This editorial accompanies a series of articles related to the recently published WHO reporting volume on lung cytopathology. The articles complement and augment the information provided in the volume and they have been written by experts involved in the original publication.
To evaluate the clinical value of fractional exhaled nitric oxide (FeNO) levels and peripheral blood eosinophil (EOS) counts and percentages in assessing airway eosinophilic inflammation in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).
In total, 119 AECOPD patients were included in the study. Patients were divided based on the percentage of EOS in their sputum into the airway EOS inflammation group (29 patients) and the non-airway EOS inflammation group (90 patients). The diagnostic values of FeNO and peripheral blood EOS for detecting airway EOS inflammation in AECOPD patients were assessed.
The airway EOS inflammation group had higher peripheral blood EOS counts and percentages. FeNO, peripheral blood EOS counts and percentages were significantly correlated with sputum EOS percentages. ROC curve analysis showed that the optimal cut-off values for predicting airway EOS inflammation were 18.5 ppb for FeNO, with sensitivities and specificities of 76% and 61%, respectively; 0.335 × 109/L for peripheral blood EOS count, with sensitivities and specificities of 41% and 98%, respectively; and 3.56% for peripheral blood EOS percentage, with sensitivities and specificities of 59% and 86%, respectively.
FeNO, peripheral blood EOS counts and percentages have a strong correlation with airway EOS inflammation. The levels of FeNO and peripheral blood EOS counts and percentages can effectively predict airway EOS inflammation in AECOPD patients.
This case highlights the importance of early, aggressive surgery for large cell neuroendocrine carcinoma and continuous cytological monitoring in detecting recurrence at the early intraepithelial stage. The pagetoid spread pattern with a biphasic synaptophysin staining differentiated LCNEC from CIN3 and AIS.
Primary cutaneous Rosai-Dorfman disease (RDD) is a rare proliferative disorder of histiocytes involving exclusively skin. The diagnosis of cutaneous RDD relies on clinical, histopathological and immunohistochemical findings. Cytological diagnosis can also be made in the presence of diagnostic features like histiocytic proliferation and prominent emperipolesis. We present two rare cases of primary cutaneous RDD: a 20-year-old male and an 8-year-old male, diagnosed on fine-needle aspiration cytology (FNAC). The first case was multicentric with swellings on the nose and arm, while the second patient had a single swelling on the right pinna. FNAC was reported as cutaneous RDD in both cases, which was later confirmed on histopathology and immunohistochemistry.
The increasing percentage of follicular neoplasms among thyroid nodules submitted to fine-needle aspiration (FNA) cytology raises concerns regarding diagnostic uncertainty and clinical management. This study aims to investigate the factors contributing to this phenomenon, including the influence of the implementation of ultrasound (US) risk stratification systems and of the third edition of the Bethesda system for reporting thyroid cytopathology.
A retrospective cohort of 1255 patients (1470 nodules) diagnosed during the first 9 months of 2023, in a single institution, was analysed.
US classifications are used in 77.8% of the reported nodules, predominantly EU-TIRADS (44.4%) and ACR-TIRADS (32.2%). Bethesda category IV (follicular neoplasm) diagnoses increased from 7.7% to 11.8% after adopting the third edition, although without statistical significance. Notably, 39% of nodules were submitted to FNA without US indication, emphasising the need for improved adherence to guidelines.
The study highlighted the significant increase in follicular neoplasms among nodules with US indication for FNA. The transition from the 2nd to the 3rd edition of the Bethesda system increases the probability of indication for surgery by 1.5-fold, while the US indication for FNA increases the probability of indication for surgery by 1.6-fold, and demonstrated that the nodules with surgical indications (Bethesda categories IV, V, VI) increased from 5.3% in 2021 to 11.4% in 2023. Despite limitations, this work underscores the importance of aligning FNA practices with evidence-based recommendations to optimise patient care and minimise overdiagnosis.
Echinococcosis is one of the zoonotic illnesses. Echinococcus granulosus larvae are the causative agents. Renal hydatid cysts are extremely rare and are typically unilateral. If they evolve slowly, they may not show any symptoms for years. Only 2%–3% of cases of hydatidosis have isolated renal hydatid cysts, making them rare. In this case, the radiological and clinical results suggested only a simple renal cyst, and cytopathology clinched the final diagnosis. A 20 mL turbid cyst fluid sample was sent for cytological analysis. Many scolices with radially arranged hooklets, scattered hooklets, macrophages, foreign body giant cells, and necro-inflammatory cell infiltrate were visible under the microscope.
In this study, the author highlights the cytology features of renal hydatidosis clinically and radiologically, mimicking a simple renal cyst. This case demonstrates the relevance of cytopathological screening in the early detection of unusual illnesses at rare locations.
A study of 24 #renal lesions found #FNA #fluid cytology on laparoscopic deroofing of the left renal cyst. Smears show singly scattered hooklets, intact scolices with radially arranged hooklets in a background of acellular debris and foreign body giant cells. #CytoJ #CytoPath #hydatid cyst #renal cyst #cytology.
The Peer Review (PR) consists of the daily examination, by all cytologists, of Pap slides that resulted abnormal/difficult, in order to reach a consensus on the final diagnosis (FD). We explore data from 5 years (2017–2021) of PR to: (i) evaluate the agreement (both inter-observer and versus FD) over time; (ii) identify new quality indicators.
5673 slides were submitted to PR and examined by an average of 8 cytologists (range: 4–13). The agreement between cytologists and between the individual diagnosis with FD were evaluated by Kappa (k) and weighted Kappa (wK) and compared between ‘experts’ and ‘less experienced’ readers.
The inter-observer agreement showed a moderate agreement among readers (whole team k = 0.44; experts k = 0.48). The highest and the lowest agreement was reported in HSIL and ASC-H, respectively. In 2018 and 2021, a significant reduction of kappa was observed, likely attributable to team turnover. The laboratory agreement versus FD resulted in significantly higher scores in experts (wk = 0.73, 95% CI 0.73–0.74) compared to less experienced individuals (wk = 0.65, 95% CI 0.64–0.66), with a general reduction of wk recorded in 2021. The individual agreement versus FD (calculated for 16 cytologists) achieved a moderate/substantial level of agreement (wK range: 0.57–0.80), with a shift toward higher wk in experts.
The levels of agreement are influenced by cytologist experience and team turnover. We propose new potential (key) performance indicators to strictly monitor the occurrence of systematic differences in interpretation criteria among cytologists. The proposed reference values are based on preliminary data and should be validated prospectively over a longer monitoring period.
Amyloidosis is the extracellular accumulation of amyloid proteins in diverse organs. While ocular and periocular involvement is rare, it can be localised or part of systemic disease. This manifestation can affect various ocular structures, including the eyelids, conjunctiva, lacrimal glands, cornea, vitreous body, extraocular muscles and ocular adnexa, leading to symptoms like ptosis. Here, we report a unique case of systemic amyloidosis presenting as papulonodules on the eyelids, diagnosed through a minimally invasive fine needle aspiration technique (FNAC).
A 43-year-old male presented with red to skin-coloured elevated lesions, primarily around the periocular region, persisting for 2 months. Examination revealed multiple waxy papulonodules predominantly on the eyelids, with some also in the perioral area, forehead, and neck. Additionally, the patient exhibited macroglossia with ulcers. While urine Bence Jones protein tests were negative, the urine protein creatinine ratio was elevated. Echocardiography indicated concentric left ventricular hypertrophy (LVH). FNAC from periocular papulonodules and abdominal fat pad yielded fluidy and greasy white material, respectively. The smears from eyelid lesions showed pale eosinophilic, acellular, waxy material, which was congophilic, and apple-green birefringence in polarised light. The abdominal fat pad FNAC also was positive for amyloidosis.
The subsequent skin biopsies from the patient's forehead, papules, and tongue revealed eosinophilic, amorphous extracellular material deposition. Congo red staining effectively highlighted the congophilic material. These biopsy findings aligned with the earlier FNAC results, confirming the diagnosis of amyloidosis in both.
This case highlights the unusual presentation of systemic amyloidosis as eyelid papules and nodules, underscoring the importance of FNAC in such scenarios. FNAC is a rapid and effective diagnostic tool for accessible lesions, as demonstrated in this case. Additionally, FNAC of abdominal fat pads can provide valuable diagnostic information swiftly, making it useful in suspected amyloidosis cases.
In summary, a review of the literature showed that there are only isolated case reports of ruptured pheochromocytoma and to the best of our knowledge this report is the first to document metastatic phaeochromocytoma in peritoneal fluid within the cytopathology literature. Our case report emphasises the importance of clinical history in the context of the cytopathologic evaluation, and good cell block preparation, which allows the use of IHCs in challenging cases as it may lead to the discovery of unusual metastatic sources.
Detection of tachyzoites of Toxoplasma gondii in cerebrospinal fluid led to the diagnosis of central nervous system (CNS) toxoplasmosis in a 20 years old male. The cerebrospinal fluid (CSF) was obtained by lumbar puncture and two cytology smears were prepared by cytocentrifugation, one of which was stained with the May-Grünwald Giemsa (MGG) stain and the other with Papanicolaou stain. Light microscopic examination revealed pleocytosis along with numerous intracellular phagocytosed as well as extracellular tachyzoites with cytomorphology characteristic of Toxoplasma gondii. The diagnosis was confirmed by the serological elevation of anti-Toxoplasma IgM levels.
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