Presentation by Dr. Mahra Nourbakhsh about current adequacy criteria for cytology specimen

1. Adequacy Criteria for
Cytology Specimens
Mahra Nourbakhsh, MD, PhD
Resident Physician, PGY-3
Anatomical Pathology

2. What is an adequate sample?
Disappointing and Confusing!!

3. • Technique (FNA, Brushing, Washing, Exfoliation, etc.)
• Operator (Clinician, Surgeon, Radiologist, Pathologist)
• Organ
• Type of lesion (Solid, Cystic, Solid/Cystic)
• Pathology: (Non/Neoplastic, Malignant, Benign,
inflammatory)
• Complexity of the pathology (Tumor with dual
differentiation, carcinosarcoma, warthine tumor, etc.)
• Preparation, processing, staining
• Patient’s condition (age, gender, history, clinical
findings)
There is no simple answer

4. False Negative & False Positive

5. Representative Sample
Normal Lesion

6. • Webster’s Dictionary: sufficient in quality
and/or quantity to satisfy one’s needs.
• Bethesda System: Appropriate labeling and
identifying information; Relevant clinical information;
Adequate numbers (a compilation from the literature)
of well-preserved and well-visualized representative
component cells
• My approach to adequacy: When there is
discordance in clinical, radiologic and cytology
findings, the adequacy of the specimen is
questionable.
What is an adequate sample?

7. Uterine Cervix
• A consensus on adequacy of cervical
smear has been reached however the
adequacy should still be considered
case by case.
• Variable:
1. Obscuring Element
2. Minimum Squamous Cellularity
3. Presence of Transformational Zone
(absence does not automatically indicates
unsatisfactory specimen)

8. Uterine Cervix
Obscuring Elements
•Elements:
– Blood
– Inflammation
– Necrotic artifacts
•If covers more than 75% of epithelial
cells unsat

9. Uterine Cervix
Minimum Squamous Cellularity
•Liquid Base
– At least 5000 squamous cells
– Metaplastic squamous cell are acceptable
– Endocervical and Endometrial cells are not
included.
•Conventional
– At least 8000-12000 squamous cells
– Metaplastic squamous cell are acceptable
– Endocervical and Endometrial cells are not
included.

10. Uterine Cervix
Presence of T Zone
•T-Zone:
– At least 10 well-preserved endocervical or
squamous metaplastic cells singly or in
cluster
•Absence of T-Zone does not automatically
classifies the specimen as unsatisfactory.
•Report if T-zone present or absent.

11. Uterine Cervix
35F TAH 2°to a benign
condition
Estimated cells of 5000-10000
Hysterectomy

12. Uterine Cervix
56F TAH 2°to Endometrial CA Estimated cells of 5000-10000
Hysterectomy

13. Uterine Cervix
56F with pelvic radiation Estimated cells of 5000-10000
Hysterectomy

14. Uterine Cervix
46F with recent chemotherapy Estimated cells of 5000-10000
Hysterectomy

15. Uterine Cervix
Does reduction of cellularity from 8000 to 2000 is
wise in post chemotherapy, post pelvic radiation or
hysterectomy?
Lu Ch, et. Al. Cancer Cytopathol. 2010;118 (6):474-81
•7059 pap, 1361 had Hx of pelvic radiotherapy,
chemotherapy and hysterectomy.
•Results:
•No increase in false-negative rate
•Hysterectomy does not significantly correlates with
unsatisfactory Pap
Unsat Criteria <8000 <2000
Post Radiotherapy 17.9% 7.6%
Post Chemotherapy 19.6% 6%

16. Respiratory Tract (Sputum)
• Guideline of Pap Society of
Cytopathology Task Force
Mod Path. 1999; 12 (4): 427-436
1. Must contain alveolar macrophages
2. No numerical cut point for macrophages,
but should be easily identifiable
3. Should be large enough to prepare at least
2-4 slides.
4. Sensitivity to diagnose malignancy increase
from 42% with a single specimen to 91%
with five specimen.

17. Respiratory Tract
(washing and brushing)
• Guideline of Pap Society of
Cytopathology Task Force
Mod Path. 1999; 12 (4): 427-436
1. Large number of (not exactly defined), well-
preserved, optimally stained ciliated
bronchial epithelial cells and macrophages.
2. Should not be heavily contaminated with
oral squamous cells or saprophytes
3. Absence of obscuring elements.

18. Respiratory Tract (BAL)
• Guideline of Pap Society of Cytopathology Task
Force
Mod Path. 1999; 12 (4): 427-436
1. >5% of ciliated or squamous epithelial cells 
contamination of distal airways.
2. Chamberlain et.al criteria of inadequacy:
Chamberline DW, et. Al. Acta Cytol 1987;31:599-605
• Less than 10 alveolar mac/ 10 hpf
• Less than 25 alveolar mac/10hpf and one of the
followings:
– Excessive epithelial cells with degenerative features or
exceeding number of macs
– Mucopurulent exudate of PMN
• Numerous obscuring RBC
• Degenerative changes or artifact obscuring cell
identity

19. Respiratory Tract (FNA)
• Guideline of Pap Society of
Cytopathology Task Force
Mod Path. 1999; 12 (4): 427-436
1. Complex issue
2. No universally acceptable criteria in the
absence of abnormality.
3. Depends on procedure, operator skills and
location and size of the lesion.
4. The findings are insufficient to account for
the lesion
5. Use non-diagnostic rather than Unsat

20. Respiratory Tract
• 65 M smoker, 5 cm speculated mass, BAL

21. Too Much Text

22. Urine and Bladder
• Usefulness of the specimen to
diagnose or broach the suspicion of
urothelial carcinoma.
• Is determined by the interplay of:
1. Collection type
2. Cellularity
3. Volume
4. Cytomorphological findings

23. Urine and Bladder
• Limited publication on the role and and
specific qualifiers of collection type,
cellularity, and volume.
• Adequacy algorithm based on Paris system
recommendation:
1. The communication between volume, collection
type and cellularity.
2. Guide for individual labs in validating appropriate
cut-offs for their own practice settings
3. Frame the future investigations dealing with
adequacy of urine specimen

24. Urine and Bladder
Cellularity
Collection Type
Volume

25. Urine and Bladder: Cellularity
Instrumental Urinary Specimen
1.Sat: 20 well-preserved, well-visualized. Urothelial cells per 10
high-power fields.
2.Sat but limited by low cellularity: 10-20 cells
3.Unsat: <10 cells
Prather J, Arville B, Chatt G, et al. J Am Soc Cytopathol. 2015;4:57-62
•1322 urothelial cells (10 per 10 hpfs) for diagnosis of atypical
urothelial cells and above.
Prather J, et. al. J Am Soc Cytopathol. 2013; 2: S24-S25
1.2644 urothelial cells (20 per 10 hpfs) in the absence of
atypical cells or higher to increase the positive predictive value
of this test.
Prather J, Arville B, Chatt G, et al. J Am Soc Cytopathol. 2015;4:57-62

26. Urine and Bladder: Cellularity
Voided Urine Specimen
1.No paper in literature review
investigating the cellularity required for
adequacy in voided urine specimen.
2.However two studies suggest cell
counts for surveillance but are older
studies (>80 urothelial cells/hpf?!).
Morse N, et. al. Acta Cytol 1974: 18:312–315
Murphy WM, et. al. J Urol 1981:126:320–322.

27. Urine and Bladder: Volume
• At least 30 ml of urine is required in voided
urine samples.
VandenBussche CJ, et. al. Cancer Cytopathol. 2016;124:174-180
1. Indication of voided urine cytology were not
provided.
2. SurePath method.
• The Paris system recommendation shows
two microscope-dependent nodes precede
volume in the adequacy algorithm:
1. finding of atypical, suspicious, or malignant cells
2. an adequate number of benign urothelial cells

28. Fluids (Pleural, Pericardial, Peritoneal)
• Adequacy have no role in providing
procurement information.
• Adequacy have a role in identifying
processing problem.
• In the absence of abnormality or
acellular fluid, no criteria has been
indicated for adequacy.
Crothers, BA. Et al. Arch Pathol Lab Med. 2009 Nov;133(11):1743-56

29. Peritoneal Wash
• In the absence of abnormal cells
presence of mesothelial cells is
recommended for reporting a
specimen adequate.
McGowan L. et. Al. Obstet. Gynecol. 1989;73:136-137
• No consensus is reached for
adequacy of washes.

30. CSF
• Adequacy have no
role in providing
procurement
information. It is
based on how much
the lesion exfoliates.
• No consensus has
reached
My dog shed

31. GI Tract (FNA)
• An adequate is one that explain the
clinical/endoscopic findings.
• It is reasonable to consider a FNA
adequate if there is sufficient cellularity to
suggest limited DDX or explain the
clinical/radiologic findings.
• Scant cellularity, obscuring elements,
poorly preserved samples are the reasons
for unsatisfactory aspirates
•

32. GI Tract (Brushing)
• No consensus is reached regarding
adequacy.
• An adequate brushing is one with 6-10 well-
visualized and well-preserved epithelial cell
groups (at least 6 cells/cluster).
• Too few cells, poor preservation, degenerated
cells, obscuring elements render the
specimen unsatisfactory
Moody Dr. CAP Today. August 2003, pp 68-70

33. Breast
• Two opposite views toward the
adequacy
• An epithelial cell cluster (ECC) cut
off number for adequacy
• Non cellular features such as type of
the lesion instead of ECC cut off
number

34. Breast
• Study #1: 4455 FNA, 51 false negative
in MD Anderson Cancer Institute from
1985-1995.
Boerner S., and Sneige N. Cancer 1998; 84: pp. 344-348
– Criteria: 6 ECCs on all slides for a
sample to be classified as adequate,
– Results: 50% of the false-negative
was avoided.
presence ≥ 10 intact bipolar cells per 10 medium-
power fields (×200),

35. Breast
• Study #2: 1779 FNA, 21 false negative
in Duke University Medical Center
(1992-1995) and UCLA Center for the
Health Sciences (1984-1990).
Boerner S., and Sneige N. Cancer 1998; 84: pp. 344-348
– Criteria: 6 ECCs or >10 bipolar cells in
each of medium power field (X200) on all
slides for a sample to be classified as
adequate,
– Results: False negative rate 1.5% and
unsat ratio of 20.2%.
Layfield L.J., Mooney E.E. et. al. Cancer 1997; 81: pp. 16-21

36. Breast
• F32 with no FHx of breast malignancy
with a Cystic Lesion at 10 O’clock,
measuring 3.2 cm in largest dimension
presence ≥ 10 intact bipolar cells per 10 medium-
power fields (×200),

37. Breast
• F52 with a Solid mass at 7 O’clock,
measuring 1.8 cm in largest dimension
presence ≥ 10 intact bipolar cells per 10 medium-
power fields (×200)

38. Breast (conclusion)
• No consensus reached.
• For suspected epithelial lesion, 6 epithelial
cell cluster of 5-10 cells each reduces the
false negativity.
• For non-epithelial lesion no minimal cell
group is proposed.
• Use of triple test is highly recommended.
• No consensus reached for nipple
discharge cytology

39. Thyroid
• Minimum six group of well preserved , well
visualized follicular cells
• Each group contains a minimum of 10 cells.
• Preferably all six groups are on same slide
• Fewer follicular cell groups may be
accepted if there is abundance of
lymphocytes, granulomas or colloid.

40. Thyroid

41. Thyroid
• F43 with a cystic nodule at inferior pole
of Lt. thyroid, measuring 2.8 cm
presence ≥ 10 intact bipolar cells per 10
medium-power fields (×200)

42. Thyroid
• F39 with a cystic nodule at superior
pole of Rt. thyroid, measuring 2.9 cm
presence ≥ 10 intact bipolar cells per 10
medium-power fields (×200)

43. Thyroid
• 6 months later

44. Salivary Gland
• Adequacy criteria has not been established yet.
• The rate of false negative is related to type of
lesion, the operator (Cytopathologist, vs.
Radiologist vs. Surgeon).
• False negative results are most common with
low-grade mucoepidermoid carcinoma, adenoid
cystic carcinoma, and non-Hodgkin lymphoma
• False-positive diagnoses are seen with cystic
lesions, particularly WT and pleomorphic
adenoma (PA).

45. Salivary Gland
• Experience of UPMC: 294 case from 1999-
2012, with FNA and then surgical specimen
obtained within 6 months.
Griffith CC, et. al, AM J Clin Pathol. 2015 Jun;143(6):839-53
• Adequacy Criteria: 4 hpf (×400) of epithelial
cells
• Results: 28.2% inadequacy rate, including
38.6% non-neoplastic, 43.4% benign and 18.1%
malignant including one case of high grade.
• Results: Specificity for pleomorphic adenoma
98.8% but sensitivity only 58.2%

46. Lymph Node
• FNA of any lymph node: at least a
moderate number of lymphocytes
must be present.
• Well preserved, well visualized
lymphocyte is required.
• Based on the location of the lymph
node the adequate sample might
be difficult to obtained.

47. Lymph Node (mediastinum)
• Rapid On-Site Evaluation of FNA
and Core Needle Biopsy
Choi, SM. et. Al. Ann Thorac Surg. 2016 Feb;101(2):444-50
• Using four sequential criteria, tissue core
size, the presence of malignant cell,
microscopic anthracotic pigments, and
LD ‡40 cells/field, the sensitivity and
accuracy rates increased from 64.4% to
98.6% and from 64.7% to 97.3%,
respectively.

48. Kidney
• Up to 30% of renal aspirates are
non-diagnostic (inadequate)
• Repeat aspiration is helpful in 50% of
case.
• Technical failure is number one
reason for inadequacy.
• No consensus on adequacy criteria

49. Kidney
• Analysis of Results and Diagnostic Problem in
108 FNA of Renal Masses in Adult.
Truong, LD. et. Al. Diagnostic Cytopathol; 1999;20(6):339-349
Adequacy criteria in solid lesion:
• Unsat:
1. soft tissue and/or normal kidney tissue only
2. Blood or necrotic material only
3. Technically poor
4. Scant cellularity: smear contains few cells or small cluster,
the nature of which cannot determined.
• Sat:
1. Large number of well-preserved, isolated or cell clusters,
which allow at least limited DDX

50. Kidney
• Analysis of Results and Diagnostic Problem in
108 FNA of Renal Masses in Adult.
Truong, LD. et. Al. Diagnostic Cytopathol; 1999;20(6):339-349
Adequacy criteria in cystic lesion:
• Unsat:
1. soft tissue and/or normal kidney tissue only
2. Blood or necrotic material only
• Sat:
1. Fluid regardless of cellularity

51. Kidney
• Analysis of Results and Diagnostic Problem in
108 FNA of Renal Masses in Adult.
Truong, LD. et. Al. Diagnostic Cytopathol; 1999;20(6):339-349
Results:
1. The rate of unsat was 16% in lesion containing
solid compartment and 0% in cystic lesion
2. Only one false negative case (out of 34) judged
benign while later biopsy showed malignant
RCC.

52. Kidney
• 72M with a cystic renal lesion

53. Kidney
Current recommendation:
•No consensus, however it is reasonable to
consider a FNA adequate if there is
sufficient cellularity to suggest limited DDX.
•Specimen composed exclusively
macrophages (typically cystic lesion) is
best reported as non-diagnostic as cystic
RCC can not be ruled out.

54. Adrenal Gland, Ovary
and Deep Solid Organs
• No Standard consensus.
• Similar to Kidney (and other deep solid
organs), presence of sufficient
cellularity to suggest limited DDXs.
• Scant cellularity, obscuring elements,
poorly preserved samples are the
reasons for unsatisfactory aspirates.

55. Conclusion
• There is no simple/single criteria for
adequacy
• Adequacy should remain in the
discretion of cytopathologists even in the
organ system with a defined adequacy
criteria
• Clinical, radiologic and cytopathologic
findings remain the most important
factors for determining adequacy criteria

56. Thank you!
Question/Discussion?!