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

Comparison of fine-needle aspiration techniques

BACKGROUND

Fine-needle aspiration (FNA) has been reported since 1912 beginning with the use of trocars and other specialized instruments that were impractical. Since then, FNA has proven to be a successful alternative technique to excisional biopsy for some assays despite a few limitations.

METHODS

In this study, we compared four different techniques for FNA in rhesus macaques by evaluating total live cells recovered and cell viability using a standard 6 mL syringe and 1.5-inch 22-gauge needle.

RESULTS

Technique B which was the only technique in which the needle was removed from the syringe after collection of the sample to allow forced air through the needle to expel the contents into media followed by flushing of the syringe and needle resulted in the highest total cell count and second highest cell viability in recovered cells.

CONCLUSION

Based on our results, Technique B appears to be the superior method.

Utility of the Proposed Sydney System for Classification of Fine-Needle Aspiration Cytopathology of Lymph Node: A Retrospective Study at a Tertiary Care Center

INTRODUCTION

Fine-needle aspiration cytology (FNAC) is an established first-line technique for the evaluation of lymphadenopathy and, with the help of ancillary testing, can in many instances obviate the need for an open biopsy. The Sydney system was recently proposed to provide consensus guidelines for the performance, classification, and reporting of lymph node FNAC. The present study was undertaken to evaluate its utility and study the impact of rapid on-site evaluation (ROSE).

MATERIAL AND METHODS

A retrospective analysis in which 1,500 lymph node FNACs was reviewed and assigned a diagnostic category from the Sydney system. Cyto-histopathological correlation and adequacy parameters were evaluated.

OBSERVATION AND RESULTS

The cervical group of lymph nodes was the commonest group aspirated (89.7%). A total of 1,205/1,500 (80.3%) cases were category II (benign), and necrotizing granulomatous lymphadenitis was the most common pathology. The 750 cases with ROSE were subclassified as follows: 15 category I (inadequate), 629 category II (benign), 2 category III (atypia of undetermined significance), 9 category IV (suspicious for malignancy), and 95 category V (malignant). Among 750 cases without ROSE, 75 cases were in category I, 576 in category II, 3 in category III, 6 in category IV, and 90 in category V. Category I was thus significantly lower in the ROSE group compared to the non-ROSE group. Overall, the risk of malignancy was L1-0%, L2-0.20%, L3-100%, L4-92.3%, and L5-100%. Accuracy parameters revealed a sensitivity of 97.7%, specificity of 100%, PPV of 100%, NPV of 99.10%, and diagnostic accuracy of 99.54%.

DISCUSSION AND CONCLUSION

FNAC can be used as the 1st line of treatment for lymph node pathology. ROSE can be used as an add-on to FNAC for reducing unsatisfactory rates and help triage material for ancillary testing whenever possible. The Sydney system should be implemented for achieving uniformity and reproducibility.

Role of Flow Cytometric Immunophenotyping for Classic Hodgkin Lymphoma in Small Biopsy and Cytology Specimens

CONTEXT.—

The diagnosis of classic Hodgkin lymphoma (CHL) traditionally requires surgical tissue biopsy because of the paucity of diagnostic Hodgkin and Reed-Sternberg cells. Diagnosis can be challenging in small core needle and cytologic biopsies, which are increasingly used because of reduced costs and minimal invasiveness. Flow cytometric (FC) identification of Hodgkin and Reed-Sternberg cells is possible, but FC test efficacy is not well studied outside of validation settings, especially in small specimens.

OBJECTIVE.—

To assess the testing efficacy of FC performed on small biopsy and cytology specimens for the diagnosis of CHL.

DESIGN.—

We reviewed 131 patients with CHL and 459 patients without CHL during a 3-year period who underwent a small biopsy procedure, including core biopsy and/or cytology evaluation, with concurrent routine clinical FC testing for CHL, assessing performance of FC in small specimens.

RESULTS.—

Evaluating testing efficacy, sensitivity was 95.4% and specificity was 98.2%, whereas positive and negative predictive values were 92.2% and 99.0%, respectively. Although there were more false-positive results than compared with published validation studies, expert review identified distinct diagnostic pitfalls; awareness of these may improve testing efficacy.

CONCLUSIONS.—

Although FC diagnosis of CHL was historically considered unfeasible, our findings in a real-world clinical setting suggest that FC adds diagnostic value to small biopsy evaluation, reducing time to treatment, costs, and invasive excisional procedures.

A Novel Approach to Classification and Reporting of Lymph Node Fine-Needle Cytology: Application of the Proposed Sydney System

Fine-needle cytology (FNC) is a useful diagnostic tool in the first line evaluation of lymphadenopathy of unknown aetiology. Nevertheless, considering the large number of conditions presenting as lymphadenopathy, lymph node cytology represents a challenging scenario. Recently, an expert panel published the proposal of the Sydney system for performing classification and reporting of lymph node cytopathology; the aim of the present study was to evaluate the applicability of this system. Thus, 300 lymph node FNCs performed over 1 year were reviewed and categorized according to the Sydney system classification. Overall, n = 20 cases (6.7%) were categorized as L1-inadequate/non-diagnostic; n = 104 (34.7%) as benign (L2); n = 25 (8.3%) as atypical (L3); n = 13 (4.3%) as suspicious (L4), and n = 138 (46%) as malignant (L5). FNC diagnoses were correlated with histopathologic and clinical follow-up to assess the diagnostic accuracy and the risk of malignancy (ROM) for each diagnostic category. Statistical analysis showed the following results: sensitivity 98.47%, specificity 95.33%, positive predictive value 96.27%, negative predictive value 98.08%, and accuracy 97.06%. The ROM was 50% for the category L1, 1.92% for L2, 58.3% for L3, and 100% for L4 and L5. In conclusion, FNC coupled with ancillary techniques ensures satisfactory diagnostic accuracy and the implementation of the Sydney system may improve the practice of cytopathologists.

Contribution of small tissue biopsy and flow cytometry to preoperative cytological categorization of salivary gland fine needle aspirates according to the Milan System: Single center experience on 287 cases

BACKGROUND

Milan system for reporting salivary gland cytopathology (MSRSGC) was proposed to provide a standardized reporting system for salivary gland fine needle aspiration biopsies. Modified Menghini type semi-automatic aspiration biopsy needles provide small tissue fragments (STFs), as well as cellular smears, and immunohistochemical and molecular studies can be performed using the STFs.

AIMS

We aimed to evaluate the contribution of STFs and ancillary techniques to pre-operative diagnosis of salivary gland lesions.

MATERIALS AND METHODS

In this study, smears of 287 cases with histopathological correlation were re-reviewed and assigned to one of the MSRSGC categories. In the second step, histopathological and immunohistochemical findings in STFs were evaluated together with cytological findings. Final diagnoses were obtained with the inclusion of flow cytometry (FC) results when available. Risk of malignancy (ROM) was calculated for each diagnostic category.

RESULTS

In the evaluation based on smears, a specific diagnosis could be obtained in 64.8% of the cases. ROMs were 0% for nondiagnostic (ND), 5.6% for non-neoplastic (NN), 55% for atypia of undetermined significance (AUS), 0.6% for benign neoplasm (BN), 27.8% for salivary gland neoplasm of uncertain malignant potential (SUMP), and 100% for suspicious for malignancy (SFM) and malignant (M) categories. With the addition of histopathological and immunohistochemical findings and FC results, a specific diagnosis could be obtained in 75.2% of the cases. ROMs were 0% for ND, 4.5% for NN, 53.8% for AUS, 0.6% for BN, 0% for SUMP, and 100% for SFM/M categories.

CONCLUSIONS

STFs contribute correct categorization of salivary gland lesions. The major contribution of ancillary methods is in the SUMP category.

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.

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.

Indications for biopsy of imaging-detected intramammary and axillary lymph nodes in the absence of concurrent breast cancer

To evaluate the prevalence of malignancy in imaging-detected abnormal lymph nodes (LNs) in women without concurrent cancer and to identify imaging features predictive of malignancy in this population. This is an IRB-approved study with waived informed consent. We retrospectively reviewed medical records of all image-guided LN FNAs and CNBs performed at our institution from 1/1/08 through 12/31/10. LNs sampled in patients without concurrent breast cancer comprised our study group (SG; n = 77), and with concurrent breast cancer our reference group (RG; n = 124). Blinded to cytology/histology, imaging features of the LNs including size, loss of fatty hilum, and cortical thickness were reviewed. A low/high suspicion category was then assigned based on LN appearance. The prevalence of malignancy in LNs in SG was 6% (5/77) and in RG 52% (64/124; P < .0001). Complete loss of fatty hilum had 100% (5/5) sensitivity, and 100% (56/56) NPV for detecting cancer in SG, compared to 39% (25/64) sensitivity and 61% (60/99) NPV in RG. When a "high suspicion" imaging feature was used as a threshold to biopsy, the sensitivity (5/5) and NPV (45/45) in SG were 100%, and in RG 78% (50/64) and 77% (47/61), respectively. The prevalence of cancer in imaging-detected abnormal LNs in patients without concurrent breast cancer is low. In the absence of concurrent cancer, using highly suspicious features of loss of fatty hilum or cortical thickness ≥ 5 mm as a threshold to biopsy will maintain high sensitivity with lower false-positive biopsy rate.

Utility of flow cytometry analysis for pleural and peritoneal fluids

INTRODUCTION

Pleural and peritoneal/ascites fluid samples with many lymphocytes are commonly received in the cytology laboratory. It is often difficult to distinguish reactive lymphocytes from hematopoietic malignancy based on morphology alone, however. Flow cytometry can be a useful adjunct in body fluids, although literature on this subject is limited.

MATERIALS AND METHODS

This study is a single-institution 5-year retrospective review of 377 fluid samples from 341 patients with corresponding flow cytometry analysis. The cytologic findings were correlated with the flow cytometry results and clinical data, as available.

RESULTS

Of 4158 pleural fluids received over 5 years, 325 (7.8%) had corresponding flow cytometry analysis. Of these 325 samples, 57 (17.5%) were positive for hematopoietic malignancy by flow cytometry. Of the positive cases, only 24 (8.7%) represented a new diagnosis of hematopoietic malignancy (ie, did not have a known history). Of 3020 peritoneal/ascites fluids received over 5 years, 52 (2%) had corresponding flow cytometry. Of these, 8 were positive for hematopoietic malignancy, and only 2 represented a presumed new diagnosis.

CONCLUSIONS

Routine flow cytometry analysis for pleural and peritoneal/ascitic fluids is of limited utility, with only rare cases positive for hematopoietic malignancy without a known history. Of these cases, many had atypical cells that suggested a positive diagnosis. Conversely, in cases with a known history, about 75% were positive for hematopoietic malignancy. Our study suggests that the utility of flow cytometry for pleural and peritoneal/ascitic fluids is limited, and should be used sparingly in cases without atypical cytologic features, high clinical suspicion, or known history.

Extranodal Lymphoproliferative Processes and Flow Cytometry

OBJECTIVE

Fine-needle aspiration (FNA) cytology is a safe and cost-effective technique for the diagnosis of lymphoproliferative processes, especially when correlated with clinical and imaging studies. However, cytology alone may be unable to detect a lymphoid neoplastic process, as architectural features are less obvious than in histologic preparations and, in certain cases, reactive processes may mimic lymphoma. Flow cytometry (FC) has been recognized as an important ancillary technique in the diagnosis of lymphoid neoplasms and it can be used in conjunction with FNA in the evaluation of lymphoproliferative processes.

STUDY DESIGN

We performed a review of the published literature concerning FC applied to the detection of salivary glands and thyroid lymphoproliferative processes, which are frequently related to autoimmune diseases and difficult to diagnose by cytomorphology alone.

RESULTS

FC is able to detect and subtype non-Hodgkin lymphomas and may contribute to the exclusion of a neoplastic process in cytologically unclear cases.

CONCLUSIONS

FC can be successfully applied in the differential diagnosis of lymphoproliferative processes in the head and neck region. The FNA-FC combined approach can reduce time to therapy and may prevent unnecessary surgical biopsies.

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.

Secondary B-cell lymphoma diagnosed by fine-needle aspiration cytology and flow cytometry following penile carcinoma: A case report

The number of studies reporting lymphoma as a secondary tumor has gradually increased. However, few studies have reported that occurrence of lymphoma as a secondary tumor following treatment for penile carcinoma, particularly cases in which the lymphoma was diagnosed by fine-needle aspiration cytology and flow cytometry. The present study reports the case of a 62-year-old male patient who was troubled with frequent urination and repeated chest tightness for 5 years. The diagnosis upon admission was penile carcinoma. Two months subsequent to the tumor removal surgery, enlarged lymph nodes were extracted from the patient using fine-needle biopsy, to be analyzed using light microscopy and flow cytometry. Smear results indicated a large number of abnormal cells scattered in the right axillary lymph node. Flow cytometry immunophenotyping of fine-needle aspiration samples indicated the increased expression of cluster of differentiation (CD)79a, CD19, CD20, CD38, κ chain and human leukocyte antigen-DR, which supported a diagnosis of B-cell lymphoma. Thus, the patient was diagnosed with B-cell lymphoma based on the results of the fine-needle aspiration biopsy and flow cytometry. The method of diagnosis and causes of therapy-related leukemia are discussed in the present report.

Systematic review of the effectiveness of fine-needle aspiration and/or core needle biopsy for subclassifying lymphoma

CONTEXT

The World Health Organization system for lymphoma classification relies on histologic findings from excisional biopsies. In contradistinction to expert guidelines, practitioners increasingly rely on fine-needle aspiration cytology and core needle biopsies rather than excisional biopsies to diagnose lymphomas.

OBJECTIVE

To determine a rate at which fine-needle aspiration cytology and core needle biopsies, combined with flow cytometry and/or genetic techniques, can provide a diagnosis sufficient for optimal medical management of lymphoma.

DATA SOURCES

The English-language literature on fine-needle aspiration cytology and core needle biopsies for lymphoma was reviewed to identify studies that provided interpretations of all specimens regardless of whether these were deemed diagnostic.

CONCLUSIONS

Forty-two studies (1989-2012) specified the lymphoma subtypes for each diagnosis or indicated a rate at which the methods failed to provide a diagnosis. The median rate at which fine-needle aspiration cytology and core needle biopsies yielded a subtype-specific diagnosis of lymphoma was 74%. Strictly adhering to expert guidelines, which state that follicular lymphoma cannot be graded by these techniques, decreased the diagnostic yield further to 66%. Thus, 25% to 35% of fine-needle aspirates and/or core biopsies of nodes must be followed by an excisional lymph node biopsy to fully classify lymphoma.

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.

Flow cytometric immunophenotyping and cell block immunocytochemistry in the diagnosis of primary Non-Hodgkin's Lymphoma by fine-needle aspiration: Experience from a tertiary care center

Background:

Accurate diagnosis of Non-Hodgkin's Lymphoma (NHL) on fine-needle aspiration (FNA) specimen is challenging and requires ancillary testing.

Aim:

The feasibility of flow cytometric immunophenotyping (FCI) along with cell block immunocytochemistry (CB-ICC) as adjunct techniques in the diagnosis of NHL as per the current World Health Organization (WHO) classification was evaluated.

Materials and Methods:

All cases of suspected lymphoma underwent FNA, and the sample was triaged for light microscopic evaluation, FCI, and CB-ICC, and each case was classified as per the current WHO classification.

Results:

A total of 65 cases was analyzed which included 40 B-cell, 21 T-cell, and 4 unclassifiable lymphomas. Of 61 cases, FCI alone was contributory in 74% (45/61) cases whereas CB-ICC alone was contributory in 65.5% (40/61) cases in typing the lymphoma. In 11.4% (7/61) cases, the lymphoma could not be classified by either technique. Thus, in a total of 88.5% (54/61) cases a combination of FCI and CB-ICC from FNA enabled a diagnosis of lymphoma with its subtyping.

Conclusion:

Flow cytometric immunophenotyping and ICC on CBs are feasible on FNA material and are very useful in a suspected case of NHL especially when a biopsy may not be possible or feasible.

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.

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.

Nodular lymphocyte-predominant Hodgkin lymphoma: cytopathologic correlates on fine-needle aspiration

BACKGROUND

Nodular lymphocyte-predominant Hodgkin lymphoma (NLPHL), a rare subtype of Hodgkin lymphoma, is an indolent tumor with frequent instances of disease recurrence but a favorable prognosis. To the best of the authors' knowledge, there are only limited descriptions of NLPHL in the cytology literature because it was only formally recognized as a distinct entity in 1994.

METHODS

In the current study, all cases of NLPHL diagnosed on excisional biopsy (n = 6 cases) at the study institution between 2000 and 2011 that had undergone previous fine-needle aspiration (FNA) were reviewed, with a focus on cytomorphologic features.

RESULTS

Four of 6 cases were termed benign on FNA; however, there was retrospective recognition of characteristic LP cells in all cases. Unlike classical Hodgkin lymphoma, the tumor cells of NLPHL were often found to be mononucleate and presented in a background of small lymphocytes. Other features identified included epithelioid histiocytes and numerous bare atypical nuclei.

CONCLUSIONS

Cases of NLPHL are commonly misdiagnosed as benign reactive lymphoid tissue and therefore a careful search using high magnification for LP cells is recommended in the evaluation of lymph node FNAs.

Diagnosis and subclassification of lymphomas and non-neoplastic lesions involving mediastinal lymph nodes using endobronchial ultrasound-guided transbronchial needle aspiration

INTRODUCTION

The value of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has been established for staging mediastinal lymph nodes in lung carcinoma patients with radiologically enlarged lymph nodes, but its utility for evaluation of primary lymph node disorders is not well defined. The objective of this study was to evaluate the usefulness of EBUS-TBNA with on-site assessment and triage of sample for multiple ancillary techniques, for the diagnosis and subclassification of lymphomas and non-neoplastic lesions involving mediastinal lymph nodes.

METHODS

One hundred and twenty consecutive patients who underwent EBUS-TBNA between January 2008 and August 2009 were reviewed. The final cytological diagnosis was based on air-dried Romanowsky and alcohol-fixed Papanicolaou stained direct smears, immunohistochemistry, immunophenotyping, and fluorescence in situ hybridization (FISH).

RESULTS

A total of 38 cases were included in this study consisting of eight reactive lymphoid hyperplasia, 20 granulomatous lymphadenitis (17 non-necrotizing and 3 necrotizing granulomatous inflammations), 3 Hodgkin lymphomas and 7 non-Hodgkin lymphomas (1 small lymphocytic lymphoma (SLL), 1 SLL with scattered Reed-Sternberg cells, 1 marginal zone lymphoma, and 4 large B cell lymphomas). Cultures performed in 13 cases were negative for AFB and fungi. Immunophenotyping and immunohistochemistry for MIB1 in six cases, and FISH in five cases provided necessary information for subclassification.

CONCLUSIONS

EBUS-TBNA is a minimally invasive procedure which provides sufficient sample for definitive primary diagnosis and classification of malignant lymphoma and granulomatous inflammation in patients with mediastinal lymphadenopathy. Rapid on-site specimen assessment is invaluable for appropriate assignment of sample to ancillary studies.

Fine-needle aspiration cytology in the follow-up of Hodgkin lymphoma

Hodgkin lymphoma (HL) is characterized by long survival and risk of relapse and second neoplasm. The aim of this study is to evaluate the possibility of improving the accuracy of fine-needle cytology (FNC) in HL follow-up using Power Doppler ultrasound (US) assistance and immediate microscopic evaluation (ICE). The study was performed in two consecutive groups of 200 FNC in HL patients. In the first group FNC of palpable lymph-nodes or extra lymph-nodal masses were performed without US assistance except for impalpable and/or deep located masses (nonassisted group); In the second group, all the FNC were performed under Power Doppler US assistance with ICE and immediately repeated in inadequate cases (assisted group). Cytological diagnoses were controlled by histology (61) or clinical follow-up (69); sensitivity and specificity were calculated in the two groups and to evaluate the effect of Power Doppler alone, adequate cases were compared with the total number of FNC in each of the two groups.FNC identified 90 negative cases, 3 false negatives, 70 HL relapse, 16 inadequate and 14 suspicious; second neoplasia were diagnosed in 12 cases and all histologically confirmed. Sensitivity and specificity were 64 and 84% in the nonassisted group and 86 and 94% in the assisted group and there were significant differences between the number of adequate cases v.s. the total number of FNC in each of the two groups. Sensitivity and specificity in assisted FNC are higher than in nonassisted ones. The main advantage of assisted FNC in the follow-up of HL is to produce accurate diagnoses avoiding invasive biopsies.