Sara S. George

Hodgkin's lymphoma: Diagnostic difficulties in fine-needle aspiration cytology

It is commonly believed that cytodiagnosis of Hodgkins lymphoma (HL) is much easier than that of non‐Hodgkin lymphoma (NHL). However, recognition of certain NHL subtypes with Reed‐Sternberg (R‐S)‐like cells and results of immunohistochemical studies point to the contrary. To study the limitations of cytology in diagnosis of HL, fine‐needle aspiration (FNA) smears of 130 lymphoma or suspected lymphoma cases were reviewed. Initial and reviewed cytodiagnoses were compared with histopathology in 89 cases. Immunocytochemical and immunohistochemical studies were performed in 56 and 59 cases, respectively. Among histologically diagnosed HL cases, definitive cytodiagnosis of HL (initial as well as reviewed) was significantly less frequent than cytodiagnosis of NHL among histologically diagnosed NHL cases (P = 0.0328 and = 0.0001, respectively). On the other hand, cytologically diagnosed HL/NHL cases were significantly more frequent in the former group (P = 0.0001 and = 0.0018, respectively). ALCL and TCRBCL were the two NHL subtypes which created confusion with HL in FNA smears. Twenty‐one cytohistological concordant HL cases and equal number of discordant cases were compared. When compared with discordant group, the patients in concordant group were significantly younger (P = 0.045). Hodgkin/Hodgkin‐like cells and typical R‐S cells were significantly more frequent in FNA smears of the concordant group (P = 0.0478 and = 0.0431, respectively). Immunocytochemical and immunohistochemical studies showed good correlation with histological diagnosis of HL. It is suggested that proper interpretation of cytologic features, together with use of immunocytochemical parameters can help in reducing the margin of error in cytodiagnois of HL. Diagn. Cytopathol. 2009.

Performance of monolayered cervical smears in a gynecology outpatient setting in kuwait

OBJECTIVE To compare ThinPrep (TP) Papanicolaou smears (Cytyc Corp., Box-borough, Massachusetts, U.S.A.) with matching conventional Papanicolaou (CP) smears for specimen adequacy, cytologic quality, diagnostic accuracy and screening time. STUDY DESIGN In this prospective study of 1,024 women a split-sample, matched-pair design in favor of CP slides based on single-blind criteria was followed with a smear on a glass slide for CP and the remaining material collected in Preserv-Cyt solution (Cytyc) for a TP smear. A Cytobrush (Medscand, Hollywood, Florida, U.S.A.) was used for smear preparation for CP. TP smears were processed in ThinPrep 2000 (Cytyc). Smears were stained with Papanicolaou stain and were interpreted according to the Bethesda system. RESULTS The number of satisfactory but limited (SBL) cases with TP were 77 (7.5%) as compared to 127 (12.4%) with the CP method. This reduction in SBL smears with the TP method and consequent increase in satisfactory smears were highly significant (P < .001) by McNemars test. As regards unsatisfactory smears in discordant pairs, although the number of unsatisfactory smears was higher with TP (41 cases) as against CP (27 cases), the difference was not statistically significant (P < .05). The split-sample method showed a high correlation between the CP and TP diagnoses. TP smears had a significant advantage over CP smears in the reduction in the number of ASCUS and AGUS cases (14 vs. 29) (P < .05) and increased the pickup rate of LSIL, 6 vs. 1. Time taken to screen the TP smears was half that of CP smears. No cases of LSIL or HSIL were missed on TP smears. CONCLUSION The liquid-based processor significantly improved the adequacy and quality of smears, resulting in fewer recall cases for SBL smears, leading to more definitive diagnoses in atypical cases, increasing the pickup rate of LSILs and reducing the screening time. A machine handling multiple specimens automatically would decrease cost and be an asset to a cytopathology laboratory.

Changing Spectrum of Squamous Cell Abnormalities Observed on Papanicolaou Smears in Mubarak Al-Kabeer Hospital, Kuwait, over a 13-Year Period

Objective: The aim of this study was to determine the incidence of squamous cell abnormalities in cervical cytology in Mubarak Al-Kabeer Hospital, Kuwait, and to document any change in the pattern of these lesions. Materials and Methods: Over a 13-year period (1992–2004), 86,434 cervical smears were studied in Mubarak Al-Kabeer Hospital, Kuwait. Conventional Pap smears were first examined by cytotechnicians and finally reported by cytopathologists. The smears were classified according to the modified Bethesda system. The age of presentation of squamous cell abnormalities in Kuwaiti women was analyzed. Results: Smears from 83,052 (96.09%) patients were found satisfactory for reporting while the remaining 3.9% was unsatisfactory. Atypical squamous cells of undetermined significance (ASCUS) were seen in 1,790 (2.2%) cases, atypical glandular cells of undetermined significance (AGUS) in 630 (0.8%) cases, low grade squamous intraepithelial lesion including human papillomavirus changes (LSIL) in 824 (1.0%) cases, high grade squamous intraepithelial lesion (HSIL) in 189 (0.2%) cases, and carcinoma in 79 (0.1%) cases of which 44 (0.05%) were squamous cell carcinoma. A comparison of average cases/annum during the study period revealed a significant increase in ASCUS from 1.13 to 2.83% (p < 0.001) and AGUS from 0.33 to 1.08% (p < 0.001). However, the percentage of LSIL, HSIL and carcinoma detected in Pap smears remained the same. Conclusion: A significant linear trend (p < 0.001) was observed in satisfactory smears, ASCUS and AGUS over the years. However, no significant change was found in the detection of LSIL, HSIL and carcinoma. A reduction in the age of LSIL/HSIL and an increasing trend in the number of Kuwaiti women over the years was also observed which makes screening of young women essential in Kuwait.

Papillary thyroid carcinoma: evidence for intracytoplasmic formation of precursor substance for calcification and its release from well-preserved neoplastic cells.

Psammoma bodies (PBs) are believed to represent a process of dystrophic calcification over nonviable and dying tissues. Light microscopic and ultrastructural observations suggest that PB formation follows the intracellular assembly of precursor substances and their calcification leading to death of tumor cells and their release. It may also be the result of local secretion of precursor substances like collagen by tumor cells into extracellular space and their calcification. In an earlier reported study, we demonstrated the extracellular localization of various precursor forms of PBs and of irregular calcification in fine‐needle aspiration (FNA) smears of papillary thyroid carcinoma (PTC). In this report, we describe a PTC case with intracellular formation precursor substances for calcification and their release from the well‐preserved neoplastic cells before undergoing calcification. Ultrasound‐guided FNA smears from a small nodule in the left lobe of thyroid in a 40‐year‐old woman revealed a PTC with numerous intracytoplasmic targetoid bodies, which were magenta colored in MGG stain. On their release from the neoplastic cells, these targetoid precursor bodies were found to be forming pools of matrix material, some of which showed evidence of calcification. The cytologic findings were confirmed by histopathology of the tumor in the thyroidectomy specimen. For the first time, we demonstrate through cytomorpholgy the intracytoplasmic formation of targetoid bodies as precursor substances for calcification and their release from well‐preserved cells in PTC. We suggest that the calcification in PTC may not necessarily be taking place over nonviable and dying cells. Diagn. Cytopathol. 2008;36:809–812.

Contribution of immunocytochemical stainings for galectin-3, CD44, and HBME1 to fine-needle aspiration cytology diagnosis of papillary thyroid carcinoma

In cytology practice some papillary thyroid carcinoma (PTC) cases have indeterminate diagnoses and overlapping cytological features with benign lesions. This study was undertaken to find out if immunocytochemistry using Galectin‐3, CD‐44 and HBME‐1 could be of help in such situations. Forty‐six cases consisting of 22 malignancy (PTC) cases, 7 suspicious of (S/O) PTC, 1 follicular neoplasm, 5 follicular lesion of undetermined significance (FLUS), and 11 benign (colloid goiter) cases diagnosed by FNA were included in this study. Staining reactions were graded in a sliding scale of –, 1+, 2+, 3+, and 4+. In an assessment of 100 cells, each cell with weak, and moderate to strong positive reaction were assigned a score of 1 and 4, respectively. Staining reaction of ≥+2 and scores >100 were considered positive. Frequency of cases with ≥+2 reaction, and scores >100 for each of Galectin‐3, CD‐44, and HBME‐1 were significantly higher in PTC or combined PTC and S/O PTC cases as compared with FLUS and benign cases taken together (P = 0.01744 to 0.00000). When the cases were compared according to histological malignant and benign diagnoses, the difference was also significant in respect of ≥+2 reaction, and scores >100 for Galectin‐3 and CD44 (P = 0.04923 to 0.00947); however, there was no significant difference, when these parameters for HBME1 were compared. Galectin 3, CD 44, and to some extent HBME 1 are useful immunocytochemical parameters with potential to support FNAC diagnosis of PTC, especially in situations with difficult differential diagnoses. Diagn. Cytopathol. 2014;42:498–505.

Gynecologic Infections Seen in Cervical Smears in Kuwait

OBJECTIVE To study the different gynecologic infections seen in cervical smears in Kuwait. STUDY DESIGN Over a 6-year period (2002-2007), a total of 42,294 cervical smears were studied in Mubarak Al-Kabeer Hospital, Kuwait. Conventional and ThinPrep (Cytyc Corp. Boxborough, Massachusetts) smears were first screened by cytotechnicians and finally reported by cytopathologists, Smears showing inflammation were analyzed with reference to Kuwaiti women. RESULTS Of the 41,748 (98.7%) patients with satisfactory smears, inflammatory changes were observed in 17, 593 (42.1%). Specific infection was identified in 2,679 (15.2%) cases, of which 60.8% were Kuwaitis. The infections seen were Candida sp (73.8%), Trichomonsa vaginalis (11.9%), human papillomavirus (HPV99) (8.2%), Actinomyces-like organisms (3.4%), Chlamydia trachomatis (2.2%) and herpes simplex virus (0.5%). No significant difference was found in the proportion of infectious agents among Kuwaiti and non-Kuwaiti women except marginally higher T vaginalis (10.9% vs 13.4%, p = 0.05) among non-Kuwaitis. Candida sp was the most detectable infectious agent in both Kuwaiti (74.6%) and non-Kuwaiti women (72.4%). Chi2 for trend revealed an increasing proportion of smears from Kuwaiti women found with specific infections (p = 0.049) as compared to those of non-Kuwaitis over the years. CONCLUSION The prevalence of infections identified on cervical smears was found to be almost similar in Kuwaiti and non-Kuwaiti women except for T vaginalis, which was higher among non-Kuwaitis as compared to Kuwaitis (10.9% vs. 13.4%, p = 0.051). The Candida sp was the most detectable infectious agent, 74.6% in Kuwaiti and 72.4% in non-Kuwaiti women, followed by T vaginalis, the second and HPV being the third.

Infarction in a thyroid nodule after fine needle aspiration: report of 2 cases with a discussion of the cause of pitfalls in the histopathologic diagnosis of papillary thyroid carcinoma.

BACKGROUND In case of difficulty in the interpretation of fine needle aspiration (FNA) smears of a thyroid nodule, histopathologic examination is advised to arrive at a definitive diagnosis. On rare occasions, a specific diagnosis may be given based on cytologic examination, but FNA is followed by infarction of the thyroid nodule, with resultant difficulty in interpretation or even misinterpretation of bistopathologic material. We report 2 such cases. CASES Two cases were diagnosed as papillary thyroid carcinoma (PTC) by FNA cytology, but histopathology reports indicated colloid goiters with infarcted nodules. Review of histopathologic material showed features of PTC in the viable tissue at the periphery of nodules. Immunohistochemical study for galectin-3 and CD44 in 1 of the cases supported the diagnosis of PTC. CONCLUSION We suggest that while reporting on an infarcted nodule in paraffin sections of a thyroidectomy specimen, the histopathologist should be careful to look thoroughly at its periphery for the surviving cells and their detailed morphologic features, especially if there is a prior FNA cytology report of a neoplasm.

Fine Needle Aspiration Cytology of Breast Masses in Children and Adolescents

Objective To study the distribution and efficacy of fine needle aspiration cytology (FNAC) in the diagnosis of breast lesions in pediatric and adolescent patients. Study Design From January 1993 to December 2006, the cytology reports of 1,404 breast aspirates (178 males and 1,226 females) performed on children and adolescents (ranging from 1 to 21 years) were reviewed. Of these 41, 179, 506 and 678 aspirates belonged to the age group 1-<12, 12-<16, 16-< 19 and 19-21 years, respectively. Results The morphologic spectrum seen in females was inflammatory lesions (4%), benign ductal cells (20%), ductal hyperplasia (0.6%), papillary lesions (0.7%), benign neoplasms (69%), suspicious cytology (0.3%) and cancer (0.3%). Of the benign neoplasms, 98% (831 of 851) were fibroadenomas, with 12 cases of phyllodes (benign), 5 cases of lipoma and 3 cases of adenoma. There were 3 cases of malignancy (2 adenocarcinoma and 1 non-Hodgkins lymphoma). Only 3% of the male breast aspirates provided a diagnostic challenge, while 89% of them showed benign ductal cells. Conclusion FNAC of children and adolescent breast masses is helpful and can reduce the need for open surgery to prevent later deformity. The aspirates are mostly benign and can be managed conservatively.

Could nuclear matrix protein 22 (NMP22) play a role with urine cytology in screening for bladder cancer? - Experience at Kuwait University

Objectives:  This prospective study was undertaken to evaluate nuclear matrix protein (NMP22) compared to urine cytology in the detection of bladder cancer and also to determine whether indexing suspicious cytology to NMP22 could enhance the clinical utility of cytology.

Role of Urinary Cytology in Detecting Human Polyoma BK Virus in Kidney Transplant Recipients

Objective: To report data on the evaluation of the efficacy of urine cytology in detecting BK virus (BKV). Material and Methods: Papanicolaou-stained cytospin preparations of randomly collected urine samples from 8 renal transplant (RTR) patients (5 males, 3 females, age: 23–63 years) who previously tested positive for BKV by PCR in urine or blood or both were studied. Urine sediment from 3 of the patients was processed for ultrastructural examination (EM). Renal biopsies before and after BKV detection were also evaluated. Results: The interval between renal transplant and urine cytology ranged between 2 and 5 years. Urine from females was difficult to assess due to vaginal contamination. In 2 of the 5 urine specimens from male recipients BKV-infected decoy cells were identified. Viral particles suggestive of BKV were identified on EM in 2 of the 3 specimens studied. Kidney biopsies showed morphologic features suggestive of BKV infection in 2 cases, 1 each detected on cytology and EM, respectively. Conclusion: Screening for the presence of decoy cells in urine provides a simple sensitive means for the diagnosis of BKV nephropathy in RTR.