The diagnostic value of on-site cytopathological evaluation and cell block preparation in fine-needle aspiration cytology of liver masses

Aspiration cytology of liver abscess uncovering metastatic rectal mucosal melanoma-A case report

Aspirates of liver abscess are frequently encountered in routine practice and are often of a low index of suspicion. However, necrotic liver metastasis clinically and radiologically mimics liver abscesses, and malignant cells can be obscured in an inflammation-rich background on cytology. It is important to recognise malignant neoplasms in this scenario, in particular uncommon conditions such as metastatic mucosal melanoma.

Hepatocyte paraffin-1, CD10, and CD34 immunostaining as a diagnostic aid in cytologic diagnosis of hepatic cancer

Background

Cytomorphological distinction between hepatocellular carcinoma and metastatic tumors to the liver may be difficult, especially when these have poor differentiation. The present study was done to assess the diagnostic utility of hepatocyte paraffin-1 (HepPar-1), CD10, and CD34 in differentiating hepatocellular carcinoma from metastatic carcinoma.

Materials and Methods

Ultrasound-guided fine-needle aspiration was performed on 50 patients with space-occupying lesions of liver suspicious for malignancy on clinical/radiologic findings. The cytological assessment was done on smears stained with May-Grünwald-Giemsa and hematoxylin and eosin. Cell blocks were prepared, and immunostaining for HepPar-1, CD10, and CD34 was done.

Results

In these 50 patients, hepatocellular carcinoma was diagnosed in 7 and metastatic tumors in 43 cases. The sensitivity of smears in diagnosing hepatocellular carcinoma was 100% and the specificity was 95.3%, while the sensitivity and specificity of cell block were 100%. A canalicular pattern of CD10 immunoreactivity had a 100% positive predictive value for diagnosing hepatocellular carcinoma. CD10 had a sensitivity of 57.1% and 41.9% in identification of HCC and metastatic tumors, respectively. For the diagnosis of hepatocellular carcinoma, the sensitivity of CD34 was 85.7% and the specificity of sinusoidal pattern of immunoreactivity was 100%. The sensitivity and specificity of granular cytoplasmic staining pattern of HepPar-1 were 100% in hepatocellular carcinoma.

Conclusions

The staining patterns of HepPar-1, CD10, and CD34 are highly specific in distinguishing hepatocellular carcinoma from metastasis. These three immunomarkers should be included in the immunocytochemical panel for differentiating hepatocellular carcinoma from metastatic carcinoma to the liver.

The strength of cytomorphology and efficacy of immuno-cytochemistry in distinguishing hepatocellular carcinoma from its mimics on fine-needle aspiration cytology

BACKGROUND

Cytomorphologic distinction of hepatocellular carcinoma (HCC) from its mimics on fine-needle aspiration cytology (FNAC) is often problematic. The present study evaluates the strength of cytomorphology and the utility of an immuno-panel of arginase-1, glypican-3, HepPar-1, thyroid transcription factor (TTF-1) and CK-19 in resolving this diagnostic issue.

METHODS

FNAC features of 71 nodular hepatic lesions were studied with an immunocyto/ histochemical (ICC/IHC) panel of arginase-1, glypican-3, HepPar-1, TTF-1 taking 10% positivity as "cut-off." Cytomorpholologic diagnoses were compared with diagnoses made on combined cytomorphologic and ICC/IHC approach.

RESULTS

Of 71 cases, 32, 10 and 29 had histopathologic, cell block and clinico-radiologic correlation respectively with 55 metastatic adenocarcinomas (MAC), 13 HCCs and one case each of hepatic adenoma (HA), cirrhotic nodule (CN) and intrahepatic cholangiocarcinoma (CC). Cytoplasmic positivity of HepPar-1 and glypican-3 were noted in 11/13 and 8/13 HCCs respectively; while only 3/13 and 1/13 HCCs revealed cytoplasmic positivity for arginase-1 and TTF-1 respectively. Benign hepatic lesions were negative for glypican-3 and TTF-1, but expressed both arginase-1and HepPar-1. Twenty-one of 55 MACs and the lone case of CC were positive for CK-19; however, all MACs and CC cases were negative for HepPar-1, arginase-1, glypican-3 and TTF-1. The immune-panel had sensitivity, specificity and diagnostic accuracy of 100%, 88.9% and 90.6%, respectively, for differentiating HCC from its morphologic mimics.

CONCLUSION

Though a meticulous cytologic evaluation in conjunction with clinicoradiologic profile helps in distinguishing HCC from its benign and malignant mimics; an immunopanel of arginase-1, glypican-3, HepPar-1, TTF-1 and CK-19 drastically improves the diagnostic accuracy.

Utility of rapid on-site evaluation for needle core biopsies and fine-needle aspiration cytology done for diagnosis of mass lesions of the liver

BACKGROUND

Fine-needle aspiration (FNA) and core biopsy (CB) are used to diagnose liver lesions. Rapid onsite evaluation (ROSE) can improve the adequacy of the procedures and help triage diagnostic material appropriately. There are very few studies evaluating the role of ROSE for CB and FNA of mass lesions of the liver.

METHODS

Liver cases with ROSE material from 2007 to 2017 were retrieved and reviewed. The ROSE material was re-evaluated by 2 cytopathologists who were blinded to the final diagnosis. Data including age, number of lesions, number of passes, adequacy assessed at time of procedure, and diagnosis made by cytopathologist on ROSE material at time of re-review was compiled.

RESULTS

A total of 82 cases were identified; 33 were primary lesions (group A) and 49 were metastatic lesions (group B). ROSE done by cytotechnologist at time of procedure showed an adequacy rate of 84%. During re-review of ROSE material by cytopathologists, the overall adequacy rates were similar, although the adequacy rates in group B increased (to 100% from 92%) and it dropped in group A (from 73% to 52%). The overall accuracy rate was 90%. Hepatocellular adenoma, regenerative nodules, well-differentiated hepatocellular carcinoma, and angiosarcoma were not possible to diagnose on smears alone during ROSE.

CONCLUSIONS

ROSE for liver lesions is useful for assessing adequacy. Certain lesions cannot be accurately diagnosed on ROSE alone. ROSE material when assessed by cytopathologist can improve adequacy rate and possibly decrease number of nondiagnostic specimens in group A, though the cost effectiveness needs to be assessed.

Role of radiological-assisted cytology in intra-abdominal lesions: A 3 years' experience in a tertiary care center

BACKGROUND

Fine needle aspiration (FNA) with assistance of radiological tools such as ultrasonography (USG) and computed tomography (CT) is an effective and safe technique for diagnosing intra-abdominal neoplastic and nonneoplastic lesions.

AIMS AND OBJECTIVES

(1) To assess the utility of image-guided cytology in the diagnosis of intra-abdominal lesions. (2) To categorize various intra-abdominal lesions according to their site of occurrence and study their cytomorphological features.

MATERIALS AND METHODS

A cross-sectional study was conducted in the Department of Pathology between January 2012 and January 2015. A total of 174 cases with intra-abdominal lesions were included in the study.

RESULTS

In our study, diagnostic yield was 84.5%. The mean age was found to be 52 years with M: F ratio 1.1:1. We found that 92 (52.87%) cases were in hepatobiliary region, 33 (18.96%) in adnexa, 13 (7.47%) in pancreatic-ampullary region, 14 (8.04%) in unknown abdominal lumps, 8 (4.6%) in lymph nodes, 6 (3.4%) in renal, 5 (2.87%) in retroperitoneum, 2 (1.1%) in omental nodules, and 1 (0.5%) in splenic mass. Of total 174 cases, 106 (61%) cases were malignant, 10 (5.7%) benign, 16 (9.1%) inflammatory, 27 (15.5%) inadequate, and 15 (8.7%) suspicious for malignancy.

CONCLUSION

Ultrasound and CT-guided FNA cytology had a significant role in diagnosis of palpable and nonpalpable intra-abdominal lesions. Being a relatively quick and safe method, it also avoids invasive diagnostic procedures.

Cell blocks in cytopathology: a review of preparative methods, utility in diagnosis and role in ancillary studies

The cell block (CB) is a routine procedure in cytopathology that has gained importance because of its pivotal role in diagnosis and ancillary studies. There is no precise review in the published literature that deals with the various methods of preparation of CB, its utility in diagnosis, immunocytochemistry (ICC) or molecular testing, and its drawbacks. An extensive literature search on CB in cytology using internet search engines was performed for this review employing the following keywords: cell block, cytoblock, cytology, cytopathology, methods, preparation, fixatives, diagnostic yield, ancillary and molecular studies. Ever since its introduction more than a century ago, the CB technique has undergone numerous modifications to improve the quality of the procedure; however, the overall principle remains the same in each method. CBs can be prepared from virtually all varieties of cytological samples. In today's era of personalized medicine, cytological specimens, including CBs, augment the utility of cytological samples in analysing the molecular alterations as effectively as surgical biopsies or resection specimens. With the availability of molecular targeted therapy for many cancers, a large number of recent studies have used cytological material or CBs for molecular characterization. The various techniques of CB preparation with different fixatives, their advantages and limitations, and issues of diagnostic yield are discussed in this review.

Immunohistochemical Study of Glypican-3 and HepPar-1 in Differentiating Hepatocellular Carcinoma from Metastatic Carcinomas in FNA of the Liver

Hepatocellular carcinoma (HCC) remains a common malignant cancer worldwide, it is considered the fifth most common malignant cancer. On the other hand, metastatic tumors are widespread in the liver , with metastatic adenocarcinoma (MA) constituting the greatest part, therefore differentiation of HCC from MA is a frequent problem facing the pathologist especially in liver fine-needle aspiration biopsies. Evaluating the diagnostic value of glypican-3 (GPC-3) and HepPar-1 immunostaining in differentiating hepatocellular carcinoma from metastatic tumors in liver cell block material. Fourty eight cell blocks prepared from FNA from the liver ( 30 cases HCC, 18 cases metastatic carcinoma in liver) stained by Glypican -3 and HepPar-1 immunohistochemical markers. Glypican-3 was immunoexpressed in 97% of cases of HCC while all cases of metastatic carcinoma were negative. HepPar-1 was expressed in 93% of cases of HCC and 11% of metastatic carcinoma of the liver. In this study the sensitivity of GPC3 in the diagnosis of HCC in cytological material was 96.7% and the specificity was 100% while the sensitivity and specificity of HepPar-1 was 93.3% and 88.9% respectively. Immunohistochemical staining for GPC-3 in cell block material of the liver is highly sensitive and specific and it is a valuable tool capable of differentiating HCC from most of metastatic tumors of the liver.

How can an endosonographer assess for diagnostic sufficiency and options for handling the endoscopic ultrasound-guided fine-needle aspiration specimen and ancillary studies

Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become well established as a minimally invasive technique in diagnosing and staging various gastrointestinal, pancreaticobiliary, and retroperitoneal malignancies. The diagnostic accuracy of this procedure is significantly enhanced by the presence of on-site cytopathology. However, in many EUS centers, cytopathology is not readily available for on-site evaluation. This article is intended to assist the independent endosonographer in the assessment of diagnostic sufficiency and in specimen handling.

[Evaluation of a cell block method in cytological diagnostics]

BACKGROUND

Cell block procedures have now become an established part of cytological diagnostics. In this study a cytoblock technique based on the plasma-thrombin method was evaluated.

MATERIALS AND METHODS

In total 389 consecutive cytological samples were initially analyzed by the classical procedure and then by the cell block technique. The latter was done by centrifugation of the remaining material of the cytological sample, resuspension of the cells in blood plasma followed by generation of a cell clot by the addition of thrombin.

RESULTS

Analysis of material from the peritoneal cavity, ascites and pleura was successful in more than 90% of cases. In 272 samples the conventional and cell block analyses revealed concordant results according to Papanicolaou classification. In 23 cases the cell block analysis induced an upgrade. In particular, malignant processes (PAP V) or precursor lesions (PAP IV) were identified in 9 cases which were not diagnosed by conventional analysis.

CONCLUSIONS

Advantages of this method include the assessment of an additional sample volume and thus reduction of sampling error, the possibility for unlimited storage and molecular testing similar to histological samples.

Arginase-1: a novel immunohistochemical marker of hepatocellular differentiation in fine needle aspiration cytology

BACKGROUND

Arginase-I is a key urea cycle metalloenzyme that has been used as an immunohistochemistry (IHC) marker for hepatocellular carcinoma (HCC). Previous studies have demonstrated the efficacy of HepPar-1 and glypican-3 (GPC-3) IHC in liver fine needle aspiration (FNA) cytology.

METHODS

Arginase-1 IHC was performed on FNA cell blocks, and its performance characteristics were compared with HepPar-1 and GPC-3. Ninety-two formalin-fixed, paraffin-embedded cell blocks were selected (HCC [n = 44], cirrhosis [n = 2], focal nodular hyperplasia [n = 3], hepatic adenomas [n = 2], dysplastic nodules [n = 6], and metastatic carcinomas [n = 35]). IHC staining with antibodies directed against arginase-1, HepPar-1, and GPC-3 was performed with appropriate positive and negative controls.

RESULTS

Arginase-1 positivity was demonstrated in 37 of 44 (84.1%) cases of HCC, compared with 32 of 44 cases (72.7%) and 25 of 44 cases (56.8%) for HepPar-1 and GPC-3, respectively. Arginase-1 and GPC-3 expression were not observed in any cases of metastatic carcinoma (0%), whereas HepPar-1 expression was present in 1 case of metastatic carcinoma. In addition, both arginase-1 and HepPar-1 expression were present in all 13 cases (100%) of nonmalignant hepatocellular lesions, whereas GPC-3 expression was absent in all 13 cases (0%).

CONCLUSION

This study demonstrates that both arginase-1 and HepPar-1 are effective IHC markers of hepatocellular differentiation. Furthermore, arginase-1 demonstrates superior sensitivity compared with GPC-3 and HepPar-1 in the diagnosis of HCC, whereas GPC-3 demonstrates superior specificity, as staining is not observed in benign hepatocellular lesions. Hence, use of arginase-1 with HepPar-1 and GPC-3 can aid in the diagnosis of HCC and separating from metastatic carcinoma.

Grading of hypervascular hepatocellular carcinoma using late phase of contrast enhanced sonography - a prospective study

BACKGROUND

Outcome of patients with hepatocellular carcinoma is influenced by their histological grade. Invasive biopsy of the lesions is the gold standard in this regard.

AIMS

We therefore analysed the diagnostic accuracy of contrast enhanced ultrasound for non-invasive grading of hypervascular hepatocellular carcinoma in liver cirrhosis.

METHODS

According to the tumour perfusion kinetics on contrast enhanced ultrasound two grading groups were prospectively defined: well-differentiated hepatocellular carcinoma (US-G1) and higher grade hepatocellular carcinoma (US-G2/G3). Immediately after contrast enhanced ultrasound-grading, biopsies of hepatocellular carcinoma-lesions (n=95, 1.2-12.5 cm) were obtained and analysed for tumour grading (G). Descriptive statistics, sensitivity, specificity positive and negative predictive values, diagnostic likelihood ratios and interoperator reproducibility were calculated (κ).

RESULTS

Histologically 77 (81.1%) patients had G2-G3 and 18 (18.9%) had G1 tumours. Higher grade hepatocellular carcinoma showed more often a washout in the portal or late phase (p<0.0001). The sensitivity, specificity, positive predictive values and negative predictive values of contrast enhanced ultrasound for grading of hepatocellular carcinoma for all patients were 94% (CI: 72-99%), 95% (CI: 88-99%), 81% and 99% and for patients with tumours<5 cm 100%(95% CI: 79-100), 96% (95% CI: 80-99), 92% and 100%. Positive and negative diagnostic likelihood ratios' were 18 and 26 and 0.06 and 0, respectively. κ=0.941 (p<0.001).

CONCLUSIONS

Contrast enhanced ultrasound has a high diagnostic value and reproducibility for non-invasive grading of hypervascular hepatocellular carcinoma >1cm in patients with liver cirrhosis.

A new technique for the diagnosis of mycetoma using fixed blocks of aspirated material

The aim of this prospective study was to evaluate the use of the cell block technique as a safe, accurate and quick tool for the cytodiagnosis of mycetoma. The study included 240 patients with suspected mycetoma. The suspected lesion was aspirated and the aspirated material was processed to form cell blocks. The cell blocks were processed as described for routine tissue histopathological examination. Haematoxylin/eosin-stained sections were reviewed to identify the morphological features of the mycetoma grains and the different inflammatory tissue reactions. The findings were compared with those seen in histopathological sections. The different mycetoma grains showed distinct morphological features on the cell block that were identical to those seen in histopathological sections. Distinction between eumycetoma and actinomycetoma and their classification according to the causative agent were possible. The cell block technique had sensitivities of 87.5% and 85.7% for eumycetoma and actinomycetoma, respectively, and there were no statistical differences in the findings obtained by the cell block and histopathological techniques. The technique is simple, rapid, specific, sensitive and inexpensive. It can be used in the routine diagnosis of mycetoma and to obtain grains for culture identification. The cell blocks can be preserved for a long period for future studies.

Algorithm for immediate cytologic diagnosis of hepatic tumors

OBJECTIVE

Immediate cytologic assessment of hepatic lesions can help determine the adequacy of specimens and may yield a preliminary diagnosis. The purpose of this study was to analyze the diagnostic accuracy of on-site cytologic assessment compared with definitive cytologic examination in the detection and correct subtyping of malignant hepatic lesions.

SUBJECTS AND METHODS

The study population included 472 consecutively registered patients with hepatic nodules who underwent sonographically guided fine-needle aspiration and core biopsies. During on-site cytologic analysis, the pathologist made a preliminary diagnosis of malignancy or negative for malignancy for each nodule. When a malignant lesion was diagnosed, immediate subtyping was attempted.

RESULTS

With immediate cytologic analysis, 280 (80.9%) of 346 malignant nodules were correctly identified without false-positive cases. With immediate subtyping, 113 (68.1%) of 166 cases of hepatocellular carcinoma, 28 (77.8%) of 36 cases of cholangiocarcinoma, and 113 (85.0%) of 133 cases of metastasis were detected.

CONCLUSION

High diagnostic accuracy for malignancy can be achieved with on-site cytologic evaluation of hepatic tumors. Specific diagnoses of hepatocellular carcinoma, cholangiocarcinoma, and metastasis also can be made on-site in most cases. The absence of false-positive diagnosis of malignancy at on-site cytologic examination may make additional biopsy unnecessary. We propose an algorithm for the cytohistopathologic management of hepatic tumors.