Orell, Orell and Sterrett's Fine Needle Aspiration Cytology E-Book

Expert Consult

Svante R Orell, Gregory F. Sterrett

• Publisher: Churchill Livingstone
• Year: 2011
• ISBN:
  9780702047558
• Edition: 5
• Topic: Médecine
• Subtopic: Pathologie

Orell & Sterrett's Fine Needle Aspiration Cytology 5e provides you with a logical and systematic approach to the acquisition, interpretation and diagnosis of FNA biopsy samples. It is an ideal resource for all those requiring an authoritative and systematic review of the cytological findings in those malignant and benign lesions likely to be the target of FNA. The book is lavishly illustrated with high quality colour images that demonstrate the cytological features as well as their relevant immunohistochemical and molecular findings. Organized into anatomical regions, each chapter is consistently organized into two parts: the first deals with clinical and technical aspects followed by a systematic presentation of cytological findings. This is your perfect practical bench resource for daily reference in the laboratory.

Provides practical tips and advice on how to avoid pitfalls and ensure accurate diagnoses.

Over 1, 200 colour illustrations capture each entity's cellular, morphological and immunohistochemical appearance.

Chapters have been up-dated and revised and a brand new one on cytological findings in infectious diseases added.

Both MGG and Pap smears illustrated in parallel as well as the corresponding histology to help provide side-by-side analysis.

Access the full text online and download images via Expert Consult.

Brand new chapter on cytological findings in infectious diseases.

Inclusion of immuno-profiles and other relevant ancillary tests.

New illustrations.

New contributing authors.

Available online via Expert Consult.

CHAPTER 1 Introduction

Svante R. Orell, Gregory F. Sterrett

Historical perspective

Fine needle aspiration cytology as we know it today dates back to around 1950. However, the idea to obtain cells and tissue fragments through a needle introduced into the abnormal tissue was by no means new. In the mid-nineteenth century, Kün¹ (1847), Lebert² (1851) and Menetrier³ (1886) employed needles to obtain cells and tissue fragments to diagnose cancer. Leyden⁴ (1883) used the same method to isolate pneumonic microorganisms. Few early pathologists were, however, involved in this pioneering work, and the development of needle aspiration cytology along with exfoliative cytology was, to a large extent, performed by ‘professional hybrids’,⁵ clinicians who used these simple techniques as aids to rapid diagnosis. For example, the common use of needling the bone marrow as an integral part of the investigation of hematological problems continued to serve as a reminder that almost every tissue could be sampled by a simple technique requiring neither anesthesia nor the expensive intervention of surgeons.⁶ In the UK in 1927, Dudgeon and Patrick⁷ proposed the needling of tumors as a means of rapid microscopic diagnosis. About the same time, Martin and Ellis⁸ at the Memorial Hospital in the USA were also advocates of needle aspiration, although the pathologists working with them initially insisted on sectioning as well as smearing the samples and would only make a confident diagnosis if tissue fragments were obtained. Consequently, Martin and Ellis used needles of a thicker caliber (18 gauge) than those commonly in use today. The pathologists at Memorial continued to use the technique, but it took nearly another 40 years for a general interest in ‘aspiration biopsy’ to develop in the USA.^9,10

It was in Europe that ‘fine needle aspiration cytology’ (FNAC), as the technique was usually called, began to flourish in the 1950s and 1960s. Söderström¹¹ and Franzén¹² in Sweden, Lopes Cardozo^13,14 in Holland (all clinician/hematologists by training), Zajdela¹⁵ in France, and others became major proponents, studying thousands of cases each year. Zajicek,^16,17 among the first of pathologists to embrace FNAC in collaboration with Franzén at the oncologic center (Radiumhemmet) of the Karolinska Hospital, applied the requisite scientific rigor to define precise diagnostic criteria and to determine diagnostic accuracy in a variety of conditions. FNAC soon became accepted and integrated in the diagnostic routines by the team of pathologists and clinicians at the Radiumhemmet. In the following years, experience accumulated rapidly and pathologists and oncologists from Sweden and many other countries came to study the technique, which subsequently spread to the rest of Europe, the Americas, Asia and Australia. FNAC is now part of the service of all sophisticated departments of pathology.

The history of clinical cytology by Grunze and Spriggs,¹⁸ and a comprehensive review of the development of cytopathology in the twentieth century by Naylor,¹⁹ are highly recommended reading. A very recent historical overview of fine needle aspiration biopsy by M. Rosa in Diagnostic Cytopathology²⁰ should also be mentioned.

FNAC as a tool in clinical investigation

Fine needle aspiration cytology was initially conceived as a means to confirm a clinical suspicion of local recurrence or metastasis of known cancer without subjecting the patient to further surgical intervention. This remains one of the most important contributions of the technique from a practical point of view. Following success in this area, the interest focused on preliminary preoperative diagnosis of all kinds of neoplastic processes, benign or malignant, in any organ or tissue of the body and on definitive, specific diagnosis in inoperable cases as a guide to rational treatment. The expansion of FNAC in primary diagnosis of tumors in the last 30 years or so has been impressive and generally successful. This development is to a large degree the result of consistent, continuous and critical correlation between cytological assessment and histopathological diagnosis facilitated by the organisational coordination of laboratory resources.²¹

The clinical value of FNAC is not limited to neoplastic conditions. It is also valuable in the diagnosis of inflammatory, infectious and degenerative conditions, in which samples can be used for microbiological and biochemical analysis in addition to cytological preparations. This is of particular importance in patients with acquired immunodeficiency syndrome (AIDS) and in other immunocompromised patients.²² FNAC has proven useful in the diagnosis and monitoring of graft rejection in transplantation surgery,^23,24 an area that is beyond the scope of this book.

Intraoperative cytology is another application using similar techniques and diagnostic criteria as in FNAC. It is a valuable alternative or complement to frozen section examination with a comparable level of accuracy.^25-29

Advantages and limitations

Fine needle aspiration cytology offers clear advantages to patients, doctors and taxpayers. The technique is minimally invasive, produces a speedy result and is inexpensive. Its accuracy in many situations, when applied by experienced and well-trained practitioners, can approach that of histopathology in providing an unequivocal diagnosis. We should stress, however, that aspiration cytology is not a substitute for conventional surgical histopathology. It should be regarded as an essential component of the preoperative/pretreatment investigation of pathological processes, in combination with clinical, radiological and other laboratory data. A definitive specific diagnosis may not be possible by cytology in a proportion of cases, but a categorisation of disease and a differential diagnosis with an estimate of probability can usually be provided to suggest the most efficient further investigations, saving time and resources. Applied in this manner, it has become just as indispensable as surgical histopathology.

The method is applicable to superficial lesions that are easily palpable, in the skin, subcutis and soft tissues, thyroid, breast, salivary glands and superficial lymph nodes. Fine needle biopsy (FNB) is less demanding technologically than surgical biopsy, has a low risk of complications and can be performed as an office procedure, in outpatient departments and in radiology theaters, saving expensive days in hospital. It is also highly suitable in debilitated patients, is readily repeatable and allows biopsy of multiple lesions in one session. Modern imaging techniques, mainly ultrasonography (US) and computed tomography (CT), make percutaneous, transthoracic and transperitoneal fine needle biopsy of deeper structures possible and safe.³⁰ Samples may be obtained from the lung and mediastinum, the abdominal, retroperitoneal and pelvic organs and tissues, deep sites in the head and neck, the skeleton and the soft tissues. US-directed FNB can also be performed through an endoscope, mainly of lesions in the pancreas or adjacent tissues.^31-33 A tissue diagnosis, preliminary or differential, can be provided within minutes rather than days to guide further investigation and management.

Instances of serious complications have been reported in relation to different sites and organs, such as major hemorrhage, septicemia, bile peritonitis, acute pancreatitis, pneumothorax, etc.³⁴ However, such complications are extremely rare in view of the vast numbers of uncomplicated FNBs performed in major centers where close monitoring of patients is the rule. Complications have also been reduced by advances in endoscopic ultrasound guidance techniques, allowing safer sampling of intra-abdominal organs such as pancreas or lesions previously relatively inaccessible such as paraoesophageal and paratracheal nodes and tumors. The possibility of cancer cells being disseminated along the needle track,³⁵ as has been reported at the site of incisional biopsy or of core needle biopsy, initially caused a great deal of concern. Reviews of the literature by Roussel et al.³⁶ in 1989 and by Powers³⁷ in 1996 showed the risk of needle track seeding to be extremely low when truly fine needles of 22 gauge or less are used. Multiple passes, larger needles and absence of normal parenchyma covering the lesion appear to increase the risk. The question is further discussed in relation to specific organs and sites in several of the following chapters. The rare severe complications do not diminish the clinical value and wide applications of FNAC, but awareness of their existence should be a reminder always to consider the indications for any invasive procedure, including FNB.

Another concern is that preoperative FNB may cause local tissue changes, which could render subsequent histological diagnosis difficult. Such changes, including hematoma, infarction, capsular pseudoinvasion and pseudomalignant reparative...