Diagnostic accuracy and clinical utility of fine-needle aspiration cytology in the diagnosis of clinically primary bone lesions

Cytological diagnosis of osteoblastoma of the talus: Case report with unusual presentation and diagnostic pitfalls

Osteoblastoma is a rare bone tumor mostly affecting the young adults and commonly involving the spinal cord and long bones. Talus is the uncommon site of presentation, and if involved, then the neck is more commonly involved than the body of talus. The cytological diagnosis of osteoblastoma is limited, and to the best of our knowledge, its fine-needle aspiration (FNA) in the talus has still not been reported in the literature. The present case of osteoblastoma is, therefore, being reported due to the unusual presentation in elderly male in the body of talus and showing extensive involvement on X-ray. The case was initially diagnosed on FNA cytology excluding the possibility of giant-cell tumor and osteosarcoma. The case also highlights the importance of vigilant observation of subtle cytological features of this rare tumor which may be helpful in avoiding diagnostic pitfalls, especially at an uncommon site and with unusual presentation. An early precise diagnosis by cytology may be followed by appropriate treatment and thus avoiding any further complications.

Is Core Needle Biopsy Reliable in Differentiating Between Aggressive Benign and Malignant Radiolucent Bone Tumors?

BACKGROUND

Although there is widespread acceptance of core needle biopsy (CNB) for diagnosing solid tumors, there is reluctance by some clinicians to use CNB for aneurysmal bone cysts (ABCs) as a result of concerns of safety (bleeding, nerve injury, fracture, readmission, or infection) and reliability, particularly to rule out malignant diagnoses like telangiectatic osteosarcoma. This is especially true when CNB tissue is sent from an outside hospital, where the technique used to obtain the tissue may be spurious.

QUESTIONS/PURPOSES

(1) Is CNB effective (provided adequate information to indicate appropriate surgical treatment without further open biopsy) as an initial diagnostic test for ABC? (2) Is CNB accurate (pathology consistent with the subsequent definitive surgical pathologic diagnosis) in differentiating between benign lesions such as primary or secondary ABCs and malignant radiolucent lesions such as telangiectatic osteosarcoma? (3) What are the complications of CNB? (4) Is there any difference in the effectiveness or accuracy of CNB performed at outside institutions when compared with a referral center?

METHODS

A retrospective study of our musculoskeletal tumor board pathology database (1990-2016) was performed using search criteria "aneurysmal bone cyst" or "telangiectatic osteosarcoma." Only patients undergoing a CNB who proceeded to definitive surgical resection with final pathology were included. Excluding outside CNBs, CNB was performed after presentation at a musculoskeletal tumor board as a result of atypical features on imaging or history concerning for malignancy. Outside CNB tissue was reviewed by our pathologists. If there was sufficient tissue for diagnosis, the patient proceeded to definitive surgery. If not, the patient underwent open biopsy. CNB diagnosis, open biopsy results, and open surgical resection pathology were reviewed. Complications, including bleeding, infection, nerve injury, readmission, or fracture, between the CNB and definitive open surgical procedure (mean 1.6 months) were documented. CNBs were considered "effective" if they yielded pathology considered sufficient to proceed with appropriate definitive surgery without additional open biopsy. CNBs were considered "accurate" if they were effective and yielded a pathologic diagnosis that matched the subsequent definitive surgical pathology. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of obtaining a malignant diagnosis using CNB were also calculated.

RESULTS

A total of 81% (59 of 73) of CNBs were effective. Ninety-three percent (55 of 59) of CNBs were classified as accurate. Diagnostic CNBs had a sensitivity and specificity of 89% (eight of nine) and 100% (51 of 51), respectively. The PPV was 1.00 and the NPV was 0.82. There were no complications. With the numbers available, there was no difference in efficacy (90% [37 of 41 versus 14 of 15]; odds ratio, 0.97 [95% confidence interval {CI}, 0.41-2.27], p = 0.94) or accuracy (92% [34 of 37 versus 13 of 14]; odds ratio, 0.87 [95% CI, 0.08-9.16], p = 0.91) between CNBs performed in house and those referred from outside.

CONCLUSIONS

These data suggest that CNBs are useful as an initial diagnostic test for ABC and telangiectatic osteosarcoma. Tissue from outside CNBs can be read reliably without repeat biopsy. If confirmed by other institutions, CNB may be considered a reasonable approach to the diagnosis of aggressive, radiolucent lesions of bone.

LEVEL OF EVIDENCE

Level III, diagnostic study.

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.

Fine needle aspiration biopsy diagnosis of primary clear cell chondrosarcoma: A case report

Clear cell chondrosarcoma is a rare chondrosarcoma variant often involving the long bone epiphyses of young to middle aged adults. We report herein a case involving the left femoral head in a 25-year-old female with a 3-month history of worsening left hip pain. Radiographs revealed a complex, multifocal and lytic lesion centered in the left proximal femoral epiphysis with involvement of the femoral neck. Computed tomography-guided fine needle aspiration biopsy with concomitant core needle biopsy was performed, and a diagnosis of clear cell chondrosarcoma was rendered. Cytologic smears revealed aggregates of matrix material accompanied by a population of mostly uniform spindled to epithelioid and histiocytoid cells, rarely accompanied by osteoclast-type giant cells. The patient underwent surgical resection with -total hip replacement, and subsequent pathologic examination confirmed the initial needle biopsy diagnosis. There has been no evidence of local recurrence or distant metastases with 3-years follow-up. To our knowledge, this is the first reported example of a primary clear cell chondrosarcoma initially evaluated by fine needle aspiration biopsy.

Diagnostic utility of fine-needle aspiration cytology of lesions involving bone

BACKGROUND

Fine-needle aspiration (FNA) is utilized in the diagnostic work-up of bone lesions in a number of institutions, either in isolation or in conjunction with core biopsy. We report our experience with FNA of bone-based lesions, including comparison of this approach with concurrent core biopsy specimens.

METHODS

Retrospective review over a 5-year period (2011-2015) revealed 233 cases of bone FNAs.

RESULTS

The most commonly encountered diagnosis was malignant neoplasm (160 cases, 68.7%); within this group of malignancies, 103 cases (64.4%) represented metastatic carcinoma. Benign lesions were encountered infrequently (9 cases, 3.9%). While 37 cases (15.9%) revealed "no evidence of malignancy," 12 cases (5.2%) showed atypical findings, 3 cases (1.3%) demonstrated inflammatory conditions, and 12 aspiration biopsies were deemed nondiagnostic (5.2%). In 202 cases, concurrent core biopsies were performed following FNA and rapid on-site evaluation (ROSE). Comparison of the FNA and core biopsy diagnoses among malignant neoplasms revealed 19 diagnostic discrepancies, including 16 cases with a false-negative FNA (7.9% of all FNAs with concurrent core biopsy) and 3 cases with a false-negative core biopsy (1.5% of all cases with corresponding FNA).

CONCLUSION

Our findings indicate that FNA of bone lesions is a useful diagnostic technique with high sensitivity, particularly when the cytologic findings are interpreted in conjunction with the core biopsy and pertinent clinical and radiologic findings. In addition, ROSE followed by open, dynamic communication with the performing radiologist leads to an extremely low rate of inadequate core biopsy specimens, resulting in optimal patient diagnosis and management. Diagn. Cytopathol. 2017;45:608-613. © 2017 Wiley Periodicals, Inc.

Current management of aneurysmal bone cysts

Aneurysmal bone cysts (ABCs) are benign bone lesions arising predominantly in the pediatric population that can cause local pain, swelling, and pathologic fracture. Primary lesions, which constitute roughly two thirds of all ABCs, are thought to be neoplastic in nature, with one third of ABCs arising secondary to other tumors. Diagnosis is made with various imaging modalities, which exhibit characteristic features such as "fluid-fluid levels," although biopsy is critical, as telangiectatic osteosarcoma cannot be excluded based on imaging alone. Currently, the standard of care and most widely employed treatment is intralesional curettage. However, tumor recurrence with curettage alone is common and has driven some to propose a multitude of adjuvants with varying efficacy and risk profiles. Historically, therapies such as en bloc resection or radiation therapy were utilized as an alternative to decrease the recurrence rate, but these therapies imposed high morbidity. As a result, modern techniques now seek to simultaneously reduce morbidity and recurrence, the pursuit of which has produced preliminary study into minimally invasive percutaneous treatments and medical management.

Image-guided percutaneous bone biopsy with a simulated van sonnenberg removable hub system

OBJECTIVE

To retrospectively examine the success and complication rates associated with image-guided percutaneous bone biopsy with a simulated Van Sonnenberg removable hub system.

MATERIALS AND METHODS

During a 3.5-year period, 27 bone lesions at different anatomic locations with an indication for biopsy based on plain film, computed tomography (CT) and/or magnetic resonance imaging (MRI) findings were determined, and a total of 28 image-guided (fluoroscopy or CT) percutaneous biopsies were performed using a simulated Van Sonnenberg -removable hub system. This technique entailed the use of a cut-out Chiba needle hub that performed as a guide for the insertion of a larger needle. Either core and aspiration biopsy or core biopsy alone was utilized.

RESULTS

The procedure yielded diagnostic material 89% of the cases (48% infection, 22% benign lesions, and 19% malignant lesions). Combined use of core and aspiration biopsy resulted in a higher diagnostic accuracy as compared to core biopsy alone. No false positive or false negative diagnoses were observed. No serious complications such as neurological deficits, bleeding, or organ injury were observed.

CONCLUSION

The simulated Van Sonnenberg removable hub system provides a useful technique for percutaneous bone biopsies and is particulary suitable for deep seated (such as vertebral) lesions with its ability to facilitate the accessibility of the lesion with its built-in guidance needle. The procedure is safe in light of the literature data.

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.

Fine-needle aspiration of primary osseous lesions: A cost effectiveness study

Fine-needle aspiration (FNA) is not widely used in the work-up of osseous lesions because of concerns regarding its high incidence of nondiagnostic specimens. Although several studies have shown that FNA is less expensive than surgical biopsy, the authors are aware of only one prior study evaluating the cost effectiveness of FNA, which includes the cost of incisional or core needle biopsies necessary to establish a diagnosis when the initial FNA was noncontributory. A computerized search of the pathology records of three medical centers was performed to obtain all FNAs of primary osseous lesions. For each FNA case, all subsequent core needle, incisional or excisional biopsies were recorded as was the result of the definitive operative procedure. The cost of obtaining the definitive diagnosis was calculated for each case including the cost of FNA, imaging guidance utilized, and cost of subsequent surgical biopsy when necessary. The cost of an alternate approach using only surgical biopsy was calculated. The average per patient costs of these two protocols were compared.A total of 165 primary bone tumors underwent FNA. One hundred six of these yielded a definitive cytologic diagnosis. In 59 cases, FNA yielded a result insufficient for definitive therapy necessitating surgical biopsy. FNA investigation of the 165 bone lesions cost 575,932 (average of 3,490 per patient). Surgical biopsy alone would have cost 5,760 per patient. FNA resulted in a cost savings of 2,215 per patient.

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.

An evaluation of the diagnostic accuracy of the grade of preoperative biopsy compared to surgical excision in chondrosarcoma of the long bones

Chondrosarcoma is the second most common primary malignant bone tumour. Distinguishing between grades is not necessarily straightforward and may alter the disease management. We evaluated the correlation between histological grading of the preoperative image-guided needle biopsy and the resection specimen of 78 consecutive cases of chondrosarcoma of the femur, humerus, and tibia. In 11 instances, there was a discrepancy in histological grade between the biopsy and surgical specimen. Therefore, there was an 85.9% (67/78) accuracy rate for pre-operative histological grading of chondrosarcoma, based on needle biopsy. However, the accuracy of the diagnostic biopsy to distinguish low-grade from high-grade chondrosarcoma was 93.6% (73/78). We conclude that accurate image-guided biopsy is a very useful adjunct in determining histological grade of chondrosarcoma and the subsequent treatment plan. At present, a multidisciplinary approach, comprising experienced orthopaedic surgeons, radiologists, and pathologists, offers the most reliable means of accurately diagnosing and grading of chondrosarcoma of long bones.

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.

Cyto-histological correlations inprimary, recurrent, and metastatic bone and soft tissue osteosarcoma. Institut Curie's experience

To determine diagnostic cytomorphologic features of osteosarcoma on fine-needle aspiration materials, we reviewed the cytologic material and corresponding histologic slides of 126 tumors in 107 patients. Fifty-five (43.6%) tumors were primary, 31 (24.6%) were recurrent, and 40 (31.8%) were metastatic. Review of original cytology reports revealed that 120 (95.3%) tumors were diagnosed as malignant. Six (4.7%) cases were reported as suspicious, false-negative, or unsatisfactory samples. Our findings showed that osteoblastic roundish cells, spindle-shaped cells, reactive giant cells, and osteoid were the most consistent features representative of osteosarcoma. Periosteal reactions, fractures with callous formation, giant cells of osteoclastic type in various conditions, chondrosarcoma with enchondral ossification are entities to consider in the differential diagnosis.

Fine-needle aspiration of chondrosarcoma

Fine-needle aspiration (FNA) is a reliable, safe and cost-effective procedure with an established role in the diagnosis of various solid tissue neoplasms. However, the role of FNA in the diagnosis of primary bone tumors, including chondrosarcoma (CS) is controversial. To determine the accuracy of FNA as a diagnostic procedure, the author reviewed the institutional experience of a series of patients with CS who underwent FNA for diagnosis. The author's objectives were to determine the accuracy of the technique as well as possible limitations to sensitivity and specificity, and perhaps to suggest the most appropriate use for this procedure. Computer records and then subsequently archives of the department were searched for patients diagnosed and treated for CS between 1993 and 2003. Patients without adequate clinical follow-up, missing materials or records otherwise unavailable for review were eliminated from study. All patients who underwent FNA for a diagnosis had to have a subsequent histological confirmation to be included in the study. FNAs were largely performed with image-guided assistance. In those that were palpable, the aspiration was performed by the aspiration cytologist using standard methods. Histologic materials were processed according to standard methods. All cytological and histologic materials were reviewed for accuracy and appropriateness of diagnosis by the author. There were 34 aspirates from 32 patients with CS (2 patients with 2 aspirates each). Attempts at diagnoses were made from 27 primary lesions, 6 recurrent lesions, and one metastatic lesion. There were an additional two patients who were assigned a diagnosis of CS on FNA who ultimately were proven to have chondroblastic osteosarcoma. Of the primary CS, 18 were definitively diagnosed as CS or "malignant chondroid neoplasm," 8 of the aspirates were considered equivocal in that an additional diagnostic procedure was required to clarify or confirm the diagnosis. Two aspirates were diagnosed as negative. Both of the false negatives were due to inadequate sampling of the lesion on FNA. Diagnostic accuracy of FNA for primary CS in this series was 67% (18/27). Accuracy for recurrent or metastatic lesions was higher at 86% (6/7). FNA appears to be a reliable means of diagnosis of recurrent and/or metastatic CS in patients with a documented history. In primary lesions, however, the accuracy of the technique is lower. In addition, there are problems of sampling chondroid components of non-CS lesions such as this study's experience with chondroblastic osteosarcoma.

Fine-needle aspiration of spinal osteoblastoma in a patient with lymphangiomatosis

Diagnosis of osteoblastoma by fine-needle aspiration (FNA) is rare, as in most patients, excisional biopsy is performed. We report a case of FNA diagnosis of a spinal osteoblastoma in a lymphangiomatosis patient. The patient had a history of lymphangiomatosis since birth with lymphangiomas removed from various locations, and had radiograph evidence of multifocal vertebral involvement. He presented with an enlarging C3 posterior element vertebral lesion. Clinically and radiologically, it was suspicious for lymphangiomatosis involvement. A computed tomography (CT)-guided FNA yielded a moderately cellular specimen. Lesional cells exhibited plasmacytoid features, fine chromatin, smooth nuclear membranes, and binucleation, in a background of occasional osteoclastic cells, spindle cells, and osteoid matrix. A cytological diagnosis of osteoblastoma was favored and confirmed with follow-up surgical biopsy. We believe that this is the first case reporting an osteoblastoma diagnosed by FNA in a lymphangiomatosis patient. We describe the clinical and cytological findings of osteoblastoma and its differential diagnosis.

Diagnosis and grading of chondrosarcomas on FNA biopsy material

A consecutive series of 47 chondrosarcomas was reviewed to identify the most useful criteria for cytological diagnosis, and grading in comparison to histology grade. This series includes 39 evaluable cases, including 2 patients with Ollier's disease and 2 with extraskeletal chondrosarcomas. Eight cases were excluded because of lack of histologic confirmation (3). nondiagnostic cytology (4). and one inconclusive histologic diagnosis. The cytologic diagnosis of these tumors was based on the identification of chondrocytes and a chondromyxoid stroma. The chondrocytes often showed double nuclei (34/39) and macronucleoli (20/39). Nuclear atypia in terms of distinct variation in size was less common (16/39). Cytoplasmic granules and vacuoles were often seen (34/39 and 29/39, respectively). In smears, chondroid fragments and a chondromyxoid background were seen in a majority of cases (36/39 and 30/39, respectively). By grade, concordance with histology was present in 4/7 grade I tumors, 26/29 grades II-III, and 5/5 grade IV, respectively.

Reliability of fine-needle aspiration biopsy in the initial diagnosis of soft-tissue lesions

We retrospectively reviewed fine-needle aspiration biopsy (FNAB) specimens of 301 soft tissue lesions of the extremities and trunk. Final diagnoses were 137 benign and 86 malignant neoplasms and 78 nonneoplastic lesions. Of the 301 FNAB samples, 279 (93%) were adequate for cytologic diagnosis. The adequate FNAB specimens were initially grouped into three broad categories: benign (197 cases), malignant (57 cases), and suspicious for malignancy (25 cases). Sensitivity and specificity for diagnosis of a malignant lesion were 92% and 97%, respectively. The specimens were cytomorphologically classified into nine categories: small round (14 cases), spindle cell (77 cases), epithelioid/polygonal (16 cases), pleomorphic (29 cases), myxoid (19 cases), lipomatous (37 cases), epithelial (23 cases), inflammatory lesions (28 cases), and others (36 cases). Specific FNAB diagnoses were correct in 151 of 279 cases (54%) in combination with clinical and radiologic findings. FNAB is a valuable technique for the primary diagnosis of soft-tissue lesions.

Scrape and fine-needle aspiration cytology of extraskeletal osteosarcoma

Extraskeletal osteosarcoma is a rare malignant soft tissue tumor whose cytologic findings are infrequently reported. We describe scrape and fine-needle aspiration biopsy (FNAB) cytology findings of an extraskeletal osteosarcoma in the right shoulder of a 24-yr-old man. Initial computed tomography revealed multiple ossification foci within the lesion. After excision of the primary tumor, the tumor recurred 13 months later. Scrape smears of both the primary tumor and FNAB smears of the recurrent tumor revealed moderate cellularity, cell clusters, and individual cells, closely associated with dense, homogeneous, acellular matrix material. The cells had elongated, oval, or partially bizarre-shaped nuclei with a coarse chromatin pattern and prominent nucleoli. The scrape smears contained large fragments of matrix material consistent with osteoid.

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

At the present time fine-needle aspiration (FNA) is considered a routine diagnostic procedure in evaluating neoplastic vs. nonneoplastic lesions in many organs, with high sensitivity and specificity. The purpose of this study was to assess the utility of FNA in areas of diagnostic difficulty and its limitations in evaluating bone lesions in patients with a previous history of malignancy. From 1989 to 2000, 249 CT-guided FNAs of bone lesion were performed at our institutions; 187/249 (75.1%) patients had a previous history of malignancy. Aspirated material was air-dried for Diff-Quik stain or fixed in ethanol for Papanicolaou staining. Subsequent surgical tissue was available in 69/187 (36.9%) of the cases. There were 114 males and 73 females, ages 14-86 yr (mean, 64 yr). The primary tumor site was lung 49, genitourinary 46, breast 31, gastrointestinal 28, hematopoietic 26, soft tissue/skin 5, and thyroid 2. There were 125 FNAs of the vertebral spine, 19 from the pelvis, 11 from the ribs, 9 from the sternum, 5 from the femur, and 18 from miscellaneous bone sites. Out of 187, 166 (88.7%) were malignant aspirates confirming the patients' primary malignancies. The most common malignancy encountered was adenocarcinoma, 126/187 (67.4%). Surgical tissue was available for review in 69 patients and the results were in agreement with the FNAs diagnosis in all cases. Nine out of 187 (4.8%) cases were diagnosed as marrow elements on cytological material. These patients have been followed for 1-9 yr and have failed to reveal signs or symptoms of clinical recurrence. Three out of 187 (1.6%) cases showed osteomyelitis. Nine out of 187 (4.8%) were unsatisfactory specimens, with biopsy follow-up available in four cases, showing three metastatic tumors and one case of osteomyelitis. FNA of metastatic bone lesions is a major step in pretreatment diagnosis. On satisfactory specimens, the cytological diagnosis viewed in the clinical-radiological context proves to be similar to surgical diagnosis. FNA is an excellent technique with a high accuracy rate in assessing metastatic bone lesions.

Concordance of histopathologic and cytologic grading in musculoskeletal sarcomas: can grades obtained from analysis of the fine-needle aspirates serve as the basis for therapeutic decisions?

BACKGROUND

Utilization of fine-needle aspiration (FNA) for the diagnosis of musculoskeletal lesions has been de-emphasized by many clinicians because of concerns regarding the technique's ability to supply all information necessary for prognostication and appropriate selection of therapy. Paramount among the concerns is the belief that FNA is incapable of supplying precise subtyping and grading in many cases. Secondary concerns regarding the use of FNA involve its perceived inability to supply adequate tissue for ancillary studies including immunohistochemistry and molecular diagnostic analysis. The authors investigated the ability of FNA to accurately subtype and grade a series of 107 primary sarcomas of the musculoskeletal system.

METHODS

The files of the Departments of Pathology at Duke University Medical Center and the University of California at Los Angeles and the private consultation files of one of the authors were searched for all fine-needle aspirates of sarcomas arising within the musculoskeletal system. A total of 107 cases were obtained and reviewed by three board-certified cytopathologists. Each cytopathologist independently assigned subtype when possible and generated a grade for each of the sarcomas. Corresponding surgical material was available for 77 cases. The surgical material was re-reviewed for accuracy of diagnosis and assignment of grade independently of the cytologic examination. Correlation of cytologic grade with histopathologic grade was made and analyzed by the kappa test. In addition, agreement on grade between cytopathologists was analyzed, and accuracy of histologic subtype prediction by cytologic analysis was studied.

RESULTS

Most of the sarcomas were cytologically graded as Grade 1 or 2 but were assigned a histologic grade of 2 or 3. Cytopathologist A graded 93% of the sarcomas as either Grade 1 or 2, cytopathologist B graded 89% of cases as Grade 1 or 2, and cytopathologist C graded 94% of cases as Grade 1 or 2. Histologic evaluation demonstrated 82% of cases to be Grade 2 or 3. Correlation of cytologic and surgical grade varied among the observers. Cytopathologist A showed the highest degree of correlation between cytologic and surgical grade with an r value of 0.5. The corresponding r values for cytopathologists B and C were 0.46 and 0.41, respectively. Correlation between cytologic and surgical grade was significant for all three observers (P < 0.001). Only nuclear grade showed a consistent correlation in predicting final surgical pathology grade. Cellularity, mitotic rate, and the presence of necrosis were not statistically significant for predicting histopathologic grade. Accurate exact subtyping by cytologic examination was achieved in approximately 55% of cases. Prediction of histopathologic subtype by cytologic analysis was most successful when a distinctive stroma was present or high-grade features indicative of malignant fibrous histiocytoma were observed. There was little agreement as to histopathologic type as predicated by cytology for low-grade spindle cell sarcomas.

CONCLUSIONS

Although there was a statistically significant correlation between cytologically assigned grade and final histopathologic grade, statistical analysis revealed only a moderate correlation between the two with an overall r value of approximately 0.57. Cytologic analysis tended to undergrade in comparison to final histopathologic grading. Only analysis of nuclear atypia showed good correlation with final surgical grade. Fine-needle aspiration was only moderately successful at predicting histopathologic subtype for musculoskeletal sarcomas in this series.

The role of fine-needle aspiration biopsy in the primary diagnosis of mesenchymal lesions: a community hospital-based experience

BACKGROUND

The objective of this study was to determine the utility of fine-needle aspiration biopsy (FNAB) in the primary diagnosis of mesenchymal lesions. A total of 162 cases with a diagnosis of benign or malignant mesenchymal lesion (excluding lipoma) on FNAB were retrieved from the cytopathology archives for the years 1990-1997.

METHODS

Patients selected for inclusion in this study underwent FNAB as the primary diagnostic modality without a previous tissue diagnosis and had a subsequent surgical procedure for definitive histologic correlation. Seventy-two patients were selected on the basis of the above criteria.

RESULTS

Cytologic diagnoses were categorized as benign, malignant, or suspicious for malignancy. Among the 72 cases selected, 42 (58%) benign, 18 (25%) malignant, and 12 (16%) suspicious diagnoses were rendered. Of the patients with benign FNAB diagnoses, 39 of 42 (93%) had a benign lesion on histologic follow-up, and 3 of 42 (7%) had a malignancy. Of the patients with malignant FNAB diagnoses, 17 of 18 (94%) had a malignant lesion and 1 of 17 (6%) proved to be benign. In the subset of suspicious lesions, subsequent histology was benign in 5 of 12 (42%) and malignant in 7 of 12 (58%).

CONCLUSIONS

Based on our study, FNAB has excellent accuracy (88%), sensitivity (89%), and specificity (87%) for classifying a mesenchymal tumor as benign or malignant. FNAB can be a rapid and effective tool for the primary categorization of mesenchymal lesions and provide reliable information to the clinician for triage of patients.

Primary musculoskeletal neoplasms: effectiveness of core-needle biopsy

PURPOSE

To analyze the effectiveness of core-needle biopsy for evaluation of possible primary musculoskeletal neoplasms, which often are evaluated with open biopsy.

MATERIALS AND METHODS

Core-needle biopsy was performed at a tertiary care institution in 141 patients suspected of having a mesenchymal neoplasm. In 85 patients, the lesion was in soft tissue; in 56 patients, the lesion was in bone. Eighty-nine patients had a malignant lesion, and 52 had a benign lesion. Twenty-eight patients had undergone previous surgery.

RESULTS

In 105 (74%) patients, core-needle biopsy results were concordant with results from specimens subsequently obtained at surgery with respect to tumor histologic features and grade, or they provided sufficient diagnostic information to obviate surgery. In 36 (26%) patients, inaccurate core-needle biopsy results were obtained: In nine, results were imprecise about exact histologic features; in three, results were correct about histologic features but incorrect about tumor grade. In 25 (18%) patients, open biopsy was performed after core-needle biopsy. The accuracy and rate of performance of open biopsy for soft-tissue lesions were not significantly different from those for bone lesions.

CONCLUSION

Percutaneous core-needle biopsy can be an effective alternative to open biopsy in the evaluation of possible mesenchymal neoplasms of either bone or soft tissue. Needle biopsy of such lesions, however, is best performed as part of a multidisciplinary team approach to tumor management.

Ultrasound-guided fine-needle aspiration biopsy of bone lesions: a preliminary report

The purpose of this preliminary study was to determine the feasibility of ultrasound-guided fine-needle aspiration biopsy of suspected neoplastic lesions of bone. Ultrasound-guided fine-needle aspiration biopsy samples were obtained in 23 patients (22 dogs and one cat) with radiographic evidence of a destructive or destructive/productive bone lesion. The lesions were located in the appendicular skeleton in 20 patients and in the axial skeleton in three. Histopathology from tissue core biopsies and/or necropsy was not deemed necessary in 11 patients where ultrasound-guided fine-needle aspiration biopsy results were conclusive for neoplasia. A cytologic diagnosis from ultrasound-guided fine-needle aspiration biopsy was confirmed by histologic samples obtained at surgery or necropsy in five patients. In one of these five, ultrasound-guided fine-needle aspiration biopsy samples were diagnostic for sarcoma when tissue-core biopsy was inconclusive. Both ultrasound-guided fine-needle aspiration biopsy and tissue core biopsy techniques were inconclusive in one patient. Ultrasound-guided fine-needle aspiration biopsy samples were nondiagnostic in five patients where a follow-up histopathologic diagnosis of neoplasia was made. It was concluded that ultrasound-guided fine-needle aspiration biopsy of bone, if diagnostic, may help avoid the need for a tissue-core biopsy in some instances. However, a negative ultrasound-guided fine-needle aspiration biopsy sample does not rule out neoplasia. A negative ultrasound-guided fine-needle aspiration biopsy should be followed by a tissue-core biopsy and histologic analysis in all patients. Ultrasound-guided fine-needle aspiration biopsy seems to be a promising technique for the diagnosis of bone lesions.

Fine-needle aspiration biopsy of skeletal versus extraskeletal osteosarcoma

BACKGROUND

Although fine-needle aspiration biopsy (FNAB) of primary skeletal osteosarcoma (OS) has been described adequately, to the authors' knowledge, cytologic descriptions of extraskeletal OS appear limited to only rare case reports.

METHODS

In an attempt to analyze the utility and accuracy of FNAB in a diagnosis of skeletal versus extraskeletal OS, the authors retrospectively reviewed their 5-year experience. The study sample included 15 skeletal OS specimens (13 primary, 1 local recurrence, and 1 pulmonary metastasis) in 14 patients ages 10-58 years (mean, 27 years; median, 25 years) and 5 extraskeletal OS specimens (3 primary and 2 metastatic) in 4 patients ages 36, 37, 65, and 79 years, respectively. Based on accepted clinical criteria, two patients (a mother with extraskeletal OS and a daughter with skeletal OS) had Li-Fraumeni syndrome.

RESULTS

Of the adequate primary skeletal OS cases analyzed by FNAB, 10 of 12 (83%) were diagnosed correctly and subsequently treated according to a disease specific protocol. One case was considered unsatisfactory. One tumor initially was diagnosed as a giant cell tumor and another was referred to nonspecifically as "spindle-cell neoplasm." On histologic examination, the former case demonstrated a high grade fibroblastic OS arising within a giant cell tumor. None of the primary extraskeletal OS cases analyzed by FNAB was recognized as OS. One was diagnosed nonspecifically as "sarcoma" and the other was referred to simply as "atypical mesenchymal cells." A third case was comprised of scant fragments of adipose tissue, fibrous tissue, and cartilage and was considered unsatisfactory. Both examples of metastatic extraskeletal OS were recognized by FNAB.

CONCLUSIONS

With appropriate clinicoradiologic correlation, skeletal OS generally is easily diagnosed by FNAB. Because of the older age of most patients with extraskeletal OS and the rather nonspecific radiographic findings (e.g., soft tissue mass), extraskeletal OS may not be recognized easily by FNAB and most likely requires incisional biopsy to establish a definitive diagnosis in most cases. Additional larger series will be required before drawing definite conclusions.

Fine-needle aspiration biopsy in the diagnosis and management of bone lesions: a study of 450 cases

BACKGROUND

Fine-needle aspiration (FNA) biopsy has proved to be a cost-effective technique, with low complication risks and high diagnostic value in distinguishing neoplastic versus nonneoplastic lesions in many organs. This study was designed to determine the reliability, areas of diagnostic difficulty, and limitations of FNA in the diagnosis of bone lesions encountered in a university-affiliated tertiary care hospital.

METHODS

The cytology of 450 FNA biopsies of bone lesions, performed on 427 patients between 1979 and 1996, were reviewed. The results were correlated with the corresponding histology when available, and with clinical follow-up, in an attempt to define the role of FNA in managing patients with bony lesions.

RESULTS

The patients ranged in age from 5 to 94 years, with a male-to-female ratio of 1.25:1. The spine was the most frequently aspirated site (49%), followed by the ilium, sacrum, mandible, ribs, and femur. Three hundred and eighty-five aspirates (86%) were adequate for evaluation, with 215 cases diagnosed cytologically as positive for malignancy, 11 cases as suspicious but not diagnostic of malignancy, and 2 cases as inconclusive. One hundred and fifty-seven cases were interpreted as showing no evidence of malignancy. Metastatic carcinoma was present in 175 of the 215 malignant aspirates, and 67% of these were adenocarcinomas. Forty cases were primary malignant bone neoplasms, including myeloma, lymphoma, Ewing's sarcoma, chondrosarcoma, ameloblastoma, chordoma, neurofibrosarcoma, and unclassified high grade sarcoma. False-negative diagnoses were rendered in ten cases; however, on review, material representative of the bone lesion was not present in six cases. Five cases were correctly diagnosed as malignant but were misclassified with regard to the type of malignancy.

CONCLUSIONS

FNA biopsy of bone lesions is a reliable and easily performed diagnostic test for metastatic and primary bone tumors. False-positive results have major therapeutic implications, hence the significance of the authors' conservative diagnostic approach, which resulted in a false-positive rate of 0.2%. Areas of difficulty were due to inadequate sampling or misclassification with regard to the exact type of malignancy. The simplicity and accuracy of this procedure, which does not require any surgical incisions (open biopsy or manipulation), supports its important role in triaging and managing bone lesions with minimum risk or morbidity.

The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society

In 1982, members of the Musculoskeletal Tumor Society, representing sixteen centers for the treatment of bone and soft-tissue cancer, compiled data regarding the hazards associated with 329 biopsies of primary malignant musculoskeletal sarcomas. The investigation showed troubling rates of error in diagnosis and technique, which resulted in complications and also adversely affected the care of the patients. These data were quite different when the biopsy had been carried out in a treatment center rather than in a referring institution. On the basis of these observations, the Society made a series of recommendations about the technical aspects of the biopsy and stated that, whenever possible, the procedure should be done in a treatment center rather than in a referring institution. In 1992, the Musculoskeletal Tumor Society decided to perform a similar study to determine whether the rates of complications, errors, and deleterious effects related to biopsy had changed. Twenty-five surgeons from twenty-one institutions submitted the cases of 597 patients. The results were essentially the same as those in the earlier study. The rate of diagnostic error for the total series (in which cases from referring institutions and treatment centers were combined) was 17.8 percent. There was no significant difference in the rate of patients for whom a problem with the biopsy forced the surgeon to carry out a different and often more complex operation or to use adjunctive irradiation or chemotherapy (19.3 percent in the current study, compared with 18 percent in the previous one). There was also no significant differences in the percentage of patients who had a change in the outcome, such as the need for a more complex resection that resulted in disability, loss of function, local recurrence, or death, attributable to problems related to the biopsy (10.1 percent in the current study, compared with 8.5 percent in the 1982 study). Eighteen patients in the current study had an unnecessary amputation as a result of the biopsy, compared with fifteen in the previous study. Errors, complications, and changes in the course and outcome were two to twelve times greater (p < 0.001) when the biopsy was done in a referring institution instead of in a treatment center.

Fine-needle aspiration of chondroblastic osteosarcoma of the skull: report of a case in an 11-year-old girl

We describe an unusual case of chondroblastic osteosarcoma of the skull in an 11-yr-old girl in whom a preoperative diagnosis was made by fine-needle aspiration (FNA) biopsy, followed by histologic confirmation of tissue biopsy and the surgically resected specimen. FNA cytology revealed pleomorphic oval cells with prominent nucleoli along with spindle cells, tumor giant cells, and a chondromyxoid background. The cell block of the aspirated material showed osteoid associated with the malignant cells. Immunocytochemical stains revealed S-100 and vimentin positivity; actin, myoglobin, and cytokeratin stains were negative. Electron microscopy revealed neoplastic cells with chondrocytic differentiation. This case demonstrates the value of FNA biopsy combined with immunocytochemical and ultrastructural studies performed on the aspirated material in diagnosing osteosarcoma from an unusual location such as the base of the skull.

Cytodiagnosis of a primary non-Hodgkin's lymphoma of bone

We report fine-needle aspiration cytology and histologic findings of a primary non-Hodgkin's lymphoma of bone involving the rib and iliac bones. Smears contained abnormal lymphoid cells and abundant lymphoglandular bodies, suggesting a malignant lymphoproliferative disease. However, histologic sections showed nests of tumor cells with extensive cytoplasmic clearing surrounded by sclerosis, thus mimicking a carcinoma. Clinical data, radiographic findings, and cytohistological correlation led to a final diagnosis of primary non-Hodgkin's lymphoma of the bone, confirmed by immunopositive staining for leukocyte common antigen CD45 and B-cell associated antigen CD20. It is concluded that finding numerous lymphoglandular bodies in bone tumor specimens allows an accurate diagnosis of lymphoid tissue. The rarity of bone lymphoma and the misleading histologic features can cause considerable difficulty in diagnosing this entity. The importance of identifying lymphoglandular bodies and the appropriate use of immunochemistry are emphasized.