Strategies to diagnose lymphoproliferative disorders by fine-needle aspiration by using ancillary studies

Reliability of lymphoma diagnosis using combined cytologic preparations and core needle biopsy: A single-center analysis

Objectives:

The diagnosis of lymphoma on cytologic preparations and core needle biopsies (CNBs) is often challenging due to limited material that precludes additional ancillary testing for accurate classification. We describe our institutional experience with patients who ultimately received a diagnosis of lymphoma using cytologic preparations and CNB material along with additional ancillary testing.

Material and Methods:

All patients whose cytology material (fluids, cytologic smears, and cell block) and CNB resulted in a diagnosis of lymphoma, atypical lymphoid population, or suspicious for lymphoma were retrieved. Diagnoses of lymphoma followed the established nomenclatures of the World Health Organization (WHO). For all cases, the ancillary test profiles were captured and summarized.

Results:

Of 389 cases identified, 17 (4.4%) were diagnosed as atypical lymphoid cells and 31 (7.9%) were suspicious for lymphoma resulting in an indeterminate rate of 12.3%. The rest of the malignant cases (341; 87.7%) were classified using 2017 WHO lymphoid classification system. Six low-grade and 26 high-grade B-cell lymphomas were not further classified because of limited tissue. B-cell lymphomas were the largest category (73.0%): Primarily diffuse large B-cell lymphoma (21.4%), followed by follicular lymphoma (17.5%) and chronic lymphocytic leukemia/small lymphocytic lymphoma (10.9%). A total of 140 cases (36.0%) had flow cytometry results, but 30 specimens (21.4%) were insufficient. Cytogenetic and molecular studies were performed for 78 cases (20.0%).

Conclusion:

Full classification of lymphomas is possible with combined cytologic preparations and CNB material and it is an attractive first sampling modality in the diagnostic process for this disease group.

Imprint cytology: Invaluable technique to evaluate fresh specimens received in the pathology department for Lymphoma workup

At the time of intraoperative consultation, cytologic preparations including smears and imprints can be used in combination with frozen sections to increase diagnostic yield; however, these simple and rapid techniques are not adopted by all pathologists and their use varies considerably between institutions. In patients under investigation for suspected lymphoma, optimal triaging of tissue received fresh in pathology for lymphoma workup is paramount to maximize the odds of obtaining an accurate and clinically meaningful diagnosis and to avoid the need for additional procedures and delays in management, particularly in the current context in which core biopsies have become common practice as a first attempt to attain this goal. Imprint cytology is invaluable in this regard, also as these patients may not have a lymphoma but rather one of its clinical mimics. Herein, imprint cytology is used to approach fresh specimens received intraoperatively for lymphoma workup. More specifically, how these specimens are triaged for ancillary studies, such as flow cytometry, florescence in situ hybridization, or molecular analyses based on an interpretation of the touch imprints, is described. Detailed imprint cytological findings of typical benign and malignant lymphoid and nonlymphoid lesions are discussed and illustrated.

Limited Tissue Biopsies and Hematolymphoid Neoplasms

OBJECTIVES

Use of fine-needle aspiration/needle core biopsy (FNA/CNB) in evaluating hematolymphoid processes has been debated. We investigate its applicability in various clinicopathologic settings.

METHODS

We retrospectively analyzed 152 cases of FNA/CNB.

RESULTS

Of 152 FNA/CNBs, 124 (81.6%) resulted in diagnoses without excisional biopsies, while 28 required subsequent excisional biopsies. Of these, 43 FNA/CNBs performed for suspected lymphoma relapse demonstrated 95.4% diagnostic rate (41/43), which was significantly better than those without history of lymphoma (77/109, 71%; odds ratio [OR], 8.5; confidence interval, 1.9-37.4). Patients with immunodeficiency also showed a high rate of diagnosis by FNA/CNB (100%). When stratified by types of disease, diffuse large B-cell lymphoma/high-grade B-cell lymphoma demonstrated a higher success rate (92.7%) than small B-cell lymphoma (79.2%), though the difference was not statistically significant (OR, 3.3; P value = .07). A subsequent excisional biopsy was required in 28 cases, 23 of which resulted in diagnoses concordant with the FNA/CNB. Five cases showed diagnostic discordance, reflecting pitfalls of FNA/CNB in unusual cases with complex pathology.

CONCLUSIONS

FNA/CNB is practical in evaluating most hematolymphoid lesions, with high efficacy in recurrent disease and some primary neoplasms with homogeneous/ aggressive histology, or characteristic immunophenotype.

The current practice of open neck mass biopsy in the diagnosis of head and neck cancer: A retrospective cohort study

Objective

To characterize current use of open neck mass biopsy for diagnosis of squamous cell carcinoma in patients presenting with a neck mass.

Methods

Using the University of Michigan Specialized Program of Research Excellence in Head and Neck Cancer patient database (2008-2014), we reviewed patients' referral documentation to identify those who received open neck mass biopsies as part of their squamous cell carcinoma diagnosis. We compared subsequent treatment between patients who did and did not receive an open neck mass biopsy.

Results

Of 940 patients, 50 patients had received open neck mass biopsy leading to squamous cell carcinoma diagnosis. Only 19 of 50 patients (38%) had undergone fine-needle aspiration prior to open neck mass biopsy. There were no statistically significant differences in treatment or outcomes between patients who did and those who did not receive open neck mass biopsy.

Conclusion

Optimal care for patients who present with a neck mass is fine-needle aspiration. Unfortunately, these data show that many patients undergo open neck mass biopsy for diagnosis, often without prior fine-needle aspirate. Compared to fine-needle aspiration, open biopsy incurs additional risks of general anesthesia and greater surgical risks. While our data did not find statistically significant differences between treatment offered and outcomes, this small study was not expected to demonstrate a difference in outcomes. Further work is needed to promote the utility of fine-needle aspiration for diagnosis of neck mass and to discourage use of open neck mass biopsy as a primary diagnostic intervention.

Level of Evidence

2c (Outcomes Research).

Time to diagnosis and associated costs of an outpatient vs inpatient setting in the diagnosis of lymphoma: a retrospective study of a large cohort of major lymphoma subtypes in Spain

BACKGROUND

Mainly because of the diversity of clinical presentations, diagnostic delays in lymphoma can be excessive. The time spent in primary care before referral to the specialist may be relatively short compared with the interval between hospital appointment and diagnosis. Although studies have examined the diagnostic intervals and referral patterns of patients with lymphoma, the time to diagnosis of outpatient compared to inpatient settings and the costs incurred are unknown.

METHODS

We performed a retrospective study at two academic hospitals to evaluate the time to diagnosis and associated costs of hospital-based outpatient diagnostic clinics or conventional hospitalization in four representative lymphoma subtypes. The frequency, clinical and prognostic features of each lymphoma subtype and the activities of the two settings were analyzed. The costs incurred during the evaluation were compared by microcosting analysis.

RESULTS

A total of 1779 patients diagnosed between 2006 and 2016 with classical Hodgkin, large B-cell, follicular, and mature nodal peripheral T-cell lymphomas were identified. Clinically aggressive subtypes including large B-cell and peripheral T-cell lymphomas were more commonly diagnosed in inpatients than in outpatients (39.1 vs 31.2% and 18.9 vs 13.5%, respectively). For each lymphoma subtype, inpatients were older and more likely than outpatients to have systemic symptoms, worse performance status, more advanced Ann Arbor stages, and high-risk prognostic scores. The admission time for diagnosis (i.e. from admission to excisional biopsy) of inpatients was significantly shorter than the time to diagnosis of outpatients (12.3 [3.3] vs 16.2 [2.7] days; P < .001). Microcosting revealed a mean cost of €4039.56 (513.02) per inpatient and of €1408.48 (197.32) per outpatient, or a difference of €2631.08 per patient.

CONCLUSIONS

Although diagnosis of lymphoma was quicker with hospitalization, the outpatient approach seems to be cost-effective and not detrimental. Despite the considerable savings with the latter approach, there may be hospitalization-associated factors which may not be properly managed in an outpatient unit (e.g. aggressive lymphomas with severe symptoms) and the cost analysis did not account for this potentially added value. While outcomes were not analyzed in this study, the impact on patient outcome of an outpatient vs inpatient diagnostic setting may represent a challenging future research.

Anaplastic Lymphoma Kinase Immunocytochemistry in Fine Needle Aspiration Diagnosis of Anaplastic Large-cell Lymphoma

Background:

Anaplastic large-cell lymphoma (ALCL) is a rare subtype of non-Hodgkin's lymphoma (NHL) characterized by the presence of unusual giant cells. It is a CD30+lymphoma of T-cells lineage, which shows anaplastic lymphoma kinase-nucleophosmin (ALK-NPM) rearrangement. ALCL on fine needle aspiration cytology (FNAC) shows unusually large and bizarre tumor cells.

Materials and Methods:

All aspirates seen over a 6-year period from November 2009 to November 2015 in which a diagnosis of ALCL or Hodgkin's lymphoma (HL) with bizarre giant cells were suspected on cytomorphology were prospectively selected. Twenty such aspirates were subjected to CD-30 and ALK-1 immunocytochemistry (ICC). Subsequent biopsy was available in all cases.

Results:

Out of 20 cases, seven cases, suspected to be ALCL on FNAC, were confirmed on biopsy. ALK-1 was positive in both cytology and biopsy of 6/7 of these. Two cases suspected to be ALCL on cytomorphology were HL (1) and diffuse large B-cell lymphoma (DLBCL) (1) on biopsy, both of which were ALK-1 negative on cytology. Eight cases of HL and three cases of large-cell NHL, which were all ALK negative on cytology, were confirmed on biopsy.

Conclusion:

ICC for ALK and CD30 is useful in aspiration cytodiagnosis of ALCL. One CD30 positive DLBCL and one ALK negative ALCL showed concordant results of ICC on cytology and histology.

Sensitivity of fine-needle aspiration biopsy for diagnosing and grading follicular lymphomas using a multiparameter approach in a cancer center

OBJECTIVES

The diagnosis and grading of follicular lymphomas (FLs) by fine-needle aspiration biopsy (FNAB) has not been systematically compared with core needle biopsy (CNB). We evaluated the sensitivity of FNAB in diagnosing and grading FLs using a multiparameter approach in a large cancer center.

METHODS

We retrospectively identified CNBs of lymph nodes diagnosed as FL that also had a concurrently acquired FNAB on the same site. The majority of cases had flow cytometric analysis and these results were available for interpretation of both the FNAB and CNB.

RESULTS

Out of 342 patients, CNB diagnoses included 291 (85%) low-grade (LG) FLs, 30 (9%) high-grade (HG) FLs, and 21 (6%) non-graded FLs/other. FNAB diagnoses included 194 (57%) LG FLs, 19 (6%) HG FLs, 93 (27%) non-graded FLs, 9 (3%) large B-cell lymphomas (LBCL) of follicle center origin, and 27 (7%) insufficient for diagnosis/other. Review of non-graded FLs showed 45% LG, 35% indeterminate due to polymorphous lymphoid cells with increased numbers of large cells, and 20% scant cellularity. Sensitivity of FNAB for diagnosing FL was 89%, and 66% for LG FL. The latter increased (94%), however, when grading was performed.

CONCLUSION

FNAB is highly sensitive for diagnosing FLs when cellular material for cytomorphology and flow cytometric analysis is obtained, and grading is feasible for most LG FLs. A subset of FLs composed of a polymorphous lymphoid population with increased numbers of large cells may be more difficult to grade, and HG FLs can be difficult to distinguish from CD10-positive diffuse LBCLs.

A Basic Approach to Lymph Node and Flow Cytometry Fine-Needle Cytology

According to the World Health Organization (WHO), the new classification of lymphomas is mainly based on morphological, immunophenotypical, and molecular criteria. Consequently, this new approach has led from the substantial role that architecture played in the past to a secondary panel highlighting the role of fine-needle biopsy (FNB). Applied together with other ancillary techniques, such as flow cytometry (FC), FNB is a potential tool for the diagnosis of lymphomas, and enlarged lymph nodes represent an excellent target for the implementation of this technique. Despite the difficulties inherent in this technology, which might pose problems in differential diagnosis, in the majority of cases this joint work allows an accurate diagnosis of malignancy and even correct subcharacterization in routine lymphomas. Additionally, in selected cases, other molecular techniques like FISH and PCR can also be performed on FNB specimens, helping in the characterization and diagnosis of lymphomas. In this review, we discuss the basic aspects of the combination of FNB cytology and FC in the diagnosis and subclassification of lymphomas. The preanalytical phase is extensively discussed. The advantages, disadvantages, and technical limitations of this joint work are addressed in general and in terms of the accurate subclassification of lymphomas.

Importance of Flow Cytometry in the Cytopathologic Evaluation of Lymphoid Lesions Involving the Kidney

BACKGROUND

Cytomorphology alone is often insufficient for the diagnosis and subclassification of lymphomas, so flow cytometry (FC) may be used as an adjuvant test.

METHODS

Renal fine-needle aspirations (FNAs) performed from January 1993 to August 2014 were reviewed for FC data or a diagnosis of lymphoma.

RESULTS

A total of 586 renal FNAs were collected. Thirty-three cases (5.1%) had FC analysis. Lymphoma was diagnosed 35 times (6%), and FC was performed in 21 (60%) cases. Both cytomorphology and FC were consistent with lymphoma in 20 cases. Cytomorphology alone was diagnostic of lymphoma in 15 cases. In 28 cases, biopsy from the kidney or another site was diagnostic of lymphoma. One subsequent biopsy revealed that a kidney FNA, which showed no definitive morphologic or FC evidence of lymphoma, likely represented necrotic diffuse large B-cell lymphoma.

CONCLUSION

FC is a useful adjuvant diagnostic test for renal FNAs, particularly for subclassification and confirmation of the diagnosis when there is insufficient material for immunohistochemistry. FC should be interpreted with caution when a sample is limited or when there is suspicion of Hodgkin lymphoma, and further work-up is warranted when cytomorphology suggests lymphoma but FC is negative.

Endobronchial ultrasound-guided transbronchial needle aspiration is useful as an initial procedure for the diagnosis of lymphoma

BACKGROUND

The usefulness of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for evaluating hilar, mediastinal and central parenchymal lesions has been well established. However, its utility for diagnosing lymphoma is controversial. The aim of this study was to evaluate the diagnostic utility of EBUS-TBNA for the definitive diagnosis of de novo lymphoma with subtype classification.

METHODS

Patients with lymphoma who underwent EBUS-TBNA for diagnostic purposes at a single institution between March 2004 and May 2013 were retrospectively reviewed.

RESULTS

Of the 971 patients who underwent EBUS-TBNA during the study period, 19 patients, who did not have a previous history of lymphoma, had a final diagnosis of lymphoma. EBUS-TBNA provided a diagnosis accompanied with subtype classification in 6 patients (32%), a suspicious but not definitive classification in 10 patients (53%), and a negative classification in 3 patients (16%). Immunohistochemical staining for definitive diagnosis was performed in 15 of 16 patients (94%), with suspicious results from routine hematoxylin and eosin staining. No procedure-related complications occurred.

CONCLUSIONS

EBUS-TBNA is a useful initial diagnostic procedure, aiding decisions for the management of patients with suspected lymphoma, even though the sensitivity of EBUS-TBNA for diagnosing lymphoma with subtype classification was lower than previously reported.

Branched-chain in situ hybridization for κ and λ light chains: A powerful ancillary technique for determining B-cell clonality in cytology samples

BACKGROUND

Current immunohistochemical and in situ hybridization (ISH) assays are generally inconclusive for clonality unless plasmacytic differentiation is present. This study examined a series of cytology specimens and explored the ability of a branched-chain RNA (bRNA) ISH assay for immunoglobulin κ constant (IGKC) and immunoglobulin λ constant (IGLC) to detect a clonal population of B lymphocytes.

METHODS

Pathology databases were used to identify fine-needle aspiration biopsies (n = 28) and exfoliative cytology samples (n = 20). Demographic, flow cytometry, and excision biopsy results were recorded. bRNA ISH was performed on the Leica Bond platform with the following probes: IGKC, IGLC, immunoglobulin λ-like polypeptide 5 (IGLL5), and a housekeeping gene (HKG).

RESULTS

The bRNA ISH assay was validated with 30 surgical biopsies. On bRNA ISH, a clonal B-cell population (light-chain ratio > 10:1) was detected in 22 of 28 cases with a final diagnosis of lymphoma. In 2 cases, a κ predominance was present, although the ratio was <10:1. Eleven of the 17 κ-clonal lymphomas also expressed IGLL5, the latter recognized by the presence of an intranuclear signal. Two B-cell lymphomas lacked IGKC and IGLC, whereas 2 cases were negative for the HKG. In 12 of the 20 cases with reactive lymphoid tissue, bRNA ISH identified a polyclonal lymphoid population. No light-chain messenger RNA was detected in 6 cases (typically those associated with very few B cells).

CONCLUSIONS

The automated bRNA ISH platform is a robust technique for detecting a clonal B-cell population in cytology material.

Impact of flow cytometry in liver cytopathology

BACKGROUND

Fine needle aspiration (FNA) is commonly used as a diagnostic tool for the evaluation of lymphoproliferative diseases. Cytomorphology alone is often insufficient for the diagnosis and subclassification of lymphoma; therefore, flow cytometry (FC) plays an important role in the characterization of lymphoproliferative disorders. This study reviews our experience with FC on liver FNA at the Johns Hopkins Hospital.

METHODS

2,424 liver FNAs performed over a 21-year period were reviewed for clinical FC data (n=74) or a subsequent diagnosis of lymphoma in the liver without FC data (n=40).

RESULTS

In our study, 114 cases (4.7%) were included out of the 2,424 liver FNAs performed during the study period. Lymphoma was diagnosed 79 times. Cytomorphology alone was diagnostic of lymphoma in 45 cases, and in 33 cases both the cytomorphology and the FC were consistent with a diagnosis of lymphoma. Neither FC nor cytomorphology were diagnostic of lymphoma on 1 specimen. In 39 cases, FC had negative results on a lesion suspicious for lymphoma based on cytomorphology. In several nonlymphoma cases, FC provided information that allowed further subclassification of the neoplasm.

CONCLUSION

FC is a useful adjuvant diagnostic test for liver FNAs performed on patients with lymphoproliferative disorders.

Evaluation of unexplained peripheral lymphadenopathy and suspected malignancy using a distinct quick diagnostic delivery model: prospective study of 372 patients

Although rapid diagnostic testing is essential in suspicious peripheral lymphadenopathy, delays in accessing them can be considerable. We investigated the usefulness of an internist-led outpatient quick diagnosis unit (QDU) in assessing patients with unexplained peripheral lymphadenopathy, focusing on the characteristics, diagnostic, and treatment waiting times of those with malignancy. Patients aged ≥ 18 years, consecutively referred from 12 primary health care centers (PHCs) or the emergency department (ED) for unexplained peripheral lymphadenopathy, were prospectively evaluated during 7 years. Diagnostic investigations were done using a predefined study protocol. Three experienced cytopathologists performed a fine-needle aspiration cytology (FNAC) systematic approach of clinically suspicious lymphadenopathy with cytomorphology and immunophenotyping analyses. We evaluated 372 patients with a mean age (SD) of 45.3 (13.8) years; 56% were women. Malignancy was diagnosed in 120 (32%) patients, including 81 lymphomas and 39 metastatic tumors. Metastatic lymphadenopathy was diagnosed by FNAC in all 39 patients and the primary tumor site was identified in 82% of them when cytomorphology and immunocytochemistry were combined. A correct diagnosis of lymphoma was reached by FNAC in 73% of patients. When accepting "suspicious of" as correct diagnosis, the FNAC diagnosis rate of lymphoma increased to 94%. Among patients with malignancy, FNAC yielded 1.3% of false negatives and no false positives. All patients with an FNAC report of correct or suspicious lymphoma underwent a surgical biopsy, as it is a mandatory requirement of the hematology department. Mean times from first QDU visit to FNAC diagnosis of malignancy were 5.4 days in metastatic lymphadenopathy and 7.5 days in lymphoma. Mean times from receiving the initial referral report to first treatment were 29.2 days in metastatic lymphadenopathy and 40 days in lymphoma. In conclusion, a distinct internal medicine QDU allows an expeditious, agile, and prearranged system to diagnose malignant peripheral lymphadenopathy. Because of the close collaboration with the cytopathology unit and the FNAC methodical approach, diagnostic and treatment waiting times of patients with malignancy fulfilled national and international time frame standards. This particular diagnostic delivery unit could help overcome the difficulties facing PHC, ED, and other physicians when trying to provide rapid access to investigations to patients with troublesome lymphadenopathy.

CT-guided needle biopsy performed with modified coaxial technique in patients with refractory or recurrent lymphomas

The aim of this study was to evaluate the role of computed tomography (CT)-guided core needle biopsy (CNB) performed by modified coaxial technique as an alternative tool to surgical biopsy in patients with refractory or recurrent lymphomas. Between May 2005 and May 2012, 57 CT-guided CNB of deep lesions were performed in patients with a previous diagnosis of lymphoma and suspected for refractory or recurrent disease. A modified coaxial technique was used in all cases and multiple samples were obtained for histological and immunohistochemical studies. A diagnosis of lymphoma with specification of subtype according to the World Health Organization (WHO) classification was established in 30/57 cases (52.6 %). The previous diagnosis of lymphoma was confirmed in 27/57 patients (47.4 %), whereas histological progression in 3/57 (5.3 %) and other malignant neoplasms in 17/57 (29.8 %) were found. Lymphoma without subtype specification was diagnosed in 6/57 (10.5 %), and no conclusive diagnosis could be established in 4/57 cases (7 %). Overall diagnostic accuracy was 82.5 %. In patients with a final diagnosis of malignant lymphoma, accuracy was 75 %. No complications occurred. Percutaneous CT-guided CNB is a safe, effective and reliable tool in the management of patients with refractory or recurrent lymphomas without superficial lymphadenopathy and can be considered as alternative to surgical sampling.

The diagnostic approach to fine-needle aspiration of malignant lymphoma: using cytomorphology and immunocytochemistry with cell transfer method

Fine-needle aspiration (FNA) cytology is generally considered to be the screening tool for lymphoproliferative lesions. The differential and decisive diagnosis, however, of malignant lymphoma from benign reactive hyperplasia by FNA cytology is sometimes challenging. The diagnostic features compatible with lymphoma as opposed to reactive hyperplasia in FNA cytology were investigated with 31 cases of lymphoma and 31 cases of reactive hyperplasia, and immunocytochemistry with cell transfer method was additionally applied to FNA cytology. The predominance of large lymphocytes, the clustering of large lymphocytes, the presence of markedly large and/or highly pleomorphic cells, the presence of apoptotic and/or necrotic cell debris were considered characteristics of lymphomas, whereas the predominance of small lymphocytes and the presence of histiocytes were considered characteristics of reactive hyperplasia. Using these cytomorphologic characteristics, the diagnostic accuracy for malignant lymphoma in FNA cytology had a sensitivity of 80.6% and a specificity of 100%. By cell transfer method, one of Papanicolaou-stained slides could be used in immunocytochemistry for several markers. Using such methods, sensitivity of FNA cytology for lymphoma was upgraded to 100%, and decisive diagnoses of diffuse large B-cell lymphoma, Burkitt lymphoma, low grade B-cell lymphoma, T- or NK-cell non-Hodgkin lymphoma (NHL), or Hodgkin lymphoma was possible. Differential diagnosis of malignant lymphoma from reactive hyperplasia, and decisive diagnoses of high, and low grade B-cell NHL, T- or NK-cell NHL, and HL could be possible by FNA cytology with cytomorphology in conjunction with immunocytochemistry using cell transfer method.

Cytopathology in the diagnosis of lymphoma

FNA is a simple, safe, and an inexpensive sampling technique that plays an important role in the evaluation of lymphadenopathy. The key to enhancing the accuracy of FNA diagnosis of lymphoma is the multi parameter approach in which the cytomorphologic features are evaluated in correlation with the results of ancillary studies and clinical context. A full understanding of the current lymphoma classification, clinical features associated with each lymphoma subtype and the impact of the diagnosis on patient management is essential in FNA diagnosis of lymphoma. It is also important to recognize the limitations of FNA in the primary diagnosis of some subtypes of lymphoma, and tissue biopsy should be recommended for a definitive diagnosis and subclassification in such cases.

Clinical utility of endoscopic ultrasound-guided fine-needle aspiration in the diagnosis of mediastinal and intra-abdominal lymphadenopathy

INTRODUCTION

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has proven to be helpful in obtaining tissue samples from enlarged mediastinal and intra-abdominal lymph nodes. This is especially beneficial in the diagnosis and staging of malignancy. We retrospectively reviewed the clinical utility of this method at a tertiary care cancer hospital in Pakistan.

PATIENTS AND METHODS

The medical records of 183 consecutive patients referred to the gastroenterology service from August 2008 to March 2012 were reviewed in this retrospective study. The mean age of the patients at presentation was 46.7 years (range 6-87; 62% males); 119 patients had mediastinal and 64 had intra-abdominal lymphadenopathy. Major indications for referral were diagnosis of lymphadenopathy of unknown origin detected on CT scan or PET-CT, to exclude lymph node metastasis in patients with a known primary tumor and to rule out relapse of lymphoma following treatment or during follow-up. Rapid on-site evaluation (ROSE) was performed in all patients to confirm the adequacy of sampling, followed by definitive cytopathological evaluation.

RESULTS

EUS-FNA with ROSE obtained adequate tissue for cytology in 97.3% of the patients in this cohort. These results were further confirmed on final cytopathological analysis in 96.2% of patients. Two patients (1.1%) had inadequate specimens for final interpretation (97.3 vs. 96.2; p = 0.001). Clinical utility was 95% for mediastinal lymphadenopathy and 98.4% for intra-abdominal lymphadenopathy. Only 1 patient had a serious complication requiring hospitalization and this was successfully managed conservatively.

CONCLUSION

EUS-FNA is safe and has a high clinical utility in diagnosing unexplained mediastinal and intra-abdominal lymphadenopathy.

[Role of cytology in hematopathological diagnostics]

The role of cytology has so far been underrecognized in the diagnostic process of hematopathological questions. This article presents an algorithm which allows a stepwise work-up of cytology specimens obtained by minimally invasive ultrasound-guided fine needle aspiration in patients with unexplained lymph node swelling. Moreover, it is shown how the selective separation of cytology specimens allows the application of immunophenotypic analysis including flow cytometry and immunohistochemistry as well as molecular analyses, such as fluorescence in situ hybridization (FISH) and polymerase chain reaction (PCR) strategies. With the integrative procedure presented, cytology offers an excellent cost-effective tool for the diagnostic approach of patients with suspected hematopathological malignancies allowing a high diagnostic accuracy, ideal for initial diagnosis or follow-up.

Diagnosis of B-cell non-hodgkin lymphomas with small-/intermediate-sized cells in cytopathology

Fine needle sampling is a fast, safe, and potentially cost-effective method of obtaining tissue for cytomorphologic assessment aimed at both initial triage and, in some cases, complete diagnosis of patients that present clinically with lymphadenopathy. The cytologic diagnosis of B-cell non-Hodgkin lymphomas composed of small-/intermediate-sized cells, however, has been seen as an area of great difficulty even for experienced observers due to the morphologic overlap between lymphoma and reactive lymphadenopathies as well as between the lymphoma entities themselves. Although ancillary testing has improved diagnostic accuracy, the results from these tests must be interpreted within the morphological and clinical context to avoid misinterpretation. Importantly, the recognition of specific cytologic features is crucial in guiding the appropriate selection of ancillary tests which will either confirm or refute a tentative diagnosis. For these reasons, we here review the cytologic characteristics particular to five common B-cell non-Hodgkin lymphomas which typically cause the most diagnostic confusion based on cytological assessment alone: marginal zone lymphoma, follicular lymphoma, mantle cell lymphoma, chronic lymphocytic leukemia/small lymphocytic lymphoma, and lymphoplasmacytic lymphoma. We summarize the most pertinent cytomorphologic features for each entity as well as for reactive lymphoid hyperplasia, contrast them with each other to facilitate their recognition, and highlight common diagnostic pitfalls.

Basics of cytology

This overview is intended to give a general outline about the basics of Cytopathology. This is a field that is gaining tremendous momentum all over the world due to its speed, accuracy and cost effectiveness. This review will include a brief description about the history of cytology from its inception followed by recent developments. Discussion about the different types of specimens, whether exfoliative or aspiration will be presented with explanation of its rule as a screening and diagnostic test. A brief description of the indications, utilization, sensitivity, specificity, cost effectiveness, speed and accuracy will be carried out. The role that cytopathology plays in early detection of cancer will be emphasized. The ability to provide all types of ancillary studies necessary to make specific diagnosis that will dictate treatment protocols will be demonstrated. A brief description of the general rules of cytomorphology differentiating benign from malignant will be presented. Emphasis on communication between clinicians and pathologist will be underscored. The limitations and potential problems in the form of false positive and false negative will be briefly discussed. Few representative examples will be shown. A brief description of the different techniques in performing fine needle aspirations will be presented. General recommendation for the safest methods and hints to enhance the sensitivity of different sample procurement will be given. It is hoped that this review will benefit all practicing clinicians that may face certain diagnostic challenges requiring the use of cytological material.

Correlation between flow cytometry and histologic findings: ten year experience in the investigation of lymphoproliferative diseases

Objective: To demonstrate the advantages of correlating flow cytometry immunophenotyping with the pathology/ immunohistochemistry of lymph nodes or nodules in the diagnosis of lymphoproliferative diseases. Methods: A retrospective study was carried out of 157 biopsy or fine-needle aspiration lymph nodes/ nodule specimens taken from 142 patients, from 1999 and 2009. The specimens were simultaneously studied with fow cytometry and pathology at Hospital Israelita Albert Einstein. The specimens were prepared in hematoxylin/eosin, Giemsa, or monoclonal antibody stained slides for detecting specific antibodies for the purposes of pathology/immunohistochemical analysis. The samples were hemolyzed and marked with different monoclonal antibody panels for different antigens in fow cytometry immunophenotyping. Results: The diagnostic results of pathology/immunohistochemical studies and flow cytometry immunophenotyping agreed in 115 patients (81%), corresponding to 127 specimens, as follows according to the pathologic diagnosis: 63 patients with non-Hodgkin's B-cell lymphoma; 26 patients with reactive lymphoid hyperplasia; 5 patients with non-Hodgkin's T-cell lymphoma; 4 patients with atypical lymphoid proliferation; 5 patients with a chronic granulomatous inflammatory process; 5 patients with a non-hematologic diagnosis; 2 patients with granulocytic sarcoma; 2 patients with thymoma; 1 patient with byphenotypic leukemia; 1 patient with kappa plasmocytoma; 1 patient with Hodgkin's lymphoma. Subtypes of lymphomas could be classified by associating the two techniques: 19 patients with follicular lymphoma; 15 patients with diffuse large B-cell lymphoma; 7 patients with small lymphocytic B-cell lymphoma/chronic lymphocytic leukemia; 3 patients with mantle cell lymphoma; 1 patient with Burkitt's lymphoma; 1 patient with MALT type lymphoma; 1 patient with post-transplant lymphoproliferative disease; 2 patients with high grade non-Hodgkin's B-cell lymphoma; 1 patient with low grade non-Hodgkin's B-cell lymphoma not otherwise specified; 1 patient with Hodgkin's lymphoma; and 12 patients with B-cell non-Hodgkin's lymphoma not otherwise specified. Conclusion: Flow cytometry adds to the results of morphologic and immunohistochemical studies, facilitating a rapid and accurate diagnosis of lymphoproliferative diseases.

The utility of endobronchial ultrasound-guided transbronchial needle aspiration biopsy in the diagnosis of mediastinal lymphoproliferative disorders

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy is routinely used to stage lung cancer; however, its usefulness in diagnosing lymphoproliferative disorders has not been well established. In this retrospective study, we determined the utility of EBUS-TBNA in evaluating mediastinal lymphadenopathy in patients with suspected lymphoproliferative disorders.

METHODS

The authors searched the pathology database at their institution to identify all patients who had undergone EBUS-TBNA biopsy for possible lymphoproliferative disorders. The cytologic diagnoses were correlated with concurrent and subsequent biopsy findings and clinical follow-up data.

RESULTS

Of 886 lymph nodes evaluated by EBUS-TBNA biopsy, 91 nodes from 33 patients (23 men and 10 women) were eligible. Fourteen patients had a history of lymphoma. Adequate material for diagnosis was obtained in 31 of 34 procedures (1 patient had 2 procedures). The cytologic diagnoses of the 31 adequate procedures included 19 with benign disease (8 reactive lymph nodes and 11 granulomatous inflammation), 8 with lymphoma (2 large B-cell, 2 small lymphocytic, 2 Hodgkin, 1 mantle cell, and 1 T-cell lymphoblastic), 2 with cells suspicious for Hodgkin lymphoma, and 2 cases with atypical cells.

CONCLUSIONS

EBUS-TBNA proved to be useful for evaluating mediastinal lymphadenopathy in patients with suspected lymphoproliferative disorders. Its use may decrease the need for invasive diagnostic procedures. Immediate assessment is valuable in these cases because of the need to triage material for immunophenotyping or other studies to determine optimal and clinically meaningful diagnoses.

Independent diagnostic accuracy of flow cytometry obtained from fine-needle aspirates: a 10-year experience with 451 cases

Although the topic is somewhat contentious, fine-needle aspiration (FNA) is frequently used in conjunction with flow cytometry (FC) to evaluate lymphoid proliferations. Despite the fact that the FNA and FC are often analyzed independently, no previous large-scale study has independently analyzed FC of FNA specimens. FC reports of 511 FNAs were retrospectively reviewed and FC diagnoses categorized as monoclonal, atypical, normal/reactive, or insufficient cellularity (3.9%). Abnormal immunophenotype was considered a positive test result. "Gold standard" diagnoses were established by histologic examination, treatment based on FNA, or clinical features. In 92.2% (451/489), there was adequate follow-up. The diagnostic accuracy of FC was 88.4%, sensitivity was 85.8%, and specificity was 92.9%. In addition, FC accuracy for classes of non-Hodgkin lymphoma was assessed. We conclude that FC is an independently accurate ancillary test in the evaluation of FNA. However, the presence of false-negative and false-positive cases supports the common practice of correlating FC with cytomorphologic findings even if performed independently.

Outcomes in lymphoma patients with obstructive jaundice: a cancer center experience

BACKGROUND

Little information is available to guide clinicians on the optimal approach to managing obstructive jaundice in lymphoma patients.

AIMS

The aim of this study was to review our experience in treating lymphoma patients with obstructive jaundice in order to develop guidelines as to the best interventional approach.

METHODS

We reviewed the medical records of all lymphoma patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and/or percutaneous biliary drainage (PBD) for obstructive jaundice between June 2002 and October 2008.

RESULTS

We identified 35 lymphoma patients who underwent ERCP and/or PBD for obstructive jaundice. The mean age was 57.6 years. Most patients (66%) had diffuse large B-cell lymphoma. Stents were placed by ERCP in 25 patients and PBD in nine. Serum bilirubin levels normalized following ERCP or PBD in 29 of 33 (85%) patients with stricture. Stricture resolution occurred in 12 cases. Patients who had obstructive jaundice at the time of their lymphoma diagnosis had significantly longer mean overall survival following intervention than patients in whom obstructive jaundice developed later in the course of their disease (21.3 months vs. 4.5 months, P = 0.0001).

CONCLUSIONS

ERCP and/or PBD effectively normalized serum bilirubin levels. Plastic stents should be used in patients who have obstructive jaundice at the time of lymphoma diagnosis because these strictures tend to resolve before stent exchanges are necessary. For patients in whom obstructive jaundice develops later in the course of their disease, the limited prognosis often makes a single intervention with insertion of a plastic stent sufficient to provide adequate biliary decompression.

Oropharyngeal lesions and cervical lymphadenopathy: syphilis is a differential diagnosis that is still relevant

Background

Syphilis (lues), a chronic infectious disease caused by Treponema pallidum, has been increasing in incidence during the last few years. Therefore, while clinically it is often not suspected, syphilis is increasingly becoming a differential diagnosis in routine pathology.

Aim

To report our experience with five cases of cervical lymphadenopathy and/or oropharyngeal lesions, clinically thought to be lymphomas, lymph node metastases or carcinoma, in which we made the mostly clinically unsuspected diagnosis of syphilis.

Methods

Fine needle aspiration of enlarged cervical lymph nodes was evaluated by cytology and flow cytometry (fluorescence-activated cell sorting analysis), and biopsies were examined by using histology. In addition, all materials were also subjected to immunostaining, silver staining and molecular (PCR) testing.

Results

Fine needle aspiration cytology revealed follicular hyperplasia in two cases and granulomatous lymphadenitis in one case. In three patients, concomitant biopsy of co-existing oropharyngeal lesions revealed histological findings compatible with syphilis. T pallidum was detected in all cytological and histological samples by immunohistochemistry/immunocytochemistry and PCR. Subsequently, a diagnosis of syphilis was confirmed clinically and by serology.

Conclusions

Syphilitic lymphadenitis is still a relevant differential diagnosis of cervical lymphadenopathy, and it is clinically often not suspected. Co-exisiting oropharyngeal lesions should alert the physician to this differential diagnosis; and lesions with compatible morphology should be tested with immunohistochemistry and immunocytochemistry and/or molecular analysis to confirm the diagnosis of syphilis.

BSCC Code of Practice--fine needle aspiration cytology

The British Society for Clinical Cytology Code of Practice on fine needle aspiration cytology complements that on exfoliative cytopathology, which was published in the last issue (Cytopathology 2009;20:211-23). Both have been prepared with wide consultation within and outside the BSCC and have been endorsed by the Royal College of Pathologists. A separate code of practice for gynaecological cytopathology is in preparation. Fine needle aspiration (FNA) cytology is an accepted first line investigation for mass lesions, which may be targeted by palpation or a variety of imaging methods. Although FNA cytology has been shown to be a cost-effective, reliable technique its accurate interpretation depends on obtaining adequately cellular samples prepared to a high standard. Its accuracy and cost-effectiveness can be seriously compromised by inadequate samples. Although cytopathologists, radiologists, nurses or clinicians may take FNAs, they must be adequately trained, experienced and subject to regular audit. The best results are obtained when a pathologist or an experienced and trained biomedical scientist (cytotechnologist) provides immediate on-site assessment of sample adequacy whether or not the FNA requires image-guidance. This COP provides evidence-based recommendations for setting up FNA services, managing the patients, taking the samples, preparing the slides, collecting material for ancillary tests, providing rapid on-site assessment, classifying the diagnosis and providing a final report. Costs, cost-effectiveness and rare complications are taken into account as well as the time and resources required for quality control, audit and correlation of cytology with histology and outcome. Laboratories are expected to have an effective quality management system conforming to the requirements of a recognised accreditation scheme such as Clinical Pathology Accreditation (UK) Ltd.

Beyond the lymphocyte predominant cell: CD4+CD8+ T-cells in nodular lymphocyte predominant Hodgkin lymphoma

Hodgkin lymphomas are characterised by the presence of rare malignant cells in a background of non-neoplastic inflammatory cells. Flow cytometric analysis of involved tissues is generally not thought to be useful in establishing the diagnosis, because of the small number of neoplastic cells present. However, two recent studies describing a CD4+CD8+ (double-positive) T-cell population in nodular lymphocyte predominant Hodgkin lymphoma (NLPHL) suggest that flow cytometry could play a role in the diagnosis of this Hodgkin lymphoma subtype. In addition, awareness of this unusual T-cell population is important in avoiding a misdiagnosis of a T-cell neoplasm. Although the function of CD4+CD8+ T-cells in NLPHL is not known, studies of phenotypically similar cells in other settings point to a reactive or regulatory role. CD4+CD8+ T-cells have also been identified in the benign entity progressive transformation of germinal centres (PTGC), suggesting a possible relationship between NLPHL and PTGC.

Fine-needle aspiration in the diagnosis of head and neck lesions: a review and discussion of problems in differential diagnosis

Fine-needle aspiration (FNA) has become the predominant initial diagnostic technique for lesions at a number of sites within the head and neck. The technique has achieved this level of usage because it is relatively inexpensive, rapid to perform, well accepted by patients, associated with low morbidity, and has a relatively high diagnostic accuracy. Sites in the head and neck amenable to FNA include the thyroid, cervical masses and nodules, salivary glands, intraoral lesions and lesions in the paraspinal area and base of skull. Diagnostic accuracy is dependent on the site of aspiration as well as the skill of the individual performing and interpreting the FNA. Studies have shown that FNA is most accurate when the individual interpreting the FNA is the same individual who obtained the aspirate material. Each site undergoing FNA within the head and neck is associated with a set of differential diagnoses and diagnostic challenges which will be discussed.

Fine-needle aspiration biopsy findings in patients with small lymphocytic lymphoma transformed to hodgkin lymphoma

Although small lymphocytic lymphoma (SLL) is an indolent lymphoma, approximately 5% of cases can transform to a higher-grade lymphoma, rarely Hodgkin lymphoma (HL). We report the fine-needle aspiration (FNA) results of 6 cases of SLL/chronic lymphocytic leukemia (CLL) that transformed to HL. FNA findings were correlated with the histologic features and clinical follow-up. The patients included 5 men and 1 woman, ranging in age from 49 to 72 years at the time of SLL/CLL diagnosis with time for development of HL ranging from 0 to 95 months (mean, 49.3 months). The FNA diagnoses were SLL with HL transformation (2 cases), SLL with large atypical cells (1 case), and atypical lymphoid proliferation with large atypical cells (3 cases). Flow cytometry performed in 5 cases (2 FNA specimens) demonstrated a monoclonal B-cell population with CD19/CD5 coexpression. The presence of large atypical mononucleated and binucleated cells in lymph node FNA specimens from patients with SLL/CLL with progressive adenopathy should raise the possibility of transformation to HL. In these cases, histologic confirmation is always recommended, not only to differentiate HL transformation from other entities but also for subclassification of HL.

Cytomorphological and immunocytochemical study of non-Hodgkin's lymphoma in pleural effusion and ascitic fluid

INTRODUCTION

Non-Hodgkin's lymphoma (NHL) is often complicated by pleural effusion and ascites. The present study is an attempt to categorize the lymphomatous effusions according to the WHO classification, using archival material.

METHODS

May-Grünwald-Giemsa and Papanicolaou-stained smears of 31 lymphomatous effusion specimens were reviewed. Of these, detailed cytological assessment was done on 12 pleural effusions and ten ascitic fluid specimens from 22 patients using the WHO lymphoma classification system. Immunocytochemical studies were performed in 21 specimens.

RESULTS

Based on cytomorphological features, the 22 lymphomatous effusion specimens were categorized into lymphoplasmacytoid lymphoma (1), follicle centre cell (FCC) grade-1 (centrocytic) lymphoma (3), FCC grade-2 (centrocytic-centroblastic) lymphoma (3), FCC grade-3 (centroblastic) lymphoma (4), large cell immunoblastic lymphoma (4), lymphoblastic lymphoma (2), anaplastic large cell lymphoma (3) and miscellaneous types (2). Immunocytochemically, the lymphoma cells were T-cell (positive for CD3) and B-cell type (CD20 positive) in five and six cases respectively.

CONCLUSION

Cytological examination of pleural effusion and ascitic fluid samples, supported by immunocytochemical studies, may be useful for the classification of lymphomas under the WHO system.

Desmoplastic small round cell tumor: Using FISH as an ancillary technique to support cytologic diagnosis in an unusual case

Desmoplastic small round cell tumor is a rare and aggressive neoplasm that predominantly affects young males. In almost all cases, a reciprocal translocation is present resulting in the fusion of the Ewing sarcoma gene with the Wilms' tumor gene. Here we describe an unusual case occurring in a 59-year-old male, in which fluorescence in situ hybridization (FISH) was used in conjunction with immunohistochemical studies to confirm the diagnosis. To our knowledge, this is the first reported case of using FISH as an ancillary technique to confirm the cytologic diagnosis of this tumor.

Combined applications of fine needle aspiration cytology and flow cytometric immunphenotyping for diagnosis and classification of non Hodgkin lymphoma

Aims and objectives

In this present study we have evaluated the feasibility of sub-classification of non-Hodgkin's lymphoma (NHL) cases according to World Health Organization's (WHO) classification on fine needle aspiration cytology (FNAC) material along with flow cytometric immunotyping (FCI) as an adjunct.

Materials and methods

In this five years study, only cases suggested or confirmed as NHL by FNAC were selected and FCI was performed with a complete panel of antibodies (CD3, CD2, CD 4, CD5, CD8, CD7, CD10, CD19, CD20, CD23, CD45, κ and λ) by dual color flow cytometry. Both cytologic findings and FCI data were interpreted together to diagnose and sub-classify NHL according to WHO classification. Wherever possible the diagnoses were compared with cytology.

Results

There were total 48 cases included in this study. The cases were classified on FNAC as predominant small cells (12), mixed small and large cells (5) and large cells (26). In five cases a suggestion of NHL was offered on FNAC material and these cases were labeled as NHL not otherwise specified (NHL-NOS). Flow cytometry could be performed in 45 cases (93.8%) and in rest of the three cases the material was inadequate because of scanty blood mixed aspirate. Light chain restriction was demonstrated in 30 cases out of 40 cases of B-NHL (75%). There were 15 cases each of κ and λ light chain restriction in these 30 cases. With the help of combined FCI and FNAC, it was possible to sub-classify 38 cases of NHL (79%) according to WHO classification. Combined FNAC and FCI data helped to diagnose 9 cases of small lymphocytic lymphoma (SLL), 2 cases of mantle cell lymphoma (MCL), 4 cases of follicular lymphoma (FL), 17 cases of diffuse large B lymphoma (DLBL) and 6 cases of lymphoblastic lymphoma. Histopathology diagnosis was available in 31 cases of NHL out of which there were 14 recurrent and 17 cases of primary NHL. Out of 15 DLBL cases diagnosed on FCI and FNAC, histology confirmed 14 cases and one of these cases was diagnosed as Burkitt's lymphoma on histology. Cases of FL (4), SLL (3) and MCL (2) were well correlated with histopathology. Out of the five cases suggestive of NHL on cytology, histopathology was available in four cases. Histology diagnosis was given as DLBL (1), SLL (1), anaplastic large cell lymphoma (1) and FL transformed into large cell NHL (1). Considering histopathology as gold standard, diagnostic specificity of combined FNAC and FCI was 100% (31/31) and sensitivity in sub-classification was 83.8% (26/31).

Conclusion

FNAC combined with FCI may be helpful in accurately sub-classifying NHL according to WHO classification. Many of the subtypes of NHL such as FL and MCL which were previously recognized as a pure morphologic entity can be diagnosed by combined use of FNAC and FCI. Other ancillary investigations such as chromosomal changes, cell proliferation markers etc. may be helpful in this aspect.

Medullary breast carcinoma: a case report with cytological features and histological confirmation

We report the case of a 83-year-old woman who presented with a left-breast lump. On physical examination the patient had a well-demarcated mass located in the upper outer quadrant of her left breast with a palpable unilateral axillary lymph node. Mammography and ultrasonography depicted a heterogeneous well-defined lesion measuring 6 cm in diameter without calcifications. Fine-needle aspiration cytology of the lesion was performed. Cytological examination revealed highly cellular smears containing large atypical cells arranged in syncytial sheets and intimately admixed with lymphocytes and neutrophils. The nuclear to cytoplasmic ratio was high in tumor cells whose nucleus exhibited coarse chromatin with one or more conspicuous nucleoli. The diagnosis of medullary breast carcinoma, which was strongly suspected by cytology, was confirmed by histological examination of the surgical specimen after a modified radical mastectomy with axillary dissection.

Fine-needle aspiration cytology combined with flow cytometry immunophenotyping is a rapid and accurate approach for the evaluation of suspicious superficial lymphoid lesions

The authors report a prospective study on 88 samples of superficial lesions (lymph nodes, skin nodules, and breast tumors), performed by fine-needle aspiration cytology (FNAC) in 74 patients, allowing (i) morphologic analysis combined with immunophenotyping by flow cytometry (FCM) and (ii) a cytogenetic study in 33 cases. Thirty-nine FNAC (44.3%) were performed at the time of diagnosis. The cytology results were correlated with histopathologic examination in 32 cases. Forty-nine FNAC (55.7%) were performed in the context of follow-up of a lymphoma and the results were correlated with those of histopathologic examination in 14 cases. In this study, the concordance between FNAC plus FCM and histopathologic examination was 90% for low-grade non-Hodgkin's malignant lymphomas (NHLs) and 83% for high-grade NHL. The limits of this morphologic and phenotypic approach are (i) partial tumor infiltrations, (ii) Hodgkin lymphoma, and (iii) T-cell NHL. In conclusion, it may be said that this combined approach is very useful for diagnosis and follow-up of patients but requires teams experienced in the sampling technique and the morphologic diagnosis of the various types of low-grade NHL in which supplementary ancillary studies may be performed when morphology and flow cytometry immunophenoyping are not conclusive.