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Fine Needle Aspiration Is a Feasible and Accurate Technique in the Diagnosis of Lymphoma

Coastal Pathology Laboratories, Charleston, SC

George G. Birdsong, President-Elect

Grady Health System, Atlanta, GA

Mary K. Sidawy, Vice President

George Washington University, Washington, DC

David B. Kaminsky, Secretary-Treasurer

Cytopathology Pathology Inc, Palm Springs, CA

American Society of Cytopathology Executive Board Members:

Barbara D. Benstein

University of Tennessee Health Science Center, Memphis, TN

Edmund S. Cibas

Brigham & Women's Hospital, Boston, MA

Dina R. Mody

The Methodist Hospital, Houston, TX

Barbara J. Guidos

American Society for Clinical Pathology, Chicago, IL

Ann T. Moriarty

AmeriPath, Indianapolis, IN

David L. Rimm

Yale University, New Haven, CT

Hormoz Ehya

Fox Chase Cancer Center, Philadelphia, PA

Michael S. Facik

University of Rochester, Rochester, NY

Lydia P. Howell

University of California Davis Medical Center, Sacramento, CA

Gary W. Gill

DCL Medical Laboratories, Indianapolis, IN

Daniel F. Kurtycz

Wisconsin State Laboratory of Hygiene, Madison, WI

Celeste N. Powers, Past President

Medical College of Virginia, Richmond, VA

Nancy A. Young

Fox Chase Cancer Center, Philadelphia, PA

To the Editor:

The American Society of Cytopathology is the largest medical society solely devoted to recognizing cellular abnormalities to benefit patients. This letter is in regard to the article by Hehn, Grogan, and Miller¹ titled "Utility of Fine-Needle Aspiration As a Diagnostic Technique in Lymphoma," published in the August 1, 2004, issue of the Journal of Clinical Oncology.

Fine-needle aspiration (FNA) is routinely utilized successfully in the diagnosis and management of non-Hodgkin's lymphoma. We take serious issue with the design, analysis, and conclusion of the retrospective series reported by Hehn, Grogan, and Miller. Diagnosis of lymphoma requires a team approach, including clinical and pathologic correlation, as described in the WHO classification. Further, as with any medical test, FNA must be performed and analyzed properly. The National Comprehensive Cancer Network (NCCN) guidelines describe that it is essential in lymphoma evaluation to have hematopathology review of all slides and adequate immunophenotyping. The need for flow cytometry as well as collaboration between the cytopathologist and hematopathologist to optimize the use of FNA is well documented.²

Hehn, Grogan, and Miller appear to have accepted the FNA diagnosis supplied by the referring pathologist without subsequent review at their center. Some hint of the value of review of the pathologic material is that in their report three cases reviewed by lymphoma experts were indeed given a specific diagnosis. On average, however, each referring pathologist submitted 1.3 cases per 5 years. This raises questions first regarding the experience of each referring pathologist in lymphoma diagnosis and second about referral bias. For instance, a patient with an FNA revealing diffuse large B-cell lymphoma in the proper clinical setting would likely be treated appropriately in the community of experienced practitioners. The authors disregard the fact that difficult and unusual cases might have been selectively referred to their center.

Hehn, Grogan, and Miller also accepted the referring diagnosis despite the fact that only 43% of cases had immunophenotyping of any kind performed. We are not given any information about whether immunophenotyping was by flow cytometry or immunohistochemistry (IHC), the extent or quality of these analyses, or whether these data were reviewed at the referral center. As indicated in their Table 4, the authors have lumped together the cases with and without IHC. It is not clear whether IHC was performed to distinguish between carcinoma and lymphoma, to establish monoclonality, or to assist in subclassification of lymphoma. Lymphocyte immunophenotyping generally is not as accurate by IHC as it is with flow cytometry. In particular, IHC as practiced in most laboratories is not suitable for establishing monoclonality of lymphoid cells. The authors do not state whether flow cytometry was performed on any of their cases, nor do they mention whether cell blocks were prepared. Cell blocks are very useful not only for performing additional IHC to further subclassify lymphomas, but also to visualize the architecture. Due to the lack of careful consideration to these factors, this report has extremely limited utility.

We will not address the authors' discussion of the limitations of FNA, such as adequacy or sampling, since these issues have been previously discussed in the medical literature and probably do not account for the majority of unsatisfactory results obtained in this study.² Solutions to the limitations of FNA are being actively investigated, including application of new technologies, such as fluorescence in situ hybridization and molecular techniques to FNA.^3-5

It is not surprising that a medical test, in this case FNA with pathologic evaluation, carried out with suboptimal techniques is found not to be clinically useful. This is not an indictment of the test, as Hehn, Grogan, and Miller erroneously conclude, but rather an emphasis on the need to apply readily available state-of-the-art analytic tools. We strongly disagree with the authors' sweeping conclusions that "FNA for lymphoma diagnosis is not helpful, not cost effective, and may misguide treatment." We believe that evaluation of lymphoma by FNA, properly evaluated using the expertise provided by cytopathology and hematopathology along with flow cytometry and molecular techniques if needed, should continue to be practiced, not only in academic pathology settings but also in community centers with appropriate training. FNA for the diagnosis of lymphoma is a well-established technique that is demonstrably faster, safer, and more cost effective than surgical biopsy.

Authors' Disclosures of Potential Conflicts of Interest

Although all authors completed the disclosure declaration, the following authors or their immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.

Authors Employment Leadership Consultant Stock Honoraria Research Funds Testimony Other Barbara J. Guidos American Society of Cytopathology (A)

Dollar amount codes: (A) < $10,000 (B) $10,000-99,999 (C) $100,000 (N/R) Not Required

Acknowledgment

We thank Tahseen Al-Saleem, MD, Mitchell R. Smith, MD, PhD, Hormoz Ehya, MD, and Nancy Young, MD, for their contribution to the original draft of this letter.

REFERENCES

1. Hehn ST, Grogan TM, Miller TP: Utility of fine-needle aspiration as a diagnostic technique in lymphoma. J Clin Oncol 22:3046-3052, 2004[Abstract/Free Full Text]

2. Young NA, Al-Saleem TI, Ehya H, et al: Utilization of fine-needle aspiration cytology and flow cytometry in the diagnosis and subclassification of primary and recurrent lymphoma. Cancer 25:252-261, 1998

3. Bentz JS, Rowe LR, Anderson SR, et al: Rapid detection of the t(11;14) translocation in mantle cell lymphoma by interphase fluorescence in-situ hybridization on archival cytopathologic material. Cancer 102:124-131, 2004[CrossRef][Medline]

4. Gong Y, Caraway N, Gu J, et al: Evaluation of interphase fluorescence in-situ hybridization for t(14;18) (q32;q21) translocation in the diagnosis of follicular lymphoma on fine-needle aspirates: A comparison with flow cytometry immunophenotyping. Cancer 25:385-393, 2003

5. Maroto A, Rodriguez-Peralto JL, Martinez MA, et al: A single primer pair immunoglobulin polymerase chain reaction assay as a useful tool in fine-needle aspiration biopsy differential diagnosis of lymphoid malignancies. Cancer 25:180-185, 2003

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Austin, R. M. Articles by Young, N. A. Search for Related Content PubMed PubMed Citation Articles by Austin, R. M. Articles by Young, N. A. Social Bookmarking                            What's this?