Journal of Pathology and Translational Medicine

Volume 18(2); September 2007

Reviews

Diagnostic Approach to Fine Needle Aspiration in a Breast Lesion.: Gyungyub Gong; Korean J Cytopathol. 2007;18(2):93-99.

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Abstract PDF: Fine needle aspiration has been widely used to diagnose of breast lesions whether they are malignant or not. When applied by experienced and well-trained practitioners, its accuracy can approach that of histopathology, In order to make optimal use of FNAB in breast lesions, this article has reviewed the criteria for sample adequacy, the diagnostic terminology and the cytomorphologic approach to making a diagnosis and avoiding diagnostic pitfalls.

General Cytological Characters of Malignant Breast Lesions.: Jee Yeon Kim; Korean J Cytopathol. 2007;18(2):100-111.

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Abstract PDF: Fine needle aspiration (FNA) cytology of breast disease is recognized to be highly accurate and cost effective, especially when this is used in combination with clinical examination and imaging as part of a triple approach. A probabilistic/categorical approach is used for the classification of breast FNA specimens. Criteria are defined from the perspective of the likelihood of making a definitive diagnosis of cancer on excision. This approach is an accurate way of classifying breast FNA specimens, and this can be reliably applied regardless of the level of experience of the pathologist for interpreting the case. When a definitive diagnosis of malignancy is made, the next step is to determining the specific histologic types of the malignancy according to their cytological features. In order to make an accurate diagnosis of carcinoma and for correct typing a tumor, an adequate, correctly sampled aspirate without any other artifacts is required.

Diagnostic Pitfalls in Breast Fine Needle Aspiration Cytology: False Positive and False Negative.: Kyeongmee Park; Korean J Cytopathol. 2007;18(2):112-118.

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Abstract PDF: Fine needle aspiration cytology (FNAC) has become a highly preferred, minimally invasive diagnostic tool of choice in the diagnosis of a palpable breast mass owing to its sensitivity, specificity, cost-effectiveness, and expediency. Although breast needle biopsies have been widely employed recently due to the increased detection rate of nonpalpable early lesions, the importance of the use of FNAC cannot be underestimated. It comprises part of the diagnostic triad for the breast along with a physical examination and mammography, which together contribute to an increasing diagnostic accuracy. The differential diagnosis of a benign and malignant lesion is of the utmost importance in the diagnosis of breast lesions, and therefore the understanding of the possible diagnostic pitfalls is of great importance.

Original Articles

Diagnostic Value of Urine Cytology in 236 cases; a Comparison of Liquid-Based Preparation and Conventional Cytospin Method.: Sun Lee, Jung Hee Park, Sung Im Do, Youn Wha Kim, Juhie Lee, Sung Gu Chang, Yong Koo Park; Korean J Cytopathol. 2007;18(2):119-125.

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Abstract PDF: Urine cytology is an important screening tool for urinary tract neoplasms. Liquid-based preparation methods, such as ThinPrep(R), have been introduced for non-gynecological samples. We aimed to assess the diagnostic accuracy of liquid-based preparations in urine cytology by comparing the results of the conventional Cytospin preparation method for the same samples. A total of 236 cases subject to urine cytology were enrolled in this study from January 2005 to December 2005. All cases were subjected to cystoscopy and if a malignancy was suspected, a biopsy was performed. Urine cytology slides were made using the ThinPrep(R) preparation method and the conventional Cytospin and/or direct smear method from the individual samples. The results of urine cytology were compared with the final cystoscopic or histological diagnoses. We analyzed the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of both cytology preparation methods. A total of 236 slides made using the liquid based method were satisfactory for slide quality, whereas 5 slides (2.1%) prepared by conventional methods were unsatisfactory because of air-drying, a thick smear, or a bloody or inflammatory background. The ThinPrep(R) method showed 53.1% sensitivity, 92.6% specificity, a 92.6% positive predictive value, a 94.1% negative predictive value and 85.6% accuracy, while the conventional method showed 51% sensitivity, 98.4% specificity, a 92.6% positive predictive value, a 98.4% negative predictive value and 88.6% accuracy. Although the diagnostic values were equivalent between the use of the two methods, the quality of the cytology slides and the time consumed during the microscopic examination for a diagnosis were superior for the ThinPrep(R) method than for the conventional method. In conclusion, our limited studies have shown that the use of the liquid based preparation method is beneficial to improve the quality of slides and reduce the duration for a microscopic examination, but did not show better sensitivity, accuracy and predictive values.

Fine Needle Aspiration Cytology of Palpable Lymph Nodes: A Single Institutional Experience of 1,346 Cases.: Dong Hoon Shin, Kyung Un Choi, Jee Yeon Kim, Hyun Jeong Kang, Ick Doo Kim, Mee Young Sol; Korean J Cytopathol. 2007;18(2):126-132.

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Abstract PDF: The aim of this study was to evaluate the diagnostic value of fine needle aspiration cytology (FNAC) for the assessment of palpable enlarged lymph nodes. The authors reviewed the results of 1,346 FNACs of palpable enlarged lymph nodes performed at Pusan National University Hospital from 1998 to 2004. Of the 1,346 cases, 1,265 (94.0%) were satisfactory and 81 (6.0%) unsatisfactory. Cytologic diagnoses were judged in 488 cases, based on subsequent histologic diagnoses, clinical follow up, or both. Global results for all malignancies (lymphoid and non-lymphoid neoplasms) based on cases with final diagnoses, showed a sensitivity of 87.4% and a specificity of 98.7%. The overall diagnostic accuracy was 93.2%, and the false negative rate reduced from 12.6% to 7.3% when lymphomatous cases were excluded. The annual data for this period showed that the number of diagnostic lymph node biopsies and the rate of inadequately sampled material markedly decreased. Gene rearrangement studies for IgH and TCR gamma were helful in 30 cases. FNAC is a useful initial diagnostic procedure for the evaluation of palpable enlarged lymph nodes. However, the technique should be assisted by the appropriate ancillary studies and by proper interpretation by a cytopathologist.

Analysis of Fine Needle Aspiration Cytology and Ultrasonography of Metastatic Tumors to the Thyroid.: Eun Yoon Cho, Young Lyun Oh; Korean J Cytopathol. 2007;18(2):133-142.

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Abstract PDF: Cytologic diagnosis of the metastatic tumors to the thyroid is important in the management of the patients. There have been rare reports analyzing fine-needle aspiration (FNA) cytology of metastatic tumors to the thyroid. This study examines comprehensive cytologic findings of metastatic tumors to the thyroid with radiologic findings. The FNA cytology slides obtained from 12 cases with metastatic tumors of the thyroid; lung cancer (n=5), tongue and tonsil cancer (n=3), esophageal cancer (n=2), and breast cancer (n=2) were reviewed. Radiological study showed single mass with heterogeneous texture or multiple masses without calcification. Metastatic tumor was easily considered in a differential diagnosis of FNA cytology because they had peculiar cytological features which were not seen in primary thyroid tumor. The smear background varied from predominantly necrotic, bloody, and inflammatory to colloid. The aspirates exhibited a mixture of benign follicular cells and malignant cells in 6 cases. The characteristic cytoplasmic features of the tumor cells, such as keratin, mucin and melanin, were found in 9 cases. Although some cases mimic primary thyroid neoplasm, a careful examination of the cytological characteristics may help cytopathologists to recognize a metastatic tumor in the thyroid by FNA, and may help the clinicians to establish a proper treatment plan.

The Usefulness of SurePath(TM) Liquid-Based Smear in Sono-Guided Thyroid Fine Needle Aspiration; a Comparison of a Conventional Smear and SurePath(TM) Liquid-Based Cytology.: Dong Hoon Kim, Min Kyung Kim, Seoung Wan Chae, Kyoung Bun Lee, Eun Mee Han, Sung Hee Kang, Jin Hee Sohn; Korean J Cytopathol. 2007;18(2):143-152.

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Abstract PDF: Sono-guided fine needle aspiration (FNA) of the thyroid is widely used, but the aspirated samples are typically not well preserved and low cellularity makes diagnosis difficult in many cases. The object of the current study is to evaluate the adequacy and diagnostic accuracy of the use of SurePath(TM) liquid-based cytology (SP-LBC) in the sonoguided fine needle aspiration of the thyroid nodule and to compare its use with that of the use of a conventional smear (CS). A total of 172 sono-guided FNAs of thyroid nodules from April to June, 2006 were prepared by the use of the split method with either SP-LBC or CS; the samples were stained with the use of hematoxylin-eosin (H&E) and Papanicolaou (Pap) stains. A cyto-histological correlation was performed in 69 (30 SP and 39 CS) cases that had been histologically confirmed. The rate of producing unsatisfactory slides by the use of the SP-LBC method (9.3%) was less than that of the use of the CS method (20.9%). The diagnostic accuracy of the SP method (93.3%) was better than that of the CS method (85.3%). The sensitivity and specificity of the SP method (94.4% and 92.3%) was better than that of the CS method (83.3% and 70%), respectively (p<0.05). The CS of sono-guided aspirated specimens had some unavoidable limitations related to inadequate sampling such as a bloody background, low cellularity and an indication that some clinicians smeared many useless slides (averaging four to ten slides), and that most slides showed only blood that included few follicular cells. The SP method resulted in more thinly smeared slides and showed cleaner background and greater cellularity than the use of the CS method. Each follicular cell shows superior nuclear detail, and more distinct cytoplasmic features than with the use of the CS method. SP-LBC appears to be an easy, highly accurate, and reliable cytological method for employ for a diagnostic approach of thyroid disease and thyroid nodules. The SP-LBC method is a suitable alternative to the CS method to overcome diagnostic difficulties.

Case Reports

Voided Urine Cytology of Small Cell Carcinoma of the Urinary Bladder: A Case Report.: Won Ae Lee, Seung Ha Lee; Korean J Cytopathol. 2007;18(2):153-156.

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Abstract PDF: Primary small cell carcinoma of the urinary bladder is an extremely rare but important entity. We experienced a case of small cell carcinoma of the urinary bladder diagnosed by urine cytology. A 59-year-old man presented with gross hematuria and dysuria, and a calcified mass was detected at the left ureterovesical junction by cystoscopy. Abdominal ultrasonography revealed focal wall thickening at the left lateral side of the urinary bladder, and urine cytology findings were of an inflammatory background and atypical small round cells with minute hyperchromatic or pyknotic nuclei, scant cytoplasm, and rare nucleoli. In addition, atypical cells were scattered in an isolated single cell pattern or in small loose clusters with prominent nuclear molding. Subsequent histological and immunohistochemical examinations confirmed a diagnosis of small cell carcinoma.

Fine Needle Aspiration Cytology of Granular Cell Tumor in Breast: A Case Report.: Soo Young Chung, Wo Chul Noh, Min Sun Jin, Seung Sook Lee, Jae Soo Koh; Korean J Cytopathol. 2007;18(2):157-160.

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Abstract PDF: Granular cell tumor (GCT) of the breast is a rare clinical entity, and is believed to be of schwannian origin and to follow a benign clinical course. A 50-year-old woman presented with a slowly growing mass in the right breast. Fine needle aspiration cytology revealed a cellular smear containing isolated or clustered cells showing round to oval nuclei with abundant oncocytic granular cytoplasm. Nuclei showed a fine granular chromatin pattern and occasional small single nucleoli. Cell boundaries were poorly defined, and naked nuclei were frequently found. Histologically, the tumor showed features of typical GCT, and immunohistochemical staining findings strongly supported the diagnosis. The present study demonstrates that GCT of the breast can mimic malignant lesions of breast both clinically and radiologically. The recognition of its cytologic features and suspicion of this lesion would undoubtedly aid the correct diagnosis of mammary GCT.

Metastatic Melanoma Mimicking a Papillary Carcinoma of the Thyroid in Fine Needle Aspiration Cytology: A Case Report.: Young Ok Hong, Jae Hee Suh, Hee Jeong Cha, Hye Jeong Choi, Young Min Kim; Korean J Cytopathol. 2007;18(2):161-164.

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Abstract PDF: Metastasis to the thyroid gland is very rare in clinical practice. We recently encountered a 65-year-old woman who presented with a large thyroid nodule that mimicked the cytologic features of a papillary thyroid carcinoma on fine needle aspiration biopsy (FNAB). Although initially diagnosed as a papillary thyroid carcinoma, a thorough clinical work-up revealed multiple lesions in the bones, liver, and nasal cavity, which were confirmed as metastases of a malignant melanoma. Despite a thorough physical examination, however, the primary skin lesion could not be identified. Although FNAB shows a high degree of accuracy in diagnosing primary thyroid tumors, it is less accurate in diagnosing metastases to the thyroid gland. A thorough clinical history with appropriate immunohistochemical staining assays is necessary for the accurate diagnosis of metastatic malignant melanoma.

Fine Needle Aspiration Cytology of Extranodal Marginal Zone B cell Lymphoma with Abundant Plasma Cells and Eosinophilic Histiocytes in Parotid Gland.: Youngseok Lee, Jungsuk An, Yang Seok Chae, Bom Woo Yeom, Jong Sang Choi, Chul Hwan Kim; Korean J Cytopathol. 2007;18(2):165-169.

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Abstract PDF: The authors present the fine needle aspiration cytology (FNAC) cytologic findings of a case of extranodal marginal zone B cell lymphoma (MZBCL), which featured abundant plasma cells and eosinophilic histiocytes arising in both parotid glands. A 49-year-old female presented with palpable masses in both parotid glands. She had been suffering from systemic lupus erythematosus and rheumatoid arthritis. The lesions were evaluated by FNAC and smears showed a small number of clusters of oncocytic cells with abundant eosinophilic granular cytoplasm and small nuclei, intermixed with small to medium-sized lymphoid cells containing round to lobulated nuclei, which suggested Warthin's tumor. Some of lymphoid cells had a plasmacytoid appearance, and some scattered large cells contained a large amount of eosinophilic cytoplasm. Bilateral superficial parotidectomy was performed and a histopathologic study indicated MZBCL with abundant plasma cells, intermixed with eosinophilic histiocytes. The presence of oncocytic cells and a mixture of lymphoid and plasma cells indicates Warthin's tumor, but the cytologic features of a relatively monotonous small to medium-sized lymphoid infiltrate suggest the possibility of MZBCL in the clinical setting of an FNAC study performed on a patient suffering from a connective tissue disease.

Imprint Cytology of Granular Cell Tumor: A Case Report.: Woo Jung Sung, Joon Hyuk Choi; Korean J Cytopathol. 2007;18(2):170-174.

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Abstract PDF: Granular cell tumor is a rare tumor of the soft tissue and this is characterized by proliferation of large cells with granular appearing eosinophilic cytoplasm. We report the imprint cytologic features of a case of granular cell tumor in the left calf of a 52-year-old woman. Microscopic examination showed moderate cellularity. The tumor cells were arranged both as single cells and in clusters. The cells were large polygonal-shaped and they had small round nuclei with finely granular chromatin and occasionally conspicuous nucleoli. The cytoplasm was abundant eosinophilic and granular. Naked nuclei and spindle-shaped tumor cells were occasionally noted. No mitosis and necrosis were present. The background showed cytoplasmic granular materials. The tumor cells showed positivity for S-100 protein. Ultrastructurally, abundant lysosomes were present in the cytoplasm of the tumor cells.

Fine Needle Aspiration Cytological Findings of Burkitt lymphoma: A Brief Case Report.: Hyang Jeong Jo, Jung Taek Oh, Gang Deuk Kim, Hun Soo Kim; Korean J Cytopathol. 2007;18(2):175-177.

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Abstract PDF: A case of Burkitt lymphoma diagnosed through fine needle aspiration cytology is described. A 66-year-old man presented with lymphadenopathy on the right cervical neck and axillary area. An ultrasonogram and CT scan for the cervical neck showed a multiple variable sized lymphadenopathy with pericapsular invasion and necrotic foci. Fine needle aspiration cytology (FNAC) of the cervical lymph nodes revealed very cellular and necrotic smears consisting of diffusely scattered intermediate monotonous round cells, tingible body macrophages and many mitotic figures. Histological features of the excised lymph nodes showed the classic morphological features of Burkitt lymphoma. Recognition of the characteristic cytological features can suggest the possibility of Burkitt lymphoma.

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