Nancy A. Young

Proteomic Analyses of Pancreatic Cyst Fluids

Objectives: There are currently no diagnostic indicators that are consistently reliable, obtainable, and conclusive for diagnosing and risk-stratifying pancreatic cysts. Proteomic analyses were performed to explore pancreatic cyst fluids to yield effective diagnostic biomarkers. Methods: We have prospectively recruited 20 research participants and prepared their pancreatic cyst fluids specifically for proteomic analyses. Proteomic approaches applied were as follows: (1) matrix-assisted laser-desorption-ionization time-of-flight mass spectrometry peptidomics with LC/MS/MS (HPLC-tandem mass spectrometry) protein identification; (2) 2-dimensional gel electrophoresis; (3) GeLC/MS/MS (tryptic digestion of proteins fractionated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and identified by LC/MS/MS). Results: Sequencing of more than 350 free peptides showed that exopeptidase activities rendered peptidomics of cyst fluids unreliable; protein nicking by proteases in the cyst fluids produced hundreds of protein spots from the major proteins, making 2-dimensional gel proteomics unmanageable; GeLC/MS/MS revealed a panel of potential biomarker proteins that correlated with carcinoembryonic antigen (CEA). Conclusions: Two homologs of amylase, solubilized molecules of 4 mucins, 4 solubilized CEA-related cell adhesion molecules (CEACAMs), and 4 S100 homologs may be candidate biomarkers to facilitate future pancreatic cyst diagnosis and risk-stratification. This approach required less than 40 &mgr;L of cyst fluid per sample, offering the possibility to analyze cysts smaller than 1 cm in diameter.

Fine-Needle Aspiration of Pulmonary Hamartoma: A Common Source of False-Positive Diagnoses in the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology

CONTEXT We use data from the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytology to evaluate the accuracy of fine-needle aspiration (FNA) biopsy for diagnosing pulmonary hamartoma (PH). OBJECTIVE To use the performance characteristics of the PH cases in the Nongynecologic Cytology Program to determine the accuracy of FNA for identifying these lesions and to determine potential sources of interpretative errors. DESIGN A retrospective review of the College of American Pathologists Nongynecologic Cytology cumulative data from 1997 to 2003 was performed to identify the overall accuracy of FNA for diagnosing PH and to determine the most common interpretative pitfalls. The slides from each of the cases of PH in the Nongynecologic Cytology Program were then reviewed in an effort to identify the cytologic characteristics that contributed to the poor performance of these cases. RESULTS A total of 766 participant responses for 19 PH FNA specimens were reviewed. The specificity of FNA for making the correct general reference interpretation of benign was 78%. The false-positive rate was 22%, with the most common false-positive diagnoses being carcinoid tumor, adenocarcinoma, and small cell carcinoma. The overall accuracy for making the correct specific reference diagnosis of PH was 26%. Microscopic review of the individual cases revealed possible explanations for some of the interpretative errors and the most frequent false-positive interpretations. CONCLUSIONS Cytologists should be aware of the potential false-positive interpretations that can occur in FNAs of PH and the potential reasons for these inaccuracies in order to minimize clinically significant diagnostic errors.

Diagnosis and subclassification of breast carcinoma by fine-needle aspiration biopsy: Results of the Interlaboratory Comparison Program in Non-Gynecologic Cytopathology

CONTEXT The College of American Pathologists Interlaboratory Comparison Program in Non-Gynecologic Cytopathology is a popular educational program for nongynecologic cytology that had 1018 participating laboratories by the end of 2000. Data generated from this program allow for tracking performance on slides in a diverse group of laboratories. OBJECTIVE We reviewed the performance of participating laboratories on fine-needle aspiration biopsies of the breast with particular interest in the ability of participants to accurately subclassify breast carcinoma. DESIGN We reviewed the responses of participating laboratories for glass slides of breast fine-needle aspiration biopsies for the year 2000. We analyzed benchmarking data provided for each specific diagnosis. RESULTS The overall false-negative rate for laboratories was 6.2%, and the overall false-positive rate was 1.1%. Most of the breast carcinomas were correctly identified as malignant on the general diagnosis, but participants had more difficulty subclassifying types of breast carcinoma. The rate of correct exact diagnosis was 65% for ductal adenocarcinoma, 20% for lobular adenocarcinoma, 12% for medullary carcinoma, and 27% for mucinous carcinoma. CONCLUSIONS This study shows that fine-needle aspiration biopsy of the breast is a reliable method for the diagnosis of breast carcinoma, but difficulties still exist in our ability to determine tumor subtype.

Clinical significance of performing immunohistochemistry on cases with a previous diagnosis of cancer coming to a national comprehensive cancer center for treatment or second opinion.

Immunohistochemistry (IHC) is an important adjunctive test in diagnostic surgical pathology. We studied the clinical significance and outcomes in performing IHC on cases with a previous diagnosis of cancer who are coming to the Fox Chase Cancer Center (FCCC), a National Cancer Institute designated National Comprehensive Cancer Center (NCCC), for treatment and/or second opinion. We reviewed all the outside surgical pathology slide review cases seen at the FCCC for 1998 and 1999 in which IHC was performed. Cases were divided into the following: confirmation of outside diagnoses without and with prior IHC performed by the outside institution (groups A and B, respectively) and cases with a significant change in diagnosis without and with prior IHC performed by the outside institution (groups C and D, respectively). During 1998 and 1999, 6678 slide review cases were reviewed at the FCCC with an overall significant change in diagnosis in 213 cases (3.2%). IHC was performed on 186 of 6678 (2.7%) slide review cases with confirmation of the outside diagnosis in 152 (81.7%) cases and a significant change in diagnosis in 34 (18.3%) cases. Patient follow-up was obtained in 32 of 34 (94.1%) cases with a significant change in diagnosis (groups C and D), which confirmed the correctness of our diagnosis in 26 of 27 cases (96%; in five cases follow-up was inconclusive). We repeated the identical antibodies performed by the outside institutions in group D (37 antibodies) and group B (133 antibodies) with different results in 48.6% and 13.5%, respectively (overall nonconcordance 21.2%). In group D additional antibody tests beyond that performed by the outside institution were needed in 88.8% of cases to make a change of diagnosis. In the setting of a NCCC, reperforming and/or performing IHC on cases with a previous diagnosis of cancer is not a duplication of effort or misuse of resources. Repeating and/or performing IHC in this setting is important in the care and management of patients with cancer.

Misinterpretation of normal cellular elements in fine-needle aspiration biopsy specimens: Observations from the College of American Pathologists Interlaboratory Comparison Program in Non-Gynecologic Cytopathology

CONTEXT The College of American Pathologists Interlaboratory Comparison Program in Non-Gynecologic Cytopathology is a popular educational program for nongynecologic cytology, with 1018 participating laboratories by the end of 2000. Data generated from this program allow tracking pathologist performance in a wide variety of laboratory practices. OBJECTIVE To review performance of participating pathologists in making patient diagnoses with fine-needle aspiration biopsy specimens, with particular interest in the false neoplastic diagnoses (both benign and malignant neoplasms) that were submitted for benign aspirates containing only normal cellular components. DESIGN We reviewed the diagnoses made from 1998 through 2000 by participating pathologists through the use of glass slides containing benign fine-needle aspiration biopsy specimens of the liver, kidney, pancreas, and salivary gland that contained only normal cellular components. RESULTS The false neoplastic rate for kidney (60%) was the highest, followed by liver (37%), pancreas (10%), and salivary gland (6%). These rates are much higher than what has previously been reported in the literature. CONCLUSIONS This study illustrates that normal cellular elements are a significant pitfall for overinterpretation of fine-needle aspiration biopsy specimens.

Fine-needle aspiration biopsy of lymphoproliferative disorders--interpretations based on morphologic criteria alone: results from the College of American Pathologists Interlaboratory Comparison Program in Nongynecologic Cytopathology.

CONTEXT Diagnosis of lymphoproliferative disorders is one of the most challenging tasks faced by the cytologist. The initial cytomorphologic evaluation of lymphoproliferative lesions directs the choice of ancillary studies that ultimately lead to a diagnosis based on the World Health Organization classification system using a composite of clinical, morphologic, immunophenotypic, and molecular features. OBJECTIVE To evaluate the ability of participating laboratories in the College of American Pathologists Interlaboratory Comparison Program in Non-Gynecologic Cytopathology to appropriately categorize lymphoproliferative lesions based solely on cytomorphologic criteria. DESIGN Laboratory responses for lymph node aspirates were examined. All responses were based on review of glass slides without ancillary immunologic or molecular data available. The benchmarking data provided for each specific diagnosis were analyzed, with a focus on the performance for evaluation of lymphoproliferative lesions. RESULTS Based on morphology alone, responses for lymph node aspirates in the Non-Gynecologic Cytopathology program were correct to the exact reference diagnosis for 87.1% of Hodgkin lymphoma. Non-Hodgkin lymphoma was identified in 69.5% of the large cell non-Hodgkin lymphoma cases, of which 66.8% were correctly classified as large cell type. Non-Hodgkin lymphoma was identified in 68.1% of non-Hodgkin lymphoma, other than large cell cases, and of these, 94.7% were identified as other than large cell type. CONCLUSIONS The spectrum of specific responses was consistent for lymphoproliferative lesions, with a reasonable differential diagnosis based on cytomorphology alone, which, in practice, facilitates the appropriate choice of immunophenotypic markers and other ancillary studies.

The Potential for Failure in Gynecologic Regulatory Proficiency Testing With Current Slide Validation Criteria: Results From the College of American Pathologists Interlaboratory Comparison in Gynecologic Cytology Program

CONTEXT Current regulatory proficiency testing scoring results in an automatic failure for identifying high-grade squamous intraepithelial lesion (HSIL) as negative. OBJECTIVE The College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology data from January 2004 to April 2005 were analyzed to estimate the percentage of failure based on negative responses for HSIL and validation criteria. DESIGN More than 15,000 participants received field-validated and educational slide sets for conventional, ThinPrep, and SurePath modules. Educational sets fulfilled the validation criteria of the Center for Medicare and Medicaid Services, which required the consensus diagnosis of biopsy-proven HSIL (not field-validated) after review by 3 pathologists. The College of American Pathologists field validation required at least 20 responses to the HSIL+ series, with 70% matched to HSIL+ (standard error < or = 0.05). Minimum regulatory proficiency testing failure estimates were based on incorrect negative responses for the reference category of HSIL. RESULTS For both cytotechnologists and pathologists, there was a statistically significant higher failure rate for slides that were not field-validated versus those that were field-validated. In conventional modules, 5.3% of the slides that were not field-validated were called negative, versus 1.2% of the field-validated slides. In all liquid-based preparations, 4.0% of the non-field-validated versus 2.2% field-validated slides were called negative. Pathologists would have failed more often than cytotechnologists for the slides that were not field-validated, whereas there was no statistical difference in failure performance with field-validated slides. CONCLUSIONS Failures were significantly greater with the slides that were not field-validated for both conventional and liquid-based preparations (ThinPrep only) and have implications for both regulatory proficiency testing and expert legal review. Poor performance of pathologists relative to that of cytotechnologists may reflect a lack of prescreening of slides or scope of practice issues.

Cytologic features of high-grade squamous intraepithelial lesion in ThinPrep Papanicolaou test slides: comparison of cases that performed poorly with those that performed well in the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology

CONTEXT Conventional Papanicolaou (Pap) test slides of high-grade squamous intraepithelial lesions (HSILs) that are frequently misdiagnosed are known to have relatively few dysplastic cells. Whether this is true of cases of HSIL in ThinPrep Pap Test specimens is not known. OBJECTIVE To determine if cases of HSIL in ThinPrep specimens that are frequently missed have relatively few dysplastic cells. DESIGN The cytologic features of 16 ThinPrep cases of HSIL that performed poorly in the College of American Pathologists Interlaboratory Comparison Program were compared with 22 ThinPrep Pap Test cases that performed extremely well. RESULTS Significantly more cases that performed poorly had fewer than 250 dysplastic cells (13/16) than cases that performed well (3/22) (P <.001). CONCLUSION ThinPrep Pap Test cases with a diagnosis of HSIL that performed poorly in this program had significantly fewer dysplastic cells than those that performed well.

The 2001 Bethesda system: Terminology for reporting results of cervical cytology

The Bethesda System for reporting the results of cervical cytology was introduced in 1988 and revised in 1991 using the actual laboratory and clinical experience with the system. After 10 years of widespread use and advances in biologic understanding of cervical neoplasia, it was felt important to reexamine this terminology. After extensive internet web-based discussion groups on various aspects of the System, a workshop was held at the National Cancer Institute in Bethesda, Maryland, with participation from a broad range of constituents including cytologists, pathologist, clinicians, epidemiologists, patient advocates, and attorneys. This consensus statement is the report of this workshop. The following table (Table 1) is an abstract of the consensus statement.

Postbrushing and fine-needle aspiration biopsy follow-up and treatment options for patients with pancreatobiliary lesions: The papanicolaou society of cytopathology guidelines: Postbrushing and Fna Follow-Up Of Pancreatobiliary Lesions

The papanicolaou society of cytopathology (PSC) has developed a set of guidelines for pancreatobiliary cytology including indications for endoscopic ultrasound (EUS) guided fine‐needle aspiration (FNA) biopsy, techniques of EUS‐FNA, terminology and nomenclature for pancreatobiliary cytology, ancillary testing, and postprocedure management. All documents are based on the expertise of the authors, a review of the literature, discussions of the draft document at several national and international meetings over an 18 month period and synthesis of online comments of the draft document on the PSC web site [www.papsociety.org]. This document selectively presents the results of these discussions and focuses on the follow‐up and treatment options for patients after procedures performed for obtaining cytology samples for the evaluation of biliary strictures and solid and cystic masses in the pancreas. These recommendations follow the six‐tiered terminology and nomenclature scheme proposed by Committee III. Diagn. Cytopathol. 2014;42:363–371.