Soft tissue aspiration cytopathology: Diagnostic accuracy and limitations

The preoperative value of fine-needle aspiration in adult soft tissue lesions: An analysis of 514 cases at Shanghai Cancer Center

BACKGROUND

Fine-needle aspiration (FNA) cytology is a rapid, inexpensive, and uncomplicated method. However, its role in the assessment of soft tissue lesions (STL) remains controversial, and its ability to guide surgical treatment remains unclear. This study investigated the positive predictive value (PPV) of FNA for detecting malignancy and its guiding role in the surgical treatment of STL.

METHODS

We retrospectively reviewed 514 patients with STL who underwent preoperative FNA and surgical resection between March 2015 and August 2021. Imaging assessments confirmed that radical surgery was possible. The FNA results were compared with the final postoperative histopathology.

RESULTS

Of the 514 patients with STL, 496 (mean age, 48.9 years; range, 21-91 years) were eligible for analysis, the male to female ratio was 111:100. According to the 496 FNA results, 90 (18.2%) were positive for malignancy, 84 (16.9%) were suspicious for malignancy, 80 (16.1%) were spindle cell present, and 242 (48.8%) were negative for malignant cells. Compared with postoperative histopathology, FNA correctly detected all 90 malignant lesions and 203 of the 242 benign lesions. A total of 39 false-negative results were obtained. FNA showed an accuracy of 88.3%, sensitivity of 69.8%, specificity of 100%, negative predictive value (NPV) of 83.9%, and PPV of 100%. In the other seven validation cohorts (n = 1157), FNA had a consistently high PPV, with values all more than 93%.

CONCLUSION

Our results demonstrate that FNA has a high PPV for detecting malignancy. For patients with resectable lesions and malignant FNA, the core needle biopsy (CNB) step can be omitted with multidisciplinary evaluation, and subsequent radical surgery can be performed.

Adjunct diagnostic strategies in improving diagnostic yields in image-guided biopsies of musculoskeletal neoplasms-A cost-effectiveness analysis

BACKGROUND

Routine use of adjunct intraprocedural fresh frozen biopsy (FFP) or point-of-care (POC) cytology at the time of image-guided biopsy can improve diagnostic tissue yields for musculoskeletal neoplasms, but these are associated with increased costs.

OBJECTIVE

This study aimed to ascertain the most cost-effective adjunctive test for image-guided biopsies of musculoskeletal neoplasms.

METHODS

This expected value cost-effectiveness microsimulation compared the payoffs of cost (2020 United States dollars) and effectiveness (quality-adjusted life, in days) on each of the competing strategies. A literature review and institutional data were used to ascertain probabilities, diagnostic yields, utility values, and direct medical costs associated with each strategy. Payer and societal perspectives are presented. One- and two-way sensitivity analyses evaluated model uncertainties.

RESULTS

The total cost and effectiveness for each of the strategies were $1248.98, $1414.09, $1980.53, and 80.31, 79.74, 79.69 days for the use of FFP, permanent pathology only, and POC cytology, respectively. The use of FFP dominated the competing strategies. Sensitivity analyses revealed FFP as the most cost-effective across all clinically plausible values.

CONCLUSIONS

Adjunct FFP is most cost-effective in improving the diagnostic yield of image-guided biopsies for musculoskeletal neoplasms. These findings are robust to sensitivity analyses using clinically plausible probabilities.

Comparative cytological and histological assessment of 828 primary soft tissue and bone lesions, and proposal for a system for reporting soft tissue cytopathology

Introduction

The aim of the study was to evaluate the diagnostic utility of fine needle aspiration (FNA) cytology and core needle biopsies (CNBs) in a series of primary soft tissue and bone lesions and to test a possible system for reporting results of FNA cytology of soft tissue lesion.

Methods

This retrospective study encompassed 828 primary soft tissue and bone lesions, analysed with FNA, CNB and/or surgical specimen in order to perform sensitivity/specificity as well as accuracy analyses. The series was then used to test a system for reporting soft tissue cytopathology with six categories and the risk of malignancy in each category was calculated.

Results

With a malignant diagnosis defined as positive test result, FNA and CNB analysis showed sensitivity of 87% and 94%, respectively, and specificity of 89% and 95%, respectively. FNA and CNB analyses identified the correct histopathological entity of the examined lesion in 55% and 66%, respectively. The risk of malignancy within the tested categories was non‐diagnostic 42%, non‐neoplastic 0%, atypia of unknown significance 46%, neoplasm benign 3%, neoplasm of unknown malignant potential 27%, suspicious for malignancy 72% and malignant 97%.

Conclusion

FNA cytology is a suitable tool to determine the malignant potential of a sampled soft tissue/bone lesion but is inferior to CNB in defining the correct entity. A standardised reporting system might improve the clinical management of patients with soft tissue tumours examined primarily by FNA cytology.

The study evaluated the diagnostic utility of fine needle aspiration cytology and core needle biopsies in 828 primary soft tissue and bone lesions. In a second step, a possible system for reporting results of fine needle aspiration cytology of soft tissue lesion was tested.

Cytologic grading of canine and feline spindle-cell sarcomas of soft tissues and its correlation with histologic grading

In humans, soft tissue spindle cell sarcomas (STSCS) grading is considered a useful parameter in determining prognosis and therapy, and it is recognized as an important prognostic factor in canine STSCS. The purpose of this study was to assess the utility and the accuracy of a cytologic grading system on fine needle aspiration cytology (FNAC) smears of canine and feline cutaneous and subcutaneous STSCS .Thirty-three cases of cytologically diagnosed STSCS were included. The smears and their tumour sections were cytologically and histologically graded, according to established methods in human oncology.Canine STSCS showed a cyto/histologic concordance in 12/20 cases (60%). Concordance was observed in 4/8 (50%) of grade 1, in 8/12 (67%) of grade 2, and in 0 cases of grade 3. Feline STSCS showed concordance in 11/13 cases (85%). Concordance was observed in 5/6 (83%) of grade 1, in 4/4 (100%) of grade 2, and in 2/3 (66.6%) of grade 3 cases. The overall concordance in the entire canine and feline population was 70%. The gradewise concordance was 65% in grade 1, 75% in grade 2, and 66% in grade 3 cases. The overall concordance is similar to that reported in humans. Although a wider population is required to strengthen our findings, these results suggest that cytologic grading of STSCSs may be a useful tool for therapeutic and prognostic evaluations in dogs and cats.

Tuberculous Lymphadenitis and Parotitis

Tuberculous lymphadenitis is the most common extrapulmonary manifestation of disseminated tuberculosis (TB). It is considered to be the local manifestation of the systemic disease that has disseminated to local lymph nodes, but a high index of suspicion is needed for the diagnosis, because there are several infectious and noninfectious diseases that can mimic the same clinical picture. In recent years, different diagnostic methods have been introduced, including fine-needle aspiration cytology, which has emerged as a simple outpatient diagnostic procedure that replaced the complete excisional node biopsy, and a number of molecular methods which have greatly improved diagnostic accuracy. This chapter covers the most actual knowledge in terms of epidemiology, clinical manifestations, pathogenesis, and treatment and emphasizes current trends in diagnosis of tuberculous lymphadenitis. TB parotid gland involvement is extremely rare, even in countries in which TB is endemic. Because of the clinical similarity, parotid malignancy and other forms of parotid inflammatory disease always take priority over the rarely encountered TB parotitis when it comes to differential diagnosis. As a result, clinicians often fail to make a timely diagnosis of TB parotitis when facing a patient with a slowly growing parotid lump. This chapter highlights the most important features of this uncommon disease.

US-guided core-needle biopsy versus US-guided fine-needle aspiration of suspicious cervical lymph nodes for staging workup of non-head and neck malignancies: A propensity score matching study

BACKGROUND AND OBJECTIVES

To compare US-guided core-needle biopsy (USCNB) and US-guided fine-needle aspiration (USFNA) of suspicious cervical lymph nodes for staging workup of malignancies in locations other than the head and neck using propensity score matching (PSM).

METHODS

This retrospective cohort study included 108 patients who underwent USFNA and 1058 who underwent USCNB for suspicious cervical lymph nodes detected by imaging modalities during the staging workup for malignancies located in regions other than the head and neck. The primary outcome was defined as the inconclusive results. To evaluate the procedures according to the outcome, we performed univariate and multivariate logistic regression analyses and a 1:1 PSM of USCNB and USFNA.

RESULTS

There was no complication for both USFNA and USCNB. The inconclusive results were 6.5% (7/108) for USFNA and 1.6% (17/1058) for USCNB. A significantly lower rate of the inconclusive results in USCNB than in USFNA before matching was maintained after a 1:1 PSM of 103 patients from each group (before PSM, odds ratio (OR) = 4.489, 95% confidence interval (CI) [1.803-11.177], P = 0.001; after PSM, OR = 1.060, 95%CI [1.013-1.109], P = 0.012).

CONCLUSIONS

Because USCNB can reduce inconclusive results compared to USFNA, it could be more helpful for staging workup of malignancies in locations other than the head and neck in patients with suspicious cervical lymph nodes.

Diagnostic utility of fine-needle aspiration cytology of lesions involving bone

BACKGROUND

Fine-needle aspiration (FNA) is utilized in the diagnostic work-up of bone lesions in a number of institutions, either in isolation or in conjunction with core biopsy. We report our experience with FNA of bone-based lesions, including comparison of this approach with concurrent core biopsy specimens.

METHODS

Retrospective review over a 5-year period (2011-2015) revealed 233 cases of bone FNAs.

RESULTS

The most commonly encountered diagnosis was malignant neoplasm (160 cases, 68.7%); within this group of malignancies, 103 cases (64.4%) represented metastatic carcinoma. Benign lesions were encountered infrequently (9 cases, 3.9%). While 37 cases (15.9%) revealed "no evidence of malignancy," 12 cases (5.2%) showed atypical findings, 3 cases (1.3%) demonstrated inflammatory conditions, and 12 aspiration biopsies were deemed nondiagnostic (5.2%). In 202 cases, concurrent core biopsies were performed following FNA and rapid on-site evaluation (ROSE). Comparison of the FNA and core biopsy diagnoses among malignant neoplasms revealed 19 diagnostic discrepancies, including 16 cases with a false-negative FNA (7.9% of all FNAs with concurrent core biopsy) and 3 cases with a false-negative core biopsy (1.5% of all cases with corresponding FNA).

CONCLUSION

Our findings indicate that FNA of bone lesions is a useful diagnostic technique with high sensitivity, particularly when the cytologic findings are interpreted in conjunction with the core biopsy and pertinent clinical and radiologic findings. In addition, ROSE followed by open, dynamic communication with the performing radiologist leads to an extremely low rate of inadequate core biopsy specimens, resulting in optimal patient diagnosis and management. Diagn. Cytopathol. 2017;45:608-613. © 2017 Wiley Periodicals, Inc.

Fine Needle Aspiration Cytology for Soft Tissue Tumours of the Hand

The purpose of this study was to evaluate the usefulness of fine needle aspiration cytology for the preoperative diagnosis of soft tissue tumours of the hand. Fine needle aspiration cytology was performed on 93 soft tissue tumours of the hand which were classified as malignant, benign or unclassified based on cytological findings. We also attempted to make specific diagnosis by cytology. The cytological diagnosis was then compared with the postoperative histopathological diagnosis. The cytological differentiation between benign and malignant tumours showed neither false-positive nor false-negative results. Of the 47 lesions with sufficient material for cytology and that were postoperatively diagnosed histologically, 35 (including one recurrent lesion) were correctly diagnosed by fine needle aspiration cytology. No complications were encountered. Fine needle aspiration cytology has a high degree of diagnostic accuracy and safety for soft tissue tumours of the hand.

Mesenchymal neoplasms of the head and neck: a cytopathologic analysis on fine needle aspiration

INTRODUCTION

Fine-needle aspiration (FNA) is commonly used to diagnose mass lesions discovered in the head and neck (H&N). Soft tissue neoplasms (STNs) are less common than epithelial tumors in this anatomic zone and often cause diagnostic difficulty when encountered in routine practice. In this study, we examine the frequency of H&N STNs at our institution and describe their cytomorphologic characteristics and clinical correlates.

METHODS

115 FNA specimens from 115 patients with STN of the H&N region were identified (2005-2015) from archives of The Johns Hopkins University Hospital. When available, slides from these cases were reviewed and any corresponding clinical and radiologic data was evaluated.

RESULTS

A total of 95 (83%) STNs were found to be primary to the H&N region and 20 (17%) were metastatic from distant sites. Of these 95 cases, 58 (61%) primary lesions were benign and 37 (39%) were malignant. The most common STNs were benign nerve sheath tumors, representing 40 (35%) cases: 30 schwannomas, 4 neurofibromas, and 6 were not further classified. The most aggressive neoplasms in terms of clinical outcome were leiomyosarcoma, Ewing sarcoma, synovial sarcoma, and chondrosarcoma. In 35 (60%) of the malignant cases and 25 (54%) of the benign cases a subsequent surgical resection was performed.

CONCLUSIONS

H&N can be involved by a wide range of primary and metastatic STNs. benign nerve sheath tumors are the most common STNs found on FNA in this region. Although not always definitively diagnostic, FNA of STNs can often provide a differential diagnosis that can help guide the need for an excision and/or further treatment.

Nodular Fasciitis: Definitive Diagnosis by Fine Needle Aspiration

OBJECTIVES

Nodular fasciitis (NF) is a self-limited, mass-forming, fibrous proliferation that can occur in the head and neck and may mimic malignancy. Fine-needle aspiration biopsy (FNAB) is a minimally invasive, rapid, accurate method of obtaining diagnostic material from head and neck masses. In this study, we verify the usefulness of FNAB in obtaining a definitive diagnosis of NF.

METHODS

Cases were identified from our laboratory information system. Cytology slides were reviewed to note morphologic features and confirm diagnoses. Clinical history was obtained to document the case presentations and outcomes.

RESULTS

All 9 cases were found to have clinical presentations and common distinguishing morphologic features consistent with NF. Two cases were excised surgically, and the remainder regressed spontaneously. There were no recurrences.

CONCLUSIONS

FNAB can produce a definitive diagnosis of NF, providing an opportunity to avoid surgical excision in patients with a typical clinical presentation.

Outcomes in the management of adult soft tissue sarcomas

Adult soft tissue sarcomas (STSs) are heterogeneous neoplasms that account for 11,410 new diagnoses and 4,390 deaths per year. This article summarizes recent NCCN guidelines for diagnosis and management of STSs of the extremities and retroperitoneum, as well as gastrointestinal stromal tumors (GIST). AJCC staging and recently reported NCDB data regarding outcomes are reviewed. Currently accepted STS prognostic variables are presented, as are future directions regarding the utility of molecular prognosticators and nomograms.

A prospective study of soft tissue tumors histocytopathology correlation

Background. Soft tissue tumors are defined as nonepithelial extraskeletal tissue of the body exclusive of the reticuloendothelial system, glia, and supporting tissue of various parenchymal organs. The absence of recognizable tissue architectural patterns in cytological preparation makes diagnosis by FNAC more difficult. Aims. To assess the utility of FNAC in diagnosing soft tissue tumors and to determine their patterns compared with with the respective histopathology results. Materials and Methods. 150 cases of soft tissue tumors were included in this study for cytologic and histologic correlation. FNAC air dried smears were stained with Giemsa stain and 95% ethanol fixed smears were stained with Papanicolaou stain. The smears were studied for cytological diagnosis and were categorized as benign, suspicious of malignancy, and malignant along with specific subtyping of the lesion. All diagnostic FNAC results were compared for diagnostic concordance using histology results as the “gold standard.” Results. The sensitivity, specificity, positive predictive value, negative predictive value, and efficiency were 70%, 100%, 97.90%, 100%, and 98%, respectively. P value was <0.0001 which shows statistically extreme significant correlation. Conclusion. FNAC is a very important preliminary diagnostic tool in palpable soft tissue lumps with high degree of correlation with the final histopathology report.

Diagnostic accuracy and clinical utility of biopsy in musculoskeletal lesions: a comparison of fine-needle aspiration, core, and open biopsy techniques

Selection of biopsy technique for musculoskeletal lesions is complex. Fine-needle aspiration (FNA) is uncommonly used due to concerns regarding accuracy. We compared diagnostic accuracy of FNA, core, and open biopsy in a series of musculoskeletal lesions. Records of the University of Utah were searched for biopsy and resection specimens of musculoskeletal lesions. Results of corresponding imaging studies were obtained. Biopsy and FNA diagnoses were correlated with resection diagnoses. For each technique, diagnostic accuracy, utility, and frequency of subsequent biopsy were calculated. Open biopsy had the highest diagnostic accuracy (89%) followed by FNA (82%) and core biopsy (78%). Clinically significant errors occurred with all methods. The likelihood of an open biopsy being performed was affected by prior performance of an FNA or core biopsy and by diagnostic imaging and FNA results.

[Cytologic diagnosis of sarcoma]

Soft tissue swelling represents a common clinical sign of a variety of neoplastic and non-neoplastic lesions. Sarcoma is rarely a cause. Fine needle biopsy as a minimally invasive, economic and accurate method is well suited for the diagnosis of inflammatory/infectious processes as well as of recurrent and metastatic disease. Cytologic diagnosis of primary soft tissue tumors is also feasible. It requires close collaboration with other medical disciplines and incorporation of clinical, radiological and morphologic findings. Clinical data such as age, gender, size and topography are important parameters. The differentiation of cells and properties of the extracellular matrix supplies clues for the differential diagnosis and forms the starting point for immunohistochemical or molecular analysis (FISH, RT-PCR). This analysis may be performed on cytological smears, paraffin embedded material of the cell blocks or on frozen material.

Preoperative fine needle cytology and imaging facilitates the management of submandibular salivary gland lesions

BACKGROUND

  Lesions of the submandibular gland represent a pleomorphically diverse group in which benign and malignant pathologies are difficult to differentiate from each other. Accurate diagnosis and surgical intervention relies upon clinical presentation, examination and investigations to guide appropriate management. The current series aimed to identify the roles of preoperative cytology and imaging with subsequent histopathology in the management of these lesions.

METHODS

Between 1998 and 2008, 54 patients of median age 54 years (range 25-94), with a male : female ratio of 1:3.5 were identified, of which, 50 patients underwent 52 excisions of the submandibular gland. Demographic data were recorded. The utility of imaging and cytology were analysed, and the accuracy of cytology correlated with histology.

RESULTS

Pathologies of resected specimens were sialadenitis 17 (32%), pleomorphic adenomas nine (17%), calculi eight (15%), lymphoma five (10%), squamous cell carcinoma two (4%), adenoid cystic carcinoma one (2%) and other 10 (20%). Twenty-eight patients (52%) underwent fine-needle aspiration cytology/core biopsies, of which 25 (89%) were correlated with histology. The accuracy, sensitivity and specificity of the fine-needle aspiration cytology correlation with histology were 88.0%, 71.4% and 94.4%, respectively. Overall, the complication rate was 9.6%; involving five temporary nerve palsies of the marginal mandibular branch of the facial nerve, including one temporary lingual nerve palsy.

CONCLUSION

This series demonstrates histological outcomes in patients specific to the submandibular salivary gland. The malignancy rate was low compared to current published literature. The transcervical surgical approach to submandibular gland pathology is a safe and effective method with minimal morbidity when performed by experienced surgeons. No single investigative modality can be solely aligned with diagnosing a specific lesion of the submandibular gland.

Fine-needle aspiration for proteomic study of tumour tissues

Fine-needle aspiration (FNA) is a technique largely applied in the diagnosis of tumours. FNA is a safe diagnostic procedure that is widely employed in the examination of masses at relatively low cost and minimal risk to the patient. In this review, we report on the state-of-the-art and the potential role of FNA to search for protein biomarkers by the proteomic approach.

Fine-needle aspiration cytology features of a recurring plexiform fibrohistiocytic tumor in the upper limb and review of the literature

Plexiform fibrohistiocytic tumor is a rare soft tissue tumor that has a propensity to occur in the extremities in adolescents and young adults. Its cytologic features are not well documented, with only two case reports available in the literature. We present the case of a recurrent plexiform fibrohistiocytic tumor in a 19-year-old male, the cytologic features of which mimic that of a high-grade sarcoma. We discuss the likely differential diagnosis based on the cytologic findings and a review of the current literature on this highly unusual tumor is also performed.

Cytologic findings and potential pitfalls in proliferative myositis and myositis ossificans diagnosed by fine needle aspiration cytology: report of four cases and review of the literature

Proliferative myositis (PM) and myositis ossificans (MO) are two uncommon, benign pseudosarcomatous lesions of soft tissue. Despite their benign nature, they are often misdiagnosed for malignant soft tissue tumors because of their alarming clinical presentation. Fine needle aspiration cytology (FNAC) is a quick and simple method that can accurately diagnose such lesions, provided that the cytopathologist is adequately familiar with the cytomorphological features of these lesions as opposed to the features of sarcomas. In this report, we present three cases of PM and one case of MO diagnosed by FNAC. Their cytomorphological features are described, and related literature is reviewed.

Dermatologic causes of heel pain

There are many causes of heel pain. Not all are characterized as plantar fasciitis or osseous pathology. Sometimes patients present with heel pain caused by a dermatologic entity. This article describes some of the most common pathologies.

Local recurrence rate of fine-needle aspiration biopsy in primary high-grade sarcomas

BACKGROUND

Fine-needle aspiration biopsy (FNAB) is an emerging technique for diagnosis of bone and soft tissue lesions. While multiple studies have demonstrated efficacy, cost-effectiveness, and convenience, none have attempted to determine if the modality leads to an increased rate of local recurrence. Our objective was to determine whether FNAB could be linked to an increased rate of local recurrence.

METHODS

We reviewed a database containing records of 388 patients who underwent FNAB without surgical biopsy tract excision between September 2002 and December 2006 in the orthopedics department at our institution. After application of rigid criteria to minimize confounding variables, 20 patients were retrospectively examined for local recurrence and distant metastasis.

RESULTS

In this cohort, no local recurrences were seen over a mean follow-up of 45 months. Fifteen percent of our patients developed one or more distant metastases over the same time interval. Our experience offers preliminary evidence for the safety of this method.

CONCLUSIONS

While further studies are needed, our data combined with already reported studies on efficacy, cost-effectiveness, and convenience are encouraging for expanding the use of FNAB in the diagnosis of bone and soft tissue tumors.

Diagnostic accuracy and limitations of fine-needle aspiration cytology of bone and soft tissue lesions: a review of 1114 cases with cytological-histological correlation

BACKGROUND

Fine-needle aspiration (FNA) cytology is increasingly being used as a diagnostic modality for soft tissue and bone lesions. These diagnoses can be challenging because of a variety of factors, including interpretation and sampling issues. This study investigates the diagnostic utility of FNA biopsy, in addition to the diagnostic pitfalls, in soft tissue and bone cytopathology.

METHODS

We retrospectively reviewed the soft tissue and bone FNAs over a 4-year period (2004-2008), along with available ancillary studies, pathological follow-up, and clinical data. The cases with a cytologic-histologic discrepancy were then reviewed.

RESULTS

A total of 1114 soft tissue and bone FNAs were identified. Of the 1114 aspirates, 525 (47%) were positive for malignant cells, 505 (45.5%) were benign aspirates (including 189 benign lesions/neoplasms), 37 (3.5%) were inadequate, 34 (3%) had atypical cells, and 13 (1%) were suspicious for malignancy. Of the 586 cases (53%) with follow-up, including 445 cases with histological follow-up and 141 with ancillary studies, the overall sensitivity was 96%, the specificity was 98%, the positive predictive value was 99%, and the negative predictive value was 92%. A total of 15 false negatives and 3 false positives were identified with errors because of sampling (9 cases), interpretation (7 cases), and screening (2 cases).

CONCLUSIONS

This large series demonstrates that there can be a high sensitivity and specificity in diagnosing bone and soft tissue lesions by FNA. Our data supports prior studies in the literature in showing that FNA cytology can be a valuable method for diagnosing these lesions.

Biopsy of soft tissue masses: evidence-based medicine for the musculoskeletal tumor society

The literature contains a number of controversies regarding key questions: (1) When is a biopsy indicated? (2) How should the biopsy be placed? (3) How should the biopsy be performed and which has the greatest diagnostic accuracy? (4) Who should perform the biopsy? (5) What clinical parameters present the greatest diagnostic difficulty? Using PubMed and Google Scholar we performed English-language literature searches of clinical studies reporting biopsy of soft tissue masses. Thirty-two studies met the inclusion criteria but were only able to address three of the five questions the authors had hoped to evaluate. Available evidence suggests open biopsy has the highest diagnostic accuracy over core needle biopsy, which was higher than fine needle aspiration. There was no evidence to address who is best suited to perform the biopsy (general surgeon, orthopaedic surgeon, radiologist, pathologist) in terms of accuracy of diagnosis. Frozen section at the time of biopsy may improve diagnostic accuracy. Diagnostic difficulty was associated with myxoid and round cell neoplasms, infections, and tumors located in the paraspinal region. The limited number of references addressing these issues demonstrated the need for more Level I research in the area of biopsy of soft tissue masses.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Scope of FNAC in the diagnosis of soft tissue tumors--a study from a tertiary cancer referral center in India

BACKGROUND

Fine needle aspiration cytology (FNAC) forms one of the first diagnostic tools in the evaluation of tumors. Its role in diagnosing soft tissue tumors (STT) has been fairly documented, as well as debated. Present study was aimed at evaluating its scope in diagnosing 127 cases of soft tissue tumors.

METHODS

Conventional Pap and MGG staining was available in all the cases. Immunocytochemistry (ICC) was performed in 15 cases. Histopathological details were available in 115 cases.

RESULTS

50% cases were referred for a primary diagnosis, while 26.8% & 22.8% cases were evaluated for recurrent and metastatic lesions, respectively. Extremities were the commonest sites. On FNAC, 101 cases (79.5%) were labeled as malignant, whereas 10 cases (7.9%) were labeled as benign. The remaining 16 cases (11%) were not categorized and were labeled as 'unsure/not specified'. Histopathological confirmation in 115 cases, gave a diagnostic accuracy of 98%, with a positive predictive value of 98% in malignant cases and a negative predictive value of 100% in benign cases. Two cases were false positive. Among the various cytological categories, 60 cases (47.2%) were of spindle cell type, followed by 32 (25.2%) of round cell type and 14 cases (11%) of lipomatous type. Other 12 cases (9.4%) were of pleomorphic type; 7 (5.5%) cases of epithelioid type and remaining 2 cases were of myxoid type. All the round cell, pleomorphic and myxoid type of tumors were sarcomas, whereas 73.3% cases of spindle cell type were labeled as 'malignant'. Exact cytological sub typing was offered in 58 cases, with rhabdomyosarcoma (RMS) as the most frequently sub typed tumor. The two false positive malignant cases were of fibromatosis and a pigmented schwannoma, on biopsy. Out of 28 metastatic lesions, lymph nodes were the commonest site for metastasis, with epithelioid tumors that formed highest percentage of metastatic cases.

CONCLUSION

FNAC is fairly specific and sensitive in STT diagnoses for primary, recurrent and metastatic lesions. The cytological types, especially round cell and pleomorphic sarcomas, can be quickly identified. Clinicopathological correlation with ICC as an adjunct, are valuable in exact sub typing.

[Cytologic diagnosis of soft tissue tumors]

Soft tissue swellings represent common clinical signs of a variety of neoplastic and non-neoplastic lesions. Sarcomas are rarely the cause. Fine needle biopsy as a minimally invasive, economic and accurate method is well suited for the diagnostics of recurrent and metastatic diseases. Cytologic diagnosis of primary soft tissue tumors is also feasible but requires close collaboration with other medical disciplines and incorporation of clinical, radiological and morphologic findings. Clinical data such as age, gender, size and topography are also important parameters. Differentiation of the cells and the properties of the extracellular matrix offer initial indications for the differential diagnosis and are the starting point for immunohistochemical and molecular analyses (FISH, RT-PCR). These analyses can be performed on cytological smears, on paraffin-embedded cell blocks on snap frozen material.

Core-needle biopsy performed by the cytopathologist: a technique to complement fine-needle aspiration of soft tissue and bone lesions

BACKGROUND

Fine-needle aspiration cytology (FNAC) is gaining increased popularity in the diagnosis of musculoskeletal lesions; and, in many patients, a definitive diagnosis can be rendered from aspiration smears alone. The main limitation of FNAC of soft tissue and bone neoplasms is in the evaluation of tissue architecture. In addition cytologic specimens are not always adequate for ancillary studies.

METHODS

A consecutive series of 130 patients with soft tissue and bone lesions was examined by core-needle biopsy (CNB) performed by a cytopathologist in conjunction with FNAC. The findings of this combined diagnostic approach were compared with histologic diagnoses made on surgical biopsies and resected specimens from 86 patients. Adequate follow-up was available in all patients.

RESULTS

FNAC combined with CNB correctly could identify 77 of 78 malignant lesions and 50 of 52 benign lesions. Only seven patients underwent incisional biopsy. The tumor subtype was determined correctly in 30 of 39 patients (77%) and the malignancy grade was determined in 35 of 39 patients (90%) with primary soft tissue and bone sarcomas compared with the biopsy or operative specimens.

CONCLUSIONS

FNAC of musculoskeletal tumors/lesions complemented with CNB combined cytomorphology with tissue architecture and ancillary procedures. In the current study, obtaining FNAC as well as CNB at the same clinic visit and by the cytopathologist made preliminary diagnosis on the day of referral possible. This speeded diagnosis increased the number of correct diagnoses and usually enabled correct subtyping and malignancy grading of sarcomas.

Successful retrieval of fine-needle aspiration biopsy material from previously stained smears for immunocytochemistry: a novel technique applied to three soft tissue tumors

Fine-needle aspiration biopsies of soft tissue tumors are often not fully diagnostic on conventional Papanicolaou or Giemsa stains. Often, more useful information can be gleaned from preparing cell blocks, which are amenable to immunocytochemistry. However, sufficiently diagnostic cell block material is not always forthcoming. We subvent this problem by employing a new 'cytoscrape' technique to create cell blocks from previously Papanicolaou-stained smear material in two cases of mesenchymal tumors where smear diagnoses were limited to 'sarcoma, not otherwise specified'. After thorough text and photographic documentation of the smear results, the slides were decolorized and tumor cells were removed for processing as for routine preparation of cell blocks. Sections cut were then submitted for immunocytochemical profiling. This resulted in definitive diagnoses in both cases, averting the need for more invasive diagnostic procedures. We applied the same technique to a third case of a lung nodule, in which the smear was inconclusive and the original cell block nondiagnostic. The subsequent immunocytochemical testing enabled a definitive diagnosis to be made. This novel technique is described here; its value and applicability are discussed in the context of fine-needle aspiration biopsies of soft tissue tumors.

Comparison of needle core biopsy and fine-needle aspiration for diagnostic accuracy in musculoskeletal lesions

CONTEXT

Needle core biopsy has been reported to be the choice of biopsy for musculoskeletal tumors. Fine-needle aspiration, on the other hand, has been widely accepted for nonmusculoskeletal tumors, but is only used in selected medical centers for musculoskeletal tumors. While fine-needle aspiration appears to have advantages to needle core biopsy in the aspects of simplicity and cost, the diagnostic accuracy should be the most critical parameter in determining the choice of biopsy. However, few studies comparing the diagnostic accuracy of these 2 biopsy methods have been performed.

OBJECTIVE

This study was designed to compare the diagnostic accuracy of fine-needle aspiration and needle core biopsy in musculoskeletal tumors.

DESIGN

Prospective study was performed in patients aged 10 years or older. Diagnostic accuracy was compared in 50 consecutive concurrent needle core biopsies and fine-needle aspirations of musculoskeletal lesions.

RESULTS

For primary musculoskeletal lesions, fine-needle aspiration achieved a diagnostic accuracy rate of 88% for nature of lesion, 64% for specific diagnosis, 78% for histologic grading, and 74% for histologic typing. Needle core biopsy achieved an accuracy rate of 93% for nature of lesions, 83% for specific diagnosis, 83% for histologic grading, and 90% for histologic typing. Both biopsy methods have a higher diagnostic accuracy rate for high-grade tumors than for low-grade or benign lesions in determining the nature, specific diagnosis, and histologic grading.

CONCLUSIONS

The needle core biopsy has a higher diagnostic accuracy than fine-needle aspiration in all aspects, including determining the nature of the tumor, establishing the histologic type and grade, and achieving a specific diagnosis.

Fine-needle aspiration in liposarcoma: Cytohistologic correlative study including well-differentiated, myxoid, and pleomorphic variants

We have reviewed cytopathology and the corresponding histopathology material of 86 liposarcomas (55 patients) seen at Institut Curie. The liposarcomas (LS) were well differentiated in 14 cases (9 pure, 2 dedifferentiated, 3 sclerosing), 64 myxoid, and 8 pleomorphic. Twenty-four tumors were primary, 34 recurrent, and 28 secondary. Smears in LS were composed in different proportions of round, spindle cells, lipoblasts, and myxoid and vascular arborizing structures. Pure well-differentiated LS were frequently composed of lipoblasts, and round or spindle cells were occasionally seen. Dedifferentiated and sclerosing liposarcomas were composed of spindle or round cells, but lipoblasts were also occasionally present. Myxoid or vascular arborizing structures were absent. Myxoid LS (including round and spindle cell LS) frequently showed a myxoid background and less frequently vascular arborizing structures. Tumor cells were round or spindle. Lipoblasts were also seen. Pleomorphic LS were composed of an admixture of all cellular and stromal elements. Well-differentiated LS should be distinguished from hibernoma and spindle cell lipoma, and myxoid LS from myxoma, myxoid chondrosarcoma, chordoma, myxoid leiomyosarcoma, and myxoid malignant fibrous histiocytoma. The demonstration of the specific translocation t(12;16)(q13;p11) of myxoid LS is very helpful to establish the diagnosis. Pleomorphic LS should be differentiated from other high-grade sarcomas, whenever possible.

Fine needle aspiration biopsy of soft tissue sarcomas: utility and diagnostic challenges

The role of fine needle aspiration biopsy (FNAB) as the primary modality for the initial diagnosis of previously undiagnosed soft tissue sarcomas presents several important challenges. Most practicing pathologists are inexperienced with the wide array of soft tissue neoplasms and their morphologic heterogeneity, making them susceptible to misdiagnosis. However, in the hands of experienced cytopathologists, FNAB in conjunction with ancillary techniques has a diagnostic accuracy approaching 95% for the diagnosis of malignancy. FNAB has been shown to have a diagnostic yield nearly identical with core needle biopsy while avoiding significant clinical complications. Nevertheless, FNAB has certain limitations related to the accurate histologic grading and subtyping of certain subgroups of sarcomas. It may also be difficult to accurately distinguish between low-grade sarcomas and benign or borderline cellular lesions, especially in the spindle cell sarcoma subgroup. The aim of this review is to highlight the utility and limitations of FNAB in the primary diagnosis of soft tissue sarcomas, highlight diagnostically challenging lesions, and comment on the limitations of FNAB in providing a "definitive" diagnosis.

Elastofibroma dorsi has distinct cytomorphologic features, making diagnostic surgical biopsy unnecessary: Cytomorphologic study with clinical, radiologic, and electron microscopic correlations

Elastofibroma dorsi (EFD) is a relatively rare soft tissue mass, probably of reactive nature. The lesion is typically located near the inferior margin of the scapula or between the inferior part of scapula and the chest wall in elderly women. Although location of the tumor together with the age/sex of the patients and radiologic findings is often suggestive of the diagnosis, tissue examination has been considered necessary to confirm the diagnosis. Although the histologic features of EFD are well known, there are only four single case reports of the cytologic findings in the English language literature. We describe the cytologic features of EFD in five patients with correlations to clinical, radiologic, histologic, and electron microscopic findings. The current study suggests that the fine-needle aspiration (FNA) features are highly diagnostic, permitting a firm diagnosis of EFD in a typical clinical setting and eliminating the need for preoperative histologic examination.

Comparative fine-needle aspiration and pathologic study of malignant fibrous histiocytoma: Cytodiagnostic features of 95 tumors in 71 patients

To determine diagnostic cytomorphologic features of malignant fibrous histiocytoma (MFH) on fine-needle aspiration (FNA) materials, we reviewed the cytologic material and corresponding histologic slides of 95 tumors in 71 patients. Forty-four (46%) tumors were primary, 38 (40%) were recurrent, and 13 (14%) were metastatic. Histological variants of MFH were as follows: 52 (54.7%, 43 patients) were of the storiform/pleomorphic, seven (7.4%, five patients) were giant cells, four (4.2%, four patients) were inflammatory, and 31 (33.7%, 19 patients) were myxoid type. Review of original cytology reports showed that only 23 (24.2%) tumors were diagnosed as MFH and 68 (71.6%) as other types of malignancies. Four (4.2%) cases were reported as unsatisfactory/suspicious. Our findings showed that spindle-shaped, round, giant cells, osteoclastic-like giant, and inflammatory cells were the most consistent features that allow identification of the storiform/pleomorphic, giant cell, and inflammatory variants of MFH. The myxoid tumors had marked myxoid background matrix with spindle-shaped cells and, less frequently, round and giant cells. Pleomorphic leiomyosarcoma and dedifferentiated liposarcoma should be considered in the differential diagnosis of stroriphorm/pleomorphic, giant cells, and inflammatory variants of MFH. However, myxoid MFH may resemble their leiomyosarcoma and liposarcoma counterparts.

Fine-needle aspiration of leiomyosarcoma: a correlative cytohistopathological study of 96 tumors in 68 patients

To better define the cytological features of various leiomyosarcoma (LMS) variants, we reviewed the fine-needle aspiration material and the corresponding histologic sections of 96 tumors in 68 patients. Histological variants of LMS were as follows: 80 (83.3%) were of the classical/usual, seven (7.3%) were epithelioid, and nine (9.4%) were myxoid. Review of original cytology reports showed that 23 (24%) tumors were diagnosed as LMS and 69 (71.8%) as other types of malignancies. Two (2.1%) cases were reported as suspicious and two (2.1%) were unsatisfactory. The classical variants of LMS were characterized cytologically by various proportions of spindle-shaped, cohesive, small- or large-sized cells arranged in parallel alignment. Large spindle, round, binucleated, giant cells with intracytoplasmic granulations were frequently seen. Blunt-ended nuclei, intranuclear inclusions and mitotic figures were occasionally seen, as well as stromal fragments. The epithelioid tumors were composed of an admixture of small and large, spindle-shaped and round cells, also arranged in parallel alignment. Tumor cells with granular cytoplasm, blunt-ended nuclei, intranuclear inclusions, mitotic figures, fibrous or myxoid stroma were not observed. The myxoid tumors disclosed large amounts of background myxoid matrix containing large spindle-shaped and giant cells. Entities such as leiomyoma, malignant peripheral nerve sheath tumor, monophasic synovial sarcoma, and malignant fibrous histiocytoma should be considered in the differential diagnosis of LMS of the classical type. Epithelioid leiomyoma may share similar cytological features with epithelioid LMS. The cytological features of the myxoid variant of LMS can be easily confused with other types of benign and malignant mesenchymal tumors depicting degenerative myxoid changes and/or a myxoid matrix component.

Reliability of fine-needle aspiration biopsy in the initial diagnosis of soft-tissue lesions

We retrospectively reviewed fine-needle aspiration biopsy (FNAB) specimens of 301 soft tissue lesions of the extremities and trunk. Final diagnoses were 137 benign and 86 malignant neoplasms and 78 nonneoplastic lesions. Of the 301 FNAB samples, 279 (93%) were adequate for cytologic diagnosis. The adequate FNAB specimens were initially grouped into three broad categories: benign (197 cases), malignant (57 cases), and suspicious for malignancy (25 cases). Sensitivity and specificity for diagnosis of a malignant lesion were 92% and 97%, respectively. The specimens were cytomorphologically classified into nine categories: small round (14 cases), spindle cell (77 cases), epithelioid/polygonal (16 cases), pleomorphic (29 cases), myxoid (19 cases), lipomatous (37 cases), epithelial (23 cases), inflammatory lesions (28 cases), and others (36 cases). Specific FNAB diagnoses were correct in 151 of 279 cases (54%) in combination with clinical and radiologic findings. FNAB is a valuable technique for the primary diagnosis of soft-tissue lesions.

Cytohistologic correlations of 24 malignant peripheral nerve sheath tumor (MPNST) in 17 patients: the Institut Curie experience

Cytomorphological patterns of malignant peripheral nerve sheath tumor (MPNST) are insufficiently documented in the literature. Cytological and histological specimens in 24 tumors in 17 patients were correlated. The review of the original cytology reports showed that four (16.6%) tumors were correctly diagnosed, eight (33.3%) were diagnosed as sarcoma not otherwise specified, four (16.7%) as fibrosarcoma, three (12.5%) as synovial sarcoma, three (12.5%) as leiomyosarcoma, and one (4.2%) case each as malignant fibrous histiocytoma and rhabdomyosarcoma. At the review tumors were histologically reclassified as well-differentiated MPNST in 11 (45.9%) cases, anaplastic MPNST in 11 (45.9%) cases, and epithelioid MPNST and malignant Triton tumor in one (4.2%) case each. Cytologically, well-differentiated MPNST were composed of polymorphous oval to round cells, small spindle-shaped cells with wavy and comma-like naked nuclei, and a fibrillary, delicate stroma. Anaplastic MPNST, moreover, were composed of anaplastic giant and polymorphous cells. The malignant Triton tumor was composed of oval to round rhabdomyoblastic cells with eccentric nuclei and the epithelioid MPNST of polymorphous and round, epithelial-like cells. The cytological diagnosis of MPNST may be difficult, especially in anaplastic tumors. The correlation between the cytological features and the clinical information--origin of the tumor from a nerve trunk, a preexisting neurofibroma, patients with known history of neurofibromatosis 1--could be indicative of an MPNST diagnosis.