Durgesh N. Rana

Automation-assisted versus manual reading of cervical cytology (MAVARIC): a randomised controlled trial

BACKGROUND The standard for reading cervical cytology is for a cytoscreener to manually search across an entire slide for abnormal cells using a conventional microscope. Automated technology can select fields of view to assess abnormal cells, which allows targeted reading by cytoscreeners. In the Manual Assessment Versus Automated Reading In Cytology (MAVARIC) trial, we compared the accuracy of these techniques for the detection of underlying disease. METHODS For this randomised controlled trial, women aged 25-64 years undergoing primary cervical screening in Manchester, UK, were randomly assigned (1:2) to receive either manual reading only or paired reading (automation-assisted reading and manual reading), between March 1, 2006, and Feb 28, 2009. In the paired arm, two automated systems were used-the ThinPrep Imaging System and the FocalPoint GS Imaging System. General practices and community clinics were randomised to either ThinPrep or to SurePath (for the FocalPoint system) liquid-based cytology with block randomisation stratified by deprivation index. Samples were then individually randomised to manual reading only or paired reading only. Laboratory staff were unaware of the allocation of each slide and concealment was maintained until the end of the reporting process. The primary outcome was sensitivity of automation-assisted reading relative to manual reading for the detection of underlying cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in the paired arm. This trial is registered, number ISRCTN66377374. FINDINGS 73,266 liquid-based cytology samples were obtained from women undergoing primary cervical screening; 24,688 allocated to the manual-only arm and 48,578 to the paired-reading arm. Automation-assisted reading was 8% less sensitive than manual reading (relative sensitivity 0·92, 95% CI 0·89-0·95), which was equivalent to an absolute reduction in sensitivity of 6·3%, assuming the sensitivity of manual reading to be 79%. Specificity of automation-assisted reading relative to manual reading increased by 0·6% (1·006, 95% CI 1·005-1·007). INTERPRETATION The inferior sensitivity of automation-assisted reading for the detection of CIN2+, combined with an inconsequential increase in specificity, suggests that automation-assisted reading cannot be recommended for primary cervical screening.

Metastatic Transitional Cell Carcinoma Causing a unilateral pleural effusion : A Case Report

BACKGROUND Transitional cell carcinoma (TCC) is a common neoplasm, but it is only rarely associated with serous effusions. The cytologic features of metastatic TCC in pleural effusions have been described only in occasional studies. One feature that raises the possibility of metastatic TCC in this setting is the presence of eosinophilic cytoplasmic inclusions (ECIs). CASE Metastatic TCC was diagnosed in a pleural fluid from a 50-year-old man with a unilateral effusion. Two years previously he had been diagnosed with a poorly differentiated TCC of the urinary bladder (WHO grade 3, stage pT2 at least), and more recently he had also been diagnosed with an omental metastasis. Cytologic examination of the pleural fluid sample revealed numerous pleomorphic malignant cells, many of which were vacuolated. Numerous eosinophilic inclusions were identified within the malignant cells in the liquid based cytology (ThinPrep) preparation. Examination of the omental cake biopsy revealed similar appearances. CONCLUSION ECIs within malignant pleural effusion fluid specimens should, if detected, raise the possibility of metastatic transitional cell carcinoma.

Adenosquamous carcinoma of the lung diagnosed by cytology?: A diagnostic dilemma

Adenosquamous cell carcinomas of the lung are rare tumours and are associated with a poor prognosis compared to other non‐small cell carcinomas. We report a case of a solitary lung carcinoma evaluated by bronchial brush and lavage cytology, bronchial biopsy and pleural fluid cytology. Cytological assessment of the pleural fluid demonstrated non‐small cell carcinoma and immunohistochemical staining confirmed a metastatic lung adenocarcinoma. The bronchial brush and lavage specimens, however, demonstrated the cytomorphological features of squamous cell carcinoma, which was confirmed by the bronchial biopsy.

EBUS-guided mediastinal lung cancer staging: monitoring of quality standards improves performance

This audit examined key performance indices related to endobronchial ultrasound (EBUS)-guided mediastinal lung cancer staging before and after the introduction of defined quality standards, at four independent EBUS centres in one cancer network. Data from 642 procedures were prospectively collected and analysed. The introduction of standards was associated with a significant increase (p<0.001) in sampling of key mediastinal lymph node stations (4R, 4L and 7) and a reduction in the variability of staging sensitivity between centres. These data reinforce the requirement for an appropriate regulatory framework for EBUS-transbronchial needle aspiration provision that includes quality assurance and performance monitoring.

Ancillary testing in liquid based cytology to distinguish cervical glandular neoplasia from tuboendometrial metaplasia in a young woman

A 33‐year old woman had a cervical sample taken at colposcopy clinic. Seven years prior to this, at the age of 26, she had had a cytological diagnosis of cervical glandular neoplasia (cytology descriptor indicated cells suspicious of endocervical neoplasia) and severe dyskaryosis. Confirmation and treatment were by LLETZ and knife cone, and, in keeping with England and Wales National Health Service guidelines, this woman was under follow‐up by the colposcopy clinic. Intervening cytological follow‐up included a number of negative cytological samples interspaced with one equivocal report. A recent repeat cytology which was rather cellular contained several hyperchromatic crowded cell groups (HCCGs). Careful examination revealed benign endometrial clusters, LUS, TEM and endocervical cells in strips showing pseudostratification and loss of polarity. Following an agar block, there was positive staining for p16 and Ki‐67 in the abnormal groups whilst the benign TEM cells stained positive for bcl‐2. Diagn. Cytopathol. 2010;38:828–832.

A retrospective 3-year study of salivary gland FNAC with categorisation using the Milan reporting system

To assess our practice using the recently developed standardised classification system designated The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) and to ascertain the rates of malignancy for each category by means of a retrospective study.

Cytological and electron microscopic findings in a bronchoalveolar lavage sample from a case of pulmonary alveolar proteinosis with radiological correlation

A case of pulmonary alveolar proteinosis (PAP) where a diagnosis was made on the bronchoalveolar lavage (BAL) specimen is reported. The residual material was used for the special stains and the transmission electron microscopy (TEM) – an examination not routinely performed on BAL samples. The learning lessons of this case are that cytological analysis of BAL samples may be just as diagnostic as a histological biopsy, and TEM can be performed on BAL samples if adequate and immediate fixation is achieved. This, to the best of our knowledge, has not previously been reported.

The Role of Cytology in the Management of Ovarian Lesions

Cytology can serve as a useful tool in the diagnosis of both cystic and solid lesions of the ovary, in conjunction with radiological evaluation and multidisciplinary discussion. The use of peritoneal washings as part of the staging procedure for ovarian neoplasms is an important application of cytology. Sample types relevant to ovarian pathology may be divided into exfoliative specimens, including serous fluid samples (ascitic, peritoneal, and pleural), as well as peritoneal washings, and fine-needle aspirates (FNA).

P37 The clinical utility of rapid on-site evaluation (rose) in the diagnosis of non-malignant granulomatous mediastinal lymphadenopathy following endobronchial ultrasound (ebus)

Introduction EBUS guided trans-bronchial needle aspiration with ROSE ensures adequacy of specimen samples and provides preliminary cytological diagnosis. Few studies have explored the utility of ROSE in granulomatous mediastinal lymphadenopathy. This retrospective study looks to further assess the validity of ROSE in the setting of non-malignant granulomatous disease. Methods We reviewed a prospectively maintained database of ROSE and laboratory cytology Results for all EBUS procedures performed during a 12 month period from 1 st January to 31 st December 2015 at our institute. We included all patients who had granuloma (including probable or possible granuloma) identified at ROSE or final cytology analysis, or both. We then reviewed clinico-radiological data to ascertain the final diagnosis and excluded those patients with malignant disease. Results During the study period, 366 EBUS were performed, with granuloma identified in 51 patients. Three patients were found to have malignancy and were excluded therefore 48 were included in the final analysis. The final diagnoses for the 48 patients are shown in Table 1. Patients with TB were more likely to have at least one granuloma at ROSE (84%) than patients with sarcoidosis (67%). Patients with granuloma identified at ROSE had a slightly lower number of nodes sampled per patient compared to those with no granuloma at ROSE (mean 1.8 vs 2.4 nodes per patient). The positive predictive value of ROSE for granuloma in our cohort was 100%, with a sensitivity of 71%. This is comparable to other studies. Conclusions In our cohort of patients, ROSE had a high positive predictive value and a sensitivity of over 70% for the diagnosis of granuloma in non-malignant disease. Our Results suggest that with the use of ROSE fewer nodes are sampled which may reduce procedure time and potential complications. This study is limited due to the small sample size but supports the use of ROSE in this context. We plan to carry out further work with larger data sets, and to look at the characteristics of those subsequently diagnosed with sarcoidosis or tuberculosis. Abstract P37 Table 1 Granuloma at ROSE Granuloma at final cytology Final diagnosis N % N % Sarcoidosis 18 38 27 56 TB (all) 16 33 19 40 TB (culture positive) 5 10 8 17 TB (culture negative) 11 23 11 23 Reactive 0 0 2 4 Total 34 71 48 100

Angioimmunoblastic T Cell lymphoma mimics reactive lymphoid tissue on cytomorphology: A multimodality approach utilising cytology, immunocytochemistry and flow cytometry to resolve this diagnostic dilemma.

Dear Editor, Angioimmunoblastic T cell lymphoma (AITL) is a common form of Peripheral T Cell Lymphoma (PTCL), amounting to 18.5% of the cases globally, and is more common in Europe than North America or Asia. Gene expression studies propose a follicular T helper cell origin, suggested by expression of CD10, BCL6 and PD1. Patients are typically adults in their 50s or 60s and present with a fever, weight loss, subacute systemic illness and up to 50% of patients have a maculopapular skin rash which can mimic inflammatory dermatoses. There is also mild to moderate systemic lymphadenopathy. Patients generally present with advanced stage disease and the prognosis is often poor. The diagnosis of PTCL by fine needle aspiration (FNA) cytology is challenging because the polymorphous population of haematolympoid cells seen in these aspirates can be easily mistaken for reactive lymphadenopathy. A case of AITL is discussed which mimicked a reactive process on cytomorphology, and the multimodality approach is outlined which helped in the diagnosis of this challenging case. A case of a 54-year-old woman is reported who presented with weight loss, rash and night sweats. Clinical examination revealed systemic lymphadenopathy. FNA of a right-sided neck lymph node was performed using a 25-G needle. Two aspirates were received and the attending Biomedical Scientist (BMS) prepared one air-dried direct spread (stained by Rapi-Diff (Atom Scientific, Manchester, UK) for each aspirate and the needle was rinsed in CytoRich Red (BD Diagnostics, Burlington, NC, USA) which was prepared as a single Papanicolaou-stained slide using the BD SurePath autostainer according to the manufacturer’s instructions. Rapid on-site adequacy assessment was performed by the BMS, and given the clinical concern for lymphoma, material was rinsed into RPMI (Sigma-Aldrich, Dorset, UK) for flow cytometry. The cytology preparations were highly cellular and contained a polymorphous population of small lymphocytes, medium-sized lymphoid cells, plasma cells, immunoblasts and lymphoglandular bodies. In areas, the lymphoid cells formed cell fragments with prominent transgressing blood vessels (Figure 1). Aggregates and dispersed dendritic cells with smooth ovoid nuclei, inconspicuous nucleoli, evenly dispersed chromatin and moderate to abundant amounts of cytoplasm, were also noted. Some of these aggregates were percolated by lymphocytes and formed so-called dendritic cell-lymphocyte complexes (Figure 2). Epithelioid histiocytes, Hodgkin / Reed-Sternberg cells, tingible body macrophages, follicle centre cell fragments and obviously malignant monotonous lymphoid cells were not identified. Immunocytochemistry performed on the agar cell block prepared from the residual material revealed a marked predominance of CD2, CD3, and CD5 positive T cells amidst a few CD20 positive B cells. Tdt was negative. The larger cells were positive for CD21. The flow cytometry analysis reported a predominance of T cells that expressed CD2, CD5 and CD4. The cells were negative for the CD3 receptor antigen, possibly indicating clonality. Despite the polymorphous morphology, given the predominance of T cells seen on immunocytochemistry and flow cytometry, a diagnosis of T cell lymphoma was raised, and the histological correlation was advised for confirmation and subtyping. AITL was confirmed on subsequent excision biopsy. The cytological appearances of a polymorphous population of lymphocytes mimicked a reactive process in this case. The differential diagnoses to consider when confronted with a mixed population of lymphocytes also includes Hodgkin lymphoma and certain nonHodgkin lymphomas, including marginal zone lymphoma, follicular lymphoma, T cell-rich B cell lymphoma and peripheral T cell lymphoma. Ancillary investigations, including flow cytometry and immunocytochemistry, were key in making the diagnosis of lymphoma in this case, but a number of cytomorphological features were also evident. The absence of tingible body macrophages together with large tissue fragments of lymphoid cells containing prominent blood vessels, which reflect characteristic histological findings of high endothelial venules, have been described in AITL. The presence of dendritic cell-lymphocyte complexes are helpful in distinguishing reactive from neoplastic processes, particularly in the differential with reactive paracortical hyperplasia. Subsequent histological confirmation is recommended for the diagnosis of lymphoma at a patient’s first presentation. Previous studies have questioned the utility of flow cytometry in AITL, given the polymorphous population of the infiltrate and the often relatively scanty nature of the malignant cells. The benefits of flow cytometry include being able to quantitatively analyse several markers and dual labelling. Aberrant T cell populations identified via flow cytometry have been reported in 63% of cases of AITL, with the most common abnormalities being loss of CD3 expression, as DOI: 10.1111/cyt.12422