Diagnostic role of fine-needle aspiration of bone lesions in patients with a previous history of malignancy

Fine-needle aspiration biopsy of lytic bone lesions: An institution's experience

OBJECTIVES

Fine needle aspiration (FNAB) is an effective, minimally-invasive, inexpensive, diagnostic technique. The objective of this study was to evaluate the accuracy of FNAB in the diagnosis of bone lesions.

METHODS

FNABs of bone lesions diagnosed at our institution over a 2-year period were retrospectively analyzed.

RESULTS

241 samples were reviewed. Patients included 121 males and 120 females, with ages ranging from 4-95 years (mean = 66 years). Of these 241 cases, 43.2% had FNAB and 56.8% had FNAB with core needle biopsy (CNB). The cytologic diagnoses were categorized as nondiagnostic, benign, atypical, suspicious, and positive for malignant cells. Total of 84.3% of FNABs were diagnostic. Of the malignant cases, 78.5% were metastases from nonosseous primary sites, 17.1% were lymphoproliferative lesions, and 4.4% were primary bone tumors. The most common site of metastasis was the pelvic bones (43.5%) followed by the vertebral column (38.7%). Breast (21%), lung (12.7%), and prostate (11.3%) were the most common identifiable primary site in metastatic cases. FNA smears and cell blocks allowed identification of metastatic lesions in 94.3% cases with immunohistochemistry (IHC). Obtaining a concomitant CNB did not result in a statistically significant increase in overall diagnostic yields (P = .20), ascertaining presence of metastatic lesion (P = .96) or ability to identify site of primary tumor in cases of metastasis (P = .53) compared to FNAB alone. Diagnostic accuracy was improved by reviewing clinical history, performing cell block, and IHC.

CONCLUSIONS

FNAB is a reliable tool for diagnosis of bone lesions with comparable diagnostic sensitivity to CNB.

Optimal Diagnostic Yield Achieved With On-site Pathology Evaluation of Fine-Needle Aspiration–Assisted Core Biopsies for Pediatric Osseous Lesions: A Single-Center Experience

Context.—

Image-guided, fine-needle aspiration–assisted core needle biopsy with an on-site evaluation by a pathologist (FNACBP) of osseous lesions is not a common practice in pediatric institutions.

Objectives.—

To evaluate the diagnostic adequacy and accuracy of FNACBP for pediatric osseous lesions and to compare the adequacy with procedures that do not use fine-needle aspiration.

Design.—

Six-year, retrospective review of 144 consecutive children biopsied for osseous lesions with and without fine-needle aspiration assistance.

Results.—

Pathologic diagnosis was achieved in 79% (57 of 72) of the core biopsies without an on-site evaluation, 78% (32 of 41) of the open biopsies (9 with intraoperative consultation), and 97% (30 of 31) of the FNACBPs as the initial diagnostic procedure. Three FNACBP cases were preceded by nondiagnostic open biopsies. Among 34 lesions sampled by FNACBP, 33 (97%) succeeded with diagnostic tissue, with most (30 of 33; 91%) being neoplasms, including 16 malignant (48%), 13 benign (39%), and 1 indeterminate (3%) lesions. The most-common diagnoses were osteosarcoma (9 of 33; 27%) and Langerhans cell histiocytosis (7 of 33; 21%). In cases with follow-up information available, 93% (28 of 30) of the FNACBP-rendered diagnoses were clinically useful, allowing initiation of appropriate therapy. The FNACBP procedure had 100% specificity, sensitivity, and positive predictive value for all 14 malignant lesions, with the sensitivity being 88% in benign lesions. Most FNACBP procedures (32 of 34; 94%) yielded adequate material for ancillary testing. A gradual upward trend was observed for the choice of FNACBP as an initial diagnostic procedure for osseous lesions.

Conclusions.—

The FNACBP procedure yields sufficient material for diagnosis and ancillary studies in pediatric, osseous lesions and may be considered an initial-diagnostic procedure of choice.

Tibial bone metastasis as an initial presentation of endometrial carcinoma diagnosed by fine-needle aspiration cytology: A case report and review of the literature

Endometrial cancer is the most common gynecologic malignancy in the United States. However, bony metastasis is infrequent and exceptionally rare as the initial presentation. We report a case of a 77-year-old female with a clinically silent endometrial carcinoma who presented with a left tibial metastasis as the first manifestation of her disease. Ours is only the third case diagnosed by fine-needle aspiration (FNA) cytology, and the first to detail the cytomorphologic features of metastatic endometrial cancer to bone. These microscopic findings, including three-dimensional cohesive clusters with cellular overlapping and cuboidal to columnar cells exhibiting low nuclear: cytoplasmic ratios and partially vacuolated cytoplasm, differ significantly from those of endometrial carcinoma on a Papanicolaou test. The tumor bore similarity to the more commonly encountered metastatic colon cancer, but immunohistochemical staining enabled reliable distinction between these entities. A review of osseous metastases of endometrial cancer demonstrates a predilection for bones of the lower extremity and pelvis with a predominance of the endometrioid histologic subtype. In about a quarter of the cases, the bony metastasis was the first manifestation of the cancer. FNA was an effective diagnostic modality for this unusual presentation of a common malignancy. Awareness of this entity and its differential diagnosis is essential for accurate and timely diagnosis.

Bone Cytology: A Realistic Approach for Clinical Use

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

Usefulness of the cytology in the diagnosis of bone lesions

OBJECTIVE

This study aims to evaluate the interest to systematically combine cytology and histology for all bone specimens.

METHODS

We reviewed all the bone biopsies performed in the University Hospital of Brest, France, between January 2000 and March 2008 and for which cytology and histology, obtained at the same time, were available. The interest of cytology and histology, alone and in combination was studied in comparison with the diagnostic made by the practitioner who treated the patient, which was considered the reference.

RESULTS

Seventy patients were included. Among them, 55 had a final diagnosis of cancer. Thirty-nine of them were identified either by cytology or histology: twenty-five were identified by the two techniques, eight only by histology, and six only by cytology. There was no false-positive result, but false-negative results occurred with cytology (n=3) and histology (n=4). The agreement malignancy/benignancy was high (κ=0.84) between cytology and histology when taking into account the only contributive results. It dropped to 0.52 when taking into account all the samples.

CONCLUSION

Cytology and histology are complementary to each other in diagnosing bone lesion. Combining cytomorphology and tissue architecture increases the accuracy of bone sample and would systematically be performed for each bone biopsy.

Should fine needle aspiration biopsy be the first pathological investigation in the diagnosis of a bone lesion? An algorithmic approach with review of literature

BACKGROUND

Fine needle aspiration biopsy (FNAB) is gaining increasing popularity in the diagnosis of musculoskeletal lesions; and in many patients, a definitive diagnosis can be rendered from aspiration smears alone. Its applicability in bone pathology, however, has been controversial due to a high percentage of inadequate smears, difficulty in evaluation of tissue architecture and nonspecific results in the diagnosis of primary bone lesions. In this study, the value of aspiration as the first pathological investigation in the diagnosis of a bone lesion was evaluated.

METHODS

91 cases of clinically suspected cases of bone lesions were aspirated over a period of two years. Direct or cytospin smears were fixed in 95% alcohol and stained by Hematoxylin and Eosin or air-dried and later fixed in methanol for May Grŭnwald Giemsa staining.

RESULTS

Of the 91 patients who were subjected to FNAB, 81 were considered satisfactory and 10.9 % (10) were inadequate\inconclusive for diagnosis. Cyto-histological concordance was obtained in 78.5 % (51/65) patients. Positive and negative predictive values were 87.5% and 97.2 % respectively. Sensitivity as a preliminary diagnostic technique was 93.3%, whereas specificity was 94.5 %. Overall, diagnostic accuracy was 94.2 %. Metastatic lesions were detected with 100% accuracy. Two cases were reported as false positive and one case as false negative.

CONCLUSION

Cytology provides valuable information to the clinician to make an informed decision regarding appropriate therapy. We conclude that time-consuming and costly investigations may be reduced by choosing FNAB as the initial pathological diagnostic method for skeletal lesions of unknown origin. The choice of radiological examinations, laboratory tests and surgical biopsies can be determined after the FNAB diagnosis.

Diagnosing appendicular osteosarcoma with ultrasound-guided fine-needle aspiration: 36 cases

OBJECTIVES

To determine the ability to obtain diagnostic cytology samples from appendicular bone lesions using ultrasound-guided needle aspirations. Secondary objectives were to compare cytological evaluations with histopathological results and to determine the utility of staining malignant mesenchymal cells for the presence of alkaline phosphatase.

METHODS

Aspirations from 36 aggressive appendicular bone lesions with histological diagnoses were included in the study. Ultrasound was used to guide the needle to the medullary cavity or the adjacent soft tissue mass. The smears stained with Wright-Giemsa and nitroblue tetrazolium chloride/5-bromo-4-chloro-3-indoyl phosphate toluidine salt (NBT/BCIP) were examined.

RESULTS

A diagnostic sample was obtained in 32 of the 36 cases. Of the 32 diagnostic samples, cytology indicated sarcoma, with a sensitivity of 97 per cent (confidence interval: 83 to 100 per cent) and a specificity of 100 per cent (confidence interval: 16 to 100 per cent). When a diagnosis of sarcoma was made on cytology, alkaline phosphatase staining indicated osteosarcoma, with a sensitivity of 100 per cent (confidence interval: 87 to 100 per cent).

CLINICAL SIGNIFICANCE

The results of this study indicate that ultrasound-guided needle aspiration of aggressive bone lesions is a viable technique for identifying malignant mesenchymal cells and for diagnosing sarcomas. It is cost-effective and minimally invasive. Furthermore, identifying alkaline-phosphatase-negative malignant mesenchymal cells from a bone aspiration may rule out osteosarcoma, whereas alkaline-phosphatase-positive malignant mesenchymal cells are suggestive of osteosarcoma.

Fine needle aspiration cytology in the diagnosis of bone lesions

OBJECTIVE

Fine needle aspiration cytology (FNAC) in combination with radiological examination has recently gained clinical recognition for evaluating skeletal lesions. We evaluated our experience with the use of FNA in diagnosing bone lesions with emphasis on areas of difficulty and limitations.

MATERIALS AND METHODS

Over a period of 5 years FNA was performed in 66 cases of bone lesions. Aspirations were done by cytopathologists using 22-gauge needle. Out of 66 cases unsatisfactory aspirate was obtained in 12 cases. Cytohistological correlation was available in 19 cases.

RESULTS

Adequate aspirates were categorized into neoplastic (27 cases) and non-neoplastic (27 cases) lesions. Of the 27 neoplastic aspirates, 20 were malignant (12 primary, 8 metastatic deposits) and 7 were benign. In the malignant group osteosarcoma was correctly diagnosed in 3 cases while other 3 were labeled as sarcoma NOS because of lack of osteoid. Metastatic deposits were sub-typed in 6 cases; from renal cell carcinoma (3 cases), proststic adenocarcinoma, follicular carcinoma thyroid, and squamous cell carcinoma. Neoplastic group comprised of 6 cases of cysts and 21 cases of chronic osteomyelitis. Thirteen cases were diagnosed as tuberculous osteomyelitis.

CONCLUSIONS

FNA is a frequent indication in metastases in the bone where distinct cytologic features can even identify an unknown primary. However, diagnosis of primary tumours of the bone is limited by precise subtyping of the tumours. FNA has emerged as a cost effective tool for initial diagnosis of both neoplastic and non-neoplastic lesions of the bone.

Bone marrow sampling in pathologic fractures: intramedullary pediatric chest tube technique

The objective of this article is to report upon a simple technique of bone marrow specimen collection of intramedullary bone tumors using a pediatric chest tube. This technique is described along with two case reports which include a 60-year-old female with metastatic breast cancer to the proximal femur, and a 63-year-old male with multiple myeloma of the proximal humerus. Utilizing this technique, in our experience, over 50 mL of aspirate can be obtained and definitive histologic material for cytogenetic diagnosis and immunohistochemistry. This technique is not indicated for biopsy of suspected primary lesions of bone due to the possibility of medullary or hematologic seeding and inappropriate invasion of soft tissue compartments.