Pitfall In Cytology Research Articles

Myoepithelioma of soft tissue in the gluteal region: Diagnostic pitfall in cytology.

Myoepithelioma of soft tissue in the gluteal region: Diagnostic pitfall in cytology.

Diagnostic Accuracy and Pitfalls in Fine Needle Aspiration Cytology Of Salivary Gland Lesions.

BACKGROUND : Fine Needle Aspiration cytology (FNAC) is an essential diagnostic method used to evaluate salivary gland lesions. However, at times, diverse morphological patterns and overlapping features between benign and malignant lesions becomes challenging and difficult to give a definitive diagnosis. Aim are to compare the findings of preoperative FNAC with their histopathological types and to discuss the causes for discordancy and identify the potential pitfalls in cytological diagnosis. METHODS: An observational analytical study was carried out over a 4 year period to review the cases of patients with salivary gland lesions who underwent FNAC in a medical college, hospital. Taking histopathological diagnosis as gold standard, the cytological diagnosis of the cases was compared and the causes of discrepancies were evaluated. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value was calculated. RESULTS: In the present study, out of 137 cases, cyto- histological correlation was available in 46 cases. Pleomorphic adenoma was the commonest lesion in the study. The diagnostic value of FNAC was: Sensitivity 66.7%, Specificity 97.4%, Positive Predictive Value 80%, Negative Predictive Value 95% and Diagnostic Accuracy 93.3%. False positive diagnosis was rendered in warthin’s tumor whereas false negative diagnosis was given in mucoepidermoid carcinoma. CONCLUSION: FNAC is useful in the preoperative diagnosis of salivary gland lesions. Pitfalls in cytologic diagnosis were due to errors in sampling, cystic lesions and interpretation of smears . DOI: 10.21276/APALM.1284

Cytolo-histological correlation of breast lump-as a part of internal quality control

Introduction: Fine Needle Aspiration Cytology (FNAC) has gained increasing importance in the diagnosis of breast lumps especially it is an easy, non-invasive, simple procedure which can be done on OPD basis. The pre–operative diagnosis of breast lesions by FNAC is highly relied upon. However, there can be some cytological pitfalls in the diagnosis, especially when all the characteristic component of a lesion are not obtained in the aspirate, or when there is an overlap in the cytological features. Hence a review was undertaken with the following objectives. 1. To correlate cytologic and histopathologic diagnosis of breast lesions as a part of internal quality control. 2. To know the incidence of false positive and false negative cases. 3. To find out the sensitivity and specificity of FNACof breast lesions. Methods: This study was conducted for a period of 3 years (April 2009 to March 2012) and 200 cases of fine needle aspirates of breast lumps studied. Out of which 126 cases were followed by histopathological correlation at pathology department; the cases are collected from Mahatma Gandhi Medical College & Research Institute, Sri Balaji Vidhyapeeth University; Pondicherry. Results: Out of 200 cases studied by FNAC, histopathological correlation was available for 126 cases. Cytological diagnosis in general was divided into four categories, benign (76.19%), malignant (15.08%), suspicious (5.56%), and unsatisfactory (3.17%). Maximum patients were in age group of 21 to 30 years. There were 119 female patients and 7 male patients. Fibroadenoma (69.79%) was most common benign neoplasm. There were 5 cases (5.21%) reported by FNAC as gynecomastia. After correlation with histopathology, there was 82.26% of correct diagnosis in all benign lesions. There were 16 cases (84.21%) diagnosed cytologically as malignant and 3 cases (15.79%) as invasive duct carcinoma. Histopathologically all were confirmed as invasive duct carcinoma. Out of that one was reported in male breast. The incidence of false positive case was zero, false negative case was (1.59%). The diagnostic accuracy after histopathological correlation in malignant cases was 98.36%, sensitivity was 92.86% and specificity was 100%. Conclusion: To conclude, fine needle aspiration cytology is a fairly safe procedure in trained hands, and it gives reasonably accurate results, thereby helping the clinicians to plan the best line of treatment. Also with invention of imaging guided aspiration, FNAC went one step ahead in diagnosis of non-palpable lesion of breast. Thus a triple modality of clinical, mammographic and cytological correlation is required and for internal quality control FNAC is correlated with histopathology. Key Words: FNAC; Breast lumps; Breast neoplasm

Fnab of the Salivary Gland Tumors: An Institutional Experience

Previous experiences have shown that FNAB of the salivary glands may lead the treatment choise with high diagnostic accuracy. Though the specificity of the method is high, sensitivity has always been lower because of the cytologic pitfalls.

Large non-functioning parathyroid cysts: our institutional experience of a rare entity and a possible pitfall in thyroid cytology.

Large non-functioning parathyroid cysts represent a rare entity with a benign clinical course. They may be misdiagnosed as thyroid cystic neoplasms on fine needle aspiration cytology (FNAC), resulting in inappropriate surgical treatment. We evaluated our institutional experience in the diagnosis of large parathyroid cystic lesions underlining all the differential diagnoses and pitfalls. In the period between 1998 and 2012, we reported the cytology of eight large (>2.5 cm) parathyroid cystic lesions (all female patients) with histological control. The aspirations were performed with a 25-gauge needle with ultrasonographic guidance. The aspirated material was processed with liquid-based cytology (LBC). All the patients had normal serum parathyroid hormone (PTH) and calcium. The cytological samples showed a fluid watery component without colloid and few or absent epithelial cells. The resulting negativity for thyroglobulin and positivity for PTH, carried out on the cystic fluids, suggested parathyroid lesions rather than either thyroid cystic lesions (including follicular thyroid neoplasm) or cystic malignant lesions. All the patients underwent surgery without complications. To the best of our knowledge, this is one of the largest series with cytohistological evaluation of large parathyroid cysts. The incidence of large parathyroid cysts remains controversial as most patients are asymptomatic. FNAC may be performed with conclusive results in the majority of cystic cases. The detection of PTH and calcium on the cystic liquid is likely to achieve a correct cytological diagnosis, allowing adequate treatment and ruling out a more frequent thyroid lesion.

Role of FNAC in the Preoperative Diagnosis of Salivary Gland Lesions.

The characteristic cytologic features of the common salivary gland lesions have been well-delineated in literature. However, there also exist cytologic pitfalls and overlapping features that make an accurate diagnosis difficult in few cases. The present study was designed to compare the cytologic findings of salivary gland lesions with the histologic diagnoses, in order to assess the sensitivity, specificity and diagnostic accuracy of FNAC, with an emphasis on discordant cases. Patients with suspected salivary gland enlargements, who were referred for FNAC, were included in this study, which was done over a 3 year period in a medical college hospital. FNAC was performed by using the standard procedure. Smears were stained by using Papanicolaou's and MGG stains. Cytologic diagnosis was compared with histopathologic diagnosis wherever it was available. Eighty eight patients with salivary gland swellings were included in the study. The ages of the patients ranged from 15 to 82 years, with the M:F ratio being 1.6:1. Out of 88 cases, 68 had swellings in parotid gland, 19 had them in submandibular gland and one had them in hard palate. Pleomorphic adenoma was the commonest neoplasm which was seen in our study. Mucoepidermoid carcinoma (MEC) was the only malignant lesion seen in our study. One each of Warthin's tumour (WT) and MEC were overdiagnosed and underdiagnosed respectively, the reason being squamous metaplasia in WT and subtle nature of malignant cells in low-grade MEC. WT and MEC can pose problems in cytologicdiagnosis. Sampling errors and interpretational errors can lead todiscordant diagnoses.

Cytologic features of stratified mucin producing intraepithelial lesion of the cervix—A case report

Stratified mucin-producing intraepithelial lesion (SMILE) of the cervix is a human papilloma virus (HPV) associated high grade intraepithelial columnar cell neoplasm that is thought to arise from the reserve cells of the transformation zone. It is composed of immature stratified cells that display intracytoplasmic mucin and is commonly associated with high grade squamous intraepithelial lesion (HSIL), adenocarcinoma in situ (AIS), and invasive carcinoma. Here, we describe the cytologic features of SMILE and discuss its pitfalls in cervical cytology. A 51-year-old woman was diagnosed with SMILE on a cervical biopsy. Histologically, the dysplastic epithelium showed enlarged nuclei with increased nuclear density and presence of mucin-producing columnar cells throughout its thickness. The slides from the last two Pap tests (ThinPrep) performed on the patient were reviewed and compared with the histology. Cytologically, groups of atypical endocervical glandular cells were seen on both Pap tests. These groups showed mild nuclear crowding, slightly enlarged nuclei, nuclear hyperchromasia, and indistinct nucleoli. The borders of these cell groups were relatively smooth. Original cytologic diagnosis was atypical squamous cells of undetermined significance (ASC-US) in both instances. HPV (Hybrid Capture 2) testing was positive on both occasions. Similar to the histology, cytologic features of SMILE are subtle. The features are not typical for AIS or for HSIL and could easily be misinterpreted as reactive. This report emphasizes that careful review of crowded groups of glandular cells in HPV positive women is absolutely critical. Based on our knowledge, this is the first description of the cytologic features of these lesions.

Extensive squamous metaplasia with cystic change in pleomorphic adenoma: A potential diagnostic pitfall in fine needle aspiration cytology

Pleomorphic adenoma (PA) is the most common salivary gland tumor, frequently affects the parotid gland. Histological diversities are common as PA may show mucous, sebaceous, oncocytic cells, and squamous metaplastic cells. Squamous metaplasia rarely results in formation of extensive keratin-filled cyst lined by squamous epithelium. This can be mistaken for malignancy, like squamous cell carcinoma and mucoepidermoid carcinoma on cytological interpretation, due to limited and selective sampling. Here, we report a case of slowly enlarging parotid mass in a 70-year-old male. Cytological smears revealed moderately atypical squamous cells, clumps of keratin material, necrosis, inflammatory cells and macrophages along with bland epithelial and myoepithelial cell in fibromyxoid stroma. Cytological diagnosis of squamous cell carcinoma ex-pleomorphic adenoma was suspected. Subsequent resection showed pleomorphic adenoma, with extensive squamous metaplasia and cystic change on histology. There was no evidence of squamous cell carcinoma. The cytopathology findings are probably related to ischemic infarction, which mimic malignancy. This case emphasizes the need for a cautious and systematic approach in the cytological interpretation of cystic pleomorphic adenoma with metaplastic epithelial changes. We discuss the pitfall in the cytological diagnosis including differential diagnosis of this uncommon presentation.

Tracheal Adenoid Cystic Carcinoma Infiltration in Thyroid: A Diagnostic Pitfall in Aspiration Cytology

Tracheal Adenoid Cystic Carcinoma Infiltration in Thyroid: A Diagnostic Pitfall in Aspiration Cytology

Nodular sclerosing adenosis of breast: A diagnostic pitfall in fine needle aspiration cytology

Fine needle aspiration cytology was performed in a 46-year-old female presenting with a breast lump and mammography suggesting a malignancy. The smears were cellular with cohesive clusters and scattered epithelial cells showing moderate nuclear pleomorphism and focal acinar formation. Stromal fragments, benign epithelial cell clusters and a few naked nuclei were noted in the background. Considering the clinical features, mammography findings as well as cytological features, a diagnosis of ductal carcinoma was suggested. Subsequent histopathological examination revealed it to be nodular sclerosing adenosis. The cytohistological correlation of this uncommon lesion, a potential pitfall in breast fine needle aspiration diagnosis which may lead to a false-positive diagnosis is discussed.

Thyroid nodules in pediatrics: which ones can be left alone, which ones must be investigated, when and how

Thyroid nodules are less frequent in childhood than in adulthood, but are more often malignant. Recent estimates suggest that up to 25% of thyroid nodules in children are malignant, therefore, a more aggressive approach is recommended. In this review, we suggest an approach based on a first-step clinical, laboratory, and sonographic evaluation. A history of irradiation of the neck, cranium or upper thorax, previous thyroid diseases or thyroid neoplasms in the family should alert clinicians as being associated with a greater likelihood of malignant nodules. Signs or symptoms of hyperthyroidism and dysmorphic features should be carefully considered during the physical examination. Palpable firm lymph nodes, found in some 70% of cases, are the most significant clinical finding in children with malignant nodules. Although the routine determination of calcitonin levels is not uniformly practiced, it can help recognize sporadic or familial medullary thyroid neoplasms. Blood thyroid stimulating hormone, free thyroxine, and free triiodothyronine determinations (the latter in case of symptoms of hyperthyroidism) are aimed at identifying the few hyperthyroid patients, for whom the next step should be scintiscan. Hyperthyroid patients usually disclose an increased uptake, and a diagnosis of toxic adenoma is commonly made. Cases with normal thyroid function or hypothyroidism (which is usually subclinical) should be evaluated by fine-needle aspiration biopsy (FNAB). In eu/hypo-thyroid patients, scintiscan provides poor diagnostic information and should not be routinely employed. Thyroid ultrasonography is used to select cases for FNAB. Although ultrasound cannot reliably discriminate between benign and malignant lesions, it does provide an index of suspicion. Sonographic features that increase the likelihood of malignancy are microcalcifications, lymph node alterations, nodule growth under levothyroxine treatment, and increased intranodular vascularization demonstrated by color Doppler. There is growing evidence that elastography may provide further information on nodule characteristics. FNAB is indicated in all cases with a likelihood of malignancy. FNAB has a diagnostic accuracy of approximately 90% and is used in selection of patients which require surgery. Recently, histological markers and elastography have been introduced to increase the specificity of FNAB and ultrasound, respectively. The pitfall in FNAB cytology is the follicular cytology, in which it is not possible to distinguish between adenoma and carcinoma and therefore thyroidectomy is advised. Conflict of interest:None declared.

Diagnostic and Prognostic Significance of Image Cytometric DNA Ploidy Measurement in Cytologic Material of Uterine Cervical Preneoplastic Lesions

neoplasm that is thought to arise from the reserve cells of the transformation zone. Morphologically, SMILE is composed of immature stratified cells that display intracytoplasmic mucin or cytoplasmic vacuoles, but lack overt gland formation that is typically seen in AIS. SMILEs are commonly associated with HSIL, AIS and invasive carcinoma. Since the first description of histologic features of SMILE in 2000, there has been a lack of description of cytologic features of SMILE in the literature. We have retrospectively reviewed cytologic features of four cases of SMILE and have discussed its pitfalls in cervical cytology. Materials and Methods: Four cytologic cases from two patients with SMILE were identified in the hospital archives. The corresponding cytology (ThinPrep) and histology slides were reviewed and compared. Immunohistochemistry for p16 was used for evaluation on the histologic material. High-risk HPV (hr-HPV) status results, analyzed with Hybrid Capture 2, were documented. Results: Histologically, SMILEs showed less impressive nuclear changes with enlarged nuclei and increased nuclear/cytoplasmic ratio. The dysplastic epithelium retained mucin-producing columnar cells with prominent intracytoplasmic mucin. Mitotic figures were encountered, but apoptotic bodies were not seen. p16 immunostaining revealed both nuclear and cytoplasmic full thickness staining of the dysplastic epithelium. HrHPV testing was positive in all four cytology cases. Cytologically, crowded groups of atypical endocervical glandular cells were consistently seen in all four cases. These groups of atypical glandular cells showed slightly enlarged nuclei, nuclear overlapping, hyperchromasia and prominent nucleoli. The borders of these cell groups were relatively smooth. In three cases, LSIL-like atypical squamous cells were encountered. Original cytologic diagnoses were rendered as negative, ASC-US (x2) and LSIL. The glandular cell abnormality was not mentioned in any of the original cytologic diagnoses. Conclusions: Similar to the histology, cytologic features of SMILE are less dramatic and are often subtle. It lacks the typical cytologic changes seen in either AIS or HSIL. The consistent finding is that of relatively crowded groups of atypical glandular cells. The architectural abnormality is more prominent than the nuclear changes. The features are not typical for AIS and these atypical glandular cells could easily be interpreted as reactive given their overlapping features with those seen in repair. In addition, concurrent atypical squamous cells serve as a distracting factor in overlooking these atypical glandular cells. Our study emphasizes that careful review of crowded groups of glandular cells in hr-HPV positive women is absolutely critical. Based on our knowledge, this is the first description of the cytologic features of these lesions.

EUS-FNA (endoscopic ultrasonography directed fine needle aspiration biopsy) and diagnostic pitfalls in diagnostic cytology of cystic lesions of the pancreas

EUS-FNA (endoscopic ultrasonography directed fine needle aspiration biopsy) and diagnostic pitfalls in diagnostic cytology of cystic lesions of the pancreas

Mucin-Producing Neoplasm of the Pancreas - Cytologic Features, Limitations and Pitfalls on FNA Samples

Mucin-Producing Neoplasm of the Pancreas - Cytologic Features, Limitations and Pitfalls on FNA Samples

Limits of fine-needle aspiration cytology in diagnosing pilomatrixoma: A series of 25 cases with clinico-pathologic correlations

Background:Pilomatrixoma (PMX) is a benign, quite uncommon, skin neoplasm, which is frequently misdiagnosed by clinicians.Aim:We have analyzed 25 PMX to determine the agreement between clinical diagnosis, preoperative FNA characteristics, and corresponding histopathological specimens; moreover, reliable cytologic criteria for PMX and the differential diagnosis to avoid cytological pitfalls have been emphasized.Materials and Methods:By fine-needle aspiration (FNA) cytology a series of consecutive cases of PMX collected during last 5 years were studied. Smears were stained by Papanicolau and May-Grünwald-Giemsa.Results:Patients affected by PMX were 11 males, 14 females (ratio 1:1.27); the mean age was 32.72 years with age range 3-78 years, being 72% (18/25) of patients 40 years or less. PMX was mainly distributed in the head-neck region (52%), scalp (16%), upper/lower arms (28%), and chest (4%). The observed diagnostic cytological features were represented by clusters of basaloid epithelial cells, shadow or ghost cells, inflammatory background, calcification, and giant cells. Unfortunately, not all these morphological aspects were always disclosed in smears, thus making the cytological preoperative diagnosis questionable and problematic.Conclusions:The experience of a well-trained cytopathologist should distinguish the relevant FNA features in terms of smear background, architecture, and cell morphology. The most dangerous mistake in FNA diagnosis of PMX regards a diagnosis of primary malignant or metastatic cutaneous lesions.

Addressing the challenges of practicing breast cytology in a tertiary teaching hospital in Kenya

Objectives To assess diagnostic accuracy of breast cytology through histological correlation and identify reasons for diagnostic pitfalls. Methods A total of 2700 cases were reported in cytology during the study period of 14 months, of which 1100 (40%) were from breast lesions. Only 96 (9%) cases had histological follow up in the form of core biopsy, lumpectomy and/or mastectomy. The cases in which cytology diagnosis did not match with histology diagnosis were reviewed by two pathologists and reasons for the diagnostic pitfalls in cytology were recorded. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of cytology were calculated. Results Seventy cases (73%) had no cytohistologic discrepancy, three cases were reported as unsatisfactory while 23(24%) showed discrepancy with histology. Interpretation errors occurred in 16 cases in 3 categories (benign C2, atypical C3 and suspicious C4). There were 2 false negatives (C2) and 14 false positives (C3 and C4). Majority (58%, 8 out of 14) of the errors in the false positive groups were due to the poor quality of smears received from our satellite centres. Misclassification of subtypes within benign and malignant categories occurred in 2 cases each due to overlapping features. Sampling errors occurred in three cases due to inherent nature of the lesion. Sensitivity of our FNA was 91%, Specificity was 79%, Positive predictive value (PPV) 59% and negative predictive value (NPV) was 96%. Conclusions There was no major discrepancy to influence the management or prognosis significantly. Minor discrepancies resulted due to sampling and interpretation errors. Poor quality smear emerged as a major cause of interpretation errors. This calls for corrective measures to be applied for both sample providers and pathologists.

Extrinsic allergic alveolitis as an uncommon diagnostic pitfall in lung cytology

House paints, the industrial products of toxic chemicals are known to be linked with severe respiratory disturbances especially in inadequately ventilated places. In this study, we aimed to report a biopsy-proven case of extrinsic allergic alveolitis (EAA) who presented with nonspecific respiratory symptoms 1 month after having her whole house interior painted. At CT scanning, we observed the ground glass opacities and the micronodular pattern typical for EAA and also a solid, consolidative lung area, highly suggestive of malignancy. The case initially was misinterpreted as a malignant tumor both radiologically and cytologically at CT-guided transthoracic fine needle aspiration biopsy. The final pathologic diagnosis was given as EAA on frozen section performed during thoracotomy operation. The patient received short-term steroid treatment and has been doing well for the last 7 months after her operation. As a conclusion, when assessing a cytologic material from a patient who has got a solid lung mass and also a history of chemical dye exposure, consolidative mass formation which is a rare form of EAA should always be kept in mind. Another final point is that the appropriate ventilation should be achieved if the exposure with the house paint chemicals is inevitable.

Diagnostic pitfalls in cytological diagnosis of subcutaneous fungal infection in renal transplant recipients

Renal transplant recipients (RTRs) are at increased risk of the development of a variety of skin infections that can result from graft-preserving immuno-suppressive therapy. In this study, we aimed to determine cytomorphological findings of fungal subcutaneous swelling in seven RTRs and to analyze diagnostic pitfalls in fungal cytology. A retrospective review of fine needle aspiration cytology (FNAC) smears of subcutaneous swelling with positive fungal elements in RTRs from 2008 to 2010 was performed. We had seven cases (all males; age range, 34-58 years, mean, 46.3 years). The time interval between the renal transplantation and appearance of swelling ranged from 8 to 19 months (mean, 13.4 months). The swelling was located on lower limb (six cases) and arm (one case). The lesion was solitary (six cases) and multiple (one case). The cytology of aspirated material showed branched septate fungal hyphae in six cases. These were well delineated on Periodic acid schiffs (PAS) and chromic silver methenamine (CSM) stains. One case showed presence of faint, thin walled, broad ribbon like hyphae. Culture of aspirated material was performed in four cases which grew phaeohyphomycosis in all. Histology of excised tissue showed numerous septate, branched, pigmented fungal elements suggestive of pheohyphomycosis in four cases and broad ribbon hyphae suggestive of zygomycosis in one case. All of our cases responded well with anti-fungal treatment. Fungal infection can manifest as subcutaneous swelling in RTRs. It is often severe, rapidly progressive and difficult to diagnose. FNAC is an important diagnostic tool which is simple, cost effective and rapid method.

Pitfalls in pulmonary cytopathology

Lung cancer is the most frequently diagnosed major cancer. Fine-needle aspiration of lung lesions is a reliable test with a high diagnostic yield, high sensitivity, and high specificity, yet differentiation of reactive pulmonary processes from neoplasms and subclassification of lung neoplasms often poses difficult diagnostic dilemmas. This review outlines potential pitfalls in pulmonary cytology and presents diagnostic tools to assist in the accurate diagnosis.

Cytological Pitfalls: Differential Diagnoses for Cytoplasmic Granulation

Cytological Pitfalls: Differential Diagnoses for Cytoplasmic Granulation