Karen Chau

Accuracy and risk of malignancy for diagnostic categories in urine cytology at a large tertiary institution.

At a high‐volume center, it became necessary to provide benchmarks for the accuracy and risk of malignancy per urine cytology diagnostic category. The additive sensitivity for the determination of the residual risk of disease was calculated with the goal of determining the performance of cytology and optimal triage, including the number of urine samples, before the detection of malignancy in surveillance patients.

Two‐tiered subdivision of atypia on urine cytology can improve patient follow‐up and optimize the utility of UroVysion

The annual incidence of urothelial carcinoma continues to increase, and it is projected that greater than 70,000 new cases will occur in the year 2015. However, as much as 23% of cytologic specimens will demonstrate some degree of atypia without meeting the criteria for urothelial carcinoma and thus will be reported as atypical.

Analysis of the Cytomorphological Features in Atypical Urine Specimens following Application of The Paris System for Reporting Urinary Cytology

Background: This study investigates the use of The Paris System (TPS) for Reporting Urinary Cytopathology and examines the performance of individual and combined morphological features in atypical urine cytologies. Methods: We reviewed 118 atypical cytologies with subsequent bladder biopsies for the presence of several morphological features and reclassified them into Paris System categories. The sensitivity and specificity of individual and combined features were calculated along with the risk of malignancy. Results: An elevated nuclear-to-cytoplasmic ratio was only predictive of malignancy if seen in single cells, while irregular nuclear borders, hyperchromasia, and coarse granular chromatin were predictive in single cells and in groups. Identification of coarse chromatin alone yielded a malignancy risk comparable to 2-feature combinations. The use of TPS criteria identified the specimens at a higher risk of malignancy. Conclusion: Our findings support the use of TPS criteria, suggesting that the presence of coarse chromatin is more specific than other individual features, and confirming that cytologic atypia is more worrisome in single cells than in groups.

How “suspicious” is that nodule? Review of “suspicious” Afirma gene expression classifier in high risk thyroid nodules

The Afirma gene expression classifier (GEC) is being increasingly utilized to confirm the benign nature of indeterminate FNA cytology results thus avoiding unnecessary surgical procedures. However the “suspicious” result of the Afirma GEC does not classify these indeterminate nodules further in determining appropriate management. This study investigated the outcome of the thyroid nodules deemed to be “suspicious” by the Afirma GEC in a high risk population.

Quality assessment and improvement of “Unsatisfactory” liquid-based cervicovaginal papanicolaou smears: MIRZAMANI et al.

The quality of cervicovaginal smears determines the success of cytology in screening programs for cervical cancer. Bethesda 2014 revisited the adequacy criteria for atrophic smears and redefined the squamous cell count in the “unsatisfactory” category. In this study, we evaluated the smear quality of Thinprep liquid‐based cervicovaginal Papanicolaou cytology slides (TPS) that were previously deemed unsatisfactory, to determine reasons for such categorization. In addition, we attempted to establish the impact of the new adequacy criteria on the rate and management of unsatisfactory diagnosis.

Utility of intraoperative frozen sections for thyroid nodules with prior fine needle aspiration cytology diagnosis: ROYCHOUDHURY et al.

The objective of this study was to evaluate the role of intraoperative frozen section (IFS) in determining the course of surgery in thyroid nodules with a prior fine needle aspiration (FNA) biopsy diagnosis. In addition, reliability of FNA interpretation to guide surgical management without IFS was investigated.

Experience of the Indeterminate Thyroid Nodules: Analysis of Risk of Malignancy and Outcomes

follicular clusters, syncytial aggregates); nuclear features [elongation, enlargement, pseudoinclusions (NP), grooves (NG), prominent nucleoli, and clearing (NC)]; fibrosis; colloid (inspissated vs. thin); calcifications; and flame cells. The frequency of each feature was compared to those of follicular neoplasms (FN) and FVPTC FNA cases and analyzed for significance by chi-square, Fisher exact test, and Student’s t-test. Results: 4500 thyroid FNA cases were collected, of which 479 had surgical follow-up and 38 were diagnosed as NIFTP. Among these, 22 cases were previously diagnosed as FVPTC. We examined 44 FNAs comprising 26 NIFTP, 13 FN, and 5 FVPTC. TCP was the most significant cytomorphologic feature in NIFTP (19/26) in comparison to FN (2/13) (pZ0.01, Figure 1). NP was consistently seen in 4/5 FVPTC cases but only observed in 3/26 NIFTPs (pZ0.005) (Table 1). When compared to FN, NIFTP has increased incidence of NG and NC (pZ0.02 and pZ0.001, respectively), but not between FVPTC and NIFTP (pZ1 and pZ1). Conclusions: Cytomorphologic features such as presence of TCP and scant NP can be helpful in distinguishing NIFTP cases from FN and FVPTC on FNA and potentially reduce unnecessary surgeries.

Urine cytology of nonurothelial malignancies-a 10-year experience in a large multihospital healthcare system: Urine cytology of nonurothelial malignancies

Urine cytology is the most frequently utilized test to detect urothelial cancer. Secondary bladder neoplasms need to be recognized as this impacts patient management. We report our experience on nonurothelial malignancies (NUM) detected in urine cytology over a 10‐year period.

Quality Assessment and Improvement of “Unsatisfactory” Liquid Based Cervicovaginal Papanicolaou Smears

Objectives The quality of cervicovaginal smears determines the success of cytology in screening programs for cervical cancer. Bethesda 2014 revisited the adequacy criteria for atrophic smears and redefined the squamous cell count in the “unsatisfactory” category. In this study, we evaluated the smear quality of Thinprep liquid-based cervicovaginal Papanicolaou cytology slides (TPS) that were previously deemed unsatisfactory, to determine reasons for such categorization. In addition, we attempted to establish the impact of the new adequacy criteria on the rate and management of unsatisfactory diagnosis. Methods About 234 unsatisfactory TPS were examined. The reasons for unsatisfactory were noted. The number of squamous cells was recounted, as per the new Bethesda criteria, in borderline adequacy cases that showed an atrophic pattern. Results The leading cause for unsatisfactory TPS was lubricating gel, followed by blood, as observed in older and younger age groups, respectively (Figure 1). Eleven borderline cases were reclassified as “satisfactory” using the new Bethesda cell count, with 27% above 60 years of age. About 82% of these borderline cases were negative for intraepithelial lesion or malignancy on repeat testing. Conclusions There was no difference of management or change in rate of unsatisfactory when patients above 60 were reclassified into the satisfactory category using the new Bethesda count. However, a larger study is needed to evaluate whether the new recommendation for minimum cellularity can be implemented in patients above a certain age cut-off. The study highlights the need for improvement in collection practices and education of practitioners.

Role of FNA cytology with cell block in the diagnosis of papillary squamous cell carcinoma of the upper aero-digestive tract: case report

Dear Editor, The role of fine needle aspiration (FNA) cytology with cell block in the diagnosis of papillary squamous cell carcinoma (PSCC) of the upper aerodigestive tract has not hitherto been emphasized sufficiently in the literature. PSCC of the head and neck, a rare subtype of squamous cell carcinoma (SCC), is often associated with human papillomavirus (HPV) and portends better patient survival than conventional head and neck SCC. Although the anatomical inaccessibility by cytological techniques, including brushing and washings, of some of the head and neck sites may limit the role of cytology as a screening test for PSCC, the current case presentation strongly underscores the value of cytological diagnosis; especially when combined with cell block material, which facilitates additional ancillary studies including HPV expression and efficient triage of management. We report the case of an 82-year-old man who was status post-glossectomy and radio-adjuvant therapy for a conventional SCC of the base of the tongue. He presented with progressive dysphagia and hoarseness for a few weeks, when a positron emission tomography/computed tomography (PET/CT) scan revealed multiple lesions in the right subglottis and trachea. As a result of the patient’s respiratory symptoms, the thoracic service elected to perform a minimally invasive endobronchial ultrasound-guided FNA to sample the tracheal lesion. The smears were both air-dried for Diff-Quik staining and fixed in 95% alcohol for Papanicolaou staining. The needle was rinsed in 10% formalin for a cell block. Cell block sections were stained with haematoxylin and eosin and for p16 immunostaining (NK 4a, clone E6H4; CINtec Histology V kit, Roche Laboratories), and examined for high-risk HPV DNA [in situ hybridization (ISH); DAKO, Carpenteria, CA, USA]. Cytomorphologically, the tumour comprised small basaloid cells with central, round, dark nuclei, coarsely granular chromatin and moderately dense cytoplasm imparting a ‘fried-egg’ appearance. Cytoarchitectural arrangements included a ‘cobble-stone’ pattern of flat sheets, syncytial fragments, papillary structures and single-lying cells. Atypia with parachromatin clearing, dyskeratotic cells and koilocytic cells were also present (Figure 1). Cell block sections accentuated an intact basement membrane, albeit with loss of surface keratinization and polarity. As p16 immunostaining predominantly highlighted the nucleus (Figure 2a), a second confirmatory HPV test was required as indicated in some studies. The positive result of HPV DNA ISH (Figure 2b) lent additional and strong support to the diagnosis of PSSC. PSCC of the upper aero-digestive tract is an uncommon and unique subtype of SCC, commonly involving the oropharynx, larynx and sinonasal tract. Diagnosis is typically made histologically after surgical excision. The differential diagnosis includes verrucous carcinoma and squamous papilloma, and remains a diagnostic challenge. The presence of subtle but unequivocally malignant cytological features, often seen in conventional SCC, is key to distinguishing between these entities. The cytology of papillomas is generally bland with occasional cellular atypia presenting as slight prominence of nucleoli and enlargement of nuclei. Papillomas may show koilocytic and binucleated cells, features supporting an association with HPV. Association with HPV and positive expression of p16, a surrogate marker for HPV, have been variably reported. In a study by Mehrad et al., HPV was found in 53.4% of cases. The current case is also unique in that patients with HPV-related oropharyngeal SCC are less likely to