To operate or not to operate? The value of fine needle aspiration cytology in the assessment of thyroid swellings.

AIMS: To evaluate all thyroid fine needle aspirations (FNA) done over a six year period to assess the accuracy and value of the technique. METHODS: There were 335 FNAs of which 184 had subsequent histology and 49 others had clinical follow up, providing 233 patients for analysis. All cytology and histology was reviewed with no significant alterations in diagnosis. The FNAs were classified into three groups: benign, suspicious (recommend excision), and malignant. The histology and medical records were reviewed to determine whether the cytology was accurate. RESULTS: There were 130 benign FNAs, 126 had non-malignant histology or normal clinical follow up, and four had malignancies on histology (two lymphomas, one follicular carcinoma, and one carcinoma not otherwise specified). There were 45 suspicious FNAs. Of these five had either follicular or papillary carcinoma, 14 had follicular adenomas, and 26 had colloid nodular goitres or normal clinical follow up. Of the 21 malignant FNAs, 11 had carcinoma and 10 had either a non-malignant histology or normal follow up. There were 126 true negatives, 30 true positives, 4 false negatives, and 36 false positives. This gives a sensitivity of 88%, a specificity of 78%, a positive predictive value of 46%, a negative predictive value of 97%, and an accuracy of 80%. CONCLUSIONS: FNA cytology of the thyroid has a high negative predictive value, which is useful to reassure the majority of patients presenting with thyroid enlargement. However, a negative FNA should never exclude malignancy if there is a strong clinical suspicion. If this rule is adhered to a large number of patients will be spared unnecessary surgery and no malignant nodule will go untreated.

Interobserver variation in the reporting of the histopathological grading of anal intraepithelial neoplasia.

AIM: To assess the consistency in the histological reporting of anal intraepithelial neoplasia (AIN) among experienced histopathologists. METHOD: One hundred anal biopsy specimens were retrieved from archival material at St Mark's Hospital, London and graded by five histopathologists according to criteria outlined by Fenger (six point scale, ranging from normal to invasive carcinoma). RESULTS: There was only moderate agreement among the pathologists, with unweighted k scores ranging from 0.09 to 0.48, and weighted k scores of 0.17 to 0.60. CONCLUSIONS: There is considerable interobserver variation in the reporting of AIN. A simplified system of grading may help to abolish this.

The use of cytology in the diagnosis of basal cell carcinoma.

Two hundred and forty patients with basal cell carcinomas (BCCs) on the head or neck were studied. Scrapings of the lesions were taken for cytological examination, and a 3-mm punch biopsy was performed for histopathological study. The accuracy of diagnosis by each method was compared. Both methods confirmed the clinical diagnosis in 226 cases, and both were negative in 10 cases. Cytopathology gave one false negative result (0.42%), and histopathology gave two false negative results (0.83%). Cytopathology gave one false positive result (0.42%), and histopathology did not produce any false positive results. We conclude that cytological examination of skin scrapings from suspected BCCs is a rapid and reliable method of diagnosis.

Rapid cervical cytology screening.

2030 Papanicolaou-stained cervical smears were submitted for rapid screening prior to routine screening; 30 seconds were allowed for each slide, and those thought to be abnormal were identified. The results were compared with those of conventional screening. All severe and moderately dyskaryotic cases were detected by the rapid technique, as were the majority of mild dyskaryosis and borderline cases. When a laboratory has a backlog it may be worth rapid-screening all slides in addition to routine screening, so that patients most at risk can receive prompt treatment.

Heart valve measurement at autopsy can distinguish cardiac from non-cardiac causes of death.

The circumferences of the four intact cardiac valves were measured during 397 coroner's autopsies using an obturator cone to assess the value of this measurement in the postmortem diagnosis of cardiac disease. Valve sizes of cases with cardiac and noncardiac causes of death were compared using logistic regression to assess the effects of confounding variables including sex, age, height, build and the presence of chronic obstructive airways disease. Mitral valve enlargement was found to be significantly associated with cardiac death, as were build, age, and sex. Measurement of the mitral valve at autopsy can help distinguish cardiac from noncardiac causes of death.

Diagonal earlobe creases and fatal cardiovascular disease: a necropsy study.

The association between diagonal earlobe creases and fatal cardiovascular disease was investigated in a consecutive series of 303 coroner's necropsies. Those studied all died outside hospital in the Brighton Health District. Data were analysed on the cause of death and on the type of earlobe, the presence or absence of diagonal creases, age, sex, height, and any previous history of cardiovascular disease or diabetes mellitus. The age of nine men and six women was not known. Cardiovascular causes of death included ischaemic and hypertensive disease, calcific valvar stenosis, ruptured dissecting aneurysm of the thoracic aorta, and ruptured atheromatous aneurysm of the abdominal aorta. The mean (SD) age at death was 72 (15) and the male to female ratio was 1.3:1. Diagonal creases were present in 123 (72%) of 171 men and 88 (67%) of 132 women. A previous history of cardiovascular disease was present in 90 (30%) of the total of 303 and 74 (35%) of the 211 with diagonal creases. A cardiovascular cause of death was present in 154 (73%) of 211 with and 41 (45%) of 92 without diagonal creases and was associated with an increased risk of a cardiovascular cause of death of 1.55 in men and 1.74 in non-diabetic women.

Aspiration cytology of solid renal tumours.

The results of needle aspiration cytology of solid renal lesions in Brighton from 1977 have been reviewed. Thirty-one lesions were aspirated and of the 21 malignant tumours, cytology accurately diagnosed 19 (90%) when sufficient material was sent for analysis. Of the eight avascular solid renal space-occupying lesions aspirated, cytology gave a correct differentiation (benign versus malignant) in seven (87%). The results compare favourably with those of other published experience. A modification is suggested to the accepted diagnostic pathway.

Rapid outpatient detection of rectal cancer by gloved digital scrape cytology.

Prior to a surgical operation for carcinoma of the rectum, it is necessary to have a tissue diagnosis. In a study undertaken to correlate rectal cytology with histopathology and to assess its accuracy, 78 patients had cytology performed at their initial rectal examination in the outpatient department. The results showed no false-positive and three false-negative cytologic diagnoses. A positive cytology report is thus indicative of carcinoma, but a negative report does not exclude it. The method is inexpensive, quick, painless and without complication.

The role of aspiration cytology in a radiotherapy and oncology centre.

The role of aspiration cytology for a Department of Radiotherapy and Oncology was assessed in 158 patients with a wide range of tumours. Aspirates were taken from breast, lymph nodes, skin, bone, muscle and subcutaneous tissues. Malignant cells were identified in 91% of 107 malignant tumour aspirates. There was one possibly false positive report on a lymph node aspirate. Fifty other lesions were aspirated in which no malignant cells were seen, and were subsequently found to be benign. Aspiration cytology was found to be a simple, cheap and convenient investigation which was useful in the management of 83% of the whole group of patients, and detrimental to none.

Membranous glomerulonephritis in transplant kidneys: recurrent or de novo disease in four patients.

Membranous glomerulonephritis in the graft is a uncommon complication of renal transplantation. In the 4 cases we describe, one patient had recurrence of his original disease, but in the other 3 it arose de novo after allografting for focal segmental glomerulosclerosis, cystinuria or secondary amyloidosis. The lesion was accompanied by mesangial changes of lesser degree and by chronic rejection, and it resulted in accelerated loss of graft function. Transmission of host disease to the graft is more likely to occur in patients whose original membranous lesion progressed to renal failure relatively rapidly, while in de novo cases, the antecedent host disease seems often to have been focal segmental glomerulosclerosis. Allograft membranous glomerulonephritis may be less rare than hitherto supposed.

Aspiration cytology in the preoperative management of breast cancer.

The value and accuracy of aspiration cytology was assessed in the management of 444 patients presenting with a solid breast lump. The first 233 patients were assessed cytologically and frozen-section histology was performed when indicated. In this group a correct positive cytological diagnosis was made in 80% of cases. There were no false positive results. The next 211 patients were assessed cytologically and, when a firm diagnosis of malignancy was made, definitive treatment was carried out without frozen-section histology. In this group cytology was 90.6% reliable in diagnosing malignancy. No mastectomies were performed for benign disease. The use of frozen-section histology has been reduced by about 80%.

Cervical cancer in younger women.

Cervical cancer does not begin in women at some vague mid-procreative term, but is a concomitant of early sexual activity. In Brighton the mean age of patients with histologically proven carcinoma of the cervix has been falling, from 50 in 1967 to 35 by 1977. In one year abnormal cells were found in cervical smears from 24 teenage girls (5 aged 16, 2 aged 17, 8 aged 18 and 9 aged 19), and in 4 of these teenage cases malignancy was subsequently proved histologically. Until the aetiology of the disease is established no lower age limit should be set for cervical screening; all young women should be entitled and encouraged to have cervical cytology tests.