CITOPATOLOGIA
MALIGNANCY RISK AND HISTOLOGICAL CORRELATION OF BREAST FINE- NEEDLE ASPIRATION
CLASSIFIED AS ATYPICAL (C3).
A RETROSPECTIVE STUDY ON 499 CASES
F. De Rosa, A. Gencarelli, E. Clery, I. Migliatico, E. Vigliar, G. Troncone, C. Bellevicine
Dipartimento di Sanità Pubblica, Università degli Studi di Napoli “Federico II”
Background. Fine needle aspiration (FNA) of clinically and/or
radiologicallysuspicious breast masseshasrepresentedthemostim-portanttooltoreachadiagnosisandguidethefurthermanagement of these patients. However, in the last years, the use of core needle biopsy has become increasingly frequent due to different reasons. 1) A trained on-site cytopathologist, who ensure the correct-ness of both the aspirative and smearing technique lowering the rates of inadequate samples, is not always available. 2) Unlike the Bethesda System for thyroid or the recent Milan System for the reporting of salivaryglandcytology,aninternationalstandardi zedreportingsystemforbreastFNAisstilllacking. This result in a poor reproducibility among different cytopathologist cause in-comprehension between cytopathologist and clinician, and may
lead to an inappropriate treatment of the patients.To overcome these issues, the International Academy of Cytology (IAC) have recently proposed during the International Yokohama Congress of 2016, the implementation of a five-tiered reporting system, 1 based on the previous system from the Australian National Mam-mographic Screening Pathology Q Group (1993) and NCI (1996). Unfortunately, as in other cytopathology classification systems, the “atypical” (C3) diagnostic class represent a “gray zone” with variable malignancy risk. In our Institution we have adopted since 2010 a classification system similar to those proposed by the NCI in1996,whichinturnhasrepresentedtogetherwiththeAustraliansche me,thebasisofthereporting system now recommended by the IAC. In order to clarify the histological basis and the malignancy risk of the “atypical” (C3) diagnoses, we have retrieved from our files the cytopathology reports of breast FNA signed-out from 2010 to 2017, closely investigating those with a matched histopathologi-caldiagnosisavailable.
Materials and Methods. The laboratory information database
of the study institution was searched to obtain the diagnostic reports recorded in the system from January 2010 to December 2017 related to breast FNA classified as “C3”. During the study period, an overall of 4625 breast FNA were performed, including 499 (10.7%) C3. Of these latter, 289/499 (57.9%) had a matched histology available. Basing on the histopathology follow-up, the over all malignancy risk of the C3 diagnosis was determined with a careful analysis of the histological outcomes.
Results. Considering the 289 C3 FNA with an available
his-tology, 213/289 (73.70%) cases showed a benign histological diagnosis, whereas 76/289 (26.30%) resulted in a malignant outcome (Tab. I). Of these latter, the majority (46/76, 60.5%) were either usual ductal (36/46, 78.2%)orlobular(10/46,21.7%)
Table I. Histological correlation of the breast FNA classified as C3, from 2010 to 2017. In the last column, thefrequencyofthehistologicaldiagnosisamon-gallC3FNAsandamongeitherbenignormalignant diagnoses(parenthesis).
Histology N. of cases % C3 FNAs with matched histology 289 57,92 of total C3 FNAs
Benign lesions
213 73,70
Fibroadenomas 86 29,76 (40,38 of benign) Fibrocystic breast disease 60 20,76 (28,17) Fibrocystic breast disease with atypia 3 1,04 (1,41)
PASH 3 1,04 (1,41)
Intraductal papillomatosis 16 5,54 (7,51) Intraductal papillomatosis with atypia 1 0,35 (0,47) Benign Phyllodes Tumours 20 6,92 (9,39) Myofibroblastoma 1 0,35 (0,47) Usual ductal hyperplasia 3 0,35 (1,41) Atypical ductal hyperplasia 5 1,04 (2,35) Reactive changes 3 1,03 (1,41) Steatonecrosis 4 1,38 (1,88) Normal breast parenchyma 8 2,77 (3,76)
Malignant tumors
76 26,30
Carcinoma in situ 6 2,08 (7,89 of malignant) Microinvasive Breast Cancer 9 3,11 (11,84)
Ductal carcinoma 35 12,11 (46,05) Lobular carcinoma 10 3,46 (13,16) Mixed ductal/lobular carcinoma 1 0,35 (1,32)
Intracystic papillary carcinoma 3 1,04 (3,95) Papillary and ductal carcinoma 1 0,35 (1,32) Cribriform invasive carcinoma 1 0,35 (1,32) Tubular carcinoma 8 2,77 (10,53) Squamous cell carcinoma 1 0,35 (1,32) Periductal stromal sarcoma 1 0,35 (1,32)
invasivecarcinoma. As showed in Table I, 30/76 (39.4%) C3FNA with a malignant outcome showed either unusual or challenging histological features. In particular, 15/76 (19.7%) C3 FNA cases showed a ductal carcinoma in situ with or without neoplastic micro- invasive foci. Fifteen C3 FNAs (15/76, 19.7%) included unusual histotypes such as papillary neoplasm, tubular carcinoma, squamous cell carcinoma and periductal stromal sarcoma (Tab. I). Among the 213 benign cases,the vast majority werediagnosed as fibroadenoma (86/273,40,38%) or fibrocystic breast disease on histology. However, 44/213 cases (20.6%) showed a range of diagnosis usually difficult to recognize on cytology specimens, including low-grade phyllodes tumor and intraductal papilloma-tosis (Tab. I).
Conclusions. In our experience, a diagnosis of C3 rendered on
breast FNA showed a malignancy risk of 26.3%, justifying its “atypical, probably benign” definition. The microscopic complex-ity or unusual features observed in a part of both malignantand be-nign histological follow-up may explain the difficulties of assign these cases to a straight forward benign or malignant class basing only on the cytological features of these lesions.Infact, these enti-ties not only may show challenging cytological features, but are also difficult to recognize even on core biopsy.
References
1 Field AS, Schmitt F, Vielh P. IAC standardized reporting of breast fine-needle aspiration biopsy cytology. Acta Cytol 2017;61:3-6.
MORPHOLOGICAL AND MOLECULAR ANALYSIS OF A SERIES OF HYALINIZING TRABECULAR TUMOR. CYTO-HISTOLOGICAL CORRELATION
M. Dell’Aquila1 2, S. Capodimonti1 2, C. Gravina3, I. Sapuppo1 2, T. Musarra1 2, V. Fiorentino1 2, S. Sfregola1 2, A. Cocomazzi1 2, M. Martini1 2, L. Revelli2 3, G. Fadda1 2, L.M. Larocca1 2, E.D. Rossi1 2
1 Division of Anatomic Pathology and Histology, Fondazione Policlinico “A. Gemelli”, IRCCS; 2 Università Cattolica del Sacro Cuore, Rome Italy; 3 De-partment of Endocrine-Surgery, Rome Italy
Objectives. Hyalinizingtrabeculartumor(HTT)isarareneo-plasmthataffectsthethyroidgland. This pathological entity is essen-tially benign, however it poses a serious challenge in diagnostic cytopathology.Asamatteroffact,onfineneedleaspirationcytology(F NA),cellularsmearsofHTT are often misdiagnosed as papillary thyroid cancer (PTC) or as medullary thyroid cancer (MTC). These false positive diagnoses often cause overtreatment as com-plete total thyroidectomies representing an unnecessary surgical approach for a benignlesion.
Cytological smears usually show cells that can be either isolated or arranged in groups with little to no cohesion. Cells are often poligonal or spindle shaped. Pseudo-inclusions and nuclear grooves are not infrequent. Hyaline material secreted by the tu-mor represents one of the pathognomonic features of this entity. However, it is often misinterpreted either as amyloid substance, wrongly suggesting a MTC diagnosis, or as colloid substance. According to the literature, the cytological interpretation of the majority of HTT cases is diagnosed as either suggestive or out-right positive for PTC.
Ancillary studies including also the membrane and cytoplas-mic positivity for the ki67 clone mib-1 and the negativity for HBME-1, are useful when HTT is suspected.
Molecular diagnostic techniques have the potential to be ex-tremely useful in the diagnostic discrimination between PTC and HTT. Since BRAF mutations are only found in PTC, the presence of a BRAFV600E mutated case would rule out a HTT diagnosis, while wild type results might not exclude a HTT diagnosis. In
the current study, we analyzed and evaluated a series of 25 HTT with cyto-histological correlation. To the best of our knowledge, this is one of the largest casuistry for a single center reported in the literature.
Materials and methods. We presented 25 HTT cases
col-lected from September 2001 to July 2018 in the Department of Anatomic Pathology and Histology of the Fondazione Policlinico Universitario Agostino Gemelli of Rome - IRCCS. Cytological cases were processed with liquid based cytology (LBC). Immu-nocytochemistry for HBME-1 and Galectine-3 antibodies were performed on both LBC and histological specimens. The search for the BRAFV600E mutation was performed on the histological specimens.
Results.
Ourgroupincluded25resectedthyroidlesionsdiagnose-dasHTT, with size ranging from 1.5 mm to 3 cm. Our series included two males out of 25 patients (8%), while 23 were off emale sex. Cytological diagnoses were available in 16 cases out of 25 (64%). The cytological cases were classified according to the Italian classification system for reporting Thyroid cytopathol-ogy. They included: Benign lesions favoring Goiter-TIR2 (one case, 6.25%), Follicular neoplasm of low risk of malignancy-TIR3A (three cases, 18.75%); Follicular Neoplasm with high risk of malignancy-TIR3B (five cases, 31.25%), Suspicious for Malignancy favoring-PTC-TIR4 (five cases, 31.25%); Malig-nant favoring-PTC-TIR5 (two cases, 12.5%). The evaluation of HBME-1 carried out on either cytological or histological samples was performed on 13 cases with negative yields. On the other hand, Galectine-3 was negative in 10 out of 13 cases (77%), while it was positive in three cases. BRAFV600E was wildt ype in all of our samples.Concerning the surgical management of our 25 HTT cases, 23 had a total thyroidectomy, one had a partial thyroidec-tomy and one was a totalization of a previous thyroidecthyroidec-tomy. All the cases in this study were incidental findings.
Conclusions. The morphological evaluation of our series
em-phasized that the majority of HTT are cytologically diagnosed in the indeterminate proliferations, including also the category of Suspicious for malignancy. This data underline the issues in the morphological evaluation alone due to the presence of some cells with the features of malignancy such as mild nuclear pleomor-phisms and nuclear pseudoinclusions. According to our results, the combined evaluation of ultrasound findings, morphology and ancillary techniques (including ICC and molecular testing) might lead to consider HTT among the differential diagnoses. In HTT it is not rare to finding congruities between an ultrasound imaging report suggestive for a benign lesion and cytological features of malignancy, especially when immunocy to chemistry isnegative. Since BRAF mutations were absent in all of our samples, our study confirms the literature data, pointing out the absence of
BRAF mutations in HTT. Moreover, we found that this molecular diagnostic test has an important value in order to differentiate PTC from HTT on cytological smears for which the morphologi-cal features are equivomorphologi-cal. A wild type yield cannot completely rule out a PTC diagnosis, however, we believe that its use in cytology can help the cytopathologist to get on the right track for HTTdiagnoses.
References
Carney JA, Hirokawa M, Lloyd RV, Papotti M, Sebo TJ. Hyalinizing trabecu-lar tumors of the thyroid gland are almost all benign. Am J Surg Pathol 2008;32(12):1877-1889.
Carney JA, Ryan J, Goellner JR. Hyalinizing trabecular adenoma of the thy-roid gland. Am JSurg Pathol1987;11:583-91.
Saglietti C, et al. Hyalinizing trabecular tumour of the thyroid: fine-needle aspiration cytological diagnosis and correlation with histology J Clin Pathol 2017;0:1-7.
EVALUATION OF ANAL LESIONS WITH CONVENTIONAL AND LIQUID BASED CYTOLOGY. COMPARISON OF RESULTS IN A LARGE INSTITUTIONAL SERIES
I.M. Sapuppo1 2, C. De Marco1 2, T. Musarra1 2, V. Fiorentino1 2, M. Dell’Aquila1 2, S. Sfregola1 2, G. Fadda1 2, C. Ratto2 3, G.F. Zannoni1 2, E.D. Rossi1 2
1 Division of Anatomic Pathology and Histology; 2 Università Cattolica del Sacro Cuore; 3 Department of Surgery, Fondazione Policlinico “A. Gemelli”, IRCCS, Rome, Italy
Objectives. Anal cytology is an important preventative screening
method for patients at risk for anal carcinoma. According to the literature, high risk patients include men who have sex with men (MSM), HIV-positive men and women, women with a history of lower genital tract neoplasms, and transplant recipients. Anal can-cer is not a common cancan-cer representing only the 26th most com-mon cancer in the United States with only 0.4% of all new cancer cases. Several different papers highlighted that anal cytology may be useful for evaluating anal lesions especially those associated with human papillomavirus (HPV) in individuals at increased risk for anal cancer. While conventional exfoliative cytology (CC) is the most commonly adopted method due to some advantages including a low-cost and the fact that it is a nonaggressive method, liquid-based cytology (LBC) emerged as an alternative and valid approach also for anal cytology. The diagnosis of anal intraepithe-lial neoplasia (AIN) and the identification of malignancy represent the most important diagnostic questions for anal cytological sam-ples. According to the literature, AIN is frequently associated with HPV infection and can be detected by cytological screening. This increasing and relevant role of anal cytology is a central part of the anal cancer screening in patients at high risk for anal neoplasia. Although studies of the efficacy of anal cancer screening methods would be of great importance for groups at high risk for AIN, few such studies have been conducted. The aim of the present study was to assess the concordance of CC and LBC in diagnosing anal pre-neoplastic lesions, and to compare cytological results with the two different cytological preparations.
Material and methods. We recorded all the anal samples in the
period between January 1999 and December 2017. We analyzed and compared the cytological features between the two prepa-rations. Concordance between the two cytology methods was calculated, as were the associations between cytology results and histological findings.
Results. A total of 589 anal Pap smears were performed
dur-ing the study period includdur-ing 74 female and 515 male patients. The series included 281patients with negative cytology, and 308 patients who had abnormal Pap tests. Among these cohort of 308 patients, 42 patients including 36 males and 6 females, had a cyto-histological correlation. They included: three ASC-US, 37 Low Grade SIL, two HSIL (high grade squamous intraepithelial lesion). Concordance between the two methods was statistically significant (P < 0.05) and the positive cytology was identified with both methods independently. Concerning the three ASC, our histological diagnoses included all cases with AIN-I. For the LSIL, 62% of the cases resulted in a histological diagnosis of AIN-I and/or condiloma whilst 19% resulted in a histological diagnosis of AIN-III and/or squamous carcinoma. The two HSIL resulted in two moderately and poorly differentiated squamous carcinoma. The morphological features were identified with both conventional and LBC with adequate material. Molecular biology results showed that patients with LSIL tested positive for the high-est number of HPV subtypes. The associations between positive biopsy and high grade HPV, HPV 16, and multiple HPV infec-tions were not statistically significant.
Conclusions. Conventional and liquid-based cytology are equally
effective in screening for anal preneoplastic and neoplastic le-sions. Anal cytology represents a valid cost-effective screening tool for evaluating human papillomavirus-related disease of the anal canal, especially in at-risk populations, principally MSM and those with HIV disease. In fact, high-risk male patients are at significant risk of epithelial cell abnormality and histopathologi-cally verifiable anal intraepithelial lesions. Education related to better follow-up and collection methods of anal Pap smears is required to reduce the number of unsatisfactory rate and false negative results.
NODULAR FASCIITIS OF THE PAROTID GLAND: THE “SIMULATOR” IN THE CYTO- HISTOLOGICAL DIAGNOSIS OF SALIVARY GLAND LESIONS
S. Sfregola, M. Dell’Aquila, C. De Marco, V. Fiorentino, T. Mu-sarra, M. Palumbo, I. Sapuppo, G. Fadda, E.D. Rossi
Division of Anatomic Pathology and Histology, Fondazione Policlinico Uni-versitario “Agostino Gemelli”, IRCCS, Rome, Italy
Background. Nodular fasciitis (NF) is a clonal, self-limited
pro-liferation. Although NF most commonly occurs in the extremities of adults, it has been described in many other anatomic sites in-cluding the neck, forehead, cheek, orbit, scalp, oral cavity, gnathic bones, ear canal, and sinonasal tract. NF involving the parotid gland is exceedingly rare in any patient, with only a few dozen reports in the English literature.
Clinically, NF is most common in the 3rd or 4th decade of life but it can occur over a wide age range without a clear gender predilection. Symptomatic onset generally arises over the course of a few weeks but with unspecific signs and symptoms, such as swallowing and pain or discomfort. On imaging modality, NF can show infiltrative borders as it extends along fascial planes and per-meates into adjacent structures, mimicking a malignant, invasive tumor. The radiologic differential diagnosis for nodules showing these characteristics includes both solid and cystic benign and malignant salivary gland neoplasms. Among the possible entities, we need to exclude Pleomorphic adenoma (PA), Acinic cell car-cinoma (ACC), Secretory carcar-cinoma (SC), and Mucoepidermoid carcinoma (MEC), neurogenic tumors such as neurofibroma and schwannoma, dermal based tumors such as dermatofibroma (DF) and dermatofibrosarcoma protuberans (DFSP), and various other lesions including, melanoma, fibromatosis, hemangioma, and sar-coidosis. The lesional sampling by FNA is commonly performed, even though NF can be easily mistaken for an aggressive neo-plasm due to its high cellularity and the overlapping morphologi-cal features. As a result, NF is often managed with unnecessary parotidectomy, which is associated with a high-risk for significant surgical complications including facial nerve injury. Accord-ing to the literature, one of the largest series of NF is a recent multi-institutional study including 15 cases with cyto-histological correlation. The results obtained from this study suggested that combination of cytomorphological findings of FNA specimens (bland, single, spindled cell proliferation with elongated cytoplas-mic processes and bland nuclei) and ancillary studies (including immunocytochemistry-ICC and molecular testing) can lead to detecting NF and to consider a conservative management. The purpose of this study is to present the clinical and cyto-morphologic findings of NF of the parotid gland by fine needle aspiration (FNA).
Methods. The anatomic pathology archive of the University of
the Sacred Heart was searched for salivary gland FNA cytology specimens with a confirmed histological diagnosis of nodular fasciitis in the period between 1998 and 2017. The clinical his-tory, pathologic diagnosis, cytomorphologic findings, and
im-munocytochemical results were recorded. The cytological cases were processed with both conventional smears and liquid based cytology (LBC).
Results. A total of two cases were identified; the average age
was 29,5 y/o with one female and one male patient. Clinically, both lesions have been described as ipoechoic masses and the average time from symptom onset to clinical presentation was seven weeks. The average lesion size was 3 cm by radiographic measurement. On both conventional and LBC smears, the two cases (100.0%) were classified as spindle cell neoplasm, not otherwise specified (NOS). On average, smears were composed of predominantly single (50.0%), spindled (100.0%) cells with short unipolar (100.0%), elongated (100.0%) nuclei, and absent nucleoli(100.0%).Concerning the architectural pattern, 100.0% showed a tissue culture appearance and 50% contained abun-dant myxoid stroma with pleat- like folding. No one showed significant cytologic atypia and/or inflammatory components. Due to the spindle bland features of the two lesions, immu-nocytochemistry was not carried out as long as it would not have changed the finale cytological diagnosis of “spindle cell neoplasm”.
Conclusions. NF is an extremely rare entity in the salivary gland
but a few dozen cases have been described. This entity can show some morphological overlap with a wide range of benign and malignant lesions. The morphological evaluation of cytological samples composed of any bland, single, spindled cell prolifera-tion with elongated cytoplasmic processes and bland nuclei may suggest including NF into the possible differential diagnoses. As a consequence, the cytological diagnosis should inform the clini-cian to consider more conservative management in the correct clinical context.
Furthermore, the limited application of ancillary techniques, including ICC and FISH for the MYH9-USP6 fusion, makes it especially important to recognize the morphologic features.
References
Allison DB, VandenBussche CJ, Rooper LM, et al. Nodular fasciitis of the parotid gland: a challenging diagnosis on fine needle aspiration. Cancer Cytopathology 2018, under publication.
Bemrich-Stolz CJ, Kelly DR, Muensterer OJ, et al. Single institution series of nodular fasciitis in children. Journal of Pediatric Hematology/Oncology 2010;32(5):354-357.
Montgomery EA, Meis JM. Nodular fasciitis: its morphologic spectrum and immunohistochemical profile. The American Journal of Surgical Pathol-ogy 1991;15(10):942-948.
Weinreb I, Shaw AJ, Perez-Ordoñez B, et al. Nodular fasciitis of the head and neck region: a clinicopathologic description in a series of 30 cases. Journal of Cutaneous Pathology 2009;36(11):1168-1173.
URINE CYTOMORPHOLOGY OF MICROPAPILLARY AND PLASMACYTOID VARIANTS OF UROTHELIAL CARCINOMA
P. Straccia1, M. Martini1, G. Fadda1, E. Sacco2, F. Pierconti1
1 Division of Anatomic Pathology and Histology, Università Cattolica del Sacro Cuore, Foundation “A. Gemelli” University Hospital, Rome, Italy; 2 Urologic Clinic, Department of Surgical Sciences; Università Cattolica del Sacro Cuore, Foundation “A. Gemelli” University Hospital, Rome, Italy
Background. Among various histologic variants of urothelial
carcinoma (UC), some variants such as the micropapillary and plasmacytoid variants exhibit very aggressive clinical be-havior. Therefore, it is important to identify the morphologic variants of UC early because these variants often present as high grade and with advanced-stage disease at the time of di-agnosis. To date, only a small number of cytology cases have
been reported on either of these variants. Herein, we report 10 cases of UC with combined micropapillary and plasmacytoid features based on urine cytology.
Methods. We performed a retrospective chart review of all
patients with carcinomas of bladder with predominant