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Primary and Secondary Hepatic Lymphomas Diagnosed by Image-Guided Fine Needle Aspiration: A Retrospective Study of Clinical and Cytomorphological Findings
S108
Abstracts
197 Primary and Secondary Hepatic Lymphomas Diagnosed by ImageGuided Fine Needle Aspiration: A Retrospective Study of Clinical and Cytomorphological Findings Matthew Swadley, MD1, Matea Deliu, BS2, Marina Mosunjac, MD1, Krisztina Hanley, MD1. 1Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia; 2Department of Pathology, Grady Memorial Hospital, Atlanta, Georgia Introduction: Image-guided fine needle aspiration (FNA) has been proven as an efficient, minimally-invasive, relatively inexpensive and rapid method for evaluation of liver lesions. Lymphoid malignancies are relatively uncommon in liver and can often resemble metastatic adenocarcinomas radiologically. On-site evaluation of aspirate material is a widely-used method to assess specimen adequacy for preliminary diagnosis and ancillary study triage. Our study describes the clinico-pathologic findings in patients diagnosed with primary or secondary hepatic lymphomas (HL) by image-guided FNA. Materials and Methods: A fifteen year (1996-2011) multi-hospital retrospective search was conducted to identify 32 cases of HL diagnosed by FNA. Hospitals included an academic medical center and an innercity public hospital. An immediate evaluation of the FNA was performed by a pathologist in each case. Pathology slides and ancillary studies (flow cytometry, immunohistochemistry [IHC]) were reviewed to confirm the diagnosis. Demographics (race, age, sex), laboratory data (HIV serology, CD4 counts, viral loads, and LDH), imaging studies (CT), and clinical information were extracted from electronic patient charts. Results: The most common types of HL diagnosed by FNA were B-cell lymphomas with predominance of diffuse large B cell lymphoma (DLBCL) (nZ11), B-cell lymphoma NOS (nZ4), and Burkitt lymphoma (nZ1) followed by plasma cell myeloma (nZ4), Hodgkin lymphoma (nZ3) and single cases of other types of lymphoma [Figure 1]. In five cases a definitive diagnosis of lymphoma was not established; either due to insufficient material or extensive cell necrosis. Flow cytometry was performed in 20 of 32 cases with diagnostic findings in 70%, and IHC was utilized in 25 of 32 cases. Primary HL (defined as non-recurrent lymphomas without biopsy-proven disease at another anatomic location) comprised 16 of 32 cases. The majority of these primary hepatic lymphomas (12/16) occurred in HIV-positive patients. The most common diagnosis was DLBCL (9/16 cases) with multiple cases of B-cell lymphoma NOS also seen (2/16). Secondary lymphomas comprised the remaining 16 cases. Recurrence of a previous lymphoma was seen in 10 of these 16 cases, and extra-hepatic disease was identified in 10 cases. Concomitant HIV infection was seen less often within this group (4/16 patients). The most common diagnoses were Hodgkin lymphoma (3/16) and plasma cell myeloma (3/16), with multiple cases of DLBCL (2) and B-cell lymphoma NOS (2) also identified. Patient demographics (age, sex, race) and imaging findings were roughly similar between primary and secondary lymphoma groups.
Figure 1 diagnoses.
Breakdown of combined primary and secondary hepatic lymphoma
Conclusions: 1. HL can be accurately diagnosed and classified by imageguided FNA, especially when combined with ancillary studies. 2. HL should be included in the differential diagnosis in the clinical setting of multiple liver lesions. 3. The most common type of primary liver lymphoma is DLBCL. 4. A more heterogeneous group of diagnoses was identified within secondary hepatic lymphomas with Hodgkin lymphoma and plasma cell myeloma being the most common subtypes. 5. Primary HL is seen most often in HIV positive patients whereas secondary lymphomas are usually seen in HIV negative patients. 6. On-site evaluation for specimen adequacy is a valuable tool for further diagnostic workup of HL. 198 Mucin-Producing Neoplasm of the Pancreas - Cytologic Features, Limitations and Pitfalls on FNA Samples Haiyan Liu, MD, Fan Lin, MD, PhD. Laboratory medicine, Geisinger Health System, Danville, Pennsylvania Introduction: Mucin-producing neoplasm (MPN) of the pancreas, including intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN), is an increasingly recognized cystic lesion of the pancreas on both FNA and surgical specimens. Even though cytologic features and diagnostic criteria have been studied and reported, the diagnostic challenges such as IPMN versus MCN, distinction from gastrointestinal (GI) contaminants, and grading of dysplasia (high grade [HG], moderate grade [MG] and low grade [LG]) are frequently encountered. Materials and Methods: Twenty-eight MPNs (18 IPMNs and 10 MCNs) on both surgical and FNA specimens available from 28 patients were included. Twenty-eight FNA samples were re-reviewed with a focus on the following features: 1) adequacy; 2) epithelial group; 3) single cell; 4) single atypical cells; 5) background; 6) gastrointestinal contamination; and 7) cell block. Correlation of the diagnoses between FNA and resection was performed. Results: The cytologic features are summarized in Table 1. On surgical resection, the diagnoses for the 18 IPMNs included 6 adenocarcinomas, 1 colloid carcinoma, 3 HG, 3 MG, and 5 LG; for the 10 MCNs: 1 HG, 1 MG, and 8 LG. On FNA specimens, the original cytologic diagnoses for 18 IPMNs were 14 IPMNs or MPNs, 1 adenocarcinoma (AD), 1 pseudocyst, and 2 cannot rule out GI contamination. Six of 7 IMPN and adenocarcinoma cases were rendered as IPMN/MPN with MG or HG on FNA. One AD case on FNA was IPMN with HG on the resection. The pseudocyst case was AD on the resection. Single atypical cells were present in this case and in two other AD cases. Two FNA samples with necrosis were AD on the resection. In contrast, among 10 MCNs, the diagnoses were 6 cyst contents, 3 MPNs, and 1 questionable MPN. Table 1
Summary of Cytologic Features
Cytologic Features
IPMN (NZ18)
MCN (NZ10)
Adequacy: Adequate, Inadequate, Low cellularity Epithelial Group: Large sheet, Papillary, Small tight cluster Single cell: Cuboid, Columnar/tall Single atypical cells Background: Thin mucin, Thick mucin, Histiocytes/muciphages, Inflammatory, Necrosis Gastrointestinal contamination: Stomach, Small Bowel Cell Block: Adequate, Low cellularity, Not available
15, 0, 3 7, 13, 12
1, 3, 6 0, 0, 5
6, 14 3 17, 4 (and thin mucin) 12, 2, 2 0, 1 13, 2, 3
1, 0 7, 1, 0, 0,
2 0, 0, 0 0 4, 6
Conclusions: This study demonstrated 1) diagnostic accuracy is significantly higher for IPMN than MCN due to low cellularity or inadequate sample in MCN; 2) large sheets and papillary groups are typical findings in an IPMN; 3) small tight clusters are seen in both IPMN and MCN; 4) single atypical cells and necrosis are suspicious features for carcinoma; 5) GI contamination is a rare finding; 6) cyst content likely represents an MCN; and 7) large epithelial sheets may be misinterpreted as GI contaminants.
Abstracts
197 Primary and Secondary Hepatic Lymphomas Diagnosed by ImageGuided Fine Needle Aspiration: A Retrospective Study of Clinical and Cytomorphological Findings Matthew Swadley, MD1, Matea Deliu, BS2, Marina Mosunjac, MD1, Krisztina Hanley, MD1. 1Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia; 2Department of Pathology, Grady Memorial Hospital, Atlanta, Georgia Introduction: Image-guided fine needle aspiration (FNA) has been proven as an efficient, minimally-invasive, relatively inexpensive and rapid method for evaluation of liver lesions. Lymphoid malignancies are relatively uncommon in liver and can often resemble metastatic adenocarcinomas radiologically. On-site evaluation of aspirate material is a widely-used method to assess specimen adequacy for preliminary diagnosis and ancillary study triage. Our study describes the clinico-pathologic findings in patients diagnosed with primary or secondary hepatic lymphomas (HL) by image-guided FNA. Materials and Methods: A fifteen year (1996-2011) multi-hospital retrospective search was conducted to identify 32 cases of HL diagnosed by FNA. Hospitals included an academic medical center and an innercity public hospital. An immediate evaluation of the FNA was performed by a pathologist in each case. Pathology slides and ancillary studies (flow cytometry, immunohistochemistry [IHC]) were reviewed to confirm the diagnosis. Demographics (race, age, sex), laboratory data (HIV serology, CD4 counts, viral loads, and LDH), imaging studies (CT), and clinical information were extracted from electronic patient charts. Results: The most common types of HL diagnosed by FNA were B-cell lymphomas with predominance of diffuse large B cell lymphoma (DLBCL) (nZ11), B-cell lymphoma NOS (nZ4), and Burkitt lymphoma (nZ1) followed by plasma cell myeloma (nZ4), Hodgkin lymphoma (nZ3) and single cases of other types of lymphoma [Figure 1]. In five cases a definitive diagnosis of lymphoma was not established; either due to insufficient material or extensive cell necrosis. Flow cytometry was performed in 20 of 32 cases with diagnostic findings in 70%, and IHC was utilized in 25 of 32 cases. Primary HL (defined as non-recurrent lymphomas without biopsy-proven disease at another anatomic location) comprised 16 of 32 cases. The majority of these primary hepatic lymphomas (12/16) occurred in HIV-positive patients. The most common diagnosis was DLBCL (9/16 cases) with multiple cases of B-cell lymphoma NOS also seen (2/16). Secondary lymphomas comprised the remaining 16 cases. Recurrence of a previous lymphoma was seen in 10 of these 16 cases, and extra-hepatic disease was identified in 10 cases. Concomitant HIV infection was seen less often within this group (4/16 patients). The most common diagnoses were Hodgkin lymphoma (3/16) and plasma cell myeloma (3/16), with multiple cases of DLBCL (2) and B-cell lymphoma NOS (2) also identified. Patient demographics (age, sex, race) and imaging findings were roughly similar between primary and secondary lymphoma groups.
Figure 1 diagnoses.
Breakdown of combined primary and secondary hepatic lymphoma
Conclusions: 1. HL can be accurately diagnosed and classified by imageguided FNA, especially when combined with ancillary studies. 2. HL should be included in the differential diagnosis in the clinical setting of multiple liver lesions. 3. The most common type of primary liver lymphoma is DLBCL. 4. A more heterogeneous group of diagnoses was identified within secondary hepatic lymphomas with Hodgkin lymphoma and plasma cell myeloma being the most common subtypes. 5. Primary HL is seen most often in HIV positive patients whereas secondary lymphomas are usually seen in HIV negative patients. 6. On-site evaluation for specimen adequacy is a valuable tool for further diagnostic workup of HL. 198 Mucin-Producing Neoplasm of the Pancreas - Cytologic Features, Limitations and Pitfalls on FNA Samples Haiyan Liu, MD, Fan Lin, MD, PhD. Laboratory medicine, Geisinger Health System, Danville, Pennsylvania Introduction: Mucin-producing neoplasm (MPN) of the pancreas, including intraductal papillary mucinous neoplasm (IPMN) and mucinous cystic neoplasm (MCN), is an increasingly recognized cystic lesion of the pancreas on both FNA and surgical specimens. Even though cytologic features and diagnostic criteria have been studied and reported, the diagnostic challenges such as IPMN versus MCN, distinction from gastrointestinal (GI) contaminants, and grading of dysplasia (high grade [HG], moderate grade [MG] and low grade [LG]) are frequently encountered. Materials and Methods: Twenty-eight MPNs (18 IPMNs and 10 MCNs) on both surgical and FNA specimens available from 28 patients were included. Twenty-eight FNA samples were re-reviewed with a focus on the following features: 1) adequacy; 2) epithelial group; 3) single cell; 4) single atypical cells; 5) background; 6) gastrointestinal contamination; and 7) cell block. Correlation of the diagnoses between FNA and resection was performed. Results: The cytologic features are summarized in Table 1. On surgical resection, the diagnoses for the 18 IPMNs included 6 adenocarcinomas, 1 colloid carcinoma, 3 HG, 3 MG, and 5 LG; for the 10 MCNs: 1 HG, 1 MG, and 8 LG. On FNA specimens, the original cytologic diagnoses for 18 IPMNs were 14 IPMNs or MPNs, 1 adenocarcinoma (AD), 1 pseudocyst, and 2 cannot rule out GI contamination. Six of 7 IMPN and adenocarcinoma cases were rendered as IPMN/MPN with MG or HG on FNA. One AD case on FNA was IPMN with HG on the resection. The pseudocyst case was AD on the resection. Single atypical cells were present in this case and in two other AD cases. Two FNA samples with necrosis were AD on the resection. In contrast, among 10 MCNs, the diagnoses were 6 cyst contents, 3 MPNs, and 1 questionable MPN. Table 1
Summary of Cytologic Features
Cytologic Features
IPMN (NZ18)
MCN (NZ10)
Adequacy: Adequate, Inadequate, Low cellularity Epithelial Group: Large sheet, Papillary, Small tight cluster Single cell: Cuboid, Columnar/tall Single atypical cells Background: Thin mucin, Thick mucin, Histiocytes/muciphages, Inflammatory, Necrosis Gastrointestinal contamination: Stomach, Small Bowel Cell Block: Adequate, Low cellularity, Not available
15, 0, 3 7, 13, 12
1, 3, 6 0, 0, 5
6, 14 3 17, 4 (and thin mucin) 12, 2, 2 0, 1 13, 2, 3
1, 0 7, 1, 0, 0,
2 0, 0, 0 0 4, 6
Conclusions: This study demonstrated 1) diagnostic accuracy is significantly higher for IPMN than MCN due to low cellularity or inadequate sample in MCN; 2) large sheets and papillary groups are typical findings in an IPMN; 3) small tight clusters are seen in both IPMN and MCN; 4) single atypical cells and necrosis are suspicious features for carcinoma; 5) GI contamination is a rare finding; 6) cyst content likely represents an MCN; and 7) large epithelial sheets may be misinterpreted as GI contaminants.