Nondiagnostic Research Articles

IS REPEAT FNAB NECESSARY FOR THYROID NODULES WITH ND / UNS CYTOLOGY?

The standard approach is to perform repeat FNAB (rFNAB) in thyroid nodules with non-diagnostic (ND) / insufficient (UNS) cytology. However, due to the nature of these nodules, recurrent FNABs may also be insufficient. Therefore, by comparing the clinical-radiological-pathological parameters of nodules with a definite diagnosis of excision, we questioned the possibility of patient management without rFNAB. Clinical-radiological parameters of 275 nodules belonging to 264 patients in the ND/UNS aspiration group with definite pathological diagnosis after surgery were determined. Under the guidance of these parameters, those with and without rFNAB were compared. The incidence of malignancy was found to be significantly higher in nodules without rFNAB compared to nodules with rFNAB (p = 0.036). In addition, the incidence of malignancy in BC-1 nodules without rFNAB was significantly higher than in nodules with rFNAB result also BC-1 (p = 0.009). In all cases, nodule size smaller than 10 mm and border irregularity were found to be statistically significant for malignancy (p <0.020, p <0.002). When looking at the distribution of rFNAB results, a significant correlation was observed with female gender, solid component, hypoechogenicity, border irregularity and halo loss around the nodule in patients with BC-4,5,6 cytology results (respectively, 0.005 / 0.031 / 0.001 / 0.012 / 0.004). rFNAB did not show the expected effect in ND / UNS nodules. We recommend direct surgical excision without rFNAB for nodules with border irregularity, solid structure, halo loss and hypoechogenicity, which should be considered more important in female patients.

Cytomorphological Categorization of Thyroid Lesions according to The Bethesda System for Reporting Thyroid Cytology and Correlation with their Histological Outcome: An Indian Oncology Centre Experience.

Objective:The objective of this study was to report the experience of an Indian premiere tertiary care oncology center in reporting fine needle aspiration cytology of thyroid lesions according to the Bethesda system of reporting thyroid cytopathology (TBSRTC) given by National Cancer Institute (NCI). These were then correlated with their histopathological outcome, analyzing the level of specificity and sensitivity of the procedure.Material and Methods:Aspiration cytology of thyroid lesions, presented during a 5.5-year duration, was reported retrospectively and prospectively, according TBSRTC, and correlated with their histopathologic diagnosis.Results:A total of 431 patients were evaluated comprising 289 females and 142 males, with a median age of 52 years. Among the cytological categories 80 (18.6%) were non-diagnostic (ND), 131 (30.2%) benign, 45 (10.4%) follicular lesion of undetermined significance (FLUS), 27 (6.3%) follicular neoplasm, 33 (7.9%) suspicious for malignancy (SM), and 115 (26.7%) malignant. Histopathology reports were available in 142 of these cases. Final malignant diagnosis was reported in 11 of 14 ND (78.6%), 5 of 18 benign cases (27.7%); 9 of 17 FLUS (52.9%), 7 of 13 FLUS (53.89%), 19 of 20 SM (95%), and 58 of 60 malignant cases (96.7%). The procedure had sensitivity of 94.4%, specificity of 61.9%, positive predictive value of 90.3% and negative predictive value of 72.22%.Conclusion:TBSRTC provides uniform categorization of thyroid cytology, which also helps in further management. This valid system has helped to streamline the reporting terminologies as well as the clinical management.

Categorisation of Salivary Lesions According to the Novel Milan’s System of Reporting Salivary Gland Cytopathology: A Retro-prospective Study

Introduction: Fine Needle Aspiration Cytology (FNAC) is an important diagnostic tool for salivary lesions, which has decreased the number of unnecessary invasive surgeries for benign conditions. But, cytopathology of salivary lesions is complex presenting with similarity in cytological features albeit with histological heterogeneity. The novel Milan’s System for Reporting Salivary Gland Cytopathology (MSRSGC) is a six tiered classification, providing standard reporting terminology for salivary gland lesions in fine needle aspirates. Aim: To categorise the salivary lesions cytologically based on MSRSGC and to assess its utility in simplification of routine diagnosis of salivary gland lesions. Materials and Methods: A retroprospective study was conducted in a tertiary care centre over a period of five years from 2017 to 2021. All patients suspected to have salivary gland lesions were subjected to FNAC in the Department of Cytology. The cases were reported according to the MSRSGC criteria and assigned one of the categories. The statistical analysis was performed using Microsoft excel software, for calculation of descriptive statistical parameters such as measures of central tendency viz., mean, median, mode, percentage, range and ratio. Results: A sample size of 82 patients with salivary gland lesions was studied. Parotid gland was most commonly involved, among others. Most of the lesions were classified as category 4a (Neoplasm benign) (39%) and category 2 (Non neoplastic) (36.6%). Non Diagnostic (ND) constituted only 2.43% while malignancies constituted 4.9%. Ambiguous categories like Salivary gland neoplasm of Uncertain Malignant Potential (SUMP) and suspicious of malignancy constituted 13.4% and 3.6%, respectively. Conclusion: The introduction of MSRSGC has to a large extent standardised the reporting patterns, thereby assisting the clinicians to render improved patient care. The present study in comparison with other studies conducted worldwide, recommends the usage of MSRSGC for routine reporting.

Categorisation of serous effusions using the International System for Reporting Serous Fluid Cytopathology and assessment of risk of malignancy with diagnostic accuracy.

The International System for Reporting Serous Fluid Cytopathology (ISRSFC) standardises the reporting of serous effusion cytology under five categories: Non-Diagnostic (ND), Negative for Malignancy (NFM), Atypia of Undetermined Significance (AUS), Suspicious for Malignancy (SFM), and Malignant (M). Very few studies have been conducted so far to confirm the risk of malignancy of the different categories. The main objectives of our study were to classify serous effusions according to the ISRSFC categories and assess their risk of malignancy (ROM) and performance parameters. All serous effusion samples received from January 2019 to December 2020 were reclassified according to the ISRSFC. Using histopathological diagnosis as the gold standard, ROM and performance parameters were calculated. A total of 831 pleural effusion samples were reclassified as follows: ND, 3 (0.4%); NFM, 635 (76.4%); AUS, 65 (7.8%); SFM, 60 (7.2%); and M, 68 (8.2%). For 457 peritoneal effusion samples, the reclassifications were ND, 5 (1.1%); NFM, 368 (80.5%); AUS, 19 (4.2%); SFM, 17 (3.7%); and M, 48 (10.5%). All 12 (100%) pericardial effusions belonged to the NFM category. The ROM for the ND, NFM, AUS, SRM, and M categories was 0%, 2.1%, 33.3%, 94.1%, 100%, respectively, in pleural effusions, and 50%, 4.8%, 22.2%, 83.3%, 100%, respectively, in peritoneal effusions. The ROM was 0% for NFM in pericardial effusions. The ISRSFC is an excellent system for accurately classifying serous effusions with greater reproducibility of reports and better communication between pathologist and clinician.

Application of the International System for Reporting Serous Fluid Cytopathology with Cytohistological Correlation and Risk of Malignancy Assessment.

The International System for Reporting Serous Fluid Cytopathology (TIS) classifies serous effusions into five categories: non-diagnostic (ND), negative for malignancy (NFM), atypia of unknown significance (AUS), suspicious for malignancy (SFM) and malignant (MAL). The main objectives of this classification comprise the establishment of a universal code of communication between cytopathologists and clinicians and histopathologists, as well as between different laboratories worldwide, paving the way for the setting of clinical management guidelines based on the risk of malignancy assessment for each diagnostic category. We retrieved the total number of pleural and peritoneal effusion cases of our department for the three-year time period between 2018 and 2020, yielding a total of 528 and 500 cases, respectively. We then proceeded to reclassify each specimen according to TIS guidelines and calculate the risk of malignancy (ROM) for each category by searching each patients’ histology records, medical history and clinical follow-up. For pleural effusions, 3 (0.57%) cases were classified as ND, 430 (81.44%) cases as NFM, 15 (2.84%) as AUS, 15 (2.84%) as SFM and 65 (12.31%) as MAL. ROM amounted to 0%, 5.3%, 33.33%, 93.33% and 100% for each category, respectively. As far as peritoneal effusions are concerned, 6 (1.2%) were categorized as ND with ROM estimated at 16.66%, 347 (69.4%) as NFM (ROM = 9%), 13 (2.6%) as AUS (ROM = 38.46%), 12 (2.4%) as SFM (ROM = 83.33%) and 122 (24.4%) as MAL (ROM = 100%). Our results underline the utility of the current classification, both as a means of communication between doctors of different specialties and as general guidelines for the further clinical management of patients.

Non-Invasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features Is Not a Cytological Diagnosis, but It Influences Cytological Diagnosis Outcomes: A Systematic Review and Meta-Analysis

Background: A low-risk thyroid tumour, non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was introduced in 2016. NIFTP criteria require a thorough histological examination to rule out capsular and lymphovascular invasion, which denies the possibility of preoperative cytological diagnosis. Nevertheless, since the adoption of the new entity, the cytology of NIFTP has been a subject of interest. Objectives: The present systematic review and meta-analysis investigate the cytological diagnosis of NIFTP. Method: An online PubMed literature search was conducted between March 1, 2020, and June 30, 2020, for all original articles considering the cytology of histologically proven NIFTP. The studies including data on fine needle aspiration specimens classified by The Bethesda System for Reporting Thyroid Cytology (TBSRTC) categories, risk of malignancy (ROMs) in the TBSRTC categories, and cytomorphological features of NIFTP were included in the meta-analysis. Non-English studies and case reports were excluded. The data were tabulated and statistical analysis was performed with Open Meta-Analyst program. Results: Fifty-eight studies with a total of 2,553 NIFTP cases were included in the study. The pooled prevalence of NIFTP cases was calculated among 25,892 surgically resected cases from 20 studies and the results show that NIFTP consisted 4.4% (95% confidence interval [CI]: 3.5–5.4%) of all cases. Most of the NIFTP cases (79.0%) belonged to the intermediate categories of TBSRTC. The pooled distribution of NIFTP cases in each TBSRTC category was 1.3% (95% CI: 0.8–1.7%) in non-diagnostic (ND), 8.9% (95% CI: 6.9–10.8%) in benign, 29.2% (95% CI: 25.0–33.4%) in atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS), 24.2% (95% CI: 19.6–28.9%) in follicular neoplasm (FN), 19.5% (95% CI: 16.1–22.9%) in suspicious for malignancy (SM), and 6.9% (95% CI: 5.2–8.7%) in malignant. Compared to pre-NIFTP era, the pooled risk differences of ROM were reduced by 2.4% in ND, 2.7% in benign, 8.2% in AUS/FLUS, 8.2% in FN, 7.3% in SM, and 1.1% in the malignant category. The cytomorphological features of NIFTP were similar to follicular variant of papillary thyroid carcinoma (FVPTC) but lesser to papillary thyroid carcinoma (PTC). Conclusions: Based on our results, NIFTP remains a histological diagnosis. Although cytomorphological features cannot be used in differentiating NIFTP from FVPTC, they may guide in separating NIFTP from PTC. Features such as papillae, microfollicles, giant cells, psammoma bodies, and the amount of papillary-like nuclear features should be taken into account when suspicious of NIFTP. NIFTP should not have papillae or psammoma bodies, and giant cells were rarely observed.

Accuracy of the Milan System for Detecting Neoplastic vs Non-Neoplastic Salivary Gland Lesions: A Retrospective Review

Abstract Introduction/Objective Overlapping morphology and heterogeneity of salivary gland tumors (SGT) poses a diagnostic challenge. FNA is commonly used diagnostic tool for evaluation of superficial and deep lesions of any site, but above limitations restrict its maximum utility. To standardize reporting and to address above limitations, Milan system (MS) of reporting salivary gland cytology, has been developed and implemented by labs. We conducted a retrospective study, applying MS to salivary gland lesions (SGL) to evaluate its accuracy and usefulness in discriminating between neoplastic and non-neoplastic conditions, and thus directing patient management (PM) Methods/Case Report 10 yr retrospective review was performed to include patients with FNA for SGL, cytology diagnosis categorized using MS, cytology-histology (CH) correlation performed, and patients’ charts reviewed for follow up. Attention given to diagnostic discrepancies between MS categories and the histologic diagnosis Results (if a Case Study enter NA) 152 patients (20-88yrs) were retrieved, peak incidence 40-49 yrs; M:F ratio 1.2:1. Distribution of the cases in the MS categories: Non-diagnostic (ND) 24, Non-neoplastic (NN) 33, Atypia of Undetermined Significance (AUS) 4, Neoplasm (N) 71, Suspicious for malignancy (SUN) 7, and Malignant (M) 10. 60 cases identified with follow-up histology, of which 51 cases were correlated, distributed as 4 ND, 4 NN, 0 AUS, 37 N, 3 SUN, and 3 M. The uncorrelated 9 cases were distributed as 4 ND due to scant sampling; 2 NN, histologically Warthin’s tumor and sialolipoma; 2 AUS, histologically basal cell neoplasm and infarcted Warthin’s tumor; 1 malignant, histologically cystic mucoepidermoid carcinoma; 0 cases for neoplastic and suspicious for malignancy categories Conclusion Milan System is a useful cytologic tool for diagnosing and segregating patients with salivary gland pathologies, however, our study shows MS to be more reliable diagnostic tool with higher accuracy (combined 98%) in N, SUN &amp; M categories as compared to ND, NN &amp; AUS categories (combined 50%)

Diagnostic value of liquid-based cytology test in intrathoracic lymph nodes and lung lesions sampled by endobronchial ultrasonography-transbronchial needle aspiration.

Liquid-based cytology (LBC) has begun to be used in non-gynecological samples such as endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). This study aims to investigate the diagnostic value of LBC in intrathoracic lymph nodes and lung lesions sampled with EBUS-TBNA. In total, 174 cases that underwent EBUS-TBNA between July 2020 and February 2021 were included (75 and 99 cases were prepared using conventional and LBC methods, respectively). The two groups were compared in terms of diagnostic categories, number of slides, cell blocks, slides per location, locations sampled, immunohistochemical studies, sensitivity, specificity, and diagnostic accuracy. The percentages of malignant, suspicious for malignancy, benign, and non-diagnostic (ND) cases were 51.8%, 1.1%, 39.6%, and 7.5%, respectively. The LBC and conventional group (CG) had similar rates in the diagnostic categories, except for ND (3.0% and 13.3%, respectively). The sensitivity of LBC and CG were 90.4% and 85.7%, respectively. There were no differences in the specificity and diagnostic accuracy between groups. There was a statistically significant difference between groups in terms of the number of slides, number of slides per location, number of cell blocks, and locations sampled (p < .001, p < .001, p < .05, p < .05). The LBC technique can be used for samples taken with EBUS-TBNA. Rapid fixation and the absence of artificial problems greatly reduce the rate of ND samples in LBC slides. Other important advantages are a lower number of slides to examine and a greater number of cell blocks.

Accuracy of fine-needle aspiration of lymph nodes: A cancer center's experience.

Lymph node fine needle aspiration (LN-FNA) is a minimally invasive method of evaluating lymphadenopathy. Nonetheless, its use is not widely accepted due to the lack of guidelines and a cytopathological categorisation that directly relates to management. We report our experience with LN FNA at a large Cancer Center in Latin America. We retrospectively collected cytological cases of lymph node FNA from the department of pathology at AC Camargo Cancer Center performed over a 2-year period. Data extracted included LN location, age, sex and final cytological diagnosis. Patients that had undergone neoadjuvant chemotherapy and/or cases for which the surgery specimen location was not clearly reported were excluded. For those cases with surgical reports, risk of malignancy was calculated for each diagnostic category, along with overall performance of cytology. False positive cases were reviewed to assess any possible misinterpretation or sampling errors. A total of 1730 LN-FNA were distributed as follows: 62 (3.5%) non-diagnostic (ND); 1123 (64.9%) negative (NEG), 19 (1.1%) atypical (ATY), 53 (3.1%) suspicious for malignancy (SUS), and 473 (27.3%) positive (POS). Surgical reports were available for 560 cases (32.4%). Risk of malignancy (ROM) for each category was 33.3% for ND, 29.9% for NEG, 25% for ATY, 74.2% for SUS and 99.6% for POS. Overall sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were 78.5%, 99.4%, 70.2% and 99.6%, respectively. Lymph node FNA is a very specific and accurate exam, which is reliable in the detection of lymph node metastasis and other causes of lymphadenopathy.

Application of the International System for Reporting Serous Fluid Cytopathology in routine reporting of pleural effusion and assessment of the risk of malignancy.

The International System for Reporting Serous Fluid Cytopathology (ISRSFC) was proposed by the International Academy of Cytology and the American Society of Cytopathology. We have applied this system for reporting of pleural effusion cytology and report our experience. All the pleural effusions from January 2019 to June 2020 were retrieved from the database. All these cases were reviewed and recategorized according to the proposed system of 5 categories: non-diagnostic (ND), negative for malignancy (NFM), atypia of uncertain significance (AUS), suspicious for malignancy (SFM), and malignant (MAL). The risk of malignancy (ROM) for each category was evaluated. A total of 939 cases were studied. The age of patients ranged from 2 to 88 years, and the volume of fluid ranged from 1 to 600 ml. There were 41 ND (4.37%), 697 NFM (74.23%), 44 AUS (4.69%), 27 SFM (2.88%), and 130 MAL (13.84%) cases. The ROM for the categories were found to be 87.5%, 51.61%, 88.23%, 87.5%, and 100% respectively. The ISRSFC is a user-friendly system for use in reporting of pleural fluid. The criteria for defining the various categories need to be further elaborative and stricter for this system to be more effective. More studies are required for the estimation of the ROM for each category.

Cytohistological Correlation in Pleural Effusions Based on the International System for Reporting Serous Fluid Cytopathology.

The International System for Reporting Serous Fluid Cytology (TIS) was recently developed. Given its novelty, most studies looking into the risk of malignancy (ROM) of serous effusion diagnostic categories were published before the development of TIS. We searched the database of our department for pleural effusions diagnosed in the last five years, excluding those without a corresponding pleural biopsy. Cases were reviewed and reclassified according to the TIS. A cytohistological correlation was performed. In total, 350 pleural effusion specimens with one or more corresponding pleural biopsies were included. After reclassification, 5 (1.43%) were nondiagnostic (ND), 253 (72.29%) were negative for malignancy (NFM), 7 (2.00%) had atypia of unknown significance (AUS), 14 (4.00%) were suspicious for malignancy (SFM), and 71 (20.57%) were malignant (MAL). Calculated ROM was 40% for ND, 20.16% for NFM, 42.86% for AUS, 78.57% for SFM, and 100% for MAL. Effusion cytology sensitivity and specificity were 60.29% and 98.56%, respectively. This is the first publication looking into the cytohistological correlation of a retrospective cohort of pleural effusions based on the TIS. We add to the body of data regarding the ROM for TIS categories, highlighting areas of potential future research.

The value of cytology in distinguishing malignant mesothelioma: An institutional experience of 210 cases reclassified according to the International System for Reporting Serous Fluid Cytopathology (ISRSFC)

Malignant mesothelioma (MM) is usually diagnosed by histological examination of tissue samples; however, effusion cytology offers an opportunity to identify a strong possibility for mesothelioma diagnosis at an early stage. We conducted a retrospective analysis of cytological specimens from a large series of histologically proven MM diagnosed over 19years. The cases were reviewed and reclassified according to the International System for Reporting Serous Fluid Cytopathology (ISRSFC). A total of 450 cases were identified. Cytological analysis was present in 210 patients (164 pleural and 46 peritoneal effusions). All cases were reviewed and reclassified according to the proposed ISRSFC scheme. A comparison among the cytomorphological features was made throughout the different diagnostic categories. The 210 cases were histologically diagnosed as follows: 192 (91.4%) cases had an epithelioid type and 18 (8.6%) had a sarcomatoid subtype of MM. The cytological cases were reclassified as follows: 2 (0.9%) as non-diagnostic (ND), 81 (38.6%) as negative for malignancy (NFM), 4 (1.9%) as atypia of undetermined significance (AUS), 11 (5.2%) as suspicious for malignancy (SFM), 112 (53.4%) as malignant (MAL). Sarcomatoid cells in the MAL category were characterised cytomorphologically by more pronounced discohesion. In comparison with the epithelioid subtype, the tumour cells appeared solitary with moderate or marked nuclear pleomorphism, and irregular chromatin. It is important to recognise the cytological characteristics of this aggressive entity to suggest an early and precise possible diagnosis. Morphological features, coupled with clinico-radiological data may help the clinicians in adequately managing the patients.

A retrospective analysis of pleural effusion specimens based on the newly proposed International System for Reporting Serous Fluid Cytopathology.

Recently, the International System for Reporting Serous Fluid Cytopathology (TIS) has been established, with an aim to standardize reporting and guide clinical decision making. The cytological and clinicopathological data of pleural effusions were retrieved from the pathology database and electronic medical records. All specimens were evaluated and reclassified in accordance with the TIS recommendations. Finally, the risk of malignancy (ROM) and performance parameters were measured. A total of 2454 pleural effusion specimens were included, among which 30 (1.2%), 1670 (68.1%), 151 (6.2%), 54 (2.2%) and 549 (22.4%) patients were classified into non-diagnostic (ND), negative for malignancy (NFM), atypia of undetermined significance (AUS), suspicious for malignancy (SFM) and malignancy (MAL) groups, respectively. The most commonly diagnosed malignancies were lung cancer (48.4%), ovary cancer (10.2%), breast cancer (7.5%), and 21.3% unknown primary site (UPS). Among the 36 UPS patients, the most common site of origin was lung (36.1%), followed by ovary (13.9%) and breast (11.1%) via immunocytochemistry of cell block. The calculated ROM values were 26.7%, 12%, 62.3%, 77.8% and 100% for ND, NFM, AUS, SFM and MAL groups, respectively. When considering MAL as the only positive group, the diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were determined to be 95.2%, 81.9%, 100%, 100% and 93.6%, respectively. The newly proposed TIS is an easy-to-master, user-friendly, and standardized classification system, especially when applying on pleural effusions. An adequate serous sample, application of immunocytochemistry, review of cytomorphological data and past medical history could enhance the accuracy of cytological diagnosis.

Can preoperative modified systemic inflammation score (mSIS) be used to predict malignancy in persistent nondiagnostic thyroid nodules?

Background/aimDespite the use of ultrasound guidance, a significant part of thyroid biopsies are nondiagnostic (ND). We aimed to investigate the utility of the preoperative modified systemic inflammation score (mSIS) to predict malignancies in patients with persistent ND thyroid nodules (TNs).Materials and methods Records of 924 patients underwent thyroidectomy between September 2016 and May 2019 were retrospectively reviewed. The calculation of mSIS was as follows: mSIS 0 [patients with albumin (ALB) ≥ 4.0 g/dL and lymphocyte to monocyte ratio (LMR) ≥ 3.4], mSIS 1 [ALB < 4.0 g/dL or LMR < 3.4], and mSIS 2 [ALB < 4.0 g/dL and LMR < 3.4].Results One hundred and thirty-six patients were included in the study. Of the patients with a median age of 49 (21–81) years, 26 (19.1%) were male, and 110 (80.9%) were female. Besides low lymphocyte count (P = 0.03), and ALB levels (P < 0.01), higher BMI (P = 0.02) were also associated with malignancy. In patients classified as mSIS 2, 1 and 0; malignancy rates were 100%, 25.8%, and 16.1%, respectively. The association between preoperative mSIS and thyroid malignancies was statistically significant (P < 0.01).ConclusionWe recommend that when patients with persistent ND TNs are assigned to mSIS 2 or 1, surgery should not be delayed due to the risk of malignancy.

Histopathologic and clinical outcomes of Milan System categories “non-diagnostic” and “non-neoplastic” of salivary gland fine needle aspirations

The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) specifies six categories with estimated risks of malignancy (ROM) and suggested management. The estimated ROM is 25% for Non-Diagnostic (ND) category, and 10% for Non-Neoplastic (NN). This study aimed to investigate histopathologic and clinical outcomes of MSRSGC categories ND and NN at the authors' institution. Cytopathology fine needle aspiration reports from 2008-2020 were searched for the word "salivary", "parotid", and "submandibular". Cases fitting Non-Diagnostic (ND) and Non-Neoplastic (NN) categories were identified. Follow-up cyto-/histopathologic and clinical data were extracted. There were 43 ND and 46 NN cases. The average age was 58.3 years. Neoplastic lesions were found in 13 of 43 (30%) ND and 3 of 46 (6.5%) NN. The rate of malignancy in ND category was 14.0% (6/43) and 0% (0/46) in NN category. Four cases in ND (9.3%) and 6 (13.0%) in NN had no neoplasm and instead had an underlying reactive condition (e.g., chronic sialadenitis) or inflammatory lesion (e.g., lymphoepithelial cyst) on histologic follow-up. There was no follow-up pathology in 46.5% NDs (20/43) and 82.6% NNs (38/46); however, no lesions were apparent clinically with a mean follow-up of 3 years and 1.5 years, respectively. MSRSGC categories ND and NN are helpful for reporting salivary gland FNA results. With proper clinical and radiologic correlation, ROM of NN is low; however, ROM of ND remains significant. Repeat FNA after correlation for ND cases seems prudent as neoplasms and malignancies may have gone undetected.

Is there a Role for Frozen Section Evaluation of Parotid Masses After Preoperative Cytology or Biopsy Diagnosis?

Fine-needle aspiration (FNA) biopsy reliably diagnoses parotid gland lesions preoperatively, whereas intraoperative frozen section (FS) has the additional benefit of assessing surgical margins and refining diagnoses; however, the role of FS in the setting of prior FNA diagnosis is not well established. Our aim was to determine whether FS should still be performed after a prior FNA/ CNB diagnosis. Parotid gland resections from January 2009 to January 2020 were identified; however, only patients who had both FNA and FS constituted our study population. For the purpose of statistical analysis, FNA diagnoses were classified into non-diagnostic (ND), non-neoplastic (NN), benign neoplasm (BN), indeterminate, and malignant. FS diagnoses were classified into benign, indeterminate, or malignant. Resections were dichotomized into benign and malignant and regarded as the gold standard to subsequently calculate diagnostic accuracy of FNA and FS. A total of 167 parotid gland resections were identified, but only 76 patients (45.5%) had both FNA and FS. In 35 cases deemed as benign preoperatively, three (8.6%) were reclassified as malignant on FS. Out of 18 lesions reported as malignant on FNA, four (22.2%) were interpreted as benign on FS, with three of these benign lesions confirmed on permanent slides. In addition, in patients with both FNA and FS, compared to FNA, FS was able to provide a definitive diagnosis in all five ND cases and in 61.1% (11/18) of indeterminate tumors. Intraoperative assessment provided a relative increase of 33.3% in specificity and 38.5% in positive predictive value when compared to preoperative FNA. The addition of FS to FNA was helpful to further refine the diagnoses of parotid gland lesions, which may provide better guidance for surgical intervention.

Factors affecting thyroid nodule fine needle aspiration non\u2010diagnostic rates: a retrospective association study of 1975 thyroid biopsies

BackgroundThyroid nodules are common in clinical practice, and it is important to distinguish benign nodules, the vast majority, from malignant ones. Non-diagnostic (ND) samples have the potential to delay or mis-diagnose or lead to unnecessary surgeries, and it is important to examine what factors influence the ND rate. Prior literature has suggested that the impact of bedside cytology on ND rate is dependent on the initial adequacy rate, whereby higher ND rates benefit most from bedside cytology. We aim to compare the impact of bedside adequacy review between specialist groups who perform high volume thyroid biopsies with low initial ND rates.MethodsWe reviewed the cytopathology results of 1975 thyroid nodule FNAs performed between January 1, 2017 to December 31, 2017 in a multi-centre Canadian city, and the corresponding histopathology reports of 340 resected nodules. Descriptive variables were used to describe the data along with chi-squared testing and univariate logistic regression.ResultsThe FNA biopsies were performed by three different speciality groups, which differed by procedural volume: radiology performed the most at 1171, pathology performed 655 and surgery performed 103. We could not define the operator for 45 of the nodules. The ND rate was lowest in the speciality groups with highest procedural volume, 3.4 % in pathology and 8.3 % in radiology, compared to 37.9 % in surgery (p < 0.001). Completion of bedside cytology rapid onsite evaluation (ROSE) significantly reduced the ND rate from 16.7 to 4.2 % for all samples (p < 0.001). When ROSE was compared with non-ROSE within a high procedural group (radiology), it further reduced the ND rate from 12.5 to 5.1 % (p < 0.001). Of the 340 resected nodules, 10.7 % (18) were in the ND category, of which 28 % (5/18) of these were found to be malignant (4 papillary carcinoma and 1 lymphoma).ConclusionsThe results from this study demonstrate that thyroid FNAs performed with bedside ROSE can significantly reduce the ND rate compared with non-ROSE, even in experienced groups with low initial ND rates. It is therefore imperative that care providers managing patients with thyroid nodules ensure that thyroid FNAs are referred to specialized individuals/groups who do high volume, and ideally with the use of bedside ROSE, whether provided by a cytotechnologist or a pathologist.

Cytohistological correlation of salivary gland tumours with emphasis on Milan system for reporting: A novel step towards internal quality assurance

Fine needle aspiration cytology (FNAC) is a cost-effective diagnostic technique for evaluation of salivary gland lesions. But, then, cytological evaluation of salivary gland lesions also has lot of challenges. To overcome the difficulties, “The Milan system for reporting salivary gland cytopathology” (MSRSGC) was introduced for diagnosis and management and establishing the risk of malignancy (ROM) in different categories. The present study was conducted to grade the salivary gland lesions according to Milan system of reporting and to correlate with their histopathological findings. The current study was conducted in the department of Pathology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pondicherry for a period of 5 years. Around 153 salivary gland lesions were aspirated. Salivary gland swellings were examined clinically, correlated with the details on the request forms and ultrasound findings, palpated and aspirated. The cytological features were evaluated and categorized according to Milan System for Reporting Salivary Gland Cytopathology”: Category 1: Nondiagnostic (ND); Category 2: Non-neoplastic (NN); Category 3: Atypia of undetermined significance (AUS); Category 4a: Neoplasm: benign (NB), Category 4b: Neoplasm: salivary gland neoplasm of uncertain malignant potential (SUMP); Category 5: suspicious of malignancy (SM); and Category 6: Malignant (M). They were further correlated with histopathological findings. All data were entered in MS excel sheet.Total 153 cases were evaluated cytologically, and histological followup was available in 134 cases. The distribution of cases into different categories were as follows Non-Diagnsotic (2.6%), Non-Neoplastic (20.9%), Atypia of Undetermined Significance (1.9%), Neoplastic-Benign (41.1%),Salivary gland neoplasm of Uncertain Malignant Potential (0%), Suspicious of Maligancy (0%) and Malignancy (33.3 %). Risk of malignancy were observed in categories 2 and 6 and were 3.84 % and 78.2 %. Sensitivity of FNAC in diagnosing salivary gland lesions was 84.2 %, specificity was 98.21%,positive predictive value was 94.64%, and negative predictive value was 91.70% with an accuracy of 93.60%.MSRSGC is a novel reporting system in cytological diagnosis of salivary gland lesions. Implementation of this reporting system in cytological diagnosis has enabled establishment of adequate diagnosis, assessment of risk stratification and facilitating clinicians to take further step in management plan.

Root cause analysis of indeterminate diagnoses in serous fluids cytopathology.

The International System for Reporting Serous Fluid Cytopathology proposed five diagnostic categories: Nondiagnostic (ND), Negative for Malignancy (NFM), Atypia of Undetermined Significance (AUS), Suspicious for Malignancy (SFM) and Malignant (MAL) (Primary or Metastatic). The indeterminate (AUS/SFM) categories are challenging for management. The goal of this study is to reveal the root causes contributing to indeterminate diagnoses (ID). We searched our archives between 1 January 2017 and 30 June 2019, and performed a root cause analysis (RCA) using the "5 whys" method to determine the contributing factors of ID. Nine hundred eleven specimens were evaluated and diagnosed: ND (9, 1%), NFM (667, 73.2%), AUS (51, 5.6%), SFM (27, 3%) and MAL (157, 17.2%). More than one factor contributed to 38/78 ID. Low volume (<50 cc), and low cellularity were identified in 31 and 51 cases, respectively. Three cases were simply deferred to concurrent biopsy. Eleven cases were called atypical, favor reactive mesothelium despite confirmatory IHC. Atypical lymphoid population was reported in seven cases. Cellblocks (CB) were low in cellularity despite volume >1000 mL in 13 cases. Two mesotheliomas were underdiagnosed as suspicious. Low cellularity and low volume were the most common contributing factors, highlighting the importance of adequate sample collection. Adequate volume specimens with low cellularity may benefit from a close inspection and a second CB. Some IDs can be switched to NFM or MAL with careful consideration of clinical, radiologic findings and ancillary testing, and concurrent surgical pathology correlation when available.

Rapid on-site evaluation (ROSE) for fine needle aspiration of thyroid: benefits, challenges and innovative solutions.

Rapid on-site evaluation/adequacy assessment (ROSE) is considered an essential component of thyroid fine needle aspiration (FNA) and many reported that it significantly decreases the nondiagnostic (ND) rate. The average reported ND rate without ROSE is about 20% and is improved by 12% when ROSE is implemented. However, the data also suggest that the improvement in ND rate after implementation of ROSE is directly related to the ND rate prior to ROSE and that it is mostly beneficial to aspirators with less experience. Several studies have also raised concerns regarding the impact of ROSE as it prolongs the procedure time, requires additional resources and increases the cost incurred by the additional fees. This resulted in a wide variation in the methodology applied to acquire the sample and implement ROSE across the globe with variation in the number of passes performed, stain utilized and the personnel reviewing the slides, e.g., cytotechnologists versus pathologist. This review summarized the literature reporting the impact of ROSE including its pros and cons, its accuracy and reproducibility, concordance between cytotechnologists and pathologists based on final diagnosis and highlights the different ways laboratories attempted to circumvent the challenges. In particular, the review highlights a unique approach practiced in Ito Hospital, Tokyo, Japan.