarmine stain for identification of the cryptococcal capsular mucin.

Fine-needle aspiration effects on benign lymph node histology.

The histology of 28 lymph nodes with benign hyperplasia were assessed for evidence of the effects of fine-needle aspiration prior to biopsy. Only 43% of the lymph nodes showed evidence of prior aspiration. This consisted of needle tracts occupying less than 5% of any one section in ten cases, and 10% in two cases. In none of the 28 lymph nodes did prior fine-needle aspiration interfere with the histologic evaluation. The authors conclude that fine-needle aspiration does not interfere with subsequent histologic evaluation of lymph-adenopathy.

Aspiration cytopathology of malignant melanoma in children. A morphologic spectrum.

Malignant melanoma (MM) is an uncommon neoplasm in the practice of pediatric cytopathology. The clinical and morphologic features of three white children with this neoplasm diagnosed by fine needle aspiration biopsy are described. All cytologic diagnoses were subsequently confirmed histologically. Two children were 16 years old and one was 9 years old. Two patients had metastatic MM to head and neck lymph nodes. In one of these children, a prior diagnosis of MM was known, whereas in the other it was unsuspected. A primary melanoma of the iris developed in the third child. The cytopathology of these children are similar to that described in adults. With the cytologic similarities, some striking differences were seen. Principal among these was the abundance of melanin in one case, its uneveness in another, and its absence in a third. The variation in individual cell morphology among the three cases is also described. Malignant melanoma is a rare neoplasm of children that can be recognized by fine-needle aspiration cytopathology.

Hodgkin's disease: diagnosis by fine-needle aspiration biopsy. Analysis of cytologic criteria from a selected series.

Two hundred thirteen cases in which a lymph node aspirate and subsequent surgical biopsy had been performed were studied independently by four observers. Each observer attempted to discriminate involvement by Hodgkin's disease from involvement by other processes. The material included 18 cases of histologically confirmed Hodgkin's disease. The remaining 195 cases included a wide range of pathologic processes. All four observers were able to distinguish Hodgkin's disease from other processes in the great majority of cases. Two observers reviewed the aspirate material from the 18 cases of Hodgkin's disease to determine the presence and significance of elements known to characterize this disease, i.e., multinuclear and mononuclear Reed-Sternberg cells, polyploidal cells, granulomatous elements, metachromatic material, necrosis, eosinophils, neutrophils, and plasma cells. Reed-Sternberg cells were present in most but not all cases. Reed-Sternberg-like cells also were occasionally encountered in other processes. Polyploidal cells were invariably present and were useful in recognizing the disease. Granulomatous elements, metachromatic material, necrosis, eosinophils, and neutrophils were frequently present and, while not specific for the process, helped to draw attention to or substantiate the diagnosis of Hodgkin's disease.

Comparison of the clinic microscopy laboratory with the cytopathology laboratory in the detection of malignant cells in body fluids.

The clinical microscopy (fluids) laboratory evaluates almost every body fluid that is obtained in the hospital. Because the fluids laboratory functions at all hours, it is often the first laboratory to receive a body fluid. In addition to its primary purpose of quantitating categories of cells, the medical technologist in this laboratory has an opportunity to identify malignant cells. To our knowledge, no formal study has ever been undertaken to evaluate the performance of the fluids laboratory in detecting malignancy. The authors therefore retrospectively identified 928 body fluids (pleural, peritoneal, cerebrospinal, and miscellaneous) over a 2-year period that had undergone simultaneous cytologic examination in our cytopathology laboratory and body fluid analysis in our fluids laboratory. Of these, a cytologic diagnosis of malignancy was made by the cytopathology laboratory in 107 cases; 821 were considered to be benign. No false-positive results were rendered by the fluids laboratory (100% specificity), but only 26 of the 107 malignant cases were identified (24% sensitivity); the overall accuracy was 93%. Factors contributing to the inability of the fluids laboratory to identify malignant cells included (1) too few cells to warrant a cytocentrifuge preparation, especially in cerebrospinal fluid specimens; (2) differences in the processing of specimens; (3) differences in staining procedures; and (4) differences in the training of personnel. The authors conclude that although the fluids laboratory correctly identifies neoplastic cells in approximately one fourth of the cases in which they are present, it should not be expected to detect malignant cells in every cytologically malignant case.(ABSTRACT TRUNCATED AT 250 WORDS)

Dendritic reticulum cells and immunophenotype in aspiration biopsies of lymph nodes. Value in the subclassification of non-Hodgkin's lymphomas.

Twenty-seven lymph node aspirates were identified for which histologic confirmation of non-Hodgkin's lymphoma was subsequently obtained. Fifteen aspirates interpreted as reactive hyperplasia were also examined. All aspirates were studied by immunoperoxidase on cytospin preparations with the use of antibodies DRC1, kappa, lambda, CD3, CD5, and CD20. The follicular lymphomas could not be identified reliably by morphologic examination of aspirate smears. Clusters of DRC1-positive (DRC1+) cells were present in seven of seven follicular lymphomas, one of one mantle zone lymphoma, and one of seven small lymphocytic lymphomas. Rare DRC1+ cells were present in one of one diffuse mixed and one of seven large cell lymphomas. One lymphoblastic, one Burkitt's, and two diffuse small cleaved cell lymphomas had no DRC1+ cells. None of the seven follicular lymphomas was CD5 positive (CD5+), whereas five of the seven small lymphocytic lymphomas were CD5+. Conversely, all seven follicular lymphomas were CD20-positive (CD20+), but only one of seven small lymphocytic lymphomas was CD20+. Nineteen of the lymphomas, including all 7 of the follicular lymphomas, were either kappa or lambda positive. The other eight lymphomas were T-cell (1), B-cell (1), true histiocytic (1), or "null" cell (5). The reactive aspirates had both kappa- and lambda-positive B-cells. Seven of the 15 had clusters of DRC1+ cells. To further evaluate these antibodies, the authors studied 29 additional, surgically biopsied, non-Hodgkin's lymphomas that had not been aspirated. Similar results were obtained, except that three of five diffuse small cleaved cell lymphomas had DRC1+ cells. DRC1, in conjunction with antibodies to CD5, CD20, kappa, and lambda, helps to distinguish follicular lymphoma from small lymphocytic lymphoma. DRC1 is not useful in separating reactive hyperplasia from follicular lymphoma.

Lymphoglandular bodies in fine-needle aspiration cytology smears.

Lymphoglandular bodies (hyaline bodies or lymphoid globules), when found in cytology smears from fine-needle aspirates, have long been accepted as being diagnostic of lymphoid tissue. To investigate the validity of this association as it relates to malignant tumors, we examined cytologic smears from 132 fine-needle aspirates of malignant neoplasms. Three experienced observers independently scored Diff-Quik-stained smears as to cellularity and number and size of lymphoglandular bodies. Discrepancies were resolved by consensus. Results of the fine-needle aspiration biopsies revealed 6 of 104 nonlymphoid malignancies with easily identifiable lymphoglandular bodies (defined as > 2 lymphoglandular bodies per high-power field) and 3 with numerous lymphoglandular bodies (> 10 per high-power field). These tumors consisted of two cases of small-cell carcinoma, four non-small-cell carcinomas, one ganglioneuroblastoma, one melanoma, and one seminoma. The tumors had few, if any, lymphocytes. Of the 28 lymphomas, 5 had easily identifiable lymphoglandular bodies and 19 had numerous lymphoglandular bodies. Although lymphoglandular bodies in the background of cytologic smears taken from malignant tumors are useful in alerting the pathologist to the possibility of lymphoma, there are exceptions.

Fine-needle aspiration biopsy of the mediastinum. A multi-institutional analysis.

The combined experience of four university medical centers with fine-needle aspiration biopsy (FNAB) of the mediastinum is reviewed. This series includes 189 cases, with 100 males and 89 females, 6 months to 86 years of age. The majority (71%) of diagnoses were neoplastic with the remainder equally distributed between nondiagnostic/unsatisfactory and nonneoplastic lesions. Malignant lymphoma and thymoma were the most frequent primary malignancies. Metastatic tumors represented the majority (60%) of neoplasms identified by FNAB. In 16% of these cases, the primary tumor was not identified. The majority (67%) of metastases were from the lung and were predominantly small cell type (52%). Sixty-six ancillary tests were performed on 51 cases (27%). Histologic correlation was available in 78 of 189 (41%) cases, with a diagnostic sensitivity and specificity of 87% to 88% for the detection of neoplasm and 82% to 83% for distinguishing benign from malignant disease. The positive predictive value for the presence of neoplasm was 97% with three cytologic false positives identified. This series is the largest to date on the utility of FNAB for lesions of the mediastinum.