Micronuclei detection in oral cytologic smear: does it add diagnostic value?

BACKGROUND: Screening and early diagnosis of oral squamous cell carcinoma (OSCC) are directly associated with increased survival rate and improved prognosis. Noninvasive diagnostic tools have been implemented in the early detection as toluidine blue staining, optical imaging, and oral cytology. This study aimed to assess and compare the presence of micronuclei (MN) in oral exfoliative cytology of healthy controls, subjects exposed to high-risk factors for oral cancer, subjects with oral potentially malignant lesions (OPMLs), and those with malignant oral lesions. SUBJECTS AND METHODS: A total number of 92 subjects were divided into 46 healthy controls with no oral mucosal lesions (23 with no evidence of cancer risk factors and 23 with cancer risk factors), 23 with OPMLs and 23 with oral malignant lesions. All the 92 participants were subjected to cytological sampling for detection of MN. The final diagnosis of the oral lesions was confirmed by the histopathological picture and compared to the cytological results. RESULTS: The results showed that the diagnostic accuracy of MN was higher in OPMLs group (95.2%). The sensitivity of MN test in malignant group was much lower (52.2%); however, all the cytological criteria of malignancy were markedly detected as compared to the OPMLs group. CONCLUSIONS: Conventional oral cytology supported by MN is highly beneficial as adjunctive tool in the screening for early detection of dysplastic oral lesions.

Artificial Intelligence Role in Subclassifying Cytology of Thyroid Follicular Neoplasm.

OBJECTIVE: Fine needle aspiration cytology has higher sensitivity and predictive value for diagnosis of thyroid nodules than any other single diagnostic methods.  In the Bethesda system for reporting thyroid, the category IV, encompasses both adenoma and carcinoma, but it is not possible to differentiate both lesions in the cytology practice and can be only differentiated after resection. In this work, we aim at exploring the ability of a convolutional neural network (CNN) model to sub-classifying cytological images of Bethesda category IV diagnosis into follicular adenoma and follicular carcinoma. METHODS: We used a cohort of cytology cases n= 43 with extracted images n= 886 to train CNN model aiming to sub-classify follicular neoplasm (Bethesda category IV) into either follicular adenoma or follicular carcinoma. RESULT: In our study, the model subclassification of follicular neoplasm into follicular adenoma (n = 28/43, images n = 527/886) from follicular carcinoma (n = 15/43, images n= 359/886), has achieved an accuracy of 78%, with a sensitivity of 88.4%, and a specificity of 64% and an area under the curve (AUC) score of 0.87 for each of follicular adenoma and follicular carcinoma. CONCLUSION: Our CNN model has achieved high sensitivity in recognizing follicular adenoma amongest cytology smears of follciualr neoplasms, thus it can be used as an ancillary technique in the subcalssification of Bethesda Iv category cytology smears.

A Comparative Study of the Diagnostic Utility of Endoscopic Ultrasound-Guided Fine Needle Aspiration Cytology (EUS-FNA) versus Endoscopic Ultrasound-Guided Fine Needle Biopsy (EUS-FNB) in Pancreatic and Non-Pancreatic Lesions.

OBJECTIVES: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has become the procedure of choice to obtain samples from pancreatic lesions. However, it still has limitations affecting its diagnostic yield. The endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) needle was developed to allow acquisition of histological core. We conducted this study to compare the diagnostic yield of the Echotip 22Gauge FNA needle with the 22Gauge acquire FNB needle in pancreatic and non-pancreatic lesions. MATERIALS AND METHODS: This prospective study was carried out on 100 cases of pancreatic and non-pancreatic lesions referred to El-Ebrashi unit of Gastroenterology and Hepatology, internal medicine department, Kasr Al-Aini hospital. The patients included were then randomized for sampling using either the standard Echotip 22Gauge FNA needle or 22Gauge acquire FNB needle. RESULTS: Patients were 57 males and 43 females with a mean age of 58±15 years. Seventy-eight patients had pancreatic lesions, while twenty-two patients had non-pancreatic lesions. Half of the patients (50 cases) underwent EUS-FNA, and the other half (50 cases) underwent EUS-FNB. The presence of adequate tissue core was significantly higher in the FNB group. In contrast, smear cellularity was not significantly different between both groups. FNB had more sensitivity and accuracy depending on cell block/tissue core examination only for diagnosing pancreatic lesions. Blood contamination was higher in cell blocks of the FNA group. The sensitivity, specificity, and accuracy in the combined cytologic and histologic evaluation were 100%. Based on smear only or tissue only, the specificity was 100%, but the sensitivity and accuracy were decreased in both techniques. No complications were reported in both techniques. CONCLUSION: EUS-guided FNA and FNB are safe with comparable diagnostic accuracy in pancreatic and non-pancreatic lesions. FNB improved the histopathological quality of specimens with little blood contamination. Depending on tissue examination only in diagnosing pancreatic lesions, FNB had more sensitivity and diagnostic accuracy.

The role of S100P and IMP3 in the cytologic diagnosis of pancreatic adenocarcinoma.

PURPOSE: The aim of this study was to assess the role of the two markers, S100P and IMP3, in differentiating between pancreatic ductal adenocarcinoma (PDA) and non-neoplastic pancreatic tissue in (fine needle aspiration cytology) FNAC. PATIENTS AND METHODS: This is a retrospective study that included 72 cases presented with pancreatic mass, where endoscopic guided FNAC was taken from pancreatic lesions. The final histopathologic diagnosis was considered the gold standard. Cell blocks were stained with anti S100P, and IMP3. Nuclear immunoreactivity with or without cytoplasmic staining for the first marker, and cytoplasmic staining for the second marker was considered specific. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and total accuracy of the two markers, as well as the combined accuracy of both markers were calculated. RESULTS: S100P achieved 96.4% sensitivity, 93.3% specificity, 98.2% PPV, 87.5% NPV and 95.8% total accuracy, while IMP3 achieved 91.2% sensitivity, 86.7% specificity, 96.2% PPV, 72.2% NPV and 90.3% total accuracy for PDA. Both markers showed a total combined accuracy of 89%. S100P showed strong and diffuse staining pattern in most of cases, while the staining pattern for IMP3 was moderate and focal in most of cases. CONCLUSION: Both markers were sensitive and specific for diagnosis of PDA. The staining pattern for S100P was easier to evaluate than IMP3.

Expression of cyclooxygenase 2 and vascular endothelial growth factor in gastric carcinoma: Relationship with clinicopathological parameters.

BACKGROUND: Gastric cancer is one of the most common cancers and the second most common cause of cancer-related death worldwide. Identification of specific prognostic indicators might allow a better prognostic stratification and more effective therapy. AIM: To assess the expression and relationship between COX-2 and VEGF protein in gastric adenocarcinoma and whether these markers are useful in predicting clinicopathological prognostic parameters. MATERIALS AND METHODS: The study included 83 formalin-fixed paraffin embedded tissue samples of excised gastric adenocarcinoma and 20 non tumorous tissue controls. The slides were subjected to COX-2 and VEGF immunohistochemical staining using a streptavidin-biotinperoxidase according to the manufacturer's protocol. The results were assessed independently by two pathologists. The relationships among COX-2 and VEGF expression and clinicopathological parameters were statistically analyzed. RESULTS: COX-2 and VEGF expressions were obviously higher in carcinoma tissues compared to normal mucosae (p<0.001). The expression rate of COX-2 was 54.2% and of VEGF was 68.7%. COX-2 positive tumors were significantly correlated with Lauren classification, tumor depth and Helicobacter pylori infection (p<0.001, p=0.008, p=0.035). VEGF was significantly associated with lymph node metastasis and tumor depth (p<0.001). There was a positive association between VEGF and COX-2 expression in gastric adenocarcinoma (Kappa value=0.55). CONCLUSION: In gastric adenocarcinoma, COX-2 expression might serve as a powerful indicator for intestinal type carcinoma, locally advanced disease and H. pylori infection, while VEGF was related to loco-regional progression. COX-2 might be involved in the development of angiogenesis in gastric carcinoma through VEGF upregulation.

The role of Napsin-A and Desmocollin-3 in classifying poorly differentiating non-small cell lung carcinoma.

UNLABELLED: There is increased need for classification of non-small cell lung cancer (NSCLC) into its major subtypes, adenocarcinoma (AC) and squamous cell carcinoma (SCC). Such a classification is enabled in poorly differentiated tumours based on routine morphology due to overlapping morphologic features. In such cases, the use of immunohistochemistry (IHC) can differentiate between the two subtypes. PURPOSE: To test the ability of the two markers; Napsin-A and Desmocollin-3, in differentiating poorly differentiated (AC) from poorly differentiated SCC in small biopsies. PATIENTS AND METHODS: This is a retrospective study including 60 patients who presented with pulmonary nodules. Cases with biopsy specimens diagnosed as poorly differentiated non-small cell lung cancer, and had corresponding resection specimens were included. Cell blocks were stained with anti Napsin-A, and anti Desmocollin-3. Cytoplasmic immunoreactivity for both markers was considered specific. Sensitivity, specificity, positive and negative predictive values, total accuracy and combined accuracy of both markers were calculated. RESULTS: Napsin A showed a sensitivity of 89.3%, a specificity of 96.9%, PPV of 96.2%, NPV of 91.2%, and a total accuracy of 93.3% for AC, while Desmocollin-3 achieved 90.6% sensitivity, 96.4% specificity, 96.7% PPV, 90% NPV, and 93.3% total accuracy. Both markers achieved a total accuracy of 90%. CONCLUSION: Napsin-A, and Desmocollin-3 were sensitive and specific markers for the diagnosis of AC and SCC, respectively. Both markers allowed classification of 54/60 cases into either AC or SCC.

Reliability of fine needle aspiration cytology (FNAC) as a diagnostic tool in cases of cervical lymphadenopathy.

PURPOSE: The aim of this work is to evaluate the reliability and diagnostic accuracy of fine needle aspiration cytology (FNAC) of cervical lymph nodes with an emphasis on discordant cases between the cytology and the histopathology. PATIENTS AND METHODS: This retrospective study was conducted on 157 selected patients with cervical lymphadenopathy that had undergone FNAC. Cervical nodal enlargement was the first clinical manifestation of the patients in all cases. Hypocelluar slides were excluded from the current study. The cytopathological diagnoses were compared with the histopathological results of the same excised nodes. For all discordant cases, special attention was focused on the cytomorphological features. Diagnostic sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and discordance rate were calculated. RESULTS: The cytological diagnoses were found to be benign in 48 cases (30.6%) and malignant in 109 cases (69.4%). The overall diagnostic sensitivity, specificity, positive predictive value, and negative predictive value of FNAC of cervical lymph nodes were 90.9%, 67.2%, 82.6%, and 81.3%, respectively. The overall diagnostic accuracy was 82.2% (129/157), while the overall discordance rate was 17.8% (28/157). The diagnostic accuracy of reactive lymphoid hyperplasia, chronic necrotizing lymphadenitis, chronic granulomatous lymphadenitis, metastatic carcinoma, Hodgkin lymphoma, and Non Hodgkin lymphoma was 85%, 83.3%, 70%, 100%, 77.8%, and 75%, respectively. CONCLUSION: The overall diagnostic accuracy of FNAC of cervical lymph nodes was 82.2% while the overall discordance rate was 17.8%. The evaluation of FNA in patients with no previously diagnosed malignancy should be interpreted by an experienced cytopathologist in the context of clinical, radiological, and laboratory finding and if any of these findings is suspicious, further investigation is justified to overcome the limitations and pitfalls of the cytomorphological features when applied alone.

Diagnostic value of p53 and ki67 immunostaining for distinguishing benign from malignant serous effusions.

BACKGROUND: The differentiation of benign mesothelial cells from malignant tumor cells, primary, or metastatic, in serous effusions based on cytomorphologic features alone can be problematic. PURPOSE: This study was conducted to evaluate the utility of p53 and ki67 immunocytochemical markers in differentiating benign from malignant tumor cells in serous effusions. PATIENTS AND METHODS: Archival Papanicolaou-stained smears of 91 pleural and peritoneal effusions were retrieved from Cytology Unit, Pathology Department, NCI, Cairo University between 2008 and 2010. Forty-one cases were positive for malignant cells and 50 cases were benign based on cytomorphologic features. Cases having doubt were excluded from the study. The slides were destained and subjected to immunocytochemical staining for p53 and ki67. Histologic sections of colonic carcinoma and tonsillar tissue were used as positive control for p53 and ki67, respectively. Smears having >5% positively stained nuclei for p53 were taken as positive and labeling index ⩾10% of ki67 was considered positive. Frequencies of the individual immunocytochemical stains; p53 and ki67, in benign and malignant effusion as well as the combination of both stains were calculated. RESULTS: p53 immunostaining showed nuclear positivity in 31 out of 41 malignant effusions (75.6%) and in 3 out of 50 benign effusions (6%), p<0.005. p53 had 75.6% sensitivity, 94% specificity, 91.2% PPV, and 82.5% NPV. ki67 immunostaining was positive in 30 out of 41 malignant effusions (73.2%) and in 17 out of 50 benign effusions (34%), p<0.05. ki67 had 73.2% sensitivity, 66% specificity, 63.8% PPV, and 75% NPV. Cases were then analyzed for combined immunoprofile of p53 and ki67. Among the 24 cases that coexpressed both antigens, 22 cases (91.7%) were malignant. Thirty two out of 34 cases (94.1%) that showed negative results for both antigens were benign. For the cases that showed p53 immunostaining only, 9 out of 10 cases (90%) were malignant. Fifteen out of 23 cases (65.2%) that showed ki67 immunostaining were benign. CONCLUSION: Benign and malignant effusions showed significantly different staining pattern for p53 and ki67. When used individually, p53 immunostaining can truly diagnose 75.6% and 94% of the malignant and benign cases, respectively. ki67 immunostaining can correctly identify 73.2% and 66% of the malignant and benign cases, respectively. When used in combination, 91.7% of p53 and ki67 positive cases were malignant while 94% of p53 and ki67 negative cases were benign. Hence they could be used when the cytomorphology fails to provide a definitive diagnosis.

Evaluation of the Value of Combined Urine Cytology and Cystoscopy for Follow-up of Superficial Transitional Cell Carcinoma of the Urinary Bladder.

OBJECTIVE: Cystoscopic biopsy is the most accurate technique used to assess the efficacy of treatment and to detect recurrence of superficial TCC of urinary bladder. Implementation of voided urine cytology to detect tumor cells in urine samples may represent an additional tool. The aims of this study are: (1) To estimate the reliability of combined cystoscopy and urine cytology examination in the follow-up of cases of superficial urinary bladder carcinoma, which might help to restrict cystoscopic biopsies for these cases with its morbidity and cost, (2) To discuss the diagnostic pitfalls of cytologic examination in these cases. PATIENTS AND METHODS: This is a prospective study, on 93 patients with superficial TCC of urinary bladder who were initially treated by complete TUR with or without adjuvant intravesical therapy with Bacillus Calmette - Guerin (BCG) (120mg÷instillation) every week for 6 weeks. Cystoscopic findings, urine cytology and histologic results of cystoscopic biopsies were assessed. RESULTS: By histologic examination, 41 (44%) cases were recurrent TCC and 52 (56%) were reported as negative for recurrence. By cystoscopic examination there were 36 positive cases, 4 of them were false positive. Out of the 57 negative cases for recurrence cystoscopically, 9 were histologically positive and were considered as false negative results. By cytology, 28 cases were positive, 3 were false positive, and 65 were negative for recurrence, 16 of them were false negative. Most of false negative cases were low grade TCC. Sensitivity of cytology and cystoscopy in the detection of recurrence was 61% and 78% respectively. When the two examinations were combined, sensitivity was 100%, and specificity was 92.3%. CONCLUSION: For follow-up of superficial bladder carcinoma, the combination of negative cystoscopic findings and negative urine cytology may replace routine biopsies with their morbidity and cost. KEY WORDS: Superficial bladder carcinoma - Cytology and Cystoscopy - Follow-up.

The Role of P63 Immunocytochemistry for Myoepithelial Cells in the Diagnosis of Atypical and Suspicious Cases in Breast Fine Needle Aspiration Cytology (FNAC).

PURPOSE: Evaluation of the usefulness of p63 immunocytochemical marker for myoepithelial cells in the diagnosis of atypical and suspicious lesions in breast cytology. PATIENTS AND METHODS: This is a retrospective study on 122 selected patients presented at Cytology Unit, Pathology Department, NCI, Cairo University, in three years interval from 2007 to 2009, with breast lumps who underwent preoperative FNAC and diagnosed cytologically as atypical or suspicious breast lesion for biopsy then they were followed by excisional biopsy for histopathologic assessment that was considered as the golden standard diagnosis against which FNAC diagnoses were compared. Paucicellular cytologic slides as well as cases with no corresponding final histopathological diagnosis were excluded. The destained cytologic slides were subjected to p63 immunocytochemical staining. Only the nuclear immunoreactivity for p63 was considered specific, cytoplasmic and membranous staining was considered nonspecific. The stained slides with p63 marker were quantified according to the percentages of positive epithelial cell clusters and positive single bare nuclei in the BACKGROUND. The immunocytochemical results were compared with histopathologic diagnoses. RESULTS: Of the 122 studied breast aspirates, 84 cases with atypical findings and 38 cases with suspicious findings were included. The two categories yielded malignant diagnoses in 53 cases (63.1%) and 31 cases (81.6%), respectively. Invasive duct carcinoma was the most common malignant diagnosis in both categories. The most common benign diagnosis in the atypical group was fibrocystic changes (48.4%), while atypical ductal hyperplasia was the most common non-malignant diagnosis in the suspicious group (42.8%). P63 consistently stained the nuclei of myoepithelial cells, either overlying clusters and/or single bare nuclei. Of the histologically confirmed malignant cases 69% and 91.7% showed no p63 nuclear staining in cell clusters or bare nuclei, respectively; while cases showed staining pattern similar to that of benign lesions. On the other hand, 84.2% and 57.9% of the benign cases showed staining in more than 75% of the clusters and bare nuclei, respectively. The staining pattern of p63 was significantly different between malignant and benign lesions (p-value <0.005). The p63 sensitivity, specificity, positive, and negative predictive value were 90.5%, 84.2%, 92.7%, and 80%, respectively. Scattered p63 positive ductal cells ( <10% of duct cells) were detected in 6% of all malignant cases. CONCLUSION: The p63 was a reliable nuclear marker of myoepithelial cells in breast cytology. Benign and malignant breast lesions showed significantly different staining pattern for p63 on inconclusive breast cytology. The diagnostic sensitivity, specificity, positive and negative predictive value of p63 marker were 90.5%, 84.2%, 92.7%, and 80% respectively. The p63 immunostaining may be used as a diagnostic adjunct to the routine fine needle aspiration cytology in cases of breast lesions with atypical and suspicious results. KEY WORDS: P63 immunocytochemistry - Breast FNAC - Inconclusive diagnoses.

Assessment of the reliability of immunocytochemical detection of estrogen and progesterone receptors status on the cytological aspirates of breast carcinoma.

PURPOSE: Evaluation of the reliability of immunocytochemical staining for estrogen and progesterone receptor status on previously papanicolaou-stained fine needle aspiration smears of breast carcinoma cases. PATIENTS AND METHODS: This is a retrospective study conducted on destained smears of fine needle aspirates (FNA) obtained from 90 breast carcinoma cases. These cases underwent subsequent tumor resection and immunohistochemical detection of estrogen and progesterone receptors allowing a comparison between the immunocytochemical and immunohistochemical results (Gold Standard). Hypocelluar slides were excluded from the current study. Only the nuclear staining was considered specific. The results were scored on the basis of the percentage of the positive nuclei among the total epithelial malignant cells after examination of the entire slide. Smears were interpreted as positive if 10% of the examined cells demonstrated nuclear staining. These results were then compared with the immunohistochemical results. RESULTS: For estrogen receptor immunocytochemistry, the overall cyto-histologic accuracy was 91.1% (82÷90) while the discordance rate was 8.9% (8÷90). The diagnostic sensitivity, specificity, positive predictive value, and negative predictive value were 93%, 84.2%, 95.7%, and 76.2% respectively. For progesterone receptor immunocytochemistry, the overall cyto-histologic accuracy was 88.9% (80÷90) while the discordance rate was 11.1% (10÷90). The diagnostic sensitivity, specificity, positive predictive value, and negative predictive value were 87.1%, 95%, 98.4%, and 67.9% respectively. CONCLUSION: Immunocytochemistry is considered as an efficient tool in evaluating estrogen and progesterone receptor status in breast carcinoma. The application of estrogen and progesterone receptor immunocytochemistry on previously Papanicolaou-stained slides provides an overall accuracy of 91.1% for estrogen receptor and 88.9% for progesterone receptor when compared with the immunohistochemical results. KEY WORDS: Estrogen receptor- Progesterone receptor- Breast carcinoma- FNA- Immunocytochemistry.

Diagnostic accuracy and pitfalls of preoperative fine needle aspiration cytology in salivary gland lesions.

PURPOSE: Evaluation of diagnostic accuracy of preoperative fine needle aspiration cytology (FNAC) in salivary gland lesions. PATIENTS AND METHODS: This is a retrospective study of 82 patients presented at NCI, Cairo University with salivary gland lesion who underwent preoperative FNAC diagnosis with subsequent excision and histopathologic assessment. Cytology results were classified as negative, positive, suspicious for cancer and inadequate. The definitive histopathologic report according to WHO Histological typing was the gold standard diagnosis against which FNAC was compared. RESULTS: Our study included 82 patients who underwent preoperative FNAC of major salivary glands with subsequent surgical excision. Male to female ratio was 1.4: 1. The median age was 42 years. Parotid gland was involved in (68.3%), submandibular in (28%) and submental gland in (3.7%). Forty cases (48.8%) were cytologically diagnosed as benign lesions, 26 (31.7%) were malignant and 10 (12.2%) were suspicious. Cytological findings were nondiagnostic in 6 (7.3%). The most common benign cytologic diagnosis was pleomorphic adenoma; 16 out of 40 cases (40%), while the most common malignant tumor was carcinoma; 22 out of 26 cases (84.6%). Cytologic diagnoses were compared with histopathologic ones and were true-negative in 37 (92.5%), true-positive in 33 (91.6%), false-negative in 3 (8.3%) and false-positive in 3 (7.5%) cases regarding detection of malignant tumors. The cytologic diagnosis achieved a sensitivity of 91.7%; a specificity of 92.5%, PPV 91.6%, NPV 92.5% and diagnostic accuracy 92%. The rates of agreement of histopathologic type for benign and malignant tumors were 89.2% and 91%, respectively. CONCLUSION: The sensitivity, specificity and diagnostic accuracy of FNAC were 91.7%, 92.5% and 92%, respectively. Attention to subtle morphologic changes, pitfalls and limitations are important to increase diagnostic accuracy. Multidirectional aspiration is preferred to avoid selective sampling. Re-aspiration of solid portion after cyst fluid aspiration is necessary to decrease the rate of inadequacy. KEY WORDS: FNAC - Salivary gland lesions - Accuracy - Pitfalls.