Chiara Sugrue

Thyroid fine-needle aspiration with atypia of undetermined significance

Atypia of undetermined significance is a controversial category in thyroid fine‐needle aspiration (FNA), not only for its questioned clinical utility, but also for its very existence as an expression of uncertainty. The current study was performed to investigate the potential impact of eliminating this category on the sensitivity and specificity for detecting thyroid neoplasms by FNA.

Endobronchial ultrasound-guided transbronchial needle aspirate (EBUS-TBNA): a proposal for on-site adequacy criteria.

This is a retrospective study of 48 patients who underwent EBUS‐TBNA procedure between the periods January 2008 to September 2009 at Long Island Jewish Medical Center. The study was undertaken with the following objectives: First, to define practical and useful on‐site adequacy criteria for EBUS‐TBNA samples; Second, to understand the diagnostic pitfalls associated with accurate interpretation of EBUS‐TBNA samples. EBUS‐TBNA procedure was able to diagnose 24/48 (50%) patients with malignancy, 1/48 (2%) suspicious for malignancy, 9/48 (19%) with granulomatous process, and 9/48 (19%) negative for disease. Only five cases (10%) could not be diagnosed with this procedure. Based on our experience, any smear with presence of > 5 low power fields (×100) with ≥ 100 lymphocytes in each and containing < 2 groups of bronchial cells/low power field (×100) can be considered adequate for evaluation. Also, the presence of germinal center fragments renders a smear adequate for evaluation, irrespective of the above mentioned criteria. Adequacy criteria are to be applied only to the smears not showing any identifiable pathology such as malignancy or granuloma. An understanding of diagnostic pitfalls associated with accurate interpretation of EBUS‐TBNA samples is essential to avoid false‐positive and false‐negative diagnosis. To conclude, an effective communication between the clinician and cytologist, an algorithmic approach to diagnosis, and the on‐site adequacy criteria proposed in this study can markedly improve the diagnostic yield of the procedure. Diagn. Cytopathol. 2011.

Clinical impact of second opinion in thyroid fine needle aspiration cytology (FNAC): A study of 922 interinstitutional consultations†

Interinstitutional consultation in pathology has shown to improve patient safety by detecting interpretive errors that may significantly impact clinical management. We conducted a study of 922 cases of thyroid FNAC slides, referred to our institution over a 2‐year period, to assess the magnitude of discrepancies and determine the clinical impact of second opinion. Disagreements were categorized as none, minor or major, the latter two defined as one‐ or two‐step deviations respectively on the NCI diagnostic categories scale. There were 122 disagreements (13%), including 44 major and 78 minor. Seventy‐five patients underwent a change in management based on second opinion, in conjunction with clinical and radiologic findings (age, size of nodule, family history, ultrasonographic appearance, and solitary versus multiple nodules). The second opinion was supported on follow‐up in 57% of major discrepancies, and the initial diagnosis was concurrent with the surgical diagnosis in 7% cases. The remainder (36%) of major discrepancy cases did not undergo surgery, precluding tissue confirmation. Critics have alleged increased costs due to interinstitutional consultations. However, cost avoidance from lost wages, potential surgical complications, and litigation is not easily quantified. Using a simplified calculation to objectively measure the costs associated with changed diagnoses, we estimate that second opinion of these 922 cases resulted in potential cost saving of

Consolidation of the North Shore-LIJ Health System Anatomic Pathology Services The Challenge of Subspecialization, Operations, Quality Management, Staffing, and Education

940,166 based on current Medicare reimbursement codes. Our study indicates the need for a quality‐control program of outside thyroid FNA slides, especially in “high discrepancy categories” as discussed in the article. Diagn. Cytopathol. 2011;.

Aetiology of non‐diagnostic renal fine‐needle aspiration cytologies in a contemporary series

OBJECTIVES To describe our experience, both in meeting challenges and in reporting outcomes, of the consolidation of anatomic pathology services in the North Shore-LIJ Health System in February 2011. METHODS We addressed issues of governance, personnel, physical plant, quality programming, connectivity, and education. CONCLUSIONS The highly regulated nature of the laboratory industry and the fact that patient care necessarily never pauses require that such a consolidation take place without a break in service or degradation in turnaround time and quality while engaging personnel at all levels in the extra duties related to consolidation. Subspecialization has allowed us to better meet the needs of our in-system health care community while increasing our access to the competitive outreach marketplace.

Number of needle passes does not correlate with the diagnostic yield of renal fine needle aspiration cytology.

To determine the aetiology of non‐diagnostic renal fine‐needle aspiration cytologies (FNACs) in a contemporary series.

Monophasic parapharyngeal synovial sarcoma diagnosed by cytology, immunocytochemistry, and molecular pathology: case report and review of the literature.

BACKGROUND AND PURPOSE Renal Fine Needle Aspiration Cytology (FNAC) has gained popularity due to increasing options in management of renal lesions such as energy ablation and active surveillance. The diagnostic yield of renal FNAC varies between 40-90%. We hypothesized that adequate and diagnostic FNA samples would be associated with higher number of needle passes and higher number of slides examined. PATIENTS AND METHODS The pathology database at our institution was retrospectively searched for renal FNACs performed between 1995 and 2005. Patient gender, side, indication, cytological diagnosis, final histological diagnosis when available, number of needle passes performed, number of slides examined, and adequacy of the FNAC sample as determined by Diff Quik staining by the cytotechnologist (CS) were recorded. Chi square test was performed for statistical analysis. RESULTS Out of 377 renal biopsies performed, 259 were core biopsies for medical renal disease, and 118 were FNACs for renal lesions, including 16 for indeterminate complex renal cysts and 102 for solid renal masses. Indeterminate renal cysts were excluded from the study. Out of 102 FNACs for solid renal masses, 22 were inadequate with 13 (59%) being non-diagnostic; and 80 FNACs were adequate with 3 (4%) being non-diagnostic. The number of needle passes was not significantly different between non-diagnostic and diagnostic samples (2.5 vs 3.2); and between inadequate and adequate samples (3.4 vs 3.0). Similarly, the number of slides examined was not significantly different between non-diagnostic and diagnostic samples (9.5 vs 10.9); and between inadequate and adequate samples (11.3 vs 10.6). Diff Quik adequate samples had significantly higher diagnostic yields when compared to Diff Quik inadequate samples (965 vs 41%; p<0.01). CONCLUSIONS The number of needle passes and microscopic slides examined did not correlate with sample adequacy or diagnostic yield of renal FNAC. Sample adequacy as determined by Diff Quik staining correlated with diagnostic FNAC. Despite the retrospective nature of this study, a cytotechnologist should be present during the FNA procedure to ensure adequate samples have been obtained to increase the diagnostic yield of renal FNAC.

Review of Accuracy of Urinary Cytology with Risk of Malignancy Assessment per Cytology Categories in a Large Tertiary Health Care System

Synovial sarcoma (SS) of the head and neck region are rare, accounting for less than 10% of all head and neck soft tissue sarcomas. A limited number of SS have been reported in the parapharyngeal space and these reports have all been based on histological examination of resection material. The diagnosis of monophasic SS on cytology is extremely difficult. We report the first case where a SS was correctly diagnosed on a fine needle aspirate by cytology with the assistance of immunocytochemistry and fluorescence in situ hybridization. We will emphasize the importance of ancillary techniques, such as immunocytochemistry and cytogenetic/molecular pathology, in avoiding diagnostic pitfalls and correctly diagnosing monophasic SS on cytologic material. We will propose an algorithmic approach to accurately diagnose parapharyngeal spindle cell neoplasms with the use of appropriate ancillary studies in conjunction to morphological features. Diagn. Cytopathol. 2010;38:822–827.