Initial Fine Needle Aspiration Cytology Research Articles

SAT454 Repetition Of Fine Needle Aspiration Cytology After An Initial Nondiagnostic Result: Does An Optimal Timing Exist?

Abstract Disclosure: I. Cosme: None. E.L. Nobre: None. M.J. Bugalho: None. Background: The optimal time to repeat a fine-needle aspiration cytology (FNAC) of a thyroid nodule, after a nondiagnostic (ND) result, is not established. It has been proposed to wait at least 3 months for a 2nd FNAC, in order to mitigate the possible inflammatory cytological changes induced by a previous FNAC. This study aimed to evaluate whether the time between 2 consecutive FNACs, influences the final cytological result. We analysed the occurrence of ND or atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) in the 2nd FNAC, in different repetition time intervals. Methods: Retrospective study (2017-2020) including thyroid nodules with a first ND FNAC, submitted to a 2nd FNAC. All FNACs were ultrasound-guided. Demographic data, time interval between FNACs and their results were collected. The 2nd FNAC results were analysed according to FNACs´ repetition interval. We considered 2 intervals: ≤ vs > 3 months and ≤ vs >6 months after the initial FNAC. The 2nd FNAC results were classified as ND, AUS/FLUS or diagnostic (including the other Bethesda FNAC categories). Results: Included 190 nodules (190 patients, 82.1% women, mean age 60±13.7 years) with a 1st ND FNAC submitted to a 2nd FNAC. The 2nd FNAC result remained ND in 63 cases, was AUS/FLUS in 9 and diagnostic in 118 (benign in 116 cases, follicular neoplasm/suspicious follicular neoplasm in 1 and malignant in 1 case). There were no statistical differences in 2nd FNAC result performed ≤3 months (13 ND, 2 AUS/FLUS, 19 diagnostic) vs >3 months (50 ND, 7 AUS/FLUS, 99 diagnostic) - p=0.71. Considering a wider time interval between FNACs, there were also no statistical differences in the 2nd FNAC result: ≤ 6 months (32 ND, 3 AUS/FLUS, 59 diagnostic) vs >6 months (31 ND, 6 AUS/FLUS, 59 diagnostic) - p=0.61. Conclusions: The time interval between FNACs was not relevant to the final cytological result. Early FNAC repetition did not increase the cases of ND or AUS/FLUS. Presentation: Saturday, June 17, 2023

P383 ‘It's not Fungus, its Nocardia’—an elementary diagnostic challenge for draining sinus on abdominal wall (rare): a case report

Poster session 3, September 23, 2022, 12:30 PM - 1:30 PMIntroductionA rare finding of abdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by Nocardia brasiliensis.MethodsHistory: A 22-year-old presented to the Dermatology OPD with complaints of swelling and tenderness and discharging sinuses with no granules around the periumbilical region in the lower abdominal area for three years. His initial fine needle aspiration cytology specimen report was inconclusive. He received anti-Kochs treatment based on a positive Montoux test and family history from outside the hospital.Initially punch biopsy samples were sent for fungal processing to our laboratory which was inconclusive. Repeat pus aspirate and punch biopsy samples were subjected to conventional techniques. The sample was inoculated on Sabouraud's Dextrose agar, Brain heart Infusion agar, and Lowenstein-Jensen media. Direct Smear was subjected to Gram stain and Modified Zeihl Neelson stain with 1% Sulfuric acid as decoloriser.ResultsOn Gram stain, Gram-positive filamentous bacilli against a background of pus cells in pus aspirate only (not in punch biopsy specimens).Modified Zeihl Neelson stain with 1% Sulfuric acid decoloriser was performed on all three samples. Beaded acid-fast filamentous bacilli with plenty of pus cells in the background were seen in pus aspirate only (not in punch biopsy specimens).No fungal elements were observed on the 20% KOH mount.Clinicians were notified immediately with the provisional report of possible Actinomycetoma due to Nocardia sp.Growth was observed within 9 days on SDA as well as LJ. It was a chalky white, dry colony to begin with that turned orangish-yellow in another week's time. Smear from the colony showed Gram-positive filamentous bacilli which on Modified ZN Smear were acid-fast filamentous beaded bacilli. The isolate was identified as Nocardia species. This was further confirmed as Nocardia brasiliensis by MALDI-TOF.On admission, the patient was initially started on Inj. Amikacin and then changed to Modified Raman regime of double dose Cotrimoxazole and Gentamicin. His lesions started showing improvement over 2 weeks of in-patient treatment. He was discharged on oral treatment thereafter.ConclusionAbdominal wall clinical presentation of persistent progressive tumefaction with draining sinus with no granules caused by N. brasiliensis is a rare clinical entity as Mycetoma. The differential diagnosis would lead to either bacterial or fungal etiology or neoplasia.Delay in correct diagnosis led to the chronicity of the clinical presentation with inappropriate therapy.For a chronic destructive debilitating infective mycetoma presentation, appropriate microbiological diagnostics become essential to have early correct detection with proper sampling technique to guide the appropriate therapy as per the causative pathogen.

Repeat thyroid FNAC: Inter-observer agreement among high- and low-volume centers in Naples metropolitan area and correlation with the EU-TIRADS.

Our institution (University Hospital “L. Vanvitelli” - Naples, Italy) is a high-volume (HV) center in Naples metropolitan area and many patients are referred there to repeat thyroid fine-needle aspiration cytology (FNAC) after initial FNAC performed in low-volume institutions (LV). The aims of the study were to 1) examine the inter-observer agreement between HV and LV institutions according to the Italian thyroid cytology system, and 2) explore how the discordant FNAC reports were distributed in the European Thyroid Imaging and Reporting Data System (EU-TIRADS) categories. All consecutive cases of repeat FNAC performed at University Hospital “L. Vanvitelli” from January 2016 to December 2021 were retrospectively reviewed. Fleiss’ kappa (κ) was used to assess the inter-observer agreement, and categorical variables were compared by chi-square testing. P < 0.05 was considered statistically significant. A total of 124 nodules from 124 adults (mean age 49 years; mean maximum diameter 19 mm) were evaluated. Initial FNAC reports at LV were: 4 (3.2%) TIR1c, 64 (51.6%) TIR2, 48 (38.7%) TIR3A, 8 (6.5%) TIR3B, 0 TIR4, 0 TIR5. The overall FNAC reports were significantly different between the LV and HV institutions. At repeated FNAC, cytological diagnosis was unchanged in 64 (51.6%) cases including TIR2 and TIR3A results. A downgraded FNAC diagnosis (i.e., TIR2 vs TIR3A, TIR2 vs TIR3B) was observed in 36 (29%) nodules. An upgraded FNAC diagnosis (i.e., TIR3B vs TIR2, TIR3B vs TIR3A, TIR4 vs TIR3A, TIR5 vs TIR2, TIR5 vs TIR3B) was recorded in 24 (19.4%) nodules. The weighted inter-observer agreement between LV and HV institutions was poor (κ=0.133). Changed FNAC results were significantly (p=0.0023) more frequent in nodules at intermediate/high-risk (i.e., EU-TIRADS 4/5) than in those at no/low risk (EU-TIRADS 2/3) [i.e., 32/48 (66.7%) and 28/76 (36.8%), respectively]. Downgraded FNAC results were significantly more frequent in EU-TIRADS 2/3 (p=0.001) while upgraded FNAC were present only in EU-TIRADS 4/5 (24/24, 100.0%). The inter-observer agreement among LV and HV thyroid services was poor. The EU-TIRADS 4 and 5 categories included all the malignant nodules with FNAC results reclassified as higher risk (i.e., TIR3B-TIR4-TIR5) by the high-volume cytology service.

Clinical utility of histogram analysis of grayscale sonograms in assessing sonographic suspicious malignant thyroid nodules.

BackgroundWhen sonographic suspicious malignant thyroid nodules initially proven to be inconsistent by aspiration, repeat fine-needle aspiration cytology (FNAC) is commonly recommended. Although FNAC is simple and reliable, it is also an invasive operation with inevitable false negative results. To determine which sonographic features and histogram parameters based on gray-scale ultrasonic images need repeat aspiration.MethodsAll of the nodules were suspicious for malignancy by preoperative ultrasound (US), and their initial FNAC findings indicated Bethesda category II, or III. Histogram analyses were performed for gray-scale ultrasonic images. Mean, variance, skewness, kurtosis, percentiles (1st, 10th, 50th, 90th, 99th), and sonographic features were compared between pathological benign nodules and malignant ones. Thereafter, receiver operator characteristic (ROC) curves were analyzed for the valuable indicators.ResultsOne hundred and nineteen consecutive patients with 123 histopathologically diagnosed focal thyroid nodules were included in the cohort. The factors associated with malignancy were taller-than-wide shape [odds ratio (OR) =15.165; 95% confidence interval (CI): 3.157–72.854], irregular margins (OR =11.492; 95% CI: 1.747–75.573), microcalcifications (OR =5.107; 95% CI: 1.455–17.927) and skewness (OR =25.800; 95% CI: 1.034–76.422). The skewness of malignant thyroid nodules is higher than that of benign thyroid nodules and has an area under the curve (AUC) of 0.776 in the diagnosis.ConclusionsFor thyroid nodules suspicious on US but not on cytology, skewness, together with taller-than-wide shape, irregular margins and microcalcifications might be a promising marker for clinicians to perform repetitive FNACs.

Tuberculosis Lymphadenitis in a Well Managed Case of Sarcoidosis

Differentiation between tuberculosis (TB) and sarcoidoisis is sometimes extremely difficult. Sequential occurrence of sarcoidosis and TB in the same patient is uncommon. We present the case of a young man, with a proven diagnosis of sarcoidosis who later developed TB after completion of treatment for sarcoidosis. A 32-year-old male patient presented with low-grade fever since two months. Physical examination revealed cervical lymphadenopathy. Initial fine needle aspiration cytology (FNAC) of the cervical lymph node was suggestive of granulomatous inflammation; the chest radiograph was normal. Repeat FNAC from the same lymph node was suggestive of reactive lymphoid hyperplasia. The patient was treated with antibiotics and followed-up. He again presented with persistence of fever and lymphadenopathy and blurring of vision. Ophthalmological examination revealed uveitis, possibly due to a granulomatous cause. His repeat Mantoux test again was non-reactive; serum angiotensin converting enzyme (ACE) levels were raised. This time an excision biopsy of the lymph node was done which revealed discrete, non-caseating, reticulin rich granulomatous inflammation suggestive of sarcoidosis. The patient was treated with oral prednisolone and imporved symptomatically. Subsequently, nearly nine months after completion of corticosteroid treatment, he presented with low-grade, intermittent fever and a lymph node enlargement in the right parotid region. FNAC from this lymph node showed caseating granulomatous inflammation and the stain for acid-fast bacilli was positive. He was treated with Category I DOTS under the Revised National Tuberculosis Control Programme and improved significantly. The present case highlights the need for further research into the aetiology of TB and sarcoidosis.

Cytomorphology of Castleman’s Disease of Parotid Gland: Pitfalls and Diagnostic Dilemma in a Young Adult

Fine needle aspiration cytology (FNAC) is an easy, effective diagnostic tool that makes it the procedure of choice for all accessible swellings in the body. Castleman’s disease (CD) may present as unicentric or multicentric swelling hence is subjected to FNAC very frequently. CD mainly presents mediastinal nodes, nonetheless when present in salivary glands such as parotid, it is often diagnosed clinically as a salivary gland tumor. However, due to lack of adequate literature on its cytological features and non- specific radiological findings, the condition is often misdiagnosed. There are few case series on cytological features of CD and even fewer cases of CD in the parotid gland. Histopathology serves as the gold standard of diagnosis for CD. In superficial locations, these swellings are easily subjected to direct fine needle aspiration cytology (FNAC). Radiologically guided FNA can be performed for deeper locations. Hence, the authors present a case of 19 year old male patient, who presented with a small superficial, preauricular swelling for FNAC. The initial FNAC yielded no conclusive opinion. however a repeat FNAC and histopathological examination led to the final diagnosis. This case report aims to highlight the cytomorphological and histopathological features of CD in the Parotid gland and various difficulties encountered in making the final diagnosis.

Comparison of core-needle biopsy and repeat fine-needle aspiration for thyroid nodules with inconclusive initial cytology.

We aimed to compare the efficacy of ultrasound-guided core-needle biopsy (CNB) with repeat fine-needle aspiration (rFNA) cytology in thyroid nodules with inconclusive results in initial fine-needle aspiration cytology. We studied 402 patients who required a repeat biopsy of thyroid nodules using ultrasound-guided CNB (n = 192) or rFNA (n = 210) because of inconclusive results in initial FNA, corresponding to categories I, III, and IV of the Bethesda System for Reporting Thyroid Cytopathology. If repeat biopsy results were benign (category II), suspicious malignancy (category V), or malignancy (category VI), they were defined as "diagnostic results". The diagnostic yield and performances of repeat biopsy were analyzed and compared between the rFNA and CNB groups. The diagnostic results were obtained significantly higher in the CNB group than in the rFNA group (72.4% vs. 52.4%; P < 0.001). In the subgroup analysis, the diagnostic results were significantly higher in the CNB group than in the rFNA group for patients of categories I and III (P < 0.001 in both) in initial FNA. However, in patients with category IV nodules, there were no significant differences in diagnostic results between the two groups (P = 0.46). Compared to rFNA, ultrasound-guided CNB is useful and effective as a repeat biopsy option for thyroid nodules with non-diagnostic results (category I) and atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) (category III) in initial FNA.

Pattern of pediatric fine needle aspiration cytology and its utility in management of head and neck swellings in a tertiary hospital in northwestern Nigeria

Childhood malignancies have emerged as an important cause of morbidity and mortality globally. Diagnosis need to be accurate and fast to reduce this. Fine Needle Aspiration Cytology (FNAC) is an accepted modality employed in the diagnosis of adult and pediatric tumors. This study aims to review the pattern of pediatric FNAC from all sites done over a 10-year period, and its utility in the management of head and neck swellings. Records of all pediatric FNAC within the 10-year study period were retrospectively retrieved and analyzed. Data regarding age, sex, site of biopsy and FNAC diagnoses were extracted. Subsequent histologic diagnoses from the head and neck region were correlated with initial FNAC diagnoses from the same region. Data were presented in frequencies and percentages in tabular form. Accuracy, sensitivity, specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) of head and neck lesions were calculated. A total of 301 pediatric FNAC were recorded. There were 160 (53.8%) males and 141 (46.2%) females with a M: F ratio of 1.1:1. The average age was 7.2 ± 3.9 years. The highest frequency of 134 (44.5%) was seen in the 5-10 years age group. Benign cytological diagnoses were rendered in 243 (80.7%) while the remaining 58 (19.3%) were malignant. Of the total, 244 FNAC were from head and neck Swellings, 209(80.7%) were benign while the remaining were malignant. Sixty-two (62) cases of head and neck FNAC had subsequent histologic tissue diagnoses (considered the gold standard) which were compared with prior FNAC results. FNAC of the head and neck showed an accuracy 82.1%, sensitivity of 53.0%, specificity of 93.3%, PPV and NPV of 75.0% and 84.0% respectively. FNAC is an easy, fast, cheap and minimally invasive screening tool that is accurate for diagnosis in the management of pediatric head and neck swellings in our setting.

Should we perform fine needle aspiration cytology of subcentimetre thyroid nodules? A retrospective review of local practice.

In light of the rising rate of incidentally detected subcentimetre thyroid nodules due to improved surveillance and diagnostic imaging, the decision of whether to perform fine needle aspiration cytology is increasingly pertinent. We aim to assess (1) the sampling adequacy of fine needle aspiration cytology, (2) malignancy rate, (3) thyroidectomy rate and (4) diagnostic accuracy of fine needle aspiration cytology. A total of 245 subcentimetre nodules in 220 patients underwent fine needle aspiration cytology between 2011 and 2014. Medical records were reviewed for cytology results, subsequent management and histopathological results in the event the patient underwent thyroidectomy. Sampling adequacy was calculated as the percentage of diagnostic results (Bethesda II-VI). Malignancy rate was defined as the percentage of Bethesda IV-VI diagnoses. Amongst patients with Bethesda IV-VI diagnoses who underwent thyroidectomy, their cytology reports were correlated with post-operative histopathological findings. The sampling adequacy of fine needle aspiration cytology was 77.1%. Malignancy rate (Bethesda IV-VI) was 9.7%. The respective malignancy rates in the < 5 mm nodule group and ≥ 5 mm nodule group were 6.67 and 10.0%. In total, 79.2% (19/24) of the malignant nodules underwent surgical excision. The rest declined surgery and/or were lost to follow-up. Amongst the malignant nodules which were surgically resected, 84.2% (16/19) had definitive malignant histology. Five of these demonstrated multifocal carcinoma and/or extrathyroidal extension of carcinoma on histology. Initial fine needle aspiration cytology and subsequent histopathological diagnoses matched in all cases except for three that had false-positive fine needle aspiration cytology results. Majority of our patients with suspicious cytology results subsequently underwent thyroidectomy, notwithstanding the relatively lower diagnostic accuracy of fine needle aspiration cytology in subcentimetre thyroid nodules.

FNAC Versus Core Needle Biopsy: A Comparative Study in Evaluation of Palpable Breast Lump.

Breast carcinoma is the most common malignant tumour and the leading cause of carcinoma death in women in world. The main purpose of FNAC or CNB of breast lumps is to confirm cancer preoperatively and to avoid unnecessary surgery in specific benign conditions. The objective of the study was to compare between Fine Needle Aspiration Cytology (FNAC) and Core Needle Biopsy (CNB) in the diagnosis of breast carcinoma with final histological diagnosis from excision specimen as it is gold standard. A prospective study was done on 50 cases. Patients undergoing all three procedures (Fine Needle Aspiration Cytology and Core Needle Biopsy done at Department of Pathology; subsequent excision surgeries done at Department of General Surgery) were selected. May Grunwald Giemsa (MGG) and Papaniculou (PAP) staining were performed on cytology smears. Haematoxylin and Eosin (H&E) staining was done on both the CNB and tissue specimens obtained from subsequent excision surgeries to see the histological features. FNAC showed sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 69%, 100%, 100%, 38.1%, and 74% respectively in diagnosing carcinoma. CNB had sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 88.3%, 100%, 100%, 53.3% and 86%. Both FNAC and CNB showed statistically significant correlation with confirmatory HPE of excision specimen (p-value <0.05) in the diagnosis of breast carcinoma. Fine needle aspiration cytology (FNAC) is a rapid, less complicated, economical, reliable and relevant method for the preoperative pathological diagnosis of breast carcinoma in a developing nation like ours. If the initial FNAC is inadequate, core needle biopsy (CNB) can be a useful second line method of pathological diagnosis in order to minimize the chance of missed diagnosis of breast cancer.

Tuberculosis sarcoidosis: case study from a tribal district

Sarcoidosis is an under diagnosed disease in India, probably due to the close resemblance to tuberculosis and the lack of awareness. Sarcoidosis is a multiorgan granulomatous disease, the most common head and neck manifestation of which is cervical lymphadenopathy is most common. Differentiation between tuberculosis (TB) and sarcoidoisis is sometimes extremely difficult. Sequential occurrence of sarcoidosis and TB in the same patient is uncommon. We present the case of a young woman, with a proven diagnosis of sarcoidosis and TB. A 32 year old female patient presented with low-grade fever since nine months. Physical examination revealed cervical lymphadenopathy. Initial fine needle aspiration cytology (FNAC) of the cervical lymph node was suggestive of granulomatous inflammation, the chest radiograph and high resolution computed tomography revealed no abnormal findings. The patient was treated with antibiotics and followed-up. She again presented with persistence of fever and lymphadenopathy and difficulty in swallowing. Her repeat Monteux test again was non-reactive; serum angiotensin converting enzyme (ACE) levels were raised. The local quack had some operation in that cervical lymph node present in anterior and posterior triangle of neck which leads to sinus formation from oesophagus. FNAC from this lymph node showed caseating granulomatous inflammation and the stain for acid-fast bacilli was positive. She was treated with Category I DOTS under the Revised National Tuberculosis Control Programme and improved significantly. The present case highlights the need for further research into the aetiology of TB and sarcoidosis.

A comparison of lymphocytic thyroiditis with papillary thyroid carcinoma showing suspicious ultrasonographic findings in a background of heterogeneous parenchyma.

Purpose:The aim of this study was to compare ultrasonographic features in patients with lymphocytic thyroiditis (LT) and papillary thyroid carcinoma (PTC) having suspicious thyroid nodule(s) in a background of heterogeneous parenchyma and to determine the clinical and radiological predictors of malignancy.Methods:We reviewed the cases of 100 patients who underwent ultrasonography between April 2011 and October 2012, and showed suspicious thyroid nodule(s) in a background of heterogeneous parenchyma. Eight patients who did not undergo ultrasonography-guided fineneedle aspiration cytology (FNAC) and 34 cases of follow-up ultrasonography after initial FNAC were excluded. We compared the benign and malignant nodules in terms of their clinical and radiological factors.Results:For the 58 nodules including 31 LTs (53.4%) and 27 PTCs (46.6%), the mean tumor sizes of the two groups were 0.96 cm for LT and 0.97 cm for PTC. A univariate analysis revealed that PTCs were more frequent in patients younger than 45 years and having microcalcifications than was LT. An independent predictor of PTC after adjustment was an age of <45 years.Conclusion:LT mimics malignancy in a background of heterogeneous parenchyma on ultrasonography. A young age of <45 years is the most important predictor of malignancy in this condition.

Combined Categorical Reporting Systems of US and Cytology Findings for Thyroid Nodules: Guidance on Repeat Fine-Needle Aspiration Cytology

To investigate the usefulness of the combined categorical reporting system of ultrasonography (US) and cytology results for thyroid nodules to suggest indications of repeat US-guided fine needle aspiration cytology (FNAC). Institutional review board approval was obtained, and the requirement for informed consent was waived for this retrospective study. From June 2001 to December 2009, 1084 patients (978 women, 106 men) who underwent repeat US-guided FNAC of thyroid nodules were included. FNAC results were reported by using the Bethesda system for reporting thyroid cytopathologic findings and five thyroid US categories (category US 1, benign; US 2, probably benign; US 3, indeterminate; US 4, probably malignant; US 5, malignant). The relative risk ratios were evaluated in each separate FNAC and combined initial category by means of Cox proportional risk model. Eighty-one of 1084 (7.5%) patients had malignancy over a mean follow-up time of 20.8 months (range, 3-98 months). Initial FNAC category of atypia of undetermined significance (relative risk ratio, 9.677) and US categories of US 3 (28.76), US 4 (142.0), and US 5 (411.6) had high relative risk ratios for malignancy (P < .05). Combined categories of benign cytology findings with US 3-5, nondiagnostic cytology findings with US 3-5, and atypia of undermined significance with any US categorization had high relative risk ratios of 104.80 (95% confidence interval: 53.328, 205.966). The combination of the categorical reporting systems between cytology and US results could be useful to suggest indications of repeat US-guided FNAC.

Accuracy of needle biopsy of breast lesions visible on ultrasound: Audit of fine needle versus core needle biopsy in 3233 consecutive samplings with ascertained outcomes

IntroductionCore needle biopsy (CNB) has progressively replaced fine needle aspiration cytology (FNAC) in the diagnosis of breast lesions. Less information is available on how these tests perform for biopsy of ultrasound (US) visible breast lesions. This study examines the outcomes of CNB and FNAC in a large series ascertained with surgical histology or clinical-imaging follow-up. Materials and methodsRetrospective five-year audit of 3233 consecutive US-guided needle samplings of solid breast lesions, from self-referred symptomatic or asymptomatic subjects, performed by six radiologists in the same time-frame (2003–2006): 1950 FNAC and 1283 CNB. The probability of undergoing CNB as a first test instead of FNAC was evaluated using logistic regression. Accuracy and inadequacy were calculated for each of CNB and FNAC performed as first test. Accuracy measures included equivocal or borderline/atypical lesions as positive results. ResultsThe probability of CNB as a first test instead of FNAC increased significantly over time, when there was a pre-test higher level of suspicion, in younger (relative to older) women, with increasing lesion size on imaging, and for palpable (relative to impalpable) lesions. Inadequacy rate was lower for CNB (B1 = 6.9%) than for FNAC (C1 = 17.7%), p < 0.001, and specifically in malignant lesions (B1 = 0.9% vs. C1 = 4.5%; p < 0.001). False negative rate was equally low for both CNB and FNAC (1.7% each test). CNB performed significantly better than FNAC for absolute sensitivity (93.1% vs. 74.4%; p < 0.001) and complete sensitivity (97.4% vs. 93.8%; p = 0.001), however specificity was lower for CNB than FNAC (88.3% vs. 96.4%; p < 0.001). Absolute diagnostic accuracy was higher for CNB than FNAC (84.5% vs. 71.9; p < 0.001) while FNAC performed better than CNB for complete diagnostic accuracy (95.4% vs. 93.2; p < 0.008). In the small subgroup assessed with CNB after an inconclusive initial FNAC (231 cases) there was improved complete sensitivity (from 93.8% to 97.0%) however this also increased costs. ConclusionFNAC and CNB were generally performed in different patients, thus our study reported indirect comparisons of these tests. Although FNAC performed well (except for relatively high inadequacy), CNB had significantly better performance based on measures of sensitivity, but this was associated with lower specificity for CNB relative to FNAC. Overall, CNB is the more reliable biopsy method for sonographically-visible lesions; where FNAC is used as the first-line test, inadequate or inconclusive FNAC can be largely resolved by using repeat sampling with CNB.

Endocrine Society of India management guidelines for patients with thyroid nodules: A position statement

Thyroid nodules are common. Thyroid cancer is rarer. No guidelines exist for management of thyroid nodules in the Indian context and these recommendations are intended for this purpose. The consensus committee reviewed important articles, including previously published consensus statements. Management points were scored according to the level of evidence. These guidelines cover the clinical evaluation and include the interpretation of imaging and fine needle aspiration cytology of thyroid nodules. The guidelines also cover the management of special situations like thyroid incidentalomas, cystic thyroid lesion and nodules detected during pregnancy. The consensus guidelines represent a summary of current medical evidence for thyroid nodule management and the committee has attempted to optimize the guidelines for the clinical practice setting in India.

A rare and an unusually delayed presentation of orbital actinomycosis following avulsion injury of the scalp

We report a rare case of orbital swelling presenting one year after head trauma. An initial fine needle aspiration cytology revealed it to be an infected organizing hematoma. However, broad-spectrum antibiotics did not resolve the infection and the orbital lesion continued to grow in size, as evaluated by magnetic resonance imaging. Incisional biopsies were done, which were reported as orbital actinomycosis. Patient has responded well to treatment with penicillin. This case is of interest due to the delayed presentation of an orbital complication of head trauma and the rare infection with actinomyces. It also highlights the importance of using appropriate antibiotics, as well as the need for long-term treatment.

Anaplastic Large Cell Lymphoma- A Cytological Masquerade

Histopathological examination with immunohistochemistry is the gold standard in the diagnosis and classification of Non Hodgkin’s lymphoma (NHL). Fine needle aspiration cytology (FNAC), without immunophenotyping has a very limited role to play in the diagnostic workup of NHL. However, cytomorphological study may at times give definitive clues to know the type of NHL. We present a case of Anaplastic lymphoma kinase negative Anaplastic large cell lymphoma (ALCL) which on initial FNAC was missed but on review showed significant number of Hallmark cells.

Primary angiosarcoma of the thyroid gland with recurrence diagnosed by fine needle aspiration: A case report

Angiosarcoma of the thyroid is a rare and aggressive primary malignant tumor of the thyroid originally reported in patients from the Swiss Alpine region. Diagnosis of this tumor rests mainly on characteristic histopathological features of a malignant vascular tumor supported by immunopositivity for vascular markers e.g., CD31, Factor VIII, and CD34. Its cytological features, however, are not well-defined. We describe a case of primary angiosarcoma of the thyroid in a 48-year-old female, who presented with a rapidly enlarging neck mass associated with compressive symptoms. She had a history of hypothyroidism. The initial fine needle aspiration cytology of the neck mass was negative. She then underwent left hemithyroidectomy. Histologically, the tumor showed poorly differentiated malignant cells with eccentrically-placed nuclei, prominent nucleoli, and intracytoplasmic vacuoles admixed with mixed inflammatory cells. These showed immunopositivity for CD31 but were negative for CD34, Factor VIII, CK5/6, EMA, TTF-1, Thyroglobulin, Calcitonin, Melan A, and Calretinin. A diagnosis of poorly differentiated malignant tumor consistent with angiosarcoma was made. The patient was treated with radiation therapy but developed recurrence of the tumor. Second aspiration cytology of the recurrent tumor yielded hypocellular smears containing singularly dispersed atypical cells having eccentrically-placed nuclei with prominent macronucleoli and intracytoplasmic vacuoles within a background of inflammatory cells, consistent with recurrent angiosarcoma. Chemotherapy was started but she succumbed to the disease 7 months after diagnosis. The cytological, histopathological, immunohistochemical findings, and the clinical course are discussed.

Fine needle aspiration cytology (FNAC) of salivary gland tumours: Repeat aspiration provides further information in cases with an unclear initial cytological diagnosis

Introduction Fine needle aspiration cytology (FNAC) for salivary gland tumours requires expertise in interpretation. When a diagnosis is not clear (despite a cellular aspirate), published work is lacking on the value of repeating the test. Methods A retrospective study of 135 patients who had FNAC followed by definitive excision for a suspected salivary gland tumour. Accuracy was compared among those requiring repeat FNAC on one more occasion because of a non-diagnostic initial cytology report. Results 33 patients (24% of study group) had repeat FNAC. A definite cytological diagnosis was subsequently made in 27/33 patients (82%). The sensitivity (84%) and specificity (93%) of repeat FNAC in distinguishing benign from malignant tumours was similar to initial FNAC (70% and 95%, respectively). Conclusions Repeat FNAC may provide a cytological diagnosis in cases where the initial diagnosis is not clear, although cytology should be used in conjunction with other investigations of salivary tumours, including image-guided biopsy examination where appropriate. Ideally salivary gland FNAC should be interpreted by a specialist pathologist.

Fine needle aspiration cytology in diagnosis and management of thyroid disease

The objective of this study was to determine the efficacy of fine needle aspiration cytology in diagnosis and management of thyroid nodules. The study also evaluated the predictive value of pre-operative fine needle aspiration cytology (FNAC) in surgical decision making, by comparing the final pathological diagnosis with the initial FNAC result. All patients who underwent thyroidectomy between 1999 and 2003 were analysed. One hundred and sixty patients who underwent pre-operative FNAC were included in this study. Fine needle aspiration was accurate in 119 (74.3 per cent) patients. Fine needle aspiration cytology and histology did not correlate in 32 (20 per cent) patients and FNAC was inadequate in nine (5.6 per cent) cases. Failures were mainly noted in cases of follicular neoplasm. Our results indicate that FNAC is helpful in the diagnosis of thyroid pathology. However, complete histopathological analysis is essential to distinguish follicular adenoma from follicular carcinoma. From this study, it can be concluded that FNAC is a cost-effective method of evaluating thyroid pathology pre-operatively and plays a useful role in planning the surgical management of thyroid nodules. However, results must be interpreted with the clinical picture in mind.