Contribution of Immunocytochemical Stainings for Galectin-3, CD44, and HBME1 to Fine-Needle Aspiration Cytology Diagnosis of Papillary Thyroid Carcinoma Dilip K. Das, M.B.B.S., M.D., Ph.D., D.Sc., F.R.C.Path,1,2* Salah K. M. Al-Waheeb, M.B.Ch.B., F.R.C.P.C.,1,3 Sara S. George, M.Sc., Ph.D.,1 Bahiyah I. Haji, M.B.Ch.B., M.Sc.,2 and Mrinmay K. Mallik, M.B.B.S., M.D.2

In cytology practice some papillary thyroid carcinoma (PTC) cases have indeterminate diagnoses and overlapping cytological features with benign lesions. This study was undertaken to find out if immunocytochemistry using Galectin-3, CD-44 and HBME-1 could be of help in such situations. Forty-six cases consisting of 22 malignancy (PTC) cases, 7 suspicious of (S/ O) PTC, 1 follicular neoplasm, 5 follicular lesion of undetermined significance (FLUS), and 11 benign (colloid goiter) cases diagnosed by FNA were included in this study. Staining reactions were graded in a sliding scale of –, 11, 21, 31, and 41. In an assessment of 100 cells, each cell with weak, and moderate to strong positive reaction were assigned a score of 1 and 4, respectively. Staining reaction of 12 and scores >100 were considered positive. Frequency of cases with 12 reaction, and scores >100 for each of Galectin-3, CD-44, and HBME-1 were significantly higher in PTC or combined PTC and S/O PTC cases as compared with FLUS and benign cases taken together (P 5 0.01744 to 0.00000). When the cases were compared according to histological malignant and benign diagnoses, the difference was also significant in respect of 12 reaction, and scores >100 for 1 Department of Pathology, Faculty of Medicine, Kuwait University, Kuwait 2 Cytology Unit, Mubarak Al-Kabeer Hospital, Kuwait 3 Pathology Laboratory, Hussain Makki Al-Juma Center for Specialized Surgery, Kuwait *Correspondence to: Dilip K. Das, MBBS, MD, PhD, DSc, FRCPath, Department of Pathology, Faculty of Medicine, Kuwait University, P.O. Box: 24923, Safat13110, Kuwait. E-mail:[email protected] Contract grant sponsor: Kuwait University; Contract grant number: MG 01/08 (to D.K.D.). Received 21 January 2013; Accepted 10 October 2013 DOI: 10.1002/dc.23062 Published online 22 November 2013 in Wiley Online Library (wileyonlinelibrary.com).

C 2013 WILEY PERIODICALS, INC. V

Galectin-3 and CD44 (P 5 0.04923 to 0.00947); however, there was no significant difference, when these parameters for HBME1 were compared. Galectin 3, CD 44, and to some extent HBME 1 are useful immunocytochemical parameters with potential to support FNAC diagnosis of PTC, especially in situations with difficult differential diagnoses. Diagn. Cytopathol. 2014;42:498–505. VC 2013 Wiley Periodicals, Inc. Key Words: papillary thyroid carcinoma; fine needle aspiration cytology; galectin-3; CD-44; HBME-1

Introduction Although thyroid cancer is 13th among the most common female cancer in the world,1 it occupies the 2nd position among cancers in Kuwaiti females and 3rd most common cancer among non-Kuwaiti females living in Kuwait.2 Papillary thyroid carcinoma (PTC) is the most common thyroid cancer2–5 and its incidence is rising over the decades.6–8 FNA cytology is the most valuable tool for the preoperative diagnosis of PTC9 with high degree of sensitivity, specificity, and diagnostic accuracy. The routine use of FNAB can reduce the need for of thyroidectomy for diagnostic purposes by 20% to 50%, while increasing the yield of cancer diagnoses in pathologic specimens by 15% to 45%.10 Despite papillary thyroid carcinoma (PTC) having well recognized cytomorphological features,11 15 to 25% of FNA reports yield indeterminate or suspicious of malignancy reports.10,12 Benign (hyperplastic) nodules also share one or more cytologic features of Diagnostic Cytopathology, Vol. 42, No 6

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PTC.13 It is observed that immunohistochemical/immunocytochemical studies using galectin-3. CD44, HBME-1, emerin, and CK 19 antibodies have served as useful diagnostic markers for PTC in paraffin sections of surgically resected tumors,14–16 decolorized archival FNA smears and cell blocks of fine-needle aspirates,17 and liquidbased smears of FNA material. 18 In the present study we utilized three of the immunocytochemical markers, i.e., Galectin-3, CD44, and HBME-1 on FNA smears in a preliminary study to find out the role of these markers in differentiating PTC from suspicious and benign thyroid lesions in fine-needle aspirates.

Materials and Methods Immunocytochemical studies were performed on material obtained by fine-needle aspiration of thyroid lesions in 46 cases categorized according to Bethesda System of Reporting during review of smears, which included 36 cases in a prospective study involving three antigens, viz., galectin-3, CD44 and HBME1 during November 2008 to October 2009, and 10 cases collected during preparatory phase of this study based on two antigens, galectin-3 and CD44. Information on subsequent histopathological diagnosis was available for cytohistological correlation in 34 cases. The age of these 46 cases ranged from 18.0 to 62.0 years with a median of 41.0 years. Male to female ratio was 17:29. The source of aspirates were thyroid nodules in 42 cases (left lobe in 15, right lobe in 19, both the lobes in 5 and isthmus in 3), cervical lymph nodes in three cases and midline swelling in upper neck, possibly related to thyroglossal duct cyst in one case. The smears were prepared from the syringe wash by cytocentrifugation; fixed in 95% ethyl alcohol; and manually immunostained for galectin-3, CD44 and HBME1 in 46, 45, and 36 cases, respectively. The primary antibodies were Galectin-3 [Novocastra, Labs, New Castle Up on Tyne, UK, NCL-GAL 3] (1:50 dilution), and CD44, Phagocytic glycoprotein-1, Clone DF 1845, [DAKO, Glostrup, Denmark M 7082], (1:20 dilution), and Anti-Human Mesothelial cell, clone HBME-1 [DAKO, Carpinteria, CA, M 3505] (1:50 dilution). LSB 2 system-HRP (Dako cytomation) was used as the detection system. Paraffin sections of papillary thyroid carcinoma with adjoining areas of adenomatous (colloid) goiter and known positive reactions for galectin-3, CD44, and HBME1 in areas of malignancy were used as controls. The material was found suitable for assessment of galectin-3 in 41 cases, CD44 in 38, and HBME1 in 31 cases. The cases were categorized in a sliding scale of – to 41 as follows during count of 100 cells: – (75% cells with moderate to strong positive reaction). Number of cases with 21 staining reactions was determined. When the staining reaction was categorized as weak in a cell, a score of 1 was assigned to it, and for moderate to strong reaction the score was 4. Cytologically diagnosed malignacy (PTC) cases were compared with suspicious (S/O PTC) cases, and with combined follicular lesions of undetermined significance (FLUS) and benign (colloid goiter) cases in respect of two parameters, i.e., number of cases with 12 (21 to 41), i.e., at least 26% cells with moderate to strong positive reaction, and scores above 100. Combined malignancy and suspicious cases were also compared with combined FLUS and benign lesions. Furthermore, the cases were compared as per malignant and benign histological diagnoses in respect of 21 reaction and scores >100 for the three antigens. The significance of difference was found out using Fisher’s Exact Test of Probability.

Results The 46 cases were categorized according to Bethesda System of Reporting as follows: 11 benign cases, 5 follicular lesion of undetermined significance (FLUS), 1 follicular neoplasm, 7 suspicious of malignancy and 22 malignant lesions. Whereas the benign lesions were reported as colloid goiter during routine cytodiagnosis, the suspicious and malignant lesions were termed suspicious of (S/O) papillary thyroid carcinoma (PTC) and PTC, respectively. Histopathology reports available in 34 cases were as follows: PTC (24 cases), follicular carcinoma (1 case), follicular adenoma (2 cases), and benign nonneoplastic lesions (7 cases). All the 19 cytologically diagnosed PTC cases were corroborated by histologic diagnosis; whereas four out of six suspicious PTC cases were confirmed as PTC, the remaining two cases turned out to be benign. The follicular neoplasm turned out to a follicular carcinoma (minimally invasive). Out of five follicular lesions diagnosed by cytology, one each was PTC (microscopic) and follicular adenoma, and the remaining three were benign lesions in paraffin sections. One of the three benign lesions was a follicular adenoma in histologic specimen and the two others were benign. The positive reaction was cytoplasmic for galectin-3, overwhelmingly membranous in CD44 and cytoplasmic with accentuation of staining in the membranous area in HBME-1. As seen in Table I, of the 22 PTC cases, there was successful immunocytochemical (ICC) staining for galectin-3 and CD44 in 21 cases each and for HBME-1 in 12 cases; 21 reactions for galectin-3, CD44, and HBME-1 were observed in 16 (76.2%), 20 (95.2%), and 8 (66.7%), respectively. Among seven cases suspicious of (S/O) PTC, successful staining for galectin-3, CD44 and Diagnostic Cytopathology, Vol. 42, No 6

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DAS ET AL. Table I. Assessment of Immunocytochemical Stainings including Grade 21 Staining and Scores above 100 for Galectin 3, CD44, and HBME 1 in Thyroid Lesions FNA cytodiagnosis No. cases studied and assessment of staining reaction

Antigen tested Galectin-3

CD44

HBME1

Nos tested Reaction

Score Nos tested Reaction

Score Nos tested Reaction

Score

2 11 21 31 41 21 >100 2 11 21 31 41 21 >100 2 11 21 31 41 21 >100

P value

A: Malig. (PTC)

B: S/O Malig (S/O PTC)

C: FLUS (Foll lesion)

D: Benign (Coll gtr)

21 2 3 3 6 7 16 18 21 1 1 5 14 20 20 12 1 3 1 5 2 8 9

6 2 2 1 1 0 2 2 4 0 1 0 1 2 3 3 5 1 3 1 0 0 1 1

4 1 2 0 1 0 1 1 4 0 2 1 1 0 2 3 4 0 3 1 0 0 1 1

10 9 1 0 0 0 0 0 9 0 8 0 1 0 1 1 9 7 2 0 0 0 0 0

A vs. B

A vs. (C1D)

A1B vs. (C1D)

0.13679 0.02391

0.00008 0.00000

0.00063 0.00005

0.30000 0.30000

0.00002 0.00012

0.00003 0.00018

0.13169 0.10078

0.00361 0.00098

0.01744 0.00673

Malig. 5 malignant, PTC 5 papillary thyroid carcinoma, s/o 5 suspicious of, FN 5 follicular neoplasm, FLUS 5 follicular lesion of undetermined significance, Coll gtr 5 colloid goiter, 2 5 100 were considered for correlation. Note: A case of follicular neoplasm with HBME score of 11 is not shown in the table.

HBME-1 was achieved in six, four, and five cases, respectively, and 21 reactions for galectin-3, CD44, and HBME1 were seen in two (33.4%), three (75.0%), and one (20.0%), respectively. Among four FLUS cases, 21 positive reactions for galectin-3, CD44, and HBME1 were observed in one (25%), one (50%), and one (25%), respectively. Only one (11.1%) of benign (colloid goiter) cases showed 31 positive reaction for CD44 but none of these benign cases was above 11 level for galectin-3 and HBME1. In 19 PTC cases at least two of the three parameters (galectin-3, CD44, and HBME-1) had score above 100 (considered positive) and in remaining two cases only one parameter crossed this mark; in nine PTC cases two to three parameters had very high score, i.e., above 300 (Fig. 1) and in remaining 10 cases the score was above 300 in respect of one parameter only (Fig. 2). Among seven cases S/O PTC as well as four cases of FLUS, two cases each had score above 100 in respect 2 parameters, and in one case each the score was >100 in respect of one parameter. The score exceeded 300 for one parameter in one S/O PTC and a FLUS case (Fig. 3). There was significant difference between PTC, and combined FLUS and benign lesions in 500

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respect of 21 galectin-3 reaction (76.2% PTC vs. 25% FLUS and 0% benign, P 5 0.00008), and scores exceeding 100 (85.7% PTC vs. 25% FLUS and 0% Benign, P 5 0.00000). There was also highly significant difference between combined PTC and S/O PTC on one hand and combined FLUS and benign lesions on the other in respect of 21 reaction for galectin-3 (P 5 0.00063) and scores above 100 (P 5 0.00005). There was significant difference between PTC on one hand and combined FLUS and benign lesions on the other in respect of 21 CD44 reaction (95.2% PTC vs. 50% FLUS and 11.1% benign, P 5 0.00002) and scores exceeding 100 (95.2% PTC vs. 75% FLUS and 11.1% benign, P 5 0.00012). There was also significant difference between combined PTC and S/O PTC vs. FLUS and benign lesions in respect of 21 CD44 reaction (P 5 0.00003) and scores exceeding 100 (P 5 0.00018). In respect of HBME1, there was significant difference between PTC and combined FLUS and benign cases for 21 reaction (66.7% PTC vs. 25% FLUS and 0% benign, P 5 0.00361), and scores exceeding 100 (75% PTC vs. 25% FLUS and 0% benign, P 5 0.00098). PTC and S/O PTC together had also significantly higher values of 21 reaction for HBME1

Diagnostic Cytopathology DOI 10.1002/dc

IMMUNOCYTOCHEMISTRY IN FNA CYTOLOGY DIAGNOSIS OF PTC

Fig. 1. PTC: FNA smears from a thyroid nodule in a 45-year-old man showing strong positive reaction for Gaectin 3, CD44, and HBME1 with scores exceeding 300 in all the three parameters. The histopathological diagnosis was PTC. A. Typical papillary configuration with multiple papillae in three dimensional form (Papanicolaou 3 100). B. Increased frequency of nuclear grooves and an intranuclear cytoplasmic inclusion [INCI] (Papanicolaou 3 1,000). C. A group of tumor cells with an INCI in one cell (MGG 3 400). D. Moderate to strong positive reaction for galectin-3 and a score of 340 (31,000). E. Moderate to strong positive reaction for CD44; the score was 358 (31,000). F. Moderate to strong positive reaction for HBME1. the score was 320 (31,000). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

(P 5 0.01744) and scores above 100 (P 5 0.00673). However, there was no significant difference between PTC and S/O PTC with respect to any of the parameters except for score exceeding 100 for galectin-3 (P 5 0.02391). When the 23 histopathologically diagnosed malignant and 8 benign cases were compared for 21 positive reaction and scores exceeding 100 (Table II), significant difference was observed in respect of 21 reaction for galectin-3 (P 5 0.04923) and CD44 (P 5 0.00947); there was also significant difference between the two groups for scores above 100 in respect of galectin-3 (P 5 0.03415) and CD44 (P 5 0.00947) but the significance was marginally lost for HBME1 (P 5 0.07458).

Discussion Ancillary studies have been utilized for the differentiating PTC from lesions causing differential diagnostic problems in histologic specimens. Saleh et al.15 using galectin-3, RET oncoprotein, HBME-1, and CK-19 observed that these immunomarkers are significantly more expressed in malignant thyroid tumors compared with benign lesions. In a study of 47 PTC cases and 11 nonneoplastic goiters, Nikiel et al.19 observed that galectin-3 was a sensitive and specific marker, present in 91% of analyzed tumors

and only in 5% of tumor margins. Figge et al.20 detected strong CD44 expression in 65 of 67 (97%) of PTC cases. According to Nasr et al.,21combination of HBME-1 and CK19 has the greatest diagnostic utility in differentiation of PTC from its benign mimics. Liu et al.14 discovered that HBME-1 was 88% accurate in differentiating FA from FVPTC. Fine-needle aspiration (FNA) cytology is a very useful tool for the diagnosis of thyroid cancers, especially PTC. The National Cancer Institute (NCI) Fine Needle Aspiration State of Science Conference Synopsis 11 divides the cytologic features of PTC into five major diagnostic criteria, viz., (1) enlarged, oval “and irregular” nucleus, (2) eccentric and often multiple micronucleoli, (3) fine, pale chromatin, (4) longitudinal nuclear grooves, (5) intranuclear pseudo- or cytoplasmic inclusions (INCI), and eight minor diagnostic features, viz., (1) papillary cytoarchitecture, (2) syncytial monolayers, (3) dense squamoid cytoplasm, (4) viscous or gummy (“bubble-gum”) colloid, (5) psammoma bodies, (6) multinucleated giant cells, (7) histiocytoid cells, and (8) cellular swirls. According to a recent report FNA has >90% sensitivity in detection of thyroid cancer but only 50%-65% specificity because of false-positive results, which necessitates surgical controls.22 It is found that the most common pitfalls for false-negative diagnoses of PTC consisted of suboptimal Diagnostic Cytopathology, Vol. 42, No 6

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Fig. 2. PTC: FNA smears from a thyroid nodule in the left lobe in a 35-year-old woman with weak to strong positive reaction for galectin-3, CD44, and HBME1 but score exceeding 300 in only one of the three parameters. A. One papillary structure with a broad fibro-collagenous stalk traced to the core of papilla (Papanicolaou 3 100). B. Most of the tumor cells with nuclear grooves in the field (Papanicolaou 3 400). C. There were occasional INCI (MGG 3 400). D. Weak to strong positive reaction for galectin-3; the score was 285 (31,000). E. Moderate to strong positive reaction for CD44; the score was 316 (31,000). F. Weak to strong positive reaction for HBME-1; the score was 240 (31,000). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

material and under diagnosis of PTC due to cystic degeneration and presence of microscopic PTC.9,23,24The false positive diagnosis in PTC is due to overlapping features between adenomatous nodules, follicular neoplasm, and follicular variant of PTC, leading to over-diagnosis of follicular neoplasm. 23 In such situations immunocytochemical staining with antibodies like RET-oncogene, galectin3, HBME1, CK19, and CD44 on thyroid FNA material has shown encouraging results by increasing the sensitivity and specificity of FNA diagnosis; reducing the falsepositive and false-negative results; and thereby improving diagnostic accuracy and reducing the need for surgical controls.18,22,25,26 Immunostainings for galectin-3 and HBME-1 yield a positive cytoplasmic reaction in thyroid malignancies. 25 Aratake et al.27 observed moderate to strong cytoplasmic staining for galectin-3 in all the 37 PTC cases (moderate in 5 and strong reaction in 32). According to Figge et al.20 CD44 staining has a strong membranous pattern in PTC. Kim et al.,28 however, observed an intense cell membrane or diffuse cytoplasmic CD44 staining in 97.8% of PTC. Ross et al.29 detected positive CD44 staining in 14 of 16 (88%) fine-needle aspirates from PTC and described the character of staining as intense perinuclear rim heavily outlining the cytoplasm and cytoplasmic membrane, creating a rim or basket-weave pattern. In a 502

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study of 56 malignant thyroid lesions, Nga et al.26 detected positive staining for HBME-1 in 45 including 42 of 45 PTC and 3 of 7 follicular carcinomas. Rossi et al.25 considered a case positive for galectin-3 and HBME-1 when at least 50% cells showed a convincing cytoplasmic positivity. Nga et al.26 also regarded a case positive for galectin-3 and HBME-1 when at least 50% cells were reactive at an intensity of at least 21. A review of six studies by Sanabria et al.10 on the utility of galectin-3 staining on FNA smears of follicular neoplasms including follicular variant of PTC revealed wide variation of criteria for considering a case positive, a case was considered positivity for galectin-3 when number of positive cells was >10%,31,33 >20%,32 or >50%.25 Categorization of our cases on a sliding scale in to 2, 11, 21, 31, and 41 is very similar to the scale used by van Hoeven et al.34 in studying the staining pattern of HBME-1, CA19-9, and CD15 in thyroid nodules. When Nga et al.26 applied a cut off value of greater than 25% cells with at least moderate (21) staining intensity it was found that both sensitivity and specificity of the combination of HBME-1 and Ck19 was 100%. In the present study, we considered 21 (>25% cells) with moderate to strong staining reaction as positive. For the purpose of scoring, weak positive reaction was given a score of 1 in our material; although initially moderate and strong reactions

Diagnostic Cytopathology DOI 10.1002/dc

IMMUNOCYTOCHEMISTRY IN FNA CYTOLOGY DIAGNOSIS OF PTC

Fig. 3. Follicular lesion. FNA smear from a right lobe thyroid nodule in a 25-year-old woman. The histopathological diagnosis was multinodular goiter. A. The smear is cellular (Papanicolaou 3 200). B. Microacinar (follicular) formation by follicular cells (Papanicolaou 3 400). C. Follicular formation and a small clump of colloid (MGG 3 200). D. Weak to strong positive reaction for galectin-3; the score was 308 (3400). E. One group of cell which appears to be metaplastic shows strong positive reaction for CD44; the score was 244 (3400). F. Only rare cells show positive reaction for HBME1; the score was 26 (3400). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Table II. Correlation of Results of Immunocytochemical Staining (Galectin-3, CD44, and HBME1) Results Between Histologically Diagnosed Malignant and Benign Thyroid Lesions Positive cases/no. cases tested, indicating 11 reaction and score >100 in FNA smears Galectin-3 Histopathological diagnosis Malignancy Benign Fisher’s P value

CD44

HBME1

No. cases

R: 21

Sc: >100

R: 21

Sc: >100

R: 21

Sc: >100

23a 8b

15/22 2/8 0.04923

16/22 2/8 0.03415

18/20 3/8 0.00947

18/20 3/8 0.00947

8/15 1/7 0.16486

9/15 1/7 0.07458

a

Histopathology reports were PTC in 22 cases and follicular carcinoma in one case. Histopathology reports were follicular adenoma in one case, and hyperplastic nodule and adenomatous (colloid) goiter with or without lymphocytic thyroiditis in seven cases. R 5 reaction, Sc 5 score. b

were supposed to get scores of 3 and 5, respectively, because of practical difficulty in delineating moderate from strong reaction, both moderate and strong reactions were assigned a score of 4 and a score above 100 was considered positive. The staining pattern was generally cytoplasmic for galectin-3, membranous for CD44, and cytoplasmic as well as membranous for HBME-1, however, it was difficult at times to distinguish the two patterns because of completeness of a cell surrounded by cell membrane on all sides in smears, unlike the paraffin sections where cytoplasm and cell membrane are better delineated. In our material, 76.2% of PTC cases showed

21 (25%) cell having moderate to strong staining reaction for galectin-3 as opposed to 7.1% of FLUS and benign cases (P 5 0.00008). There was significant difference between the two groups based on scores above 100 (P 5 0.00000). Similar significant difference was observed between combined PTC and S/O PTC cases versus combined FLUS and benign lesions based on 21 reaction (P 5 0.00063) and score exceeding 100 (P 5 0.0005). According to Ersoz et al.35 galectin-3 expression in thyrocytes is a strong indicator of malignant proliferative lesion, especially PTC and to some extent in follicular thyroid neoplasm, and review of literature shows that Diagnostic Cytopathology, Vol. 42, No 6

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galectin-3 has a sensitivity and specificity of 75% to 100%.25,30–34All the results on galectin-3 suggest its potential utility in FNA smears to better select patients for surgical treatment. However, to avoid possibility of false-negative tests based only on determination of galectin-3, it has been demonstrated that the combination of several markers (i.e., galectin-3, HBME-1, and CK19) could increase the diagnostic accuracy of immunocytochemistry.36 Besides galectin-3, we used CD44 and HBME-1 to differentiate PTC from benign lesions; 95.2% of PTC cases showed 21 positive reaction for CD 44 as opposed to 23.1% of the group containing FLUS and benign cases (P 5 0.00002). The two groups had also significant difference in respect of CD 44 score above 100 (P 5 0.00012). This was true when combined PTC and S/ O PTC cases were compared with combined FLUS and benign lesions for 21 reaction (P 5 0.00003), and score >100 (P 5 0.00018). Similarly PTC or combined PTC and S/O PTC cases had significantly different HBME1 values as compared with combined FLUS and benign lesions based on 21 positive reaction and scores above 100. Previous studies on ICC with multiple antibodies on thyroid FNA18,25,26 has so far shown encouraging results. Rossi et al.25 studied thyroid neoplasms using three antibodies (RET-oncogene, galectin-3, HBME1) on LBC material and observed 100% sensitivity, 76.4% specificity, and 89.1% diagnostic accuracy for ICC, and overall (cytology and ICC) sensitivity, specificity, and diagnostic accuracy of 100%, 92.3%, and 97.0%, respectively. Nga et al.26 observed the sensitivity and specificity of 100% in a study of cell blocks in 20 FNAs using CK19 and HBME1. Pazaitou-Panayiotou et al.18 studied 83 FNAs positive for PTC (44 thyroid nodules and 39 cervical lymph nodes) with four antibodies (CK19, galectin-3, HBME1, and CD44) with high expression of 92.7%, 89.1%, 78.3%, and 86.7% respectively. Even when the benign and malignant cases were compared in our material taking into consideration histopathological diagnoses, significant difference was observed between the two groups for galectin-3 (21 reaction, P 5 0.04923, score above 100, P 5 0.03415) and CD44 (21 reaction as well as score above 100, P 5 0.00947). However, in respect of HBME1 there was no significant difference in 21 reaction (P 5 0.16486) and difference was marginally lost for score above 100 (P 5 0.07458). The histologically diagnosed benign cases with positive results in immunostaining in cytologic samples included one each case of follicular adenoma with lymphocytic thyroiditis, hyperplasic nodule with lymphocytic thyroiditis and mutinodular colloid goiter; the cytodiagnoses in these cases were S/O PTC (one case) and FLUS (two cases). It is possible that the high score in these benign lesions could be due to metaplastic changes. According to Rossi et al.25 distinctive features of oxyphilic cells (rich in mitochondria) and the influence of inflammation on 504

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follicular cells of the hyperplastic nodules in the Hashimoto’s thyroiditis can be responsible for false cytoplasmic positivity. In conclusion, the results of our study supports the findings of other studies with one or more antibodies that galectin-3, CD 44, and HBME-1 are useful immunocytochemical parameters in PTC. However, as compared with galectin-3 and CD44 antibodies, HBME-1 had some limitations, as revealed by statistical tests, which could be partly due to smaller number of samples.

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Diagnostic Cytopathology, Vol. 42, No 6

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Contribution of immunocytochemical stainings for galectin-3, CD44, and HBME1 to fine-needle aspiration cytology diagnosis of papillary thyroid carcinoma.

In cytology practice some papillary thyroid carcinoma (PTC) cases have indeterminate diagnoses and overlapping cytological features with benign lesion...
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