- Email: [email protected]
Risk of Malignancy in Cervical Lymph Node Fine Needle Aspiration
S16
Abstracts
Diagnostic Challenges in Salivary Gland Aspiration Cytology: A 20 Year Retrospective Study
fine needle aspiration of salivary glands was searched for “amendments” or “revisions”. Medical records of the revised cases were reviewed for the subsequent surgical pathology results. All cases with diagnostic discrepancy between primary cytologic diagnosis and final histology diagnosis were included in this study. Histologic Diagnosis was considered gold standard. Results: Among seventy one charts, twenty cases were selected for this study. Upon reviewing the charts, cases were subsequently divided into six different categories based on their final diagnosis: 1) benign pleomorphic adenoma (2), 2) mucoepidermoid carcinoma (2), 3) oncocytic neoplasms (3), 4) lymphocytic rich aspirates (5), 5) lesions with prominent squamous cell features (3), and 6) others (5). Prior history of malignancy was misleading in 2 cases. Four cases were diagnosed malignant on cytology while surgical resections were benign. Two cases were considered malignant on cytology and the corresponding histology diagnoses were benign. The findings are tabulated in Table-1. Conclusion: The interpretation of salivary gland FNA can be influenced by several factors including prominent metaplasia, focal atypia, cystic changes, variable cellular components within the lesions, scant cellularity, prior history of malignancy, and variants of neoplasms. Multiple passes representing the entire mass, imaging findings, and familiarity with salivary gland lesions may decrease the misdiagnosis.
Sajad Salehi, MD1, Zahra Maleki, MD2. 1St John Hospital and Medical Center, Detroit, MI; 2Johns Hopkins University, Baltimore, MD
PST33
needle aspirations. Liao’s scoring system was applied to lymph nodes while a modified scoring interpretation was applied to the thyroids. Since thyroid nodules will not have normal lymph node architecture, whether benign or malignant, a positive echogenicity score was attributed to a mixed echo signal and a positive vascular score was attributed to signs of increased vascularity. Results: In our sample, the benign lymph nodes had an average score of 4.9 while the malignant nodes had an average of 8.4. When using a cut off score of 7 between benign and malignant this gave an 80% sensitivity and 85% specificity. The Bethesda-II thyroids had an average score of 9.87, while malignant thyroids averaged 9.31. When applying the same cut off of 7, this yielded 83% sensitivity and 11% specificity. A cut off with a meaningful sensitivity and specifity was not found. Conclusions: Liao’s scoring system, when applied to our fine needle aspiration sample, proved to be helpful in the prediction of malignancy in lymph nodes but is non-contributory when applied to the thyroid. PST32
Introduction: Fine needle aspiration (FNA) is routinely performed to evaluate salivary gland mass lesions and it provides valuable information regarding the cytomorphology of the lesional cells in most instances. However, due to the heterogeneity of cell types, metaplastic changes, and sampling issues there are occasions that there are morphology overlaps between benign and malignant conditions. Herein, we present a retrospective study of diagnostic pitfalls in salivary gland cytology and the simulating conditions. Materials and Methods: A 20 year retrospective review (1995 -2015) of medical records was performed. Cytology report of patients who underwent
Cases with diagnostic discrepancy
Risk of Malignancy in Cervical Lymph Node Fine Needle Aspiration Danielle Hutchings, MD, Christopher VandenBussche, MD, PhD. The Johns Hopkins Hospital, Baltimore, MD Introduction: Fine needle aspiration (FNA) is an important tool in the assessment of cervical lymphadenopathy. The aim of this study was to investigate the malignancy risk associated with the different cervical lymph node FNA diagnostic categories at our institution. Materials and Methods: 1,945 consecutive cervical lymph node FNAs over 9 years were reviewed and classified into five diagnostic categories as follows: insufficient for diagnosis, benign, atypical, suspicious for malignancy and malignant. If an associated follow up surgical pathology (SP) specimen existed, the diagnosis was recorded. The rate of malignancy (ROM) was calculated for each FNA diagnostic category as a percentage of the total FNA cases and also as a percentage of cases with a follow up SP specimen. Results: The results are summarized in Table 1. 605 (31.1%) cases were diagnostic of malignancy, 54 (2.8%) were suspicious, 158 (8.1%) were atypical, 973 (50.0%) were benign and 155 (8.0%) were insufficient for diagnosis. Among cases that were malignant, 72 (11.9%) were primary lymphoid and 533 (88.1%) were metastatic with the most common metastases being papillary thyroid carcinoma (268 cases; 50.2%) and squamous cell carcinoma (123 cases; 23.1%). 569 (29.3%) cases had follow-up SP specimens. The overall rates of malignancy were as follows: insufficient, 5.8%; benign, 1.7%; atypical, 13.9%; suspicious, 50.0%; malignant 61.8%. ROM in cases with SP follow-up were as follows: insufficient, 45.0%; benign, 16.5%; atypical, 64.6%; suspicious, 90.0%; malignant, 97.9%. Conclusions: Cervical lymph node FNAs classified as benign carried an overall ROM of 1.7% while atypical, suspicious or malignant results carried a ROM with SP follow-up of 64.7%, 90.0% and 97.9% respectively.
Table 1
Abstracts Importantly, cases with an insufficient diagnosis had a significantly increased ROM over the benign category (P Z 0.004), which highlights the importance of this category.
PST34 Diagnosis and Classification of Non-Hodgkin Lymphoma with Endoscopic Ultrasound-Guided Fine Needle Aspiration
S17 benign/atypical, and 13(19%) were unsatisfactory/non-diagnostic. The most common neoplastic diagnosis was hematolymphoid (88%), predominantly non-Hodgkin’s lymphoma, and the most common benign/atypical diagnosis was atypical lymphoid infiltrate (40%). Conclusion: FNA is a method in identifying hematolymphoid malignancy in the orbit, especially non-Hodgkin’s lymphoma. It is rarely used in pediatric patients in our institution.
Elizabeth Jacobi, MD, Anneliese Velez-Perez, MD, Nirav Thosani, MD, MHA, Songlin Zhang, MD, PhD. University of Texas Medical School, Houston, TX
PST36
Introduction: Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) is an important tool for diagnosis of gastrointestinal lesions and cancer staging. The primary diagnosis and classification of lymphoproliferative disorders is occasionally encountered by cytopathologists. We report four cases of non-Hodgkin lymphoma with complete diagnosis and classification by EUS-FNA. Materials and Methods: For all cases, cell block and flow cytometric analysis was performed. Immunohistochemistry and fluorescent in situ hybridization (FISH) was performed in select cases. Results: Case 1, lymphoma cells positive for CD20, CD10, PAX-5, BCL-2, BCL-6, and Ki67 80%. Flow cytometry showed an abnormal B-cell population, positive for CD20, CD22, CD10, and surface kappa light chain restriction. FISH showed 80% of nuclei positive for BCL-2 and IGH rearrangement, and 30% positive for c-Myc. The final diagnosis was diffuse large B-cell lymphoma, germinal center type. Case 2, flow cytometric analysis showed an abnormal B-cell population positive for CD5 with surface lambda light chain restriction, and negative for CD23, consistent with mantle cell lymphoma. Case 3, tumor cells positive for CD20 and CD10 with small centrocytes. Flow cytometry showed an abnormal B-cell population positive for CD20, CD22, CD10, and surface lambda light chain restriction. The final diagnosis was follicular lymphoma grade 1 e 2. Case 4, tumor cells positive for CD10, CD20, and Ki67 100%, and negative for CD5, BCL-2, and cyclin D1. Flow cytometry showed an abnormal B-cell population positive for CD20, CD22, CD10, and surface kappa light chain restriction. FISH showed 90% nuclei positive for c-Myc, BCL-2, and IGH rearrangement, supporting the diagnosis of double hit B-cell lymphoma. Conclusions: Our case series shows EUS-FNA can obtain adequate tissue for diagnosis and classification of non-Hodgkin lymphoma. The 22 procore or 25 sharkcore produce fragments of tumor tissue for architecture evaluation. Molecular study should be performed on some cases for the lymphoma classification.
Kossivi Dantey, MD, Sara Monaco, MD, Juan Xing, MD, Alka Palekar, MD, Liron Pantanowitz, MD. University of Pittsburgh Medical Center, Pittsburgh, PA
PST35 Fine Needle Aspiration of the Orbit: A Single Institution Experience of 67 Cases
Fine Needle Aspiration of Malignant Mesothelioma Presenting as Localized Tumors
Introduction: Malignant mesotheliomas (MM) are relatively rare neoplasms that rarely present as a localized tumor. The cytologic features of MM in fine needle aspiration (FNA) specimens are not well established in the literature. The aim of this study was to characterize the cytopathology of MMs presenting as mass lesions sampled by FNA. Materials and Methods: Archival cases (NZ46) of FNA specimens from 1999-2014, diagnosed as positive for MM (35, 76%) or with atypical mesothelial proliferations (11, 24%) were reviewed. Cases with available cytology slides (NZ17, 37%) and corresponding surgical resections (NZ12, 26%) were examined for cytology, histopathology and ancillary test findings. Results: Most patients were male (MZ34, FZ12) of average age 67 years (range 24-88). Fifteen patients (33%) had a known history of mesothelioma and 9 (19.5%) reported asbestos exposure. Sampled lesions were from the thorax (27, 59%), abdomen (9), soft tissue (4), nodes (4) and pelvis (2). The cytology specimens had low to medium cellularity and associated inflammatory cells. Most tumor cells were arranged in compact (NZ10) and loose (NZ6) clusters. Only one case had discohesive cells. In 16 cases (94%), cells were round to angulated with dense and occasionally microvacuolated cytoplasm. The nuclei were round, slightly irregular, and eccentric (NZ15), except in 2 cases where they were centrally located. The binucleate cells were rare. Immunohistochemistry (NZ15) and fluorescence in-situ hybridization (FISH) studies for p16 gene deletion (NZ7) were helpful in a subset of cases. Conclusions: The FNA diagnosis of MM presenting as a mass lesion is challenging given the unusual clinical presentation and cytological findings of angulated tumor cells with eccentric nuclei and associated inflammation. However, the cytomorphology in most cases resembles features seen in exfoliative specimens. Clinical history of MM and/or asbestos exposure, as well as ancillary studies, can help in challenging cases.
Angela Niehaus, MD, Ariel Frost, AB, Sarah Masoud, Ziyan Salih, MD, MIAC. Wake Forest University, Winston-Salem, NC
PST37
Introduction: Orbital tumors are rare and often referred to a tertiary care medical center for management. As a result, there is limited familiarity with orbital specimens and the diagnostic differential they pose. Fine needle aspiration (FNA), with or without radiologic assistance, is a well-accepted and reliable procedure in the orbit. A single institution experience with FNA of the orbit is reviewed. Materials and Methods: Retrospective review of surgical pathology database for orbital FNA specimens performed at a single institution between the years 1990 through 2016. A total of 67 specimens were identified and classified into three categories: neoplasm, benign/atypical, and unsatisfactory/non-diagnostic. Results: Of the 67 patients, 36 were female and 31 were male, with an age range of 3 months to 94 years (mean 63 years). There was only one pediatric patient. 34(51%) specimens were neoplastic, 20 (30%) were
Daniel Johnson, MD1, Julieta Barroeta, MD2, Tatjana Antic, MD1, Ricardo Lastra, MD1. 1University of Chicago, Chicago, IL; 2Cooper University Hospital, Camden, NJ
Cytopathologic Features of Metastatic Endometrioid Adenocarcinoma
Introduction: Approximately 2.8% of women will be diagnosed with endometrial cancer and another 1.2% will be diagnosed with ovarian cancer at some point during their lifetime. Metastatic disease is commonly seen with high grade carcinomas, such as serous and clear cell types, but may also occur from low grade endometrioid carcinomas (LGEMCAs), and may be the primary presentation of disease. Tissue confirmation is necessary to guide therapy, but performing biopsies might not always be feasible or practical. In these cases, fine needle aspiration (FNA) is a safe and efficient alternative. We describe the cytomorphologic features of metastatic LGEMCAs.
Abstracts
Diagnostic Challenges in Salivary Gland Aspiration Cytology: A 20 Year Retrospective Study
fine needle aspiration of salivary glands was searched for “amendments” or “revisions”. Medical records of the revised cases were reviewed for the subsequent surgical pathology results. All cases with diagnostic discrepancy between primary cytologic diagnosis and final histology diagnosis were included in this study. Histologic Diagnosis was considered gold standard. Results: Among seventy one charts, twenty cases were selected for this study. Upon reviewing the charts, cases were subsequently divided into six different categories based on their final diagnosis: 1) benign pleomorphic adenoma (2), 2) mucoepidermoid carcinoma (2), 3) oncocytic neoplasms (3), 4) lymphocytic rich aspirates (5), 5) lesions with prominent squamous cell features (3), and 6) others (5). Prior history of malignancy was misleading in 2 cases. Four cases were diagnosed malignant on cytology while surgical resections were benign. Two cases were considered malignant on cytology and the corresponding histology diagnoses were benign. The findings are tabulated in Table-1. Conclusion: The interpretation of salivary gland FNA can be influenced by several factors including prominent metaplasia, focal atypia, cystic changes, variable cellular components within the lesions, scant cellularity, prior history of malignancy, and variants of neoplasms. Multiple passes representing the entire mass, imaging findings, and familiarity with salivary gland lesions may decrease the misdiagnosis.
Sajad Salehi, MD1, Zahra Maleki, MD2. 1St John Hospital and Medical Center, Detroit, MI; 2Johns Hopkins University, Baltimore, MD
PST33
needle aspirations. Liao’s scoring system was applied to lymph nodes while a modified scoring interpretation was applied to the thyroids. Since thyroid nodules will not have normal lymph node architecture, whether benign or malignant, a positive echogenicity score was attributed to a mixed echo signal and a positive vascular score was attributed to signs of increased vascularity. Results: In our sample, the benign lymph nodes had an average score of 4.9 while the malignant nodes had an average of 8.4. When using a cut off score of 7 between benign and malignant this gave an 80% sensitivity and 85% specificity. The Bethesda-II thyroids had an average score of 9.87, while malignant thyroids averaged 9.31. When applying the same cut off of 7, this yielded 83% sensitivity and 11% specificity. A cut off with a meaningful sensitivity and specifity was not found. Conclusions: Liao’s scoring system, when applied to our fine needle aspiration sample, proved to be helpful in the prediction of malignancy in lymph nodes but is non-contributory when applied to the thyroid. PST32
Introduction: Fine needle aspiration (FNA) is routinely performed to evaluate salivary gland mass lesions and it provides valuable information regarding the cytomorphology of the lesional cells in most instances. However, due to the heterogeneity of cell types, metaplastic changes, and sampling issues there are occasions that there are morphology overlaps between benign and malignant conditions. Herein, we present a retrospective study of diagnostic pitfalls in salivary gland cytology and the simulating conditions. Materials and Methods: A 20 year retrospective review (1995 -2015) of medical records was performed. Cytology report of patients who underwent
Cases with diagnostic discrepancy
Risk of Malignancy in Cervical Lymph Node Fine Needle Aspiration Danielle Hutchings, MD, Christopher VandenBussche, MD, PhD. The Johns Hopkins Hospital, Baltimore, MD Introduction: Fine needle aspiration (FNA) is an important tool in the assessment of cervical lymphadenopathy. The aim of this study was to investigate the malignancy risk associated with the different cervical lymph node FNA diagnostic categories at our institution. Materials and Methods: 1,945 consecutive cervical lymph node FNAs over 9 years were reviewed and classified into five diagnostic categories as follows: insufficient for diagnosis, benign, atypical, suspicious for malignancy and malignant. If an associated follow up surgical pathology (SP) specimen existed, the diagnosis was recorded. The rate of malignancy (ROM) was calculated for each FNA diagnostic category as a percentage of the total FNA cases and also as a percentage of cases with a follow up SP specimen. Results: The results are summarized in Table 1. 605 (31.1%) cases were diagnostic of malignancy, 54 (2.8%) were suspicious, 158 (8.1%) were atypical, 973 (50.0%) were benign and 155 (8.0%) were insufficient for diagnosis. Among cases that were malignant, 72 (11.9%) were primary lymphoid and 533 (88.1%) were metastatic with the most common metastases being papillary thyroid carcinoma (268 cases; 50.2%) and squamous cell carcinoma (123 cases; 23.1%). 569 (29.3%) cases had follow-up SP specimens. The overall rates of malignancy were as follows: insufficient, 5.8%; benign, 1.7%; atypical, 13.9%; suspicious, 50.0%; malignant 61.8%. ROM in cases with SP follow-up were as follows: insufficient, 45.0%; benign, 16.5%; atypical, 64.6%; suspicious, 90.0%; malignant, 97.9%. Conclusions: Cervical lymph node FNAs classified as benign carried an overall ROM of 1.7% while atypical, suspicious or malignant results carried a ROM with SP follow-up of 64.7%, 90.0% and 97.9% respectively.
Table 1
Abstracts Importantly, cases with an insufficient diagnosis had a significantly increased ROM over the benign category (P Z 0.004), which highlights the importance of this category.
PST34 Diagnosis and Classification of Non-Hodgkin Lymphoma with Endoscopic Ultrasound-Guided Fine Needle Aspiration
S17 benign/atypical, and 13(19%) were unsatisfactory/non-diagnostic. The most common neoplastic diagnosis was hematolymphoid (88%), predominantly non-Hodgkin’s lymphoma, and the most common benign/atypical diagnosis was atypical lymphoid infiltrate (40%). Conclusion: FNA is a method in identifying hematolymphoid malignancy in the orbit, especially non-Hodgkin’s lymphoma. It is rarely used in pediatric patients in our institution.
Elizabeth Jacobi, MD, Anneliese Velez-Perez, MD, Nirav Thosani, MD, MHA, Songlin Zhang, MD, PhD. University of Texas Medical School, Houston, TX
PST36
Introduction: Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA) is an important tool for diagnosis of gastrointestinal lesions and cancer staging. The primary diagnosis and classification of lymphoproliferative disorders is occasionally encountered by cytopathologists. We report four cases of non-Hodgkin lymphoma with complete diagnosis and classification by EUS-FNA. Materials and Methods: For all cases, cell block and flow cytometric analysis was performed. Immunohistochemistry and fluorescent in situ hybridization (FISH) was performed in select cases. Results: Case 1, lymphoma cells positive for CD20, CD10, PAX-5, BCL-2, BCL-6, and Ki67 80%. Flow cytometry showed an abnormal B-cell population, positive for CD20, CD22, CD10, and surface kappa light chain restriction. FISH showed 80% of nuclei positive for BCL-2 and IGH rearrangement, and 30% positive for c-Myc. The final diagnosis was diffuse large B-cell lymphoma, germinal center type. Case 2, flow cytometric analysis showed an abnormal B-cell population positive for CD5 with surface lambda light chain restriction, and negative for CD23, consistent with mantle cell lymphoma. Case 3, tumor cells positive for CD20 and CD10 with small centrocytes. Flow cytometry showed an abnormal B-cell population positive for CD20, CD22, CD10, and surface lambda light chain restriction. The final diagnosis was follicular lymphoma grade 1 e 2. Case 4, tumor cells positive for CD10, CD20, and Ki67 100%, and negative for CD5, BCL-2, and cyclin D1. Flow cytometry showed an abnormal B-cell population positive for CD20, CD22, CD10, and surface kappa light chain restriction. FISH showed 90% nuclei positive for c-Myc, BCL-2, and IGH rearrangement, supporting the diagnosis of double hit B-cell lymphoma. Conclusions: Our case series shows EUS-FNA can obtain adequate tissue for diagnosis and classification of non-Hodgkin lymphoma. The 22 procore or 25 sharkcore produce fragments of tumor tissue for architecture evaluation. Molecular study should be performed on some cases for the lymphoma classification.
Kossivi Dantey, MD, Sara Monaco, MD, Juan Xing, MD, Alka Palekar, MD, Liron Pantanowitz, MD. University of Pittsburgh Medical Center, Pittsburgh, PA
PST35 Fine Needle Aspiration of the Orbit: A Single Institution Experience of 67 Cases
Fine Needle Aspiration of Malignant Mesothelioma Presenting as Localized Tumors
Introduction: Malignant mesotheliomas (MM) are relatively rare neoplasms that rarely present as a localized tumor. The cytologic features of MM in fine needle aspiration (FNA) specimens are not well established in the literature. The aim of this study was to characterize the cytopathology of MMs presenting as mass lesions sampled by FNA. Materials and Methods: Archival cases (NZ46) of FNA specimens from 1999-2014, diagnosed as positive for MM (35, 76%) or with atypical mesothelial proliferations (11, 24%) were reviewed. Cases with available cytology slides (NZ17, 37%) and corresponding surgical resections (NZ12, 26%) were examined for cytology, histopathology and ancillary test findings. Results: Most patients were male (MZ34, FZ12) of average age 67 years (range 24-88). Fifteen patients (33%) had a known history of mesothelioma and 9 (19.5%) reported asbestos exposure. Sampled lesions were from the thorax (27, 59%), abdomen (9), soft tissue (4), nodes (4) and pelvis (2). The cytology specimens had low to medium cellularity and associated inflammatory cells. Most tumor cells were arranged in compact (NZ10) and loose (NZ6) clusters. Only one case had discohesive cells. In 16 cases (94%), cells were round to angulated with dense and occasionally microvacuolated cytoplasm. The nuclei were round, slightly irregular, and eccentric (NZ15), except in 2 cases where they were centrally located. The binucleate cells were rare. Immunohistochemistry (NZ15) and fluorescence in-situ hybridization (FISH) studies for p16 gene deletion (NZ7) were helpful in a subset of cases. Conclusions: The FNA diagnosis of MM presenting as a mass lesion is challenging given the unusual clinical presentation and cytological findings of angulated tumor cells with eccentric nuclei and associated inflammation. However, the cytomorphology in most cases resembles features seen in exfoliative specimens. Clinical history of MM and/or asbestos exposure, as well as ancillary studies, can help in challenging cases.
Angela Niehaus, MD, Ariel Frost, AB, Sarah Masoud, Ziyan Salih, MD, MIAC. Wake Forest University, Winston-Salem, NC
PST37
Introduction: Orbital tumors are rare and often referred to a tertiary care medical center for management. As a result, there is limited familiarity with orbital specimens and the diagnostic differential they pose. Fine needle aspiration (FNA), with or without radiologic assistance, is a well-accepted and reliable procedure in the orbit. A single institution experience with FNA of the orbit is reviewed. Materials and Methods: Retrospective review of surgical pathology database for orbital FNA specimens performed at a single institution between the years 1990 through 2016. A total of 67 specimens were identified and classified into three categories: neoplasm, benign/atypical, and unsatisfactory/non-diagnostic. Results: Of the 67 patients, 36 were female and 31 were male, with an age range of 3 months to 94 years (mean 63 years). There was only one pediatric patient. 34(51%) specimens were neoplastic, 20 (30%) were
Daniel Johnson, MD1, Julieta Barroeta, MD2, Tatjana Antic, MD1, Ricardo Lastra, MD1. 1University of Chicago, Chicago, IL; 2Cooper University Hospital, Camden, NJ
Cytopathologic Features of Metastatic Endometrioid Adenocarcinoma
Introduction: Approximately 2.8% of women will be diagnosed with endometrial cancer and another 1.2% will be diagnosed with ovarian cancer at some point during their lifetime. Metastatic disease is commonly seen with high grade carcinomas, such as serous and clear cell types, but may also occur from low grade endometrioid carcinomas (LGEMCAs), and may be the primary presentation of disease. Tissue confirmation is necessary to guide therapy, but performing biopsies might not always be feasible or practical. In these cases, fine needle aspiration (FNA) is a safe and efficient alternative. We describe the cytomorphologic features of metastatic LGEMCAs.