Limitations Of Fine-needle Aspiration Research Articles

Image-guided lymph node fine-needle aspiration: the Johns Hopkins Hospital experience.

Although the diagnostic utility of lymph node fine-needle aspiration (FNA) is well established in the evaluation of metastatic malignancy, its value in the diagnosis of lymphoma is more controversial; yet, there is a growing trend among practitioners towards less-invasive procedures such as FNA and core needle biopsy (CNB). The guidelines recently published by the American Society for Clinical Pathology/College of American Pathology (CAP) regarding the workup of lymphoma include recommendations on the value and limitations of FNA. We reviewed 1237 image-guided lymph node aspirates from 695 procedures (410 nodes from 360 ultrasound [US]-guided cases, 799 from 309 endobronchial ultrasound [EBUS], 25 from 23 endoscopic ultrasound [EUS], and 3 from 3 computed tomography [CT]). The majority (40 of 46, 87%) of lymph nodes suspected of lymphomatous involvement were aspirated under ultrasound. Core needle biopsy [CNB] was obtained for 41 (89%) lymph nodes, including all 40 US specimens. Flow cytometry (FC) was performed on 37 (80%) aspirates; aspirates without FC were from patients who had a history of Hodgkin lymphoma, or showed granulomata or non-hematologic malignancy onsite. Thirty-one (67%) lymph nodes were sent for review by hematopathology. Forty-two (91%) lymph node FNA/CNB yielded actionable diagnoses. Seventeen of 241(7%) cases aspirated for other indications (14 US, 3 EBUS) were involved by a lymphoproliferative process. All were reviewed by hematopathology. All 14 US cases had FC and CNB. Our institutional approach towards lymph node cytopathology for lymphoma workup appears to be in accordance with the new CAP guidelines, and demonstrates a potential triage and workflow model for lymph node FNA specimens that allows for accurate diagnosis in cases where lymphoma is a consideration.

The Diagnostic Value of Ultrasound Elastography and Colour Doppler Ultrasonograhy in Predicting Malignancy in Intermediate Thyroid Nodules

Abstract Background: Nodules of thyroid gland are very common and the majority of them are benign. Sonography has many favorable features, such as detection of non-palpable nodules, estimation of size and volume of the nodule and guidance for Fine Needle Biopsy (FNB). High-resolution ultrasound is very sensitive in detection of thyroid nodules, enabling dif-ferentiation of solid and fluid-containing lesions. Indeterminate and non diagnostic patterns represent the main limitation of Fine Needle Aspiration (FNA) cytology of thyroid nodules, clinical and echographic features can poorly predictive of malignancy. The newly developed real-time Ultrasound Elas-tography (USE) has been applied to differentiate malignant from benign lesions. Aim of Study: To evaluate indeterminate thyroid nodules by US elastography and colour Doppler study. Material and Methods: In this study, 73 cases were in-cluded from which 57 cases were benign and 16 cases were malignant. The cases were subjected to complete U/S, Doppler examination, Micro pure imaging and US elastography the results were compared to U/S guided FNAC. Results: The most predictive combined ultrasound features are disappearing halo sign with the appearance of dots of micro calcifications and by colour Doppler ultrasound marked intra nodular and absent or slight peri nodular blood flow represented with malignant nodules more than benign, the combination of US elastography with US findings clears that hypoechogenicity/score 4-5 was the most predictive of malig-nancy with sensitivity 80% and specificity 100%; and accuracy 93.4%. Conclusion: US-elastography combined with colour Dop-pler US, has rapid and easy performance and can help to identify nodules of thyroid gland that are likely seems to be malignant.

Contribution of Immunocytochemistry to the Diagnosis of Usual and Unusual Lymphoma Cases.

Some of the limitations of fine needle aspiration (FNA) in the cytodiagnosis of lymphoma include problems encountered in differentiating reactive hyperplasia from low-grade non-Hodgkin lymphoma (NHL), lower cytodiagnostic accuracy for NHL with a follicular (nodular) pattern and nodular sclerosis type of classical Hodgkin lymphoma (HL), and overlapping morphological features between T-cell-rich B-cell lymphoma (TCRBCL), anaplastic large cell lymphoma (ALCL), and HL. Immunocytochemistry may be of help in such situations. The B-cell lymphomas such as small lymphocytic lymphoma/CLL, follicular lymphoma (FL), mantle cell lymphoma (MCL), MALT lymphoma, Burkitt lymphoma (BL), and diffuse large B-cell lymphoma (DLBCL) have pan-B-cell markers (CD19, CD20, CD22, CD23, and CD79a). The FL (centrocytic), MCL, and MALT lymphoma can be differentiated with the use of a panel consisting of CD5, CD10, and CD23. In addition, FL is BCL2+ and MCL is BCL2+ as well as cyclin D1+. The DLBCL is BCL6+ in 60–90% cases. Besides pan B-cell marker, the immunocytochemical profile of BL includes CD10+, BCl6+, EBV±, and Ki67+ (100% cells). TCRBCL, a rare variant of DLBCL can be immunocytochemically differentiated from anaplastic large cell lymphoma (CD45+, CD30+, CD15‒, T±, B‒, EMA+, ALK1±) and classical HL (CD30+, CD15+, CD45‒, B‒, T‒, EMA‒). Unlike classical HL, the nodular lymphocytic predominant HL has a phenotype that includes LCA+, CD20+, CD79a+, CD15‒, and CD30‒. Whereas the immature neoplastic cells of T-lymphoblastic lymphoma (LBL) are CD3+, CD20‒, and Tdt+, the rarely encountered mature T-CLL/T-PLL are immunophenotypically CD3+, CD4+, CD5+, CD7+, CD8‒, CD20‒, CD23‒, and Tdt‒.

Computed tomography-guided fine-needle aspiration and concurrent core biopsy in diagnosis of intrathoracic mass: An evaluation of 54 cases in a tertiary care hospital

Introduction: Fine-needle aspiration cytology (FNAC) is a simple, safe, and effective tool for cytological diagnosis of different neoplastic lesions. Computed tomography (CT)-guided core biopsy is also essential for tissue diagnosis. Aims and Objectives: The aim of this study is to assess the diagnostic value and limitations of fine-needle aspiration and core biopsy in diagnosis of intrathoracic lesions; we have done this retrospective study. Materials and Methods: In all 54 cases with mean age of 57.37 years, CT-guided FNAC and core biopsy were performed on same sittings. 20–22 G Chiba needle was used for FNAC, and core biopsy was performed by 18–20 G coaxial automated cutting needle. The cytological and histological evaluations were done in our cytology and histopathology laboratory. Complications were managed by pulmonologists. Results: On the evaluation of FNAC smears, diagnosis was done in 44 cases and 10 cases were inconclusive. In core biopsy, five cases were inconclusive. Most of the tumors were of epithelial origin (43 cases, 87.75%) and 95.59% cases were malignant in our series. Sensitivity and diagnostic accuracy of core biopsy (90.38% and 90.74, respectively) were higher than FNAC (84.62% and 85.18%, respectively). Conclusion: CT-guided core biopsy was more effective and accurate in diagnosis and tumor classification than FNAC in spite of higher complication rate.

Role of fine-needle aspiration in the surgical management of pancreatic neuroendocrine tumors: utility and limitations in light of the new World Health Organization classification.

Pancreatic neuroendocrine tumors (Panc-NETs) are rare and tend to get overshadowed by their more prevalent and aggressive ductal adenocarcinoma counterparts. The biological behavior of PancNETs is unpredictable, and thus management is controversial. However, the new World Health Organization classification has significantly contributed to the prognostic stratification of these patients. Concurrently, there have been advances in surgical techniques for benign or low-grade pancreatic tumors. These procedures include minimally invasive and parenchyma-sparing operations such as laparoscopy and enucleation. To report on the utility and limitations of fine-needle aspiration in the preoperative evaluation and management of PancNETs. This was a retrospective review of our institutional tumor database from 2002 to 2012. There were 25 cases of PancNETs that were localized and staged by medical imaging and diagnosed by fine-needle aspiration. Fourteen patients underwent laparotomy, with some requiring only limited surgery; 4 had laparoscopic resections; 4 were serially observed without surgical intervention; and another 3 were inoperable. After a mean follow-up of 37 months, more than half of the patients had no evidence of disease, including most of those who underwent minimally invasive surgery. Fine-needle aspiration is a useful diagnostic adjunct to medical imaging in the preoperative evaluation and management of PancNETs. However, there are limitations with regard to grading PancNETs using this technique.

Detection of PAX8/PPARG and RET/PTC Rearrangements Is Feasible in Routine Air-Dried Fine Needle Aspiration Smears

The diagnostic limitations of fine needle aspiration (FNA), like the indeterminate category, can be partially overcome by molecular analysis. As PAX8/PPARG and RET/PTC rearrangements have been detected in follicular thyroid carcinomas (FTCs) and papillary thyroid carcinomas (PTCs), their detection in FNA smears could improve the FNA diagnosis. To date, these rearrangements have never been analyzed in routine air-dried FNA smears, but only in frozen tissue, formalin-fixed paraffin-embedded (FFPE) tissue, and in fresh FNA material. Fixed routine air-dried FNA samples have hitherto been judged as generally not suitable for testing these rearrangements in a clinical setting. Therefore, the objective of the present study was to investigate the feasibility of extracting RNA from routine air-dried FNA smears for the detection of these rearrangements with real-time polymerase chain reaction (RT-PCR). A new method for RNA extraction from routine air-dried FNA smears was established, which allowed analysis for the presence of four variants of PAX8/PPARG and RET/PTC 1 and RET/PTC 3, which were analyzed in 106 routine FNA smears and the corresponding surgically obtained FFPE tissues using real-time quantitative PCR (RT-qPCR). To assess RNA quality, an intron-spanning PAX8 cDNA was amplified. Acceptable RNA quality was obtained from 95% of the FNA samples and 92% of the FFPE samples. PAX8/PPARG was detected in 4 of 96 FFPEs and in 6 of 96 FNAs. PAX8/PPARG was present in 4 of 10 FTCs and in 3 of 42 follicular adenomas (FAs). Similarly, RET/PTC was found in 3 of 96 FFPEs and in 4 of 96 FNAs. Two of 21 PTC samples and 3 of 42 FA samples carried this rearrangement. These data are the first to show the feasibility of extracting RNA from routine air-dried FNA smears for the detection of PAX8/PPARG and RET/PTC rearrangements with RT-qPCR. These promising methodological advances, if confirmed in larger series of FNA and FFPE samples, may lead to the introduction of molecular analysis of routine air-dried FNA smears in everyday practice.

Ultrasound‐guided fine‐needle aspiration biopsy of thyroid bed lesions from patients with thyroidectomy for thyroid carcinomas

To evaluate the efficacy and the limitation of fine-needle aspiration (FNA) biopsy in thyroid bed lesions, a retrospective review was performed of the medical records of thyroid cancer patients who underwent ultrasound-guided FNA biopsy of the thyroid bed at The University of Texas MD Anderson Cancer Center over a 5-year period. Data were reviewed on 220 FNA biopsies taken from thyroid bed lesions in 195 patients who had undergone thyroidectomy for thyroid carcinoma. Thyroid bed FNA results were compared with clinical follow-up, including neck dissection results. Recurrent carcinoma was diagnosed by FNA biopsy in 139 of 220 (63%) cases. Neck dissections were performed for 112 sites identified by FNA biopsies, and recurrent carcinoma was confirmed in 110 sites. The concordance between positive and/or suspicious FNA diagnosis and positive neck dissection results was 98% (118 of 120 cases). A false-positive FNA occurred in one patient with follicular thyroid carcinoma. The other discrepancy was attributed to failure to remove the lesion by neck dissection. The diagnostic accuracy of thyroid bed FNA was 100% in papillary and medullary thyroid carcinoma and 93% in follicular thyroid carcinoma. Suspicious and rare false-negative FNA results were attributed to low cellularity and lack of characteristic cytomorphologic features of thyroid carcinoma. Ultrasound-guided thyroid bed FNA biopsy is accurate and efficient in triaging patients who require post-thyroidectomy follow-up for recurrent thyroid carcinoma. Caution should be taken in the interpretation of FNA specimens that have low cellularity and lack characteristic cytologic features of thyroid carcinoma.

Challenging breast lesions: Pitfalls and limitations of fine‐needle aspiration and the role of core biopsy in specific lesions

Core biopsy rapidly replaced fine needle aspiration (FNA) over the past decade in evaluation of diseases of the female breast in many centers in the USA. We continue to heavily utilize FNA for the initial evaluation of breast masses in our institution. In this article, we discuss the cytologic and core biopsy findings in challenging breast lesions such as papillary and mucinous proliferations, fibroepithelial neoplasms, and low grade cancers. We specifically focus on the pitfalls and limitations of both diagnostic modalities in these selected specific lesions.

Fine‐needle aspiration in the evaluation of thyroid lesions in children

The role of fine-needle aspiration (FNA) cytology in the evaluation of thyroid lesions in not as well established in children when compared with adults. Hence we aimed to ascertain the utility and limitations of FNA in childhood thyroid lesions. This was a retrospective analysis of all thyroid FNA performed in children less than 14 years of age over a 4-year period (2005-2009). Histopathological follow-up was available in six cases. A total of 77 cases were included in the analysis. The most common cytological diagnosis was lymphocytic thyroiditis (49.3%), followed by colloid goiter (18.2%), hyperplasia (10.4%), and benign aspirate (7.8%); malignancy was identified in six cases (7.8%). Of these six cases, three were papillary thyroid carcinoma. There was one false-positive case reported as a Hurthle-cell neoplasm, which on histology showed Hashimoto's thyroiditis. One case each of rhabdomyosarcoma and spindle epithelial tumor with thymus like differentiation was wrongly diagnosed as thyroid neoplasm, NOS, and medullary carcinoma (spindle variant), respectively. The overall diagnostic accuracy was 98.6% with 100% sensitivity, 98.6% specificity, 80% positive predictive value, and 100% negative predictive value. FNA is extremely valuable in the initial evaluation of thyroid swelling in children. Rare neoplasms masquerading as thyroid nodules in children can pose difficulties in diagnosis; however, papillary carcinoma is easily recognized. In lymphocytic thyroiditis, it provides a tissue diagnosis, thereby avoiding more invasive procedure for merely diagnostic purposes.

Comparison of vacuum biopsy systems

More than 15 years ago breast radiologists recognised the limitations of fine-needle aspiration and core biopsy as methods for accurate percutaneous breast diagnosis and a variety of different devices were developed to retrieve larger needle biopsy specimens. Vacuum-assisted mammotomy (VAM) has been the most successful of these methods. While core biopsy remains the method of choice for routine needle breast biopsy, VAM is now in routine use as a proven method for minimising the sampling error of subtle and borderline breast lesions and for therapeutic excision of benign breast lesions as an alternative to surgery. VAM achieves significant 50% reduction in understaging of premalignant and malignant disease. VAM technology has been refined in recent years and there are now four different VAM devices available. All are designed for use under X-ray and ultrasound guidance. The third-generation devices are closed systems that use larger gauge probes to ensure that ample material can be rapidly acquired. The latest devices are designed to be used with both prone table and upright X-ray equipment, and are particularly suitable for lateral approach stereotactic biopsy. Sensitivity rates for invasive and in situ carcinoma of 95% to 100% are achievable and VAM should now be considered routine for most stereotactic biopsy procedures. VAM can also be used routinely in place of surgery for the excision of benign lesions and for confirmation excision of papillary lesions and radial scars. Comparative analyses of the current VAM devices will be presented.

Fine needle aspiration of the thyroid: a pathologist’s perspective

I have been aspirating palpable “lumps and bumps” for over 30 years and also interpreting aspirates performed by radiologists, endocrinologists, and other physicians; the last 9 years performing mostly thyroidal...

Transthoracic Fine-Needle Aspiration vs Concurrent Core Needle Biopsy in Diagnosis of Intrathoracic Lesions

To assess the value and limitations of fine-needle aspiration (FNA) and core needle biopsy (CNB) in the diagnosis of intrathoracic lesions, we retrospectively compared the diagnostic accuracy of 362 FNA and concurrent CNB procedures performed on 350 patients. Based on the final diagnoses that were determined based on combined information from biopsy, resection, clinical, radiologic, and microbiologic findings, the study cases were grouped into 188 malignant, 161 benign, and 13 inconclusive lesions. FNA and CNB yielded similar diagnostic accuracy for malignant tumors (85.1% vs 86.7%) and epithelial malignant neoplasms (86.4% vs 85.2%), whereas CNB yielded better diagnostic accuracy (96%) than FNA (77%) for nonepithelial malignant neoplasms. Combined FNA and CNB substantially improved the rate of malignancy diagnosis (95.2%). Of 161 benign cases, 50 were proven to be benign-specific lesions; FNA provided specific diagnosis in 20 (40%) and CNB in 46 (92%). The remaining 111 benign lesions yielded benign-nonspecific findings on both specimens. These results indicate that CNB should be obtained when clinical or radiologic findings do not match the cytologic findings or nonepithelial lesions and benign lesions are considered likely.

Transthoracic Fine-Needle Aspiration vs Concurrent Core Needle Biopsy in Diagnosis of Intrathoracic Lesions

To assess the value and limitations of fine-needle aspiration (FNA) and core needle biopsy (CNB) in the diagnosis of intrathoracic lesions, we retrospectively compared the diagnostic accuracy of 362 FNA and concurrent CNB procedures performed on 350 patients. Based on the final diagnoses that were determined based on combined information from biopsy, resection, clinical, radiologic, and microbiologic findings, the study cases were grouped into 188 malignant, 161 benign, and 13 inconclusive lesions. FNA and CNB yielded similar diagnostic accuracy for malignant tumors (85.1% vs 86.7%) and epithelial malignant neoplasms (86.4% vs 85.2%), whereas CNB yielded better diagnostic accuracy (96%) than FNA (77%) for nonepithelial malignant neoplasms. Combined FNA and CNB substantially improved the rate of malignancy diagnosis (95.2%). Of 161 benign cases, 50 were proven to be benign-specific lesions; FNA provided specific diagnosis in 20 (40%) and CNB in 46 (92%). The remaining 111 benign lesions yielded benign-nonspecific findings on both specimens. These results indicate that CNB should be obtained when clinical or radiologic findings do not match the cytologic findings or nonepithelial lesions and benign lesions are considered likely.

Fine‐needle aspiration of an unusual case of poorly differentiated insular carcinoma of the thyroid

Poorly differentiated insular carcinoma of the thyroid is a rare thyroid malignancy that is intermediary in biological behavior between well-differentiated and undifferentiated thyroid carcinoma. We used fine-needle aspiration (FNA) to diagnose a poorly differentiated insular carcinoma with unusual cytological features in a 53-yr-old woman with a history of goiter and hypothyroidism, who presented with a massively enlarged thyroid gland and a large liver metastasis. The hypercellular aspirates were comprised predominantly of individually dispersed tumor cells. The tumor cells were small, monotonous, round to oval, and often plasmacytoid with eccentric hyperchromatic nuclei and occasional binucleation; finely granular, ill-defined cytoplasm; and smooth nuclear contours, with hyperchromasia, and small to inconspicuous nucleoli. There were no identifiable microfollicles, necrosis, and mitotic figures. The differential diagnosis included poorly differentiated insular carcinoma, medullary carcinoma of the thyroid, and low-grade lymphoma. Immunocytochemical staining for thyroglobulin, calcitonin, and CD45 yielded negative findings. The insular pattern and scattered microfollicles were appreciated only focally in the specimen from the total thyroidectomy, which also showed other histological patterns including solid, trabecular, and papillary forms. In addition to small, uniform cells, Hurthloid, columnar, and clear cells were focally noted. Thyroglobulin immunoreactivity was recognized only in areas with well-formed follicles. In view of the aggressive nature of insular carcinoma, preoperative recognition is important in planning appropriate therapy. Familiarity with the cytomorphological features, a high index of suspicion, and consideration of appropriate differential diagnoses can greatly aid in reaching a definitive preoperative diagnosis. The limitations of FNA in the sampling of a large tumor with heterogeneous patterns should be kept in mind when interpreting the cytomorphological and immunocytochemical results.

The Adequacy of Ultrasound-Guided Fine Needle Aspiration in Thyroid Nodules

Background: Fine needle aspiration (FNA) is an accurate and safe method for the diagnosis of thyroid nodules. One of the limitations of FNA is the variable rate of unsatisfactory specimens, especially in small sized, deep seated or complex cystic nodules. To overcome this problem, ultrasound-guided FNA (US-FNA) has been widely used. In this study, the adequacy of cytologic specimens by US-FNA was compared with that of conventional palpation-guided FNA (P-FNA). Methods: The medical records of all patients who were engaged in FNA due to thyroid nodules at Chungnam National University Hospital from January 2003 to July 2004 were retrospectively examined. The US-FNA and P-FNA were performed in 114 and 185 patients, respectively. Results: Comparison of the adequacy of the two techniques in providing sufficient material for the cytologic diagnosis showed that specimens in 24 (13.0%) and 6 (5.3%) patients collected by P-FNA and US-FNA, respectively, were unsatisfactory (P =0.031). A total of 23 patients underwent thyroid surgery due to strong suspicion of malignancy at cytologic finding and/or on clinical judgement. Seventeen patients belonged to the P-FNA group and 6 patients to the US-FNA group. In the P-FNA group, a histologic diagnosis revealed two false-negative cytologic findings, but no false-negative findings were found in the US-FNA group. Conclusion: Compared with P-FNA, US-FNA may reduce the possibility of unsatisfactory cytologic specimens and the rate of false-negative diagnosis, and may improve the diagnostic accuracy in investigating thyroid nodules (J Kor Soc Endocrinol 20:154～159, 2005).

6959 Eus/cus of rectal lesions: fna or emr?

EUS and catheter ultrasound (CUS) have been accurate in diagnosing and staging rectal and perirectal diseases. Fine needle aspiration (FNA) and endoscopic mucosal resection (EMR) have been recently introduced. The aim of this study was to assess the accuracy and limitations of FNA and EMR in assessing rectal and perirectal Diseases. Methods: Between January of 1998 and December of 1999, 23 patients were evaluated with EUS/CUS for rectal lesions. All patients were evaluated with CUS and standard EUS (Radial, Linear array or both). Results: A total of 23 patients (15 with mucosal and 8 with submucosal lesions) were identified. Table 1 and table 2 show the EUS/CUS results B= Benign; M=malignant; ND= non-diagnostic; EMR= Endoscopic mucosal resection; *= Nodular lesions: Tubular adenoma; hyperplastic polyp(2); inflammatory nodules; normal colonic mucosa. Patients were divided into 2 groups: Group 1 consisted of 15 patients with mucosal lesions. Group 2 consisted of 8 patients with SM lesions. The results of EUS/CUS were correlated with FNA and EMR if available. Conclusions: 1- FNA was accurate in assessing benign mucosal lesions. 2-FNA was accurate in diagnosing and staging malignancy in mucosal lesions. 3- EMR can be performed in limited mucosal and submucosal carcinoids. 4- EUS/CUS and FNA was as accurate as EMR. 5- Complications may occur in recto-vaginal cystic lesions. EUS and catheter ultrasound (CUS) have been accurate in diagnosing and staging rectal and perirectal diseases. Fine needle aspiration (FNA) and endoscopic mucosal resection (EMR) have been recently introduced. The aim of this study was to assess the accuracy and limitations of FNA and EMR in assessing rectal and perirectal Diseases. Methods: Between January of 1998 and December of 1999, 23 patients were evaluated with EUS/CUS for rectal lesions. All patients were evaluated with CUS and standard EUS (Radial, Linear array or both). Results: A total of 23 patients (15 with mucosal and 8 with submucosal lesions) were identified. Table 1 and table 2 show the EUS/CUS results B= Benign; M=malignant; ND= non-diagnostic; EMR= Endoscopic mucosal resection; *= Nodular lesions: Tubular adenoma; hyperplastic polyp(2); inflammatory nodules; normal colonic mucosa. Patients were divided into 2 groups: Group 1 consisted of 15 patients with mucosal lesions. Group 2 consisted of 8 patients with SM lesions. The results of EUS/CUS were correlated with FNA and EMR if available. Conclusions: 1- FNA was accurate in assessing benign mucosal lesions. 2-FNA was accurate in diagnosing and staging malignancy in mucosal lesions. 3- EMR can be performed in limited mucosal and submucosal carcinoids. 4- EUS/CUS and FNA was as accurate as EMR. 5- Complications may occur in recto-vaginal cystic lesions.

Fine-needle aspiration cytology findings in 214 cases of nonparotid lesions of the head

The use and limitations of fine-needle aspiration (FNA) of lesions of the parotid gland are known, but those of nonparotid lesions of the head have been described only sporadically. We conducted this study to evaluate the utility of FNA and to analyze the causes of diagnostic discrepancies for these lesions. A total of 6,898 FNAs of different sites was performed at our institutions between January 1991–August 1998, and 214 (3.1%) of the cases were FNAs of nonparotid lesions of the head. The most common diagnosis of nonparotid lesions was squamous-cell carcinoma, in 22% (n = 48), and the most common site aspirated was the scalp, in 34% (n = 73). Lipomas and keratinous cysts comprised 5% (n = 9) of the total. A statistical analysis was conducted on 98 paired cytology and histology (n = 83) and cytology and flow cytometry (n = 15) specimens (70 malignant and 28 benign). FNA recognized the malignant and benign nature of the lesion in 60 and 26 cases, respectively, with 86% sensitivity, 93% specificity, and 88% accuracy. Causes of false-negative FNA diagnoses (n = 10) included sampling error (n = 6), bloody smears with scant cellularity (n = 3), and bland cytomorphology (n = 1). Florid granulation tissue and a mucocele of the tongue accounted for the two false-positive cases. We conclude that FNA is an effective tool for triage of surgery candidates with nonparotid lesions of the head. Adequate samples with sufficient cellularity are required for avoiding false-negative diagnoses. Occasionally, tissue biopsy is needed for diagnosis of equivocal cases. Diagn. Cytopathol. 2000;22:211–217. © 2000 Wiley-Liss, Inc.

Fine-needle aspiration cytology findings in 214 cases of nonparotid lesions of the head.

The use and limitations of fine-needle aspiration (FNA) of lesions of the parotid gland are known, but those of nonparotid lesions of the head have been described only sporadically. We conducted this study to evaluate the utility of FNA and to analyze the causes of diagnostic discrepancies for these lesions. A total of 6,898 FNAs of different sites was performed at our institutions between January 1991-August 1998, and 214 (3.1%) of the cases were FNAs of nonparotid lesions of the head. The most common diagnosis of nonparotid lesions was squamous-cell carcinoma, in 22% (n = 48), and the most common site aspirated was the scalp, in 34% (n = 73). Lipomas and keratinous cysts comprised 5% (n = 9) of the total. A statistical analysis was conducted on 98 paired cytology and histology (n = 83) and cytology and flow cytometry (n = 15) specimens (70 malignant and 28 benign). FNA recognized the malignant and benign nature of the lesion in 60 and 26 cases, respectively with 86% sensitivity 93% specificity and 88% accuracy. Causes of false-negative FNA diagnoses (n = 10) included sampling error (n = 6), bloody smears with scant cellularity (n = 3), and bland cytomorphology (n = 1). Florid granulation tissue and a mucocele of the tongue accounted for the two false-positive cases. We conclude that FNA is an effective tool for triage of surgery candidates with nonparotid lesions of the head. Adequate samples with sufficient cellularity are required for avoiding false-negative diagnoses. Occasionally, tissue biopsy is needed for diagnosis of equivocal cases.

Fine Needle Aspiration Cytology in a Rural Setting

To analyze the value and limitations of fine needle aspiration (FNA) cytology in a rural setting. Prospective analysis of 1,196 FNA cytology results of superficial and deep masses from 1,088 patients in rural New South Wales, Australia, between September 1990 and May 1996. The FNA procedures were performed by palpation and image guidance using various-gauge needles and core biopsies as appropriate. FNA cytology results were analyzed, based on body organs and cytomorphologic findings. Breast, 450 (41%); thyroid, 152 (14%); superficial lymph nodes, 150 (14%); lung, 98 (9%); and liver, 55 (5%), made up the majority of the cases. The following general cytologic categories were used: nonrepresentative (inadequate), 39 (3.58%); benign, 662 (60.85%); atypical, 45 (4.13%); suspicious, 30 (2.76%); and malignant, 312 (28.68%). Clinical and histologic follow-up (core biopsies in 100 patients and histology of the atypical, suspicious and malignant cytologic categories in 387 patients) showed over 96% sensitivity for a diagnosis of malignancy, with about a 4% false negative rate and 99.04% predictive value of a malignant FNA diagnosis. The false positive rate in the cytologically malignant group of 312 patients was 0.96%. The breast, thyroid and lymph node fine needle aspirations were mostly benign. The great majority of deep organ fine needle aspirations were malignant. Atypical and suspicious FNA cytology, seen in both superficial and deep sites, was due to either technical difficulty in obtaining material or problems of interpretation (genuine cytologic overlap or inexperience). The radiologically suspicious cases with negative cytology were either reaspirated or subjected to surgical biopsy. FNA cytology, when practiced in a multidisciplinary setting with direct involvement of pathologists, radiologists and clinicians, is an extremely accurate, well-tolerated, relatively noninvasive and low-risk test that obviates the need for surgical intervention in most benign conditions and disseminated malignancies. Therefore, by taking an active role with on-site assessment of the FNA material and discussion with radiologic colleagues, the cytopathologist could offer an FNA service comparable to surgical pathology in sensitivity and very similar to frozen section in specificity.

Fine Needle Aspiration Cytology vs. Core Biopsy in a Rural Setting

To compare, contrast and analyze the value and limitations of fine needle aspiration (FNA) cytology and core biopsy (CB) in a rural setting. Retrospective analysis of 100 FNA cytology and 100 CB results of mass lesions from 193 patients matched for age, sex and body organs, and referred for FNA or CB in rural New South Wales, Australia, between September 1990 and May 1996. FNA cytology and CB results from 193 patients were analyzed, based on anatomic location and cytologic criteria. Sites included lung, retroperitoneum, liver, breast, kidney, pancreas and ovary. The FNA group contained 6 inadequate, 14 benign, 3 atypical, 6 suspicious and 71 malignant cases, whereas the CB group had 1 inadequate, 24 benign and 75 malignant conditions. The inadequate samples in both groups were due to technical difficulty in obtaining representative material. The indeterminate (atypical and suspicious) group, which was the main pitfall of FNA, contained 4 low grade carcinomas, 3 low grade non-Hodgkin's lymphomas and 2 fibrocystic breast changes. The benign FNA group comprised 8 cysts, 5 inflammatory/reactive conditions and 1 benign tumor/hamartoma, whereas the benign CB group contained 11 cysts, 9 inflammatory/reactive conditions and 4 benign tumors. FNA was comparable to CB at most anatomic sites. CB occasionally offered additional information. This slight advantage was due to the availability of tissue from the first and often the only pass for assessment of architecture and performance of ancillary tests, which obviated the need for further sampling. On-site assessment of the core imprints at the time of the procedure by the highly skilled and experienced interventional cytopathologist was responsible for limiting the number of attempts to one core in most of the instances, therefore minimizing complications. Pathologists are encouraged to become more familiar with the criteria of aspiration cytology, which has proven its validity in the new cost-conscious environment. Despite the recent surge in the popularity of core biopsy, FNA cytology, when practiced in a multidisciplinary setting, with involvement of pathologists, radiologists and clinicians, is an extremely accurate test with very high sensitivity, which approaches that of surgical pathology, and specificity very similar to that of frozen section. FNA has a positive predictive value for a malignant diagnosis of almost 100%. FNA is a well-tolerated, relatively noninvasive test with a very low risk of complications.