PART TWO
Diagnostic Cytology
Table 17.2 Final Diagnoses for Lesions Aspirated at UCLA, 1987-1994
Lymphoid lesions
(43%)
Atypical/reactive
13
Malignant lymphoma
15
Plasma cell dyscrasia (myeloma)
2
Leukemia
1
Sclerosing orbititis
1
Acute/chronic inflammation
2
Abscess
1
Dacryoadenitis
1
Granulomatous lesions
(8%)
Granulomas
4
Chalazion
1
Wegener's granulomatosis
1
Eosinophilic granuloma
1
Epithelial tumors
(20%)
Adenocarcinoma (breast, prostate)
4
Squamous carcinoma (sinus, lungs)
3
Adenoid cystic carcinoma
3
Melanoma
3
Undifferentiated carcinoma
2
Sebaceous carcinoma
1
pleomorphic adenoma
1
Small-cell tumors
(4%)
Oat cell carcinoma
1
Neuroblastoma
1
Rhabdomyosarcoma
1
Miscellaneous tumors
(24%)
Meningioma
5
Dermoid cysts
3
Cavernous hemangioma
3
Schwannoma
2
Myxoid tumor
1
Mucocele
1
Insufficient
5
Total
83
UCLA = University of California, Los Angeles.
Reproduced from Glasgow BJ, Goldbert RA, Gordon LK, et al. Fine-needle
aspiration of orbital masses.
O phthalm ol Clin North Am
1995;8:73-81.
inconsistent and therefore diagnostically unreliable inflamma-
tory pattern.48 Another article correlated perinatal ocular and
maternal genital infections and concluded that only 61% of 54
mothers of a set of infected newborns had diagnosable
Chlamydia
in recent cervical smears, further emphasizing the need for reli-
able identification of this organism.5 Some have emphasized the
importance of immunocytochemical confirmation of suspected
disease and recommend that Giemsa-stained smears be used
as a screening procedure. Since the availability of monoconal
antibodies to
Chlamydia
, we no longer use Giemsa-stained
smears for
Chlamydia
screening. Another article suggests con-
sidering the diagnostic sensitivity of DNA-probe technology for
this difficult morphologic diagnosis.49 Polymerase chain reac-
tion was compared with standard McCoy cell culture to detect
Chlamydia trachomatis
in cervical and ocular secretions from
100 mother/newborn pairs. It was concluded that polymerase
chain reaction is equally specific and more sensitive than McCoy
cell culture.50 In another study, PCR performed comparably to
culture for detection of
C.
trachomatis
in conjunctival and
nasopharyngeal specimens from infants with conjunctivitis.51
Key features of chlamydial conjunctivitis
• Epithelial cytoplasmic inclusion bodies.
Neoplasia
The most common malignant neoplasm of the conjunctiva is
squamous carcinoma. Although generally amenable to biopsy,
rarely, the less preferred method of scraping cells from the cornea
or conjunctiva may be performed. Ideally these preparations, if
smeared, should be fixed in 95% ethanol and PAP-stained. The
criteria for diagnosis include cytologic atypia, which in some
cases may be accompanied by keratinization. The difficulty with
this method is that the level of dysplasia cannot be assessed
easily and invasion cannot be excluded.
Key features of conjunctival neoplasias
• Clusters and single cells with nuclear enlargement;
and
• High nuclear-to-cytoplasmic ratios.
Orbit
Most lesions of the orbit are approached by FNA,52 a technique
requiring an ophthalmologist familiar with the anatomy of the
orbit and adnexa and capable of treating any complications.
A number of series on FNA of the orbit have been reported. In one
report, 156 orbital lesions were aspirated, with carcinomas being
the most common (28%), followed by inflammation (19%),
lymphoid lesions (17%), neural tumors (6%), other neoplasms
(6%), and miscellaneous diseases (3%).53 This report observed
that insufficient aspirates are usually a consequence of a fibrous
lesion, an orbital apical location, or a lymphocytic tumor with
insufficient cells for a definitive diagnosis.54 In more recent stud-
ies, the results of fine-needle aspiration of six primary lacrimal
gland neoplasms were reported.55
The published UCLA/JSEI experience of 83 orbital aspirates
is summarized by frequency of cellular component and by
final diagnosis Table 17.2.56 The most common diseases were
lymphoid lesions (43%), followed by miscellaneous tumors
including neural lesions (24%), epithelial tumors (20%), gran-
ulomatous lesions (8%), and small-cell tumors (4%).
A report in the literature analyzed the diagnostic errors in
a total of 644 published cases of orbital lesions, including the
83 originating at UCLA.56 Interpretive errors (false-positives)
resulted from overreacting to reactive or benign cells or the clini-
cal setting. Insufficient cellularity was the greatest cause of false-
negative diagnoses. The most common lesions in this category
were basal cell epitheliomas and lymphoid lesions.
Successful
FNA diagnosis
of this relatively unfamiliar
area depends on a team of skilled individuals: ophthalmolo-
gist, radiologist, ophthalmologic pathologist, and cytopatho-
logist.
460
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