[New aspects in fine needle biopsies of the lymph nodes]

BACKGROUND

The cytology of lymph nodes is a cost-effective method with a short turnaround time and low risk to patients that delivers valuable information on the cause of the lymphadenopathies.

OBJECTIVES

To discuss the value of lymph node cytology in the diagnosis of lymph node swellings.

METHODS

Analysis of the causes of the controversially discussed aspects of lymph node cytology. Presentation of the diagnostic groups of lymph node cytology according to the Sydney system.

RESULTS

The technical aspects of lymph node sampling during fine needle biopsy, as well as the subsequent preparation of the correctly fixed direct smears and the triage of the sample for the auxiliary studies, may pose a significant challenge for some puncturers. The whole spectrum of modern pathologic auxiliary studies can be applied to correctly triaged cytologic samples. The diagnoses of fine needle biopsies of the lymph nodes can be divided into five groups according to the recently proposed Sydney reporting system: insufficient/non-diagnostic, benign, atypical, suspicious, and malignant. Further details concerning the diagnosis as well as recommendations on how to proceed are additionally included in cytologic reports.

CONCLUSIONS

The improvement of lymph node sampling as well as the technical aspects of the sample handling, including the application of auxiliary studies, considerably increase the diagnostic value of fine needle biopsy of the lymph nodes. Wide implementation of the usage of the diagnostic groups for reporting fine needle biopsies of the lymph nodes can standardize reporting and improve communication with other clinical specialists.

Diagnostic accuracy of Thinprep® in cervical lymph node aspiration: Assessment according to the Sydney system

BACKGROUND

Fine-needle aspiration cytology (FNAC) is a reliable technique that has been used for many years in lymphadenopathy diagnosis. Although conventional smear is the standard approach in FNAC, liquid-based cytology (LBC) is accepted as an alternative method. Reporting standardization is a significant gap in fine-needle aspiration cytology, leading to failure in pathologist-clinician dialog and interobserver variability. In 2020, an expert panel proposed the Sydney system for classifying and reporting lymph node aspiration cytology. This study aimed to evaluate the diagnostic accuracy of LBC in lymph node aspiration cytology under the guidance of the Sydney system.

METHODS

Five hundred-four LBC samples were reevaluated and classified according to the Sydney system. Of these, n = 24 were categorized as L1-inadequate/non-diagnostic, n = 283 as L2-benign, n = 36 as L3- atypical cells of undetermined significance/atypical lymphoid cells of uncertain significance (AUS/ALUS), n = 48 as L4-suspicious, and n = 113 as L5-malignant. Four hundred-one samples were histopathologically confirmed. The diagnostic accuracy of LBC and the risk of malignancy for each Sydney category were calculated.

RESULTS

The results were as follows: sensitivity 98.97%; specificity 98.60%; positive predictive value 94.80%; negative predictive value 99.29%; and overall diagnostic accuracy 98.75%. The ROM was 16.6% for L1, 0.7% for L2, 88.8% for L3, and 100% for L4 and L5.

CONCLUSION

LBC is suitable for use in lymph node aspiration under the guidance of the Sydney system and has high diagnostic accuracy. Future comprehensive studies will increase the applicability of the Sydney system and minimize interobserver variability.

CYTOLOGICAL DIAGNOSIS OF FINE-NEEDLE PUNCTURE BIOPSIES OF THE THYROIDGLAND IN UKRAINE: COMPARIS ON WITH INTERNATIONAL PRACTICE

Thyroid cancer is one of the few cancers diagnosed by cytological examination of thin nodule puncture biopsies. To achieve standardization of diagnostic terminology, morphological criteria and risk of malignancy in the whole world, the 6-level Bethesda system is used. The work aimed to analyze the results of cytological examination of fine-needle aspiration puncture biopsies (TAPBs) of thyroid nodules according to the international Bethesda system for the last three years and compare them with the world practice. As a result, 5687 surveys were conducted, where the proportion of women was 87.9% and of men 12.1%. Of all the cases, the most extensive cytological findings were of class II (benign formation) - 3061 studies (57%). The number of cases interpreted as class III was within the reference values, i.e. 8.2%. The fourth class accounted for 8.2%, the fifth for 3.5%, and the sixth for 5.0%. In total, these three classes account for 17.2%. Our analysis compared the reference values and data from other laboratories revealed comparable results. The analysis of the structure of the results of cytological investigations according to Bethesda revealed a high rate of the first class (non-informative), which indicates the need for more accurate interaction between clinical physicists and cytologists.

Accuracy of fine-needle aspiration of lymph nodes: A cancer center's experience

INTRODUCTION

Lymph node fine needle aspiration (LN-FNA) is a minimally invasive method of evaluating lymphadenopathy. Nonetheless, its use is not widely accepted due to the lack of guidelines and a cytopathological categorisation that directly relates to management. We report our experience with LN FNA at a large Cancer Center in Latin America.

METHODS

We retrospectively collected cytological cases of lymph node FNA from the department of pathology at AC Camargo Cancer Center performed over a 2-year period. Data extracted included LN location, age, sex and final cytological diagnosis. Patients that had undergone neoadjuvant chemotherapy and/or cases for which the surgery specimen location was not clearly reported were excluded. For those cases with surgical reports, risk of malignancy was calculated for each diagnostic category, along with overall performance of cytology. False positive cases were reviewed to assess any possible misinterpretation or sampling errors.

RESULTS

A total of 1730 LN-FNA were distributed as follows: 62 (3.5%) non-diagnostic (ND); 1123 (64.9%) negative (NEG), 19 (1.1%) atypical (ATY), 53 (3.1%) suspicious for malignancy (SUS), and 473 (27.3%) positive (POS). Surgical reports were available for 560 cases (32.4%). Risk of malignancy (ROM) for each category was 33.3% for ND, 29.9% for NEG, 25% for ATY, 74.2% for SUS and 99.6% for POS. Overall sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were 78.5%, 99.4%, 70.2% and 99.6%, respectively.

CONCLUSION

Lymph node FNA is a very specific and accurate exam, which is reliable in the detection of lymph node metastasis and other causes of lymphadenopathy.

A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System

BACKGROUND

The evaluation of lymph nodes (LN) by fine-needle aspiration cytology (FNAC) is routinely used in many institutions but it is not uniformly accepted mainly because of the lack of guidelines and a cytopathological diagnostic classification. A committee of cytopathologists has developed a system of performance, classification, and reporting for LN-FNAC.

METHODS

The committee members prepared a document that has circulated among them five times; the final text has been approved by all the participants. It is based on a review of the international literature and on the expertise of the members. The system integrates clinical and imaging data with cytopathological features and ancillary techniques. The project has received the endorsement and patronage of the International Academy of Cytology and the European Federation of the Cytology Societies.

RESULTS

Clinical, imaging, and serological data of lymphadenopathies, indications for LN-FNAC, technical procedures, and ancillary techniques are evaluated with specific recommendations. The reporting system includes two diagnostic levels. The first should provide basic diagnostic information and includes five categories: inadequate/insufficient, benign, atypical lymphoid cells of undetermined/uncertain significance, suspicious, and malignant. For each category, specific recommendations are provided. The second diagnostic level, when achievable, should produce the identification of specific benign or malignant entities and additional information by utilizing ancillary testing.

CONCLUSION

The authors believe that the introduction of this system for performing and reporting LN-FNAC may improve the quality of the procedure, the report, and the communication between cytopathologists and the clinicians. This system may lead to a greater acceptance and utilization of LN-FNAC and to a better interdisciplinary understanding of the results of this procedure.

Announcement: The International System for Reporting Lymph Node Cytopathology

Fine needle aspiration biopsy cytopathology (FNAC) of lymph nodes is a very common, inexpensive, and rapid diagnostic procedure and can lead to the accurate and timely diagnosis of one of the wide range of pathological processes that involve lymph nodes. These diagnoses include specific reactive processes, specific infections such as tuberculosis, metastatic carcinomas and melanomas, and some lymphomas. The FNAC effectively triages the lymph node material, but the initial diagnosis often requires ancillary testing as a second diagnostic step to make a specific diagnosis, such as the particular infectious agent, the type of lymphoma or Hodgkin lymphoma, or the specific type of metastatic malignancy. An international group of cytopathologists have begun the process of developing a system for the standardized reporting of lymph node FNAC. The group is addressing the pre-analytical issues related to the FNAC, including the role of clinical information and the use of ultrasound, and developing a structure of reporting categories based on the cytopathological findings linked to management recommendations. The basis of the system is the integration of the FNAC with the clinical setting, imaging, and ancillary tests that utilize the FNAC material, to produce a final report that will enhance patient care.

To Obtain More With Less: Cytologic Samples With Ancillary Molecular Techniques-The Useful Role of Liquid-Based Cytology

CONTEXT

- Fine-needle aspiration cytology has been increasingly used as the first tool in the evaluation of several diseases. Although cytology has a relevant role in the discrimination between benign and malignant lesions, conventional slides cannot lead to 100% conclusive results. It was hoped that the introduction of liquid-based cytology (LBC) would improve the efficacy of cytology through standardization, quality improvement, and the possibility of carrying out ancillary techniques on the residual stored material. In recent decades, the application of genomic alterations has been studied on cytologic samples with feasible and reliable results. The molecular analysis offers a powerful aid to define the best clinical or surgical approaches and follow-up for patients. In recent years, the application of different ancillary techniques has been carried out on conventional slides even though LBC represents a useful additional and alternative method for molecular testing.

OBJECTIVE

- To demonstrate the relevance of LBC as a valid aid to overcoming the difficulties encountered in the application of ancillary techniques on conventional slides.

DATA SOURCES

- We examined and reviewed our experience with the application of ancillary techniques on LBC performed on different body sites.

CONCLUSIONS

- We emphasize that LBC achieves significant and accurate results. It represents a valid method for cytologic evaluation and it provides highly reproducible and informative molecular yields.

RNA Analysis as a Tool to Determine Clinically Relevant Gene Fusions and Splice Variants

CONTEXT

- Technologic advances have contributed to the increasing relevance of RNA analysis in clinical oncology practice. The different genetic aberrations that can be screened with RNA include gene fusions and splice variants. Validated methods of identifying these alterations include fluorescence in situ hybridization, immunohistochemistry, reverse transcription-polymerase chain reaction, and next-generation sequencing, which can provide physicians valuable information on disease and treatment of cancer patients.

OBJECTIVE

- To discuss the standard techniques available and new approaches for the identification of gene fusions and splice variants in cancer, focusing on RNA analysis and how analytic methods have evolved in both tissue and liquid biopsies.

DATA SOURCES

- This is a narrative review based on PubMed searches and the authors' own experiences.

CONCLUSIONS

- Reliable RNA-based testing in tissue and liquid biopsies can inform the diagnostic process and guide physicians toward the best treatment options. Next-generation sequencing methodologies permit simultaneous assessment of molecular alterations and increase the number of treatment options available for cancer patients.

Integrated morphologic and molecular analysis of Trichomonas vaginalis, Mycoplasma hominis, and human papillomavirus using cytologic smear preparations

Pathogenic microbes may colonize the female genital tract via sexual transmission and cause health issues like inflammation or malignancy, summarized as sexually transmitted disease (STD). A major representative of such pathogens is Trichomonas vaginalis (T.v.), whose role in the etiology of cervical cancer remains elusive. Traditional morphologic screening of cervical smears is able to detect T.v., although its identification may be complicated by look-alikes such as degenerated granulocytes and basal cells. In addition, the parasite's endosymbiont Mycoplasma hominis (M.h.) cannot be detected in the Pap test. This investigation was aimed at designing a PCR-based method to detect specific pathogenic germs by using cervical cytology slides to overcome morphologic uncertainty and increase diagnostic accuracy. To test our molecular screening method on T.v., M.h., and HPV in archival smears, we elaborated a multiplex PCR approach based on microdissection. This assay was applied to a minute quantity of starting material which harbored or was suspected to harbor T.v.; the resulting isolated DNA was used for subsequent molecular analyses of T.v., M.h., and HPV. We clarified the diagnosis of genital T.v. infection in 88 and 1.8% of morphologically suspicious and T.v.-negative cases, respectively. We also revealed a tendency of M.h. co-infection in high-risk HPV cases. In conclusion, a microdissection-based approach to detect pathogenic microbes such as T.v., HPV, and M.h. is a molecular tool easy to implement and may help to better understand the interactivity of these germs with respect to pathogenesis.

Molecular diagnostic techniques in cytopathology: From the bench to the patient's bedside

Molecular techniques are increasingly used in everyday practice for patient diagnosis and also to guide therapy. Their application in cytological specimens can allow a more cost-effective management with fewer risks. However, standardized protocols are needed to guarantee accurate and reproducible results. We herein report five practical examples of the application of ancillary techniques in cytopathology and review the literature on the issue, highlighting the practical aspects of sample management.

Sponge Sampling with Fluorescent In Situ Hybridization as a Screening Tool for the Early Detection of Esophageal Cancer

INTRODUCTION

Sponge cytology is a novel screening tool for esophageal cancer but has been unable to be validated for widespread use. Our aim was to apply fluorescent in situ hybridization to sponge cytology samples in order to evaluate the safety and efficacy of this modality in screening for esophageal cancer.

MATERIALS AND METHODS

At a single, multidisciplinary, NCI-designated cancer center, patients completed sponge cytology sampling prior to upper endoscopy. Samples were analyzed by p53 fluorescent in situ hybridization, and results were compared to the endoscopic diagnosis.

RESULTS

Fifty patients were enrolled (96 % Caucasian, 68 % male, median age of 67). All patients successfully swallowed the capsule. No complications (string breakage, bleeding, mucosal injury) occurred. Endoscopy revealed that 38 % had normal esophageal mucosa and 62 % had an esophageal mucosal abnormality. In total, six samples demonstrated p53 loss (94 % specificity for any abnormality). The sensitivity of the p53 fluorescent in situ hybridization probe was13.3 % for any abnormality, 10 % for intestinal metaplasia, and 0 % for dysplasia or esophageal cancer.

DISCUSSION

Esophageal sponge cytology is a promising, safe, and tolerable method for collecting esophageal cell samples. However, our data suggest that p53 fluorescent in situ hybridization does not improve the sensitivity for detecting cancer in these samples.

Cytopathology of Follicular Cell Nodules

The detection of thyroid nodules, consisting of different diseases, represents a common finding in population. Their evaluation and diagnosis are mostly achieved with fine-needle aspiration cytology (FNAC). Even though the majority of thyroid nodules are correctly diagnosed, a total of 25% to 30% of them are classified "indeterminate" comprising lesions with varying risk of malignancy and different types of management. Although the number of thyroid FNACs, including small lesions, is increasing due to the reliance upon sonographic and cytologic interpretations, there are issues concerning cytomorphologic interpretation and interobserver reproducibility. Different classification systems have tried to better define the criteria for inclusion in specific categories and to therefore reduce the rate of indeterminate diagnoses such as atypia of undetermined significance, follicular neoplasms, and suspicious for malignancy. However, the support of ancillary techniques (eg, immunocytochemistry and molecular analysis) are reshaping morphologic diagnoses made on materials obtained from FNAC.

Molecular diagnosis of infectious diseases using cytological specimens

Pathologists have an important role in the diagnosis of infectious disease (ID). In many cases, a definitive diagnosis can be made using cytopathology alone. However, several ancillary techniques can be used on cytological material to reach a specific diagnosis by identifying the causative agent and consequently defining the management of the patient. This review aims to present the effectiveness of the application of molecular studies on cytological material to diagnose IDs and discuss the advantages and disadvantages of the various molecular techniques according to the type of cytological specimen and the infectious agents.

Diagnosing lung cancer in the 21st century: are we ready to meet the challenge of individualized care?

BACKGROUND

Histologic and molecular subtyping have become increasingly important as predictors of treatment benefit in lung cancer. The objective of the present study was to determine whether current diagnostic approaches provide adequate tissue to allow for individualized treatment decisions.

METHODS

Our retrospective cohort study of new lung cancer patients seen at an academic centre between July 2007 and June 2008 collected baseline demographic and diagnostic information, including mode of diagnosis, type of diagnostic material, and pathology diagnosis.

RESULTS

Of the 431 study patients, 20% had stage i or ii non-small-cell lung cancer (nsclc), 24% stage iii disease, and 39% stage iv nsclc. Three quarters of the small-cell lung cancer (sclc) cases were extensive stage. Diagnostically, 18% of patients had sclc; 30%, adenocarcinoma; 27%, squamous-cell cancer; 2%, large-cell carcinoma; 1%, bronchoalveolar carcinoma; 1%, mixed histology; 18%, nsclc not otherwise specified; 4%, other; and 2%, no pathology diagnosis. Surgical pathology material was available in 80% of cases, and cytology material alone in 20%. Surgical pathology material was more common in patients with early-stage than with advanced disease (89% for stages i and ii vs. 74% for stages iii and iv, p < 0.0001). The pathology report included ambiguous terms in 24% of cases: "consistent" (12%), "suspicious" (3%), "favour" (2%), "suggestive" (2%), "likely" (1%), "compatible" with malignancy (1%), "at least" (1%), "atypical" (0.5%), and "no pathology" (1.5%).

CONCLUSIONS

Current diagnostic approaches in most lung cancer patients appear adequate, but complete histopathologic identification is missing in nearly 20% of cases, and some uncertainty as to the final diagnosis is expressed in 24% of pathology reports. Some improvement in diagnostic sampling and pathology reporting are required to allow for implementation of current treatment approaches.

The potential of liquid-based cytology in lymph node cytological evaluation: the role of morphology and the aid of ancillary techniques

OBJECTIVES

Our aim was to evaluate the feasibility and diagnostic accuracy of liquid-based cytology (LBC) on lymph node fine needle aspiration (FNA). FNA may fulfil a challenging role in the evaluation of the majority of primary (benign and malignant) diagnoses as well as metastatic lymph node lesions. Although the morphological features may be quite easily recognized, cytological samples with a scant cellular component may raise some issues.

METHODS

We appraised 263 cytological lymph nodes from different body regions analysed between January and December 2013, including 137 male and 126 female patients, and processed with LBC.

RESULTS

The cytological diagnoses included 160 benign and 103 malignant lesions. We reported 35 benign and 73 malignant lesions from 108 with surgical follow-up. The latter malignant series included 68 metastatic lesions, four suspicious for malignancy and one inadequate sample. The cytological diagnoses were supported by 62 conclusive immunocytochemical and 28 molecular analyses. Of the 108 cases, we documented 35 true negatives, 72 true positives, one false negative and no false positives, resulting in 98.6% sensitivity, 100% specificity, 99% diagnostic accuracy, 97.2% negative predictive value and 100% positive predictive value.

CONCLUSIONS

FNA represents the first diagnostic tool in lymph node management and a reliable approach in order to avoid an excision biopsy. Furthermore, LBC is a feasible method for ancillary tests for which methanol-fixed samples are suitable, such as immunocytochemistry and molecular analysis.

Role of ancillary testing in thyroid fine needle aspiration: Review and update

Thyroid nodules are common, and ultrasound-guided fine needle aspiration identifies 70-75% as benign, and 4% as malignant. The remainder falls into categories of "indeterminate" with a widely ranging malignancy rate from 10-75%. The diagnosis and clinical management of indeterminate lesions is evolving, and we will review ancillary testing as an aid to diagnosis.

Automated Cellient(™) cytoblocks: better, stronger, faster?

OBJECTIVE

Cytoblocks (CBs), or cell blocks, provide additional morphological detail and a platform for immunocytochemistry (ICC) in cytopathology. The Cellient(™) system produces CBs in 45 minutes using methanol fixation, compared with traditional CBs, which require overnight formalin fixation. This study compares Cellient and traditional CB methods in terms of cellularity, morphology and immunoreactivity, evaluates the potential to add formalin fixation to the Cellient method for ICC studies and determines the optimal sectioning depth for maximal cellularity in Cellient CBs.

METHODS

One hundred and sixty CBs were prepared from 40 cytology samples (32 malignant, eight benign) using four processing methods: (A) traditional; (B) Cellient (methanol fixation); (C) Cellient using additional formalin fixation for 30 minutes; (D) Cellient using additional formalin fixation for 60 minutes. Haematoxylin and eosin-stained sections were assessed for cellularity and morphology. ICC was assessed on 14 cases with a panel of antibodies. Three additional Cellient samples were serially sectioned to determine the optimal sectioning depth. Scoring was performed by two independent, blinded reviewers.

RESULTS

For malignant cases, morphology was superior with Cellient relative to traditional CBs (P < 0.001). Cellularity was comparable across all methods. ICC was excellent in all groups and the addition of formalin at any stage during the Cellient process did not influence the staining quality. Serial sectioning through Cellient CBs showed optimum cellularity at 30-40 μm with at least 27 sections obtainable.

CONCLUSIONS

Cellient CBs provide superior morphology to traditional CBs and, if required, formalin fixation may be added to the Cellient process for ICC. Optimal Cellient CB cellularity is achieved at 30-40 μm, which will impact on the handling of cases in daily practice.

Metastatic breast cancer: mechanisms and opportunities for cytology

Despite significant advances in diagnosis, surgical techniques, general patient care, and local and systemic adjuvant therapies, metastatic disease remains the most critical condition limiting the survival of patients with breast cancer. Therefore, the development of effective treatment against late-arising metastasis has become the centre of clinical attention and is one of the current challenges in cancer research. A deeper understanding of the metastatic cascade is fundamental, and the need for repetitive tumour assessments for the evaluation of tumour evolution is a relatively new practice in routine medical care. As such, fine needle aspiration cytology (FNAC) is ideally placed to monitor biological changes in metastasis that may affect treatment and response. As FNAC is a minimally invasive method, it can be performed repeatedly with relatively little trauma, and selective ancillary tests can be applied to FNAC specimens, including for tumour whose primary nature is known. Herein, we review how the linear and parallel models explain metastatic dissemination, thus influencing therapeutic and clinical decisions, and how cytology, together with immunocytochemistry and molecular analysis, can be a tool for routine clinical practice and clinical trials aimed at metastatic disease with a special emphasis on breast cancer.

Immunohistochemistry practices of cytopathology laboratories: a survey of participants in the College of American Pathologists Nongynecologic Cytopathology Education Program

CONTEXT

Immunohistochemistry (IHC) is important for cytology but poses special challenges because preanalytic conditions may differ from the conditions of IHC-positive controls.

OBJECTIVE

To broadly survey cytology laboratories to quantify preanalytic platforms for cytology IHC and identify problems with particular platforms or antigens. To discover how validation guidelines for HER2 testing have affected cytology.

DESIGN

A voluntary survey of cytology IHC practices was sent to 1899 cytology laboratories participating in the College of American Pathologists Nongynecologic Cytopathology Education Program in the fall of 2009.

RESULTS

A total of 818 laboratories (43%) responded to the survey by April 2010. Three hundred fourty-five of 791 respondents (44%) performed IHC on cytology specimens. Seventeen different fixation and processing platforms prior to antibody reaction were reported. A total of 59.2% of laboratories reported differences between the platforms for cytology specimens and positive controls, but most (155 of 184; 84%) did not alter antibody dilutions or antigen retrieval for cytology IHC. When asked to name 2 antibodies for which staining conditions differed between cytology and surgical samples, there were 18 responses listing 14 antibodies. A total of 30.6% of laboratories performing IHC offered HER2 testing before publication of the 2007 College of American Pathologists/American Society of Clinical Oncologists guidelines, compared with 33.6% afterward, with increased performance of testing by reference laboratories. Three laboratories validated a nonformalin HER2 platform.

CONCLUSIONS

The platforms for cytology IHC and positive controls differ for most laboratories, yet conditions are uncommonly adjusted for cytology specimens. Except for the unsuitability of air-dried smears for HER2 testing, the survey did not reveal evidence of systematic problems with any antibody or platform.

The nightmare of indeterminate follicular proliferations: when liquid-based cytology and ancillary techniques are not a moon landing but a realistic plan

OBJECTIVE

Thyroid nodules are a common finding in the general population, including both nonneoplastic and neoplastic entities. Fine-needle aspiration cytology (FNAC) is the first tool for evaluating thyroid nodules. In spite of its high diagnostic accuracy, 25% of nodules result in the category of follicular neoplasms (FN), with varying risk of malignancy and different management strategies.

STUDY DESIGN

The use of ancillary techniques is reshaping the practice of FNAC. These tools can significantly empower the morphological diagnosis and prognosis of thyroid nodules, allowing a more accurate prediction of the nature of the lesion. Several studies have underlined the role of single or multiple testing for the category of FN as strong indicators of cancer. Every cytological preparation can be used for the application of ancillary techniques but the introduction of liquid-based cytology (LBC) might facilitate the application.

RESULTS

Our experience involving an immunocytochemical panel made up of HBME-1 and galectin-3 pointed to an 81% overall diagnostic accuracy in discriminating between low and high risk of malignancy in FN.

CONCLUSIONS

The application of these techniques on LBC represents an adjunct to the morphological evaluation of FN. They represent a critical and challenging, but also a feasible, tool in the preoperative diagnoses, allowing specific prognostic and predictive details regardless of the cytological preparation. © 2014 S. Karger AG, Basel.

Detection of common and less frequent EGFR mutations in cytological samples of lung cancer

OBJECTIVE

Lung cancer represents the leading cause of cancer death. EGFR mutations, detected in 10-40% of lung adenocarcinomas, are an essential key to therapeutic management. EGFR-activated mutations comprise mainly deletions in exon 19 and point mutations in exon 21. Although histology is the traditional method of detection, we investigated the role of cytology in EGFR mutations.

STUDY DESIGN

A total of 774 lung cancers were studied for EGFR mutations (676 histological and 98 cytological samples), including 424 adenocarcinomas, 326 non-small cell lung carcinomas not otherwise specified, and 24 squamous cell carcinomas.

RESULTS

We had a total of 164 (21.2%) cases of mutations. Common mutations were short in-frame deletions in exon 19 (53.7%) and single-nucleotide substitutions in exon 21 (34.1%); less frequent mutations included single-nucleotide substitutions in exon 18 (3.7%) and in-frame insertions/deletions in exon 20 (8.5%). Histologically, EGFR mutations in exons 19 and 21 occurred in 19.4% and in exons 18 and 20 in 2.2%, while the rates cytologically were 13.3% for exons 19 and 21 and 5.1% for exons 18 and 20.

CONCLUSIONS

The sensitivity for the detection of EGFR mutations in cytological samples overlaps histology, so the use of cytological material constitutes an adequate approach for treatment selection in patients with locally advanced or metastatic lung cancer.

Pre-analytic steps for molecular testing on thyroid fine-needle aspirations: The goal of good results

Fine-needle aspiration cytology (FNAC) represents a valid alternative to biopsy in a variety of clinical settings mainly based on its simplicity and less invasive clinical approach. In some cases, morphology evaluation alone is not sufficient to manage the patients, so that the application of ancillary techniques can contribute to diagnosis, prognosis and prediction of tumor behavior. These techniques include polymerase chain reaction (PCR), fluorescence in situ hybridization (FISH), in situ PCR, direct Sequencing, microarrays and proteomic methodologies. Although several recent experiences underline the superior value of deoxyribonucleic acid (DNA) quality mainly for advanced genomic high throughput platforms, very scant literature studied the role of the pre-analytical or analytical phases. Despite the high specificity of molecular techniques as a support for diagnosis, there is a need for an increased standardization of pre-analytical/analytical steps such as providing appropriate clinical history, proper collection of laboratory specimens and proper preparation of samples, adequate fixative/reagent concentrations and technical equipments. All these requirements are crucial according to the results from 42 American laboratories, which reported 0.33% of significant molecular errors with 60% of them in the pre-analytical phase. The most common error is to forget that cytological preparation requires specific molecular variables, which are different from histological specimens. Cytological samples offer the advantage of a well preserved DNA, readily extractable and reasonably stable (from 6 months to 5 years) avoiding pitfalls due to formalin-fixation. Freshly prepared, unstained direct, alcohol-fixed papanicolaou, air-dried diff-quick smears are all suitable for DNA extraction and preservation. In the specific field of thyroid FNAC, molecular analysis has been supported by the growing evidence that papillary thyroid carcinoma (PTC), the most common thyroid cancer, frequently is a diploid lesion and can display non-overlapping mutations of the v-Raf murine sarcoma viral oncogene homolog B1 (BRAF) in 46% to 70%, cases, ret proto-oncogene (RET) in 3 to 85% and Rat Sarcoma oncogene (RAS) in 0-21% cases. Recently, several cytological papers demonstrated that the combination of morphology and molecular analysis can increase the diagnostic accuracy allowing more precise prediction of malignancy regardless of the diagnostic categories. In conclusion, the correct use of the pre-analytical-analytical steps might lead to optimal results on cytology and empower the prognostic value of molecular techniques as strong indicators of cancer for their high specificity and positive predictive value.

Ancillary Studies, Including Immunohistochemistry and Molecular Studies, in Lung Cytology

The importance of cytologic techniques for investigation of respiratory conditions has been recognized since the earliest days of clinical cytology. Cytology is able to detect most of mycoses and parasitic and viral infections based on the morphologic recognition of these agents. The most relevant application of lung cytology today is in the diagnosis and management of lung cancer; approximately 70% of those cancers are diagnosed at a late stage and are unresectable. This article addresses the most common ancillary techniques, such as special stains, immunocytochemistry, and molecular testing, used to refine the cytologic diagnosis of lung cancer and to guide personalized therapy.

Cytological diagnosis of adult-type fibrosarcoma of the neck in an elderly patient. Report of one case and review of the literature

BACKGROUND

Fibrosarcoma (FS) accounts for about 3% of all soft tissue sarcomas. It may arise in any area of the body, but it is relative rare in the head and neck district. Fine-needle cytology (FNC) is widely used in the diagnosis of neoplastic and non-neoplastic lesions of soft tissue. This article describes a case of FS of the neck diagnosed by FNC.

METHODS

FNC was performed in a sub-fascial supraclavicular mass of an elderly patient under ultrasound (US) control. FNC was used to prepare cytological smears that were conventionally and immunocytochemically (ICC) stained.

RESULTS

Smears showed a monomorphous spindle cell population and were positive at ICC for Vimentin and negative for CKAE1AE3, Actin, S-100, CD68, CT and PAX-8. The cytological diagnosis was confirmed by histological diagnosis. The patient underwent surgical resection and subsequent radiotherapy.

CONCLUSIONS

FNC diagnosis of FS is reliable and accurate and may be conveniently used in the scheduling of surgical procedures, when needed, avoiding the treatment of benign nodules.

Cytopathology of the pancreatobiliary tract-the agony, and sometimes, the ease of it

Pancreatic cytopathology is recognized as a rapid, reliable, safe and cost-beneficial modality of investigation of pancreatic mass lesions. Optimal cytodiagnosis depends on multiple factors including sample quality, and expertise of the cytopathologist and endoscopist. This article discusses key cytologic features of specific tumor types, specimen handling, differential diagnoses and pitfalls.

Role of cytopathology in the diagnosis and management of gastrointestinal tract cancers

Cytology of gastro-intestinal (GI) tract lesions can be used successfully to diagnose neoplastic and non-neoplastic conditions, especially when combined with biopsies. Cytologic evaluation is widely accepted as a cost-effective method that allows rapid interpretation and triaging of material. Technical advances over the years have allowed simultaneous visualization of abnormal tissue and procurement of needle aspirates, brushings and biopsies from mucosal and deeper seated lesions. Successful cytologic examination of the GI tract is highly dependent on the skill of the endoscopist, specimen preparation, the expertise of the pathologist, and the recognition of the limitations of cytology. This article reviews the key cytologic features of important GI tract lesions, differential diagnoses, and pitfalls, and addresses the advantages and limitations of different collection techniques.