Your experience in mesothelial hyperplasia vs mesothelioma on cytology

[Patho2009]

Have you ever encountered a cytology material (pleural or peritoneal) where you couldn't rule out malignant mesothelioma (mm) and you found yourself between benign mesothelial hyperplasia and mm?

Do you sign it out as (atypical mesothelial proliferation) and write your impression in a comment.

Have you ever tried IHC such as desmin and EMA (EMA pos in mm while neg in mesothelial hyperplasia. The opposite is true for desmin).

Just like to know your experiences, if any.

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[pathstudent]

Have you ever encountered a cytology material (pleural or peritoneal) where you couldn't rule out malignant mesothelioma (mm) and you found yourself between benign mesothelial hyperplasia and mm?

Do you sign it out as (atypical mesothelial proliferation)

Have you ever tried IHC such as desmin and EMA (EMA pos in mm while neg in mesothelial hyperplasia. The opposite is for desmin).

Just like to know your experiences, if any.

The AFIP book on mesothelioma says you can't determine invasion on exfoliative cytology.

Even on biopsies the authors say it is best to undercall invasion if you are not sure as there is no advantage to early diagnosis for a disease that is fatal with no effective treatment.

I did see a cytologists call it on a pleural fluid; however, she knew there was a biopsy that the patient already had the diagnosis. So it wasn't all that bold.

 

[raider]

As in everything in pathology, if its obvious you can predict fairly accurately (as long as there is strong supportive evidence from radiology). I have diagnosed mesothelioma on cytology only twice, and in both cases there was strong radiologic evidence of the disease process.

Most of the cases (hyperplasia vs. mesothelioma) show significant overlap on cytology , and one goes along with a differential raising the possibilities (favoring one or the other), recommendations of correlating with clinico-radiologic data and additional diagnostic procedures (e.g. biopsies etc.)

IHC e.g. Desmin, p53, GLUT1, p53 etc (on cytology), in most cases is useless.

 

[zao275]

IHC e.g. Desmin, p53, GLUT1, p53 etc (on cytology), in most cases is useless.

I essentially agree. I have done some research on mesos with a prominent pulmonary pathologist who is on the international mesothelioma panel. My understanding is that the majority of the experts still make the distinction based on morphology (particularly invasive architecture), rather than on IHC. The search for truly specific stains for malignant vs reactive mesothelial cells continues, but so far none of the stains seem robust enough to be routinely used to make such a serious diagnosis (at least from observing the sign out practices of some of the experts).

 

[pathstudent]

Why don't they just due array based molecular studies to see what makes the difference. That way they could just do molecular studies on pleural fluids.

 

[BierstiefelAndy]

I did see a cytologists call it on a pleural fluid; however, she knew there was a biopsy that the patient already had the diagnosis. So it wasn't all that bold.

A pure cytologic diagnosis of mesothelioma based on immunohistochemistry remains debatable. Mesothelioma can be diagnosed on cytology however based on morphology when you have large morular clusters (assuming you've proven mesothelial differentiation rather than adenocarcinomatous lineage). However, when you are arguing for a diagnosis of malignant mesothelioma based on seeing single atypical cells, this is a lot tougher. Regardless of which side of the fence you stand on this issue, this whole topic reaffirms my views on cytopathologists in general. There are two classes of cytopathologists:

a) When a cytopathologist knows the correct answer, he/she will talk your ears off about all the features that support that answer (i.e., "I told you so"). This is similar to how John Madden rationalizes plays in football after the play is over ("Let me tell you why that run play was the perfect call!") However, when the final answer is not certain, they will speak equivocally but in an authoritative fashion such that he/she still sounds smart.

b) Those who are humble and realize that cytology is useful but not perfect, base their conclusions on reproducible, scientific evidence, and learn from mistakes to better themselves for the sake of their patients and not their personal pride.

 

[2121115]

I was taught to never call mesothelioma on cytology (i.e. pleural fluid). There is no upside to getting it right (if they are that concerned they will get a biopsy) and tremendous downside to getting it wrong. There is really no reason to stick your neck out like that. Just call it atypical or whatever.

 

[BierstiefelAndy]

I was taught to never call mesothelioma on cytology (i.e. pleural fluid). There is no upside to getting it right (if they are that concerned they will get a biopsy) and tremendous downside to getting it wrong. There is really no reason to stick your neck out like that. Just call it atypical or whatever.

Agree completely. Calling something unequivocably malignant only sets you up to look stupid in some cases, especially in controversial situations such as this. In certain instances, calling something "suspicious" is sufficient; that way, the next prudent step in management is done.

Breast FNA is a notorious example of this. In many institutions, if you call something atypical, suspicious, or malignant, the patient will undergo an excision anyway. Unless you are absolutely sure a breast FNA is malignant, exercise caution. Because if you call an FNA malignant when the excision turns out to be otherwise, you could have a mess on your hands that could have been avoidable (phone calls from clinicians and having to pull the slides to explain cyto-histo discrepancies). Again, sticking your neck out only puts you in a position to potentially look stupid.

Cytology is a screening test. This message often gets lost in our current medicine environment where doctors feel the need to justify their existence and overemphasize their importance (sometimes at the expense of patient care). Overall, the goal is to stratify patients into two categories:

a) Those who need further workup (i.e., biopsy or resection).
b) Those who have a clean bill of health.

 

[Parts Unknown]

Have you ever encountered a cytology material (pleural or peritoneal) where you couldn't rule out malignant mesothelioma (mm) and you found yourself between benign mesothelial hyperplasia and mm?

Do you sign it out as (atypical mesothelial proliferation)

Have you ever tried IHC such as desmin and EMA (EMA pos in mm while neg in mesothelial hyperplasia. The opposite is for desmin).

Just like to know your experiences, if any.

Yes, I have encountered some nasty atypical mesothelial specimens from time to time. I agree that IHC is useless except to rule out adenocarcinoma. Other than that you really need a chest CT and some clinical suspicion to push forward.

 

[lipomas]

I know you run into people who insist that the dx can be made on cytology. These are usually experts who see many many cases every year. For the rest of us I would truly hesitate before making an outright dx of mesothelioma on a cytology specimen. If the history, radiology, etc, fit you can say "consistent with" or something I suppose. But the value of cytology is confirming abnormalities and often triaging patients for more definitive studies. In the case of metastatic adeno, it can be a diagnostic test. But for a patient with no prior dx who presents with a pleural effusion and it is not adeno, I'm not going any further than suspicious. That will likely be fine, because I will talk to the clinician. Most patients then have further treatment and diagnostic modalities. In the rare case where nothing else is going to be done and the diagnosis has to be made, that could change.

 

[KCShaw]

I would say that if nothing else is going to be done, then the diagnosis doesn't need to be made.

If you call something outright, especially mesothelioma, be prepared that you may have to testify with regard to that diagnosis when the family brings a suit against the patient's employer for exposing them to asbestos 30 years ago. If you then waffle, you open yourself up for suit for making a definitive diagnosis that you didn't really think was definitive yet lead family to not have an autopsy because they thought the diagnosis was already clear. If you aren't adequately sure, don't pretend to be; in general, a "consistent with" when that's what you really mean is probably perfectly OK.

Worst case scenario, to be sure, but not that rare.

 

[yaah]

I would say that if nothing else is going to be done, then the diagnosis doesn't need to be made.

If you call something outright, especially mesothelioma, be prepared that you may have to testify with regard to that diagnosis when the family brings a suit against the patient's employer for exposing them to asbestos 30 years ago. If you then waffle, you open yourself up for suit for making a definitive diagnosis that you didn't really think was definitive yet lead family to not have an autopsy because they thought the diagnosis was already clear. If you aren't adequately sure, don't pretend to be; in general, a "consistent with" when that's what you really mean is probably perfectly OK.

Worst case scenario, to be sure, but not that rare.

If nothing else needs to be done, the diagnosis often has to be made so that nothing else can be done. Odd, I know. But that is how clinicians have to work sometime. Hospice will see the patient more quickly and care for them if they have a diagnosis of an incurable malignancy. Plus, the diagnosis makes them eligible for compensation whereas "suspicious" probably wouldn't. But in those cases, an expert would probably end up seeing it anyway. Asbestos lawsuits are so common that the word of the general pathologist who signed it out probably wouldn't even matter much. You wouldn't be likely to get sued for failing to call it positive (versus suspicious). If they really wanted a positive diagnosis an expert would get involved.

 

[pathstudent]

I know you run into people who insist that the dx can be made on cytology. These are usually experts who see many many cases every year. For the rest of us I would truly hesitate before making an outright dx of mesothelioma on a cytology specimen. If the history, radiology, etc, fit you can say "consistent with" or something I suppose. But the value of cytology is confirming abnormalities and often triaging patients for more definitive studies. In the case of metastatic adeno, it can be a diagnostic test. But for a patient with no prior dx who presents with a pleural effusion and it is not adeno, I'm not going any further than suspicious. That will likely be fine, because I will talk to the clinician. Most patients then have further treatment and diagnostic modalities. In the rare case where nothing else is going to be done and the diagnosis has to be made, that could change.

I an not so sure you have a clue as to what you are talking about. The people that write the fasicles are the experts and they expliciloty state that mesothelioma cannot be diagnosed on exfoliative cytology. And they also say don't even diagnose it on biopsy unless it is patently obvious as there is no point to ovetdiagnosing a disease that is 1000 % fatal and that has no effective therapy.

 

[pathstudent]

I know you run into people who insist that the dx can be made on cytology. These are usually experts who see many many cases every year. For the rest of us I would truly hesitate before making an outright dx of mesothelioma on a cytology specimen. If the history, radiology, etc, fit you can say "consistent with" or something I suppose. But the value of cytology is confirming abnormalities and often triaging patients for more definitive studies. In the case of metastatic adeno, it can be a diagnostic test. But for a patient with no prior dx who presents with a pleural effusion and it is not adeno, I'm not going any further than suspicious. That will likely be fine, because I will talk to the clinician. Most patients then have further treatment and diagnostic modalities. In the rare case where nothing else is going to be done and the diagnosis has to be made, that could change.

Seriously mesothelioma is diagnosed based on invasion, not on cytologic atypia. How could you ever diagnose it on exfoliative cytology? That is like claiming you can diagnose a parathyroid carcinoma on cytology

 

[BierstiefelAndy]

That is like claiming you can diagnose a neuroendocrine tumor as malignant based on cytology

Well, if the neuroendocrine tumor has nuclear molding, necrosis, and significant mitotic activity, I'll call it malignant...even on cytology.

I might even go as far as calling it...small cell carcinoma...just maybe...

 

[BierstiefelAndy]

If nothing else needs to be done, the diagnosis often has to be made so that nothing else can be done. Odd, I know. But that is how clinicians have to work sometime. Hospice will see the patient more quickly and care for them if they have a diagnosis of an incurable malignancy. Plus, the diagnosis makes them eligible for compensation whereas "suspicious" probably wouldn't. But in those cases, an expert would probably end up seeing it anyway. Asbestos lawsuits are so common that the word of the general pathologist who signed it out probably wouldn't even matter much. You wouldn't be likely to get sued for failing to call it positive (versus suspicious). If they really wanted a positive diagnosis an expert would get involved.

Agreed. This also holds true on pancreatic FNA where there is this mystical boundary that separates "suspicious" from "malignant". Some folks are cautious, others are more daring. Nonetheless, clinicians frequently won't treat (surgical or chemo) unless they have an unequivocal diagnosis. I think a word muttered by clinicians that relaxes the cytopathologist's sphincter tone is "unresectable" as a subsequent Whipple will not be done eliminating the risk of proving you wrong. Of course, clinicians may say the word just to bias you enough to stick your neck out and call a very limited sample as "malignant." Then a Whipple crash-lands on the grossing bench and it's a [insert non-malignant entity here]. Gotta be careful...

As for mesothelioma, the landscape is far more treacherous as this disease is ripe fodder for litigation. Here, I have a hunch, as yaah said, that the difference in liability (for the pathologist) of calling something suspicious vs. malignant is probably small.

 

[pathstudent]

Well, if the neuroendocrine tumor has nuclear molding, necrosis, and significant mitotic activity, I'll call it malignant...even on cytology.

I might even go as far as calling it...small cell carcinoma...just maybe...

Right.

I meant an endocrine carcinoma like parathyoid or pituitary.

 

[zao275]

Cytology is a screening test.

Although I agree with pretty much everything else you said, I respectfully disagree with this statement, at least partially. The way I was taught (by a former president of the American Society of Cytopathology) is that GYN cytology is indeed a screening test, but NON-GYN cytology is a diagnostic test (ie - the diagnosis may be used as final and definitive for further treatment). Now, I agree that practically speaking, this might not (or maybe even should not) be done in many cases, but I just wanted to clarify the wording of this point. Maybe others disagree? I must admit, I am not a big fan of cytology personally (I like looking at architecture and find individual cells and pap stains to be somewhat less visually appealing...although I do like the Dif Quik!), so I am just saying this on the basis of the way I was trained.

 

[zao275]

As for mesothelioma, the landscape is far more treacherous as this disease is ripe fodder for litigation. Here, I have a hunch, as yaah said, that the difference in liability (for the pathologist) of calling something suspicious vs. malignant is probably small.

I think this is an important point to keep in mind when dealing with anything to do with a meso case: it will most likely end up in court. So I try to be extra careful with checking the accuracy and formatting of the report, spelling and grammar, etc, seeing as it may end up being used as evidence for a toxic tort lawsuit. Not sure what risk there is of malpractice on the pathologists part (I guess maybe unless a specimen is called benign only to have the patient die of mesothelioma 6 months later, although in that case, even if the pathologist misdiagnosed the case, it would be hard to prove that the incorrect diagnosis actually caused harm or injury to the patient, as earlier treatment would not have impacted the outcome).

 

[yaah]

Seriously mesothelioma is diagnosed based on invasion, not on cytologic atypia. How could you ever diagnose it on exfoliative cytology? That is like claiming you can diagnose a parathyroid carcinoma on cytology

The WHO defines it as such, but that hasn't stopped many experts from making the diagnosis in the absence of tissue invasion.

 

[2121115]

Right.

I meant an endocrine carcinoma like parathyoid or pituitary.

Run and tell that. Homeboy!

 

[lipomas]

I an not so sure you have a clue as to what you are talking about. The people that write the fasicles are the experts and they expliciloty state that mesothelioma cannot be diagnosed on exfoliative cytology. And they also say don't even diagnose it on biopsy unless it is patently obvious as there is no point to ovetdiagnosing a disease that is 1000 % fatal and that has no effective therapy.

You know, just because you express an opinion without concern for its level of correctness doesn't mean it's correct. Have you seriously never seen anyone call a pleural fluid cytology "mesothelioma" without a tissue biopsy? It happens. The fact that you don't want it to happen doesn't mean it doesn't happen.

 

[KCShaw]

There's a difference between "we're not going to do anything more with this patient regardless of your report" and "we're not going to do anything more with this patient if you tell us it's malignant". You still can only call it as you see it, which may mean descriptive, suspicious, or consistent with, rather than definitive, more times than the surg/onc colleagues might like.

And with death certificates, probable is still actually an acceptable qualifying term for clinicians -- less so if an autopsy has been performed and the results available, of course. But, death certificates are a medical opinion, based on "only" a reasonable degree of medical certainty.

One mesothelioma risk for pathologists lies in overcalling the diagnosis on an inadequate sample (basically the crux of the thread), and no future sample being obtained prior to cremation/burial. Experts claim inadequate sample, and/or when put on the spot the original pathologist waffles. That pathologist then becomes liable for the family's inability to obtain compensation from whoever they were trying to sue. Just because one or more experts is likely to be called in doesn't get the original pathologist off the hook -- depending on the "error." This isn't the same as simply having a discrepancy when reading adequate tissue. But I generally agree that using cautious terminology (as cautious as your confidence makes you feel about the case) and letting the "experts" get involved and battle it out is pretty low-liability-risk.

That said, if you're confident in the call up front -- great! If you want to call malignancy based on a combination of clinical information and your sample, groovy too, so long as you're clear it's not solely the tissue. Just don't get sucked into calling something because a clinician or family or whoever is piling on pressure or saying Dr. X makes that call all the time on this kind of limited sample/cytology.

Let's face it, though...oodles of clinical management decisions are made based on imperfect assessments ranging from history, physical exam, x-ray, CT, cultures, any of the gobs of CP tests, or some combination of these. It's a matter of making a reasonable medical decision, in conjunction with the patient/family, based on available information. Surg path diagnoses, more specifically tumor diagnoses, are not generally afforded the same latitude of imperfection.

 

[Freak]

That brings up an interesting philosophical/medicolegal issue.
Why make definitive diagnoses rather than consistent with?

 

[Entgegen]

Why make definitive diagnoses rather than consistent with?

'Cuz then they'd just be radiologists.

 

[yaah]

That brings up an interesting philosophical/medicolegal issue.
Why make definitive diagnoses rather than consistent with?

Because our job is to make diagnoses. While it is appropriate to not go too far if the information or material is not adequate, it is also important to make the diagnosis if it is appropriate.

Waffling in your diagnosis too frequently does not help anyone.

 

[KCShaw]

Heh. Fair question, and agree with the answers.

We make diagnoses because..that's what we get paid to do. But we do it based on evidence that X appearance +/- ancillary tests +/- clinical information means Y diagnosis. We just can't/shouldn't always provide a definitive diagnosis; appearances aren't always clear, tissue may be inadequate, ancillary tests &/or clinical information may be absent, confusing, or inconsistent.

Some subspecialties recognize this better than others -- derm, for example, is heavily loaded with descriptive "diagnoses" rather than definitive diagnoses, because we know the clinical information is critical in coming to a definitive conclusion.

I knew a few pathologists rabidly refused to offer a definitive diagnosis if the ordering clinician/surgeon failed to provide any/adequate clinical information -- instead a descriptive diagnosis would be provided. They refused to work in a complete vacuum. And I suspect some clinicians would pass on taking a patient who refused to communicate with them.

 

[BierstiefelAndy]

Although I agree with pretty much everything else you said, I respectfully disagree with this statement, at least partially. The way I was taught (by a former president of the American Society of Cytopathology) is that GYN cytology is indeed a screening test, but NON-GYN cytology is a diagnostic test (ie - the diagnosis may be used as final and definitive for further treatment). Now, I agree that practically speaking, this might not (or maybe even should not) be done in many cases, but I just wanted to clarify the wording of this point. Maybe others disagree? I must admit, I am not a big fan of cytology personally (I like looking at architecture and find individual cells and pap stains to be somewhat less visually appealing...although I do like the Dif Quik!), so I am just saying this on the basis of the way I was trained. <!-- / message --><!-- SDNCODE: one sig per thread -->

Good point. My previous statement that cytology is a screening test does not exclude the role of cytology as a diagnostic test. I agree with you that cytology is an important diagnostic test especially in non-GYN where cytologic sampling may not be followed by a biopsy.

Please let me clarify--my rationale is for what I said (albeit incomplete, as I stated above) is due to the fact that cytologic interpretations are tiered:

Negative
Atypical
Suspicious
Malignant

Cytology is a great diagnostic test if you can call something Negative or Malignant. It's when you can't call something definitively Negative or Malignant where there are issues. Because of this tiered system, one can imagine that there are nuances that come into play when dealing with threshholds that separate these four categories. This is where the cytologist really plays the role of the doctor's doctor. Questions that come into play include:

1) Am I really worried about this patient?
2) Should additional investigation be done? (repeat aspirate, biopsy but not necessarily resection, special tissue triaging).
3) Or is this probably nothing (implied: but I just wanna cover my butt).
4) If I make an unequivocal diagnosis, could I be hurting the patient via unnecessary therapy?
5) If I make an equivocal diagnosis instead of an outright diagnosis, could I be hurting the patient by delaying therapy?

External factors (i.e., how a clinician responds to the diagnosis) also come into consideration to complement the above questions. In that vein, threshholds are important. For instance, in breast cytology, the algorithm may look like this:

Negative ---> clinical followup
------------
Atypical ---> excision
Suspicious ---> excision
Malignant ---> excision

Here, cytology is a screening test and the excision serves as the final diagnostic test. Exception, the cytology is flat out fibroadenoma, fibrocystic change, or carcinoma...then it's a diagnostic test. But don't ask me to diagnose ADH or DCIS with precision and accuracy.


In pancreas, the algorithm may look like this:

Negative ---> clinical followup
------------
Atypical ---> repeat sampling
Suspicious ---> repeat sampling
------------
Malignant ---> Whipple +/- chemo

Here, cytology serves as a screening test at a minimum...but has the potential to serve as a powerful diagnostic test.


In voided urine cytology, the algorithm may look like this:

Negative ---> clinical followup
Atypical ---> clinical followup
------------
Suspicious ---> cystoscopy and biopsy
Malignant ---> cystoscopy and biopsy

Here, I understand if opinions are mixed I believe that cytology is mainly a screening test in this regard.


In the above three scenarios, we see that different interpretations lead to different management decisions and that the threshhold for additional investigation, as opposed to simple clinical followup, are different.

Yes, cytology is a very useful diagnostic test when you can outright call something Negative or Malignant. However, when things are unclear usually due to limited sampling and information, the cytologist can serve as a gatekeeper...this was the spirit in which my comment of "cytology is a screening test" was made. Regardless, one of the most often overlooked aspects of all of this is that a cytologist should not be shy in communicating with the clinicians to discuss challenging cases. In some cases, the clinician can really provide helpful information that the cytologist would not have been aware of otherwise.

Personally, in my young career, this is my general approach. I'm open to others' opinions. We can all learn from each other.

 

[KCShaw]

I think that's a good series of examples to remind everyone the utility of knowing enough about the the discipline you're consulting for (urology, GI, breast, pulmonary, etc.), and not only what any available national/international treatment algorithms might claim but also what your specific clientele will do with your diagnoses.

 

[lipomas]

The other thing to remember about cytology is that "negative" does not always mean "benign." This is particularly true in lung cytology specimens. Clinicians need to know that a negative cytology may simply mean the lesion wasn't sampled. For fluids it's less of an issue although there are many times where a repeat fluid cyto will show cancer that wasn't on the original one.

So if a case is "negative" you have to add something if you think it wasn't sampled. This happens with EUS/bronch FNAs when they are trying to sample a mass or a node but only get benign mucosa.

 

[pathstudent]

You know, just because you express an opinion without concern for its level of correctness doesn't mean it's correct. Have you seriously never seen anyone call a pleural fluid cytology "mesothelioma" without a tissue biopsy? It happens. The fact that you don't want it to happen doesn't mean it doesn't happen.

It is not my opinion. I am stating what it states in the fasicle, which is presumably written people who know what the **** they are talking about.

The AFIP says you can't diagnose mesothelioma on exfoliative cytology as the reactive mesothelial cells can show all the same atypical features of malignant ones. It also says you can't completely exclude on cytology either as mesothelioma can be extremely bland. In fact it says cytology is essentially worthless (but it says it nicely, very limited usefullness, or something like that.

Your attendings who made the diagnosis probably already knew the patient had the diagnosis or knew that it was already clinically a slam dunk (i.e. a ship builder whose lungs were completely encased and a CT scan showing invasion in the heart or something like that).

Trust me, no cytologists are all that bold.

 

[2121115]

Have you seriously never seen anyone call a pleural fluid cytology "mesothelioma" without a tissue biopsy?

Actually, no I have not. Not an initial diagnosis. I'm not trying to get in the middle of a flame war or anything, but the cytopathology attendings at my institution recommend strongly against this and, as pathstudent says, the AFIP takes this same point of view.

 

[Parts Unknown]

Actually, no I have not. Not an initial diagnosis. I'm not trying to get in the middle of a flame war or anything, but the cytopathology attendings at my institution recommend strongly against this and, as pathstudent says, the AFIP takes this same point of view.

There are certainly some pockets of mesothelioma in the country, and some groups with a lot more experience diagnosing it than your average pathologist. Say you have a pleural effusion from a guy who spent 25 years blasting asbestos in the Norfolk ship yard, and he's a smoker, and he's got a suspicious lesion on chest CT, and he's got no other discernible proximal cause for the effusion, and it's loaded with highly atypical mesothelial cells, and it looks just like the last 8 confirmed cases you had... well, you get the idea. Perhaps some would feel a little emboldened.

 

[BierstiefelAndy]

The other thing to remember about cytology is that "negative" does not always mean "benign." This is particularly true in lung cytology specimens. Clinicians need to know that a negative cytology may simply mean the lesion wasn't sampled. For fluids it's less of an issue although there are many times where a repeat fluid cyto will show cancer that wasn't on the original one.

Excellent point. Clinicians should always correlate to determine if a "negative" diagnosis is/could be representative of the lesion of interest. This rule is universal whenever you are dealing with small biopsies whether they be obtained for cytologic analysis or core biopsies to be examined histologically. For instance, cervical biopsies are notorious for being prone to sampling error.

So if a case is "negative" you have to add something if you think it wasn't sampled. This happens with EUS/bronch FNAs when they are trying to sample a mass or a node but only get benign mucosa.

In this instance, I just call them non-diagnostic, especially in cases where they are trying to sample something deep to the bronchus. I guess that's the fifth category of interpretation, which is a no-brainer in my opinion. You never know though...

 

[Patho2009]

......
I just call them non-diagnostic, especially in cases where they are trying to sample something deep to the bronchus. I guess that's the fifth category of interpretation, which is a no-brainer in my opinion. You never know though...

I liked your point. It is better to call things sometimes non-diagnostic rather than negative or benign. In the scenario of a lung mass and bronchial washing showing benign respiratory mucosa, I describe the cytological material as benign bronchial cells and in a comment, I mention that in the clinical context of a mass lesion, the current material might not be reperesentative of the lesion.

 

[zao275]

...this was the spirit in which my comment of "cytology is a screening test" was made.

Now I understand what you were saying. Thanks. I was just repeating what I was told, anyway. Like I said, cytology is not my cup of tea, so I really don't have much room to talk! Nice post, too. I like algorithms...especially useful ones.

One additional comment on the pancreas: In some cases, even suspicious will buy the patient a Whipple (granted, if a patient is severely obstructed and the stents keep failing or cannot be used for some reason, a Whipple may be required, even without a diagnosis of malignancy). At least it was this way sometimes at our hospital, which was pretty terrifying in one respect, although on the other hand, you might worry a lot less knowing they have to take out the panc anyway!

 

[zao275]

In this instance, I just call them non-diagnostic, especially in cases where they are trying to sample something deep to the bronchus. I guess that's the fifth category of interpretation, which is a no-brainer in my opinion. You never know though...

Yeah, my understanding is that you should make a clear difference between saying "negative" (meaning adequate sample, but no malignancy) and "non-diagnostic/unsatisfactory" (inadequate sample). Sometimes this distinction must be carefully explained to clinicians, so that they know when re-biopsy/FNA is needed.

 

[BierstiefelAndy]

One additional comment on the pancreas: In some cases, even suspicious will buy the patient a Whipple (granted, if a patient is severely obstructed and the stents keep failing or cannot be used for some reason, a Whipple may be required, even without a diagnosis of malignancy). At least it was this way sometimes at our hospital, which was pretty terrifying in one respect, although on the other hand, you might worry a lot less knowing they have to take out the panc anyway!

Especially in pancreas, there are quite a bit of nuances in clinical/surgical management that I am learning more and more about. You mentioned the topic of stents. Calling a pancreatic FNA malignant (during an on-site assessment, especially) can also influence the decision to treat with a certain type of stent (plastic vs. metal stents). This decision could have implications for the future possibility of surgery. In that fashion, my algorithm is a bit simplistic.

Ultimately, whether a Whipple is performed or not depends on the clinical scenario and the aggressiveness of the surgeon too. In a minority of instances, I have seen a Whipple performed after a "suspicious" diagnosis. In one case, I saw a Whipple performed after a "non-diagnostic" diagnosis. So clearly, an unequivocal cytologic diagnosis of malignancy is not the end-all, be-all when it comes down to Whipple surgery in all instances. Again, it is helpful to get to know your clinicians and to communicate with them. Medical care is fragmented now requiring effective communication amongst clinicians of various specialties.

 

[BierstiefelAndy]

Yeah, my understanding is that you should make a clear difference between saying "negative" (meaning adequate sample, but no malignancy) and "non-diagnostic/unsatisfactory" (inadequate sample). Sometimes this distinction must be carefully explained to clinicians, so that they know when re-biopsy/FNA is needed.

As Patho2009 also said, I really really try not to sign out any cytology report as simply "non-diagnostic" without a comment. I qualify it with phrases such as "acellular specimen", "hypocellular specimen, rare fragments of [insert non-lesional cell/tissue type here]", or "the findings do not account for a mass lesion."