Daniel F.I. Kurtycz

Thin-layer technology: Tempered enthusiasm

With the introduction of new technologies we often see a pattern of development. As a useful technology moves into the public sector there is often an episode of wild enthusiasm and uncritical acceptance, followed by a time of progressive disillusionment. However, with time and experience, a proper place for the method becomes established. Thin-layer technology is certainly an improvement and solves many of our preanalytical problems; however, it introduces some difficulties of its own. The rounding up of cells in liquid fixation makes cells of high-grade lesions smaller than they would be on a conventional preparation. The abnormal cells are often separated. For both of these reasons they may be overlooked. Furthermore, benign glandular cells can take on an ominous appearance. These differences in conventional and thin-layer morphology are proving to be a fruitful area for publication. Thin-layer technology cannot be all things to all situations, and this is especially true in body fluid and fine-needle cytomorphology. In our experience, while occasionally helpful, the thin-layer technique should not be the primary method for diagnosis in nongynecologic specimens. Time and effort would be better spent on trying to educate select clinicians on how to obtain better samples than to totally convert to thin-layer methodologies. Regarding FNA, the patient is best served when the pathologist is directly involved with the initial sample acquisition. Reimbursement is available for immediate sample interpretation, so funding should be available for staffing if an institution has the interest. For the record, we believe that liquid fixation and thin-layer methodology should not be the primary method for FNA, unless circumstances are absolutely prohibitive. An important problem with thin-layer technology lies with its added cost. Thin-layer interposes another series of steps into cytologic sample preparation. There is additional labor, additional time, another machine in the laboratory, and the significant cost of the reagents. In a situation where the price of a cytologic test is already close to margin, costs of the vial, filter, and preservative throw the test into unprofitability. Price structures have to be changed. Some institutions are waiting until there is more competition in the market and costs decrease. Alternatively, a lot of effort has been expended in trying to get government and other groups to accept the additional costs of the new test for gynecologic examinations, and many payers seem to be falling in line to accept the methodology, secondary to clinician and patient demand. Basic questions about ancillary technologies and gynecologic samples remain to be answered. Cytology is big business. Every year a significant segment of the population has a Pap smear performed. Hardly any other laboratory test can claim the volume of activity of the cervical smear. Any business that can hook into that market stands to prosper. Since the Pap smear has some well-publicized problems, the door is open for technology to nibble away at a few percentage points of false negativity. We are far from the first to ask if we can afford the incremental improvements of thin-layer and other ancillary technologies. There is a conundrum. Government, insurance companies, and our administrators are calling for us to hold back cost increases in medical care. Alternatively, these new technologies, patient demand for the perfect test, increased regulatory oversight, and legal challenges are increasing the cost of doing business. We do not know how to respond to the often-voiced fear that these ancillary technologies increase the cost of cytology services beyond some patients ability to pay. In this confusion, we do know that we should use the best test to get the most accurate answer for our patients. In selected scenarios this may mean that we will have to accept the cost and follow thin-layer technology.

Diagnosis of fibromatosis colli by fine-needle aspiration

Fibromatosis colli is a benign disorder presenting as a neck mass in neonates and older children. The differential diagnosis includes malignancies such as rhabdomyosarcoma. Neck masses in ten infants, discovered between the second and sixth week of age, were evaluated by fine‐needle aspiration (FNA). The male to female ratio was 7:3. In 8 patients there was good obstetrical history. Six of the 8 patients had a difficult delivery, as indicated by breech presentation or the need for forceps. Diagnostic aspirations were performed between the second to ninth week of age. The major cytologic finding was benign spindle fibroblasts, usually arrayed in clusters. The cells possessed plump, ovoid nuclei. There were also multinucleated cells consistent with degenerating skeletal muscle fibers. Only one case demonstrated significant inflammation. FNA can provide a rapid and reliable diagnosis in fibromatosis colli. There is support for the idea that in this setting, the disorder is related to perinatal muscular trauma. Diagn. Cytopathol. 2000; 23:338–342.

Exfoliative cytology of primary poorly differentiated (small-cell) neuroendocrine carcinoma of the uterine cervix in ThinPrep material: a case report.

Poorly differentiated neuroendocrine (small‐cell) carcinoma of cervical origin is a rare neoplasm that frequently metastasizes. Although the cytologic features have been described for conventional cervical smears, we know of no reports of its appearance in ThinPrep® (TP) material. Therefore, we present a TP case of primary small‐cell carcinoma arising in a 46‐yr‐old female, confirmed by histologic and immunohistochemical analysis. Similar to conventional smears, the neoplastic cells occurred either individually or in small clusters. The cells were relatively monomorphic, with stippled chromatin and minimal amounts of cytoplasm. Unlike conventional smears, nuclear molding was not prominent (although overlap was observed), and nuclear smearing was not identified. The features are compared to TP cases of squamous‐cell carcinoma, small‐cell type, and endometrioid adenocarcinoma, which are close mimics of small‐cell carcinoma. We conclude that correct diagnosis of small‐cell carcinoma in TP is difficult, requiring a high degree of suspicion and immunohistochemical confirmation. Diagn. Cytopathol. 23:14–18, 2000.

Fine‐needle aspiration diagnosis of spindle‐cell lipoma: A case report and review of the literature

Spindle‐cell lipoma (SCL) is an uncommon subcutaneous soft‐tissue neoplasm that usually arises in the posterior neck and shoulder of older male patients. To our knowledge, there have been only two reports describing the cytologic findings of this benign tumor, only one of which was confirmed by subsequent histologic examination. We report on a SCL of the occipital scalp in a 62‐yr‐old man diagnosed by fine‐needle aspiration. Air‐dried and alcohol‐fixed smears revealed scattered clusters of mildly pleomorphic spindled cells admixed with mature adipocytes, numerous mast cells, and small fragments of collagen. The diagnosis was confirmed by histologic sections and immunohistochemical studies for CD34 and bcl‐2 oncoprotein. Cytomorphologic features of SCL and a review of the literature are presented. Diagn. Cytopathol.2000;23:362–365.

Cytologic diagnosis of true thymic hyperplasia by combined radiologic imaging and aspiration cytology: A case report including flow cytometric analysis

True thymic hyperplasia (TH) is an age‐dependent increase in size and weight of the thymus gland, which by definition maintains a normal histologic architecture. TH can mimic other important diseases, including lymphofollicular hyperplasia, thymoma, lymphoma, and germ‐cell tumors. Traditionally, separating these entities has required a formal surgical biopsy. Given that many of these conditions occur in children, this can be a traumatic experience for both the patient and family members. Fine‐needle aspiration biopsy has the distinct advantage of being able to obtain diagnostic material without requiring general anesthesia. We are aware of only one previously reported case of an enlarged thymus being subjected to aspiration cytology. We therefore present a case of thymic hyperplasia in a 5‐mo‐old child diagnosed by combined radiologic and cytologic parameters, including flow cytometric analysis. Diagn. Cytopathol. 2000;23:417–421.

Leiomyosarcoma metastatic to the orbit: Diagnosis by fine‐needle aspiration

A 47‐yr‐old man with history of metastatic low‐grade rectal leiomyosarcoma presented with progressive protrusion of his left eye due to an enlarging orbital mass. The differential diagnosis included tumor metastasis or orbital infection due to an unknown infectious agent. Diagnostic fine‐needle aspiration (FNA) of the orbit was performed on an urgent basis to institute proper therapy and to save the patients eyesight. Cytomorphologic examination of the material demonstrated a spindle‐cell neoplasm consistent with metastatic leiomyosarcoma.