The Bethesda system for reporting thyroid cytopathology – our first experiences

Citološka punkcija štitnjače nezamjenjiva je dijagnostička metoda u procjeni rizika za malignitet u čvorovima štitnjače. Bethesda klasifikacija citoloških nalaza štitnjače nastala je 2007. godine kao rezultat analize velikog broja podataka prikupljenih iz različitih ustanova i sadrži šest kategorija. Za svaku kategoriju procijenjen je rizik za malignitet i usvojene preporuke za daljnji postupak s pacijentom, a ujednačena je i terminologija u citološkim nalazima. Primjenjuje se u Sjedinjenim Američkim Državama i većini europskih zemalja uz neke nacionalne modifikacije. Prikazani su također i prvi rezultati njene primjene na Odjelu za opću citologiju Kliničkog bolničkog centra Rijeka u 2015. godini.. Fine needle aspiration is the essential tool in evaluation of patients with a thyroid nodule. The Bethesda system for reporting Thyroid cytopathology proposed in 2007, is the result of a large amount of data gathered from many medical institutions and literature. Cytological reports are divided in six categories. Each of them implies a certain cancer risk and contains a recommendation for further management of patients. It is used in the USA and the majority of European countries with some national modifications. Our first experiences with Bethesda classification in thyroid cytology in 2015 are presented

Additional Cytomorphological Criteria in Diagnosis of Pilomatricoma – Benign Tumor with Bad Reputation

Pilomatricomas (PM) are benign skin appendageal tumors, with differentiation towards hair-forming cells, usually found in children. They are frequently misdiagnosed by clinicians, and there are also many reports of false positive diagnoses made on fine needle aspiration (FNA) cytology. PM are often mistaken for »small round blue cell« tumors in children, or for Merkel cell carcinoma, basalioma and metastatic small cell carcinoma in adults, with possible over-aggressive therapeutic approach. We present 6 cases of PM, correctly diagnosed preoperatively by FNA. Clinical, cytomorphologic and basic morphometric features were analyzed, and compared with 4 cases of malignant tumors with similar clinical presentation. Morphometric data (longest nuclear diameter) did not prove to be helpful, while basophilic cytoplasmatic protrusions, observed in all 6 analyzed cases, could be useful additional cytomorphologic feature of PM. We concluded that cytomorphologic characteristics of PM are reliable enough for correct preoperative diagnosis in adequate specimens, however the best results are achieved when FNA is performed by an experienced cytologist, and when all relevant clinical data are obtained

Clinical cytology

Klinička citologija je dijagnostička medicinska struka koja pomoću analize citoloških uzoraka pod svjetlosnim mikroskopom prepoznaje fiziološka stanja te dijagnosticira razne benigne, premaligne i maligne patološke procese, a uključena je u dijagnostiku gotovo svih organa i organskih sustava. Kod nas je gotovo 40 godina postojala kao samostalna specijalizacija iz medicinske, a potom kliničke citologije. Od 2015. godine uveden je novi program specijalizacije koji objedinjava citologiju i patologiju, pod nazivom specijalizacija iz patologije i citologije. Citologija je od svojih početaka neraskidivo vezana s klinikom i najbolji rezultati dobivaju se u uskom kontaktu pacijenta, kliničara raznih specijalnosti i citologa. Kao minimalno invazivna i brza metoda, gotovo bez kontraindikacija i značajnih komplikacija, citologija je izuzetno atraktivna dijagnostička metoda, a citološki uzorci prikladni su i za dodatne analize (imunofenotipizacija, citogenetika, molekularna analiza). U članku je prikazana primjena citologije u dijagnostici pojedinih organskih sustava, kao i prednosti i ograničenja citološke dijagnostike i čimbenici o kojima ovisi kvaliteta citoloških nalaza. Posebnu pažnju treba posvetiti pravilnom uzimanju uzoraka i pripremi preparata, i neophodno je da svaku fazu dijagnostičkog postupka izvode primjereno educirani zdravstveni djelatnici. Citološka analiza neizostavna je dijagnostička pretraga za rano otkrivanje, dijagnostiku i praćenje prvenstveno upalnih, benignih neoplastičnih, premalignih i malignih promjena gotovo svih organa i organskih sustava.Clinical cytology is a diagnostic medical branch that by means of light microscopic analysis of cell and tissue specimens recognizes various physiological variations, benign and malignant diseases. Cytology is involved in diagnostics of virtually every organ and tissue. Cytology has been a separate specialization in Croatia for almost 40 years, at first as Medical cytology, later as Clinical cytology. In 2015 a new specialization was introduced, synthesizing cytology and pathology, and is called “specialization in pathology and cytology”. From the very beginning, cytology is closely connected to clinics, and the best results are achieved in team work of the cytologists and clinicians of different specialities, and in direct contact with the patient. As minimally invasive and rapid diagnostic method, with almost no contraindications and rare and minor potential complications, cytology is extremely attractive diagnostic method, especially considering that cytological specimens are convenient for ancillary diagnostic methods such as flow cytometric immunofenotypization, cytogenetic, molecular techniques. In this paper we discuss the role of cytology in the diagnostics of some organ systems, as well as its advantages and limitations, and factors that influence the end the result and quality of cytological findings. Particular attention should be paid to the quality of sampling, and specimen preparation techniques. It is of utmost importance that all phases of the procedure are performed by adequately educated medical staff. Cytological analysis is an indispensable diagnostic procedure for early detection, diagnosis and follow-up of various, especially inflammatory, benign, premalignant and malignant conditions in various organs and organ systems

The role of the pathologist in diagnosis and therapy of the breast cancer patients

Histopatološke značajke karcinoma dojke uključuju brojne podatke koji su neophodni za daljnji odabir terapije pacijentica, stoga oni moraju biti jasni, nedvojbeno navedeni i pouzdani. Osim tradicionalnih podataka o invaziji, metastatskom potencijalu i odgovoru na terapiju, sve više informacija o prognostičkim i prediktivnim čimbenicima koji utječu na terapiju pacijentica daju i genetska istraživanja na temelju kojih su tumori prema ekspresiji određenih gena stratificirani u podtipove.Histopathological features of breast cancer include numerous details that are essential for the further choice of patient’s therapy because it must be clear, unambiguously stated and reliable. In addition to traditional data on invasion, metastasis and response to therapy more information on prognostic and predictive factors that affect the treatment provide patients and genetic research on the basis of which tumors according to the expression of certain genes in the stratified subtypes

Rhabdomyosarcoma with Bone Marrow Infiltration Mimicking Hematologic Neoplasia

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children younger than 15 years. According to the World Health Organization, there are embryonal, alveolar and pleomorphic types of RMS. Most RMS patients present with a tumor mass in the head and neck region, urogenital tract or lower extremities. Unusual clinical presentation of the disease with massive bone marrow infiltration at the disease onset and mimicking hematologic neoplasm is rarely seen. A case is presented of a 14-year-old, previously healthy girl hospitalized for outpatiently detected leukocyte elevation. For the last two weeks, she had complained of fatigue, myalgia and frequent bruising. On admission, clinical examination revealed numerous petechiae and hematomas, enlarged left inguinal lymph node and palpable spleen 2 cm below left costal arch. Laboratory findings showed leukocytosis, anemia and thrombocytopenia. Bone marrow fine needle aspiration (FNA) produced a hypercellular bone marrow sample with suppression of all three hemocytopoiesis lines and bone marrow infiltration with numerous undifferentiated tumor cells. Considering the morphological, cytochemical and phenotypic characteristics, the cytologic diagnosis was: bone marrow infiltration with RMS cells. Abdominal computerized tomography revealed a primary tumor occupying the entire retropeoritoneal space. Tumor biopsy confirmed alveolar subtype of RMS. In conclusion, in cases of bone marrow infiltration with primitive, immature cells, RMS should be considered as differential diagnostic possibility. Adjuvant technologies (cytochemistry, immunocytochemistry, cytogenetic analysis, flow cytometry, and molecular analysis) can be very helpful in diagnostic work-up, and may lead to definitive diagnosis in some cases

Aksilarnu limfadenektomiju trebalo bi izostaviti kod bolesnica sa karcinomom dojke i minimalnom rezidualnom bolesti u sentinel limfnom čvoru nakon neoadjuvantnog sistemskog liječenja

Background: In modern breast cancer management, SLNB is a standard of care. For the patients with limited sentinel lymph node involvement in the upfront surgery setting, ALND can be safely omitted. However, for any sentinel node metastasis detected following neoadjuvant systemic treatment (NST), ALND is still considered a mandatory procedure. Patients and methods: Present retrospective analysis has included all breast cancer patients submitted to surgery following NST in Clinical Hospital Centre (CHC) Rijeka in the period from 2017 till 2020. Results: SLNB was performed in 151 of 222 consecutive patients, and sentinel node metastasis was detected in 49 cases. The risk of non-sentinel lymph node involvement in sentinel node-positive patients was 34.7%, but exclusively for cases with macro-metastatic disease detected in the sentinel node. In addition, for the patients diagnosed with clinically uninvolved axilla, the risk of ypN2-3 status was only 2.8%. Conclusions: ALND following NST is overtreatment in 65.3% of sentinel node-positive patients. Axillary irradiation with the omission of ALND should be considered for the sentinel-positive patients with only micro-metastatic disease detected in the sentinel node following neoadjuvant chemotherapy, as well as for those with low volume macro metastatic disease, diagnosed with the uninvolved axilla.Uvod: U modernom kirurškom pristupu liječenja kacinoma dojke SLNB je univerzalno prihvaćeni standard. Izostavljanje ALND, u slučajevima sa metastazom pronađenom u do dva sentinel limfna čvora, ne utječe na onkološke ishode kod primarno kirurški liječenih pacijentica, Međutim, svaka metastaza detektirana u sentinel limfnom čvoru nakon provedenog neoadjuvantnog sistemskog liječenja još uvijek se smatra apsolutnom indikacijom za ALND. Pacijenti i metode: Sve pacijentice operirane zbog karcinoma dojke u Kliničkom Bolničkom Centru (KBC) Rijeka nakon provedene neoadjuvantne kemoterapije, u periodu od 2017. do 2020., uključene su u ovu retrospektivnu analizu. Rezultati: SLNB je učinjena kod 151 od 222 uzastopne pacijentice, a metastaza u sentinel čvoru pronađena je u 49 slučajeva. Rizik metastatske bolesti u ne-sentinel limfnim čvorovima kod sentinel-pozitivnih pacijentica je 34.7%, međutim isključivo u slučajevima sa makrometastazom u sentinel čvoru. Nadalje, kod skupine pacijenica dijagnosticiranih sa klinički i radiološki negativnom aksilom, rizik od ypN2-3 statusa je samo 2.8% Zaključak: Nakon neoadjuvantne kemoterapije ALND je overtreatment u 65.3% sentine-pozitivnih pacijentica. Izostavljanje ALND uz zračenje aksile nakon provedenog neoadjuvantnog liječenja je opcija koju bi trebalo razmotriti za sentinelpozitivne bolesnice sa mikro-metastazom u sentinel čvoru, kao i za bolesnice sa malim volumenom makrometastatske bolesti u sentinel limfnim čvorovima, a koje su inicijalno dijagnosticirane sa klinički negativnom aksilom

Predictive value of intraoperative sentinel lymph node imprint cytology analysis for metastasis in patients with melanoma

Since there are no standardized protocols regarding the detection of microscopic melanoma deposits in sentinel lymph nodes (SLN), the aim of this study was to present our experience with intraoperative cytological evaluation of SLN in patients with melanoma. The study included 475 SLN biopsies (SLNB) from 201 patients with primary cutaneous melanoma of intermediate thickness. Each lymph node was cut in half; touch imprint cytology (TIC) preparations of all cut surfaces were performed and stained according to a modified May-Grünwald-Giemsa method. The results were compared to definitive postoperative histology. Twenty of 25 SLNB positive on TIC proved to be metastatic when compared to definitive histology. Most of 32 SLN that were suspicious but not diagnostic on TIC were proven negative (23/32, 71.8%), while 7 nodes had metastases (one micrometastasis and one with isolated tumor cells only). The majority (94%) of SLNBs negative on TIC remained negative on final histology, while 6% or 25 nodes were positive, mostly with micrometastases or isolated tumor cells (17/25). In frozen sections performed in cases of suspicious or positive SLN cytology, metastasis was confirmed in 80% of positive and in 21.9% of suspicious TIC. Altogether, 49% (27/55) of positive SLNB were identified intraoperatively in 57% (24/42) of patients, and in those cases a complete regional lymph node dissection was performed in the first step. TIC assessment of SLNB with 99% specificity and 57% sensitivity for intraoperative identification of metastasis is useful and beneficial for avoiding a second operative procedure.  </p

Predictive value of intraoperative sentinel lymph node imprint cytology analysis for metastasis in patients with melanoma

Since there are no standardized protocols regarding the detection of microscopic melanoma deposits in sentinel lymph nodes (SLN), the aim of this study was to present our experience with intraoperative cytological evaluation of SLN in patients with melanoma. The study included 475 SLN biopsies (SLNB) from 201 patients with primary cutaneous melanoma of intermediate thickness. Each lymph node was cut in half; touch imprint cytology (TIC) preparations of all cut surfaces were performed and stained according to a modified May-Grünwald-Giemsa method. The results were compared to definitive postoperative histology. Twenty of 25 SLNB positive on TIC proved to be metastatic when compared to definitive histology. Most of 32 SLN that were suspicious but not diagnostic on TIC were proven negative (23/32, 71.8%), while 7 nodes had metastases (one micrometastasis and one with isolated tumor cells only). The majority (94%) of SLNBs negative on TIC remained negative on final histology, while 6% or 25 nodes were positive, mostly with micrometastases or isolated tumor cells (17/25). In frozen sections performed in cases of suspicious or positive SLN cytology, metastasis was confirmed in 80% of positive and in 21.9% of suspicious TIC. Altogether, 49% (27/55) of positive SLNB were identified intraoperatively in 57% (24/42) of patients, and in those cases a complete regional lymph node dissection was performed in the first step. TIC assessment of SLNB with 99% specificity and 57% sensitivity for intraoperative identification of metastasis is useful and beneficial for avoiding a second operative procedure.  </p

ANALYSIS OF SENTINEL LYMPH NODE IN EARLY BREAST CANCER PATIENT – CLINICAL HOSPITAL CENTER RIJEKA

Biopsija limfnog čvora čuvara (LČČ) pouzdana je metoda za detekciju aksilarnih metastaza kod bolesnica s ranim rakom dojke koja omogućava izbjegavanje nepotrebne disekcije aksile. Međutim, u svakodnevnoj praksi i sad se rabe različiti protokoli za detekciju i patohistološku evaluaciju čvora zbog čega postoji potreba za standardiziranjem načina rada, analize i pisanja izvješća kako bi se bolesnice pouzdano raščlanile u odgovarajuće prognostičke grupe. Cilj ovog rada bio je prikazati naše iskustvo u pregledu LČČ-a kod bolesnica s ranim rakom dojke i kliničkim stadijem bolesti T1-2 i N0. U razdoblju od 2003. do 2011. pregledana je 1071 uzastopna bolesnica, odnosno ukupno 1915 LČČ-a ili prosječno 2,1 po bolesnici. Protokol je uključivao intraoperacijski pregled histoloških smrznutih rezova, odnosno citoloških otisaka, a potom pregled parafinskih rezova prema protokolu koji uključuje narezivanje cijelog LČČ-a u intervalima od 250 µm. Ovakvom analizom utvrđen je negativan LČČ u oko 75% slučajeva. Postignuti rezultati analize LČČ-a uspoređeni su s literaturnim podatcima.Sentinel lymph node (SLN) biopsy is an accurate method for the detection of axillary metastases in early breast cancer patients and is of value as a replacement for axillary dissection. However, variations in the methods and protocols used for the pathological evaluation of SLN exist in everyday practice. Therefore, standardization how to detect, dissect, process, stain, assess and report SNL is required in order to stratify patients into adequate prognostic groups. The aim of this study was to present our experience in SLN analysis in patients with early breast cancer and clinical stage T1-2 and N0. In the period between 2003 and 2011, 1071 consecutive patients or 1915 SLN were analyzed. The protocol included intraoperative analysis of histological frozen sections and cytological imprint, followed by analysis of paraffin sections according to the protocol that included sections of whole SLN with the interval of 250 µm. According to the accepted protocol 75% of SLN were negative. The obtained results were correlated with literature data

Povezanost molekulskih podtipova raka dojke i ekspresije NF-kB i HIF-1a : doktorski rad

Uvod: karcinom dojke pokazuje veliku kliničku i molekulsku različitost. Prognostički čimbenici su vrlo značajni za predviđanje tijeka bolesti za svakog pojedinog bolesnika. Nuklearni faktor kapa B (NF-κB) i hipoksijom inducirani faktor 1 alfa (HIF-1α) su transkripcijski čimbenici uključeni u karcinogenezu i metastaziranje. Cilj: procijeniti ekspresiju NF-κB i HIF-1α u duktalnom invazivnom karcinomu dojke i usporediti imunohistokemijsku ekspresiju ovih čimbenika s molekulskim podtipom karcinoma dojke kao i njihov utjecaj na ishod bolesti. Ispitanici i metode: retrospektivno istraživanje provedeno je na 208 uzastopno dijagnosticiranih slučajeva duktalnog invazivnog karcinoma dojke. Svi su reklasificirani prema molekulskom podtipu u skladu s preporukama Konferencije iz St. Gallena iz 2011. godine. Na tkivnim mikroarejama (po tri promjera 1 mm iz svakog karcinoma) učinjeno je imunohistokemijsko bojenje na NF-κB i HIF-1α. Samo je nuklearno bojenje bez obzira na intenzitet u više od 10% tumorskih stanica smatrano pozitivnim rezultatom za oba ispitivana čimbenika. Vrijeme praćenja bolesnika iznosilo je 7-11 godina. Rezultati: NF-κB bio je pozitivan u 31% karcinoma a HIF-1α u 41%. Ekspresija NF-κB obrnuto je korelirala s ekspresijom estrogenskih receptora (p=0,005). Pozitivna korelacija utvrđena je između NF-κB i markera proliferacije Ki-67 (p=0,015). Kaplan-Meierova krivulja pokazala je kraće ukupno preživljenje za bolesnike s Her2 pozitivnim i luminalnim B(Her2+) podtipom, dok su najbolju prognozu imali bolesnici s luminalnim A podtipom karcinoma (p<0,001). Ukupno preživljenje unutar luminalnog A podtipa bilo je bolje kod onih tumora koji su bili NF-κB pozitivni (p=0,021). HIF-1α pozitivni tumori bili su povezani s kraćim preživljenjem bez obzira na molekulski podtip carcinoma (p=0,036). Zaključak: Obrnuta korelacija NF-κB i estrogenskih receptora govori u prilog njihovoj međusobnoj supresiji i protumorskom djelovanju NF-κB. S druge strane bolje preživljenje skupine bolesnica s pozitivnim NF-κB karcinomima unutar luminalnog A podtipa govori u prilog protutumorskog djelovanja NF-kB. HIF-1α pokazao se kao loš prognostički čimbenik u ukupnoj ispitivanoj grupi bolesnika. Prema našem mišljenju, praktični značaj NF-κB i HIF-1α ekspresije kao prognostičkih čimbenika i potencijalnih ciljnih molekula za specifičnu terapiju zaslužuje dalje istraživanje.Introduction: breast cancer shows extensive clinical and molecular heterogeneity. Prognostic factors are very important for outcome estimation in individual patients. Nuclear factor kappa B (NF-κB) and hypoxia inducible factor 1 alfa (HIF-1α) are transcriptional factors involved in cancerogenesis and metastatic spread of tumors cells. Aim: to evaluate the expression of NF-κB and HIF-1α and to correlate the immunohistocemical expression of these markers with breast cancer subtype and patient outcome. Patients and methods: Retrospective study included 208 cases of ductal invasive breast cancers stratified by the molecular subtype according to St. Gallen 2011 classification. Three tissue cores, 1 mm in diameter from each tumor were obtained to form tissue microarray on which immunohistochemical staining for NF-kB and HIF-1α were done. Only nuclear staining for both markers was recorded and expression in more than or equal to 10% nuclei of entire tumor area was considered positive. Follow up period for entire cohort of patients was 7-11 years. Results: NF-κB showed positive staining in 31% and HIF-1α in 41% of tumors. Activation of NF-B showed inverse correlation with expression of estrogen receptor (p=0,005) and positive correlation with expression Ki-67 proliferation index (p=0,015). Kaplan-Meier survival curve showed that increased mortality risk was associated with the tumor belonging not to the luminal A subtypes but belonging to the Her-2 enriched and luminal B-Her-2 positive subtypes instead (p<0,001). We found better overall survival in NF-B positive tumors in luminal A subtype (p=0,021). HIF-1α was related to overall survival as poor prognostic factor (p=0,036). Conclusion: Inverse correlation of NF-κB and estrogen receptor expression could be explained by the fact that estrogen represses NF-κB. That can be result of NF-κB tumor promoting effect. On the other hand, NF-κB was favorable prognostic factor in overall survival in luminal A subtype what can be result of its tumor suppressing effect. We found that HIF-1α is an unfavorable prognostic factor on overall survival. In our opinion, the practical relevance of NF-B and HIF-1α expression as prognostic indicators and potential target for specific therapies deserve further investigation