Fine-needle-aspiration cytodiagnosis of recurrent malignant melanoma

Cytologic diagnosis of metastatic melanoma by FNA: A practical review

Malignant melanoma (MM) is a highly aggressive neoplasm with a growing worldwide incidence. It is not uncommon that the disease is already metastatic at the time of the first diagnosis. Regional lymph nodes and skin are the first and most common metastatic sites, followed by distant visceral sites (lungs, liver, and central nervous system) and bone. In this clinical setting, fine-needle aspiration (FNA) often represents the first diagnostic approach. FNA is a useful tool to obtain a rapid and accurate diagnosis, in conjunction with ancillary techniques and molecular analysis, as recommended by recent guidelines. The aim of this review was to describe the cytomorphology, immunocytochemical tools, and molecular tools used for the diagnosis of MM metastases on FNA.

Peritheliomatous pattern: A diagnostic clue for diagnosing metastatic melanoma in cytology

BACKGROUND

A peritheliomatous pattern (PP) in tumors is characterized by a sheath of viable tumor cells closely surrounding a central blood vessel. In the authors' cytology practice, such a PP has been recognized in several metastatic melanoma specimens. The aim of this study was to evaluate the frequency of a PP in cytology samples of melanoma in comparison with other tumors.

METHODS

Eighty archival fine-needle aspiration (FNA) cases of metastatic melanoma were compared with 65 control cases (35 poorly differentiated/metastatic carcinomas, 15 lymphomas, and 15 recurrent/metastatic/high-grade sarcomas). Cytologic findings were correlated with corresponding histologic specimens, which were available for 44 cases (55%) in the melanoma group and for 23 cases (35.38%) in the control group. All slides were examined for a PP and were semiquantitatively graded for comparison.

RESULTS

A PP was present in 51.3% of the cytologic preparations (n = 41) among the melanoma group cases, whereas in the control group, a PP was present in only 3.1% of the cases (n = 2). A PP was present in 65.9% of melanomas with available histologic sections (n = 29) and in 8.7% of tissue samples from the control group (n = 2). A PP was seen more often in cell blocks than direct smear preparations (51.3% vs 40.0%) from patients with melanoma.

CONCLUSIONS

The presence of a characteristic PP can be helpful in diagnosing melanoma in FNA samples because it was present in almost half of the metastatic melanoma cases in this study and was rarely present in other tumor types. A PP is easier to recognize and more often presents in cell blocks than aspirate smears. Ancillary studies such as immunohistochemistry are helpful for excluding other entities that may exhibit a PP.

Fine-needle aspiration cytology for the diagnosis of metastatic melanoma: systematic review and meta-analysis

OBJECTIVES

To perform a thorough review and meta-analysis of studies that have shown non-image-guided fine-needle aspiration cytology (FNAC) to be highly sensitive and specific for assessing questionable metastatic melanoma to lymph nodes.

METHODS

MEDLINE and Scopus were searched for potentially relevant articles with a search string including the words "melanoma" and "fine needle." All relevant articles were screened by two authors (B.J.H. and R.L.S.). Full articles were screened for extractable data, and the data was pooled for analysis.

RESULTS

Of 978 unique studies found, 10 (5,518 cases) met our inclusion criteria. In a pooled analysis of palpation and ultrasound-guided fine-needle aspirations, the area under the receiver operating characteristic curve was 0.99 (95% confidence interval [CI], 0.99-1.00). The summary estimates for the sensitivity and specificity were 0.97 (95% CI, 0.95-0.98) and 0.98 (95% CI, 0.98-1.00), respectively.

CONCLUSIONS

With a sensitivity and specificity of 0.97 and 0.99, the overall diagnostic accuracy of FNAC for metastatic melanoma is quite high, and with a positive and negative likelihood ratio of 58 and 0.03, FNAC for metastatic melanoma should be the first-line option in a patient with a clinically suspected mass and a history of melanoma.

Cytodiagnosis of erosive melanoma and basal cell carcinoma of the skin using cutaneous tissue smear

BACKGROUND

Cytomorphological assessment of erosive skin tumours offers a rapid and minimally invasive way to obtain a diagnosis. However, the studies so far conducted on this method have been relatively small.

AIM

To conduct a large retrospective study on cytomorphological assessment of erosive skin tumours.

METHODS

In this study, 86 cytological smears prepared from erosive cutaneous tumours clinically suspicious for melanoma were examined to test the diagnostic accuracy and practicability of cytomorphological evaluation of such tumours, and to compare the assessments of two investigators with different experience levels. In a subgroup of tumours, cytological assessment was compared with dermoscopic evaluation.

RESULTS

There was agreement in the cytological and histopathological results for 68 of 86 cases (79%) assessed by the experienced investigator and in 64 of 86 cases (74%) assessed by the inexperienced investigator. The diagnosis was confirmed cytologically in 39 and 34 of 42 melanomas, and in 28 and 27 of 35 basal cell carcinomas, respectively. The sensitivity of the cytodiagnosis was not significantly different between the two investigators. The dermoscopic evaluation showed good agreement with the cytological results for melanoma (82.4%), although use of dermoscopy was only possible for 49.9% of the lesions because of difficulties with the samples.

CONCLUSIONS

Cytological assessment of erosive melanoma and BCC lesions is a useful tool for gaining additional information on clinically uncertain skin tumours, and shows good agreement between different investigators.

Diagnostic accuracy of fine needle biopsy for metastatic melanoma and its implications for patient management

BACKGROUND

The use of fine needle biopsy (FNB) for the diagnosis of metastatic melanoma can lead to the early removal and treatment of metastases, reduce the frequency of unnecessary surgery, and facilitate the staging of patients enrolled in clinical trials of adjuvant therapies. In this study, the accuracy of FNB for the diagnosis of metastatic melanoma was investigated.

METHODS

A retrospective cohort study was performed with 2204 consecutive FNBs performed on 1416 patients known or suspected to have metastatic melanoma. Almost three-quarters (1582) of these FNBs were verified by either histopathologic diagnosis following surgical resection or clinical follow-up.

RESULTS

FNB for metastatic melanoma was found to have an overall sensitivity of 92.1% and a specificity of 99.2%, with 69 false-negative and 5 false-positive findings identified. The sensitivity of the procedure was found to be influenced by six factors. The use of immunostains, reporting of the specimen by a cytopathologist who had reported >500 cases, lesions located in the skin and subcutis, and patients with ulcerated primary melanomas were factors associated with a significant improvement in the sensitivity of the test. However, FNBs performed in masses located in lymph nodes of the axilla and FNBs that required more than one needle pass to obtain a sample were far more likely to result in false-negative results.

CONCLUSIONS

FNB is a rapid, accurate, and clinically useful technique for the assessment of disease status in patients with suspected metastatic melanoma.

Fine-needle biopsy as a diagnostic technique for metastatic melanoma

Fine-needle biopsy (FNB) is a rapid, minimally invasive technique, widely used for the investigation and diagnosis of lesions in a variety of body sites. It is a procedure with high diagnostic accuracy for metastatic melanoma, with a sensitivity of 92.1% and a specificity of 99.2% in a recent large study. Although at present FNB has virtually no role in the initial diagnosis of pigmented primary cutaneous tumors, recent evidence suggests that it should be the first-line diagnostic modality for confirmation of clinically and/or radiologically suspected metastases in melanoma patients. As the specimen procured by FNB can be examined within minutes of performing the procedure, an on-demand FNB service with rapid communication of results to the patient's treating clinician enables a more efficient and cost effective approach to the multidisciplinary management of melanoma patients. In the future, it is likely that molecular analysis of very small amounts of tumor tissue obtained by FNB will provide an accurate estimate of prognosis and will facilitate selection of patients who may benefit from targeted molecular therapies.

Fine-needle aspiration biopsy with ultrasound guidance in patients with malignant melanoma and palpable lymph nodes

BACKGROUND

Recurrence after treatment of stage I-II melanoma involves regional lymph nodes in about 50% of patients. A reliable method is needed to evaluate lymph node status (metastatic or not) in the case of palpable lymph nodes.

OBJECTIVES

To evaluate the efficiency of fine-needle aspiration biopsy (FNAB) in examining clinically detected suspicious lymph node in patients followed up after surgical removal of stage I-II melanoma.

PATIENTS AND METHODS

One hundred and twenty FNABs were performed in 67 patients with a suspicious node in an open study conducted in a French melanoma regional referral centre, Hôpital de l'Hôtel-Dieu. Cytodiagnosis was classified as positive, negative, inadequate or inconclusive. Sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios were calculated after final histopathological evaluation.

RESULTS

Fifty-eight of 120 FNABs were positive (48%), 50 of 120 (42%) were negative, four of 120 (3%) were inconclusive and eight of 120 (7%) were inadequate. Among the 108 FNABs in which a definitive diagnosis could be given, sensitivity was 98.2% [95% confidence interval (CI) 90.7-99.9] and specificity was 96.1% (95% CI 86.8-98.9).

CONCLUSIONS

FNAB under ultrasound guidance is an efficient tool to discriminate better between cases in which surgical treatment of the lymph node basin should be performed and patients who should return for follow-up. Surgical treatment appears to be required in cases of positive FNAB or in inconclusive cases.

Diagnosis of melanoma aspirates on ThinPrep: the University of Michigan experience

The purpose of this study was to compare the cytologic features of melanoma fine-needle aspirates (FNAs) prepared by ThinPrep (TP) with those in conventional smears (CS) and to identify any diagnostic pitfalls. Fifty-one aspirates diagnosed as melanoma were obtained, 36 of which were prepared by both TP and CS. The preparations were evaluated for cellularity, cell aggregates, cellular appearance, melanin pigment, cytoplasmic, and nuclear features. Categorical data were analyzed by the chi-square test and continuous data by the Wilcoxin-signed rank test. Correlation was determined by Spearman's test for bivariate correlations (rho). Good correlation between the two methods was identified for the following features: cellularity, cell type, bi/multinucleated cells, cytoplasmic features, NC ratio, and presence of macronucleoli. TP exhibits coarser chromatin compared to CS (P = 0.005). Six of 36 CS contained large cellular groups; none of the TP contained them (P = 0.018). Twenty-five of 36 CS contained intranuclear inclusions as opposed to 12/36 TP (P < 0.001). The number of inclusions was significantly reduced on TP. The amount of intracellular melanin was the same with both techniques. Background melanin was markedly reduced on TP except when either trapped by fibrin or attached to cellular clusters (P = 0.006). Background blood was also markedly reduced on TP (P < 0.005). In summary, the cytological features of TP and CS for FNA evaluation of melanoma correlate well; however, one needs to be aware of the cytologic alterations introduced by TP. TP is a sufficient preparation method in the diagnosis of melanoma FNA aspirates when performed by clinicians. It is also a useful adjunct in bloody or low-cellular aspirates, where it tends to reduce the background blood and concentrate the cells.

Aspiration biopsy and the clinical management of patients with malignant melanoma and palpable regional lymph nodes

BACKGROUND

The presence of lymph node metastases in patients with malignant melanoma implies a significant decrease in survival. The authors investigated the efficacy of fine-needle aspiration biopsy (FNAB) in the diagnosis of metastatic malignant melanoma in 115 patients with melanoma and clinically suspicious regional lymph nodes.

METHODS

One hundred thirty-three FNABs were performed by cytopathologists after referral from surgeons or oncologists using a 25-gauge or 27-gauge needle.

RESULTS

The cytologic diagnosis was negative in 35, atypical in 1, suspicious in 2, and positive for malignant melanoma in 95. Regional lymph node dissections were performed in 78 patients. Of these, 70 positive FNABs were confirmed with no false-positive results. The atypical FNAB was proven positive for malignant melanoma at surgery. Of the two suspicious FNABs, one was confirmed as positive and one showed dermatopathic lymphadenopathy. Of the 35 negative FNAB specimens, 5 patients underwent surgery; 3 FNABs were found to be negative and 2 FNABS were falsely negative. Twenty patients with negative aspirates were followed clinically for 22-45 months (mean, 32 months); 19 patients had no evidence of disease and 1 patient died of disseminated melanoma.

CONCLUSIONS

FNAB of palpable lymphadenopathy in patients with malignant melanoma can provide a rapid and accurate assessment of lymph node status and expedite the therapeutic management of these patients.

Fine needle aspiration in the diagnosis of metastatic melanoma

BACKGROUND

Fine needle aspiration is an accurate technique to diagnose metastatic melanoma. Few reports exist in the literature describing its usefulness in many patients with melanoma confirmed by open biopsy.

OBJECTIVE

The purpose of this study was to determine the utility and predictive value of fine needle aspiration in patients with malignant melanoma who presented with lesions suspected to be metastatic.

METHODS

We retrospectively reviewed 99 cases of fine needle aspiration and the corresponding histologic findings obtained by open biopsy in 82 patients.

RESULTS

Of the 99 cases, 86 were positive for melanoma, 12 were negative, and one was indeterminate. The positive predictive value of fine needle aspiration was 99%. One patient had a false-positive diagnosis.

CONCLUSION

Fine needle aspiration is a rapid, accurate, and minimally invasive procedure that is useful in the diagnosis of metastatic melanoma. Patients with a positive aspirate of palpable regional nodes can proceed directly to surgery, bypassing the need for an open biopsy.

Fine-needle aspiration biopsy of malignant melanoma: a cytologic and immunocytochemical analysis

The immunoreactivity of alcohol-fixed cell blocks from 15 fine-needle aspiration (FNA) specimens of malignant melanoma was investigated using monoclonal antibodies to keratin and vimentin intermediate filaments, melanoma cytoplasmic antigen (HMB-45), and S-100, as well as polyclonal antibodies to S-100. The results were compared with the immunoprofiles obtained using formalin-fixed surgical specimens from 10 of the same patients. In all cases, immunostaining for keratin was negative and immunostaining for vimentin was positive. Immunostaining for HMB-45 was positive in 13/15 aspirates and in 9/10 surgical specimens. Immunostaining for S-100 protein showed the greatest variability in staining, with 5/15 fine needle aspiration biopsies and 9/10 surgical specimens being positive using the polyclonal antibody and only 1/15 FNA specimens and 7/10 surgical specimens being positive using the monoclonal S-100 reagent. Our findings indicate that immunocytochemical studies can be very useful as an adjunct in the FNA diagnosis of melanoma. Also included in our series is an unusual variant of malignant melanoma, the so-called signet ring melanoma. Given the location of the anal verge, the use of immunocytochemical markers was essential in establishing the correct diagnosis in this case. While S-100 protein is of limited value as a marker of melanoma in alcohol-fixed FNA specimens, a definitive diagnosis of malignant melanoma can be made using a panel of antibodies including keratin, vimentin, and HMB-45.