Aetiology of non-diagnostic renal fine-needle aspiration cytologies in a contemporary series.

OBJECTIVES: To determine the aetiology of non-diagnostic renal fine-needle aspiration cytologies (FNACs) in a contemporary series. PATIENTS AND METHODS: We retrospectively reviewed our institutional database of renal FNACs performed between 1995 and 2005. There were 118 patients with renal lesions that underwent FNAC. Indications for FNAC were indeterminate complex renal cysts, significant medical comorbidities, previous history of malignancy, multiple bilateral renal lesions, and suspected metastatic disease. A cytotechnologist was present during the FNA procedure to perform Diff-Quik staining and ensure an adequate sample of cells were obtained. Except for seven (six open, one ultrasound-guided), all of the FNACs were performed with CT guidance. RESULTS: The median (range) number of passes for each FNAC session was 2.7 (1-6). Of the 16 FNACs performed for indeterminate complex renal cysts, nine (56%) were adequate with the cytodiagnosis of benign cysts. Of the seven inadequate specimens, three had benign cysts and another three were non-diagnostic due to acellularity. Therefore, the technical failure rate was 19% (3/16) for indeterminate complex renal cysts. The last patient had a cytodiagnosis of benign cyst and the final histological diagnosis of renal cell carcinoma (RCC; papilllary, grade III). Therefore, this represents a sampling error (false negative rate) of 0.8% (1/118). For the 102 solid renal masses, 22 (22%) had inadequate specimen by Diff-Quik staining. The technical failure rate (inability to obtain sufficient epithelial cells) was 16% (16). In 18 patients, immunocytochemistry (ICC) was used to differentiate primary renal parenchymal tumours from others such as transitional cell carcinoma (TCC), lymphoproliferative, colon, and lung. There were two FNACs with misdiagnosis (2%), where ICC was not used. In both, the cytodiagnosis was TCC and the final histological diagnosis was RCC in one and atypical urothelium in another. CONCLUSIONS: Non-diagnostic renal FNACs can be attributed to misdiagnosis (2%), sampling error (0.8%) and technical failure (16%).

Molecular testing in lung cancer: fine-needle aspiration specimen adequacy and test prioritization prior to the CAP/IASLC/AMP Molecular Testing Guideline publication.

BACKGROUND: Subtyping of lung carcinoma with immunohistochemistry is essential for diagnosis, whereas molecular testing (MT) is required for therapy guidance. In the current study, the authors report on MT performed on fine-needle aspiration specimens at the study institution over a 2-year period preceding the April 2013 College of American Pathologists (CAP)/International Association for the Study of Lung Cancer (IASLC)/Association for Molecular Pathology (AMP) Molecular Testing Guideline (MTG) publication. METHODS: The database of the study institution was retrospectively queried for cases of lung and thoracic/lower cervical lymph node fine-needle aspiration specimens for 2011 through 2012. RESULTS: Of 246 selected cases, 26 featured a limited amount of material in cell blocks. MT increased significantly between 2011 and 2012 and was requested in 39.4% of cases (97 of 246 cases): 86 of those cases had at least 1 MT result and 11 had insufficient material for any MT. Anaplastic lymphoma kinase (ALK) testing was performed in 9 cases in which DNA was insufficient for epidermal growth factor receptor (EGFR) testing. In addition, 13 cases of adenocarcinoma/non-small cell lung carcinoma had at least 1 MT canceled because of insufficient DNA, but at the same time had an average of 3.46 immunohistochemical stains performed. CONCLUSIONS: Of all the cytology specimens, 10.6% featured limited material; however, no universally accepted testing sequence priority was available at the time the study was performed. As per the MTG, MT should take precedence over immunohistochemistry in cases of adenocarcinoma/non-small cell lung carcinoma. Approximately 5.3% of the specimens in the current study had insufficient material for MT while having multiple stains performed instead. The MTG also recommend performing EGFR before ALK testing; the authors found 9 cases with insufficient material for EGFR testing that had ALK testing performed. The results of the current study underscore the need for a testing prioritization algorithm in view of the MTG publication to serve as reference for both clinicians and pathologists.

The role of monitoring interpretive rates, concordance between cytotechnologist and pathologist interpretations before sign-out, and turnaround time in gynecologic cytology quality assurance: findings from the College of American Pathologists Gynecologic Cytopathology Quality Consensus Conference working group 1.

CONTEXT: The College of American Pathologists (CAP) conducted a national survey of gynecologic cytology quality assurance (QA) practices. Experts in gynecologic cytology were asked to join 5 working groups that studied the survey data on different aspects of QA. Evaluating the survey data and follow-up questions online, together with a review of pertinent literature, the working groups developed a series of preliminary statements on good laboratory practices in cytology QA. These were presented at a consensus conference and electronic voting occurred. OBJECTIVE: To evaluate a set of QA monitors in gynecologic cytology. Working group 1 evaluated (1) monitoring interpretive rate categories for Papanicolaou tests (Pap tests), (2) concordance of cytotechnologist and pathologist interpretations before sign-out, and (3) turnaround time for Pap tests. DATA SOURCES: The statements are based on a survey of gynecologic cytology QA practice patterns and of opinions from working group members and consensus conference attendees. CONCLUSIONS: The outcomes of this process demonstrate the current state of practice patterns in gynecologic cytology QA. Monitoring interpretive rates for all Bethesda System categories is potentially useful, and it is most useful to monitor interpretive rates for cytotechnologists individually and in comparison to the entire laboratory. Laboratories need to determine what level of discrepancy between cytotechnologist and pathologist interpretations of Pap tests is important to track. Laboratories should consider formalizing procedures and policies to adjudicate such discrepant interpretations. Turnaround time should be monitored in gynecologic cytology, but individual laboratories should determine how to measure and use turnaround time internally.

Consolidation of the North Shore-LIJ Health System anatomic pathology services: the challenge of subspecialization, operations, quality management, staffing, and education.

OBJECTIVES: To describe our experience, both in meeting challenges and in reporting outcomes, of the consolidation of anatomic pathology services in the North Shore-LIJ Health System in February 2011. METHODS: We addressed issues of governance, personnel, physical plant, quality programming, connectivity, and education. CONCLUSIONS: The highly regulated nature of the laboratory industry and the fact that patient care necessarily never pauses require that such a consolidation take place without a break in service or degradation in turnaround time and quality while engaging personnel at all levels in the extra duties related to consolidation. Subspecialization has allowed us to better meet the needs of our in-system health care community while increasing our access to the competitive outreach marketplace.

Clinical impact of second opinion in thyroid fine needle aspiration cytology (FNAC): A study of 922 interinstitutional consultations.

Interinstitutional consultation in pathology has shown to improve patient safety by detecting interpretive errors that may significantly impact clinical management. We conducted a study of 922 cases of thyroid FNAC slides, referred to our institution over a 2-year period, to assess the magnitude of discrepancies and determine the clinical impact of second opinion. Disagreements were categorized as none, minor or major, the latter two defined as one- or two-step deviations respectively on the NCI diagnostic categories scale. There were 122 disagreements (13%), including 44 major and 78 minor. Seventy-five patients underwent a change in management based on second opinion, in conjunction with clinical and radiologic findings (age, size of nodule, family history, ultrasonographic appearance, and solitary versus multiple nodules). The second opinion was supported on follow-up in 57% of major discrepancies, and the initial diagnosis was concurrent with the surgical diagnosis in 7% cases. The remainder (36%) of major discrepancy cases did not undergo surgery, precluding tissue confirmation. Critics have alleged increased costs due to interinstitutional consultations. However, cost avoidance from lost wages, potential surgical complications, and litigation is not easily quantified. Using a simplified calculation to objectively measure the costs associated with changed diagnoses, we estimate that second opinion of these 922 cases resulted in potential cost saving of $940,166 based on current Medicare reimbursement codes. Our study indicates the need for a quality-control program of outside thyroid FNA slides, especially in "high discrepancy categories" as discussed in the article.

Endobronchial ultrasound-guided transbronchial needle aspirate (EBUS-TBNA): a proposal for on-site adequacy criteria.

This is a retrospective study of 48 patients who underwent EBUS-TBNA procedure between the periods January 2008 to September 2009 at Long Island Jewish Medical Center. The study was undertaken with the following objectives: First, to define practical and useful on-site adequacy criteria for EBUS-TBNA samples; Second, to understand the diagnostic pitfalls associated with accurate interpretation of EBUS-TBNA samples. EBUS-TBNA procedure was able to diagnose 24/48 (50%) patients with malignancy, 1/48 (2%) suspicious for malignancy, 9/48 (19%) with granulomatous process, and 9/48 (19%) negative for disease. Only five cases (10%) could not be diagnosed with this procedure. Based on our experience, any smear with presence of > 5 low power fields (×100) with ≥ 100 lymphocytes in each and containing < 2 groups of bronchial cells/low power field (×100) can be considered adequate for evaluation. Also, the presence of germinal center fragments renders a smear adequate for evaluation, irrespective of the above mentioned criteria. Adequacy criteria are to be applied only to the smears not showing any identifiable pathology such as malignancy or granuloma. An understanding of diagnostic pitfalls associated with accurate interpretation of EBUS-TBNA samples is essential to avoid false-positive and false-negative diagnosis. To conclude, an effective communication between the clinician and cytologist, an algorithmic approach to diagnosis, and the on-site adequacy criteria proposed in this study can markedly improve the diagnostic yield of the procedure.

Monophasic parapharyngeal synovial sarcoma diagnosed by cytology, immunocytochemistry, and molecular pathology: case report and review of the literature.

Synovial sarcoma (SS) of the head and neck region are rare, accounting for less than 10% of all head and neck soft tissue sarcomas. A limited number of SS have been reported in the parapharyngeal space and these reports have all been based on histological examination of resection material. The diagnosis of monophasic SS on cytology is extremely difficult. We report the first case where a SS was correctly diagnosed on a fine needle aspirate by cytology with the assistance of immunocytochemistry and fluorescence in situ hybridization. We will emphasize the importance of ancillary techniques, such as immunocytochemistry and cytogenetic/molecular pathology, in avoiding diagnostic pitfalls and correctly diagnosing monophasic SS on cytologic material. We will propose an algorithmic approach to accurately diagnose parapharyngeal spindle cell neoplasms with the use of appropriate ancillary studies in conjunction to morphological features.

Thyroid fine-needle aspiration with atypia of undetermined significance: a necessary or optional category?

BACKGROUND: Atypia of undetermined significance is a controversial category in thyroid fine-needle aspiration (FNA), not only for its questioned clinical utility, but also for its very existence as an expression of uncertainty. The current study was performed to investigate the potential impact of eliminating this category on the sensitivity and specificity for detecting thyroid neoplasms by FNA. METHODS: Forty cases originally diagnosed as atypia of undetermined significance with histologic follow-up were selected for the present study. These cases were reinterpreted blindly by 2 experienced reviewers, who eliminated atypia of undetermined significance as a diagnostic possibility and reclassified these cases as either benign, follicular neoplasm, suspicious for malignancy, or malignant. Twenty-six cases of atypia of undetermined significance were randomly selected and reevaluated 6 months later to study intraobserver variation. RESULTS: After eliminating the atypia of undetermined significance category, the sensitivity for detecting papillary thyroid carcinoma (PTC) was reduced from 100% to 27% (P = .04). In those atypia of undetermined significance cases that were reclassified as benign, 37% had PTC. In those reclassified as follicular neoplasm or suspicious for malignancy, 38% were histologically proven to be benign lesions. Unanimous interobserver and intraobserver agreement was observed in only 60% of cases. CONCLUSIONS: Eliminating the diagnosis of atypia of undetermined significance substantially decreases the sensitivity of thyroid FNAs and increases both false-positive and false-negative rates. In addition, it increases interobserver and intraobserver variability. Therefore, the atypia of undetermined significance category should not be eliminated; but we advocate minimizing its use.

Number of needle passes does not correlate with the diagnostic yield of renal fine needle aspiration cytology.

BACKGROUND AND PURPOSE: Renal Fine Needle Aspiration Cytology (FNAC) has gained popularity due to increasing options in management of renal lesions such as energy ablation and active surveillance. The diagnostic yield of renal FNAC varies between 40-90%. We hypothesized that adequate and diagnostic FNA samples would be associated with higher number of needle passes and higher number of slides examined. PATIENTS AND METHODS: The pathology database at our institution was retrospectively searched for renal FNACs performed between 1995 and 2005. Patient gender, side, indication, cytological diagnosis, final histological diagnosis when available, number of needle passes performed, number of slides examined, and adequacy of the FNAC sample as determined by Diff Quik staining by the cytotechnologist (CS) were recorded. Chi square test was performed for statistical analysis. RESULTS: Out of 377 renal biopsies performed, 259 were core biopsies for medical renal disease, and 118 were FNACs for renal lesions, including 16 for indeterminate complex renal cysts and 102 for solid renal masses. Indeterminate renal cysts were excluded from the study. Out of 102 FNACs for solid renal masses, 22 were inadequate with 13 (59%) being non-diagnostic; and 80 FNACs were adequate with 3 (4%) being non-diagnostic. The number of needle passes was not significantly different between non-diagnostic and diagnostic samples (2.5 vs 3.2); and between inadequate and adequate samples (3.4 vs 3.0). Similarly, the number of slides examined was not significantly different between non-diagnostic and diagnostic samples (9.5 vs 10.9); and between inadequate and adequate samples (11.3 vs 10.6). Diff Quik adequate samples had significantly higher diagnostic yields when compared to Diff Quik inadequate samples (965 vs 41%; p<0.01). CONCLUSIONS: The number of needle passes and microscopic slides examined did not correlate with sample adequacy or diagnostic yield of renal FNAC. Sample adequacy as determined by Diff Quik staining correlated with diagnostic FNAC. Despite the retrospective nature of this study, a cytotechnologist should be present during the FNA procedure to ensure adequate samples have been obtained to increase the diagnostic yield of renal FNAC.