FNA is the ideal tool to study and analyze tumor heterogeneity at metastatic sites

In routine practice, suspected metastases in patients with cancer are only occasionally biopsied, primarily because of the cost and invasiveness of the procedure. However, biopsies of metastatic lesions can be valuable, not only in confirming the presence of metastatic disease, but also in revealing unsuspected benign disease or secondary malignancies. In addition, such biopsies also allow the assessment of biomarkers that might differ from those on primary tumor cells, and can thereby facilitate selection of the optimal treatment. Because of the increasing recognition of clonal and phenotypic heterogeneity of tumors, we anticipate that in the near future, biopsying of metastatic lesions will constitute a standard-of-care practice, allowing assessment of molecular differences between the primary tumor and metastatic lesions. In our opinion, fine-needle aspiration is currently the best method for making repeated biopsies to monitor the tumor: it is minimally invasive, safe, and cost effective and can be coupled with modern ancillary techniques. Here we provide an up-to-date review of the clinical implications of tumor heterogeneity in metastatic disease and the ancillary molecular techniques used in cytology; we also discuss the role of modern cytology in contemporary diagnosis and management of metastatic cancer.

Beca F, Schmitt F. Growing indication for FNA to study and analyze tumor heterogeneity at metastatic sites. Cancer Cytopathol. 2014 Jan 29.

Ultrasound guided FNA: The new challenges and opportunities for cytopathologists

Numero monografico di Diagnostic Cytopathology dedicato alla categoria degli Interventional Pathologists (vedi post del 24 febbraio 2013). Perchè il patologo non è solo quello che campiona un reperto macroscopico e che legge i preparati al microscopio, ma è sempre più un professionista completo che fa in prima persona il prelievo, visita il paziente e discute la strategie diagnostiche e terapeutiche più appropriate con i colleghi. 

Masood S. Ultrasound guided fine needle aspiration biopsy: The new challenges and opportunities for cytopathologists. Diagn Cytopathol. 2013 Dec;41(12):1017-8.

Looking too closely at thyroid nodules

Endocrinologi e patologi sono certamente co-responsabili dell' incrementata incidenza dei tumori della tiroide. Troppi noduli vengono inviati all' agoaspirato, troppi pazienti subiscono un intervento chirugico e troppe neoplasie a differente comportamento biologico e clinico vengono riunite sotto la stessa terminologia. Un corretto studio clinico può certamente evitare inutili FNA che, talora, vengono utilizzati dai clinici anche in funzione "difensiva". Così come può essere limitata l' indicazione all' intervento chirurgico, applicando agli aspirati i criteri classificativi correnti. Ad esempio, la maggior parte delle citologie "atipiche" (AUS/FLUS) può essere risolta con la semplice ripetizione dell' aspirato (con un risultato il più delle volte di benignità). Diverso il discorso per le lesioni follicolari. Considerata l' incidenza piuttosto bassa del carcinoma follicolare siamo costretti, a causa dei limiti dell' FNA, a mandare consapevolmente molti adenomi follicolari all' intervento chirurgico. Le tecniche di biologia molecolare basate sui profili di espressione genica, aumentano il valore predittivo negativo dell' aspirato "indeterminato", ma non riescono a discriminare (ancora) meglio della morfologia le lesioni effettivamente maligne. Inoltre, sono costose e attualmente non applicabili alla routine clinica. Infine, carcinomi indolenti vengono ancora classificati insieme a quelli a comportamento aggressivo, i cosiddetti "real thyroid carcinomas". Molti carcinomi papillari, come è noto, hanno un comportamento "benigno", come testimoniano i numerosi incidentalomi scoperti nelle sezioni seriate di gozzi nodulari o nelle autopsie di pazienti deceduti per altre cause. Sforzi di correlazione clinica, morfologica e molecolare devono essere fatti per separare i tumori a basso potenziale dai veri carcinomi tiroidei, in modo da ottimizzare efficacemente il managment dei pazienti con patologia nodulare tiroidea.

Bibliografia.

Brito JP, Morris JC, Montori VM. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. BMJ. 2013 Aug 27;347:f4706.

Renshaw AA. How closely do thyroid fine-needle aspirates need to be screened? Diagn Cytopathol. 2002 Nov;27(5):259-60

Alexander EK. et al, Preoperative diagnosis of benign thyroid nodules with indeterminate cytology. N Engl J Med. 2012 Aug 23;367(8):705-15. Epub 2012 Jun 25.

Faquin WC. Can a gene-expression classifier with high negative predictive value solve the indeterminate thyroid fine-needle aspiration dilemma? Cancer Cytopathol. 2013 Mar;121(3):116-9.

Baloch Z, Livolsi VA, Tondon R. Aggressive variants of follicular cell derived thyroid carcinoma; the so called 'Real Thyroid Carcinomas'. J Clin Pathol. 2013 Sep;66(9):733-43.

Talking to patients about a diagnosis of malignancy in a FNA clinic setting

Informing patients of a cancer diagnosis is never easy and requires skills not systematically taught in US medical schools and residency programs. The absence of a universally accepted best method for delivering bad news presents an additional challenge. In specialties like pathology, practitioners typically have little patient contact. Training programs, including Cytopathology fellowships, in which patient encounters are routine during fine-needle aspiration (FNA) procedures, offer minimal education on this topic. Formal teaching in this area is lacking, even in medical fields where physicians frequently must present bad news to patients, such as palliative care and oncology.Without adequate training, delivering bad news to patients is made more difficult for physicians in all fields, and the FNA pathologist in particular may be reluctant to participate in patient care beyond obtaining the FNA sample. [...]

Pathologists are integral members of the clinical team, and cytopathologists in particular need to develop communication skills for discussing disease with patients. Deciding whether and how much to tell a patient about the FNA diagnosis is subject to personal judgment and the unique interaction between a patient and pathologist.

Ly, A. (2013), Talking to patients about a diagnosis of malignancy in a fine-needle aspiration clinic setting. Cancer Cytopathology, 121: 339–340. 

A brief chronicle of clinical cytology

Posto un breve excursus sulla storia della citologia clinica apparso recentemente su Diagnostic Cytopathology. Per chi volesse approfondire l' argomento, consiglio l' ottimo libro di Grunze e Spriggs corredato da uno splendido apparato iconografico.

Hampeln, in 1887, published the first case of primary squamous cell carcinoma of the lung and pleura with an illustration of a drawing of cancer cells

(Hampeln P. Über einen Fall von primären Lungen-Pleura-Carinom. St. Petersburg med Wohenschr 1887; 12: 137.)

Bibliografia.

Diamantis A,et al. A brief chronicle of cytology: From Janssen to Papanicolaou and beyond. Diagn Cytopathol. 2013 Jun;41(6):555-64.

Grunze, H. and A. I. Spriggs (1983). History of clinical cytology: a selection of documents, G-I-T Verlag E. Giebeler.