Fine Needle Aspiration of Germ Cell Tumors of Ovary.

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This chapter should be cited as follows: This chapter was last updated:

McGrath, C, Yu, G, et al , Glob. libr. women's med .,(ISSN: 1756-2228) 2008; DOI 10.384 3/GLOWM.102 64

October 2008

Fine Needle Aspiration

Cindy M. McGrath, MDUnive rsity of P ennsylvania Medical Center, Pennsylvania, USA

Gordon H. Yu, MD As sistant Pro fessor o f Patholo gy, Direct or, Fine nee dle Aspira tio n Clinic , Hospita l of th e Unive rsity of Pe nnsylva nia, Phila de lphia, Pe nnsylva nia,USA

Karen S. Gustafson, MD, PhDChief Resident, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philidelphia, Pennsylvania, USA

Ch arles D. Sturg is, MD Direct or o f Cytopatho log y, Dep artment of Pat ho log y, No rthw est ern Unive rsity , Evansto n Hospita l, Evansto n, I llino is, USA

INTRODUCTIONTECHNIQUESLABORATORY PREPARA TION OF FINE NEEDLE ASPIRATION S PECIMENSCLINICAL UTILI TY OF FINE NEEDLE ASPIRA TIONCY TOMORPHOLOGIC CRITERIA REFERENCES

INTRODUCTION

Fine-needle aspiration (FNA) biopsy is a reliable, cost-effective pr ocedur e that may b e useful in the workup of patients with both palpable anddeep-seated mass lesions. An extremely simple procedure technically, FNA biopsy involves the introduction of a small-gauge needle into themass and the extraction of representative cellular material. Numerous large series studying the diagnostic accuracy of this procedure in a variety of organ systems (including the gynecologic tract) have repeatedly confirmed it as both a sensitive and specific test that may be performed with

minimal morbidity and at a relatively low financial cost to the patient. 1, 2, 3

Needle aspiration biopsy was first performed in the United States in the 1920s at the Memorial-Sloan Kettering Cancer Center. 4 Surgeons wereencouraged to perform these procedures, largely because of pathologists' concerns that open incisional biopsy might lead to early metastases.Biopsies were initially per formed with the use of relativ ely large needles (18 gauge) after a small skin incision ov er the mass in question. Multiplesmears were then made onto glass slides, which were stained and interpreted by a patho logist. Initial reports of their experienc e appeared in the

literature in the early 1930s. 5, 6

Needle aspiration biopsy did not flourish elsewhere in the country, however, and further refinements in the procedure were largely the work of Europeans in the years that followed. With the help of their pathology colleagues, c linicians continued to make useful rev isions to the technique,such as the use of significantly smaller needles (2225 gauge). The technique that we know today as fine-needle aspiration biopsy is the result of these earlier refinements. In addition, much o f their material was stained with a Romanowsky-ty pe stain after the smear was air dried, apreparation used largely in hematopathology.

A r ev iv al o f inte res t in FNA amo ng US c linic ians a nd pa tho log ists began in the 1960s, and t ec hniq ues tha t were r efine d overs eas b ega n to beadopted in the United States. The popularity of the technique grew steadily as reports of its high diagnostic accurac y and tec hnical simplicity appeared in the pathology and clinical literature. In addition, improveme nts in radiologic imaging techniques led to the detect ion of increasingnumbers of deep-seated mass lesions, often in patients studied for unrelated reasons; such lesions are o ptimally sampled by image-guided FNA asan initial step in their diagnostic workup. Finally, initial concer ns over t racking and subsequent seeding of tumor cells within the needle tract have been quie ted by the ex traor dinarily low inc idence of suc h occ urr enc es o ver t he c ourse of lit erally tens of thousands o f aspir ate bio psie s in the
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Fig. 1. A. An aspiration gun (Cameco) with attached syringe may be used to easily generatenegative pressure at needle tip. B. Franzen needle guide, which is useful in the aspiration of paravaginal and pararectal lesions. (Photograph courte sy o f Wesley W. Simms, MD.)

past 50 years. 7, 8, 9

TECHNIQUES

Fine-needle aspiration biopsy may be performed with a number of variations. First, the indications for the proce dure are discussed with thepatient. In addition, potential risks or co mplications or both are discussed, including bleeding and infection in the area after the procedure. Therisk of a significant complication is minimal, and although such incidents have been reported, the chances of such an occurrence may be equatedto the risk incurred when undergoing simple venipuncture. Indee d, drawing similarities to venipunctur e often alleviates the patient's anxiety

toward the procedure. 10 As with venipuncture, local anesthetic is generally not required for FNA of palpable masses, with the rare exception of certain anatomic loc ations (i.e., periareolar breast aspirations). After consent is obtained, slides are labeled and a suitable fixativ e (e.g., 95%alcohol o r spray fixativ e) is made accessible. The area is then prepared with alcohol, and after stabilization of the mass with the fingers of onehand, the needle is placed into the lesion.

Two sampling techniques may be used. An open-ended needle, without attached negative suction, may be used alone for almost all biopsies(known as the French technique). Short, rapid stro kes within the lesion cause dislodgement of ce lls and allow effectiv e co llection within theneedle via capillary action. A syringe with the plunger removed may be attached for the collection of excess fluid if a cystic lesion is suspected.Regardless of the attachment used, it is critical that the end of the apparatus be open to the atmo sphere to allow proper collec tion of thespecimen; care must be taken not to c ov er this opening with a fingertip during the procedure, partic ularly when using a needle alone. Rapidstrokes are made within the lesion, and care is taken not to extract the tip of the needle completely at any time. After 1520 seconds, the needle isremov ed, pressure is applied to the area with sterile gauze, and slides are prepared immediately . If blood appears in the needle hub at any time,the needle should be remo ved immediately and slides prepared. Any de lay results in clotting of the bloo d within the hub, making retrieval of thespecimen difficult.

A s ec ond tec hniq ue involv es applica tio n of ne gat iv e pr essure dur ing the p roce dure, t y pic ally with the use of a sy ring e (1 020 mL) plac ed in asyringe ho lder (aspiration gun/handle; Fig. 1A). When using an aspiration gun or handle, one must remember to pull the plunger back only afterthe needle has been placed into the lesion; the plunger should remain pulled while rapid, short strokes are made. More important, it is imperativethat suction be released before the needle is removed, because continued negative pressure results in suction of the material back into the syringepreventing preparation of direct smears. Although rinsing with saline solution may allow retrieval of this material, cell recovery is poor andpreparations are generally inferior to direct smears.

Aft er r emo val o f the needle , the ma ter ial c ollec ted must be ex pel led ont o g lass s lides using a sy ringe. I f using the open-ended needle te ch niqu e, aready clean syr inge with the plunger pulled back should be attac hed to the needle. If using the negative pressure aspiration tec hnique, the samesyringe c an be used to ex pel the material onto the slides. If material is not expelled on the initial plunging of air through the syringe, remo ve theneedle from the syringe, pull the plunger back fully and reco nnect to the needle and ex pel quickly again. Direct smears should be made withoutdelay. The te chnique for preparing smears is similar to that o f preparing peripheral blood smears, with gentle pre ssure applied as two slides arepassed ove r one another. One slide of the pair should be left to air-dry, while the ot her is immediately fixed, either by immersion in 95% alcoholor by spraying. It is imperative that fixed slides not be allowed to air-dry even partially before being fixed. Air exposure can cause markedcellular degeneration and distortion, hindering pathologic interpretation and resulting in an equivoc al diagnosis. Air-dried smears should belabeled clearly as such, as these may then undergo Giemsa staining. The number of slides prepared obv iously depe nds on the vo lume of materialobtained. Any remaining material within the needle may be rinsed into a saline solution for further processing.

There are essentially no contraindications to FNA of a superficially located mass. FNA may be performed in patients with thrombocytopenia andin those taking anticoagulant medication, assuming their laboratory parameters are not beyond the therapeutic range. Although firm pressureshould be applied for at least 10 minutes after each needle stick, the incidence of bleeding complications does no t seem to be incre asedsignificantly in this population. In addition, patients with mitral valve prolapse generally do not require prophylactic antibiotics before thisprocedure, provided proper technique is followed.

With the use o f radiolo gic guid anc e (e .g. , ult raso und, co mputed tomography [CT], fluoro scopy ), sim ilar tec hniq ues may be used to samp le de ep-

seated and other nonpalpable lesions. 11 , 12 Generally, a needle guide is first placed percutaneo usly, followed by passage of a small-gauge(generally 21 22-gauge) needle. After radiologic confirmation of accurate nee dle placement within the mass, material is extr acted either with or with out neg ativ e suct ion . The co llec ted material is t hen e xpel led ont o sl ides, di rec t smear s prepared as de scrib ed e arlier, and t he need le andsyringe are rinsed into saline solution for future processing. The diagnostic yield for such pro cedures, as with FNA of superficial lesions, isoptimized by immediate, onsite evaluation of the material by pathology personnel. Although such an approach adds to the total time of theproce dure, nondiagnostic results are minimized, and cases requiring special studies (e.g., lympho ma, poorly differentiated malignancies) may bemanaged appropriately with the collection and proper distribution of additional material. A bleeding diathesis or abnormal clotting/coagulationparameters are co nsidered a contraindication to FNA o f deep-seated lesions. It is recommended that such deficienc ies (i.e., administration of fresh frozen plasma or interruption of anticoagulant medication) be corrected before the procedure.
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Finally, transvaginal and transrectal FNAs may be performe d in patients with both palpable and nonpalpable pelvic, parav aginal, and pararectalmasses. Such aspirates may be approac hed with the use of a Franzen needle guide (Fig. 1B), which maximizes acc urate needle placement while

minimizing the risk of self-puncture. 13 , 14 , 15 Similar needle guides may also be attac hed to ultrasound prob es for image-guided aspiration. 16 Tominimize the risk of abscess formation, it is generally recomme nded that prophy lactic antibiotic s be administered to those undergoing a

transrectal approac h, as proper sterilization in this area is difficult. 17

A b rie f rev iew o f som e c ommon misc onc ept ions regarding the per formanc e o f FNA b iop sies is in o rde r. I t is b elie ved b y som e that the u se o f larger needles results in more cellular specimens. Larger needles, however, generally cause a greater amount of bleeding during the procedure,resulting in dilution of the specimen and the presence of large amounts of obscuring blood. Indeed, lesions that typically yield hypocellularaspirates, such as those with ext ensive fibrosis, are best sampled with smaller gauge needles (e.g., 25 gauge). In addition, the incidence of

complications can be expected to rise as needle size increases. 18 , 19

Anot her co mmo n misco ncept ion of FNA is that the applica tio n of ne gative suct ion at the t ime of sampling (i.e ., wi th t he aspir atio n gun) lead s to aspecimen with a greater number of cells. Experience has sho wn, however , that similar amounts of material are obtained from both b enign andmalignant lesions regardless of the presence of negative pre ssure. A study comparing absolute number s of cells obtained with versus without

aspiration (aspiration gun versus Frenc h technique) showed no significant differences with respect to numbers of cells obtained. 20 On a practicalnote, the French technique makes for a much less-cumbersome procedure and allows the technician greater sensitivity and accuracy by permitting a more c omfortable hand-and-wrist position (similar to that assumed when o btaining an arterial blood gas specimen). Finally, patientsgenerally tolerate the Frenc h technique well, but many beco me anxious at the sight of the relatively large, aspiration handle often used.

Finally, some believ e that multiple areas of a give n mass can, and should, be sampled with the same needle in a single needle stick. In a large mass,the angle of the needle may be c hanged in small increments during sampling. Major changes in the direction o f the needle should be avoided,howev er, bec ause it can lead to increased bleeding and result in suboptimal specimens. Therefore, to sample three different areas of a givenlesion, one should consider performing three separate passes. Multiple needle punctures are generally well tolerated, prov ided the rationale forsuch an approach is discussed with the patient before the procedure.

LABORATORY PREPARATION OF FINE NEEDLE ASPIRATION SPECIMENS

A numb er o f preparatio ns may result from a given aspiratio n depend ing o n the manner in which the material is r ec eiv ed. The m ajo rity of th ematerial should be receiv ed on glass slides, already smeared by the aspirator on site. It is preferred that at least half of the slides be immediately fixed in 95% alcohol or spray fixative in preparation for Papanicolaou staining. The remainder of the smears may be allowed to air-dry inpreparation for staining with Diff-Quik, a Romanowsky-type stain, similar to the Giemsa stain. Both preparations are valuable to the interpretingpathologist: the Papanic ola ou s tain permits detect ion of subtle nuclear abno rmalities, allowing a definitive diagnosis of malignancy; the Diff-Quikstain highlights cyto plasmic features and background compo nents, including extracellular material (i.e., mucin), which may be helpful in tumorsubclassification. All slides must be labeled properly with pencil (ink will dissolve o n contac t with alcohol); which slides were air-dried and whichones were immediately we t-fixed sho uld be clearly marked on the slides. If all slides were inadvertently allowed to dry , Papanicolaou stainingmay still be performed. Previously air-dried smears may be rehydrated by immersion in balanced saline solution for approximately 30

seconds, followed by conventional Papanicolaou staining. 21 The results are generally acceptable for cytologic evaluation and can be easily performed in all laboratories. Thus, if it appears that a smear has even partially dried, suc h an approach should be taken rather than a delay edattempt at fixation, which almo st certainly results in degeneration of the material and an indeterminate diagnosis.

Material receive d in a rinse solution (e.g., balanced saline, RPMI) may be pro cessed with a liquid-based preparation (i.e., ThinPrep or SurePath)or cytospin preparation, which concentrates the material via centrifugation. The liquid-based preparations are typically Papanicolaoustained. Cytospin preparations may be Diff-Quik stained after being air-dried, or the y may b e Papanicolaou stained after being fixed with alco hol.In addition, rinse solutions c ontaining a significant amount o f material (seen as a distinct but ton or "pellet" after centrifugation) may besubmitted for a cell block preparation, which inv olve s formaldehyde solutio n fixation, paraffin embedding, and hematoxy lin and eosin staining of thin sections. Such preparations are useful for the e valuation o f larger volumes o f material and are invaluable if special stains (e.g., mucin,immunocy tochemistry) are necessary.

The majority of cytologic preparations and stains may be completed within hours of specimen receipt, allowing a more rapid diagnostic result when compared t o rou tine histologic p roce ssing . Obv iou sly , pr eparat ion o f a ce ll bloc k and perfo rmance o f spec ial st udie s re qui re a ddit ionaltechnical time, equivalent to that required for tissue specimens.

CLINICAL UTILITY OF FINE NEEDLE ASPIRATION

Throughout the evolution of FNA and its acceptance as a useful diagnostic procedure, some controversy has surfaced as to its ability to classify alllesions accurately when compared to the gold standard, namely, histologic evaluation. It is generally accepted by pathologists and clinicians thatthe acc urate subclassification of some neoplasms, including epithelial ov arian and endometrial neoplasms, requires thorough sampling andcareful histologic evaluation of a surgically resected specimen. This is especially true as further subclassification of primary gynecologicneoplasms, often based on subtle histologic features, continues. However, FNA can reliably separate hematopoietic (i.e., lymphoma) andmesenchymal (i.e., sarcoma) neoplasms from the more common epithelial lesions, based on cytomorphologic features and supporting special
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Fig. 2. ( A ) Well-organized, 2D tissue fragment ty pical o f benign glandular epithelium(stain, Papanicolaou) in co ntrast to ( B ) architecturally crowde d, 3D tissue fragment fromcase of adenoc arcinoma showing complet e loss of cellular polarization and organization(stain, Papanicolaou).

Fig. 3. Cytologic criteria of malignancy are shown in this case of transitional cell carcinoma. Adjacent cellsshow significant v ariation in nuclear size and shape; individual nuclei display abnormal c hromatindistribution and nuclear membrane irre gularities (stain, Papanicolaou).

studies when necessary. In addition, nonneoplastic lesions, including inflammatory and infectious processes, are easily recognized on cytologicevaluation, often obviating an unnecessary surgical procedure.

A r ec ognized limit atio n inhe ren t to FNA is the iss ue o f pot ent ial sampl ing e rro r, part icular ly in asp ira tes y ield ing ne gat iv e re sult s. A ltho ughmultiple areas of a given lesion can be sampled with multiple needle passes, one can nev er co mpletely sample a lesion via needle aspiration bio psy , re sult ing in s ome false-ne gative pr oc edu res . Thus , it i s a ge neral dict um that alth ough a p osi tiv e FNA co nstit ute s definitiv e pr oo f of malignancy, a negative FNA of a clinically suspicious lesion does not obviate further workup (i.e., surgical biopsy).

False-positive FNA results are rare and are generally because of misinterpretation of hypercellular specimens with minimal cytologic atypia oroverinterpretation of a few atypical cells in patients with a history of cy totoxic or radiation therapy. Strict adherence to cy tomorphologic criteriaof malignancy (see the next section) minimizes such occurrences. Although such an approach may lead to increased numbers of suspiciousrather than frankly po sitive repo rts, these cases will be appropriately identified as requiring further workup, and proper evaluation and treatmentof these patients should result.

Thus, although the debate will undoubtedly continue, primarily within the pathology community, the fact remains: FNA is a p roc edu re o f extremely low morbidity and cost that, w hen taken in context w ith the clinical findings of a given patient, is extremely useful in guiding therapyor subsequent diagnostic procedures.

CYTOMORPHOLOGIC CRITERIA

The specific cytomorphologic features of lesions in a variety of body sites follows; however, general cytomorphologic criteria of malignancy forepithelial lesions are presented here. The most useful diagnostic cr iterion applied to FNA specimens is cellularity, as nearly all neoplasms(particularly malignancies) yield ce llular specimens on aspiration, whereas aspirates of nonneoplastic lesions and some benign neoplasms are

generally hypocellular. Another useful diagnostic criterion is that of architectural complexity within intact tissue fragments. Although thepractice of cytology is generally thought to rely entirely on evaluation of subtle cellular and nuclear details, large tissue fragments are oftenpresent in FNA biopsy spec imens of epithelial lesions and contain valuable information. In general, normal parenchy ma and benign epitheliallesions are characte rized by arc hitecturally flat, two-dimensional fragments with well-organized and uniformly spaced and predic table nuclei(Fig. 2A), whereas malignant epithelial neoplasms generally y ield complex , three-dimensional fragments with significant nuclear ov erlap anddisorganization (Fig. 2B). Obviously, all cases must be ev aluated for conv entional nuclear criteria of malignancy, including var iation in nuclearsize, shape, and chromatin pattern in adjacent cells. In addition, nuclear membrane abnormalities, altered chro matin distribution (including bothhypochromasia and hyperchromasia), and elevated nucleus-to-cytoplasm ratios are important features of malignancy in individual cells (Fig.

3). 22 General cytologic features of commonly encountered lesions in the breast, lymph nodes, gynecologic tract, and pelvis are presented.

Breast

Fine-needle aspiration is a reliable and cost-effectiv e tool in the evaluation o f palpable and nonpalpable breast masses. 23 , 24 , 25 , 26 Thecombination of physical examination, imaging findings (mammography or ultrasound or both), and cytologic examination, known as the triple

test, has a diagnostic accuracy reported to be greater than 95% when all three elements of the test are concordant. 27 , 28 , 29 , 30 , 31 , 32 Currentreco mmendations for patients undergoing the triple test are as follows:

1. If all three tests are compatible with a benign process, the patient may simply be followed clinically, with close observ ation.

2. If all three tests are compatible with malignancy, the patient may undergo definitive therapy .

3. If there is a mixed or inco nclusive triple test result (i.e., one or two of the tests suggest malignancy ), excisional biopsy of the

index mass should be performed. 33 , 34

The breast lesions most commonly encountered in FNA specimens are nonneoplastic masses, best classified as fibrocystic change. Aspirates from
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Fig. 4. Fine-needle aspiration of fibroc ystic change of breast often y ields ( A ) few cohe sive fragments of benign duc tal epithelium (stain, Diff-Quik) and ( B ) fragments of apocrine metaplasia (stain, Diff-Quik); proteinaceous debris may also be seen in cy sticlesions.

Fig. 5. Fine-needle aspiration of adenocarcinoma of breast typically yields hypercellular smearscontaining a single population of dyscohesiv e epithelial cells (stain, Papanicolaou).

these lesions generally contain foam cells (histiocytes) and proteinaceous debris, consistent with cyst contents. In addition, most aspiratescontain relatively few fragments of ductal epithelium, all of which are tightly cohesiv e, compo sed of small, well-organized nuclei and a distinctsecond cell population (myoepithelial cells); apocrine metaplasia, characterized by abundant granular cytoplasm, is also commonly encountered(Fig. 4). Occasio nal cases of fibroc ystic change with ductal hy perplasia may y ield increased numbers of ductal epithelial tissue fragments, often with some nu clear enla rge ment and ov erlap. Such finding s, in t he abse nce of wo rri some c linic al o r mammo graphic finding s, warra nt simpleobservation rather than surgical intervention.

The question of the need for pathologic ex amination of cyst fluid from clinically benign breast lesions should be addressed. There are two patientgroups in whom one might argue against routine cy tologic ev aluation of all cases: (1) those whose fluid is clear, and (2) those who have to talresolution of the lesion with no residual mass. Patients in whom this is not the case (e.g., tho se who have o paque or blo ody fluid or in whom amass remains), however, should hav e all aspirated material sent for pathologic examination as well as additional sampling to rule out a cy stic

malignancy. 33 , 35 , 36

Anot her benign b rea st le sio n often encountered in FNA spe cim ens, par tic ular ly in the y ounger pa tient po pula tio n, is fib ro adenom a. Conside red atrue neoplasm, this lesion is composed o f both an epithelial and a stromal compo nent, which should be represented in aspirate smears. Theepithelial component is classically composed of numerous cohesive antler-shaped tissue fragments, often with some proliferative changes(nuclear enlargement and overlap). The stromal component is typically represented by stripped ovoid naked nuclei in the background, often

referred to as bipolar cells. In addition, intact stromal fragments, often with myxoid changes, may be observed in occasional cases. A comb ination of these findings, in the contex t of the typic al clinical findings of a well-circumscr ibed, mov able, rubbery mass, is diagnostic o f fibroadenoma.

Papillary lesions in the breast are a frequent source of indeterminate cy tologic diagnoses when aspirated. Both papilloma (a proliferative, b enignlesion) and papillary c arcinoma (a malignant lesion) yield hy percellular aspirate smears, which co ntain numerous intact tissue fragments as well

as numerous single, intact epithelial cells that are o ften columnar in shape. 37 , 38 Because of the cytomorphologic overlap of these entities, suchfindings generally result in a FNA diagnosis of papillary lesion, with surgical exc ision recommended for definitive histologic classification.

Al tho ugh s ome re ports hav e at tem pte d to establ ish c riteria for rel iab ly separa ting benign fro m mal ignant papilla ry les ions, 39 a conservativeapproach should be adopted in these cases.

Carcinoma of the breast may be reliably diagnosed by FNA in the presence of three criteria: (1) hypercellularity; (2) dyscohesion, defined assignificant numbers of intact single ce lls; and (3) lack of a second (my oepithelial) cell population in intact tissue fragments (Fig. 5). Strictadherence to these criteria results in an extremely high specificity for the diagnosis of breast carcinoma. Aspiration of some tumor subtypes, suchas lobular and tubular carcinoma, may yield material that may not fulfill all criteria of malignancy, resulting in a suspicious diagnosis and arecommendation for surgical biopsy and histologic confirmation. Nuclear grading may be performed on FNA smears and correlates well with

nuclear grading of the subsequently resected tumors. 40 , 41 , 42 , 43 Immunocytochemical stains for the presence of hormone receptors (e.g.,estrogen, progesterone) may be performed on cytologic or cell-block material or both obtained from the FNA of a primary breast tumor or

metastatic lesions. 44 , 45 , 46 , 47 Assessment of c-erbB2/Her-2/neu overexpression may be analyzed by immunohistochemistry or fluorescence in

situ hyb ridization on aspirate samples, which may prov ide important prognostic information for presurgical treatment planning. 48 , 49 , 50 , 51

There are some limitations of FNA of the breast that should be recognized. Although many breast tumor subtypes display classic histologicfeatures, the accurate subclassification of tumor subtype (i.e., ductal, lobular, or medullary carcinoma) cannot be performed consistently basedon simple cytomorphologic criteria alone. In addition, the determination of tumor invasion cannot be made based on cytologic smears andrequires definitive histologic demo nstration of stromal invasion; thus, the FNA diagnosis of adenocarc inoma in the breast encompasses in situ

and invasive c arcinoma. 52 In some c ases, particularly image-guided FNA of nonpalpable breast lesions, the addition of core needle biopsy may

result in improved diagnostic accuracy . 53 , 54 , 55 Finally, as with FNA in any site, c linical findings must be taken into acco unt. Thus, a positive FNA diagnosis in the breast in the context o f suspicious c linical or mammographic findings or both is sufficient for definitive the rapy, wher eas anegative FNA diagnosis in the presence of such findings requires further ev aluation to rule out an unsampled or low-grade malignancy.

Soft tissue and subcutaneous lesions

Fine-needle aspiration represents an extr emely useful diagnostic tec hnique for patients with a soft tissue or subcutaneo us nodule, particularly in
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Fig. 6. A. Fine-needle aspiration (FNA) of abdominal wall no duleoccurring 2 years after initial surgery for squamous cell carcinomaof ovar y (arising in teratoma) shows malignant epithelial cells withmoderate amounts of cytoplasm, consistent with metastaticsquamous cell carc inoma (stain, Papanicolaou). B. Corresponding

histologic section of previously resected tumor shows morphologic features similar to that of FNA (stain, hematoxylin-eosin). C.FNA of enlarged cervical lymph node that appeared approximately 3 years after initial surgery, also consistent with metastaticsquamous cell c arcinoma (stain, Papanicolaou).

Fig. 7 . Fine-needle aspiration of keratinous cyst pr esenting as firm subcutaneous nodule in patient with ahistory of malignancy yields mature and anucleated squamous cells admixed with inflammatory cells (stain,Papanicolaou).

Fig. 8. ( A ) Fine-needle aspiration (FNA) of reactive lymph node shows polymorphous

population of small, mature lymphocytes and larger activated lymphoid cells, consistent with ly mphoid hy per plas ia (st ain, Diff-Quik); compare wit h ( B ) FNA of malignantlymphoma displaying monotonous population of large lymphoid cells, consistent withlarge cell lymphoma (stain, Diff-Quik).

the presence of a history of malignancy. Exclusion of metastatic disease is obviously of paramount importance to the patient and clinician.Positive cases are easily recognized but require comparison with previous histologic or cytologic material for confirmation of metastasis (Fig. 6A and B). In contrast, multiple samples by an experienced aspirator without evidence of malignancy are generally sufficient to exclude metastasis.In addition to the absence o f malignancy , howev er, an explanation for the presence of a mass lesion is generally reassuring for both patient andclinician. Simple keratinous or e pidermal inclusion cy sts and fat necrosis are two such entities that are o ften seen in aspirate specimens in thisclinical setting. Keratinous cysts generally yield benign and anucleated squamous cells admixed with debris and variable numbers of acuteinflammatory cells (Fig. 7 ). Aspiration of fat necrosis, which may appear c linically suspicious, y ields only histiocy tes and granular debris,sometimes admixe d with fragments of mature adipose tissue. Identification of the diagnostic features o f either of these entities allowsconservative management and simple observation.

Lymph nodes

The FNA of lymph nodes, regardless of their location, is generally performed to determine whether their enlargement is because of (1) a benign,reactive process that c an be treated co nservatively; (2) a neoplastic hematopoietic process (lymphoma) that may require ex cisional biopsy forfurther subclassification and subsequent treatment; or (3) a neoplastic nonhematopoietic process (e.g., metastatic carcinoma, melanoma,sarcoma) that may require an extensive workup to identify a potential primary site. Both palpable and deep-seated lymph nodes may harbor any

of these processes, and FNA represents a cost-effective approach to their diagnostic evaluation. 56 , 57 , 58

Benign, reactive conditions generally yield cellular specimens composed of a dyscohesive (i.e., single cell) mixed population of lymphoid cells.Lymphocytes in a number of different states of activation are present, including small mature lymphocytes, large activated cells, immunoblasts,

and plasma cells, resulting in the classic polymorphous population of lymphocytes indicative of a reactive condition (Fig. 8A). 59 Histiocytes may

also be present, often with ingested intracytoplasmic cellular debris (tingible body macrophages) and also suggest a reactive process. Incontrast, aspirates of lymphoma yield a dyscohesive population of lymphoid cells in an abnormal distribution, with one subpopulation indominance, resulting in the classic monotono us population ty pical of malignant lympho ma (Fig. 8B). Such a monot onous population of small,

intermediate, or large lymphoid cells without the accompanying cell types just described is highly suggestive of lymphoma. 59 Material from aFNA may be submitted for immunophenotyping by flow cy tometry, in the hopes of objectively showing a monoty pic cell population, consistent with malignancy . A ltho ugh s urg ical b iop sy may be req uired fo r fur the r subc lassi fica tio n of so me t y pes of ly mphoma, FNA with flow c y tomet ry

may be used for diagnosing and subclassifying cases of primary and rec urrent non-Hodgkin lymphoma. 60 , 61 , 62 , 63 Such an approach isparticularly appropriate for deep-seated masses in which open biopsy is technically difficult and perhaps even contraindicated in debilitatedpatients.

Metastatic neoplasms are generally easily reco gnized in aspirates of enlarged lymph nodes. A foreign population of nonlymphoid ce lls is usually obvious, often with an admixture of lymphoid cells in the background. Metastatic carcinoma is by far the most common entity encountered and y ield s bo th single tumor ce lls and cohesive tis sue fragm ents of v ario us sizes. Nuclear and a rc hitec tur al aty pia, as de scribed e arlier, sho uld b epresent and may be pro found in poorly differentiated malignancies (Fig. 6C). The distinction between squamo us cell carc inoma andadenocarcinoma can often be made via cytologic preparations, particularly in well-differentiated tumors. Cells of squamous carcinoma generally possess homogeneo us, dense cy toplasm with distinct cell boundaries and occ asional intercellular bridges. In addition, streaming or spindling of tumor ce lls is often seen in squamous lesions. Finally, keratin pearls may also be seen in some cases and are diagnostic of squamousdifferentiation. Cells of adenocarcinoma, in contrast, typically display granular or vacuolated cytoplasm, sometimes with intracytoplasmic mucin
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Fig. 9. ( A ) Fine-needle aspiration of enlarged inguinal lymph node in patient with history of endometrial adenocarc inoma shows sync yt ial fragment of malignant epithelium with vesic ular nuc lei and pr ominent nuc leo li, c ons iste nt wit h me tast atic ade noc arc inoma(stain ,Papanicolaou), morpholo gically similar to ( B ) histologic section of previously resected primary tumor of endometrium (stain, hematoxylin-eosin).

secretions. Cell boundaries are generally indistinct, resulting in tissue fragments with a syncy tial appearance (Fig. 9A), and glandular structures with dist inc t lum en forma tio n may be see n in so me t issue frag ments. It s hould b e no ted , ho wev er, tha t a signific ant perce ntag e o f cases do no tshow definitive features of either squamous o r glandular differentiation, resulting in a diagnosis of simply poorly differentiated carc inoma.

Other metastatic neoplasms (e.g., melanoma, sarcoma) are less frequently enco untered in lymph node aspirates. A lthough special stains (i.e.,immunocytochemistry) may be helpful in this setting, clinical history is often most useful in these less common cases.

Two sites in which lymphadenopathy must be evaluated in patients with a history of gynecologic malignancy are the inguinal and supraclavicularareas. Palpable lymph nodes are present in the inguinal region of most persons and simply re present chro nically stimulated nodes with a variabledegree of fibrosis and fatty replacement. In the presence of a history of malignancy, however, the possibility of metastatic disease must be

excluded for any mass larger than the typical shotty node; FNA is perfectly suited to suc h a clinical setting (Fig. 9). 64

Enlarged supraclavicular lymph nodes should always be viewed with high clinical suspicion, particularly in the oncologic patient population. FNA

in this location is easily performed and can reliably establish the presence of metastatic disease. 65 , 66 , 67 , 68

Deep-seated lymph node s aspirated under radiologic guidance in the gy necologic patient population include those in the pelvis and

retroperitoneum. Although ultrasonography 69 , 70 and lymphangiography 71 , 72 have b een used to guide aspirates of these lesions, CT guidance has

beco me increa singly popular bec ause of a numb er o f adv anta ges . 73 These include a high degree of accuracy in detecting pathologic changes in

these nodal groups (often superior to lymphangiography) 74 and the ability to detect heterogenous tissue densities in pathologic nodes; suchinformation allows selective sampling of viable, potentially malignant tissue rather than necrotic de bris.

Ovary

The volume of gynecologic, cytopathologic, and radiologic literature on the subject of needle aspiration of the ovary has markedly increased overthe past two decades. Despite the expanding literature and increasing use of the technique, the role o f aspiration of the ov aries is stillcontroversial, with some authors suggesting that aspiration biopsy of the ovary (except for the purpose of oocyte retrieval) is potentially

dangerous and should not be regarded as a routinely acceptable clinical practice. 75 The arguments against the use of FNA include the po ssiblespillage of malignant cells into the abdo minal cavity , leading to the po tential dissemination of tumor, as well as misdiagnosis related to sampling

errors. 76 Having noted this opinion, it is important to po int out that some of the literature also indicates t hat the use of needle aspiration o f the

ovary is valuable, safe, and even the standard of care in certain clinical settings, notably in young women who wish to preserve their ovarianfunction. 77

The technique of FNA is increasingly being used by gynec ologists because o f its valuable diagnostic capabilities, its lack of significant morbidity for the patient, its simplicity of performance, and its diagnostic rapidity in co mparison with conv entional surgical exc ision and processing in

pathology laboratories. 9, 78 Aspiration of the ovary can be performed through a transvaginal or transrectal approach with a sheathed needleguide (e.g., Franzen needle guide; see Fig. 1B). In addition, radiologically (ty pically ultraso nographically) guided transabdominal aspiration is

possible, as is direct aspiration through either laparotomy or laparoscopy. 9, 78

Most ov arian mass lesions in premenopausal women are self-limited functional cy sts. 76 Aspiration of such cystic lesions generally yields

cytologically accurate diagnoses and reassurance of the patient while avoiding unnecessary surgery. 79 , 80 , 81 , 82 Transvaginal sonographicexamination of ov arian masses has led to scoring systems that are useful for evaluating adnexal lesions before aspiration or surgic al exc ision.These scoring systems use parameters such as cystic versus solid nature, smooth-walled versus papillated cyst lining, cyst wall thickness,

presence o f septations, and echogenicity . These systems can be a useful starting point in patient treatment and reportedly facilitate the distinction be tween b enign les ions (widely acce pte d as aspir able) and their malignant ov aria n counterparts with a spe ci fici ty of 83 % and a se nsit iv ity of

100%. 83 , 84 FNA can also be used in young women during laparotomy when only one ovary is tumor bearing and bilateral oophorectomy is

unplanned. Aspiration of the contralateral ovary may avoid an unnecessary resection and help reassure both the surgeon and patient. 77

Pregnant women constitute a special group of premenopausal patients in whom cy stic ov arian lesions are often noted. As with adnexal lesions inthe general population, ov arian masses in pregnant women are usually simple (unilocular-to-trilocular) cy sts measuring 5 cm or less in diameter.These cysts are usually functional and resolve spontaneously. The number of pregnant women reported in the literature who have undergone

aspiration biopsy of the ovary is small; however, most cytologically studied cases are reported as benign cystic masses. 85 , 86 Pregnant patientsshould be selected carefully for FNA. Those with a history of pelvic surgery or pelvic inflammatory disease may be unsuitable candidates for FNA because of fib rosis, whic h c an pr oduc e a hy poce llula r, no ndiagno stic spe cim en. As pira tio n is su ggeste d whe n a dia gno stic pro ce dur e is indic ate d

and radiologic studies favor a benign process. Ovarian FNA of a gravid patient should be performed only by an experienced operator. 85
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Women pre sent ing fo r in vitro fertilization (IVF) constitute another subset of young women frequently noted to have ovarian lesions.Transvaginal ultrasound is routinely performed in the course o f egg retrieval in these patients, and lesions are generally noted at that time. Therecent literature confirms that the nature of ovarian cysts in IVF patients can be determined in many cases by the cytologic features of the

cysts. 87 , 88 Aspirated material may even help in defining an unsuspected cause o f infertility, suc h as endometriosis. 87 FNA cytology o f ovariancy sts in IVF patients can also play a role in the detec tion of occ ult ovar ian neoplasms, although detection of malignancies in this group of patientsis rare. Until the exact incidence of ovarian carc inoma in this subset of patients is known, it would seem prudent to c ontinue to ex amine all cyst

fluids obtained by needle aspiration. 87 , 88

FNA may be indicated in older patient cohor ts as well. For example, the use of aspiration biopsy is generally acc epted (if not indicated) in that

subset of patients with previously documented ovarian malignancy in whom there is a suspicion of local recurrence. 89 , 90 When a previo us

diagnosis of malignancy is known, the minimally invasive te chnique of aspiration can be of great v alue in documenting disease spread and

recurrence, with a specificity of up to 100% and a sensitivity of 96% in one large review. 90

Al tho ugh not genera lly reco mme nded, the u se o f aspir atio n bio psy for the primary diagnos is and classific atio n of o varia n ca rc inoma is ac curat e.For most nonfollicular cystic lesions, the specificity is reported at greater than 90%, especially if strict criteria for specimen adequacy are used

and on-site assessment of the specimen is made during aspiration by a c yto pathologist. 14 , 91 , 92 Because ov arian cancer rarely producescharacteristic symptoms or signs in the early stages, many affected patients present with advanced disease, even carcinomatosis. In cases of diffuse abdominal involv ement, FNA may be a useful first-line approach to diagnosis, as the potential for dissemination of disease associated withspillage at the time of aspiration is of much less clinical import.

Early detection of ovarian malignancies markedly improves patient outcomes, with 5-year survival rates for patients with stage I disease

approaching 80 85%. 93 , 94 Therefore, early detection of ovarian cancer, especially in young women with strong family histories, is highly desirable. To benefit this patient group, protocols designed to screen for ovarian cancer, based on routine transvaginal sonography

complemented by FNA cy tology of ovarian masses, are currently under consideration. 77 Only when significant numbers of early canc ers are

detected will the debate be resolved regarding efficacy, safety, and risk-to-benefit ratio of ovarian cyst aspiration. 93 Having discussed theindications for FNA of the ovary, let us turn to the characteristic cytodiagnostic findings and clinicopathologic correlates associated with themost frequently encountered primary ovarian lesions.

The classification of ovarian tumors is primarily morphologic but is intended to reflect the current concepts of the embryogenesis of this complexorgan. It is based on the premise that the female gonad is compo sed of four major tissue derivativ es, all of which are c apable of giving rise to

neoplasms: (1) surface, c elomic, or germinal epithelium; (2) germ cells; (3) supporting sex c ords; and (4) specialized ov arian stroma. 95

Nonneoplastic ovarian lesions

Ap pro pria te p atie nt tr eat ment re qui res tha t all fo ur abo ve-me ntio ned neo plas tic pro ce sses be rec ognized ; how ev er, the majo rity of o varia nlesions (especially in the pre menopausal population) represent nonneoplastic changes in the or gan. The following is a discussion of a number o f benign (o ften p hy sio logic or func tio nal) o varia n mass les ions.

SIMPLE CYSTI C LESIONS

Simple ovarian, paraovarian, serous, epithelial inclusion, paramesonephric, and paratubal cysts as well as hydrosalpinx are cytologically

charact erized by a smear c ontaining only a few epithelial cells in a clear fluid background. 77 , 96 These entities are often cytologically

indistinguishable from one another. 29 The cells are generally cuboidal to low columnar and on occasion may possess cilia. 9, 77 , 96 , 97 The presenceof ciliated bodies in the fluids of ovarian cysts indicates the existence of ciliated columnar epithelial cells on the wall of the cysts, which excludes

the differential diagnosis of cy sts of follicular origin. 98 Cilia may also be no ted in aspirates from malignant ovarian tumors and therefore are no t

pathognomonic of a benign process. 98 , 99 The cellularity may be exceedingly sparse and degenerated with only a few macrophages, consistent with the cy stic natu re o f these le sions. Hem ato salp inx may pre sent as a s imple parao varia n cy st, and aspir ate d cont ents may co ntainpleomorphic epithelial cells with degenerated erythrocytes and cellular debris, raising the possibility of a false-positive diagnosis of

malignancy. 91

FUNCTIONAL CY STIC LESIONS (FOLLICULA R AND CORPUS LUTEUM CYSTS)

Physiologic (functional) cy sts of the ovaries usually appear benign (i.e., thin-walled, unilocular, and not mo re than 5 cm in diameter) on

ultrasound examination; however, they may mimic malignant tumors. 77 Aspirates generally contain follicular cells, typically granulosa cells,arranged both singly and as tightly cohesive fragments (Fig. 10). These cells house ovoid nuclei with granular chromatin and occasional nuclear

grooves, and they have a small rim of distinct cytoplasm; mitoses may be present. 100 The background of the smear typically shows clear,

proteinaceous material but may be bloody . 77 Cyst fluid from functional cysts of folliculogenesis typically have a high estrogen content. Mulvany

and colleagues 101 reported a sensitivity of 84% for the detection of follicular cysts by estrogen assay. As a follicular cyst undergoes luteinization,

cytomorphologically altered granulosa cells appear with prominent nucleoli and more ample granular cytoplasm. 100 Cytoplasmic hyaline

droplets may be seen in the corpus luteum of pregnancy. 82 On occasion, fluid aspirated from functional cy sts may be highly cellular, with cells

featuring high nuclear-to-cytoplasmic ratios and hyperchromasia; papillary clusters and even small glandular structures may be noted. 102 , 103

Clinical and radiologic impressions, as well as the presence of well-preserved granulosa cells in the smears, are helpful for reac hing the correc t
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Fig. 10. A. Fluid aspirated from a unilocular ov arian cy st in a young woman shows small,cohe sive aggregates of benign lining cells from the inner granulosa cell laye r of afunctional (follicle) cy st; the cells are intermediate in size with round, vesic ular nucleiand scant cy toplasm (stain, Papanicolaou; c ourtesy of Bradford Tan, MD). B.Corresponding histologic section of a follicular cyst shows orderly layering of

granulosa/theca c ells in the cyst wall with bland nuclear features, similar to that seen in the aspirated fluid (stain, hematoxy lin-

eosin).

Fig. 11 . A. Fluid aspirated from a cystic ovarian mass contains cohesive fragments of epithelial cells with small, basally located nuclei without atypia and abundant vacuolatedcy toplasm; cy tologically, they resemble endocerv ical cells and are compatible with amucinous neoplasm (stain, Papanicolaou). B. Corresponding histologic section shows asingle, undulating layer of well-organized, endocerv ical-type glandular epithelium,

consistent with mucinous cystadenoma (stain, hematoxylin-eosin).

diagnosis. 103 The granulosa cells lining follicular cysts are immunohistochemically negative for cytokeratins, whereas those epithelial neoplasms

considered in the differential diagnosis would be immunoreactiv e with antibodies directed against cy tokeratins. 102

ENDOMETRIOTIC LESIONS

Symptomatic lesions associated with active endometriosis are composed of both cystic and solid regions and often yield a thick, chocolate-

colo red fluid on aspiration. 9 Endometriosis primarily affects women of repro ductiv e age, and if it is identified by FNA, the need for a diagnostic

surgical procedure is eliminated. 104 The cellularity in aspirations of endometriosis is typically scant. The examiner should attempt to find allthree co mponents of the classic diagnostic triad, which includes endometr ial glandular cells, endometrial stromal ce lls, and hemosiderin-laden

macrophages. 9 Fresh blood may also be a prominent feature. 100 The glandular cells are small, with scanty cytoplasm, round-to-ovoid nuclei,finely granular chromatin, and oc casional chro mocenter s. When present in intact tissue fragments, glandular cells are well organized, indicating

their benign nature. Stromal cells may appear as naked, isolated nuclei. 77 Generally, the presenc e of at least two o f the three c lassic findings issufficient for the diagnosis of endometriosis in the appropriate clinical setting. Finally, it should be no ted that endometriotic nodules may

undergo malignant change and should be evaluated for such transformation.

Neoplastic Ovarian Lesions

Neoplastic ov arian tumors are grouped by the World Health Organization classification (1995 ) into surface epithelial-stromal tumors, sex cord-stromal tumors, germ cell tumors, tumors of uncertain histogenesis, soft tissue tumors not specific to the ovary, and secondary (metastatic)

processes. 95

SURFACE EPITHELIAL-STROMAL NEOPLASMS

The epithelial group of ovarian neoplasms includes benign, borderline, and malignant subsets of serous, mucinous, endome trioid, clear c ell, andtransitional (Brenner) tumors as well as squamous c ell lesions, tumors of mixe d epithelial derivation, and undifferentiated epithelial lesions thatlack the characte ristic findings of the more specific cate gories.

Serous fluid aspirated from cy stic serous neoplasms generally displays a granular, eosinophilic background with low ce llularity in benign and

well -differ ent iate d lesions. 77 The epithelial cells are small and tightly packed, and they have a high nuclear-to-cytoplasmic ratio (sometimesresembling reactive mesothelial cells). Spindled stromal cells may be noted if the tumor has a connective tissue component (e.g.,

cystadenofibroma). 9, 77 Histiocy tes may also b e a prominent compo nent in benign and well-differentiated tumors.

Low-grade carcinomas and bor derline tumors are indistinguishable on cyto logy . FNA of malignant serous tumors y ields thick, turbid fluid with

increased cellularity , including single cells. 9 Papillary structures and psammoma bodies may occur. 82 Cellular pleomorphism, c oarsening of the

chromatin pattern, and prominent nucleo li are all markers of malignancy . 82 The differential diagnosis of ov arian serous malignancies includes

reactive mesothelial cells (which may be papillary), endometrioid carcinoma, and metastatic processes. 9 Ancillary studies such as DNA ploidy analysis (highly malignant ovarian tumors likely to be nondiploid) and CA1 25 measureme nt (markedly elevated in most sero us malignancies),

may prov e helpful. 105 , 106 , 107

Epithelial cells from mucinous tumors generally resemble endoc ervic al cells (Fig. 11), particularly in benign and low-grade neoplasms. Benign

cases are characterized by small, regular fragments of uniform columnar cells with bland, basally located nuclei and vacuolated cytoplasm. 82

Desquamated epithelial cells may resemble foamy macrophages. 77 Keratin immunohistochemical studies and cytochemical stains for mucin may be u sefu l in dis tinguish ing epithel ial c ells from mac rophages .

FNA material from malignant mucinous lesions (borderline lesions as well as cystadenoc arcinomas) is often highly visco us and mucoid. Single
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cells, irregular groupings of cells, and syncy tial fragments of epithelium with cellular atypia are noted in malignant mucinous tumors. 82 Elevatedcarcinoembryonic antigen (CEA) and CA125 levels are appreciated in the cyst fluid aspirated from primary mucinous cystadenomas and

cystadenocarcinomas. 106 , 107 Multinucleated tumor cells may be noted, and the degree of cellular atypia tends to increase as the lesion becomes

more poorly differentiated. 82

Benign and borderline endometrioid tumor s are uncommo n. Most lesions in this category are carc inomas. Such lesions can be distinguished fromtheir serous co unterparts by their more abundant, granular, eosinophilic cy toplasm as well as focal areas of squamoid differentiation, which are

not seen in serous lesions. 77 , 82

As with endometr iod lesions , mo st pr imar y clear ce ll tumors o f the o vary are frankly malignant . Cyto logically , they resemble cle ar c ell t umo rs

arising in the vagina, cervix, or endometrium. 77 Generally, the cells of clear cell adenocarcinoma have abundant, pale, vacuolated (glycogenated)

cytoplasm with indistinct cell borders and pleomorphic nuclei. 9 The differential diagnosis includes metastatic renal cell c arcinoma and y olk sac

tumor. 9, 77

FNA of benign Brenner tumors shows co hesive fragments and sheets of uniform ce lls with oval nuclei and moderate, eo sinophilic cy toplasm. Deep

nuclear grooves and small prominent nucleoli may be noted; stromal elements may also be apparent. 9, 77 , 82

Malignant Brenner tumors of the ovary are difficult to categorize cytologically and may be confused with metastatic transitional cell carcinoma ornonkeratinizing squamous cell carc inoma. These cells are often arranged in papillary gro ups and exhibit dense basophilic c yto plasm and coarsely

granular chromatin. 77 Many binucleate and multinucleate forms and mitotic figures may also be se en. 108

SEX CORD-STROMAL NEOPLASMS

This broad category of primary ovarian lesions includes thecoma-fibroma, granulosa-stromal cell tumors, Sertoli-Leydig cell lesions,androblastoma, sex cord tumors with annular tubules, and gynandroblastomas.

Thecoma-fibroma aspirates are extremely hypocellular and may be interpreted as nondiagnostic. 77 Aspirated tumor cells are ovoid with

elongated, hyperchromatic nuclei and scanty, ill-defined cytoplasm. 77

As pira tes of gr anulosa cell t umo rs ar e usually high ly ce llula r, with r elat iv ely smal l tum or ce lls ar rang ed b oth singly and in aggreg ate s of a fe w to

several hundred cells. 109 The nuclei are round to ovoid, single, and centrally located, and they may have marked membrane indentations

appearing as longitudinal groov es. 109 Rosette-like structur es with central, dense, eo sinophilic material (Call-Exner b odies) may be found and are

very useful in su ppo rting th e dia gno sis. 77 In the absence of such bo dies and in cases with frequent mitoses, the differential diagnosis of small cellcarcinoma (either primary or metastatic) must be ruled out.

Sertoli-Leydig cell tumors y ield fragments of uniform, round cells with moderate amounts of cy toplasm on aspiration. 82 These cells may be

arranged in cords, acini, or trabe culae, and a few bare nuclei of stromal origin may be note d. 77

Sex co rd-stromal tumor with anular tubules is a rare primary lesion, at times seen in association with Peutz-Jeghers sy ndrome. Smears from suchlesions have been repo rted as cellular; both single cells and cohesiv e fragments of neoplastic cells arranged in follicular, solid, and trabecular

patterns. 110 In classic cases, homogenous, eosinophilic, hyaline bodies surrounded by palisading nuclei are very helpful at suggesting the

appropriate diagnosis. 77

GERM CELL NEOPLASMS

Mature cystic teratomas are the most common germ cell tumors of the ovary. Other entities in this category include dysgerminoma, yolk sac

tumor, embryonal carcinoma, choriocarcinoma, and polyembryo ma. 77 , 95 It is not uncommo n for lesions in the germ cell group to present withmixed mor phologies. Malignant germ cell tumors acco unt for less than 5% of all ovarian cance rs, and such lesions are most often encountered in

y oung females (y ounger than 20 y ear s of age). 111 In this age group, the tumor may be treated in such a way that reproductive function is

preserved. 111

As pira tes of ma tur e c y stic ter ato mas show num ero us su per ficial and anuc lea ted squamo us c ells ; ci liated and c olu mnar epit hel ial c ells may also

be o bse rv ed. 77 Amor phous material (amphophilic, extrac ellular sebaceous sec retions) is a frequent finding in the background of smears from

benign terato mas, and it may elic it a fo reign body gian t c ell r eac tio n. 77 More important, transvaginal collection of any ovarian aspirate may yieldmany c ontaminating squamous cells. This finding alone should not be misinterpreted as suggestive of ov arian teratoma. Immature terato mas arepredominantly c omprised of neuroglial elements; the presence of a frankly malignant neuroglial component in a smear favors c lassification as a

malignant neoplasm. 77 Cells normally present in cerebrospinal fluid cytology, such as ependymal and choroidal cells, may be noted in ovarian

aspirates. 112 , 113 When such cells are present in materials obtained from the ovary, malignant neuroectodermal tumors must be considered.

Ovarian carcinoids may be primary to the ovary , a co mponent of ov arian teratomas, or metastatic. 77 Such tumors yield cells with an oval-to-spindled configuration and moderate cy toplasm. The classic salt and pepper chro matin pattern is most useful in diagnosis.

Smears from dysgerminoma are characteristically hypercellular and composed of large tumor cells with prominent nucleoli admixed with a
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Fig. 12. A. Cytologic preparation of material obtained from a large ovarian mass in a y oung wo man s hows a b ipha sic ce ll po pula tio n compris ed o f large tu mor c ells ( solid arrow ) admixed with small lymphocy tes ( open arrow ) consistent with dysgerminoma(stain, Diff-Quik). Many of the tumo r ce lls are stripped o f their cy toplasm and c ontainprominent nucleoli on Papanicolaou stain. B. Corresponding histologic section displays

the characteristic fried-egg appearance of dysgerminoma (stain, hematoxylin-eosin).

separate population of lympho id cells (Fig. 12). 77 , 114 The background is classically described as t igroid and is best apprec iated in air-dried, Diff-

Quick-stained smears. 114

Y olk sac tumors are als o c harac ter istic ally hy per ce llula r on asp irat ion and a re c omposed of mo der ate ly sized ov al c ells , disper sed bo th as sing le

elements and in fragments. Vacuolated cytoplasm and both intracellular and extracellular hyaline globules are noted. 114 The serum alpha-

fetoprotein is ty pically elevated. 77

Embryonal carcinoma of the ovary is very rare, and aspirates of such lesions are hypercellular, often showing hemorrhage and necrosis. Tumorcells are bizarre with a high nucleus-to-cyt oplasm ratio. The differential diagnosis is usually poo rly differentiated adenocarc inoma.

Immunohistochemical studies may show positivity for chorionic gonadotropin in syncytiotrophoblastic-like cells. 95 Embryonal tumors largely

composed of embryoid bodies are referred to as polyembry omas. 95

Most choriocarcinomas of the ovary represent metastases from uterine primaries. Therefore, thorough evaluation of the uterine corpus is

indicated when a diagnosis of ovarian choriocarcinoma is considered. 95 Microscopically, an admixture of sy ncytial and cy totrophoblasticelements in a necrotic and hemorrhagic background is typical of this lesion. Immunohistochemical reactivity for human chorionic gonadotropin

is the rule. 95

OTHER NEOPLASMS

Primary ovarian tumors of uncertain histogenesis include small cell carcinoma and oncocytoma, among others. 95 In two thirds of cases, primary

ovarian small cell tumors produce paraendocrine hypercalcemia. 115 In ovarian small cell carcinoma, an intermediate-sized, round-to-oval cell

population with scanty cytoplasm and coarse granular chromatin may predominate. 115

Processes known to secondarily involve the ovary include metastatic carcinomas (from breast, colon, stomach, pancreas, and gallbladder),

malignant lympho mas, and myeloid leukemias. 77 , 116 , 117 Cases of metastasis to an ovary that already contains a primary ovarian neoplasm have

been repo rte d in the li ter ature. 118 Such cases of double cancers are exceedingly rare, but they show the need for careful review of obviously diagnostic aspirates to not overlook cellular populations whose recognition may dramatically alter patient treatment.

Thus, despite reported controversial views on the role of ovarian needle aspiration, the technique has been accepted by many as a relatively

innocuous proc edure that can be ac complished with minimal complications and risks for the patient. 77 Without question, the procedure of aspiration with cytodiagnosis can be used to preserve ovarian hormonal and reproductive function. If definitive surgical treatment becomesindicated based on information gleaned from aspirated material, the surgeon and patient may plan appropriately for expected outcomes.

Pelvis

Fine needle aspiration of both palpable and nonpalpable pelv ic masses may be readily performed in the initial evaluation and follow-up of patients with gy nec olo gic malignanc ies. Altho ugh t he is sue of th e dia gno stic rel iab ility of FNA in pr imar y ov aria n masses is the subje ct of so me d eba te, asdiscussed previously, the utility of FNA for the evaluation of nonovarian primary tumors and potential recurrent gynecologic tumors isunquestioned. Masses noted during pelvic ex amination may be aspirated v ia either a transvaginal or transrectal approac h, often with the aid of aFranzen needle guide. Lesions located above the pelvic brim and those deep within the posterior pelvis require radiologic guidance for accurateplacement of the biopsy needle. Ultrasound guidance may be sufficient for a number of these cases, although CT guidance is preferred for those

lesions deep to bowel or bone. 73

Numerous series with histologic or long-term c linical follow-up have c onfirmed the extremely high specificity (99%) of the technique for pelvic

lesions. 15 , 17 , 119 , 120 , 121 As with FNA in other anatomic regions, the sensitivity of the procedure is slightly lower (8595%) because of occasional

false-negative results. 15 , 17 , 119 , 120 Such occurrences are generally ascribed to either technical difficulties (e.g., inexperienced aspirator) or, morefrequently, to intrinsic properties of the lesion (e.g., significant fibrosis). Thus, a negative FNA result in the presence of suspicious clinical findings warrant s furt her ev alua tio n to ex clude malig nanc y .

FNA is also valuable in the surveillance of patients with a history o f malignancy after therapy . In a series of patients who underwent FNA bio psy for evaluation of pelvic masses (parametrial, pelvic sidewall) noted on pelvic ex amination or imaging studies after primary therapy (including

radiation therapy and hysterectomy) for cervical carcinoma, 22 of 30 patients had a positive aspirate. 122 The utility of FNA biopsy in patient
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follow-up after radiation therapy alone was shown in another study of 58 patients with cervical or endometrial carcinoma. 17 Approximately 40%of the patients were prov ed to have re sidual or recurrent disease on aspiration biopsy, with a 7 % false-negative rate. More important, one third of the patients with a positive FNA had an equivocal or negative pelvic examination and imaging study results before the biopsy. Thus, FNA is anextre mely useful tool that may be v aluable in the often-difficult distinction between postradiation fibrosis and recurrent tumo r.

As with all sp ec imens, p roper co mmunic atio n with the inte rpr eting pa tho logist i s c ruc ial fo r asp ira tes from this site . In additio n to the mass inquestion, a large number of normal structures may be concurrently sampled depending on the needle approach and direction, including bladder,ureter, and colon. A history of radiation or chemotherapy or both must also be relayed to the pathologist, perhaps avoiding a falsely suspiciousor positive diagnosis based on marked therapy changes.

Endometrium

True fine needle aspirates of endometrial lesions are rarely performed. Biopsy is the standard of care for endo metrial lesions. If present,intracavitary fluid can be collected and sent for cytologic evaluation. Abnormal cells in routine cervical-endocervical smears can at times also be s uffic ient for a diagno sis o f malig nanc y .

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17 Sevin B-U, Nadji M, Greening SE et al: Fine-needle-aspiration cyto logy in gy necologic onco logy: Early detec tion of occ ult persistent, or recurr entcancer after radiation therapy. Gynecol Oncol 9: 351, 1980

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Fine Needle Aspiration of Germ Cell Tumors of Ovary.

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