Fine-needle aspiration (FNA) is a well accepted initial approach in the management of thyroid lesions. It has come a long way since its introduction for nearly a century ago. In the Philippines, FNA of the thyroid was first introduced 30 years ago and has been utilized until now as a mainstay in the diagnosis of thyroid malignancy. The procedure is performed by pathologists, endocrinologists, surgeons, and radiologists. Most pathologists report the cytodiagnosis using a combination of the aspiration biopsy cytology method that closely resembles the histopathologic diagnosis of thyroid disorders and the six-tier nomenclature of The Bethesda System for Reporting Thyroid Cytopathology. Local endocrinologists and surgeons follow the guidelines of the 2015 American Thyroid Association in the management of thyroid disorders. There is still a paucity of local research studies but available data deal with cytohistologic correlations, sensitivity, specificity, and accuracy rates as well as usefulness of ultrasound-guided FNA. Cytohistologic correlations have a wide range of sensitivity from 30.7% to 73% and specificity from 83% to 100%. The low sensitivity can be attributed to poor tissue sampling since a majority of the thyroid FNA is done by palpation only. The reliability can be improved if FNA is guided by ultrasound as attested in both international and local studies. Overall, FNA of the thyroid has enabled the diagnosis of thyroid disorders with an accuracy of 72.8% to 87.2% and it correlates well with histopathology.
Biopsy, Fine-Needle* ; Biopsy, Needle ; Cytodiagnosis ; Diagnosis ; Methods ; Palpation ; Philippines* ; Sensitivity and Specificity ; Surgeons ; Thyroid Gland* ; Ultrasonography

A 65-year-old man consulted with a history of chronic snorting with a sensation of obstruction in the left side of the nasopharynx particularly when in supine position. A few days prior to consult, the patient had blood-tinged nasal discharge, thus this admission. No other symptoms were reported.

 

Nasal endoscopy showed a sessile exophytic lesion with a vaguely nodular surface, seen as a polypoid nasopharyngeal mass on Computed Tomography scan. (Figure 1)

 

Excision of the mass was performed. Received in the surgical pathology laboratory was a 1.8 x 1.5 x 0.6 cm red to brown, rubbery to firm, vaguely ovoid mass with a nodular external surface. Cut section showed a light gray solid surface. 

 

Microscopic examination shows a broad-based exophytic mass with invaginations of the surface epithelium and proliferated glands within the stroma. (Figure 2) The glands are tubular or variably dilated - many are lined by a respiratory-type epithelium with goblet cells and a thickened basement membrane, while the tubular glands are lined by a monolayered cuboidal epithelium. (Figure 3) Based on these features, we signed the case out as a respiratory epithelial adenomatoid hamartoma (REAH).

 

REAH is a benign proliferation of sinonasal tract glands derived from the surface epithelium.1 It occurs primarily in male adults, with a median age in the sixth decade of life. Most cases arise in the posterior nasal septum, while less common sites of involvement include other parts of the nasal cavity, the nasopharynx, and paranasal sinuses.2 Common symptoms include nasal obstruction, stuffiness, and epistaxis.1,3,4

 

REAH presents as a polypoid lesion and may measure up to 6 cm in widest diameter.1 Microscopically, there is a proliferation of small to medium-sized glands dispersed in abundant stroma. Invagination of the glands from the surface epithelium may be seen.3 The glands are round to oval, lined by respiratory-type epithelium with admixed goblet cells. Thickened basement membranes surround some of the glands, and smaller seromucinous glands lined by cuboidal epithelium may also be admixed among the latter. Other alterations may include squamous, chondroid, and osseous metaplasia.1,4

 

Rarely, REAH may occur synchronously with inverting sinonasal papillomas or inflammatory polyps.1 It may be mistaken for these two entities along with sinonasal low-grade adenocarcinomas. Careful attention to the typical morphology including absence of an infiltrative growth pattern and atypia allow distinction from these entities particularly the malignant mimics.3 A related entity is a seromucinous hamartoma with which REAH is believed to form a morphological spectrum.1

 

REAH is benign and complete excision confers cure.1 Malignant transformation has not been reported.1,3,4

 

Human ; Male ; Aged (a Person 65 Through 79 Years Of Age) ; Nasopharynx

Objectives: To evaluate abnormal Papanicolau smear results at the Philippine General Hospital (PGH) for the past four years by comparing abnormal smear cytology with histologic interpretations. Possible causes of discrepant results were also determined.

Methods: All Pap smears released as abnormal from January 2014 to December 2017 and the corresponding available biopsies were retrieved. Discrepancy between cytologic and histology diagnosis was assessed and pairs with major discordance were reviewed.

Results: There were a total of 30,237 conventional pap smears signed out of which 239 (0.79%) were abnormal and only 56 (23%) had a subsequent tissue biopsy. The overall concordance rate is 75% while strict or absolute concordance rate is 32%. The overall discordance rate is 25%. Positive predictive value is highest for pap smears signed out as atypical glandular cells favor neoplastic (AGC-NEO) (100%), followed by malignant (93%), high grade squamous intraepithelial lesion (HSIL) (83%), and then atypical squamous cells cannot exclude an HSIL (ASC-H) and atypical squamous cell of undetermined significance (ASCUS), both at 67%.

Conclusions: Considering that the Philippine General Hospital is a referral and academic center, we have a low percentage of abnormal pap smears compared to other developing countries and even a lower percentage of patients who had subsequent biopsies. Cytohistologic correlation detected interpretative as well as sampling errors, and the aim is to work on these deficiencies by improving quality assurance protocols and modifying current local practices of both pathologists and clinicians.

Human