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• W2770780493 abstract "We read with interest the recent publication by Rohilla et al,1 which discussed the clinical applicability and potential benefits of the forthcoming Milan System for Reporting Salivary Gland Cytopathology (MSRSGC). Akin to The Bethesda System for Reporting Thyroid Cytopathology, the MSRSGC is an evidence-based tiered classification system that comprises 6 diagnostic categories associated with an average risk of malignancy (ROM) and clinical management strategies. By providing a uniform international reporting system, the MSRSGC is expected to improve communication between the cytopathologist and the treating clinician, facilitate cytologic-histologic correlation, and lead to overall better patient care. In their study, Rohilla et al retrospectively classified a series of 631 salivary gland fine-needle aspiration (FNA) specimens according to diagnostic categories analogous to those proposed in the MSRSGC as follows: nondiagnostic, nonneoplastic, atypical, benign neoplasm, neoplasm of uncertain malignant potential, suspicious for malignancy, or positive for malignancy.1 In addition, the authors attributed an overall ROM for different categories with available histopathology as follows: 17.4% for nonneoplastic, 100% for atypical, 7.3% for benign neoplasm, 50% for neoplasm of uncertain malignant potential, and 96% for positive for malignancy. Although the ROMs in their study1 demonstrated some similarities to the actual ROM of the MSRSGC (Table 1), there also are some significant deviations, especially for the atypical (AUS) and nonneoplastic categories. Therefore, we would like to offer some possible explanations and additional insights into the MSRSGC. It is imperative for the readership of Cancer Cytopathology to note that even though the general diagnostic categories and criteria of the MSRSGC have been presented in several international meetings,2 in Webinars,3 on social media (ie, Twitter4 and Facebook5), and in articles6-8 over the past 2 years, detailed criteria for classifying FNA specimens according to the MSRSGC still are being formulated. An explanation of these details is the key goal of the upcoming Atlas (expected publication in early 2018), which is meant to be practical and user-friendly, akin to The Bethesda System for Reporting Thyroid Cytopathology. The application of strict diagnostic criteria when classifying a salivary gland FNA specimen is essential to maximize diagnostic reproducibility. For example, based on the specimen cellularity as determined from the images in the article by Rohilla et al1 classified as “atypical” that corresponded with mucoepidermoid carcinomas, one might have considered classifying those aspirates as neoplastic-salivary gland neoplasm of uncertain malignant potential or suspicious for malignancy, both of which are associated with a higher expected ROM compared with the AUS category. Regardless, having only 2 of 94 cases (2%) classified as per MSRSGC as AUS is insufficient and statistically insignificant (ROM of 100% in the published study1). In addition, some of the cases in the nonneoplastic category, especially cystic lesions, might have been better classified as AUS or as nondiagnostic. This might have contributed toward lowering the overall ROM of the nonneoplastic category (17% in the study by Rohilla et al1). It is interesting to note that this study consists of a greater percentage of cases (352/631 cases; 55.8%) classified as nonneoplastic (15% in the parotid and 38% in the submandibular gland) than reported in the literature. Furthermore, the authors also stated that a “majority of the submandibular gland aspirates were to rule out metastases” in patients with known head and neck cancers. Although it is mentioned that these aspirates were due to the swelling of the submandibular gland, one may consider some of these as nondiagnostic if the swelling represented a distinct mass. The nonneoplastic category is expected to have a ROM of ≤10% to be clinically useful. The AUS category is a novel category in salivary gland cytology that includes a limited number of specimens in which a neoplasm cannot be entirely ruled out after examination of the entire specimen. A subset of cystic lesions, especially those demonstrating absent or scant epithelial cells in a mucinous background, can be classified as AUS. To the best of our knowledge, the ROM of the AUS category is not well established, but is expected to be within the range of ROMs for the nonneoplastic and the neoplastic categories (10%-35%). In a recent multi-institutional, interobserver variability study using a similar risk stratification system to report salivary gland cytopathology, Griffith et al9 demonstrated good interobserver agreement between the diagnostic categories, which is encouraging. Finally, histopathologic follow-up was limited to only 94 cases (14.9%), with 88% concordance (83 of the 94 cases). The scarcity of cytohistologic correlation creates a potential selection bias of cases that have a higher likelihood of being neoplastic and/or malignant, resulting in an overestimation of the overall ROM. Akin to the thyroid gland,10 the published ROM commonly represents an overestimation because it is based on cases that have undergone surgical excision, and may have been impacted by patient demographics, institutional referral patterns, and publication bias. Therefore, it will not be far-fetched to assume that the actual ROM will be in the mid-range of what is reported in the literature. In addition, for a salivary gland mass, the ROM prior to FNA varies depending on its size and location: 20% to 25% for the parotid, 40% to 50% for the submandibular, and 50% to 81% for the sublingual and minor salivary glands. In the study by Rohilla et al,1 approximately 61.3% of cases were from the parotid gland followed by the submandibular gland (35.7%) and the minor salivary gland (3%). This higher percentage of nonparotid gland FNA specimens in the current series1 may have contributed to the elevated ROMs reported. Overall, the study by Rohilla et al1 highlights several important issues that will be faced with implementation of the MSRSGC. Other studies using larger numbers of cases and with long-term clinical and radiologic follow-up and histologic correlation will be needed to further refine various aspects of the MSRSGC. No specific funding was disclosed. The authors made no disclosures. Marc Pusztaszeri, MD Department of Pathology Jewish General Hospital McGill University Montreal, Quebec, Canada Zubair Baloch, MD Department of Pathology and Laboratory Medicine Hospital of the University of Pennsylvania Perelman School of Medicine Philadelphia, Pennsylvania Philippe Vielh, MD Department of Anatomic and Molecular Pathology National Laboratory of Health Dudelange, Luxemburg William C. Faquin, MD Department of Pathology Massachusetts General Hospital Harvard Medical School Boston, Massachusetts" @default.
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• W2770780493 date "2017-11-22" @default.
• W2770780493 modified "2023-10-12" @default.
• W2770780493 title "Application of the Milan system for reporting risk stratification in salivary gland cytopathology" @default.
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