Comparative Study of Conventional Ziehl Neelsen and Modified Bleach Method of Ziehl Neelsen with CBNAAT in the Diagnosis of Tuberculous Lymphadenitis

Tuberculosis is one of the major health problems in developing countries like India. Even though lungs are the commonly involved organs in Tuberculosis, extrapulmonary presentations are on the rise nowadays. Among the various types of presentations of extrapulmonary tuberculosis, lymphadenitis is the most common presentation. A spectrum of investigations is available for diagnosis, and molecular methods like CBNAAT and PCR analysis are highly reliable. But their disadvantage is their cost and requirement of trained personnel. FNA is the first line of investigation but is lacking in sensitivity and culture method is time consuming. So, Modified Ziehl Neelsen method with low cost and less time may be considered as an alternative. We wanted to evaluate the sensitivity of the Modified Bleach Ziehl Neelsen method and compare the Modified and Conventional Ziehl Neelsen Method in association with the CBNAAT in the diagnosis of TB lymphadenitis.METHODSDiagnostic validation study was conducted with 30 clinically suspected cases of tuberculosis. FNA was done and aspirated material was spread on 2 slides. Slides were stained with H & E stain and convention Ziehl Neelsen stain. Part of the aspirate material was centrifuged with 5 % sodium hypochlorite. Sediment was smeared on a slide and stained with Ziehl Neelsen stain. Remaining material was subjected to CBNAAT assay.RESULTSCorrelation shows that 9, 6, and 11 out of 30 cases were positive for tuberculosis in Conventional, Modified and CBNAAT methods respectively. Sensitivity was 81.81 %; specificity was 94.74%, positive predictive value was 90% and negative predictive value was 90% for Conventional Ziehl Neelsen Method and 54.55%, 94.73%, 85.71% and 78.26%, respectively for modified bleach method.CONCLUSIONSConventional method is found to be more sensitive than modified method. CBNAAT negative results do not rule out TB. So, they should be correlated with cytology and microbiological studies.

Evaluation of Modified Core-Needle Biopsy in the Diagnosis of Thyroid Nodules

OBJECTIVE: Core needle biopsy (CNB) of the thyroid is an additional diagnostic method for non-diagnostic or indeterminate cytology samples. We sought to evaluate a new modified core biopsy technique and compare the concordance of its diagnosis with the final diagnosis of the surgically resected specimen. MATERIALS AND METHODS: A retrospective analysis was conducted on 842 patients who had a thyroid CNB with or without a previous fine-needle aspiration from August 2002 to March 2015; 38% of patients ultimately underwent thyroidectomy. We divided the patients into two groups for comparison: conventional group (n = 329) and new modified technique group (n = 513) that enabled sampling of not only the lesion but also the margin and surrounding parenchyma. The diagnostic conclusiveness of CNB and concordant rate with thyroidectomy was compared between the two groups. RESULTS: The overall diagnostic conclusiveness did not exhibit a significant increase (77% in the conventional technique group and 75% in the modified technique group, p = 0.408). In terms of the diagnostic concordance rate between CNB and thyroidectomy, no overall significant increase was observed (83% in the conventional technique group and 88% in the modified technique group, p = 0.194). However, only in follicular-patterned lesions (nodular hyperplasia, follicular neoplasm, and follicular variant of papillary thyroid carcinoma), a significant increase in the diagnostic concordance rate was observed (83% in the conventional group and 94% in the modified technique group, p = 0.033). CONCLUSION: Modified CNB technique can be beneficial for the accurate diagnosis of follicular-patterned thyroid lesions.

Accuracy of Cytological Analysis in Metastatic Lymphadenopathy; a Retrospective Study.

Background: Presently, fine needle aspiration (FNA) biopsy is the preliminary, non-invasive test for diagnosis of suspected lymphadenopathy. Apart from its diagnostic yield, it helps identifying the origin, grading and typing of the metastatic lesions in many cases. Methods: In the present study, data of 369 patients with suspected neoplastic lymphadenopathy presenting to the surgical and medical outpatient department of our institute over a period of 3 years was collected. FNA biopsy was performed on the most prominently visible and palpable lymph node. The use of special stains was performed in selected cases. Results: Of 369 cases studied, cytological diagnosis was offered in 358 cases, while unsatisfactory smears were reported in 11 cases. Of these 358 cases where a cytological diagnosis of either primary or metastatic lymphadenopathy was given, 244 were males and 114 were females. Metastatic tumors in the lymph nodes were reported in 307 cases and lymphoma in 51 cases. The distribution of lymphadenopathy revealed involvement of cervical group in 222 cases, axillary group in 57 cases, supraclavicular in 28 cases & inguinal in 24 cases. The commonest primary tumor, metastasizing to lymph nodes was squamous cell carcinoma (52.44%). Conclusion: In our study, FNA biopsy proved to be a safe and non-expensive technique that provided a high diagnostic accuracy with zero false positive results, confirmed the presence of secondaries where primary tumor was evident and guided the response to medical treatment.

Diagnosis of fat necrosis on FNAC – A case report.

Fine needle aspiration (FNA) of the breast has gained significant credibility in the diagnosis of breast diseases especially malignancy. Fat necrosis of the breast is a phenomenon that occurs within breast adipose tissue following exposure to trauma. It can mimic breast cancer clinically or radiologically. FNA of fat necrosis is a useful tool in directing management and treatment of the patients and avoiding unnecessary surgeries although histopathological examination is the gold standard for the final diagnosis.

Fine needle aspiration cytology in breast tuberculosis: Diagnostic difficulties - study of eleven cases.

Background: Incidence of extra-pulmonary tuberculosis is on the rise. Tuberculosis of breast is rare and have multifaceted clinical presentation, often mimicking carcinoma and pyogenic breast abscess. Aim: To study morphologic variations and diagnostic difficulties of breast tuberculosis on fine needle aspiration cytology (FNAC). Methods: FNAC smears of breast tuberculosis were studied by Leishman’s Stain and categorized into four groups. Cytology smears were also studied for presence of Acid Fast Bacilli (AFB) by Ziehl Neelsen (ZN) stain. Histology of excised tissue was studied by Hematoxylin and Eosin stain ( H& E). Results: Out of 11 cases, 10 were females and 1 was male. Group1 (n=2) showed epithelioid granulomas with necrosis. Group2 (n=2) showed epithelioid granulomas without necrosis. Group3 (n=3) showed necrosis with a few scattered epithelioid histiocytes. Group4 (n=4) showed necrosis with numerous neutrophilic inflammatory cells. In four cases, caseous necrosis could be identified on cytology smears. AFB were found in five cases on FNAC smears. Histology confirmed diagnosis of tuberculosis in all cases. Conclusion: In developing countries like India, based on clinical history and other features, FNAC smears showing epithelioid granulomas with or without necrosis should be considered as breast tuberculosis as demonstration of AFB is not mandatory. Identification of caseous necrosis alone is diagnostic of breast tuberculosis in cytology smears.

Dialysis catheter fibrin sheath stripping: a useful technique after failed catheter exchange

Fibrin sheath formation around long-term haemodialysis catheter is a common cause of failed dialysis access. Treatment options include pharmacological and mechanical methods. This paper reports a case of failed dialysis access due to fibrin sheath encasement. Pharmacologic thrombolysis, mechanical disruption using guide wire and catheter exchange had failed to address the issue. Eventually, fibrin sheath stripping using the loop snare technique was able to successfully restore the catheter function.

Actinomicosis pulmonar: Diagnóstico por punción-aspiración con aguja fina / Pulmonary actinomycosis: Fine needle aspiration diagnostic

Se presentan 4 casos de actinomicosis pulmonar en pacientes mayores de 40 años, 2 de ellos con enfermedad pulmonar obstructiva crónica (EPOC), que mostraron un aumento de la tos productiva, episodios de disnea, hemoptisis y fiebre de larga evolución. En las radiografías de tórax de rutina se observaban imágenes segmentarias de consolidación aérea, sugestivas de cuadros neumónicos no resueltos o neoplasia. La tomografía axial computarizada (TAC) mostró hallazgos similares a los anteriores. Los cultivos de esputo y las pruebas de Mantoux fueron repetidamente negativos. Debido a la mala evolución de los pacientes y a los hallazgos radiológicos, se practicó una punción-aspiración con aguja fina (PAAF) para descartar neoplasia. En la citología se observaron conglomerados tridimensionales, de bordes filamentosos y aspecto algodonoso compatibles con Actinomyces. El tratamiento antibiótico produjo la mejoría del cuadro clínico y el seguimiento demostró la desaparición de las opacidades radiológicas. Actualmente, la actinomicosis pulmonar es infrecuente y la sintomatología inespecífica, por lo que puede confundirse con procesos neoplásicos. Por tanto, en pacientes con factores de riesgo, síntomas de neumonía subaguda e imágenes radiológicas de consolidación del parénquima es aconsejable considerar la posibilidad de actinomicosis pulmonar. Es una enfermedad tratable y su correcto diagnóstico mediante la PAAF evita al paciente pruebas diagnósticas más agresivas, retrasos en el diagnóstico y le permite una cura completa con tratamiento antibiótico.

We present four cases of pulmonary actinomycosis in patients over 40 years of age, two of them with chronic obstructive pulmonary disease (COPD), showing an increase in productive cough, episodes of dyspnea, hemoptysis and long-term fever. Routine chest radiographs revealed segmental air-space consolidation, suggestive of unresolved pneumonia or neoplasm. Computed tomography (CT) scan showed similar findings to the ones previously described. Sputum cultures for mycobacteriae and Mantoux tests were constantly negative. Due to the poor clinical and radiodological outcome of the patients, a fine needle aspiration (FNA) was made to rule out a neoplasm. Tridimensional filamentous colonies of Actinomyces were observed in cytology. Antibiotic treatment resulted in an improvement of symptoms. The follow-up showed a decrease of the consolidation areas. Pulmonary actinomycosis is rare nowadays and clinical symptoms are unspecific and can be confused with a neoplasm process. Therefore, in patients with risk factors, symptoms of subacute pneumonia and radiologic findings of consolidation, it is advisable to consider pulmonary actinomycosis as a diagnostic possibility. It is a treatable disease and its correct diagnosis by FNA, avoids performing invasive diagnostic tests, delays in the diagnosis and allows for a complete cure by antibiotic therapy.

Differential Diagnosis of Fine Needle Aspiration Cytology of Benign Lymphadenopathy / 대한세포병리학회지

In the investigation of superficial lymphadenopathy of unknown cause, fine needle aspiration (FNA) cytology plays an invaluable role. It enables the differentiation of benign lymphadenopathy from lymphoid and non-lymphoid malignancies, obviating the need for open biopsy, and allowing the triage of patients. Cytopathologists should be familiar with the typical FNA patterns of benign lymphadenopathy, and recognize and differentiate among categories. In a minority of cases of benign lymphadenopathy, FNA can render a specific diagnosis. Benign lymphadenopathies are generally categorized into reactive lymphoid hyperplasia (RLH), inflammatory or infectious processes, and benign lymphoproliferative disorders. RLH characteristically presents with a heterogeneous and polymorphous smear composed of normal cellular constituents of lymph nodes, in contrast with the homogeneous or monomorphic smear of most lymphomas. The caveat is that various malignant disorders may also present with polymorphous populations. It is also important to recognize thatbenign lymphoid smears may sometimes contain atypical cells that raise the suspicion of malignancy. Clinical information should always be the integral part of the diagnostic criteria in FNA of lymphadenopathy. If there is any doubt about the benign nature of the smear, it is prudent to suggest biopsy and ancillary studies.

Usefulness of Thallium-201 Scintigraphy for Differentiating Benign and Malignant Thyroid Nodules in Inconclusive Cases with Fine Needle Aspiration / 대한내분비학회지

BACKGROUND: Although fine needle aspiration(FNA) is recognized as the most accurate procedure in the differential diagnosis of thyroid nodules, about 20~30% of nodules remain inconclusive in FNA. Therefore, we assessed the usefulness of Thallium-201 scintigraphy in differentiating benign from malignant thyroid nodules in patients with inconclusive diagnosis by FNA. METHODS: We studied 43 patients with inconclusive diagnosis(29 of follicular neoplasm, 11 of cystic change and 3 of inadequate) by FNA, with the results being confirmed histopathologically by operation. Thallium-201 scintigraphy was performed at 15 minutes(early scan) and 2-3 hours(late scan) after the intravenous administration of 37 MBq of thallium-201. Malignant nodules were defined by the retention of Thallium-201 on delayed images. RESULTS: In the 43 patients with inconclusive FNA diagnosis, Thallium-201 scan had a sensitivity of 75.0%, specificity of 62.9% and accuracy of 65.1%. The positive and negative predictive values were 31.6% and 91.7%, respectively. In the 29 patients with follicular neoplasm by FNA, Thallium-201 scan had a sensitivity of 83.3%, specificity of 60.9% and accuracy of 65.5%. The positive and negative predictive values were 35.7% and 93.3%, respectively. CONCLUSION: In particular, Thallium-201 scintigraphy demonstrated a high negative predictive value, Therefore, for patients with inconclusive FNA findings, Thallium-201 scintigraphy might be useful in differentiating between benign and malignant thyroid nodules, and has the potential to reduce the rate of unnecessary operations in benign nodules.

Clinical Features Associated with an Increased Risk of Malignancy in Indeterminate Group by Find Needle Aspiration of Thyroid Nodules / 대한내분비학회지

BACKGROUND: The recommended management of patients who have cytologic diagnosis of indeterminate group by fine fine needle aspiration (FNA) in thyroid nodules is controversial. Our objective was to identify the incidence of malignancy through thyroidectomy in indeterminate group and clinical features associated with an increased risk of malignancy that might guide future practice. METHODS: We retrospectively reviewed the medical records of 222 patients who had cytologic diagnosis of indeterminate group by FNA in thyroid nodules at Seoul National University Hospital from Jan. 1990 to Aug. 1998. Patients characteristics and clinical features were compared between benign and malignant nodules classified as pathologic findings through thyroidectomy. RESULTS: The frequency of indeterminate group was 6% (222/3981) among patients underwent thyroid FNA. The frequency of malignant nodules was 47.4% (64/135) among 135 patients underwent thyroidectomy. Among clinical features, rapid increase in size (7.0% vs 20.3%, p=0.024), local symptoms such as dysphagia, hoarseness, pain (1.4% vs 15.6%, p=0.003), fixation (4.4% vs 35.7%, p<0.001), hard consistency(15.7% vs 59.7%, p<0.001) and irregular surface(6.3% vs 25.6%, p=0.001) were significantly more common in malignant nodules than in benign nodules. However, clinical features such as mean age of patients, male sex, presence of past history of benign thyroid disease, family history of benign thyroid disease, solitary nodule, presence of cervical lymph nodes, mean size of nodules and cold nodules by thyroid scan in malignant nodules were not significantly different from that in benign nodules. Among clinical features that were significantly more common in malignant nodules, fixation(p=0.042) and presence of local symptoms (p=0.043) were significantly independent risk factors predictive of malignancy. CONCLUSION: Its better to recommend thyroidectomy in patients with clinical features such as presence of local symptoms, fixed nodule and hard nodule in indeterminate group, in otherwise to decide treatment with repeated FNAs when clinical features such as patients symptoms and physical examinations of nodule change through regular follow-up.

Estrogen Receptor Analysis on Fine Needle Aspirates and Biopsies from Palpable Breast Carcinoma

The estrogen hormone receptor (ER) content of human breast cancer has assumed an important role as a predictor of hormone therapy response and as a prognostic indicator. The conventional technique is the dextran-coated charcoal (DCC) method or a ligand-binding assay (LBA) based on the measurement of radiolabeled steroids in cytosolic extracts of tissue homogenate. The recent introduction of monoclonal antibodies with high specificity for human ERs has allowed the application of immunocytochemical assays (ICA) in human cancer tissue. An extension of the ICA technique to cytologic specimens is also widely used. Our aim was to evaluate the reliability of ER-ICAs on fine needle aspirates(FNA) from breast cancer patients by comparing it with ER-ICAs and ER-LBAs performed on surgically removed tissues. During a recent 6-month period, ER-ICAs and ER-LBAs were performed in 83 cases. Among these 83 cases, only the 40 cases for which the ER-ICA and the ER-LBA were performed simultaneously ere included in this study. As positive cutoff values, we assumed 10 fmol/mg protein for the ER-LBAs and a semiquantitative score of 4 for the ER-ICAs. The results were as follows : 1) The ER positive rate was 55% (22/40) for ICAs and 47.5% (19/40) for LBAs. The concordance rate between the ER of ICAs and that of LBAs was 82.5% (33/40). 2) The Pearson correlation coefficient between ER-ICAs of fine needle aspirates and that of surgically removed tissue was good (r=0.94, p<0.005) 3) The Spearman correlation coefficient between ER-ICAs of fine needle aspirates and ER-LBAs of surgically removed tissue was good (r=0.57, p=0.0001) In conclusion, ER determination by using the fine needle aspirate is a reliable method in palpable breast cancer. FNA-ER may be a useful method when it is difficult to take sufficient breast cancer tissue, i.e., in cases of diffusely recurrent cancer, liver metastasis, malignant pleural effusion, etc.

A Clinical Analysis of 2,500 Cases of Thyroid Nodules in the Korean People / 대한내분비학회지

Background: Thyroid nodules are one of the most clinical problems encounted by physieian. Palpation, radianuclide imaging, and sonography do not deterrnine whether a thyroid nodule is benign and malignant. So, the purpose of this study is to investigate how many thyroid cancer consist in thyroid nodule by using the fine needle aspiration(FNA) technique. Methods: With a disposable #23 gauge needle attached to 5rnl disposable plastic syringe was inserted at the thyroid nodules of the patients after rectinilinear thyroid scanning or ultrasono- graphy. All cells aspirated from the thyroid nodules were smeared on the 3 slide glasses and then, 2 slide glasses were immersed in 95% ethanol for Papanicolaou staining and one slide was air dried m room temperature for Giemsa staining. After complete staining the cytologic diagnosis of all slide glasses were reviewed by general light mi~eroscope. Results: Approximately, three-quarters(73.0%) of thyroid nodules aspirated by FNA were diagnosed as benign or inflammatory nodules, rnalignant neoplasia including follicular neoplasia 12.5%, and indeterminate cases 14.5% of thyroid nodules. Conclusion: Fine needle aspiration(FNA) has become the diagnostic procedure of choiee in the evaluation of the nodular thyroid disease because of its easiness, safety, cost effectiveness, and high diagnostic accuracy. Malignant neopleasia including follicular neopleasia were found 12.5% of thyroid nodules in Korean, aspirated by FNA which was same category in prevalence rate compared to known abroad results(8~20%).