Fine-needle aspiration cytology of soft tissue lesions: Diagnostic challenges

What is the association of preoperative biopsy with recurrence and survival in retroperitoneal sarcoma? A systematic review by the Australia and New Zealand Sarcoma Association clinical practice guidelines working party

Preoperative biopsy for retroperitoneal sarcoma (RPS) enables appropriate multidisciplinary treatment planning. A systematic review of literature from 1990 to June 2022 was conducted using the population, intervention, comparison and outcome model to evaluate the local recurrence and overall survival of preoperative biopsy compared to those that had not. Of 3192 studies screened, five retrospective cohort studies were identified. Three reported on biopsy needle tract seeding, with only one study reporting biopsy site recurrence of 2 %. Two found no significant difference in local recurrence and one found higher 5-year local recurrence rates in those who had not been biopsied. Three studies reported overall survival, including one with propensity matching, did not show a difference in overall survival. In conclusion, preoperative core needle biopsy of RPS is not associated with increased local recurrence or adverse survival outcomes.

Myxoid neurofibroma masquerading as lymphatic-venous malformation and poses a diagnostic challenge on fine needle aspiration biopsy

BACKGROUND

Myxoid neurofibromas (NF) are uncommon, benign spindle cell tumors that originate from peripheral nerve sheaths, often posing a diagnostic challenge due to their hypocellularity on cytology specimens. Distinguishing myxoid spindle cell lesions can be challenging, given the broad range of potential differential diagnoses.

CASE PRESENTATION

A 26-year-old female with a past medical history of embolized inguinal, flank, and retroperitoneal venolymphatic malformation presented with a left pelvic pain causing significant disability. CT scan showed an extensive 8.7 cm × 6.6 cm retroperitoneal mass. FNA was performed and alcohol-fixed papanicolaou-stained smears showed a hypocellular specimen with loosely arranged clusters of bland spindle cell proliferation in the background of a mucoid matrix. Spindle cells showed scant cytoplasm and elongated oval-shaped regular nuclei. Prominent nucleoli were not seen. An excisional biopsy revealed a bland spindle cell proliferation in a myxoid background associated with shredded collagen bundles. Immunohistochemical staining showed diffuse positivity for S100 and CD34. Based on the overall findings, a definitive diagnosis of myxoid neurofibroma was rendered.

DISCUSSION

Cytological features of myxoid neurofibroma include the presence of hypocellular spindle-shaped cells arranged in small, loosely organized groups within a myxoid matrix background. Cells exhibit scant cytoplasm with regular oval and elongated nuclei. Nucleoli are typically not identified. The differential diagnosis includes myxoid neurofibroma, myxoma, myxoid liposarcoma, myxoid chondrosarcoma, myxoid dermatofibrosarcoma protuberans, low-grade fibromyxoid sarcoma, and low-grade myxo-fibrosarcoma.

CONCLUSION

We aim to highlight the importance of considering myxoid neurofibroma in the differential diagnosis of hypocellular myxoid spindle cell lesions encountered on fine-needle aspiration cytology.

Apprenticeship and the art of making meaning in cytopathology

The exemplary work of Wakely et al goes beyond the diagnosis of a rare entity. Therein resides an apprenticeship in the art of cytopathology itself: making meaning from specimens.

Cytology of Undifferentiated Round-Cell Sarcomas of Bone and Soft Tissue: Ewing Sarcoma or Not Ewing Sarcoma , That Is the Question

BACKGROUND

Undifferentiated round-cell sarcomas (URCSs) of soft tissue and bone are a group of clinically heterogeneous tumors. Diagnosis of these malignancies is based mainly on recurrent genetic alterations. The most common and the best known representative of this group is Ewing sarcoma (ES) which is characterized by gene fusions including EWSR1 or FUS and ETS transcription factors family. Other newly described entities are CIC-rearranged sarcoma, sarcoma with BCOR genetic alterations, and round-cell sarcoma with EWSR1-non-ETS fusions. All these novel tumors are known as Ewing-like sarcomas.

SUMMARY

It is believed that morphologic features of ES and Ewing-like sarcomas vary only slightly or even that cytomorphology is not relevant. But differences are usually obvious, and some cytologic findings, such as spindle cells, connective tissue fragments, or myxoid stroma, are typical for Ewing-like sarcomas but not for ES. Each of these entities is also characterized by different immunoprofiles. The aim of this review was to summarize cytomorphologic and immunohistochemical features of URCS and compare them with other small round-cell tumors. Key Messages: Cytology can be successfully used in URCS diagnosis as a complementary tool for core-needle biopsy or even alone in selected cases, especially in recurrent and metastatic tumors. Knowing the morphologic and immunohistochemical differences between URCS is essential to provide appropriate ancillary studies and make a definitive diagnosis.

Diagnostic use of fine-needle aspiration cytology and core-needle biopsy in head and neck sarcomas

The diagnostic role of fine-needle aspiration cytology (FNAC) and core-needle biopsy (CNB) has not been comprehensively assessed in head and neck sarcomas. A systematic review of published cases (1990-2020) was conducted. Diagnostic performance of both FNAC/CNB to determine tumor dignity and histopathological diagnosis was calculated. One hundred and sixty-eight cases were included for which FNAC (n = 156), CNB (n = 8), or both (n = 4) were used. Predominant histologies were skeletal muscle, chondrogenic and vascular sarcomas. FNAC correctly assessed dignity in 76.3% and histology in 45% of cases. Dignity was significantly better for vascular tumors, metastatic and recurrent specimens, and worse for chondrogenic sarcomas. CNB showed a 92% accuracy to identify dignity and 83% for histopathology. FNAC and CNB are useful methods for the diagnosis of head and neck sarcomas, particularly well-suited in the context of recurrent or metastatic disease. The role of CNB remains largely unexplored for this indication.

Role of fine needle aspiration cytology in the diagnosis of soft tissue tumours

Fine needle aspiration cytology (FNAC) is a widely accepted safe, simple and rapid diagnostic procedure used in the examination of neoplastic and non-neoplastic lesions of various locations. Since its introduction, FNAC has developed into an effective diagnostic tool practiced in a large majority of medical centres evaluating and treating oncological patients. The role of FNAC has been limited in the examination of primary soft tissue lesions, however, as many physicians working in this area recommended against using FNAC. An increasing use of minimally invasive diagnostic procedures in the last decade has resulted in a better acceptance of FNAC as a first-line approach or as a complementary tool to core needle biopsy in the diagnosis of musculoskeletal lesions. This review discusses the role and value of FNAC in the evaluation and treatment of soft tissue tumours based on the experience gathered over the course of 48 years at the Sarcoma Center in Lund, Sweden. FNAC reports most often provide diagnostic information allowing the initiation of treatment or, when definitive diagnosis cannot be rendered from a cytological examination, guiding the continued diagnostic investigation. The main advantages of soft tissue FNAC are good sensitivity and specificity, low morbidity, speed of diagnosis, and low cost/benefit ratio. The most important disadvantages stem from limited experience in cytological diagnosis of soft tissue tumours and a lack of standardised and uniform reporting system for soft tissue FNAC.

An update on touch preparations of small biopsies

Touch preparations (TPs) are being increasingly utilized in the era of personalized medicine. They fill a gap in cytopathology practice by providing a method to perform rapid onsite evaluation of small tissue samples such as core needle biopsies. However, there is a paucity of literature about how best to perform and interpret a TP. A high-quality TP can provide excellent diagnostic accuracy and good concordance with core needle biopsy histopathology findings. Although many of the cytomorphologic features of TPs overlap with fine needle aspirate smears, TP cytology is unique and differs from conventional smears in many aspects. It is important for cytologists to recognize these features, as well as potential pitfalls and artifacts in order to avoid misinterpretation. Core depletion of tumor cells is a notable drawback if TPs are performed too aggressively. TP slides are also valuable for ancillary testing because they often contain a cellular and pure population of whole tumor cells. This paper reviews all of the aspects of TPs including their clinical utility, proper slide preparation techniques, distinctive cytomorphologic characteristics, limitations, and potential pitfalls.

Mesenchymal neoplasms: Is it time for cytology? New perspectives for the pre-operative diagnosis of soft tissue tumors in the molecular era

Soft tissue tumors comprise a great variety of common and rare entities with overlapping features. Their diagnosis is based on the evaluation of several histological parameters which are difficult to assess on small incisional biopsies. Useful diagnostic markers in the field of soft tissue tumors include: 1) molecular biomarkers detecting pathogenetically relevant, distinctive alterations; 2) immunohistochemical surrogate biomarkers of pathogenetically relevant, distinctive molecular alterations; 3) highly specific immunohistochemical biomarkers indicating tumor differentiation. Their introduction in clinical practice has revolutionized the pre-operative diagnosis of soft tissue tumors. Cytology has long been considered inadequate as a first-line approach in this setting. However, since the implementation of new immunohistochemical and molecular tests with high diagnostic specificity, fine needle aspiration cytology (FNAC) is starting to gain acceptance for the pre-operative assessment of soft tissue tumors. FNAC represents a versatile, poorly expensive and well-tolerated diagnostic strategy with relevant advantages over histological biopsies. Moreover, evidences suggest that, in expert hands, FNAC can also aim at a definite diagnosis, especially if a cell block is prepared, allowing the application of multiple ancillary techniques.

Oncological Treatment Considerations Differ across Surgical Subspecialties Treating Malignant Peripheral Nerve Sheath Tumors: An International Survey

Background

Malignant peripheral nerve sheath tumors (MPNSTs) are rare and aggressive soft tissue sarcomas (STS) that, because of their origin, are operated by several surgical subspecialties. This may cause differences in oncologic treatment recommendations based on presentation. This study investigated these differences both within and between subspecialties.

Methods

A survey was distributed among several (inter)national surgical societies. Differences within and between subspecialties were analyzed by χ²-tests.

Results

In total, 30 surgical oncologists, 30 neurosurgeons, 85 plastic surgeons, and 29 “others” filled out the survey. Annual caseload, tumor sites operated, and fellowship training differed significantly between subspecialties. While most surgeons agreed upon preoperative use of MRI, the use of radiological staging and FDG-PET use differed between subspecialties. Surgical oncologists agreed upon core needle biopsies as an ideal type of biopsy while other subspecialties differed in opinion. On average, 53% of surgeons always consider preservation of function preoperatively, but 42% would never perform less extensive resections for function preservation. Respondents agreed that radiotherapy should be considered in tumor sizes >10 cm, microscopic, and macroscopic positive margins. A preferred sequence of radiotherapy administration differed between subspecialties. There was no consensus on indications and sequence of administration of chemotherapy in localized disease.

Conclusion

Surgical oncologists generally agree on preoperative diagnostics; other subspecialties do not. Considering the preservation of function differed among all subspecialties. Surgeons do agree on some indications for radiotherapy, yet the use of chemotherapy in localized MPNSTs lacks consensus. A preferred sequence of multimodal therapy differs between and within surgical subspecialties, but surgical oncologists prefer neoadjuvant radiotherapy.

Diagnostic capability of fine-needle aspiration cytology in assessment of intraosseous lesions of the jaws: A systematic review

PURPOSE

To systematically review (SR) and critically appraise studies that investigated the diagnostic capability of fine-needle aspiration cytology (FNAC) in the assessment of intraosseous lesions of the jaws.

METHODS

Six main electronic databases and three gray literature databases were searched aiming diagnostic studies, which were selected in a two-phase process. Risk of bias (RoB) of included studies was assessed using the Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies.

RESULTS

A total of eight articles were included, of which six evaluated the FNAC smear technique exclusively, one assessed both smear and cell-block techniques, while one investigated only the cell-block technique. With regard to the FNAC smear technique, from 134 benign lesions investigated, concordance with the histopathological diagnosis was achieved in 64.17% of cases. In addition, considering the 32 malignant lesions assessed through this technique, concordance with histopathology was achieved in all cases. Regarding the cell-block technique, only benign lesions (n = 40) were evaluated in the included studies, in which the concordance rate with histopathology was of 77.5%. The overall RoB judgment was "at risk of bias" for seven included studies mostly due to lack of information or reportedly absence of blinding of evaluator.

CONCLUSIONS

Within the limitations of this SR, FNAC presented modest to satisfactory diagnostic capability for the assessment of intraosseous jaw lesions, showing concordance rates higher than 64% for the smear and 77% for the cell-block technique. Also, considerably high concordance rates were found for the assessment of malignant lesions regarding FNAC smear technique.

Retrospective Analysis of Spectrum of Presentation and Treatment Outcome in Extremity Sarcomas: A Single-Centre Experience

INTRODUCTION

The most common site for soft tissue sarcoma is extremity. As complete surgical resection is possible in majority, outcome of this subset is relatively better. There is paucity of data regarding extremity soft tissue sarcoma (STS) from sub-Himalayan and hilly geographical regions.

MATERIALS AND METHODS

Retrospective analysis was done for extremity STS visiting the study center over a period of 5 years. Data were collected and analyzed for demography, disease characteristics, treatment modalities, and outcome.

RESULT

Extremity STS constituted 32.8% of all STS enlisted. Most common subtype noted was pleomorphic STS. Metastatic disease at presentation was noted among 7/43 cases with lung being the most common metastasis site. Wide local excision was done in 37 cases while amputation was required in 5 cases. Adjuvant radiotherapy was given in 27 cases while 18 cases received adjuvant chemotherapy. At median follow-up of 47 months, the overall survival and event-free survival were noted as 47.64% and 41.49%, respectively.

CONCLUSION

This study depicts single-center experience of extremity STS. The population analyzed was from sub-Himalayan region with significant lost to follow-up. Pooling of data from different centers has been advocated to derive conclusive results.

Suitability of the CellientTM cell block method for diagnosing soft tissue and bone tumors

BACKGROUND

The diagnosis of tumors of soft tissue and bone (STB) heavily relies on histological biopsies, whereas cytology is not widely used. Cellient^TM cell blocks often contain small tissue fragments. In addition to Hematoxylin and Eosin (H&E) interpretation of histological features, immunohistochemistry (IHC) can be applied after optimization of protocols. The objective of this retrospective study was to see whether this cytological technique allowed us to make a precise diagnosis of STB tumors.

METHODS

Our study cohort consisted of 20 consecutive STB tumors, 9 fine-needle aspiration (FNAC) samples, and 11 endoscopic ultrasonography (EUS) FNACs and included 8 primary tumors and 12 recurrences or metastases of known STB tumors.

RESULTS

In all 20 cases, H&E stained sections revealed that diagnostically relevant histological and cytological features could be examined properly. In the group of 8 primary tumors, IHC performed on Cellient^TM material provided clinically important information in all cases. For instance, gastrointestinal stromal tumor (GIST) was positive for CD117 and DOG-1 and a PEComa showed positive IHC for actin, desmin, and HMB-45. In the group of 12 secondary tumors, SATB2 was visualized in metastatic osteosarcoma, whereas expression of S-100 was present in 2 secondary chondrosarcomas. Metastatic chordoma could be confirmed by brachyury expression. Two metastatic alveolar rhabdomyosarcomas were myf4 positive, a metastasis of a gynecologic leiomyosarcoma was positive for actin and estrogen receptor (ER) and a recurrent dermatofibrosarcoma protuberans expressed CD34.

CONCLUSION

In the proper clinical context, including clinical presentation with imaging studies, the Cellient^TM cell block technique has great potential for the diagnosis of STB tumors.

Use of minimally invasive spine surgical instruments for the treatment of bone tumors

INTRODUCTION

Orthopedic oncologists often encounter patients with minor bony lesions that are difficult to access surgically and therefore require large exposures out of proportion to the severity of disease that confer significant patient morbidity. Minimally invasive surgical techniques offer the advantage of smaller incisions, shorter operative times, decreased tissue damage, and decreased costs. A variety of surgical procedures have emerged using minimally invasive technologies, particularly in the field of spine surgery. Areas covered: In this article, we describe the Minimal Exposure Tubular Retractor (METRx^TM) System which is a minimally invasive surgical device that utilizes a series of dilators to permit access to a surgical site of interest. This system was developed for use in treatment of disc herniation, spinal stenosis, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion and spinal cord stimulation implantation. We also describe novel uses of this system for minimally invasive biopsy and treatment of benign and metastatic bone lesions at our institution. Expert commentary: Minimally invasive surgical techniques will continue to expand into the field of orthopedic oncology. With a greater number of studies proving the safety and effectiveness of this technique, the demand for minimally invasive treatments will grow.

Fine needle aspiration for the diagnosis and treatment of musculoskleletal tumours

Objective

The aim of this study was to evaluate the diagnostic accuracy of FNA and analyse its efficacy in enabling the initiation of treatment in musculoskeletal tumours.

Methods

A total of 130 FNA were performed (94 bone and 36 soft tissue lesions) guided by CT scan (n = 64), ultrasonography (n = 36) and radioscopy (n = 30). Diagnostic yield and accuracy were evaluated. A diagnosis was considered accurate when confirmed by histology or ulterior clinical/imaging evaluation. Exclusion of malignancy or infection was considered as diagnoses.

Results

Ninety diagnoses (69.2%) were obtained: 87 (96.7%) were accurate and 3 were wrong. FNA was non-diagnostic in 40 cases (30.8%) but in 15 (11.5%) it has been possible to conclude if the lesion was malignant (n = 6) or benign (n = 9). This method was completely inconclusive in 25 cases (19.2%).

Conclusion

Despite the low diagnostic yield, accuracy was high. FNA allowed the initiation of treatment in all 87 patients with a correct diagnosis and in 9 in which malignancy was excluded. Two of the 6 biopsies with the information of malignancy were soft tissue lesions. Even here, treatment could be done, as the majority of soft tissue sarcoma protocols begin with surgery. This study validates FNA as a method with a high diagnostic accuracy.

Surgical Management of the Radiated Chest Wall and Its Complications

Radiation to the chest wall is common before resection of tumors. Osteoradionecrosis can occur after radiation treatment. Radical resection and reconstruction can be lifesaving. Soft tissue coverage using myocutaneous or omental flaps is determined by the quality of soft tissue available and the status of the vascular pedicle supplying available myocutaneous flaps. Radiation-induced sarcomas of the chest wall occur most commonly after radiation therapy for breast cancer. Although angiosarcomas are the most common radiation-induced sarcomas, osteosarcoma, myosarcomas, rhabdomyosarcoma, and undifferentiated sarcomas also occur. The most effective treatment is surgical resection. Inoperable tumors are treated with chemotherapy, with low response rates.

A New Method for Endoscopic Sampling of Submucosal Tissue in the Gastrointestinal Tract: A Comparison of the Biopsy Forceps and a New Drill Instrument

Background Sampling of submucosal lesions in the gastrointestinal tract through a flexible endoscope is a well-recognized clinical problem. One technique often used is endoscopic ultrasound-guided fine-needle aspiration, but it does not provide solid tissue biopsies with preserved architecture for histopathological evaluation. To obtain solid tissue biopsies from submucosal lesions, we have constructed a new endoscopic biopsy tool and compared it in a crossover study with the standard double cupped forceps. Methods Ten patients with endoscopically verified submucosal lesions were sampled. The endoscopist selected the position for the biopsies and used the instrument selected by randomization. After a biopsy was harvested, the endoscopist chose the next site for a biopsy and again used the instrument picked by randomization. A total of 6 biopsies, 3 with the forceps and 3 with the drill instrument, were collected in every patient. Results The drill instrument resulted in larger total size biopsies (mm²; Mann-Whitney U test, P = .048) and larger submucosal part (%) of the biopsies (Mann-Whitney U test, P = .003) than the forceps. Two patients were observed because of chest pain and suspicion of bleeding in 24 hours. No therapeutic measures were necessary to be taken. Conclusion The new drill instrument for flexible endoscopy can safely deliver submucosal tissue samples from submucosal lesions in the upper gastrointestinal tract.

Fine-needle aspiration cytology of retroperitoneal lesions: a 5-year experience with an emphasis on cytohistological discrepancy

BACKGROUND

The retroperitoneal space contains various organs which can be affected by various non-neoplastic and neoplastic pathological processes. A diagnosis of these retroperitoneal lesions is often difficult. Fine-needle aspiration cytology (FNAC) under image guidance is now becoming an effective tool for the initial evaluation of retroperitoneal lesions.

OBJECTIVE

The present study was undertaken to evaluate the role of ultrasound-guided FNAC in the diagnosis of retroperitoneal lesions in comparison to histopathology and to assess the probable causes of failure in cases of pitfalls in cytodiagnosis.

MATERIALS AND METHODS

During the study period of 5 years, a total of 104 cases of retroperitoneal lesions were aspirated under USG guidance. Seven cases yielded inadequate material, the remaining 97 cases were included in the study group.

RESULTS

Out of 97 cases, the kidney was the most common organ aspirated (27 cases; 27.8%). Malignant lesions (68 cases; 70.1%) were much more frequent than benign or non-neoplastic lesions (29 cases; 29.9%). Tuberculosis was the most common non-malignant lesion (14 cases) and renal cell carcinoma was the most frequent malignant lesion encountered (15 cases). In 5 cases (7.9%), the histological diagnosis showed inconsistent results in comparison to cytodiagnosis.

CONCLUSION

USG-guided FNAC is a safe, rapid, relatively cheap and fairly accurate procedure for the assessment of retroperitoneal lesions.

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.

Elastic fibers in elastofibroma dorsi by fine-needle aspiration

Fine-needle aspiration (FNA) features of elastofibroma dorsi (EFD) in a 56-year-old woman were evaluated. The patient presented with 5 cm soft tissue mass located between the inferior part of scapula and the chest wall. FNA smears were hypercellular, characterized by a mixture of uniform spindle cells, mature adipocytes, and collagen tissue fragments in varying proportions. The cytological findings included abundant degenerated elastic fibers presented as linear ("braid-like") and globular bodies with shell-like and stellate appearances with serrate borders, permitting a diagnosis of EFD. Occurrence of degenerated elastic fibers in FNA smears of elastofibroma is a highly diagnostic sign in the typical clinical setting and eliminates the need for preoperative histological examination.

Magnetic resonance imaging-guided biopsy of musculoskeletal lesions using open low-field systems

With the development of open-configuration magnetic resonance imaging (MRI) systems, magnetic resonance-compatible navigational tools, and fast pulse sequences, MRI-guided biopsy of musculoskeletal lesions has evolved into an effective and safe, minimally invasive technique. Magnetic resonance-guided percutaneous biopsy of musculoskeletal lesions is especially suited for lesions that are detectable only with MRI, lesions that require double-angulated needle paths, and for patients in which radiation exposure needs to be avoided. In this article, we review pertinent principles, techniques, and clinical applications of low-field MRI for biopsy procedures in the musculoskeletal system.

Synovial sarcoma with relevant immunocytochemistry and special emphasis on the monophasic fibrous variant

Background:

Monophasic fibrous synovial sarcoma (SS) is the most common variant of SS. Only a few cytological studies are available on this entity. Bcl-2 protein expression has been described as a characteristic marker of SS and is useful for its differentiation from other sarcomas. Cytokeratin and CD99 are also used in detecting SS.

Aims:

To evaluate synovial sarcoma and its variants cytomorphologically.

Materials and Methods:

During a period of 10 years 7 months, i.e. from January 1998 to July 2008, 12 cytologic specimens diagnosed as synovial sarcoma were reviewed. Ten cases were diagnosed as SS on aspiration alone but two cases required ancillary technique i.e., immunocytochemistry staining with bcl-2 and cytokeratin. The smears were stained with Papanicolaou and May-Grünwald-Giemsa stains.

Results:

All cytologic specimens in our study had similar appearance. Most smears were highly cellular and were made up of densely packed tri-dimensional groups and singly scattered round to oval cells. Cellular monomorphism and vascular channels within the cell groups were the remarkable findings. Only one case showed cytologic evidence of epithelial differentiation. Bcl-2, cytokeratin, CD99 positivity was seen on immunohistochemistry staining. Results were categorized according to age, sex and morphologic variants.

Conclusions:

Although cytomorphologic features of synovial sarcomas are characteristic enough to permit its recognition, clinical correlation is necessary for accurate diagnosis. Monophasic variant is the most common entity observed in the present study.

The diagnosis and treatment of soft tissue sarcomas of the limbs

BACKGROUND

The diagnosis of soft-tissue sarcomas of the limbs is often delayed, sometimes markedly so, even though prompt and appropriate treatment improves survival and lowers the amputation rate.

METHODS

On the basis of a selective literature review and consideration of the relevant guidelines, we developed an algorithm that can serve as a guide to the diagnosis of soft-tissue tumors in general and to the treatment of soft-tissue sarcomas of the limbs.

RESULTS

Surgical resection accompanied by multimodal therapy is the only treatment strategy for soft-tissue sarcoma that provides a chance of cure. Particularly when the tumor is located in the distal part of a limb, plastic-reconstructive surgical techniques often enable adequate local control, along with limb salvage and preservation of function. The role of adjuvant or neo-adjuvant radiotherapy and/or chemotherapy is currently debated. The overall survival rate at 5 years is 87% for low-grade sarcomas and 62% for high-grade sarcomas.

CONCLUSION

Any solid mass of the limbs that has been present for more than four weeks requires diagnostic evaluation. Excisional biopsy is suitable only for epifascial lesions measuring less than 5 cm in diameter. All other lesions should be imaged with MRI and then diagnosed with an incisional biopsy. Patients with soft tissue sarcomas must be treated in an interdisciplinary collaboration so that they can undergo multimodal treatment. The proposed algorithm should help avoid delays in diagnosis and optimize treatment strategies.

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

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

Fine needle aspiration for clinical triage of extremity soft tissue masses

BACKGROUND

Fine needle aspiration cytology (FNAC) is a rapid and low-morbid alternative to open biopsy or needle core biopsy for soft tissue masses. Numerous reports describe its use with metastatic or recurrent lesions, but FNAC is less accepted for primary lesions.

QUESTIONS/PURPOSES

We wished (1) to estimate the sensitivity, specificity, and positive and negative predictive values of FNAC for diagnosing malignancy; (2) to estimate the accuracy of subtyping and grading.

METHODS

We retrospectively examined the diagnostic accuracy and clinical effectiveness of office-based FNAC performed by a trained pathologist on 213 females and 219 males (mean age, 51.8 years) who presented with a palpable soft tissue mass to one musculoskeletal oncology clinic between 2002 and 2008.

RESULTS

The FNAC was reported as benign in 62.0%, indeterminate in 8.1%, and malignant in 29.9%. A second technique, such as needle core biopsy or open biopsy, was performed for 24.8% of lesions before a definitive treatment plan was rendered. Final tissue confirmation by open biopsy or resection was available for 52.2% of benign FNAC and 78.3% of malignant FNAC. Sensitivity, specificity, and positive and negative predictive values for detecting malignancy with either histopathologic confirmation or clinical followup were 89.2%, 89.8%, 96.1%, and 98.1%. There were seven sampling and nine interpretation FNAC errors in determining the nature of the lesion. Subtyping and grading for malignant lesions were 77.2% and 95.2% accurate, respectively.

CONCLUSIONS

FNAC is effective for initial triage and treatment selection at tertiary referral centers with close collaboration among the surgeon, pathologist, and radiologist.

LEVEL OF EVIDENCE

Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Fine-needle aspiration biopsy of the distal extremities: a study of 141 cases

We reviewed our cytopathology databases for an 11-year period to identify all fine-needle aspiration biopsy (FNAB) cases of palpable masses of the hand, wrist, ankle, or foot. Cases were included only if there was a subsequent tissue biopsy or a minimum 1-year clinical follow-up. Of 141 aspirates, 41, 23, 34, and 43 were from the hand, wrist, ankle, and foot, respectively. Specific benign or malignant diagnoses were achievable in 71.6% of cases, whereas the remaining cases were given a descriptive diagnosis (26.2%) or, infrequently, a "suspicious for" diagnosis (2.1%). Overall sensitivity and specificity for distinguishing a benign from malignant entity from all 4 sites were 100% and 96%, respectively, whereas positive and negative predictive values were 88% and 100%, respectively. The most common lesion was a ganglion. Of the benign neoplasms, giant cell tumor of tendon sheath (17) and desmoid-type fibromatosis (7) were most common. Of 31 malignancies, 24 were sarcomas: sarcoma not otherwise specified (6), high-grade pleomorphic sarcoma (5), and Ewing sarcoma (3) were most common. Seven nonsarcomas included melanoma (3), metastatic squamous carcinoma (2), and malignant lymphoma (2). An FNAB-procured cytopathologic diagnosis is clinically reliable in a high percentage of distal extremity mass lesions.

Role of cytology in diagnosis of soft tissue sarcomas with special reference to false positive cases

Background:

Histological diagnosis of soft tissue sarcomas is a difficult job not only for diverse architecture of different variants but also for variability in picture among different parts of a single tumor. Thus, cytodiagnosis of these tumors is one of the most challenging jobs.

Aims:

To evaluate the role of fine needle aspiration cytology in diagnosis of soft tissue malignancies and discuss the false-positive cases with particular reference to causes of misdiagnosis and possible ways of correction.

Materials and Methods:

In the present study, we used cytology for categorization of 59 soft tissue malignancies according to predominant cell type and also on the basis of differentiation.

Results:

Out of 59 cytodiagnosed malignant soft tissue tumors, 36 were classified as high grade and rest as low grade. Spindle cell sarcoma was the commonest diagnosis, followed by pleomorphic variant. Histological correlations were performed in 47 cases showing consistency in 41 cases. Rest six cases with disparity were further discussed to ascertain causes of failures and to chalk out possible plans to evade these pitfalls in future.

Conclusions:

Overall our study established the role of cytology in diagnosis of soft tissue sarcomas with good cytohistological correlation rate (87.2%).

Image-guided musculoskeletal biopsy

Image guidance allows safe passage of needles, often into small and otherwise inaccessible lesions, and into the portions of the lesion most likely to yield useful samples, while avoiding damage to important structures. This article hopes to provide a useful guide to image-guided musculoskeletal biopsy for radiologists in practice and in training.