FNA diagnosis of deep-seated lymphoma: an institutional experience

Diagnostic Discrepancies in Small-volume Biopsy for the Initial Diagnosis, Recurrence, and Transformation of Follicular Lymphoma: A Multi-Institutional Collaborative Study

Small-volume biopsies (SVBs) including fine-needle aspiration (FNA), cell block, and needle core biopsies (NCB) are increasingly utilized to diagnose and guide the clinical management of lymphoma. We established a multi-institutional interdisciplinary collaboration of cytopathologists, hematopathologists, and oncologists focused on the role of SVB in the management of patients with follicular lymphoma (FL). To assess the performance characteristics of SVB in this setting, we evaluated all consecutive SVBs performed for clinical indications of initial diagnosis, recurrence, or transformation of FL over a 5-year period and focused on the 182 that had at least one subsequent biopsy within 3 months as part of the same clinical work-up. The most common outcome of a subsequent biopsy as part of the same clinical work-up was a more specific diagnosis usually assigning the pathologic grade (111/182, 61%), followed by a complete agreement with the SVB (24/182, 13%), and change from nondiagnostic on initial biopsy to diagnostic on subsequent biopsy (21/182, 12%). A minority resulted in a diagnostic change from benign to lymphoma (17/182, 9%), a change in FL grade (5/182, 3%), or change in the lymphoma diagnostic category (4/182, 2%). There were no cases where an initial diagnosis of lymphoma was overturned. The distribution of discrepancies was similar across initial SVB types (FNA, FNA + cell block, NCB with or without FNA). Tissue limitations were noted in a minority of cases (53/182, 29%) and were enriched among initially nondiagnostic biopsies (16/21, 76%). Flow cytometry immunophenotyping was performed in the majority of cases both at the first and last biopsy (147/182, 81%). SVB can be a powerful method to detect FL in various clinical indications, with discrepant cases mostly resulting from a refinement in the initial diagnosis.

Lymph node FNA cytology: Diagnostic performance and clinical implications of proposed diagnostic categories

BACKGROUND

Despite widespread clinical use, lymph node fine-needle aspiration cytology (LN-FNAC) lacks universal acceptance for definitively diagnosing lymphomas. This is likely due to reports of lower diagnostic performance, inconsistent terminology use in cytopathology diagnostic reports, and only limited data on the clinical implications of LN-FNAC diagnoses. Recently, a uniform LN-FNAC cytopathological diagnostic reporting system was proposed (the Sydney System). This study evaluated LN-FNAC diagnostic performance and risks of malignancy associated with the proposed diagnostic categories.

METHODS

LN-FNAC specimens obtained in 2018-2019, with and without concurrent core biopsy, to evaluate for suspected lymphoma were analyzed (n = 349). LN-FNAC diagnoses were compared with final diagnoses obtained via subsequent tissue biopsy and/or clinical assessment.

RESULTS

The mean patient age was 57.6 years, and 41% were female. LN-FNAC was the initial diagnostic test in 223 (63.9%), and it was used to evaluate for recurrence in 126 (36.1%). LN-FNAC diagnosed 202 hematological malignancies (57.9%), 23 nonhematological malignancies (6.6%), and 124 reactive processes (35.5%). Subsequent tissue biopsy was performed in 42 (12%). The risks of malignancy per diagnostic category were as follows: inadequate, 58.3%; benign, 6.4%; atypical, 69.2%; suspicious, 96.7%; and malignant, 99.3%. LN-FNAC demonstrated up to 96.3% sensitivity, 91.91% specificity, and 87.35% accuracy. Optimal specimen quality and the use of intradepartmental consultation reduced diagnostic error rates in FNA cases without concurrent core biopsy (P = .029 and P = .0002 respectively).

CONCLUSIONS

LN-FNAC is accurate and reliable for the diagnosis of lymphoma. Inadequate LN-FNAC samples should be resampled due to a significant associated risk of lymphoma. The diagnostic performance of LN-FNAC may be improved with good specimen quality and reviews by multiple pathologists. Understanding the risks of malignancy associated with LN-FNAC diagnostic categories will help to guide optimal patient management.

Diagnosis of Hodgkin Lymphoma from Cell Block: A Reliable and Helpful Tool in "Selected" Diagnostic Practice

Background: The diagnosis of lymphoma requires surgical specimens to perform morphological evaluation, immunohistochemical and molecular analyses. Ultrasound-guided fine needle aspiration may represent an appropriate first approach to obtain cytological samples in impalpable lesions and/or in patients unsuitable for surgical procedures. Although cytology has intrinsic limitations, the cell block method may increase the possibility of achieving an accurate diagnosis. Methods: We retrospectively selected a total of 47 ultrasound-guided fine needle aspiration and drainage samples taken from patients with effusion and deep-seated lesions which are clinically suspicious in terms of malignancy. Results: In 27 cases, both cell block and conventional cytology were performed: 21/27 cell blocks were adequate for the diagnosis of lymphoma and suitable for immunocytochemistry and molecular analyses vs. 12/20 samples to which only conventional cytology was applied. Moreover, in five patients we were able to make a diagnosis of Hodgkin lymphoma with the cell block (CB) technique. Conclusions: Contrary to conventional cytology, the cell block method may allow immunocytochemistry and molecular studies providing useful information for the diagnosis and subtypization of lymphoma in patients unsuitable for surgical procedure or with deep-seated lesions or extra-nodal diseases; additionally, it is a daily, simple and helpful approach. Moreover, we describe the usefulness of cell blocks in the diagnosis of Hodgkin lymphoma.

The Value of Cellblock in Diagnosing Pancreatic Lymphomas

BACKGROUND

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is the diagnostic tool of choice for pancreatic solid mass lesions. Pancreatic lymphomas represent an infrequent and challenging cytologic diagnosis. Our aim was to determine the diagnostic value of cellblock (CB) in the diagnosis of pancreatic lymphomas.

METHODS

We retrieved pancreatic EUS-FNAs performed over 10-years from our institution's database. We correlated the cytologic and CB diagnosis with the histologic diagnosis as a gold standard.

RESULTS

We found 5 cases (2 women and 3 men; age range, 37-66 years [average age, 52 years]) of pancreatic lymphomas with histologic follow-up biopsies. They included 1 case of T-cell lymphoma (TCL), 1 case of plasma cell neoplasm (multiple myeloma [MM]), 1 case of diffuse large B-cell lymphoma (DLBCL), 1 case of classic Hodgkin lymphoma (HL), and 1 case of high-grade B-cell lymphoma (HGBCL). Cytologically, the cases of HL and DLBCL were suspected, the cases of TCL and MM were confused with undifferentiated carcinoma and neuroendocrine carcinoma, and the case of HGBCL was inconclusive. CB samples were of value in highlighting the morphologic details of lymphomas and allowed confirmation, proper classification, and grading of the lymphomas using immunohistochemistry that matched tissue biopsies.

CONCLUSIONS

EUS-FNA smears with CBs are helpful diagnostic tools, differentiating lymphomas from other malignancies and from nonneoplastic lymphocyte-rich lesions. CBs allow proper classification and grading of cases of pancreatic lymphomas.

Differential Diagnosis of Malignant Lymphadenopathy Using Flow Cytometry on Fine Needle Aspirate: Report on 269 Cases

Introduction: Fine needle aspiration (FNA) is frequently the first noninvasive test used for the diagnostic workup of lymphadenopathy. There have been many studies showing its usefulness, especially in conjunction with other techniques for the diagnosis of lymphoma, but it remains inferior to histological examination. The data regarding this subject have mostly been reported mostly from first-world countries, but are scarce for emerging economies. Thus, the current study assesses the agreement between fine needle aspiration flow cytometry (FNA FC) and histology in the aforementioned region. Material and Methods: We conducted a retrospective study including the FNA FC adenopathy diagnoses made between January 2011 and December 2016 at the Tygerberg Hospital, Cape Town, South Africa. Additional variables included were the histological diagnosis, sex and age of the included patients. Results: In the descriptive part of the current study, 269 FNA FC samples were included. The most frequent diagnoses made on these were represented by B-cell lymphoma, reactive adenopathy, no abnormality detected (NAD), and non-hematological malignancy. In the analytical part of the current study, there were 115 cases included that had both valid FNA FC and histological diagnoses. It could be observed that FNA FC can correctly diagnose B-cell lymphoma in most cases, but it is a poor diagnostic tool especially for Hodgkin lymphoma in this setting as only a four-color flow cytometer was available for diagnosis. Moreover, FNA FC diagnosis of reactive adenopathy and of no abnormalities detected was shown to frequently hide a malignant disease. Conclusion: In countries with scarce resources, FNA FC represents a useful diagnostic tool in the case of B-cell lymphoma, but may misdiagnose reactive adenopathy. Thus, FNA FC should be used in a case-specific manner, in addition to as a screening tool, with the knowledge that in cases with a high clinical suspicion of lymphoma, histological diagnosis is a necessity.