EDITORIAL
DOI:10.1111/cyt.12130
Multidisciplinary and multimodal diagnostic approach in paediatric tumours combining fine needle aspiration, core needle biopsy and ancillary techniques
In this issue of Cytopathology, Drs Helena Barroca and Maria do Bom-Sucesso, from Porto Centro Hospitalar de S. Joao in Portugal, describe the combination of fine needle aspiration (FNA) and molecular analysis in paediatric tumours, which now appears to be both the optimal and required multimodal approach to diagnosis.1 For many decades, the modalities of tumour diagnosis in children have been the subject of debate. Several centres practice an ‘open sky’ surgical biopsy, obtaining abundant tumour material sufficient for histopathological and molecular analyses, but with a number of drawbacks, such as the non-repeatability of the procedure and the relatively longer delay in providing a provisional report. Moreover, the fragile clinical status of young patients makes it difficult for an open biopsy to be performed, can be difficult in newborns and may possibly be dangerous in patients with advanced disease. In recent years, ‘small volume biopsies’, such as FNA and core needle biopsy (CNB), have overcome the insistance of clinicians and ‘old school pathologists’ on open biopsy and have entered common use in adult and paediatric oncology. The multidisciplinary team, including an oncologist, radiologist, pathologist and molecular biologist, is called upon to decide the combined or separate use of FNA, CNB and molecular studies, according to the consensus hospital protocol. For paediatric tumours FNA is performed with 23- or 27-gauge (outer diameter, 0.57 and 0.36 mm) needles, either using the simple non-aspirative Zajdela’s technique2 or with aspiration through a syringe, with or without radiological guidance. (The lack of aspiration, or negative pressure, in their fine needle technique is the reason Barroca and Bom-Sucesso use the term ’fine needle biopsy’ in their article.1). This simple technique bears a low complication rate and can be repeated in sedated patients until the material is considered to be satisfactory after microscopic examination of slides stained using a modified Giemsa or rapid Diff-Quick method: rapid on-site evaluation (ROSE). When sedation is not used, the ROSE technique should always be employed to evaluate the quality of the material since children may not tolerate a second attempt: the © 2014 John Wiley & Sons Ltd Cytopathology 2014, 25, 3–5
pathologist or radiologist should be proficient enough to obtain adequate material on the first attempt. Apart from evaluation of the sample for adequacy, and in many instances provision of a preliminary diagnostic opinion, ROSE permits immediate decisions to be made, such as catheter installation, bone marrow biopsy sampling, saving appropriate material for immunocytochemistry (ICC), molecular analysis or flow cytometry, or the need for further biopsy. Examples of the value of ROSE are the differential diagnosis between nephroblastoma, neuroblastoma and non-Hodgkin lymphoma, where flow cytometry might be helpful, or between Ewing sarcoma versus osteosarcoma, when clinical or radiological settings are non-specific. However, and most important for planning educational programmes for European Union pathologists and radiologists, the quality of the sample is operator dependent and FNA techniques require specific training, experience and dedication.3 CNB performed with 16- (outer diameter 1.3-mm) or 14-gauge needles usually harvests an adequate volume of tumour tissue for histopathology and immunohistochemistry, but cannot be repeated if excessive haemorrhage or necrosis is harvested, whereas, under ultrasound or computed tomography guidance, FNA can avoid necrotic areas, targeting the solid foci of the tumour. Moreover, new techniques allow precise molecular evaluation from a few cells, and also from archival material.4 Specific anatomical sites, such as retrobulbar, deep orbit, intracranial, intrathoracic, retroperitoneal nodules or vascularized tumours, cannot be reached by CNB, but are easily accessible by thin needles. As in the experience of Barroca and BomSucesso, we believe that many malignancies can be unquestionably diagnosed using FNA material, as in Ewing sarcoma,5 rhabdomyosarcoma,6 neuroblastoma,7 rhabdoid tumour,8 and myxo-inflammatory fibroblastic sarcoma.9 Cytological features are sufficient to permit grading and to predict MYC amplification in neuroblastoma.10 For certain rare entities such as retinoblastomas and nephroblastomas, imaging can be sufficient for a conclusive diagnosis and in many other cases FNA cytology is
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Editorial
satisfactory for diagnosis. Although nephroblastomas in patients under 1 year or over 6 years of age should have complete cytohistological analyses to confirm the diagnosis, diseases such as Langerhans cell histiocytosis (histiocytosis X) can be reliably diagnosed using cytological material alone.11 Haemopathies are the ideal target for cytological diagnosis.12 Aspiration provides cell-rich material, which can be successfully used for flow cytometry, cell block preparation and ICC, molecular studies and cryo-preservation.13 In several hospitals, ICC is performed using liquid-based material. At the Institut Curie and Padova University Hospital, we have devised protocols to obtain cell blocks, which allow the use of a standardized panel of different antibodies with a ‘histopathological level of quality’. As pathologists and cytopathologists, we now have to confront the emerging role of so-called ‘liquid biopsy’, in which, in serial plasma sampling, it will be possible to monitor disease progression, response or resistance to therapy by the investigation of circulating tumour cells or exosomes.14–17 These techniques are still confined to specialized laboratories, but it is expected that, in the near future, they will be automated and commercially available. In the meantime, however, tissue sampling remains mandatory for diagnosis. If molecular abnormalities allow the re-definition and ‘molecular’ classification of paediatric tumours, it has been demonstrated that FNA can achieve a sample of high cellularity with an absence of necrosis and nontumoural and stromal cells. Barroca and BomSucesso deal with these problems with the clear vision that in primitive or metastatic paediatric tumours, in a dedicated multidisciplinary team and an adequate cytological sample, an educated and expert cytopathologist can safely and rapidly reach the correct diagnosis, and obtain sufficient material for molecular and genetic investigations, cell block preparations and tissue banking. A. Fassina* and J. Klijanienko† *Department of Medicine, Surgical Pathology and Cytopathology Unit, University of Padoua, Padoua, Italy and † Department of Pathology, Institut Curie, Paris, France E-mail: [email protected] References 1. Barroca H, Bom-Successo M. Multidisciplinary diagnostic approach combining fine needle aspiration, core
2.
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8.
9.
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needle biopsy and ancillary techniques in paediatric tumors. Cytopathology 2014;25:6–20. Zajdela A, Zillhardt P, Voillemot N. Cytological diagnosis by fine needle sampling without aspiration. Cancer 1987;59:1201–5. Simonato F, Ventura L, Sartori N et al. Detection of microRNAs in archival cytology urine smears. PLoS One. 2013,8:e57490. T€ otsch M, Cuvelier C, Vass L, Fassina A. The UEMS section/board of pathology, chapter 6: requirement for recognition of postgraduate training in pathology: a presentation of the Paris document. Cytopathology 2012;23:295–9. Brisse HJ, Orbach D, Klijanienko J. Soft tissue tumours: imaging strategy. Pediatr Radiol 2010;40: 1019–28. Barroca H, Souto Moura C, Lopes JM et al. Ewing’s sarcoma/primitive neuroectodermal tumor with neuroendocrine differentiation: report of an unusual lung tumor. Int J Surg Pathol 2013; doi: 10.1177/1066896913 502227 [Epub ahead of print]. Klijanienko J, Caillaud JM, Orbach D et al. Cyto-histological correlations in primary, recurrent and metastatic rhabdomyosarcoma: the Institut Curie’s experience. Diagn Cytopathol 2007;35:482–7. Klijanienko J, Couturier J, Bourdeaut F et al. Fine-needle aspiration as a diagnostic technique in 50 cases of primary Ewing sarcoma/peripheral neuroectodermal tumor (ES/PNET). Institut Curie’s experience. Cancer Cytopathol 2012;40:19–25. Thomson T, Klijanienko J, Bourdeaut F et al. Fine needle aspiration in rhabdoid tumor. Institut Curie’s experience. Cancer Cytopathol 2011;119:49–57. Alaggio R, Coffin CM, Dall’Igna P et al. Myxoinflammatory fibroblastic sarcoma: report of a case and review of the literature. Pediatr Dev Pathol 2012;15: 254–8. Klijanienko J, Couturier J, Brisse J et al. Diagnostic and prognostic information obtained using fine-needle aspirates in primary neuroblastic tumors. Proposition of cytology prognostic score. Cancer Cytopathol 2011;119: 411–23. Fassina A, Olivotto A, Cappellesso R, Vendraminelli R, Fassan M. Fine-needle cytology of cutaneous juvenile xanthogranuloma and Langerhans cell histiocytosis. Cancer Cytopathol 2011;119:134–40. Mathiot C, Decaudin D, Klijanienko J et al. Fineneedle aspiration cytology combined with flow cytometry immunophenotyping is a rapid and accurate approach for the evaluation of suspicious superficial lymphoid lesions. Diagn Cytopathol 2006;34: 472–8. Fassina A, Marino F, Siri M et al. The miR-17-92 microRNA cluster: a novel diagnostic tool in large B-cell malignancies. Lab Invest 2012;92:1574–82.
© 2014 John Wiley & Sons Ltd Cytopathology 2014, 25, 3–5
Editorial
15. Pantel K, Alix-Panabieres C. Real-time liquid biopsy in cancer patients: fact or fiction? Cancer Res 2013;73: 6384–8. 16. Raimondi C, Gradilone A, Gazzaniga P. Controversies in circulating tumor cell count during therapy. Expert Rev Mol Diagn 2013;13:499–507.
© 2014 John Wiley & Sons Ltd Cytopathology 2014, 25, 3–5
17. Murtaza M, Dawson SJ, Tsui DW et al. Non-invasive analysis of acquired resistance to cancer therapy by sequencing of plasma DNA. Nature 2013;497:108–12. 18. Heyn H, M endez-Gonz alez J, Esteller M. Epigenetic profiling joins personalized cancer medicine. Expert Rev Mol Diagn 2013;13:473–9.
5
DOI:10.1111/cyt.12130
Multidisciplinary and multimodal diagnostic approach in paediatric tumours combining fine needle aspiration, core needle biopsy and ancillary techniques
In this issue of Cytopathology, Drs Helena Barroca and Maria do Bom-Sucesso, from Porto Centro Hospitalar de S. Joao in Portugal, describe the combination of fine needle aspiration (FNA) and molecular analysis in paediatric tumours, which now appears to be both the optimal and required multimodal approach to diagnosis.1 For many decades, the modalities of tumour diagnosis in children have been the subject of debate. Several centres practice an ‘open sky’ surgical biopsy, obtaining abundant tumour material sufficient for histopathological and molecular analyses, but with a number of drawbacks, such as the non-repeatability of the procedure and the relatively longer delay in providing a provisional report. Moreover, the fragile clinical status of young patients makes it difficult for an open biopsy to be performed, can be difficult in newborns and may possibly be dangerous in patients with advanced disease. In recent years, ‘small volume biopsies’, such as FNA and core needle biopsy (CNB), have overcome the insistance of clinicians and ‘old school pathologists’ on open biopsy and have entered common use in adult and paediatric oncology. The multidisciplinary team, including an oncologist, radiologist, pathologist and molecular biologist, is called upon to decide the combined or separate use of FNA, CNB and molecular studies, according to the consensus hospital protocol. For paediatric tumours FNA is performed with 23- or 27-gauge (outer diameter, 0.57 and 0.36 mm) needles, either using the simple non-aspirative Zajdela’s technique2 or with aspiration through a syringe, with or without radiological guidance. (The lack of aspiration, or negative pressure, in their fine needle technique is the reason Barroca and Bom-Sucesso use the term ’fine needle biopsy’ in their article.1). This simple technique bears a low complication rate and can be repeated in sedated patients until the material is considered to be satisfactory after microscopic examination of slides stained using a modified Giemsa or rapid Diff-Quick method: rapid on-site evaluation (ROSE). When sedation is not used, the ROSE technique should always be employed to evaluate the quality of the material since children may not tolerate a second attempt: the © 2014 John Wiley & Sons Ltd Cytopathology 2014, 25, 3–5
pathologist or radiologist should be proficient enough to obtain adequate material on the first attempt. Apart from evaluation of the sample for adequacy, and in many instances provision of a preliminary diagnostic opinion, ROSE permits immediate decisions to be made, such as catheter installation, bone marrow biopsy sampling, saving appropriate material for immunocytochemistry (ICC), molecular analysis or flow cytometry, or the need for further biopsy. Examples of the value of ROSE are the differential diagnosis between nephroblastoma, neuroblastoma and non-Hodgkin lymphoma, where flow cytometry might be helpful, or between Ewing sarcoma versus osteosarcoma, when clinical or radiological settings are non-specific. However, and most important for planning educational programmes for European Union pathologists and radiologists, the quality of the sample is operator dependent and FNA techniques require specific training, experience and dedication.3 CNB performed with 16- (outer diameter 1.3-mm) or 14-gauge needles usually harvests an adequate volume of tumour tissue for histopathology and immunohistochemistry, but cannot be repeated if excessive haemorrhage or necrosis is harvested, whereas, under ultrasound or computed tomography guidance, FNA can avoid necrotic areas, targeting the solid foci of the tumour. Moreover, new techniques allow precise molecular evaluation from a few cells, and also from archival material.4 Specific anatomical sites, such as retrobulbar, deep orbit, intracranial, intrathoracic, retroperitoneal nodules or vascularized tumours, cannot be reached by CNB, but are easily accessible by thin needles. As in the experience of Barroca and BomSucesso, we believe that many malignancies can be unquestionably diagnosed using FNA material, as in Ewing sarcoma,5 rhabdomyosarcoma,6 neuroblastoma,7 rhabdoid tumour,8 and myxo-inflammatory fibroblastic sarcoma.9 Cytological features are sufficient to permit grading and to predict MYC amplification in neuroblastoma.10 For certain rare entities such as retinoblastomas and nephroblastomas, imaging can be sufficient for a conclusive diagnosis and in many other cases FNA cytology is
3
4
Editorial
satisfactory for diagnosis. Although nephroblastomas in patients under 1 year or over 6 years of age should have complete cytohistological analyses to confirm the diagnosis, diseases such as Langerhans cell histiocytosis (histiocytosis X) can be reliably diagnosed using cytological material alone.11 Haemopathies are the ideal target for cytological diagnosis.12 Aspiration provides cell-rich material, which can be successfully used for flow cytometry, cell block preparation and ICC, molecular studies and cryo-preservation.13 In several hospitals, ICC is performed using liquid-based material. At the Institut Curie and Padova University Hospital, we have devised protocols to obtain cell blocks, which allow the use of a standardized panel of different antibodies with a ‘histopathological level of quality’. As pathologists and cytopathologists, we now have to confront the emerging role of so-called ‘liquid biopsy’, in which, in serial plasma sampling, it will be possible to monitor disease progression, response or resistance to therapy by the investigation of circulating tumour cells or exosomes.14–17 These techniques are still confined to specialized laboratories, but it is expected that, in the near future, they will be automated and commercially available. In the meantime, however, tissue sampling remains mandatory for diagnosis. If molecular abnormalities allow the re-definition and ‘molecular’ classification of paediatric tumours, it has been demonstrated that FNA can achieve a sample of high cellularity with an absence of necrosis and nontumoural and stromal cells. Barroca and BomSucesso deal with these problems with the clear vision that in primitive or metastatic paediatric tumours, in a dedicated multidisciplinary team and an adequate cytological sample, an educated and expert cytopathologist can safely and rapidly reach the correct diagnosis, and obtain sufficient material for molecular and genetic investigations, cell block preparations and tissue banking. A. Fassina* and J. Klijanienko† *Department of Medicine, Surgical Pathology and Cytopathology Unit, University of Padoua, Padoua, Italy and † Department of Pathology, Institut Curie, Paris, France E-mail: [email protected] References 1. Barroca H, Bom-Successo M. Multidisciplinary diagnostic approach combining fine needle aspiration, core
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
needle biopsy and ancillary techniques in paediatric tumors. Cytopathology 2014;25:6–20. Zajdela A, Zillhardt P, Voillemot N. Cytological diagnosis by fine needle sampling without aspiration. Cancer 1987;59:1201–5. Simonato F, Ventura L, Sartori N et al. Detection of microRNAs in archival cytology urine smears. PLoS One. 2013,8:e57490. T€ otsch M, Cuvelier C, Vass L, Fassina A. The UEMS section/board of pathology, chapter 6: requirement for recognition of postgraduate training in pathology: a presentation of the Paris document. Cytopathology 2012;23:295–9. Brisse HJ, Orbach D, Klijanienko J. Soft tissue tumours: imaging strategy. Pediatr Radiol 2010;40: 1019–28. Barroca H, Souto Moura C, Lopes JM et al. Ewing’s sarcoma/primitive neuroectodermal tumor with neuroendocrine differentiation: report of an unusual lung tumor. Int J Surg Pathol 2013; doi: 10.1177/1066896913 502227 [Epub ahead of print]. Klijanienko J, Caillaud JM, Orbach D et al. Cyto-histological correlations in primary, recurrent and metastatic rhabdomyosarcoma: the Institut Curie’s experience. Diagn Cytopathol 2007;35:482–7. Klijanienko J, Couturier J, Bourdeaut F et al. Fine-needle aspiration as a diagnostic technique in 50 cases of primary Ewing sarcoma/peripheral neuroectodermal tumor (ES/PNET). Institut Curie’s experience. Cancer Cytopathol 2012;40:19–25. Thomson T, Klijanienko J, Bourdeaut F et al. Fine needle aspiration in rhabdoid tumor. Institut Curie’s experience. Cancer Cytopathol 2011;119:49–57. Alaggio R, Coffin CM, Dall’Igna P et al. Myxoinflammatory fibroblastic sarcoma: report of a case and review of the literature. Pediatr Dev Pathol 2012;15: 254–8. Klijanienko J, Couturier J, Brisse J et al. Diagnostic and prognostic information obtained using fine-needle aspirates in primary neuroblastic tumors. Proposition of cytology prognostic score. Cancer Cytopathol 2011;119: 411–23. Fassina A, Olivotto A, Cappellesso R, Vendraminelli R, Fassan M. Fine-needle cytology of cutaneous juvenile xanthogranuloma and Langerhans cell histiocytosis. Cancer Cytopathol 2011;119:134–40. Mathiot C, Decaudin D, Klijanienko J et al. Fineneedle aspiration cytology combined with flow cytometry immunophenotyping is a rapid and accurate approach for the evaluation of suspicious superficial lymphoid lesions. Diagn Cytopathol 2006;34: 472–8. Fassina A, Marino F, Siri M et al. The miR-17-92 microRNA cluster: a novel diagnostic tool in large B-cell malignancies. Lab Invest 2012;92:1574–82.
© 2014 John Wiley & Sons Ltd Cytopathology 2014, 25, 3–5
Editorial
15. Pantel K, Alix-Panabieres C. Real-time liquid biopsy in cancer patients: fact or fiction? Cancer Res 2013;73: 6384–8. 16. Raimondi C, Gradilone A, Gazzaniga P. Controversies in circulating tumor cell count during therapy. Expert Rev Mol Diagn 2013;13:499–507.
© 2014 John Wiley & Sons Ltd Cytopathology 2014, 25, 3–5
17. Murtaza M, Dawson SJ, Tsui DW et al. Non-invasive analysis of acquired resistance to cancer therapy by sequencing of plasma DNA. Nature 2013;497:108–12. 18. Heyn H, M endez-Gonz alez J, Esteller M. Epigenetic profiling joins personalized cancer medicine. Expert Rev Mol Diagn 2013;13:473–9.
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