Use Of Fine-needle Aspiration Research Articles

COMPARATIVE EVALUATION OF CELL BLOCK METHOD AND SMEAR CYTOLOGY IN FINE NEEDLE ASPIRATION CYTOLOGY OF PALPABLE THYROID LESION IN PATIENTS ATTENDING KIST MEDICAL COLLEGE TEACHING HOSPITAL

Background: Most patients with thyroid diseases present with palpable neck swelling. Accurate evaluation of thyroid nodules is crucial as they can be neoplastic. The use of fine needle aspiration and smear cytology for the detection of malignant thyroid lesions is the usual practice. However, it has its limitations and diagnostic pitfalls. Cell block analysis can be a useful adjunct to smears for establishing a more definitive cytopathologic diagnosis. This study was aimed to evaluate cytology and cell block findings in the patients of palpable thyroid lesions. Methods: A cross sectional, hospital-based comparative, observational study was conducted in Department of Pathology after receiving ethical approval from Institutional Review Committee. The study was conducted from 1st August 2022 to 1st August 2023. Statistical analysis of the diagnostic utility of cell block was evaluated taking into account sensitivity and specificity. Results: Among the 50 cases diagnosed as non-neoplastic by smear cytology, 2 were found to be neoplastic by cell block and similarly among the 5 cases which were not diagnosed by cytology, 2 cases were confirmed to be non-neoplastic thyroid lesions by cell block. Sensitivity of FNAC to detect neoplastic lesions was 66.6% and specificity was 100%, while cell block had 100% sensitivity and 100% specificity to detect those lesions. Conclusions: As both smear cytology and cell block procedures are done in a single setting, combination of two procedures has beneficial effect not only to support diagnosis but also to establish new diagnosis.

Tuberculosis manifesting as bilateral acute parotid swelling with unilateral lower motor neuron facial palsy: an unusual presentation

A 41-year-old female presented to the otorhinolaryngology department with a history of painful swelling over the bilateral parotid region, low-grade fever for the past one month and progressively worsening left-side facial weakness for the last 15 days. She had received multiple courses of antibiotics elsewhere, which did not result in any improvement except pain. She had no past history of any comorbidities or any previous history of tuberculosis. Examination revealed that she had a non-tender, circumscribed, solitary, 3×3 cm size, firm swelling over the bilateral parotid region. Clinical signs of grade V facial nerve palsy (House and Brackmann classification) were noted. There was a severe grade left lower motor neuron facial nerve palsy (left side) seen. There was no cervical lymphadenopathy. The rest of the head and neck examination was unremarkable. Fine needle aspiration cytology (FNAC) from the most prominent part of the swelling was suggestive of granulomatous inflammation. The patient was initially treated with intravenous antibiotics, supportive care and started on antitubercular drugs (once the diagnosis was established) under the National Tuberculosis Eradication Program (NTEP) to which she responded well and after three months of therapy, her swelling and facial weakness improved significantly. In addition to reporting a completely rare kind of presentation, this paper reviews relevant literature and stresses the need for a high degree of suspicion for tuberculous parotitis in a patient with bilateral parotid swelling. The use of fine needle aspiration is important so that this curable condition can be diagnosed early and medically treated. In this way, surgical intervention can be avoided and further complications can be prevented.

Evaluation of the HBV liver reservoir with fine needle aspirates

Background & AimsFinite duration of treatment associated with HBsAg loss is the current goal for improved therapeutic approaches against chronic HBV infection, as it indicates elimination or durable inactivation of intrahepatic covalently closed circular DNA (cccDNA). To assist drug development, the definition of early predictive markers of HBsAg loss by assessing their value in reflecting intrahepatic cccDNA levels and transcriptional activity is essential. Fine needle aspirates (FNAs) have recently emerged as a less invasive alternative to core liver biopsy (CLB) and showed to be useful for investigating intrahepatic immune responses. The aim of this study was to optimise and validate the use of FNA vs. CLB to evaluate the intrahepatic viral reservoir. MethodsPaired FNA/CLB samples were obtained from patients with HBeAg+ chronic hepatitis (n = 4), HBeAg− chronic hepatitis (n = 4), and HBeAg− chronic infection (n = 1). One HBeAg+ patient was undergoing tenofovir treatment. HBV 3.5-kb RNA and cccDNA were quantified by droplet digital PCR. ResultscccDNA was quantifiable in all but one FNA/CLB pair, showing the highest levels in untreated HBeAg+ patients, except for the tenofovir-treated patient. Similarly, 3.5-kb RNA was detectable in all but one FNA sample and showed higher levels in HBeAg+ patients. When comparing cccDNA and 3.5-kb RNA quantification in FNA vs. CLB samples, no statistically significant differences were identified. ConclusionsThese results demonstrate the possibility to quantify cccDNA and assess its transcriptional activity in patients with chronic hepatitis B by combining FNA and droplet digital PCR. This supports the use of FNA in clinical trials to evaluate the intrahepatic viral reservoir during the development of new antivirals and immunomodulatory agents. Impact and implicationsChronic hepatitis B infection is characterised by a complex interplay between immune responses and viral replication in the liver, which determines the long-term outcome of the disease. In this study, we show that fine needle aspiration of the liver, a less-invasive alternative to core biopsies, allows the assessment of the hepatic viral reservoir.

The TNAPP web-based algorithm improves thyroid nodule management in clinical practice: A retrospective validation study.

The detection of thyroid nodules has been increasing over time, resulting in an extensive use of fine-needle aspiration (FNA) and cytology. Tailored methods are required to improve the management of thyroid nodules, including algorithms and web-based tools. To assess the performance of the Thyroid Nodule App (TNAPP), a web-based, readily modifiable, interactive algorithmic tool, in improving the management of thyroid nodules. One hundred twelve consecutive patients with 188 thyroid nodules who underwent FNA from January to December 2016 and thyroid surgery were retrospectively evaluated. Neck ultrasound images were collected from a thyroid nodule registry and re-examined to extract data to run TNAPP. Each nodule was evaluated for ultrasonographic risk and suitability for FNA. The sensitivity, specificity, positive and negative predictive values, and overall accuracy of TNAPP were calculated and compared to the diagnostic performance of the other two algorithms by the American Association of Clinical Endocrinology/American College of Endocrinology/Associazione Medici Endocrinologi (AACE/ACE/AME), which it was derived from the American College of Radiology Thyroid Imaging Reporting and Data System (ACR TI-RADS). TNAPP performed better in terms of sensitivity (>80%) and negative predictive value (68%) with an overall accuracy of 50.5%, which was similar to that found with the AACE/ACE/AME algorithm. TNAPP displayed a slightly better performance than AACE/ACE/AME and ACR TI-RADS algorithms in selectively discriminating unnecessary FNA for nodules with benign cytology (TIR 2 - Bethesda class II: TNAPP 32% vs. AACE/ACE/AME 31% vs. ACR TI-RADS 29%). The TNAPP reduced the number of missed diagnoses of thyroid nodules with suspicious and highly suspicious cytology (TIR 4 + TIR 5 - Bethesda classes V + VI: TNAPP 18% vs. AACE/ACE/AME 26% vs. ACR TI-RADS 20.5%). A total of 14 nodules that would not have been aspirated were malignant, 13 of which were microcarcinomas (92.8%). The TNAPP algorithm is a reliable, easy-to-learn tool that can be readily employed to improve the selection of thyroid nodules requiring cytological characterization. The rate of malignant nodules missed because of inaccurate characterization at baseline by TNAPP was lower compared to the other two algorithms and, in almost all the cases, the tumors were microcarcinomas. TNAPP's use of size >20mm as an independent determinant for considering or recommending FNA reduced its specificity. TNAPP performs well compared to AACE/ACE/AME and ACR-TIRADS algorithms. Additional retrospective and, ultimately, prospective studies are needed to confirm and guide the development of future iterations that incorporate different risk stratification systems and targets for diagnosing malignancy while reducing unnecessary FNA procedures.

Childhood sarcomas: fine-needle aspiration cytopathology with an emphasis on the use of molecular studies.

In children and adolescents, most sarcoma subtypes have a simple karyotype with a single genetic alteration; cytologic findings combined with ancillary testing can lead to a specific diagnosis. The goal of this study was to review the use of fine-needle aspiration in conjunction with immunohistochemistry and molecular studies as a part of an integrated, multidisciplinary diagnostic workup for bone and soft tissue sarcomas in this population. We searched for cases aged ≤18 years old with a malignant bone or soft tissue tumor that had corresponding cytology specimens from 3 institutions. Clinical data, cytologic findings and diagnoses, histologic diagnoses, and ancillary testing were documented. Of 99 cases, 55% were male with a mean age of 12 years. Ninety-four cases (95%) had a specific histologic diagnosis, and 84 cases (85%) were primary neoplasms. Ninety-four cases (95%) had a malignant cytologic diagnosis, and 71 cases (72%) had a specific cytologic diagnosis concordant with the histologic diagnosis. Among primary tumors with a specific histologic diagnosis, a specific cytologic diagnosis was made in 63 cases (79%). After excluding osteosarcoma, 74% of the tumors (n = 50) had molecular studies. Specific genetic alterations supporting a definitive diagnosis were found in 42 cases (84%), the majority of which were demonstrated using Fluorescence In Situ Hybridization (n = 33, 79%). We found that fine-needle aspiration in conjunction with core needle biopsy, immunohistochemistry, and molecular studies allowed cytopathologists to accurately classify sarcomas in a pediatric age group.

Fine-Needle Aspiration Cytology for Parotid Tumors.

Fine-needle aspiration (FNA) cytology is widely used in clinical practice as a simple and minimally invasive test for parotid tumors that allows for preoperative estimation of benignancy and malignancy, histological type, and malignancy grade and can be performed on an outpatient basis. In recent years, cell blocks prepared with core needle biopsy (CNB) and liquid-based cytology (LBC) have increased the reliability of immunostaining and molecular biological testing, leading to improved diagnostic accuracy. In 2018, the Milan System for Reporting Salivary Gland Cytology was introduced, but it does not include malignancy grade or histological type, so we proposed the Osaka Medical College classification as a more clinically based cell classification that includes both types of information, and we have reported on its usefulness. This review gives an overview of the history and use of FNA and describes CNB and LBC and the two classification systems.

50. Molecular profiling of Cytolyt-Fixed FNA washes to improve diagnostic yield in lung cancer

For therapeutic purpose, tumor molecular profiling (MP) of both DNA and RNA is standard-of-care in lung cancer patients. With increased use of fine needle aspiration (FNA) to assist in diagnosis, MP can be challenging given the limited cell block material. At our institution, only 40% of 309 FNA with lung cancer diagnosis over 2 years were successful for DNA and RNA MP as a send out, compared with 90% of surgically-resected specimens. To improve the diagnostic yield, we salvaged left over FNA washes (FW, 30-40mL) from the Cytology Laboratory within a median of 10 days from collection. For 211 FW with a malignant diagnosis, DNA/RNA extraction from 4 mL FW was performed using QIAamp ccfDNA kit (QIAGEN), where 97% and 83% yielded adequate levels for MP of DNA and RNA respectively. MP of DNA only (48) or DNA/RNA (35) workflows were performed using a 50-gene Hotspot, OCAV3, or OCAplus NGS panels (ThermoFisher). For 67 cases with a concurrent or other profiled specimen, 94% concordance for SNVs/indels and 77% for CNVs detection was observed, and expected EML4-ALK and FGFR3-TACC fusions detected. Discordance of 21 variants calls in 13 FW was due to low VAF, low coverage, or failure of CNV QC metrics. Importantly, 7 relevant variants and fusions were detected in 4 specimens previously reported as insufficient and one with prior DNA results only. Thus, the use of FW as a source of nucleic acids afforded increased diagnostic yield of FNAs for MP in lung cancer and timely targeted therapeutic intervention.

The value of concurrent endoscopic ultrasound-guided fine needle aspirates and needle core biopsies in the diagnosis of pancreatic neoplasms.

BackgroundEndoscopic ultrasound (EUS) fine needle aspiration (FNA) is highly sensitive and specific in the detection and diagnosis of pancreatic neoplasms. EUS‐guided needle core biopsy has been used alone or as an adjunct to maximize diagnostic yield. This study compared the use of FNA versus needle core biopsy in the diagnosis of pancreatic neoplasms.MethodsFrom January 1, 2018 through December 21, 2020, the Cytopathology Laboratory processed 374 FNAs from solid pancreatic masses of which 332 (89%) had concurrent pancreatic biopsies and form the basis of this study.ResultsOf the 332 FNAs, 173 (52%) were positive/suspicious for pancreatic adenocarcinoma, 33 (10%) were positive for a neoplasm, 20 (6%) were atypical 19 (6%) were negative and 87 (26%) were non‐diagnostic. Biopsies were concordant in 248 (75%) cases and discordant in 84 (25%) cases. Of the 84 discordant cases, 29 (35%) had neoplastic cells on FNA of which 14 were atypical, 11 were negative and 4 were nondiagnostic on core biopsy. Of the 18 (21%) FNAs with atypical cells, 8 showed adenocarcinoma on core biopsy. Thirty‐seven nondiagnostic FNAs showed adenocarcinoma on 25 (70%) core biopsies. If nondiagnostic FNAs were included, FNA sensitivity was 89% and specificity; 100%, and both were 100%, if the nondiagnostic cases were excluded. The needle core biopsy sensitivity was 91% and specificity; 100%.ConclusionBoth FNAs and core biopsies show high sensitivity and specificity in the detection of pancreatic neoplasms. However, combining the techniques enhances cellular yields and provides material for ancillary tests.

TESTICULAR CORE BIOPSY PRIOR TO SURGICAL SPERM EXTRACTION: A NOVEL ALGORITHM FOR AZOOSPERMIA

Men who present to infertility clinics with a diagnosis of nonobstructive azoospermia are often recommended to undergo surgical sperm extraction necessitating an operating room before proceeding with in-vitro fertilization (IVF) with microscopic intracytoplasmic sperm injection (ICSI). Prior studies have reported the use of fine needle aspiration with a 23-gauge needle as a diagnostic tool in these patients; however, the use has been limited to cytological evaluation of spermatogenesis and interstitial cells.

Clinical and pathological characteristics and hormone receptor status of women with breast cancer in the European Gaza Hospital: a retrospective chart-based review

BackgroundBreast cancer is the most common cancer (accounting for 31·3% of all cancers) among women in the Gaza Strip. This audit examines clinical and pathological characteristics of women presenting with breast carcinoma to the European Gaza Hospital (EGH), a governmental hospital and oncological centre serving 600 000 people in the southern Gaza Strip. MethodsData were collected from the records of patients with breast cancer treated at the EGH from March, 2015, to Sept, 2017. 397 cases were identified, including 218 patients with full hormone receptor status (oestrogen, progesterone, and Her2/neu receptor status). Data were analysed using Student's t test. FindingsThe mean age was 54 years (SD 11·2). 64% of the women (139 of 218) were older than 50 years, and 16% (33 of 218) were younger than 40 years. Histological grade was assessed for 56% of the women (122 of 218), and 55% of these women (67 of 122) presented with grade II tumours. Tumour size was documented in 82% of the files (178 of 218), and tumours were 2–5 cm in 47% of the documented cases (83 of 178). Furthermore, 51% of women (112 of 218) tested positive for the presence of cancer cells in lymph nodes, and 6% (14 of 218) had distant metastasis at presentation. The clinical stage at diagnosis was recorded in 56% of cases (122 of 218), of whom 4% (five of 122) presented at stage I, 54% (66 of 122) presented at stage II, and 42% (51 of 122) presented at stage III/IV. Pre-operative histopathology was carried out for 120 women, of whom 85% (102 of 120) had intraductal carcinoma. Only 81% of women (177 of 218) had post-operative histopathology, of whom 79% (139 of 177) had intraductal carcinoma. The histopathological type was significantly different for pre-operative and post-operative specimens (p<0·0001). Oestrogen receptor status was positive in 58% of patients (127 of 218), progesterone receptor status was positive in 57% of patients (124), and HER2/neu receptor was overexpressed in 33% of patients (65). Triple-negative breast cancer (testing negative for oestrogen, progesterone, and HER2/neu) was found in 23% of the women (49) and double-negative breast cancer (testing negative for oestrogen and progesterone but positive for HER2) in 11% of the women (24). InterpretationPatients with breast cancer present with advanced disease in the Gaza Strip. HER2/neu overexpression was approximately 10% higher than the percentages reported in the literature for the USA. The significant difference between pre-operative and post-operative specimens’ histopathological type could be due to use of fine-needle aspiration. Guidance from the Royal College of Radiologists recommends pre-operative core biopsy. It should be noted that documentation in the patient medical files was incomplete, which is a common obstacle in Gaza that must be tackled for effective improvement in the quality of care. FundingNone.

Overview of the Ultrasound Classification Systems in the Field of Thyroid Cytology.

Simple SummaryUltrasound (US) is the preferred imaging modality for thyroid nodule evaluation. Accurate US assessment of thyroid lesions can help decrease unwarranted FNA procedures of benign nodules. Several thyroid nodule risk classification systems that focus on US features have been published. Some of them highlight simple US patterns, while others rely on the presence of multiple US features to categorize thyroid nodules. The current review offers an evaluation of different US system, combining them with the use of fine needle aspiration and the cytological classification systems.The increasing application of ultrasound (US) in recent years has led to a greater number of thyroid nodule diagnoses. Consequently, the number of fine needle aspirations performed to evaluate these lesions has increased. Although the majority of thyroid nodules are benign, identifying methods to define specific lesions and tailor risk of malignancy has become vital. Some of the tools employed to stratify thyroid nodule risk include clinical factors, thyroid US findings, and reporting systems for thyroid cytopathology. Establishing high concordance between US features and cytologic diagnoses might help reduce healthcare costs by diminishing unnecessary thyroid procedures and treatment. This review aims to review radiology US classification systems that influence the practice of thyroid cytology.

Evaluation of DNA ploidy and S-phase fraction in fine needle aspirates from breast carcinoma.

The use of fine-needle aspiration (FNA) as a primary tool in the diagnosis of breast carcinoma provides opportunity for early proliferative characterization of the tumor. This study was undertaken to assess DNA ploidy and S-phase (SPF) fraction by flow cytometry in fine needle aspirates of patients with breast cancer. Fifty patients of breast cancer diagnosed on fine needle aspiration cytology (FNAC) and who subsequently underwent either mastectomy or lumpectomy were included. Material obtained by FNAC was subjected to DNA ploidy and SPF analysis. Immunohistochemical estimation of Ki-67 was done on histopathology sections. The proliferation markers (SPF and Ki-67) were compared with each other and with the histopathologic parameters. On DNA flow cytometry, 27 (54%) cases were aneuploid and 23 (46%) cases were diploid. The median SPF was 12.43% and 4.03% in aneuploid and diploid tumors respectively. Median Ki-67 among aneuploid tumors was 28.6% compared to 8.7% among diploid tumors. Aneuploid tumors were significantly associated with higher values of SPF and Ki-67, with Kappa 0.437 and agreement of 72%. Diploid tumors showed lower values of SPF and Ki-67, with Kappa 0.455 and agreement of 72.7%. Correlation among SPF and Ki-67 was highly significant with Kappa value 0.446, P value of .002 and agreement of 72.3%. DNA ploidy and proliferative activity by flow cytometric SPF estimation on fine needle aspirates from breast cancer can provide valuable prognostic and predictive information at the time of diagnosis in patients with breast cancer. This might help in selection of appropriate treatment modality.

A shift to more targeted thyroidectomies increased the detection of thyroid cancer and in particular low-risk papillary tumors in Southwestern Greece the decade 2007 to 2016.

ObjectivesData regarding thyroid cancer (TC) epidemiology in Greece in the last decade are scarce, so we investigated the trends in TC detection during 2007 to 2016.MethodsWe retrospectively studied 2040 pathology reports of total thyroidectomies performed at our institution from 2007 to 2016.ResultsA number of 478 cases of TC were identified in the studied decade. The overall incidence of TC among thyroidectomies rose over the years. The proportion of papillary T1 tumors among thyroidectomies increased in the second period of our study (2012‐2016), while that of papillary T2 to T4 tumors and other TC subtypes remained unchanged. Papillary T1 tumors represented 63.6% of all TC cases and 75.3% of them were low‐risk microcarcinomas (papillary thyroid microcarcinoma). The strategy of fine needle aspiration (FNA) prior to surgery in the management of thyroid nodules was adopted by more clinical endocrinologists in the area of Southwestern (SW) Greece in the second period of our study (2012‐2016:29.7% vs 2007‐2011:18.4%, P < .001). Consequently, the indication for thyroidectomy was set by FNA more frequently in 2012 to 2016 than in 2007 to 2011 (42.5% vs 26.4% of cases, P < .001).ConclusionsThe wider use of FNA in the triage of thyroid nodules led to increased rates of TC in thyroidectomies performed in SW Greece during the decade 2007 to 2016; low‐risk, small papillary tumors represented the majority of TC cases.

Fine-needle aspiration biopsy for the diagnosis of bone and soft tissue lesions: a systematic review and meta-analysis

The workup of musculoskeletal (MSK) lesions utilizes a range of diagnostic tests including incisional biopsy, core needle biopsy, and fine-needle aspiration (FNA). FNA is the most cost-effective and least invasive biopsy method, but variation in its reported diagnostic performance has constrained its use for MSK lesions. Herein, we undertake a meta-analysis to clarify the diagnostic performance of FNA for bone and soft tissue lesions. A systematic search was run in MEDLINE, EMBASE, and CINAHL. Included studies were aggregated for pooled estimates of adequacy, accuracy, and sensitivity/specificity for all MSK lesions as well as bone and soft tissue independently. Analysis of heterogeneity and risk of bias were assessed across studies. Covariate subgroup analyses were attempted to investigate potential influences on diagnostic accuracy. Twenty-five articles met inclusion criteria, representing 4604 FNAs. Adequacy was 92.3% (range: 59.2%-98.0%, S = 9.4%), and sensitivity/specificity for the nature (malignant or benign) of the lesion was 95.6% (95% CI: 94.5%-96.5%) and 96.9% (95% CI: 95.9%-97.7%). FNA was 75.8% accurate (range: 42.5%-99.3%, S = 17.3%) for definitive diagnosis. FNA provides higher accuracy for benign versus malignant nature in bone lesions but achieves a definitive diagnosis more frequently in soft tissue lesions. The results of this meta-analysis support the expanded use of FNA in the diagnostic workup of bone and soft tissue lesions, particularly in light of a sensitivity and specificity comparable to incisional and core needle biopsy.

Su1252 ENDOSCOPIC ULTRASOUND TRENDS IN UNITED STATES: PRACTICE CHANGES OVER A DECADE

The endoscopic ultrasound (EUS) fine needle aspiration (FNA) technique has been refined improving tissue acquisition and allowing targeted analgesic injection. During the last years, new research and guidelines advocate for conservative management of low risk pancreatic cysts. Simultaneously, an increasing number of reports have shown the limitations of celiac plexus block and neurolysis to treat chronic abdominal pain. We aims to describe changes in EUS practice over a decade. The Clinical Outcomes Research Initiative (CORI v.3) database was reviewed for EUS procedures between 2000 and 2010. EUS procedures were included if they had complete demographic data and details on FNA performance, celiac plexus block or neurolysis. Linear regression models compared temporary trends in FNA completion, celiac plexus block or neurolysis. Subgroup analysis evaluated FNA practice by different procedure indications (i.e. pancreatic mass, pancreatic cyst, esophageal lesion, and rectal lesion). EUS complications and medications are not consistently recorded in CORI, and were not included in our study design. Initial database review revealed 20,230 EUS procedures meeting our inclusion criteria. Mean age was 61.08 ±14.19 years, 11,936 (59%) patients were male, 17,027 (84%) non-Hispanic white, 1,476 (7%) non-Hispanic black and 1,197 (6%) Hispanic. The majority of procedures were completed as outpatients 14,782 (90%) and 8,202 (41%) had a fellow or trainee involved. Procedure indications included evaluation of a pancreatic mass (1,951 [10%]), pancreatic cyst (1,815 [9%]), esophageal mass (1,506 [7%]), and rectal or anal mass (1,087 [5%]). 275 patients (1%) underwent a celiac plexus block or neurolysis. Only 9,834 (49%) procedures provided details of the device used, with the majority done with a radial probe (77%). Overall FNA utilization increased over the study period (regression coefficient 0.10 [95%CI 0.02 to 0.18], P=0.013). Subgroup analysis revealed a decreasing trend in pancreatic cyst aspiration (-0.55 [-0.80 to -0.30], p <0.001). No significant trend was identified on use of FNA for pancreatic masses (0.20 [95%CI -0.17 to 0.56]), esophageal lesions (-0.05 [95%CI -0.40 to 0.30]) or rectal lesions (-0.74 [95%CI -1.93 to 0.45]) (p=0.29, 0.779, and 0.225 respectively) (Figure 1). An increase in celiac plexus block or neurolysis was seen during the time period evaluated (regression coefficient 0.75 [0.42 to 1.07], p<0.001). Despite an overall increase in FNA utilization in EUS procedures, there was a decreasing trend in pancreatic cyst aspiration. We hypothesize this is secondary to better management and radiological modalities for surveillance of pancreatic low risk lesions. Celiac plexus injection rate remained the same overtime. Efforts to limit these procedures to a select patient population should continue.

Thyroid Malignancy in Long Standing Multinodular Goitre A Case Series with Review of Literature

Clinical presentation of patients with multinodular goitre is variable. Fine-needle aspiration (FNA) has been widely accepted as an initial step in the management of thyroid nodules. However, the usefulness of FNA to assess the risk of malignancy in thyroid nodules occurring within a long standing multinodular goitre (MNG) has not been completely clarified. Moreover, an unresolved issue is whether MNG is significantly associated with malignancy. MNG had been traditionally thought to be at a low risk for malignancy as compared to a solitary thyroid nodule (STN). However, review of literature showed no statistical difference in incidence of malignancy in both MNG and solitary nodular goitre. The incidence of malignancy in multinodular goitres has been found to vary from 7.5% to 17%. The duration of the associated goitre varies and ranges from the shortest of one month to the longest of more than 20 years. Considering this background, we are reporting a series of three cases of thyroid malignancies diagnosed on FNAC in patients having long standing goitre.

Pediatric neuroblastic tumors: A critical evaluation of cytomorphological features for risk stratification on aspiration cytology.

Neuroblastic tumor (NT) is the most common extracranial solid tumor of childhood with variable outcome which again depends on risk stratification related to distinct biology of the tumor. The use of fine-needle aspiration (FNA) material for evaluation of cytomorphological parameters and risk stratification in NTs using cytology prognostic score (PS) is limited in routine practice. We reviewed 38 FNA cytology cases diagnosed as pediatric small round cell tumor between time period June 2017 to December 2019 for clinical, cytomorphological and immunohistochemical features. Ten out of 38 small round cell tumors were NTs. All 10 cases were further subclassified according to International Neuroblastoma Pathology Classification into undifferentiated neuroblastoma (n = 1), poorly differentiated neuroblastoma (n = 5), differentiating neuroblastoma (n = 2), and ganglioneuroblastoma (n = 2). Cytologic PS was done using the morphological criteria as described previously in literature. The patients were divided into favorable and unfavorable cytomorphological prognostic categories with a cut off scoring of 12. A score of more than 12 is associated with high risk morphology and advanced stage. All cases with PS > 12 (n-4) (unfavorable cytomorphology) had a poor outcome compared to six patients with PS < 12 (n-6) (favorable cytomorphology). Aspiration cytology can be used as a first line investigation to evaluate the cytomorphological features for risk stratification and diagnosis in patients with NTs using cytological prognostic scoring system. A larger multi-centric validation study necessitates for cytological risk stratification.

Percutaneous Lung Biopsy in Immunocompromised Pediatric Patients.

To determine the diagnostic yield and safety of image-guided lung biopsies in immunocompromised pediatric patients. This was a retrospective pediatric cohort study conducted from June 2000 to April 2017. Subjects were 0-17 years of age (median, 10 years of age). There were 46 males (48%). A total of 73 consecutive image-guided lung biopsies were performed in 68 patients (weight range, 4.9-97.3 kg [median, 25.3 kg]). The indication for biopsy was to isolate an organism to tailor medical therapy. All patients were immunocompromised with an underlying history of bone marrow transplantation (n= 50), primary immunodeficiency (n= 14), and solid organ transplantation (n= 4). Patient and technical factors were analyzed for rates of complication. Overall diagnostic yield was 43 of 73 patients (60%). There were 14 minor (19%) and 8 major (11%) complications. Major complications included pneumothorax or hemoptysis requiring intervention (n= 6), and death (n= 2). The histological diagnosis was an infectious cause in 5 of 8 major complications (63%). There were statistically significant differences between the rates of complications with the imaging modality used (P= .02) and the use of fine needle aspiration (P= .02). Image-guided percutaneous lung biopsy can be helpful in isolating an organism to tailor therapy. Biopsies performed in immunosuppressed patients result in an elevated complication risk of up to 30% and demonstrate lower diagnostic yield and increased mortality, which should warrant detailed discussion with the primary team and family.

The Impact of Regional Variation in Clinical Practice on Thyroid Cancer Diagnosis: A National Population-Based Study

Objective: Regional variation in thyroid cancer incidence in Belgium, most pronounced for low risk cancer, was previously shown to be related to variation in clinical practice, with higher thyroid surgery rates and lower proportions of preoperative fine-needle aspiration (FNA) in regions with high thyroid cancer incidence (period 2004–2006). The objective of this study was to investigate regional thyroid cancer incidence variation in relation with variation in thyroid surgery threshold in a more recent Belgian thyroid cancer cohort. Methods: A population-based cohort of thyroid cancer patients that underwent a (near) total thyroidectomy in the period 2009–2011 (n = 2,329 patients) was identified and studied by linking data from the Belgian cancer registry and the Belgian health insurance companies, and case-by-case study of the pathology protocols. The execution of preoperative FNA and the thyroid resection specimen weight were compared between high and low thyroid cancer incidence regions. Thyroid weight in the pT1a-restricted group was studied as a proxy for surgical threshold for benign nodular goiter. Furthermore, time trend analyses were performed for the execution of FNA for the period 2004–2012. Results: Although a lower proportion of FNA in the high thyroid cancer incidence region persisted in the period 2009–2011 (41.2% [31.9–50.9] vs. 72.9% [64.9–79.7] in the low-incidence region (LIR), p < 0.001), a positive time trend was observed for the period 2004–2012. The median thyroid surgical specimen weight was lower in the high incidence region compared to the LIR (27.0 g [IQR 18.0–45.3] vs. 36.0 g [IQR 22.0–73.0], p < 0.0001), and this finding was corroborated in the pT1a-restricted group. Conclusion: Interregional differences in use of FNA and surgical thyroid specimen weight are consistent with an inverse relation between thyroid cancer incidence and thyroid surgery threshold, carrying risk for overdiagnosis.

1694 Endoscopic Ultrasonography With Fine-Needle Aspiration in the Diagnosis of Metastatic Rectal Adenocarcinoma in Left Atrium

INTRODUCTION: Endoscopic ultrasonography(EUS) of the mediastinum with the use of fine needle aspiration(FNA) or biopsy can be used to characterize lesions that are within or adjacent to the esophageal wall, posterior and inferior mediastinum with minimal risk to the patient. EUS is an underutilized tool for identifying mediastinal masses and can help guide clinical decision making in patients with concerning lesions found on non-invasive imaging modalities. CASE DESCRIPTION/METHODS: A 71-year-old male with history of adenocarcinoma of the rectum with metastases to the liver and lung was treated with surgical resection and adjuvant chemotherapy. Patient responded well and was under regular surveillance when a new irregularly shaped abnormal soft tissue density measuring approximately 5.4 × 3.0 cm adjacent to the aorta and esophagus appearing to invade into the left atrium (Figure 1a) was found on a CT scan and confirmed on PET imaging. These findings favored rectal metastatic disease over thrombus but could not definitively rule out a new carcinoma. For that reason, an endoscopic ultrasonography was performed to determine the nature of the mass. A curvilinear array echoendoscope was used to visualize a 36 × 30 mm exophytic lesion within the left atrium which extended into the posterior mediastinum (Figure 2). Using Doppler to identify a vessel-free path, a 25-gauge needle was passed under ultrasound guidance through the esophagus and directly into the mass with the use of an endoscopic fine needle biopsy (FNB) device for three passes. Histopathological examination confirmed adenocarcinoma (Figure 3) and immunophenotype was compatible with colorectal primary which ruled out a pulmonary adenocarcinoma. DISCUSSION: The patient was determined to not be a surgical candidate due to the location of the mass and high risk nature of the surgery. The multidisciplinary team’s consensus was to repeat chemo-adjuvant therapy since he had responded so well previously. He received treatment and had follow up imaging six months after EUS diagnosis which showed decrease in size (Figure 1b) and activity of the mass. He is planned to have have stereotactic body radiation therapy to further decrease the size of the atrial mass. This case demonstrated how EUS with the use of FNA is a helpful tool in the prompt evaluation and confirmation of a mediastinal mass which allowed all physician’s involved in the care of the patient to develop and implement a treatment plan quickly. Watch the video: http://bit.ly/2Giu99S.