Ex vivo fine-needle aspiration cytology and flow cytometric phenotyping in the diagnosis of lymphoproliferative disorders: a proposed algorithm for maximum resource utilization

Primary gastric Hodgkin's lymphoma: a case report and review of the literature

Primary gastric Hodgkin's lymphoma is a rarely encountered lesion. Most cases are observed in the course of systemic disease. Other cases have been reclassified in retrospective studies as non-Hodgkin's lymphomas, after the employment of immunohistochemistry. Some Hodgkin's lymphomas may masquerade non-Hodgkin's lymphomas, and vice versa. Therefore, an accurate diagnosis is important, as treatment and outcome differ significantly for these entities. We report a case of primary Hodgkin's lymphoma arising in the stomach of a 46-year-old male, and discuss the diagnostic approach as well as the differentials of Hodgkin's disease in this anatomic site.

Fine-needle cytology and flow cytometry immunophenotyping and subclassification of non-Hodgkin lymphoma: a critical review of 307 cases with technical suggestions

BACKGROUND

Flow cytometry (FC) is a useful adjunct to fine-needle aspiration cytology (FNC) in evaluating lymphoproliferative disorders. The authors present a critical review of 307 lymph nodal and extra lymph nodal lymphoproliferative disorders that were diagnosed with FNC and FC.

METHODS

FC was performed over a 4-year period on 185 palpable and 122 impalpable lymph nodal and extra lymph nodal lymphoproliferative processes under ultrasound or computed tomography guidance. FC was performed using the following fluoresceinated antibodies: CD3, CD4/CD8, CD2/CD7/CD3, CD5/CD10/CD19, CD19/kappa/lambda, FMC7/CD23/CD19, CD38/CD56/CD19, and bcl-2. The series included 15 inadequate, 10 suspicious, and 135 benign reactive hyperplasias (BRHs); 70 primary non-Hodgkin lymphomas (NHLs), and 77 recurrent NHLs (rNHLs). FC/FNC diagnoses of suspicious, NHL, and rNHL were controlled either histologically or clinically or by the interphase fluorescence in situ hybridization demonstration of t(11;14)(q13;q32) in two cases of mantle cell lymphoma. BRHs were controlled by follow-up. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the FC/FNC diagnoses of NHL, rNHL, and BRH were calculated as well as the identification of specific subtypes among the small- and medium-sized cells.

RESULTS

Statistical analysis showed 93% sensitivity, 100% specificity, 100% PPV, and 91% NPV in NHL, rNHL, and BRH discrimination. The subclassification of small cell and medium-sized NHLs showed 63% sensitivity, 88% specificity, 95% PPV, and 37% NPV.

CONCLUSIONS

FC applied to FNC enhanced the precision of cytologic diagnosis in lymph nodal and extra lymph nodal lymphoproliferative disorders and allowed further subclassification in more than half of the cases, thus avoiding invasive surgical biopsies in many patients.

Flow cytometry as an adjunct to cytomorphologic analysis of serous effusions

The role of flow cytometry (FC) in the diagnosis of lymphoid lesions by fine-needle aspiration (FNA) is well established. However, studies evaluating the usefulness of FC in serous cavity effusions (SCE) are few. We performed a retrospective review of 115 consecutive SCE with concurrent FC analysis, comparing the provisional cytopathologic diagnosis (PCD), i.e., before the FC results were added, with final diagnoses as modified by subsequent FC immunophenotyping. The predominant clinical indication for the FC analysis was the presence of a spontaneous SCE in a patient with a history of malignant lymphoma. Three- or four-color analysis was performed using antibodies against CD45, CD71, CD33, CD22, CD19, CD20, kappa, lambda, CD5, CD3, and CD56. The PCD was benign in 47%, atypical in 16%, and malignant in 37% of cases. The latter category consisted mostly of malignant lymphoma (n = 32), but also included acute lymphoblastic leukemia (1 case), T-cell lymphoma/leukemia (2 cases), acute myelogenous leukemia (1 case), multiple myeloma (1 case), Hodgkin's lymphoma (1 case), sarcoma (1 case), and adenocarcinoma (4 cases). In 18 cases (16%), the PCD was later modified by the FC results from atypical/suspicious to benign (8) and from benign or atypical/suspicious to malignant (10 cases). The latter group included acute natural killer (NK) cell leukemia (1 case), chronic lymphocytic leukemia (1 case), mantle cell lymphoma (2 cases), follicular lymphoma (3 cases), angioimmunoblastic lymphoma (1 case), large cell lymphoma (1 case), and multiple myeloma (1 case). As expected, FC was noncontributory in cases of Hodgkin's lymphoma and nonlymphoid malignancies. In summary, immunophenotyping by FC modified the PCD significantly in 16% of SCE, permitting appropriate cancer staging and management. The above data underscore the importance of FC as an adjunct to cytomorphology in SCE.

Fine-needle aspiration biopsy and flow cytometry immunophenotyping of lymphoid and myeloproliferative disorders of the spleen

BACKGROUND

Flow cytometry (FC) is a useful adjunct to fine-needle aspiration biopsy (FNAB) in the evaluation of lymphoproliferative disorders. The application of FC to FNAB of the spleen (sFNAB) is reported.

METHODS

Flow cytometry was performed on 18 sFNAB collected over 3 years. The series comprised 10 cases of non- Hodgkin lymphomas (NHL), 2 cases insufficient for diagnosis, 2 cases of reactive hyperplasia (RH), and 4 cases of myeloid metaplasia (MM). FNAB was performed under ultrasound guidance using a 22-gauge needle. One or two passes were sufficient to prepare a conventional smear that was immediately evaluated to select the cases studied and to prepare a cell suspension for FC. The following fluoresceinated antibodies were used: CD3, CD19/kappa/lambda, FMC7/CD23/CD19, Bcl-2, and CD13/HLA-DR. In six cases, cytospins were also prepared for immunocytochemistry and were tested for CD20 (L26), CD45Ro, and kappa and lambda light chain expression.

RESULTS

Flow cytometry contributed to the diagnosis of all cases of NHL by assessing light chain restriction. The specific subtype was also diagnosed by CD19/CD5 and CD 19/CD10 coexpression in two cases. Flow cytometry quantified the percentage of myeloid cells in MM cases and contributed to the cytologic diagnosis showing a polyclonal light chain expression in RH cases. Immunocytochemistry was effective and concordant in four cases. Patients tolerated the sFNAB well and no complications were reported. Cytologic and FC diagnoses were confirmed by follow-up and by histologic evaluation in cases in which splenectomy was performed for therapeutic purposes.

CONCLUSION

Flow cytometry applied to sFNAB corroborates the cytologic diagnosis in lymphoid and myeloproliferative disorders of the spleen and allows therapeutic decisions avoiding splenectomy.

Lymphoma masking sarcoidosis

The relationship between sarcoidosis and lymphoma has been described in the past. Here we present a 56 year old patient who presented with massive splenomegaly, bone marrow involved by lymphoma and granulomas who responded to chemotherapy and subsequently developed a full blown picture of sarcoidosis.

Utility of flow cytometry immunophenotyping for the diagnosis and classification of lymphoma in community hospital clinical needle aspiration/biopsies

CONTEXT

Flow cytometry immunophenotyping (FC) of needle aspiration/biopsy (NAB) samples has been reported to be useful for the diagnosis and classification of lymphoma in university and cancer center-based settings. Nevertheless, there is no agreement on the utility of these methods.

OBJECTIVE

To further define the utility of adjunctive FC of clinical NAB for the diagnosis and classification of lymphoma, and to determine if this approach is practicable in a routine clinical practice setting.

SETTING

A community-based hospital.

METHODS

Clinical NABs were submitted for adjunctive FC between June 1996 and September 1999 if initial smears were suspicious for lymphoma. Smears and cell block or needle core tissues were routinely processed and paraffin-section immunostains were performed if indicated. The final diagnosis was determined by correlating clinical and pathologic data, and the revised European-American classification criteria were used to subtype lymphomas.

RESULTS

Needle aspiration/biopsies from 60 different patients were submitted for FC. Final diagnoses were lymphoma (n = 38), other neoplasm (n = 15), benign (n = 6), or insufficient (n = 1). For 38 lymphomas (20 primary, 18 recurrent), patients ranged in age from 32 to 86 years (mean, 62 years); samples were obtained from the retroperitoneum (n = 11), lymph node (n = 9), abdomen (n = 8), mediastinum (n = 6), or other site (n = 4); and lymphoma subtypes were indolent B-cell (n = 20; 2 small lymphocytic, 14 follicle center, 4 not subtyped), aggressive B-cell (n = 14; 3 mantle cell, 10 large cell, 1 not subtyped), B-cell not further specified (n = 2), or Hodgkin disease (n = 2). For the diagnosis of these lymphomas, FC was necessary in 20 cases, useful in 14 cases, not useful in 2 cases, and misleading in 2 cases. Thirty-two of 36 lymphoma patients with follow-up data received antitumor therapy based on the results of NAB plus FC.

CONCLUSIONS

Adjunctive FC of NABs is potentially practicable in a community hospital, is necessary or useful for the diagnosis and subtyping of most B-cell lymphomas, and can help direct lymphoma therapy. Repeated NAB or surgical biopsy is necessary for diagnosis or treatment in some cases.

The accuracy of combined cytopathologic and flow cytometric analysis of fine-needle aspirates of lymph nodes

We studied flow cytometry in 156 fine-needle aspirations (FNAs) of lymph nodes performed between June 1993 and September 1998. Information from flow cytometry was combined with cytomorphologic evaluation, and the diagnosis determined by using combined modalities was compared with tissue biopsy results or clinical follow-up. In 74 cases, a combined cytopathologic-flow cytometric diagnosis of lymphoma was made; histologic material was available for 52 patients; in no case was a benign process found. The lymphoma grade assigned agreed with histopathologic findings in 45 of 48 cases with a specific cytologic diagnosis. Treatment was initiated on the basis of the FNA alone for 17 of 52 patients with a history of lymphoma and in 22 additional patients with no follow-up biopsy. Among 71 cases in which the diagnosis using both modalities was benign, the only false-negative was 1 case of Hodgkin disease. Of the 156 cases, 11 were considered atypical or suggestive of lymphoma; biopsies from 8 of 10 patients revealed lymphoma. A combination of flow cytometry and cytomorphology of cells obtained by FNA of lymph nodes can distinguish between benign and malignant lymphoid infiltrates and support a diagnosis of lymphoma that permits definitive therapy in most cases.

Diagnosis and classification of lymphoma based on cytospin preparations: a comparison of hematopathologists and cytopathologists

The diagnosis of malignant lymphoma based on cytologic preparations is a source of much debate. The purpose of this study was to assess the ability of a number of pathologists to diagnose and classify lymphoma using cytospin preparations, and to compare the rate of agreement between cytopathologists and hematopathologists. One hundred twenty-five cytospins prepared from histologically confirmed hematologic lesions were examined retrospectively and independently by four hematopathologists/fellows and two cytopathologists without knowledge of the final diagnosis; the results were compared with the final diagnoses derived from histology and immunophenotyping. Eighty-one cases were histologically diagnosed as lymphoma (including 67 cases of B-cell non-Hodgkin's lymphoma), and 44 cases represented a reactive process histologically. The distinction of a malignant from a benign process was made in 75% of the cases by cytospin examination, with cytopathologists correctly diagnosing 75% and hematopathologists 76% of the cases. The accuracy rate for subclassification of the lymphoma cases was 49% (46% for cytopathologists, 52% for hematopathologists). The cytopathologists correctly recognized large-cell lymphoma at an increased frequency compared with the hematopathologists (70% vs. 56%, P = 0.11), while the hematopathologists showed a greater ability to recognize and classify nonfollicle center low-grade B-cell lymphomas (57% vs. 28%, P = 0.01). We conclude that cytopathologists and hematopathologists generally achieve similar accuracy rates in the morphologic evaluation of cytologic preparations of lymphoid lesions, though some differences in their performance do exist.

Evaluation of lymphoid cell populations in cytology specimens using flow cytometry and polymerase chain reaction

Differential diagnosis between lymphomas and reactive lymphoid proliferations often requires ancillary techniques and morphologic evaluation. Flow cytometry (FCM) and polymerase chain reaction (PCR) can aid the detection of monoclonal B-cell populations. In the present study, the sensitivity and specificity of these two methods in the study of cytology specimens were compared. Eighty-six cytologic specimens from 81 patients (lymph nodes, solid organs, and body cavities) were evaluated. These specimens were taken from three groups of patients: those who underwent an initial evaluation for suspected lymphoma; those who were previously diagnosed with B-cell lymphoma and were now evaluated for possible disease recurrence; and those who were diagnosed with a nonhematologic malignancy. Histologic diagnosis was available for 51 samples. All samples were tested by FCM for the detection of monoclonality using kappa:lambda ratio and for clonal immunoglobulin heavy chain (IgH) gene rearrangements using a single-round PCR after cytologic evaluation. Tissue morphology, FCM and PCR results, and clinical findings in specimens without histologic diagnosis were correlated. Histologic evaluation (N = 51) revealed 44 specimens with B-cell malignancy. Twenty of the 44 lymphoma specimens (45%) were accurately diagnosed in cytologic smears, 18 (41%) were classified as suspicious of lymphoma, and 6 (14%) were diagnosed as reactive. FCM had superior sensitivity compared with PCR (77% vs. 64%). Fifty-six percent of specimens with B-cell malignancy were FCM+/PCR+, 23% were FCM+/PCR-, 14% were FCM-/PCR+, and 7% were FCM-/PCR-. The combined use of FCM and PCR resulted in a diagnosis of B-cell lymphoma in 41 (93%) of 44 B-cell lymphoma specimens and increased the sensitivity of fine needle aspiration by 48%. Both FCM and PCR aid in the diagnosis of lymphoid lesions in cytology specimens, and both can detect monoclonal B-cell populations that may be interpreted in cytology smears as reactive, even by experienced cytologists. Although FCM had higher sensitivity than PCR test in the present study, their combined use should be considered because of a relatively large number of specimens that were detected as monoclonal only with PCR.

Value and limitations of fine-needle aspiration cytology in diagnosis and classification of lymphomas: A review

The fine needle aspiration (FNA) cytologic diagnosis of non-Hodgkin's lymphoma (NHL) depends upon finding a relatively monotonous population of lymphoid cells in smears. Lymphomas have successfully been classified by FNA cytology following the prevalent histologic classifications. The success rate of FNA cytology ranges from 80%-90% in diagnosis of NHL and from 67.5%-86% in its subtyping. The cytodiagnosis of Hodgkin's disease (HD) depends upon demonstration of Reed-Sternberg cells or Hodgkin's cells amongst appropriate reactive cell components. The diagnostic accuracy of FNA cytology for HD has also been invariably high (>85%). Yet, the role of cytology in primary diagnosis, subclassification and management of patients with lymphoma remains controversial. The differential diagnostic problems for NHL include a group of small round cell tumors, nonlymphoid acute leukemias and HD. Reservations have been expressed regarding the efficacy of cytology in separating florid reactive hyperplasia from low-grade malignant lymphoma. The reported cytodiagnostic accuracy for follicular lymphomas and nodular sclerosis type of HD is less compared to other subtypes of NHL and HD respectively since nodular pattern and sclerosis are strict histologic criteria which can not be appreciated in cytologic preparations. Entities like atypical lymphoproliferative disorders, peripheral T-cell lymphomas and Ki-1 positive anaplastic large cell lymphomas pose diagnostic challenges to cytologists. Despite these limitations, FNA cytology remains the first line of investigations (screening test) used in cases of lymphadenopathy. Besides initial diagnosis of lymphoma, it helps in detection of residual disease, recurrences and progression of low-grade to high-grade lymphoma, and helps in staging the disease. Availability of prior FNA cytology report facilitates the histologic diagnosis and classification of NHL. Various special ancillary techniques are now being performed on lymph node aspirates to diagnose lymphoma versus other malignancies, and to decide the functional character of lymphomas and their clonal nature. Diagn. Cytopathol. 1999;21:240-249.

Lymphocyte-depleted Hodgkin's disease: diagnostic challenges by fine-needle aspiration

The diagnosis of Hodgkin's disease by fine-needle aspiration (FNA) can be problematic. A case of Hodgkin's disease, lymphocyte depleted subtype, sample by FNA biopsy is presented. We describe the cytomorphologic features present in this unusual subtype of Hodgkin's disease and discuss the differential diagnosis. Immunohistochemical and morphologic findings of a subsequent biopsy specimen supported the diagnosis. Although FNA is an increasingly used diagnostic modality to evaluate tumors including malignant lymphomas, Hodgkin's disease remains, as in this case, a difficult diagnosis by FNA.

Fine needle aspiration cytology in the investigation on non-Hodgkin's lymphoma

AIMS

To assess the value of flow cytometry (FCM) in the diagnosis and classification of reactive lymphoid hyperplasia and malignant lymphoma by fine needle aspiration (FNA) cytology.

METHODS

Forty six fine needle aspirates of lymphoproliferative disorders were examined by FCM as well as routine cytological assessment. An immunoglobulin light chain ratio (LCR) was calculated for clonality analysis. Additional immunophenotyping was performed in 15 cases.

RESULTS

All 25 cases of reactive lymphoid hyperplasia were polyclonal by FCM (LCR < 2/1); 17 of 20 cases of B cell non-Hodgkin's lymphoma were monoclonal (LCR > 3/1). Analysis of cells based on size facilitated detection of small populations of clonal neoplastic cells. Analysis of CD5, CD10, and CD23 expression by FCM facilitated subclassification of mantle cell lymphoma, small lymphocytic lymphoma, and some lymphomas of follicle centre cell origin. One case of T cell non-Hodgkin's lymphoma was correctly classified by FCM.

CONCLUSIONS

FNA cytology is a reliable method for investigation of lymphoproliferative disorders. Although excision biopsy and histopathological examination remain the gold standard for primary diagnosis and classification of non-Hodgkin's lymphoma, FNA cytology with clonality analysis and immunophenotyping by FCM is useful for distinguishing reactive from neoplastic lymphoid populations, and can facilitate lymphoma classification.