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BACKGROUND: Conservative management of Warthin tumor (WT) may be a viable alternative to surgery, but there are concerns of missed malignancies on fine needle aspiration biopsy (FNAB). The purpose of this study is to measure the sensitivity and positive predictive value of FNAB for WT, and to identify clinical features associated with WT that can aid in this diagnosis. METHODS: Retrospective analysis of patients from January 1, 2006 to April 30, 2017 at a tertiary care center in London, Ontario, Canada. All patients with a diagnosis of WT on FNAB or resection were included. Electronic medical records were identified for 177 patients that fit the criteria. Study outcomes included the sensitivity and positive predictive value of FNAB alone for WT, and, when including clinical features associated with WT. RESULTS: The mean age of patients in this study was 63.2 years (SD 10.4); 115 (65%) were male, and 157 (89%) were past or present smokers. The measured sensitivity and positive predictive value of FNAB for WT were 95.8 and 97.2% respectively. Two cases were classified as WT on FNAB but confirmed at resection as mucoepidermoid carcinoma and acinic cell carcinoma. When only patients with multifocal, bilateral or incidental tumors were assessed, sensitivities and positive predictive values for each were 100%. Isolating for inferior pole location also resulted in a positive predictive value of 100%. CONCLUSIONS: The sensitivity and positive predictive value of FNAB for WT in this study are high, with two false negatives on FNAB. Multifocal, bilateral, incidentaloma and inferior pole location were identified as potential clinical features that may increase the diagnostic confidence for WT, strengthening the argument for conservative management in these patients. Overall, this study serves as an initial exploration into whether clinical features may be included with FNAB results to improve the sensitivity and positive predictive value of diagnosing WT. Further research is necessary before these findings can be translated into clinical practice.

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There are no widely accepted pathologic criteria for reporting endometrial samples with limited tissue and no consensus on the clinical follow-up of patients with these samples. Our study compares clinicopathologic outcomes and determines reporting consistency for these samples. This was done in 3 parts: (1) retrospective chart review of all patients with reported insufficient or scant endometrial samples from 2010 to 2013 at our center to determine repeat sampling and final pathologic diagnosis; (2) survey of gynecologists about their practice for managing patients with these samples; (3) blind review of 99 cases of previously reported scant or insufficient samples in which 4 reviewers separately reassigned cases as scant, insufficient, or diagnostic. Agreement was determined across reviewers. For part (1): 1149 patients had insufficient (49%) or scant (51%) samples with no significant difference in repeat biopsy rate (33% vs. 31%; P=0.33). Final diagnosis of uterine malignancy was higher in patients with a previous insufficient sample than with scant (19% and 9%, respectively), but this was not statistically significant. For part (2): among gynecologists surveyed, 4 of 5 reported managing patients with insufficient or scant samples similarly. For part (3): complete consensus across raters occurred in 57% of cases (Fleiss κ, 0.4891). Similar repeat biopsy rates between scant and insufficient samples suggest that our clinicians choose similar management for both terminologies. As such, distinction between insufficient and scant samples may not be necessary in pathologic reporting. Given the malignancy outcomes, both groups merit repeat sampling in the appropriate context.

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STUDY OBJECTIVES: To report 2 cases of uterine tumors resembling ovarian sex cord tumors (UTROSCTs) and examine the clinical significance of these tumors found during hysteroscopic endometrial ablation despite benign preoperative endometrial biopsy analysis and imaging suggestive of leiomyoma. DESIGN: Case report (Canadian Task Force classification III). SETTING: Tertiary care hospital. PATIENTS: Two patients with abnormal uterine bleeding. INTERVENTIONS: Hysteroscopic endometrial ablation/resection. MEASUREMENTS AND MAIN RESULTS: Pathological analysis of intrauterine tissue/lesions obtained by curettage or resection identified 2 unexpected UTROSCTs masquerading as leiomyomas. Following hysterectomy, no residual UTROSCT was identified in the specimens, and both women are well, one at 1 year postsurgery and the other at 3 years postsurgery. CONCLUSION: Obtaining additional tissue by routine curettage before endometrial ablation and/or endomyometrial resection, in conjunction with removal of any intrauterine lesions, can identify rare unexpected endometrial lesions not sampled by endometrial biopsy, not detected with ultrasound, and masquerading as leiomyomas during endometrial ablation.

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The AFC in cytopathology program was created in 2012 to address the societal need in Canada for Cytopathology leaders with in-depth specific knowledge of Cytopathology diagnostics, laboratory management, quality assurance and risk management to ensure high quality and accurate patient outcomes. So far, the developed AFC program in Cytopathology has been successfully implemented in three academic centres, and it stands as a model for competency-based advanced training in Cytopathology.

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INTRODUCTION: The decision to offer surgical staging in endometrial cancer is often based on preoperative histology and grade from endometrial biopsy or dilatation and curettage. The primary objective of this study was to evaluate the concordance between preoperative and final pathology from a population-based study of endometrial cancer to address whether preoperative biopsy is a reliable determinant in selecting patients for surgical staging. METHODS: Retrospective cohort study in Ontario, Canada, from 1996 to 2000. The study included all women with a preoperative diagnosis of endometrioid adenocarcinoma on endometrial biopsy or dilatation and curettage, followed by definitive surgery. All other histological types were excluded. Surgical staging rates were compared according to preoperative pathology. Primary outcome measure was the concordance between preoperative and final pathology, expressed as a Spearman correlation coefficient (rho). A multivariable logistic regression estimated the effects of demographic variables and grade on our outcome measure. RESULTS: There were 1804 evaluable cases in this study. For preoperative grades 1, 2, and 3 endometrioid adenocarcinoma, surgical staging rates were 9.1%, 13.7%, and 25.6%, respectively. Concordance rates with final pathology were 73%, 52%, and 53%, respectively. There was only moderate concordance between preoperative and final pathology (rho = 0.52). There was no significant difference in concordance rates according to age, year, or hospital volume, but lower concordance rates among teaching hospitals. CONCLUSION: Preoperative biopsy has only a moderate ability to predict final pathology in endometrial cancer, and therefore, additional factors should be considered in selecting patients for a surgical staging procedure.

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OBJECTIVE: To survey and improve the pathological reporting of colorectal cancer (CRC) specimens in a tertiary care pathology department. METHODS: We identified CRC specimens reported in a 6-month period before and after educational sessions and the introduction of a standardized CRC synoptic reporting protocol. Gross and microscopic descriptions were analyzed according to published guidelines for important staging and prognostic features. We then reexamined these parameters for a further 6-month period 15 months later to ensure that the quality of reporting had been maintained. RESULTS: In total, 108 and 166 cases were analyzed before and after standardization, respectively. Many features were reported appropriately, including tumour size, type and grade, depth of invasion, nodal status and proximal and distal margin status. Several underreported features showed significant improvement after standardization, including serosal involvement (reporting increased from 22% to 84%), distance to radial margin (from 14% to 64%), extramural venous invasion (from 18% to 88%), host response (from 19% to 94%) and mean number of nodes retrieved (mean numbers retrieved increased from 11 to 16). The subsequent review 15 months later showed continued long-term improvement in these areas. CONCLUSION: Education and synoptic reporting significantly improved CRC reporting at our centre.

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OBJECTIVE: Discrepancies may exist between an original pathology report and formal pathology review, with subsequent implications for treatment. We conducted a study of pathology review in endometrial cancer from a population-based study to identify areas of discrepancy and effect on treatment. METHODS: This was a retrospective cohort study in Ontario, Canada from 1996 to 2000. We identified hysterectomy cases from patients with endometrial cancer that were subject to formal pathology review by a gynecologic pathologist at one of six tertiary care centers. Sarcomas and other rare histologic subtypes with fewer than five cases were excluded. We evaluated discrepancy between original pathology and review by demographics, stage, grade, and risk group. Four risk groups were defined: 1) low (stage I), 2) intermediate (stage I and II), 3) high-risk (stage I and II), and 4) advanced stage (all stage III and IV). Reclassification from one risk group to another upon pathology review represented a potential change in treatment. Factors associated with significant discrepancy were identified by a multivariable logistic regression model. RESULTS: Formal pathology review was available on 450 cases. There were no differences by age, year, or hospital type. The overall discrepancy rate was 42.7% (95% confidence interval 38.2-47.3%). The intermediate-risk group had the highest rate of reclassification into another group (33.1%). The most significant rates of discrepancy were associated with endometrioid grades 2 and 3 tumors and stage IIA disease (39.8%, 50.9%, and 79.6%, respectively). CONCLUSION: There was significant discrepancy between original pathology and formal review in endometrial cancer, with implications for guidelines on pathology review at a population level. LEVEL OF EVIDENCE: III

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BACKGROUND: ThinPrep (TP) cytology for evaluation of nongynecological specimens is being increasingly used. There are few studies comparing TP with conventional smears (CS) in salivary gland (SG) fine-needle aspiration biopsies (FNAB). This study compares diagnostic accuracy and morphology of TP and CS in SG FNABs. METHODS: The authors retrospectively reviewed 98 satisfactory SG FNABs with both TP and CS. All cases had surgical resection. CS and TP slides were assessed for multiple morphological parameters, as well as the ability to make the diagnosis. Chi-square analysis was performed to compare CS and TP. RESULTS: An accurate diagnosis was rendered more commonly with CS compared with TP (57% versus 42%; P = .032), whereas the unsatisfactory rate was greater with TP compared with CS (19% versus 9%; P = .041). The error (4%) and indeterminate (35%) rates for TP were similar to CS. The diagnostic yield was greater for cellular cases, which were more frequent with CS compared with TP, than for cases of low cellularity; the diagnostic yield of cellular TP cases and cellular CS cases was similar. Artifacts (crush, air drying, obscuring blood) were more frequent (12%, 13%, and 27% versus 2%, 0%, and 1%; P

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Breast fine-needle aspiration biopsy (FNAB) has been increasingly accepted as an important triage tool for the evaluation of breast lumps. We examined the clinical utility and diagnostic accuracy of a negative breast FNAB result by studying 450 breast aspirates in 413 patients (average age 45 years) with a "negative" or benign cytologic interpretation performed at Massachusetts General Hospital over a 4-year period. Of these patients, 121 (29%) underwent subsequent biopsy and 17 (4%) were found to have malignancy (3% of total negative FNABs; 14% with histology). None of these 17 patients had a triple negative test. A cohort of 115 patients had documentation of negative physical, radiologic, and cytologic examinations (the triple negative), none of whom were found to have malignancy on histologic or at least 2-year clinical follow-up (negative predictive value [NPV] = 100% with a triple-negative test). Outside of the triple-negative test, the NPV of a negative breast FNAB is reduced with a false-negative rate of 7%. However, in the setting of a triple-negative test, the NPV in our patient population was 100%, reassuring the patient and clinician that clinical follow-up and not surgical intervention was sufficient for proper patient care.

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We retrospectively determined the clinical impact of 1,000 randomly selected interinstitutional pathology consultations (IPCs). An IPC included all specimens from the patient. IPCs were classified as concordant or discordant with the original diagnosis. Discordant IPCs were classified as having a clinical impact or no impact. Discordant IPCs owing to interpretation differences were subclassified further. The IPCs included 1,522 specimens (1,204 histology, 318 cytology); 923 (92.3%) were concordant, 9 (0.9%) indeterminate, and 68 (6.8%) discordant (clinical impact, 37; no impact, 31). Reasons for discordant IPCs were interpretation differences, 45; additional sectioning, 7; ancillary testing, 1; clerical error, 5; or a combination, 10. Reasons for 26 discordant IPCs with clinical impact owing to interpretation differences were overdiagnosis, 11; tumor subtype change, 4; stage change, 4; underdiagnosis, 3; resection margin status change, 2; undergrading, 1; and understaging with resection margin status change, 1. IPC may identify diagnostic discrepancies that impact management for some patients. The prevalence of a clinical impact of IPC on management varies according to body site. Mandatory IPC does ensure identification of clinically significant diagnostic discrepancies; targeted IPC by body site or specimen type may represent an alternative strategy after further data accumulation. Discordant IPCs may be due to factors other than interpretation difference.

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BACKGROUND: Long-acting injectable contraceptive agents may cause changes in cervical smears that could impair the detection of epithelial abnormalities. The objectives of the current study were to 1) compare the hormonal effects of depot-medroxyprogesterone acetate (Depo-Provera) (DP) in cervical smears with those of levonorgestrel and ethinyl estradiol (Triphasil) (TP) and postmenopausal (PM) changes; and 2) determine whether the duration of DP use affects squamous maturation. METHODS: Satisfactory cervical smears from 50 DP users, 55 TP users, and 51 PM patients were evaluated blindly for: 1) squamous cell curling, crowding, cytolysis, and navicular cell formation; 2) pseudoparakeratosis, blue blobs, and histiocytes; 3) endometrial cells and blood; 4) single or enlarged endocervical nuclei and mucin-depleted endocervical cells; 5) lactobacilli and coccobacilli amounts; and 6) squamous maturation (ratio of parabasal:intermediate:superficial cells). RESULTS: No statistically significant differences were observed for blue blobs, histiocytes, blood, endometrial cells, or single or enlarged endocervical nuclei among smears from the three groups. More smears from DP and TP users demonstrated squamous cell curling, crowding, and cytolysis as well as navicular cells and abundant lactobacilli compared with smears from PM patients. There were more PM smears with pseudoparakeratosis and mucin-depleted endocervical cells compared with the other groups. The majority of PM smears (98%) demonstrated predominantly parabasal cells with some intermediate cells. The majority of DP (86%) and TP (93%) smears demonstrated mostly intermediate and some superficial cells, regardless of the duration of DP use. CONCLUSIONS: Certain progestational-dependent effects (i.e., curling, crowding, navicular cells, and abundant lactobacilli) were identified more often in TP users compared with DP users and less often in PM patients. The mostly parabasal pattern observed in smears from PM patients contrasted with the predominantly intermediate pattern found in smears from DP and TP users. The duration of DP use did not appear to have any effect on squamous maturation.

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PURPOSE: To compare the adequacy of aspirated material and procedure time when performing ultrasonography-guided fine-needle aspiration biopsy of thyroid nodules with and without immediate cytologic analysis of the aspirated sample. MATERIALS AND METHODS: One hundred twenty-one thyroid nodules were sampled for biopsy in 109 patients. In group A, results of 50 biopsies in which immediate cytologic analysis was performed were retrospectively reviewed for cytologic adequacy. In group B, 50 biopsies were performed without immediate cytologic analysis, and the procedure time was recorded. In group C, 21 biopsies were performed with immediate cytologic analysis, and the procedure time was recorded. Cytologic adequacy rates were compared by using the proportional odds model, and procedure times were compared by using linear regression to adjust for differences in the character of the nodules. RESULTS: For groups A and C (immediate cytologic analysis performed), the adequacy categories included the following results: 39 (55%) satisfactory, 15 (21%) limited, and 17 (24%) unsatisfactory. For group B (immediate cytologic analysis not performed), the adequacy categories included the following results: 25 (50%) satisfactory, 15 (30%) limited, and 10 (20%) unsatisfactory (Wald test, P =.815). The average procedure time was 12.5 minutes for group B and 44.4 minutes for group C (P <.001). CONCLUSION: There was no significant difference in cytologic adequacy whether immediate cytologic analysis of aspirated material was performed or not. The procedure time was significantly shorter when immediate cytologic analysis was not performed.

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