Osteosarcoma and the role of fine-needle aspiration. A study of 51 cases

Cytological diagnosis of osteosarcoma with emphasis on diagnostic pitfalls

INTRODUCTION

Fine needle aspiration is a well-established technique for evaluating primary and secondary bony lesions. With use in selected cases, it achieves a diagnostic yield comparable to biopsies.

METHODS

Cases of osteosarcoma (OS) with available histological follow-up were retrieved over a 10-year period. Detailed morphological evaluation was done, with special emphasis on pitfalls in the diagnosis of OS on cytology and the various variants of OS.

RESULTS

Of the 41 cases with available follow-up histology, 56% were correctly diagnosed as OS on cytology. The most common false-negative cytological diagnosis of OS, in 17% cases, was giant cell tumour. The possible explanations for this included low cellularity, minimal atypia, absence of typical osteoid, misinterpretation of metachromatic osteoid material as fibro-collagenous material and non-availability of radiology at time of aspiration.

CONCLUSION

A triple-phase evaluation including clinical evaluation, appropriate radiological correlation and cytology/histopathology, is important to clinch an accurate diagnosis.

The role of fine-needle aspiration cytology in the diagnosis of soft tissue nodules: Experience in a tertiary center

INTRODUCTION

Excisional or core needle biopsy is considered the gold standard for diagnosing soft tissue lesions (STL). However, the role of fine-needle aspiration cytology (FNAC) in STL remains controversial.

MATERIALS AND METHODS

We have reviewed 234 FNAC of STL diagnosed in our institution with the aim of analyzing the reliability of FNAC in STL. Cytological diagnoses were classified into groups and correlated with histological diagnoses. We have also reviewed the literature and compared our results with those previously reported.

RESULTS

The majority of patients were male (53.4%) and mean age was 61 years. Lesions were mainly located in the head and neck region. Inadequate material was obtained in 22.6% of cases and most lesions were inflammatory lesions or benign soft tissue tumors. Carcinoma and benign soft tissue tumor were the most frequent cytological diagnoses. Biopsy was performed in 36.1% of cases, and carcinoma was detected in 33.3% of inflammatory FNACs. General and specific concordances were 65.9% and 47.1%. Diagnostic sensitivity, specificity, negative and positive predictive values were 71.4%, 100%, 85.7% and 93.8%, respectively.

CONCLUSIONS

FNAC of STL is a valuable tool for diagnosing benign epithelial cysts, carcinomas, hematolymphoid neoplasms and benign soft tissue tumors. Inflammatory smears may be associated with false-negative cases. The availability of a multidisciplinary team, clinical and imaging features, ROSE and immunohistochemical and molecular techniques is required for improving the role of FNAC of STL.

Comparative Assessment of the Accuracy of Cytological and Histologic Biopsies in the Diagnosis of Canine Bone Lesions

BACKGROUND

Osteosarcoma (OSA) should be differentiated from other less frequent primary bone neoplasms, metastatic disease, and tumor-like lesions, as treatment and prognosis can vary accordingly. Hence, a preoperative histologic diagnosis is generally preferred. This requires collection of multiple biopsies under general anesthesia, with possible complications, including pathological fractures. Fine-needle aspiration cytology would allow an earlier diagnosis with a significant reduction of discomfort and morbidity.

HYPOTHESIS/OBJECTIVES

The aim of this study was to compare the accuracy of cytological and histologic biopsies in the diagnosis of canine osteodestructive lesions.

ANIMALS

Sixty-eight dogs with bone lesions.

METHODS

Retrospective study. Accuracy was assessed by comparing the former diagnosis with the final histologic diagnosis on surgical or post-mortem samples or, in the case of non-neoplastic lesions, with follow-up information.

RESULTS

The study included 50 primary malignant bone tumors (40 OSAs, 5 chondrosarcomas, 2 fibrosarcomas, and 3 poorly differentiated sarcomas), 6 carcinoma metastases, and 12 non-neoplastic lesions. Accuracy was 83% for cytology (sensitivity, 83.3%; specificity, 80%) and 82.1% for histology (sensitivity, 72.2%; specificity, 100%). Tumor type was correctly identified cytologically and histologically in 50 and 55.5% of cases, respectively.

CONCLUSIONS AND CLINICAL IMPORTANCE

The accuracy of cytology was similar to histology, even in the determination of tumor type. In no case was a benign lesion diagnosed as malignant on cytology. This is the most important error to prevent, as treatment for malignant bone tumors includes aggressive surgery. Being a reliable diagnostic method, cytology should be further considered to aid decisions in the preoperative setting of canine bone lesions.

Unique Image Characteristics of an Occipital Primary Chondroblastic Osteosarcoma: A Rare Case Report and a Brief Literature Review

Primary osteosarcomas of the skull and skull base are rare and comprise < 2% of all skull tumors. In head and neck osteosarcomas, the chondroblastic subtype occurs most frequently, which has an exceedingly poor outcome, but its image characteristic remains unknown. Herein, we report a case in the right occipital bone of the skull base and the unique characteristics of image. Pathologic examination of the surgical specimens led to the diagnosis of chondroblastic osteosarcomas. We believe those image characteristics can improve the understanding of skull chondroblastic osteosarcoma and the preoperative diagnosis.

Cytological diagnosis of small cell osteosarcoma of the bone

Small cell osteosarcoma (OS) is a rare histological variant of OS that poses unique diagnostic difficulties. We present a case of a 10-year-old child who underwent fine needle aspiration cytology (FNAC) from a mass in the right thigh. The cytological findings were those of a malignant small round cell tumor, closest to small cell OS. The FNAC findings were confirmed on histopathology.

Role of FNAC in the diagnosis of intraosseous jaw lesions

Background

FNAC of intraosseous jaw lesions has not been widely utilized for diagnosis due to rarity and diversity of these lesions, limited experience and lack of well established cytological features. Aim of the study was to determine the role of FNAC in the diagnosis of intraosseous jaw swellings.

Material and Methods

42 patients underwent FNAC over a period of 7 years (2007-2013), of which 37 (88.1%) aspirates were diagnostic. Histopathology correlation was available in 33 cases and diagnostic accuracy of FNAC was calculated.

Results

Lesions were categorized into inflammatory 3, cysts/hamartomas 15 and neoplasms 19. Mandibular and maxillary involvement was seen in 21 and 16 patients respectively. Of these, benign cysts and malignant lesions were commonest, accounting for 27% lesions (10 cases) each. One case of cystic ameloblastoma was misdiagnosed as odontogenic cyst on cytology. Overall, sensitivity and specificity of FNAC were 94.7% and 100% respectively with a diagnostic accuracy of 97.3%. Definitive categorization of giant cell lesions, fibro-osseous lesions, odontogenic tumors and cystic lesions was not feasible on FNAC.

Conclusions

FNAC is a simple, safe and minimally invasive first line investigation which can render an accurate preoperative diagnosis of intraosseous jaw lesions, especially the malignant ones in the light of clinic-radiological correlation.

Key words: Jaw swellings, intraosseous, FNAC.

[Open biopsy of bone and soft tissue tumors : guidelines for precise surgical procedures]

OBJECTIVE

The objective of an open biopsy is to obtain a sufficient amount of representative tumor tissue in terms of adequate quality and quantity, without adverse effects on later therapy.

INDICATIONS

Suspected malignancy after non-invasive diagnostic procedures. Histopathologic evaluation of tumor entity and grading. Planning of the definitive tumor resection and initiation of neoadjuvant therapeutic regimen. Obtaining unfixed, fresh-frozen tumor samples for molecular/genetic analyses or tumor tissue bank.

CONTRAINDICATIONS

Hemorrhagic diathesis. Tumor is only accessible with a surgical approach leading to a significant damage of the surrounding tissue. High probability of tumor cell contamination with incisional biopsy. Poor physical status. Poor therapeutic compliance.

SURGICAL TECHNIQUE

The biopsy tract should be carefully planned according to oncological principles. The operation begins with a small incision in longitudinal direction to the extremity. The shortest path between skin and lesion that avoids contamination of other compartments is selected. The biopsy tract should be located within the surgical approach which is later used for definitive tumor resection. During the definitive procedure it should be possible to resect the biopsy approach with adequate surgical margins because it is considered to be contaminated with tumor cells. In principle, a wide resection of the biopsy tract should be possible. During the operation meticulous hemostasis has to be performed because any hematoma around a tumor may contaminate the entire extremity. In cases of an intraosseous tumor a cortical window should be made to obtain intramedullary tumor tissue. Drains should be located in continuity with the skin incision or in direct extension of the wound. Wound closure with intracutaneous suture technique. Excisional biopsy in terms of marginal resection should be performed only in the presence of small, epifascial lesions that are assumed to be benign after completion of basic diagnostic procedures. In cases of larger or subfascial tumors an incisional biopsy should be conducted.

POSTOPERATIVE MANAGEMENT

Compressive dressing to prevent postoperative hematoma. In cases of tumors affecting load-bearing bones, weight-bearing should be prohibited after biopsy, if there is any fracture risk. Upon receipt of the histopathological results the definitive tumor resection is planned.

Small cell osteosarcoma of the mandible: Case report and review of its diagnostic aspects

Small cell osteosarcoma, a rare histological subtype, has very infrequently been reported in the mandible. We present a case of a 28-year-old female who had classic signs, symptoms, and radiographic features of the lesion. The histology showed sheets of small round cells and osteoid. The absence of the latter would have made it difficult to distinguish from other small round cell tumors of bone, especially Ewing's sarcoma. We have reviewed the clinical and radiographic features, cytologic and histologic characteristics, as well as the immunohistochemistry and molecular genetics of small cell osteosarcoma.

Bone Cytology: A Realistic Approach for Clinical Use

This article presents the use of bone cytology for diagnosis of bone tumors. It discusses critical factors and considerations of fine-needle aspiration and bone cytology and presents diagnostic options and differential diagnosis for benign and malignant bone lesions. Osteomyelitis, chrondroblastoma, Langerhans cell histiocytosis, chondromyxoid fibromas, enchondromas, giant cell tumor of bone, osteosarcoma, chondrosarcoma and variants, Ewing sarcoma, chordoma, plasmacytoma, multiple myeloma, lymphoma, and metastatic bone disease are presented.

Diagnosis of high-grade osteosarcoma by radiology and cytology: a retrospective study of 52 cases

The diagnostic value of combined radiology and fine needle aspiration cytology (FNAC) was retrospectively assessed in a consecutive series of 52 patients with high-grade osteosarcoma. The series was divided into typical and atypical osteosarcomas according to radiological features and site. Thirty-two of 33 radiologically typical osteosarcoma cases were correctly diagnosed by cytology; one lesion was diagnosed as sarcoma NOS. Nineteen osteosarcoma cases were radiographically atypical. Six of these were diagnosed as osteosarcoma and another six as sarcoma NOS. In three cases another type of sarcoma was suggested. One case was falsely classified as benign. FNAC of three cases were non-diagnostic. Overall, the diagnostic difficulties pertained to the radiologically atypical cases. Notably, four of these also posed considerable difficulties in the histopathological assessment prompting external consultation. Our study suggests that open biopsy can be obviated in high-grade osteosarcomas exhibiting typical radiological features, i.e., in two-thirds.

Chondroblastic osteosarcoma of the temporal region: a diagnostic dilemma

Chondroblastic osteosarcoma (OS) accounts for about 25% of all cases of OS. It can pose diagnostic difficulty on cytology, as the tumor cells may resemble the carcinomatous cells. We present a case of a 35-year-old female patient who presented with a firm swelling in the left temporal region. On fine-needle aspiration, the smears revealed abundant cellularity with tumor cells showing significant nuclear pleomorphism and multinucleation. The tumor cells had abundant foamy to vacuolated cytoplasm, thereby indicating sebaceous differentiation and it was cytologically interpreted as sebaceous carcinoma. However, on subsequent histopathology, similar tumor cells were seen lying down abundant amount of osteoid material along with foci of chondroid differentiation and was diagnosed as chondroblastic OS. Pitfalls in the cytodiagnosis of this case along with differential diagnosis on cytology are discussed.

Small cell osteosarcoma: cytopathologic characteristics and differential diagnosis

Small cell osteosarcoma may present a challenging primary diagnosis on cytologic assessment owing to its rarity and its morphologic similarity to other small round blue cell tumors. Five cases of small cell osteosarcoma from our cytopathology archives were identified and reviewed and cytologic features elaborated. Three cases were fine-needle aspirations from bony lesions in the classic location for osteosarcoma (2 distal femur and 1 proximal tibia), and 2 aspirations were from metastases. Common cytomorphologic features included relatively small to intermediate cell size, high nuclear/cytoplasmic ratios, round nuclei, minimal anisonucleosis, finely granular nuclear chromatin, fine cytoplasmic vacuoles, and only rare osteoid. Small cell osteosarcoma shares many of the well-described cytomorphologic features of classic osteosarcoma, but the relatively small cells, round hyperchromatic nuclei, and scant osteoid constitute the common denominator. Correlation with radiographic findings and ancillary tests can aid in definitive diagnosis.

Surgical management of primary osteosarcoma

Surgical strategies for the primary tumor for patients with extremity and pelvis osteosarcoma have evolved from the ablative to limb-sparing approaches over the past three decades. Favorable oncologic and functional outcomes with contemporary tissue-conserving techniques consistently observed in skeletally mature patients have prompted the application of similar approaches to a growing number of eligible skeletally immature patients. In response to emerging long-term outcome data, current strategies have focused principally on refining the nature and scope of surgical resection to preserve uninvolved tissues, and on the adoption of novel biological and nonbiological skeletal and soft-tissue reconstruction methods to optimize function. We focus on these clinical issues and discuss current efforts to advance the surgical management of the primary tumor and address the limitations of the definitive treatment of the primary tumor, including locally recurrent disease and complications of skeletal reconstructions.

Fine needle aspiration biopsy of intra-osseous lesions of the mandible and maxilla

This study was done with an aim to assess the reliability and diagnostic accuracy of fine needle aspiration biopsy of intraosseous jaw lesions. Of the 42 cases, adequate material for cytologic evaluation was obtained in 35 cases. Malignant cells were found in 9 of 35 cases. FNAB diagnosis was confirmed by histopathology in all 9 of these specimens (100% accuracy). The FNAB diagnosis of benign lesions was confirmed in 19 of 26 cases (73% accuracy). The most common benign lesions were odontogenic cysts, followed by fibro-osseous and giant cell lesions. Incorrect diagnosis was related to lack of architectural context of the FNAB material, inadequate quantity of the aspirate and sampling of a non-representative part of a large lesion. Thus FNAB is a useful, simple, fairly reliable and outpatient procedure for diagnosis of intra-osseous jaw lesions, especially to distinguish between malignant and benign jaw lesions.

Pulmonary metastasis of giant cell tumor of the bone diagnosed by fine-needle aspiration biopsy

Giant cell tumor is a benign but locally aggressive tumor that primarily affects the epiphyses of long bones of young adults. Pulmonary metastases in giant cell tumor are rare (about 1-9%). Here, we report a case of metastatic pulmonary giant cell tumor in a patient who had a previous history of giant cell tumor of the distal femur with multiple recurrences. The diagnosis of pulmonary metastasis was achieved by cytologic evaluation with concurrent immunohistochemical studies in material obtained by fine-needle aspiration biopsy. The aspirate smears contained clustered and dispersed mononuclear and osteoclast-like giant cells that had bland nuclei with inconspicuous nucleoli. All multinucleated cells showed immunoreactivity to KP-1 antibody, a histiocytic marker (not lineage specific) and only a subset of mononuclear cells (30%) stained with this marker. Twenty percent of the mononuclear cells also displayed increased Ki-67 and p53 protein expression. The pulmonary metastasis was similar morphologically and immunophenotypically to the recurrent giant cell tumor of the bone.

Cyto-histological correlations inprimary, recurrent, and metastatic bone and soft tissue osteosarcoma. Institut Curie's experience

To determine diagnostic cytomorphologic features of osteosarcoma on fine-needle aspiration materials, we reviewed the cytologic material and corresponding histologic slides of 126 tumors in 107 patients. Fifty-five (43.6%) tumors were primary, 31 (24.6%) were recurrent, and 40 (31.8%) were metastatic. Review of original cytology reports revealed that 120 (95.3%) tumors were diagnosed as malignant. Six (4.7%) cases were reported as suspicious, false-negative, or unsatisfactory samples. Our findings showed that osteoblastic roundish cells, spindle-shaped cells, reactive giant cells, and osteoid were the most consistent features representative of osteosarcoma. Periosteal reactions, fractures with callous formation, giant cells of osteoclastic type in various conditions, chondrosarcoma with enchondral ossification are entities to consider in the differential diagnosis.

Efficacy of CT-guided percutaneous needle biopsy in the diagnosis of malignant lymphoma at first presentation

PURPOSE

The aim of this study was to evaluate retrospectively the accuracy and reliability of CT-guided percutaneous biopsy as an alternative to surgical biopsy in a selected population of patients without superficial enlarged lymph nodes and a final diagnosis of malignant lymphoma at first presentation.

METHODS

The results of 145 CT-guided needle biopsies in 137 patients with malignant lymphoma at its first presentation and without superficial enlarged lymph nodes were analyzed retrospectively. Biopsies were performed in 24 patients with Hodgkin's disease (HD) and 113 with non-Hodgkin lymphoma (NHL). Factors such as patient's sex, age, type of lymphoma and biopsy site were evaluated to detect factors that could influence the success rate of the procedure.

RESULTS

Biopsy specimens were diagnostic in 101 of the 113 patients with NHL and in 18 of the 24 patients with HD. Repeating of a previously nondiagnostic biopsy was successful in 7 out of 13 patients with NHL. No positive results were obtained, repeating the inconclusive biopsy in six patients with HD.

CONCLUSIONS

Our results suggest that percutaneous CT-guided biopsy is a useful and reliable tool in the diagnosis and classification of malignant lymphomas in patients without superficial lymphadenopathy and can be considered as an alternative to surgical sampling. However, little advantages were obtained, repeating previously inconclusive biopsies: In these cases, surgical sampling is mandatory.

Seeding of osteosarcoma in the biopsy tract of a patient with multifocal osteosarcoma

We report a case of multifocal osteosarcoma in a 7-year-old boy who developed iatrogenic seeding of tumor along the biopsy tract. The results of the plain radiograph, CT, and histopathological correlation are presented.

Fine-needle aspiration of primary osteosarcoma: A cytological-histological study

This study aims to determine the diagnostic accuracy of fine-needle aspiration (FNA) evaluation of primary osteosarcoma (OS) and to review diagnostic criteria and adjunctive methods that can contribute to a confident diagnosis of OS in cytological smears. We evaluated FNA smears of OS in 59 patients for the following: cytomorphology and occurrence of osteoid, usefulness of adjunctive methods in evaluation of FNA smears and correspondence of FNA to the clinical data, and the histological features of excised tumors. Reliable cytological criteria of malignancy were found in 49 smears of high-grade OS. These criteria, correlated with radiographic studies and complemented by ancillary techniques, allowed diagnosis of OS or suspicion of OS in 44 cases. An additional four smears were diagnosed as sarcoma and one case was diagnosed erroneously as being carcinoma metastasis. There were no false positive or false negative diagnoses. We conclude that FNA smears from high-grade OS have characteristic features, which together with clinical and radiological data and ancillary studies allow correct diagnosis in most tumors.

Assessment of cytological criteria for diagnosing osteosarcoma in dogs

OBJECTIVES

To evaluate the specific cytological criteria of osteosarcomas in dogs.

METHODS

Significant cytological characteristics of osteosarcoma and benign mesenchymal bone proliferations were determined from imprint smears of 25 dogs with osteosarcoma (group 1) and 20 dogs admitted for removal of surgical bone implants after uncomplicated healing of bone fractures (group 2).

RESULTS

Mild to moderate cellular necrosis occurred frequently in patients with osteosarcoma. The cytoplasm of osteoblasts was pale blue to blue with a more pronounced basophilia in group 2. In 48 per cent of the patients in group 1, but none in group 2, osteoblasts showed a slight to moderate eosinophilic cytoplasmic granulation. In both groups, osteoblasts contained one red to pale blue nucleus with one or two grey-red to blue nucleoli in group 2. Forty-four per cent of animals in group 1 had osteoblasts with more than two nucleoli per nucleus. The median nuclear:cytoplasmic ratio was higher in group 1 (1:2.0) than in group 2 (1:3.5). Osteoblasts in group I were frequently seen to have a clumped chromatin pattern and showed significantly more criteria of malignancy (median six criteria per patient) than those in group 2 (median two criteria per patient). In group 1, mitoses of osteoblasts were detectable in 23 of 25 dogs, whereas only one dog in group 2 had evidence of mitotic osteoblasts.

CLINICAL SIGNIFICANCE

Cytological criteria can be helpful in the diagnosis of canine osteosarcoma.

Biopsy of hand, wrist, and forearm tumors

This article describes three biopsy methods currently used for treating masses arising in the hand, wrist, and forearm: open biopsy, fine needle aspiration, and core needle biopsy. The forearm, wrist, and hand comprise a complex and diverse anatomic region, and biopsy is emphasized as the most important element in the diagnosis of the musculoskeletal tumor. Biopsy methods for assessing true neoplasms, bony protuberances, cysts,infection and abscesses, foreign bodies, reactive granulomas, tenosynovial proliferation,and skin and fascial lesions are discussed.

Osteosarcoma in a patient with McCune-Albright syndrome and Mazabraud's syndrome: a case report emphasizing the cytological and cytogenetic findings

Osteosarcomatous transformation in fibrous dysplasia is unusual. The incidence is increased in patients with concomitant Mazabraud's syndrome and McCune-Albright syndrome. We report the cytological, histological, and cytogenetic findings of this rare entity arising from a mass in the right elbow of a 44-year-old African-American woman. The fine-needle aspiration (FNA) findings were diagnostic of malignancy, with markedly atypical spindle and polygonal cells admixed with osteoid. The diagnosis of osteosarcoma by FNA was subsequently further confirmed by histological evaluation of an above-elbow amputation specimen. Fluorescence in situ hybridization and comparative genomic hybridization demonstrated trisomies of chromosomes 5 and 7 in the fibrous dysplasia and osteosarcoma. In addition, multiple chromosomal abnormalities were also noted in the osteosarcoma. We are unaware of any previous reports of the cytogenetic findings in the tissue of this rare condition, and argue for the value of FNA in the evaluation of such patients under selected conditions.

Scrape and fine-needle aspiration cytology of extraskeletal osteosarcoma

Extraskeletal osteosarcoma is a rare malignant soft tissue tumor whose cytologic findings are infrequently reported. We describe scrape and fine-needle aspiration biopsy (FNAB) cytology findings of an extraskeletal osteosarcoma in the right shoulder of a 24-yr-old man. Initial computed tomography revealed multiple ossification foci within the lesion. After excision of the primary tumor, the tumor recurred 13 months later. Scrape smears of both the primary tumor and FNAB smears of the recurrent tumor revealed moderate cellularity, cell clusters, and individual cells, closely associated with dense, homogeneous, acellular matrix material. The cells had elongated, oval, or partially bizarre-shaped nuclei with a coarse chromatin pattern and prominent nucleoli. The scrape smears contained large fragments of matrix material consistent with osteoid.

Cytology of bone lesions by intraoperative sampling during fracture treatment

Cytology was performed on 314 patients who were treated by surgery for hip joint fracture, to determine and evaluate the role, accuracy, and perspective of intraoperative bone sampling. Specimens were collected from bone lesions during surgery by imprints or driller washing in normal saline. The results were compared with those of subsequent biopsies or clinical follow-up. All 13 neoplastic cases (malignant or benign) were identified by cytology. An accuracy rate of 69.2% was achieved by this method when the type and origin of the neoplasms were to be conclusive. There were no false-positive diagnoses, and all benign conditions showed negative results on cytology (specificity and sensitivity of 100%). Cytology can play a valuable role in the diagnosis of bone lesions. The morphologic diagnostic criteria allow for a high level of diagnostic accuracy of cytologic assessments in most cases of bone lesions, no matter the sampling technique.

Is fine-needle aspiration biopsy a practical alternative to open biopsy for the primary diagnosis of sarcoma? Experience with 140 patients

We reviewed the clinicopathologic features of 145 consecutive fine-needle aspiration biopsy (FNAB) specimens from 140 patients without a previous diagnosis of sarcoma. Among 138 adequate specimens, 42 bone sarcomas and 80 soft tissue sarcomas were recognized as sarcomas; histologic subtyping was easier in bone than in soft tissue sarcomas and in pediatric than in adult cases. There was no correlation in accuracy of subtyping in low- vs high-grade sarcomas. FNAB was most accurate for subtyping of skeletal osteosarcoma, pediatric small round cell bone/soft tissue sarcomas, synovial sarcoma, skeletal chondrosarcoma, and adult myxoid soft tissue sarcomas. Although almost always recognized as sarcoma, subtyping of adult pleomorphic soft tissue sarcomas generally was not possible but did not influence therapy; all were considered high-grade sarcomas for treatment purposes. There were 4 misinterpretations of subtype in soft tissue sarcomas; none resulted in a change in therapy. Cytogenetic analysis on aspirated material confirmed t(11;22) in 2 Ewing and t(X;18) in 3 synovial sarcomas. No procedure-related complications occurred. Among bone and soft tissue sarcomas, FNAB was sufficient for initiation of definitive therapy in 87% and 83% of patients, respectively. Most FNAB specimens from bone and soft tissue sarcomas are recognized easily as sarcoma, but subtyping seems more accurate in bone sarcomas. Although histologic subtyping of adult soft tissue sarcomas is often impossible, no influence on initial therapy is usually observed. In contrast, subtyping of pediatric sarcomas by FNAB seems highly accurate and is necessary for appropriate therapy.

Fine-needle aspiration cytology of spindle cell lesions of the breast

BACKGROUND

Fine-needle aspiration biopsy (FNA) has been successful in diagnosing epithelial lesions of the breast. Its role in the evaluation of spindle cell and mesenchymal lesions of the breast, which include a variety of benign and malignant conditions, is less clear. This article discusses the cytologic features and differential diagnosis of these lesions, as well as the potential diagnostic pitfalls associated with them.

METHODS

FNAs of the breast, in which a spindle cell or mesenchymal component was a key or dominant feature, were retrieved. Fibroadenomas without cellular stroma and typical lipomas were excluded.

RESULTS

Forty-six aspirates (0.87%) in a series of 5306 breast FNAs contained a significant spindle cell or mesenchymal component. The aspirates were classified into 4 categories: 1) reactive conditions, including 2 diabetic mastopathies, 3 granulation tissue specimens, and 7 granulomatous lesions; 2) benign neoplastic conditions, including 1 mammary hamartoma, 1 dermatofibroma, 1 fibromatosis, 2 granular cell tumors, 2 angiolipomas, and 7 cellular fibroadenomas; 3) low grade malignant neoplastic lesions, including 10 low grade phyllodes tumors; and 4) high grade malignant neoplastic lesions, including 1 metaplastic carcinoma with chondroid stroma, 1 pleomorphic liposarcoma, 2 malignant fibrous histiocytomas, 2 osteosarcomas, and 4 metastatic melanomas. A specific diagnosis was rendered in 38 cases (82.6%). The mammary hamartoma was diagnosed as fibrocystic changes; the dermatofibroma as benign spindle cell lesion, not otherwise specified (NOS); and the primary osteosarcoma as an atypical spindle cell proliferation, NOS. The reactive ductal epithelial cells in one of the granulomatous mastitis specimens, as well as the hyperplastic ductal epithelial cells in one of the phyllodes tumors, were interpreted as atypical ductal proliferation. The marked cytologic atypia displayed by one granular cell tumor was interpreted as low grade adenocarcinoma and the primary liposarcoma as poorly differentiated carcinoma.

CONCLUSIONS

Breast lesions with a significant spindle cell or mesenchymal component are rarely encountered in FNA and constitute a heterogeneous group that may pose a diagnostic dilemma. FNA should be the initial diagnostic procedure for investigating these lesions, as a specific diagnosis was rendered in the majority of cases. Cancer (Cancer Cytopathol)

Fine-needle aspiration biopsy of chondroblastic osteosarcoma of the vertebral column complicated by Corynebacterium infection: a case report

We describe a case of chondroblastic osteosarcoma of the vertebral column in a 67-yr-old male in whom the preoperative diagnosis was made by fine-needle aspiration biopsy (FNAB). This diagnosis was subsequently confirmed in the T8 corpectomy specimen. Although the smears of the aspirate revealed only occasional markedly atypical spindle-shaped nuclei, the cell block was diagnostic of malignancy. It showed a well-preserved fragment of neoplastic cartilage populated by markedly atypical hyperchromatic cells and a crushed fragment of anaplastic spindle-shaped cells surrounded by opaque collagenous matrix reminiscent of osteoid. The surgically resected specimen exhibited comparable histological features as well as colonies of gram-positive bacilli within the necrotic tumor. Culture confirmed the presence of Corynebacterium species. It is likely that these skin organisms were introduced at the time of FNAB. This case demonstrates the value of FNAB in the diagnosis of primary bone tumors and reports a rare complication of this procedure.

Fine-needle aspiration biopsy of skeletal versus extraskeletal osteosarcoma

BACKGROUND

Although fine-needle aspiration biopsy (FNAB) of primary skeletal osteosarcoma (OS) has been described adequately, to the authors' knowledge, cytologic descriptions of extraskeletal OS appear limited to only rare case reports.

METHODS

In an attempt to analyze the utility and accuracy of FNAB in a diagnosis of skeletal versus extraskeletal OS, the authors retrospectively reviewed their 5-year experience. The study sample included 15 skeletal OS specimens (13 primary, 1 local recurrence, and 1 pulmonary metastasis) in 14 patients ages 10-58 years (mean, 27 years; median, 25 years) and 5 extraskeletal OS specimens (3 primary and 2 metastatic) in 4 patients ages 36, 37, 65, and 79 years, respectively. Based on accepted clinical criteria, two patients (a mother with extraskeletal OS and a daughter with skeletal OS) had Li-Fraumeni syndrome.

RESULTS

Of the adequate primary skeletal OS cases analyzed by FNAB, 10 of 12 (83%) were diagnosed correctly and subsequently treated according to a disease specific protocol. One case was considered unsatisfactory. One tumor initially was diagnosed as a giant cell tumor and another was referred to nonspecifically as "spindle-cell neoplasm." On histologic examination, the former case demonstrated a high grade fibroblastic OS arising within a giant cell tumor. None of the primary extraskeletal OS cases analyzed by FNAB was recognized as OS. One was diagnosed nonspecifically as "sarcoma" and the other was referred to simply as "atypical mesenchymal cells." A third case was comprised of scant fragments of adipose tissue, fibrous tissue, and cartilage and was considered unsatisfactory. Both examples of metastatic extraskeletal OS were recognized by FNAB.

CONCLUSIONS

With appropriate clinicoradiologic correlation, skeletal OS generally is easily diagnosed by FNAB. Because of the older age of most patients with extraskeletal OS and the rather nonspecific radiographic findings (e.g., soft tissue mass), extraskeletal OS may not be recognized easily by FNAB and most likely requires incisional biopsy to establish a definitive diagnosis in most cases. Additional larger series will be required before drawing definite conclusions.

Chondroblastoma of bone: use of fine-needle aspiration biopsy and potential diagnostic pitfalls

Chondroblastoma of bone is a well-characterized entity. When the radiographic features are classic and the lesion is present in typical locations (i.e., epiphysis of a long bone), the diagnosis is often easily established by fine-needle aspiration biopsy and/or surgical curettage. Tumors in unusual locations, in older patients, or when complicated by aneurysmal bone cysts may pose more diagnostic difficulty. We report four examples (three primary and one-recurrent) of chondroblastoma of bone diagnosed by fine-needle aspiration biopsy. All patients were men, ranging from 18 to 28 yr of age. Sites of involvement included the acromion process of the scapula, left humerus, right ischium, and left distal femur. Three of the tumors were diagnosed as chondroblastoma on fine-needle aspiration cytology; the fourth case, involving the scapula, consisted mostly of a large aneurysmal bone cyst and remained unrecognized until surgical curettage was performed. Typical-appearing chondroblasts were present in three of the cases; osteoclast-type giant cells were observed in all four cases. Matrix material consistent with chondroid was also identified in all cases. We believe that in the absence of inflammatory cells, the presence of classic-appearing chondroblasts, even without chondroid matrix, is sufficient for a diagnosis of chondroblastoma of bone.

Cytogenetic studies on fine-needle aspiration samples from osteosarcoma and Ewing's sarcoma

The preoperative multidrug chemotherapy of osteosarcoma and Ewing's sarcoma patients requires a reliable diagnosis. There are several advantages with obtaining the diagnosis by fine-needle aspiration (FNA) and cytologic examination. Although cytologic criteria have been defined, adjunctive methods such as cytogenetic analysis are valuable to support the diagnosis. We have cytogenetically analyzed FNAs from 18 primary bone sarcomas (six osteosarcomas and 12 Ewing's sarcomas). Two of the osteosarcomas showed abnormal, complex karyotypes seen in most highly-malignant osteosarcomas. Seven Ewing's sarcoma aspirates displayed abnormal karyotypes; five of these had the characteristic 11;22 translocation, and in one of these cases molecular genetic analysis revealed the hybrid EWS/FLI1 transcript. Since only two of six osteosarcomas showed clonal changes, chromosomal analysis of FNAs from suspected osteosarcoma seems to be of limited value, but may in some cases support the diagnosis of high-grade malignancy. In Ewing's sarcomas, however, the finding of an 11;22 translocation was valuable and strongly supported the cytologic diagnosis. As shown in one case, the material obtained by FNA is sufficient for cytologic, cytogenetic, and molecular genetic analysis.

Diagnostic accuracy and charge-savings of outpatient core needle biopsy compared with open biopsy of musculoskeletal tumors

We performed a prospective study of sixty-two patients who were managed with a closed core needle biopsy in an outpatient clinic for a soft-tissue mass or a bone tumor with soft-tissue extension between August 1, 1992, and June 1, 1994. Eight (13 percent) of the closed core needle biopsies yielded no neoplastic tissue. Two needle biopsies (3 percent), which were of myxomatous masses, did not allow distinction between a benign and a malignant neoplasm; both masses were extraskeletal myxoid chondrosarcomas. Additionally, the histological grade of four resected specimens (6 percent) differed from that determined with the closed needle biopsy. The diagnostic accuracy of the closed needle biopsies was 84 percent (fifty-two of sixty-two). All ten diagnostic errors involved soft-tissue tumors. A retrospective study of a similar cohort of patients who had open biopsy in an outpatient operating room by the same surgeon in a contemporary period in the same institution and with analysis by the same pathologist, revealed a diagnostic accuracy of 96 percent (forty-eight of fifty). The hospital charges for the closed core needle biopsy were $1106, compared with $7234 for the open biopsy. We concluded that core needle biopsy can be performed in an outpatient clinic with use of local anesthesia and that it is substantially less expensive and more convenient than open biopsy. This technique has an acceptable but definitely lower rate of accuracy compared with open biopsy, especially for soft-tissue tumors, and it should be used only in a small subset of patients (those who have a large soft-tissue mass or a bone tumor with palpable soft-tissue extension). However, given the small size of the tissue sample, the clinician must recognize possible disadvantages, including a non-diagnostic biopsy, an indeterminate biopsy, or a potential error in the histological grade. These problems are much more likely to occur after core needle biopsy of soft-tissue masses. Because of the potential for errors in diagnosis when core needle biopsy is used, the musculoskeletal oncologist must rely on his or her clinical acumen. When a diagnosis is in reasonable doubt, there is no radiographic confirmation, the biopsy shows no tumor cells, or there is a combination of these findings, operative decisions should be made as if no biopsy had been performed. The management of patients who, after core needle biopsy, have a diagnosis of a bone or soft-tissue tumor, is best carried out by an experienced musculoskeletal oncologist working in close collaboration with an experienced musculoskeletal pathologist.

Fine-needle aspiration of chondroblastic osteosarcoma of the skull: report of a case in an 11-year-old girl

We describe an unusual case of chondroblastic osteosarcoma of the skull in an 11-yr-old girl in whom a preoperative diagnosis was made by fine-needle aspiration (FNA) biopsy, followed by histologic confirmation of tissue biopsy and the surgically resected specimen. FNA cytology revealed pleomorphic oval cells with prominent nucleoli along with spindle cells, tumor giant cells, and a chondromyxoid background. The cell block of the aspirated material showed osteoid associated with the malignant cells. Immunocytochemical stains revealed S-100 and vimentin positivity; actin, myoglobin, and cytokeratin stains were negative. Electron microscopy revealed neoplastic cells with chondrocytic differentiation. This case demonstrates the value of FNA biopsy combined with immunocytochemical and ultrastructural studies performed on the aspirated material in diagnosing osteosarcoma from an unusual location such as the base of the skull.

Diagnostic accuracy and clinical utility of fine-needle aspiration cytology in the diagnosis of clinically primary bone lesions

Optimal treatment of primary bone sarcomas requires minimal disturbance of the tumor prior to preoperative radiation and chemotherapy. Currently, carefully planned incisional or cutting needle biopsies are the favored methods for procurement of specimens. Recently, fine-needle aspiration has gained favor as the initial diagnostic procedure at some centers. We investigated the diagnostic accuracy and the effects of errors in diagnosis and of complications on the patient's course in a series of 101 patients presenting with lesions clinically believed to have arisen in bone. We found that 29% of aspirates were insufficient for the diagnosis; 41% of aspirates yielded a correct diagnosis that had a significant favorable impact on the patient's course, while 20% of aspirates gave a correct diagnosis that did not significantly influence therapy. In 7% of cases, the aspirates were associated with an incorrect diagnosis that negatively influenced therapy, and in an additional 3% of cases an incorrect diagnosis was obtained that had no impact on patient outcome. No complications were encountered in this series of patients.

Chondrosarcoma of bone as second tumor after diffuse anaplastic Wilms' tumor: diagnosis by fine-needle aspiration cytology

A 6-yr-old boy already treated (surgery and chemotherapy) for a diffuse anaplastic Wilms' tumor discovered at the age of 10 mo, presented with a large tumor in the left femur. This proved to be a chondrosarcoma after fine-needle aspiration cytology, a diagnosis later confirmed by histology of the tumor. The patient was treated with marginal excision and prosthetic replacement but died 1 yr after this operation with lung metastasis. It is proposed that this case may represent a new association of unusual types of tumors.

Intrathoracic osteosarcoma diagnosed by CT scan and pleural biopsy

Osteosarcoma rarely presents as a primary lesion in the chest, whereas pulmonary metastases are common. The diagnosis of primary intrathoracic osteosarcoma has invariably been by thoracotomy or autopsy. We present a case of a densely calcified, primary intrathoracic osteosarcoma where diagnosis was made antemortem by pleural biopsies and computed tomography scan.