Fine-Needle Aspiration Biopsy in the Diagnosis and Classification of Primary and Recurrent Lymphoma: A Retrospective Analysis of the Utility of Cytomorphology and Flow Cytometry

Rapid detection of the t(11;14) translocation in mantle cell lymphoma by interphase fluorescence in situ hybridization on archival cytopathologic material

BACKGROUND

The cytomorphologic diagnosis of mantle cell lymphoma (MCL) can be difficult and requires ancillary studies for accurate subclassification. More than 95% of MCLs are known to carry the t(11;14) chromosomal translocation. However, traditional cytogenetic studies on cytologic material can be both difficult technically and time consuming. Interphase fluorescence in situ hybridization (FISH) can be a powerful tool for detecting chromosomal changes in individual tumor cells. The authors evaluated the utility of interphase FISH for the rapid detection of t(11;14) in archival cytologic material.

METHODS

The cytopathology data bases at two institutions were searched for patients with well characterized MCL (biopsy, immunophenotyping). Ten patients with MCL (8 fine-needle aspiration samples and 2 body cavity fluid samples) were identified. The area of interest on the cytology slides was marked and hybridized with two-color, locus-specific identifier DNA probes. A dual-fusion probe signal was used to detect the juxtaposition of the immunoglobulin heavy-chain (IgH) (14q32) locus with cyclin D1 (CCND1) gene sequences (11q13). Samples with tumor cell nuclei that showed at least one yellow fusion signal in addition one green signal (IgH) and one orange signal (CCND1) were interpreted as positive. Positive and negative controls were used.

RESULTS

The t(11;14) translocation was detected by FISH in 10 of 10 patients (100%) with MCL.

CONCLUSIONS

The cytomorphology of small-to-intermediate cell lymphomas, including MCL, follicular lymphoma, and marginal zone/mucosa-associated lymphoid tissue lymphoma, can show overlapping cytomorphologic features with one another as well as with reactive lymphoid proliferations. In selected samples in which specific classification is not possible or when confirmation is required on a small sample size, molecular analysis and cytogenetics may be helpful in arriving at an unambiguous cytodiagnosis and subclassification. Distinction of MCL from other lymphomas is important, because the clinical course is aggressive, and response to conventional chemotherapy is poor. This study showed that the detection of t(11;14) by FISH can be performed rapidly and easily on archival cytologic material for the molecular diagnosis of MCL.

Role of fine-needle aspiration cytology in breast lymphoma

Lymphomas of the breast are rare and may mimic carcinoma clinically. We investigated the ability of fine-needle aspiration (FNA) biopsy combined with adjunctive flow cytometry (FC), immunofluorescence microscopy (IFM), and immunocytochemistry (ICH) to diagnose and eventually subclassify lymphomas of the breast according to the Revised European American Lymphoma/World Health Organization classification. We retrieved 21 breast aspirates from 19 patients with a cytologic diagnosis of lymphoma or plasmacytoma over a 10-year period (1992-2002), excluding 98 benign intramammary lymph nodes and 1 atypical lymphohistiocytic proliferation (Rosai Dorfman disease). FC was performed in 15/21 aspirates, IFM in 1/21, ICH in 3/21. Histologic follow-up (HF) was obtained for 10 patients, most of them with primary lymphoma. For the remaining nine patients without HF, flow cytometric analysis, comparative morphology, or remission after chemotherapy regimens supported the cytologic diagnosis. Of 19 patients, 11 patients had a secondary lymphoma (SL) and 8 patients had a primary lymphoma (PL). FNA and FC/IFM/ICH classified 7/8 PLs as B-cell lymphomas and 1/8 PLs as plasmacytoma. However, FNA could only subclassify 3 of 8 PLs. FNA and/or FC subclassified accurately 10/11 SLs. All cases were accurately immunophenotyped as B-, T-cell non-Hodgkin's lymphomas or plasmacytoma. World Health Organization classification was achieved in 3/8 PLs (42%) and 10/11 SLs (91%; P = 0.04). Subclassification (which has an impact on long-term management and prognosis) was significantly better in SL, when a previous histologic diagnosis had already been made, when compared to PL, of which 5/8 cases (62.5%) could not be accurately classified.

CD56 expression of neuroendocrine neoplasms on immunophenotyping by flow cytometry: a novel diagnostic approach to fine-needle aspiration biopsy

BACKGROUND

CD56 antigen or NCAM (neural cell adhesion molecule) has an established role in the diagnosis of non-Hodgkin lymphoma (NHL)-natural killer cell type and other hematologic malignancies. Therefore, it is included routinely in the panel of antibodies for flow cytometric (FC) analysis of suspected lymphomatous tissue specimens obtained from fine-needle aspiration biopsy (FNAB). The authors evaluated the role of CD56 expression on FC of neuroendocrine (NE) tumors. An initial diagnosis of NHL was suspected based on an on-site FNAB evaluation.

METHODS

Ten FNABs were identified from the cytopathology files at The Johns Hopkins Hospital, Baltimore, MD (2000-2001). Flow cytometric analysis was negative for NHL but revealed a CD56-positive nonlymphoid cell population. An FNAB evaluation was performed on air-dried Diff-Quik-stained smears and FC analysis used a fixed panel of 12 antibodies (B-cell markers, T-cell markers, CD33, CD56, and CD71). Immunoperoxidase staining (IPOX) was performed on the cell block sections from four of the tissue specimens using epithelial and NE markers, CD56, desmin, and O13 antibodies. Sites of FNAB included the lung (five cases), liver (one case), lymph node (three cases), and peritoneum (one case). Only one patient had a history of cancer at the time of FNAB.

RESULTS

All cytologic diagnoses were confirmed by histopathologic follow-up on resection or biopsy or both. Diagnoses included small cell carcinoma (eight cases), Merkel cell carcinoma (one case), and primitive neuroectodermal tumor/Ewing sarcoma (one case). All tissue specimens that underwent IPOX stained strongly with NE markers, with one tissue section staining only with O13.

CONCLUSIONS

CD56 expression by FC in the presence of negative immunostaining with lymphoid markers represented a unique yet highly specific method for the diagnosis of NE tumors by FNAB. This procedure eliminated the need for further IPOX studies on the already limited cytologic sample and provided a timely and accurate diagnosis.

Cytologic findings of marginal zone lymphoma

BACKGROUND

Low-grade lymphomas can be difficult to diagnose in cytology specimens, especially marginal zone B-cell lymphomas (MZLs). MZL is a low-grade lymphoma characterized by a heterogeneous lymphoid population, which can be difficult to distinguish from reactive processes in cytology specimens.

METHODS

Fourteen cytology specimens of MZL from 11 patients with histologically confirmed MZL (n = 10) or flow cytometry (FC)-confirmed MZL (n = 1) were reviewed, including 13 fine-needle aspiration biopsy (FNAB) specimens (salivary gland, n = 6; lung, n = 3; lymph node, n = 2; breast, n = 1; and soft tissue, n = 1) and 1 pleural effusion specimen. Cytologic preparations included air-dried and alcohol-fixed direct smears, ThinPrep(R) slides, and cell blocks. FC studies were available in six specimens.

RESULTS

All 13 FNAB specimens were composed predominantly of intermediate-sized lymphoid cells with interspersed small, round lymphocytes and transformed cells. The intermediate-sized cells displayed a moderate amount of cytoplasm, slight nuclear membrane irregularities, and inconspicuous-to-absent nucleoli. The pleural fluid contained mostly small-to-intermediate-sized, round lymphocytes. In 10 specimens, the intermediate-sized cells often showed plasmacytoid morphology, which were seen best in Diff-Quik (Mercedes Scientific Co., Inc., Sarasota, FL)-stained slides. Monocytoid cells (n = 6 specimens), plasma cells (n = 7), lymphohistiocytic aggregates (n = 11), and tingible body macrophages (n = 5) were variably identified. Lymphoepithelial lesions were not observed. Three specimens with FC studies showed a phenotype compatible with MZL, and three specimens were nondiagnostic.

CONCLUSIONS

Cytologic features suggestive of MZL included abundant intermediate-sized lymphoid cells with mild atypia in a background of small lymphocytes and transformed cells, often with plasmacytoid morphology. Flow cytometry was beneficial only in selected MZL cytology specimens. Surgical correlation may be necessary to confirm the diagnosis.

B-cell lymphomas with coexpression of CD5 and CD10

Coexpression of CD5 and CD10 is highly unusual in B-cell lymphomas and may pose a diagnostic challenge. We report 42 cases of B-cell lymphoma with simultaneous expression of CD5 and CD10. They made up approximately 0.4% of all B-cell lymphomas seen during the study period and included the following cases: large B-cell lymphoma (LBCL), 14 (33%); follicular lymphoma (FL), 10 (24%); mantle cell lymphoma (MCL), 9 (21%); chronic lymphocytic leukemia, 4 (10%); acute precursor B-cell lymphoblastic leukemia/lymphoma, 2 (5%); and other low-grade B-cell lymphomas, 3 (7%). All MCLs had overexpression of bcl-1 or the t(11;14) and were CD43+. All FLs had typical histomorphologic features and were bcl-2+ and bcl-6+ but CD43-. Of 14 LBCLs, 5 were histologically high-grade. Six (43%) of 14 patients with LBCL died within 10 months of diagnosis of CD5+CD10+ lymphoma (median survival, 4 months), including all 3 patients with stage IV disease and 2 of 5 with histologically high-grade lymphoma. Our findings indicate that coexpression of CD5 and CD10 is rare but occurs in diverse subtypes of B-cell lymphoma. Investigation of bcl-1, bcl-6, and CD43 and morphologic evaluation may resolve the potential confusion in diagnosis and lead to the recognition of the correct lymphoma subtype.

Ultrafast Papanicolaou stain and cell-transfer technique enhance cytologic diagnosis of Hodgkin lymphoma

Diagnosis of Hodgkin lymphoma (HL) by fine-needle aspiration (FNA) is often hampered by aspirated blood that camouflage scattered Hodgkin cells and Reed-Sternberg (HRS) cells, and the absence of HRS cells in the smears submitted for immunophenotyping. The objective of this study was to develop a simple protocol to overcome these problems. The visibility of HRS cells in Diff-Quik, traditional, and Ultrafast Papanicolaou (UFP) stains in FNA smears were compared in 73 cases of HL. HRS cells were found to be most visible in UFP because of the hemolysis of aspirated blood and the highlighting of HRS cells by the red-staining nucleoli. UFP-stained smears containing HRS cells were subsequently immunophenotyped via the cell-transfer technique. UFP staining was found to have no deleterious effect on the immunoreactivity of cellular CD15 and CD30 antigens of HRS cells. This simple protocol enhances the cytologic diagnosis of HL, feasible even with a single smear.

Large B-cell lymphomas: fine-needle aspiration plays an important role in initial diagnosis of cases which are falsely negative by flow cytometry

Large B-cell lymphomas (LBCLs) have significant false-negative results when immunophenotyped by flow cytometry (FC). To clarify the role fine-needle aspiration (FNA) in reducing this false-negative rate, 28 cases ultimately diagnosed as LBCL that had FNA as part of the workup and a negative FC were identified. We examined their clinical and cytologic features, in comparison with cases of LBCL with FNAs that were positive by FC. In 24/28 FC-negative cases (86%) a cytologic diagnosis of suspicious or positive for malignancy was rendered. We conclude that cytologic analysis is more sensitive than FC in the diagnosis of malignancy in FNA of LBCL, particularly in aspirates with low cellularity and/or low viability. Examination of cytospin preparations of the actual material analyzed by FC may provide an indication that an FC result is falsely negative. It is important to recognize the potential of false-negativity by FC of LBCLs when interpreting FNAs with features suggesting lymphoma.

Diffuse large B-cell lymphoma with fibrillary matrix

Diffuse large B-cell lymphoma (DLBCL) with fibrillary matrix is an extremely rare variant of non-Hodgkin's lymphoma (NHL) whose pathological features are poorly known. Here, we report on our experience with such a condition arising in a 71-yr-old woman. Our findings not only demonstrate that DLBCL with fibrillary matrix actually represents a peculiar subtype of DLBCL, but they also illustrate that the cytologic and flow cytometric features in this disorder can be deceptive enough as to mislead even the most experienced cytopathologist.

Fine-needle aspiration in non-Hodgkin lymphoma: evaluation of cell size by cytomorphology and flow cytometry

We studied 48 non-Hodgkin lymphoma (NHL) fine-needle aspiration (FNA) specimens with initial cytomorphology (CM) and flow cytometry (FC) and subsequent surgical biopsy of the same lesion to determine whether a reliable diagnosis of large cell lymphoma or large cell transformation could be made. CM was evaluated by examining 200 lymphocytes in each specimen. FC was performed by analyzing monoclonal or abnormal B-cell populations. Percentages of large cells were evaluated by CM and FC and results correlated with the histologic diagnosis. All small cell NHLs showed fewer than 40% large cells by CM and FC; 100% (9/9; FC) and 67% (6/9; CM) of diffuse large B-cell lymphomas demonstrated greater than 40% large cells. Variable numbers of large cells were detected in grade III follicular lymphoma, low-grade lymphoma with partial large cell transformation, and large B-cell lymphoma containing fewer than 10% neoplastic cells. By using combined CM and FC, large cell lymphoma and large cell transformation can be diagnosed reliably by FNA if greater than 40% large cells are present. Surgical biopsy is necessary when there is necrosis, fewer than 10% neoplastic cells by FC, or fewer than 40% large cells with clinical signs of transformation.

B-cell lymphoproliferative disorders

The differential diagnosis of the B-cell lymphoproliferative disorders can sometimes by tricky. When the morphology and flow cytometric studies are classic, the case should not present a diagnostic challenge. However, when the lesion does not read the book, one must take into consideration the morphology/cytology, flow cytometry, and clinical history. Integrating all three of these will often lead to the correct diagnosis; however, there will be occasional cases where the best that a pathologist can say is "B-cell lymphoproliferative disorder". In those instances, one should not overcall something, but rather should state what the problems are, and what are most likely to be the diagnostic possibilities.

Assessment of CD10 in the diagnosis of small B-cell lymphomas: a multiparameter flow cytometric study

We evaluated the usefulness of multiparameter flow cytometry with cluster analysis in the diagnosis of a series of 100 well-characterized small B-cell lymphomas (SBCLs). The histologic diagnoses in the 100 cases were follicular lymphoma (FL) in 58, marginal zone lymphoma (MZL) in 17, small lymphocytic lymphoma in 15, and mantle cell lymphoma (MCL) in 10. Of the 58 FLs, 57 were CD10 positive (98% sensitivity). The 1 negative case was unusual in that it occurred in the small intestine. However; architectural, cytologic, and immunohistochemicalfeatures were diagnostic of FL. Of 42 other SBCLs, 2 were CD10+ (95% specificity); 1 was a CD5+/cyclin D1 + MCL, and the other was an extranodal MZL. We found that assessment of CD10 expression using multiparameter flow cytometry with cluster analysis is highly sensitive and specific for the diagnosis of FL, validating its usefulness in situations in which adequate tissue is not available for definitive histologic diagnosis.