Is it time to standardize fine needle aspiration of gall bladder lesions and what city name it will be stamped with?

In the current era of “Total Quality Management”, all stake holders in health care are trying their best to improve the standards of care coupled with attempts to reduce cost.[123] Although, almost all experts in the field of health care quality agree that creating and applying additional quality standards may add some extra cost; many strongly believe that long term benefits would balance these initial financial restrains.[34] The quality care trends are highly infectious and pathology and laboratory medicine is not an exception. The art and science of cytopathology has been a leader in the field of standardization as we witnessed the level of quality in the Bethesda systems for the “Pap test” and thyroid in addition to the Paris system for urine cytology and the recent addition of Milan system for salivary gland cytology.[5678]

In the current issue of CytoJournal, Chandra et al. attempted to plant the initial seeds to standardize the terminology of aspirate smears from gall bladder lesions.[9] They retrospectively reviewed 433 fine needle aspirate smears from gall bladder lesions in their institutions followed up by cytohistological correlation analysis for 93 cases where tissue diagnosis was available with a cytohistological concordance of 94%. Their cytomorphological review included objective analysis of multiple parameters. These included architectural patterns, cellular morphology, nuclear features and the type of background material. Similar to the terminology utilized in other systems; they proposed 5 distinct major categories: Category I: Inadequate, Category II: Benign, Category III: Atypical, Category IV) Atypical suggestive or suspicious for malignancy, and Category V: Malignant. The inadequate category in this study comprised 7.8% which is essentially an acceptable rate given the peculiarities of these aspirates where in few cases the procurement of diagnostic material is either acellular or unsatisfactory to make a reasonable interpretation. The second category was the essentially the negative cases where the interpretation included reactive cases, inflammatory conditions and benign neoplasms. And this category comprised 11.5% of their cases. Almost less than 10% of the cases represented the equivocal cases where definitive diagnosis could not be reached. The first one is the atypical category where the atypia was mild enough not to raise suspicious of malignancy and the authors recommended repeat aspiration taking into consideration the clinical and radiological features of these patients. The second one of this group is those cases where there was enough atypia crossing the threshold to raise suspicion of malignancy. Although the authors placed these categories in an equivocal box; we believe that their low rate (less than 10% for both category III and IV) is quite reasonable. Consequently; the follow up approach would likely depend on the degree of clinical and radiological suspicion of such cases where repeat aspiration or tissue biopsy would give a more definitive diagnosis. The fifth category was the positive cases where the cytomorphological criteria were met and this group was the most common where it comprised 71% of the study population cases.

The authors went further and tried to sub-classify their positive cases into a more specific diagnosis of malignancy including papillary, mucinous, small cell and poorly differentiated carcinoma. This latest attempt by authors, although sometimes helpful, we believe that this additional sub-classification might be included in a final comment, rather in the main stem diagnosis.

As expected, the lowest concordance rate was for category IV (80% cytohistological concordance rate), where 4 cases revealed a benign diagnosis. However, and as mentioned before, this category was relatively small and only comprised 4.3% of the study population. A previous trial to utilize the WHO histological classification of gall bladder carcinoma was attempted on a comparable number of cases but without delving into standardizing the terminology.[10]

In conclusion; the authors are commended in their attempt to standardize the interpretation categories for gall bladder lesions fine needle aspiration cytology. The study was based on objective cytomorphological criteria emphasizing evidence-based cytology.[11] We hope that this study will entice more efforts to add on the current authors findings. If the domino effect prevails here; it will be interesting to see which name this gall bladder cytology system will carry.

The authors are to be commended on their efforts on this well-written manuscript and their attempt to entice standardization of gall bladder lesions FNA.

COMPETING INTERESTS

The authors declare that they have no competing interests.

LIST OF ABBREVIATIONS (In alphabetic order)

FNA – Fine needle aspiration

Pap – Papanicolaou.