Cytopathology in Low Medical Infrastructure Countries

Fine needle aspiration biopsy in low- and middle-income countries

Fine needle aspiration biopsy (FNAB) in low- and middle-income countries (LMIC), can provide minimally invasive, cost-effective tissue diagnosis with rapid assessment and specimen triage, which is advantageous in these resource-limited settings. Nevertheless, challenges such as equipment shortages, reagents, and lack of trained personnel exist. This article discusses the effectiveness of FNAB for diagnosis of malignant and inflammatory conditions across various organs, such as lymph nodes, breast, soft tissue, and thyroid and advocates for increased training opportunities and collaboration with academic centers to enhance diagnostic accuracy and access to pathology services.

Real-World Diagnostic Accuracy of the On-Site Cytopathology Advance Report (OSCAR) Procedure Performed in a Multidisciplinary One-Stop Breast Clinic

Fine-needle aspiration (FNA) cytology has been widely used for the diagnosis of breast cancer lesions with the objective of differentiating benign from malignant masses. However, the occurrence of unsatisfactory samples and false-negative rates remains a matter of concern. Major improvements have been made thanks to the implementation of rapid on-site evaluation (ROSE) in multidisciplinary and integrated medical settings such as one-stop clinics (OSCs). In these settings, clinical and radiological examinations are combined with a morphological study performed by interventional pathologists. The aim of our study was to assess the diagnostic accuracy of the on-site cytopathology advance report (OSCAR) procedure on breast FNA cytologic samples in our breast OSC during the first three years (April 2004 till March 2007) of its implementation. To this goal, we retrospectively analyzed a series of 1820 breast masses (1740 patients) radiologically classified according to the American College of Radiology (ACR) BI-RADS lexicon (67.6% being either BI-RADS 4 or 5), sampled by FNA and immediately diagnosed by cytomorphology. The clinicoradiological, cytomorphological, and histological characteristics of all consecutive patients were retrieved from the hospital computerized medical records prospectively registered in the central information system. Histopathological analysis and ultrasound (US) follow-up (FU) were the reference diagnostic tests of the study design. In brief, we carried out either a histopathological verification or an 18-month US evaluation when a benign cytology was concordant with the components of the triple test. Overall, histology was available for 1138 masses, whereas 491 masses were analyzed at the 18-month US-FU. FNA specimens were morphologically nondiagnostic in 3.1%, false negatives were observed in 1.5%, and there was only one false positive (0.06%). The breast cancer prevalence was 62%. Diagnostic accuracy measures of the OSCAR procedure with their 95% confidence intervals (95% CI) were the following: sensitivity (Se) = 97.4% (96.19-98.31); specificity (Sp) = 94.98% (92.94-96.56); positive predictive value (PPV) = 96.80% (95.48-97.81); negative predictive value (NPV) = 95.91% (94.02-97.33); positive likelihood ratio (LR+) = 19.39 (13.75-27.32); negative predictive ratio (LR-) = 0.03 (0.02-0.04), and; accuracy = 96.45% (95.42-97.31). The respective positive likelihood ratio (LR+) for each of the four categories of cytopathological diagnoses (with their 95% CI) which are malignant, suspicious, benign, and nondiagnostic were 540 (76-3827); 2.69 (1.8-3.96); 0.03 (0.02-0.04); and 0.37 (0.2-0.66), respectively. In conclusion, our study demonstrates that the OSCAR procedure is a highly reliable diagnostic approach and a perfect test to select patients requiring core-needle biopsy (CNB) when performed by interventional cytopathologists in a multidisciplinary and integrated OSC setting. Besides drastically limiting the rate of nondiagnostic specimens and diagnostic turn-around time, OSCAR is an efficient and powerful first-line diagnostic approach for patient-centered care.

A Retrospective Analysis of the Clinicopathological Features of Patients with Tuberculous Mastitis: A Single Institution's Experience

INTRODUCTION

Tuberculosis remains a global health burden, especially in low- and middle-income countries. Breast tuberculosis is a rare disease with minimal research available. This disease produces a diagnostic challenge as the clinical presentation is variable, and diagnosis often requires additional investigations. This study was undertaken to determine the efficacy of cytology and histology, together with ancillary studies, in diagnosing tuberculous mastitis.

METHODS

This retrospective study was conducted in a Johannesburg Hospital over 5 years. Thirty-two patients with confirmed tuberculous mastitis were included. The patients were considered positive for tuberculous mastitis if histological or cytological findings were confirmed with either a positive tuberculosis culture, Ziehl-Neelsen stain, or polymerase chain reaction examination/GeneXpert.

RESULTS

This case series comprises 3 males and 29 females with a mean age of 35.66. A breast mass was the most common presentation. Over these 5 years, more biopsies were performed on inflammatory breast lesions than fine needle aspirations. There was a higher confirmation rate for cytology diagnoses compared to histology diagnoses.

CONCLUSION

This study supports using fine needle aspiration combined with GeneXpert as the primary diagnostic modality in diagnosing tuberculous mastitis. This test combination is advantageous in resource- and financially constrained environments as it is relatively simple to perform, cost-effective, and has a rapid turnaround time.

Importance of Cytopathologic Diagnosis in Early Cancer Diagnosis in Resource-Constrained Countries

PURPOSE

The rising cancer burden in low- and middle-income countries (LMICs) stresses already weak health care systems and poses unique challenges. In resource-constrained LMICs and in circumstances where most patients must pay out of pocket for diagnostic tests, these may not be available or affordable for many. Cytopathology provides a simple, inexpensive, standardized, and low-technology diagnostic procedure that is increasingly used as an effective tool to address the hurdles faced in cancer control programs in LMICs. This review explores the potential role of cytopathology in LMICs in reducing the cancer burden.

METHODS

This review studied the existing literature across the globe regarding the utilization of cytopathology as a diagnostic or screening tool for various types of malignancies as well as its advantages and disadvantages, depending on the local situation.

RESULTS

Apart from the usefulness of cytopathology, this review also sheds light on the barriers to using cytopathology in LMICs. Most recently, SARS-CoV-2 has produced several unique challenges for cytopathology. These are being met with innovative measures to combat the effects of the pandemic and ensure the safe delivery of essential cytopathology services.

CONCLUSION

The usefulness of cytopathologic techniques has been demonstrated via various studies, even during the recent pandemic. If cytology is to be used appropriately, the focus needs to be on integrating it into the national cancer screening and diagnostic programs as well as providing well-trained human resources.

Metastatic olfactory neuroblastoma: A small round blue cell puzzle on fine-needle aspiration cytology

Small round blue cell tumors (SRBCTs) are a heterogeneous group of malignant neoplasms that can be challenging to distinguish on fine-needle aspiration (FNA) cytology. Ancillary tests as well as clinico-radiological correlation are often required to make an accurate diagnosis. FNA is a low-cost, low-infrastructure test, making it a coveted diagnostic tool, especially in low-resource settings. Olfactory neuroblastoma (ONB) is a rare SRBCT encountered in both pediatric and adult patients. Awareness of the cytomorphologic and immunocytochemical features of ONB is important in the workup of a SRBCT. This case report describes the primary diagnosis of metastatic ONB on FNA cytology.

Needle Biopsy Adequacy in the Era of Precision Medicine and Value-Based Health Care

CONTEXT.—

Needle biopsy of diseased tissue is an essential diagnostic tool that is becoming even more important as precision medicine develops. However, the capability of this modality to efficiently provide samples adequate for diagnostic and prognostic analysis remains quite limited relative to current diagnostic needs. For physicians and patients, inadequate biopsy frequently leads to diagnostic delay, procedure duplication, or insufficient information about tumor biology leading to delay in treatment; for health systems, this results in substantial incremental costs and inefficient use of scarce specialized diagnostic resources.

OBJECTIVE.—

To review current needle biopsy technology, devices, and practice with a perspective to identify current limitations and opportunities for improvement in the context of advancing precision medicine.

DATA SOURCES.—

PubMed searches of fine-needle aspiration and core needle biopsy devices and similar technologies were made generally, by tissue site, and by adequacy as well as by health economics of these technologies.

CONCLUSIONS.—

Needle biopsy adequacy can be improved by recognizing the importance of this diagnostic tool by promoting common criteria for needle biopsy adequacy; by optimizing needle biopsy procedural technique, technologies, clinical practice, professional education, and quality assurance; and by bundling biopsy procedure costs with downstream diagnostic modalities to provide better accountability and incentives to improve the diagnostic process.

The International Academy of Cytology Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy Cytopathology

The International Academy of Cytology (IAC) gathered together a group of cytopathologists expert in breast cytology who, working with clinicians expert in breast diagnostics and management, have developed the IAC Yokohama System for Reporting Breast Fine-Needle Aspiration Biopsy (FNAB) Cytology. The project was initiated with the first cytopathology group meeting in Yokohama at the 2016 International Congress of Cytology. This IAC Yokohama System defines five categories for reporting breast cytology, each with a clear descriptive term for the category, a definition, a risk of malignancy (ROM) and a suggested management algorithm. The key diagnostic cytopathology features of each of the lesions within each category will be presented more fully in a subsequent atlas. The System emphasizes that the crucial requirements for diagnostic breast FNAB cytology are a high standard for the performance of the FNAB and for the making of direct smears, and well-trained experienced cytopathologists to interpret the material. The performance indicators of breast FNAB, including specificity and sensitivity, negative predictive value, positive predictive value and ROM stated in this article have been derived from the recent literature. The current practice of breast FNAB has evolved with the increasing use of ultrasound guidance and rapid on-site evaluation. Two recent publications have shown a range of ROM for the insufficient/inadequate category of 2.6-4.8%, benign 1.4-2.3%, atypical 13-15.7%, suspicious of malignancy 84.6-97.1%, and malignant 99.0-100%. The management algorithm in the System provides options because there are variations in the management of breast lesions using FNAB and core-needle biopsy in those countries utilizing the "triple test" of clinical, imaging, and FNAB assessment, and also variations in the availability of CNB and imaging in low- and middle-income countries. The System will stimulate further discussion and research, particularly in the cytological diagnostic features of specific lesions within each category and in management recommendations. This will lead to continuing improvements in the care of patients with breast lesions and possible modifications to the IAC Yokohama System.

Task Sharing and Shifting to Provide Pathology Diagnostic Services: The Kenya Fine-Needle Aspiration Biopsy Cytology and Bone Marrow Aspiration and Trephine Biopsy Training Program

Purpose

Fine-needle aspiration biopsy (FNAB) cytology is a simple, inexpensive, and accurate diagnostic test for benign, infectious, and malignant lesions of the breast, thyroid, lymph nodes, and other organs. Similarly, bone marrow aspiration and trephine (BMAT) biopsy procedures are relatively simple and inexpensive techniques that are important for diagnosing and monitoring many hematologic diseases including leukemias and lymphomas. However, the scarcity of pathologists in Kenya limits patient access to these simple diagnostic tests. We describe a task sharing and shifting program that sought to improve the provision of FNABs and BMAT biopsies in tertiary public hospitals in Kenya.

Methods

Between January 2016 and February 2017, we trained pathologists, pathology residents, and technologists from the University of Nairobi and Aga Khan University Hospital, Nairobi, in FNAB and BMAT biopsies, who in turn trained pathologists, medical officers (MO), clinical officers (CO), and technologists at five tertiary public hospitals. The program involved curriculum development, training workshops, the establishment of new and strengthening existing FNAB and BMAT biopsy clinics, interim site visits, audits, and stakeholder workshops.

Results

Fifty-one medical personnel at the tertiary hospitals were trained. The FNAB numbers increased by 41% to 1,681, with 139 malignant diagnoses (7.1%). BMAT biopsy numbers increased by 268% to 140, with 34 malignant cases. Between 60% and 100% of the FNAB and BMAT biopsy procedures were performed by MO and CO over the project period. One new FNAB and two new BMAT biopsy clinics were established.

Conclusion

This project demonstrates a successful model of task sharing and shifting from specialist pathologists to MO and CO that improved access to important FNAB and BMAT biopsy services in a low-resource setting.