Historical aspects.

1 Two marine officers, Greig and Gray [1], are recognized as the first to use needle biopsy of lymph nodes. In 1904, they reported that motile trypanosomes could be observed in smears from biopsied nodes. For many years node biopsy was considered a valuable means of demonstrating bubonic plague, trypanosomes and spirochetes. Thus, the technique was only used to identify microorganisms and not to evaluate the cellular components in lymph node disorders. The first report on lymph node puncture to give a cytomorphologic diagnosis of malignant lymphoma, lymphoblastoma, was published in 1914 by Ward [2]. An attempt to systematically describe cytologic findings in lymph node aspirates from a variety of diseases was presented by Guthrie [3], who as early as 1921 had used air-dried smears stained with Romanowsky. Six years later, Forkner [4] reported on the cytologic presentation of several lymph node disorders in a paper entitled ‘Materials from lymph nodes of man’. From then on several papers and monographs were published but the procedure was only slowly accepted by the medical community. In 1952, Morrison et al. [5] reported a large series of lymph node punctures, which included the sensitivity and specificity of the technique. It is puzzling that such an important study had so little impact on the clinical management of patients with lymph node disorders. In the 1950s and 1960s the development of lymph node cytology was to a large extent the work of clinicians, in particular, those with an interest in hematology. Among them were Pavlowsky, Lopes Cardozo, Abramov, Söderström, and Franzén who all made invaluable contributions [6–10]. However, the clinical background of these pioneers may have been one reason for the slow acceptance of the technique: the pathologists were often unfamiliar with the interpretation of air-dried cells stained with the Romanowsky technique, and also feared that open biopsies could be replaced by fine-needle aspirates. As a consequence, the method was not adopted at most centers for tumor diagnosis in the 1960s. Several monographs and atlases were however published in the 1960s and 1970s which documented the diagnostic accuracy and wide applicability of fine-needle aspiration cytology. It is of interest to note that even among the enthusiasts and experts in FNA cytology, there seemed to be a discrepancy in the concept of the accuracy of lymphoma diagnosis using cytomorphology alone. Based on a rather limited study, Zajicek [11] concluded that ‘about 20% of cases of well-differentiated lymphocytic lymphoma cannot at present be recognized in smears of aspirates’. However, in poorly differentiated (high-grade) lymphoma, he believed that a reliable diagnosis could be made by an experienced examiner. A somewhat more optimistic but at the same time cautious standpoint was presented by Koss et al. [12] in their textbook in which they state that the question ‘Is it or is it not a malignant lymphoma? Can be answered on an aspirate of untreated lesions in most cases’. In fact, the authors believe that ‘a precise identification of subtypes of malignant lymphoma can be made by observers with an adequate experience’. The most optimistic view was expressed by Linsk and Franzén [13] who stated that ‘There is no question that the diagnosis can be made with ease by FNA’. Although it may not be all that easy to diagnose lymphomas, one is inclined to believe that it can be made by an experienced examiner after reading the excellent results presented by Lopes Cardozo [14] who accurately diagnosed 1,023 lymphomas on cytology. Moreover, the ‘Atlas of clinical cytology’ by Lopes Cardozo contains an overwhelming series of beautiful color illustrations of various lymphomas which should make most morphologists interested in lymphoma cytology and accept it as a potentially valuable adjunct to histopathology [15]. Chapter 1