- Email: [email protected]
Upper Gastrointestinal Tract Spindle Cell Neoplasms Diagnosed by Fine Needle Aspiration: A Single Institution Experience of 15 Years
Abstracts
S15
(5), and single cells (11). Plasmacytoid cells (8) and spindles cells (7) were seen commonly. The nuclear findings were anisonucleosis (11), marked nuclear pleomorphism (13) with scattered binucleation and multinucleation, speckled (4) or coarse chromatin (3), nuclear grooves (11), intranuclear pseudoinclusions (5), nuclear molding (2) and prominent nucleoli (1). The cytoplasm was delicate, abundant and granular (14). Naked nuclei (10), nuclear streaking artifact (3) and necrosis (1) were other findings. Conclusion: The interpretation of paragangliomas on FNA specimens can be a diagnostic challenge, especially in unsuspected cases. Since FNA is routinely performed as an initial diagnostic procedure to evaluate mass lesions, the proper recognition of paraganglioma is essential to reach the correct diagnosis and to prevent unnecessary aggressive treatment. In difficult cases, immunohistochemical stains can be particularly helpful to confirm the diagnosis. 21 Does Local Anesthesia for FNA Impact Specimen Adequacy and Cytomorphology? Jacqueline Cuda, BS, SCT(ASCP), Sara Monaco, MD, Liron Pantanowitz, MD University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Introduction: Many cytopathologists do not use local anesthesia when performing a fine needle aspiration (FNA) on palpable lesions because they believe it may impair aspiration and/or alter cytomorphology. We introduced the use of local anesthetic injections in our FNA clinic in 2014. Our aim was to determine if this practice had any impact on cytology specimen adequacy or quality. Materials and Methods: All cytopathologist-performed FNA procedures performed using 1% lidocaine without epinephrine (Hospira, Inc) were retrospectively evaluated over a 9 month time period. Specimen adequacy was evaluated in these cases relative to cases in which no local was administered. Available slides were reviewed grading (from 1 to 3) the overall quality of the cytomorphology, nuclear detail, and cytoplasmic detail of lesional cells. Results: In 28 FNA cases lidocaine was given by 3 different pathologists. The FNA sites included 20 (72%) soft tissue lesions, 6 (21%) lymph nodes and 2 (7%) fat pad aspirations. The specimen adequacy rate was equivalent to that for FNA cases performed without lidocaine during the same time frame (Table 1). The overall morphology in these cases was graded 2.7, nuclear detail graded 2.1 and cytoplasmic detail graded 1.8. In 9 (32%) cases there were cytoplasmic vacuoles, and in 5 (18%) cases nuclei were smudged and/or had vacuoles. In 4 cases the background had vacuoles. Conclusion: The majority of specimens were of adequate cellularity irrespective of whether cytopathologists gave local anesthesia prior to performing a FNA. While lidocaine did not appear to markedly impair the overall cytomorphology of aspirated material, in some cases vacuolization and smudgy nuclei were noted. Therefore, local anesthesia can be administered to patients without causing serious deleterious effects on the quality of FNA specimens, while improving the patient’s FNA experience.
Table 1
FNA adequacy with/without local
22 Upper Gastrointestinal Tract Spindle Cell Neoplasms Diagnosed by Fine Needle Aspiration: A Single Institution Experience of 15 Years Kelsey McHugh, MD, Shelley Odronic, MD, Amber Smith, MD, Ghada Aramouni, BS, CT(ASCP), Bridgette Springer, CT(ASCP), Ashley Kolosiwsky, BS, Jordan Reynolds, MD Cleveland Clinic, Cleveland, Ohio Introduction: Spindle cell lesions constitute <1% of fine needle aspirations (FNA) of the upper gastrointestinal (GI) tract. The differential diagnosis is
challenging and includes gastrointestinal stromal tumor (GIST) in addition to other neoplastic and non-neoplastic processes. We describe a large case series of all SCN of the upper GI tract diagnosed by FNA and characterize the cytomorphologic findings. Material and Methods: The pathology database was retrospectively searched for all FNAs of the upper GI tract tract that demonstrated a SCN from 1/1/2000 to 10/1/2014. Surgical pathology was the gold standard for final diagnosis. We reviewed available cytology slides to assess for cellularity, architectural patterns, and nuclear features. JMP Pro 10 (SAS, Cary, IN) was used to perform statistical analysis. Results: Ninety-eight patients had a SCN on FNA of the upper GI tract tract over the 15-year study period. Eighty-seven cases (88.7%) were obtained using endoscopic ultrasound (EUS)-guided FNA. Twenty-five cases (25.5%) had immunohistochemical characterization. Twentythree of 26 cases (88.5%) had concurrent non-diagnostic biopsies. Sixty-nine patients (70%) had a definitive pathologic diagnosis (65 neoplastic and 4 non-neoplastic, Table 1). Although there were no statistically significant morphologic criteria suggestive of GIST or to determine a benign from malignant SCN, FNA from malignant neoplasms tended to be moderately to highly cellular with inconspicuous nucleoli compared to benign and non-neoplastic cases, which had predominately low cellularity. Conclusion: Among cases with definitive final diagnoses, FNA demonstrated high specificity (94.2%) for the diagnosis of SCN of the GI tract, with 4 cases that were not SCN on follow-up. Although some cytomorphologic criteria suggest a malignant over benign GI tract SCN, the specific diagnosis relies on collaboration of clinical, radiologic, cytomorphologic, and immunohistochemical data.
S16
Abstracts
23 Diagnostic Utility of Arborizing Stromal Meshwork Fragments in Mucinous Tumors Liron Pantanowitz, MD, Natalie Perlov, Joshua Pantanowitz, Stell Patadji, MD, Sara Monaco, MD University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Introduction: Differentiating mucin associated with mucinous adenocarcinoma from contaminating mucus during endobronchial ultrasound-guided (EBUS) fine needle aspiration (FNA) can be challenging. The finding of arborizing stromal meshwork fragments (ASMFs) has been proposed as a useful clue to the presence of a mucinous neoplasm. Our aim was to review FNA cases from mucinous tumors to determine the diagnostic utility of ASMFs. Material and Methods: Archival FNA cases (NZ40) were reviewed (Diff-Quik smears) of adenocarcinomas with mucinous features, including primary tumors (17 cases) and metastases (12 cases) of gastrointestinal (GI) and lung origin. FNAs of cystic mucinous neoplasms (3 cases) and 8 control cases with mucin contamination were included. FNAs were procured by image-guidance (17 cases), endoscopic ultrasound (EUS; 15 cases) and EBUS (8 cases). All cases were reviewed for ASMFs, which were defined as metachromatic, spidery extensions with frayed edges within a background of mucinous material. Results: ASMFs were identified in 4 (10% of cases, 14% of adenocarcinomas) cases (2 male, 2 female, average age 67 years) of metastatic GI mucinous adenocarcinoma in various locations (liver, lymph node, lung and bone), but absent in mucin contamination. ASMFs with Diff-Quik smears were magenta colored compared to background blue mucin (Figure A). Histologically, they corresponded to intervening stroma between dissecting mucin in the tumor (Figure B). Non-arborizing desmoplastic stroma (Figure C), inspissated mucus (Figure D), crush artifact in thick smears, and cartilage fragments were morphologically similar to ASMFs.
24 Adrenal Fine Needle Aspiration at a Large Tertiary Academic Medical Center Kenneth Hennrick, MD, Anna Nam, MD, Thomas Dilcher, BS, June Koizumi, MD, Theresa Scognamiglio, MD, Brian Robinson, MD, Tamar Giorgadze, MD, PhD Weill Cornell Medical College, New York, New York Introduction: Adrenal fine needle aspiration (FNA) is a common method of diagnosis of adrenal lesions. Besides being relatively safe and fast, adrenal FNA has a high sensitivity and specificity. Definitive differentiation between primary adrenal neoplasm and metastatic malignancy (MM) involving the adrenal allow for appropriate triage and surgical management of patients. Materials and Methods: We performed a computerized search for consecutive adrenal FNAs performed at our institution from 20112015. In total 52 cases were identified. FNAs were reviewed and when possible compared with concurrent surgical pathology biopsy and/or subsequent resection. Imaging and clinical characteristics were documented. Results: The mean patient age was 67 years (range 47-90 years). There were 26 men and 26 female patients. Interestingly, left sided lesions (nZ34) were more common than right sided lesions (nZ18). Biopsies were performed under CT imaging guidance in 44 cases and under ultrasound guidance in 8 cases. The mean size of the lesions by imaging was 2.6 cm (range 0.7 e 10.0 cm). All cases with MM were morphologically correlated with primary sites or confirmed by immunohistochemistry . (Table 1) demonstrates clinico-pathological data and figures 2-4 selected adrenal lesions from our case series: oncocytic pheochromocytoma (FIGURE 2), metastatic (clear cell) renal cell carcinoma (FIGURE 3), and metastatic squamous cell carcinoma from esophageal primary (FIGURE 4). FNA diagnoses had a high concordance
Conclusion: These data show that ASMFs may be encountered in some (14%) cases of adenocarcinoma with mucinous differentiation. When present, ASMFs can be diagnostically helpful to differentiate adenocarcinoma with mucinous features from contaminating mucus. ASMFs need to be distinguished from mimics such as desmoplastic fibrous stroma, cartilage and dense mucus.
Arborizing stromal meshwork fragments and mimics
Table 1
S15
(5), and single cells (11). Plasmacytoid cells (8) and spindles cells (7) were seen commonly. The nuclear findings were anisonucleosis (11), marked nuclear pleomorphism (13) with scattered binucleation and multinucleation, speckled (4) or coarse chromatin (3), nuclear grooves (11), intranuclear pseudoinclusions (5), nuclear molding (2) and prominent nucleoli (1). The cytoplasm was delicate, abundant and granular (14). Naked nuclei (10), nuclear streaking artifact (3) and necrosis (1) were other findings. Conclusion: The interpretation of paragangliomas on FNA specimens can be a diagnostic challenge, especially in unsuspected cases. Since FNA is routinely performed as an initial diagnostic procedure to evaluate mass lesions, the proper recognition of paraganglioma is essential to reach the correct diagnosis and to prevent unnecessary aggressive treatment. In difficult cases, immunohistochemical stains can be particularly helpful to confirm the diagnosis. 21 Does Local Anesthesia for FNA Impact Specimen Adequacy and Cytomorphology? Jacqueline Cuda, BS, SCT(ASCP), Sara Monaco, MD, Liron Pantanowitz, MD University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Introduction: Many cytopathologists do not use local anesthesia when performing a fine needle aspiration (FNA) on palpable lesions because they believe it may impair aspiration and/or alter cytomorphology. We introduced the use of local anesthetic injections in our FNA clinic in 2014. Our aim was to determine if this practice had any impact on cytology specimen adequacy or quality. Materials and Methods: All cytopathologist-performed FNA procedures performed using 1% lidocaine without epinephrine (Hospira, Inc) were retrospectively evaluated over a 9 month time period. Specimen adequacy was evaluated in these cases relative to cases in which no local was administered. Available slides were reviewed grading (from 1 to 3) the overall quality of the cytomorphology, nuclear detail, and cytoplasmic detail of lesional cells. Results: In 28 FNA cases lidocaine was given by 3 different pathologists. The FNA sites included 20 (72%) soft tissue lesions, 6 (21%) lymph nodes and 2 (7%) fat pad aspirations. The specimen adequacy rate was equivalent to that for FNA cases performed without lidocaine during the same time frame (Table 1). The overall morphology in these cases was graded 2.7, nuclear detail graded 2.1 and cytoplasmic detail graded 1.8. In 9 (32%) cases there were cytoplasmic vacuoles, and in 5 (18%) cases nuclei were smudged and/or had vacuoles. In 4 cases the background had vacuoles. Conclusion: The majority of specimens were of adequate cellularity irrespective of whether cytopathologists gave local anesthesia prior to performing a FNA. While lidocaine did not appear to markedly impair the overall cytomorphology of aspirated material, in some cases vacuolization and smudgy nuclei were noted. Therefore, local anesthesia can be administered to patients without causing serious deleterious effects on the quality of FNA specimens, while improving the patient’s FNA experience.
Table 1
FNA adequacy with/without local
22 Upper Gastrointestinal Tract Spindle Cell Neoplasms Diagnosed by Fine Needle Aspiration: A Single Institution Experience of 15 Years Kelsey McHugh, MD, Shelley Odronic, MD, Amber Smith, MD, Ghada Aramouni, BS, CT(ASCP), Bridgette Springer, CT(ASCP), Ashley Kolosiwsky, BS, Jordan Reynolds, MD Cleveland Clinic, Cleveland, Ohio Introduction: Spindle cell lesions constitute <1% of fine needle aspirations (FNA) of the upper gastrointestinal (GI) tract. The differential diagnosis is
challenging and includes gastrointestinal stromal tumor (GIST) in addition to other neoplastic and non-neoplastic processes. We describe a large case series of all SCN of the upper GI tract diagnosed by FNA and characterize the cytomorphologic findings. Material and Methods: The pathology database was retrospectively searched for all FNAs of the upper GI tract tract that demonstrated a SCN from 1/1/2000 to 10/1/2014. Surgical pathology was the gold standard for final diagnosis. We reviewed available cytology slides to assess for cellularity, architectural patterns, and nuclear features. JMP Pro 10 (SAS, Cary, IN) was used to perform statistical analysis. Results: Ninety-eight patients had a SCN on FNA of the upper GI tract tract over the 15-year study period. Eighty-seven cases (88.7%) were obtained using endoscopic ultrasound (EUS)-guided FNA. Twenty-five cases (25.5%) had immunohistochemical characterization. Twentythree of 26 cases (88.5%) had concurrent non-diagnostic biopsies. Sixty-nine patients (70%) had a definitive pathologic diagnosis (65 neoplastic and 4 non-neoplastic, Table 1). Although there were no statistically significant morphologic criteria suggestive of GIST or to determine a benign from malignant SCN, FNA from malignant neoplasms tended to be moderately to highly cellular with inconspicuous nucleoli compared to benign and non-neoplastic cases, which had predominately low cellularity. Conclusion: Among cases with definitive final diagnoses, FNA demonstrated high specificity (94.2%) for the diagnosis of SCN of the GI tract, with 4 cases that were not SCN on follow-up. Although some cytomorphologic criteria suggest a malignant over benign GI tract SCN, the specific diagnosis relies on collaboration of clinical, radiologic, cytomorphologic, and immunohistochemical data.
S16
Abstracts
23 Diagnostic Utility of Arborizing Stromal Meshwork Fragments in Mucinous Tumors Liron Pantanowitz, MD, Natalie Perlov, Joshua Pantanowitz, Stell Patadji, MD, Sara Monaco, MD University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Introduction: Differentiating mucin associated with mucinous adenocarcinoma from contaminating mucus during endobronchial ultrasound-guided (EBUS) fine needle aspiration (FNA) can be challenging. The finding of arborizing stromal meshwork fragments (ASMFs) has been proposed as a useful clue to the presence of a mucinous neoplasm. Our aim was to review FNA cases from mucinous tumors to determine the diagnostic utility of ASMFs. Material and Methods: Archival FNA cases (NZ40) were reviewed (Diff-Quik smears) of adenocarcinomas with mucinous features, including primary tumors (17 cases) and metastases (12 cases) of gastrointestinal (GI) and lung origin. FNAs of cystic mucinous neoplasms (3 cases) and 8 control cases with mucin contamination were included. FNAs were procured by image-guidance (17 cases), endoscopic ultrasound (EUS; 15 cases) and EBUS (8 cases). All cases were reviewed for ASMFs, which were defined as metachromatic, spidery extensions with frayed edges within a background of mucinous material. Results: ASMFs were identified in 4 (10% of cases, 14% of adenocarcinomas) cases (2 male, 2 female, average age 67 years) of metastatic GI mucinous adenocarcinoma in various locations (liver, lymph node, lung and bone), but absent in mucin contamination. ASMFs with Diff-Quik smears were magenta colored compared to background blue mucin (Figure A). Histologically, they corresponded to intervening stroma between dissecting mucin in the tumor (Figure B). Non-arborizing desmoplastic stroma (Figure C), inspissated mucus (Figure D), crush artifact in thick smears, and cartilage fragments were morphologically similar to ASMFs.
24 Adrenal Fine Needle Aspiration at a Large Tertiary Academic Medical Center Kenneth Hennrick, MD, Anna Nam, MD, Thomas Dilcher, BS, June Koizumi, MD, Theresa Scognamiglio, MD, Brian Robinson, MD, Tamar Giorgadze, MD, PhD Weill Cornell Medical College, New York, New York Introduction: Adrenal fine needle aspiration (FNA) is a common method of diagnosis of adrenal lesions. Besides being relatively safe and fast, adrenal FNA has a high sensitivity and specificity. Definitive differentiation between primary adrenal neoplasm and metastatic malignancy (MM) involving the adrenal allow for appropriate triage and surgical management of patients. Materials and Methods: We performed a computerized search for consecutive adrenal FNAs performed at our institution from 20112015. In total 52 cases were identified. FNAs were reviewed and when possible compared with concurrent surgical pathology biopsy and/or subsequent resection. Imaging and clinical characteristics were documented. Results: The mean patient age was 67 years (range 47-90 years). There were 26 men and 26 female patients. Interestingly, left sided lesions (nZ34) were more common than right sided lesions (nZ18). Biopsies were performed under CT imaging guidance in 44 cases and under ultrasound guidance in 8 cases. The mean size of the lesions by imaging was 2.6 cm (range 0.7 e 10.0 cm). All cases with MM were morphologically correlated with primary sites or confirmed by immunohistochemistry . (Table 1) demonstrates clinico-pathological data and figures 2-4 selected adrenal lesions from our case series: oncocytic pheochromocytoma (FIGURE 2), metastatic (clear cell) renal cell carcinoma (FIGURE 3), and metastatic squamous cell carcinoma from esophageal primary (FIGURE 4). FNA diagnoses had a high concordance
Conclusion: These data show that ASMFs may be encountered in some (14%) cases of adenocarcinoma with mucinous differentiation. When present, ASMFs can be diagnostically helpful to differentiate adenocarcinoma with mucinous features from contaminating mucus. ASMFs need to be distinguished from mimics such as desmoplastic fibrous stroma, cartilage and dense mucus.
Arborizing stromal meshwork fragments and mimics
Table 1