Fine needle aspiration cytology of lymphoproliferative lesions of the oral cavity

Immunohistochemical algorithms and gene expression profiling in primary cutaneous B-cell lymphoma

OBJECTIVE

to assess whether immunohistochemical (IHC) algorithms used to classify the cell of origin (COO) of nodal Diffuse Large B-cell lymphoma (nDLBCL) in Germinal Center type (GCB) and non-GCB subtypes may be applied to Primary Cutaneous B-cell lymphoma (PCBCL) too, and which of these algorithms performs better on PCBCL.

DESIGN

Retrospective case control study.

SETTING

Pathology Department of the University Hospital "San Giovanni di Dio e Ruggi d'Aragona" Salerno, Italy.

PARTICIPANTS

Fourteen PCBCL, including Primary Cutaneous follicle centre lymphoma (PCFCL) and primary cutaneous diffuse large B-cell lymphoma, Leg type (PCDLBCL-LT) and 14 nDLBCL were evaluated for 7-year period (January 2011 to December 2017). Primary cutaneous marginal zone cell lymphoma (PCMZL) cases were not included in the present study.

INTERVENTION

Evaluation of immunohistochemical CD10, BCL6, MUM1/IRF4, BCL2, MYC and Ki-67 expression and classification according to three different algorithms. Gene expression profiling (GEP) was performed on the same series using Lymph2Cx assay (Nanostring). The data obtained were compared and analysed.

RESULTS

All the IHC algorithms showed 13 GCB and 15 non-GCB. GEP showed 12 GCB, 12 activated B cell-type and 4 unclassified.

CONCLUSIONS

The PCBCL were classifiable as GCB and non-GCB like the nDLBCL as IHC algorithms were concordant to GEP and produced the same results.

Oral manifestations of extranodal lymphomas - a review of the literature with emphasis on clinical implications for the practicing dentist

OBJECTIVE

Lymphoma is a heterogenous group of malignant tumours with proliferation of lymphoid cells or their precursors. Lymphomas in the head and neck region are usually found in Waldeyer's ring. Intraoral lymphomas are rare and the clinical presentation and roentgenological appearance may resemble other and benign conditions, entailing a risk for diagnostic delay. The objective of the present literature review was to identify subjective symptoms, clinical presentations and roentgenological appearances which should raise suspicion of lymphoma.

MATERIALS AND METHODS

The literature review identified 41 case series with head and neck lymphomas (n = 3880) and 384 case reports (n = 567 cases) of intraoral lymphomas. Information of demographics, clinical presentation, subjective symptoms and roentgenological appearance was registered.

RESULTS

The most common clinical presentation was a broad-based swelling or bulging mass with or without simultaneous ulceration, frequently with a relatively rapid growth pattern. Subjective symptoms varied considerably. Intraosseous lymphomas were frequently associated with paresthaesia or numbness. The most common roentgenological finding was a radiolucency with diffuse demarcation.

CONCLUSIONS

The clinical presentation, symptomatology and roentgenological appearance of intraoral lymphomas varied. Diagnostic delay was usually associated with a lymphoma initially misdiagnosed as a lesion of dental aetiology or a reactive lesion. Inadequate healing after tooth extraction or symptoms of numbness or pain without obvious dental origin should merit further clinical and roentgenological examination. Biopsy is indicated when there is the slightest doubt of the true nature of mucosal lesion.

Utility of fine needle aspiration cytology to diagnose intraoral lymphoma: 7 years study from a tertiary care center

OBJECTIVE

Fine needle aspiration (FNA) cytology has been successfully utilized in the preoperative diagnosis of oral masses. Lymphoma involving other sites has also been diagnosed frequently on FNA. Oral cavity lymphoma (OL) is rare and is clinically indistinguishable from other lesions of the mouth. A complete excision of these may be difficult. Our experience with FNA diagnosis of 11 OLs along with histopathological correlation is reported herein in a tertiary health care setting.

METHODS

In this retrospective study, clinico pathological characteristics of patients with final diagnosis of non-Hodgkin's lymphoma (NHL) were reviewed over a 7 year period. Routine cytological giemsa staining was performed in all cases along with immunocytochemistry (ICC) wherever possible. The gold standard for diagnosis of NHL was based on: (1) Histopathology and immunohistochemistry and/or (2) Flow cytometry (FC).

RESULTS

A total of 11 cases were diagnosed as NHL. All showed B cell immunophenotype. Two of them were diagnosed as follicular lymphoma on histopathology. Male to female ratio was 7:4 and ranged in age from 37 to 70 years. The most common site was tonsillar fossa (N = 5), followed by hard palate (N = 3), soft palate (N = 2), and buccal mucosa (N = 1). Size ranged from 1 to 6 cm.

CONCLUSIONS

Diagnosis of OLs may be hampered by its rarity and difficulties in obtaining sufficient cellularity in oral FNA but there is need for immediate and accurate diagnostic procedures, including immunohistochemical analysis to avoid delay in treatment. FNA along with ICC helps in early diagnosis of this rare entity and can also provide sample for FC.

Atypical cytological presentation of granular cell tumour: Tumour-associated fibrosis may affect fine-needle aspiration cytology accuracy

The cytological features of granular cell tumour (GCT) are generally quite typical but, in some cases, the fine needle aspiration cytology (FNAC) diagnosis of GCT may be difficult or impossible because of unusual sites of onset or equivocal cytological features. In this report, two GCTs with atypical FNAC features are described in order to investigate the causes and provide possible diagnostic tips. From a series of nine histologically proven GCTs, two inconclusive FNAC cases were retrieved. Smears were poorly cellular showing isolated naked nuclei, anisonucleosis, granular chromatin and occasional small nucleoli. The background was finely granular in one case. Histological controls of these cases revealed marked fibrosis. Tumour-associated fibrosis in GCT is variable and does not seem to influence clinical behaviour but it influences the harvest and the integrity of granular cells collected by FNAC. When GCT smears are poorly cellular, attention should be paid to the granular background and to the few granular cells, if any, as they might be the only features to suggest a GCT.

An audit of cytopathology in the oral and maxillofacial region: 18 years of experience

INTRODUCTION

The aim of this study was to perform an audit of oral and maxillofacial specimens submitted for cytological diagnosis to verify the importance of this complementary examination.

METHODS

A retrospective analysis of our institutional cytopathology database was performed over an 18-year period. Clinical information and cytological data were collected. Associations between independent variables and outcomes were assessed using the Pearson χ² test or Fisher's test, with a 5% significance level. When available, the histological diagnosis was compared with cytological diagnosis to identify the percentage of agreement and the specificity, sensitivity and accuracy of cytology in identifying malignant neoplasms.

RESULTS

A total of 1082 cases were identified, which included 65 different cytological diagnoses. Exfoliative cytology (EC) was performed in 312 cases (29.1%) and fine needle aspiration cytology (FNAC) in 770 cases (70.9%). EC was mainly employed to diagnose oral infectious diseases (P < 0.001) and FNAC to diagnose neoplasms, cystic, reactive and miscellaneous lesions (P < 0.001). Cell-block was performed in 555 FNAC cases (51.3%). Panoptic, Papanicolaou and haematoxylin-eosin staining were performed in FNAC and periodic acid-Schiff in EC (P < 0.001). In 211 cases (19.5%), the histological diagnosis was available and the percentage agreement with the cytological diagnosis was 41.2%. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy to identify malignant neoplasms were 84.6%, 100%, 100%, 77.8% and 90.0%, respectively.

CONCLUSIONS

EC was mainly performed for diagnosis of infectious diseases and FNAC for diagnosis of salivary gland tumours, odontogenic lesions, reactive lesions and cervical metastasis.

Awareness about oral pathology specialty among medical professionals in hospitals under Kerala Health Services Department in Malappuram district in Kerala, India

Background and Aim:

There is a paucity of information about awareness about oral pathology speciality among medical professionals. To the best of my knowledge, this is the first study to be reported in literature. This study aimed to assess and create awareness of oral pathology specialty among medical professionals in hospitals under Kerala Health Services Department in Malappuram district in Kerala.

Materials and Methods:

The study was conducted between January 2018 and April 2018. The printed and validated questionnaire regarding oral pathology specialty was supplied to medical professionals in hospitals under Kerala Health Service Department in Malappuram district. The questionnaire comprised of the demographic data of the participants, including age, gender, position, and years of experience, and basic facts about oral pathology speciality.

Results:

Most participants surveyed (91.7%) were aware of the oral pathology specialty. In total, 77.8% of medical professionals refer oral pathology cases to general pathologists for histopathology report. However, 41.7% of medical professionals know about the new terminology potentially malignant oral disorders and their histopathological interpretation. Approximately, 33.33% of medical doctors were aware about common oral cancer (squamous cell carcinoma) grading.

Conclusion:

Medical professionals are aware of oral pathology specialty. The stance of referring and consulting oral pathologists for oral pathology cases for histopathology report is poor.

Idiopathic pleural panniculitis with recurrent pleural effusion not associated with Weber-Christian disease

A 82-year-old patient with dyspnea and a recurrent history of pleural effusion was admitted into our unit. He performed a Chest computed tomography showing right pleural effusion. Video-assisted thoracoscopy (VATS) exploratory showed parietal pleural thickening of adipose tissue. The surgical procedure consisted, therefore, in the execution of multiple biopsies of the parietal pleura which appeared covered, on the whole surface, by islands of adipose tissue, without macroscopic pathological aspects. After the procedure was performed pleurodesis with talc. The definitive histological examination consisted of normal mesothelial cells surrounded by fatty tissue infiltrated by small lymphocytes in a patient without skin lesions or visceral or systemic signs of inflammatory involvement of the adipose tissue. We reported a rare case of idiopathic pleural panniculitis with recurrent pleural effusion not associated with Weber-Christian disease.

Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia

The management of older patients with chronic primary immune thrombocytopenia (ITP) is still very challenging because of the fragility of older patients who frequently have severe comorbidities and/or disabilities. Corticosteroid-based first-line therapies fail in most of the cases and patients require a second-line treatment, choosing between rituximab, thrombopoietin-receptor agonists and splenectomy. The choice of the best treatment in elderly patients is a compromise between effectiveness and safety and laparoscopic splenectomy may be a good option with a complete remission rate of 67% at 60 months. But relapse and complication rates remain higher than in younger splenectomized ITP patients because elderly patients undergo splenectomy with unfavorable conditions (age >60 year-old, presence of comorbidities, or multiple previous treatments) which negatively influence the outcome, regardless the hematological response. For these reasons, a good management of concomitant diseases and the option to not use the splenectomy as the last possible treatment could improve the outcome of old splenectomized patients.

Prenatal diagnosis, 3-D virtual rendering and lung sparing surgery by ligasure device in a baby with "CCAM and intralobar pulmonary sequestration"

Congenital cystic lung lesions are a rare but clinically significant group of anomalies, including congenital cystic adenomatoid malformation (CCAM), pulmonary sequestration, congenital lobar emphysema (CLE) and bronchogenic cysts. Despite the knowledge of these lesions increasing in the last years, some aspects are still debated and controversial. The diagnosis is certainly one aspect which underwent many changes in the last 15 years due to the improvement of antenatal scan and the introduction of 3-D reconstruction techniques. As it is known, a prompt diagnosis has an essential role in the management of these children. The new imaging studies as 3D Volume rendering system are the focus of this paper. We describe our preliminary experience in a case of hybrid lung lesion, which we approached by thoracoscopy after a preoperative study with 3D VR reconstruction. Our final balance is absolutely positive.

Fine-needle cytology in the follow-up of breast carcinoma

The postoperative follow-up strategies for breast carcinoma (BC) utilize different procedures; the aim of this study was to investigate the role of fine-needle cytology (FNC) in the follow-up of BC patients. Two hundred sixty-six FNC samples from 190 BC patients have been reviewed. The target anatomical sites were 190 breast including 155 ipsilateral and 145 contralateral breast lesions and 76 extra-mammary nodules. Extra-mammary lesions included lymph nodes, thyroidal nodules, soft tissue lesions, (subcutaneous and sub-scars), salivary glands and deep located masses. Diagnostic distribution of the breast lesions was as follows: 51 positive, 15 indeterminate/suspicious, 119 negative and 5 inadequate. Positive cases included 43 ipsilateral and 8 contralateral BC, 9 BC in different quadrants from those of onset of the first BC. Sensitivity, specificity and accuracy have been 90, 91 and 90&, respectively. FNC, in a correct setting, is a reliable and effective method for the follow-up management of BC patients.

Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer

Conventional transbronchial needle aspiration (C-TBNA) is a minimally invasive technique used primarily in the diagnosis and staging of lung cancer. Currently lung cancer is mostly considered a disease of the elderly and the management of this disease in older patients is a growing concern. In this study we aimed to assess the diagnostic yield and safety of C-TBNA in elderly patients. A retrospective review of 88 consecutive C-TBNA procedures for nodal staging in suspected or confirmed primary lung cancer or pathological confirmation in suspected advanced lung cancer was performed. Patients were divided into less than 70 (<70yrs) or 70 and older (≥70yrs) age groups for analysis. There were no significant differences either in the diagnostic yield (69% in patients aged < 70 yrs and 74% patients aged ≥ 70 yrs (p=0.5) nor in the complication rate (respectively 8.8% in patients aged < 70 yrs and 6.9% in patients aged ≥ 70 yrs (p=0.7) between the two age groups. Reported complications were minor bleeding and poor tolerance; no major complications were observed. Based on our experience, C-TBNA represents a useful and safe alternative procedure for the diagnosis and staging of lung cancer in elderly patients.

Lymph Node Fine-Needle Cytology: Beyond Flow Cytometry

Lymph node (LN) fine-needle cytology (FNC) coupled with flow cytometry immunophenotyping provides relevant information for the diagnosis of non-Hodgkin lymphoma (NHL). Numerous studies have shown FNC samples to be suitable for different molecular procedures; in this review, some of the molecular procedures most commonly employed for NHL are briefly described and evaluated in this perspective. Fluorescence in situ hybridization and chromogenic in situ hybridization are briefly described. Polymerase chain reaction (PCR)-based assays are used to identify and quantify mutations and translocations, namely immunoglobulin (IGH) and T-cell receptor rearrangements by clonality testing and IGVH somatic hypermutations either by Sanger sequencing, single-strand conformational polymorphisms or RT-PCR strategies. High-throughput technologies (HTT) encompass numerous and different diagnostic tools that share the capacity of multiple molecular investigation and sample processing in a fast and reproducible manner. HTT includes gene expression profiling, comparative genomic hybridization, single-nucleotide polymorphism arrays and next-generation sequencing technologies. A brief description of these tools and their potential application to LN FNC is reported. The challenge for FNC will be to achieve new knowledge and apply new technologies to FNC, exploiting its own basic qualities.

Oral manifestations of lymphoma: a systematic review

Lymphoma is a malignant disease with two forms: Hodgkin's lymphoma (HL) and non-Hodgkin's lymphoma (NHL). Non-Hodgkin's lymphoma is diagnosed in extranodal sites in 40% of cases, and the head and neck region is the second most affected, with an incidence of 11-33%, while HL has a very low incidence in extranodal sites (1-4%). The aim of this study was to identify the oral manifestations of lymphoma through a systematic literature review, which we conducted using the PubMed, Lilacs, Embase, and Cochrane Library databases. We found 1456 articles, from which we selected 73. Among the intraoral findings, the most frequent were ulcerations, pain, swelling, and tooth mobility, while the extraoral findings included facial asymmetry and cervical, submandibular, and submental lymphadenopathy. Among the few studies reporting imaging findings, the most cited lesions included hypodense lesions with diffuse boundaries, bone resorptions, and tooth displacements. The publications reviewed highlight gaps in the areas of early detection, diagnosis, and proper treatment.

Role of FDG-PET scan in staging of pulmonary epithelioid hemangioendothelioma

In this report we describe a case of pulmonary epithelioid hemangioendothelioma (PEH) in a young woman. The neoplasm manifested with dry cough, chest pain, finger clubbing, and multiple bilateral pulmonary nodules on chest x-ray and computed tomographic (CT) scan. She underwent thoracoscopy, and the histological features of the lung biopsies were initially interpreted as consistent with a not-well-defined interstitial lung disease. Our patient was clinically and radiologically stable over a period of four years, after which the disease progressed to involve not only the lung but also mediastinal lymph nodes, liver and bone. Fiberoptic bronchoscopy showed subtotal occlusion of the right middle and lower lobe bronchi. The histologic examination of bronchial biopsies revealed a poorly differentiated neoplasm immunohistochemically positive for vimentin and vascular markers CD31, CD34 and Factor VIII. A diagnosis of malignant hemangioendothelioma was made. Positron emission tomography (PET) is more sensitive than CT scan and bone scintigraphy in detecting PEH metastases. Furthermore, 18-fluorodeoxyglucose (FDG) uptake seems to be related to the grade of malignancy of PEH lesions. Therefore, we suggest that FDG-PET should be included in the staging system and follow-up of PEH.

Pulmonary arterovenous malformation causing hemothorax in a pregnant woman without Osler-Weber-Rendu syndrome

Pulmonary arteriovenous malformations (PAVMs), although most commonly congenital, are usually detected later in life. Case report: We present a case of a 19-year-old woman with no previous history of AVM or telangiectasia, who presented dyspnea and hypoxia by massive left hemothorax in the 34th week of gestation. After emergent cesarean delivery, a chest computed tomography (CT) with i.v. contrast showed a likely 3 cm area of active contrast in left lower lung. Chest tube placement revealed about 2 liters of blood. The patient was subsequently found to have pulmonary AVM. A successful embolisation of AVM followed by lung atipic resection involving AVM and decortication for lung re-expansion were the treatments provided. Conclusions: Women with known pulmonary AVM should be maximally treated prior to becoming pregnant, and the physician should be alert to complications of pulmonary AVM during pregnancy.

Hemangiomas of the maxillofacial area: Case Report, Classification and Treatment Planning

Vascular lesions of the maxillofacial area are even more challenging than in other different body district, because of the high aesthetic and functional relevance of this area for the sense organs presence like eye, brain, tongue, ear and nose. For these reasons, we propose an accurate classification based on hemodynamic and histologic aspects usefulthat is for diagnostic and therapeutic planning. A female, 60 years old patient came to our observation showing a vascular lesion of the lower left lip, and complaining for aesthetical and functional impairment. To confirm the diagnosis of vascular malformation and to detect lesion flow rate or other possible localization, a Tc red blood cell scintigraphy was carried out. Result was a venous low flow lesion; hence, sclerotherapy by a 3% Polidocanol solution (Atossisclerol) followed by surgery was planned. The aim of this work was to propose a diagnostic and therapeutic scheme with an integration of ISSVA and a flow rate classifications for a three-step planning based on 1) the biological findings in an early age at the lesion discover with a pharmacological treatment; 2) Hemodynamic study of the lesions at growing age followed by sclerotherapy or embolization; 3) Imaging study of these lesions for patients candidate to surgery when after step 1 and step 2 diagnostic and therapeutic planning results were incompletely successful.

Neuroendocrine differentiation in breast carcinoma with osteoclast-like giant cells. Report of a case and review of the literature

Osteoclast-like giant cells (OGCs) may occur in several types of breast carcinomas (BS). Neuroendocrine differentiation may be present in BS but, associated with OGCs, neuroendocrine differentiation has been rarely reported. A case of invasive ductal carcinoma with OGCs and neuroendocrine differentiation diagnosed by fine needle cytology (FNC) is described. A 72-year-old woman with a nodular lesion of the right breast underwent to fine-needle cytology (FNC) The smears showed a dissociated cell population of monomorphous, mononucleated atypical cells with interspersed multinucleated giant cells osteoclast-like. The mononuclear cell component showed plasmacytoid features and frequent vacuoles of secretion. Immunostaining (IHC) performed on cell block sections showed oestrogen receptor positivity in the mononucleated cells and OGCs positivity for LCA and CD68. Histologically the tumour showed cell nests or cords separated by thin fibrovascular septa. The neoplastic cells were monomorphic, with round-oval nuclei, granular chromatin and evident nucleoli. The cytoplasm was indistinct and eosinophilic, finely granular, often containing eosinophilic globules that were positive at the PAS and mucicarmine stainings. Numerous non-neoplastic OGCs were also detected in the interstitial septa. The ICH showed positivity of the tumoral cells for E-Cadherin, oestrogen and progesterone receptors and c-ErbB2 negativity. Mitotic index was inconspicuous with a low Ki67 positivity rate (<10%). OCGs were CD68 and LCA positive. IHC also showed strong positivity for the chromogranin and synaptophysin. A diagnosis of invasive ductal BC with OGCs and neuroendocrine differentiation was performed. The expression of chromogranin and synaptophysin was then retrospectively assessed on CB sections too. The identification of OGCs component on breast FNA samples is not difficult, depending on a good sampling only. On contrary, the neuroendocrine differentiation still represents still a challenge in breast FNC.

Age as a risk factor in the occurrence of pneumothorax after transthoracic fine needle biopsy: our experience

Transthoracic needle biopsy (TTNB) of the lung is a well-established technique for diagnosing many thoracic lesions, and is an important alternative to more invasive surgical procedures. Complications of TTNB include pneumothorax, hemoptysis, hemothorax, infection, and air embolism, with the most common complication as pneumothorax. From June 2011 to June 2014 we performed a prospective study of 188 patients who underwent TTNB with CT guidance at University Hospital of Salerno, Italy. Pneumothorax occurred in 14 of 188 biopsies (7.45%). With the respect of age of patients pneumothorax occurred more frequently in patients aged 60-70 years, while it was less frequent in younger (<60 years) and older patients (>70 years). In conclusion, data of our prospective study documented that CT-guided TTNB is a safe and reliable procedure in elderly patients with suspected chest malignancy and is well tolerated.

Bone and soft tissue non-Hodgkin lymphoma of the maxillofacial area: report of two cases, literature review and new therapeutic strategies

Primary mandibular non-Hodgkin lymphoma (NHL) and soft tissues NHL of the maxillofacial are extremely rare representing a minimal percentage of the head and neck tumors. Two cases of bone and soft tissue maxillofacial NHL are reported. Clinical, radiological and pathological features are described and the therapeutic procedures are discussed accordingly. Mandibular radiologic features have been carefully analyzed and discussed to achieve an early and accurate diagnosis avoiding improper dental therapies.

Post-pneumonectomy broncho-pleural fistula successfully closed by open-window thoracostomy associated with V.A.C. therapy

Broncho-pleural fistula (BPF), is a dramatic complication that may occur after lung resection. The treatment is challenging due to its high rate of morbidity and mortality. Herein, a case of BPF associated with empyema, occurred in an elderly patient who had undergone to left pneumonectomy for non-small cell lung cancer (NSCLC), is reported. After various treatments including chest drainage and endoscopic procedures, BPF was successfully closed by open-window thoracotomy associated with vacuum assisted closure (V.A.C.) device therapy. The authors conclude that V.A.C. is a convenient and safe measure in the management of empyema with BPF. Moreover, in similar clinical contexts, V.A.C. may be the only option available that may assure the survival of the patient and the avoiding any later-phases of residual cavity.

Detection of RAS mutation by pyrosequencing in thyroid cytology samples

INTRODUCTION

Fine-needle aspiration cytology (FNAC) is the primary means to distinguish benign from malignant thyroid nodules. However, adjunctive diagnostic tests are needed as 20-40% of FNAC are inconclusive. RAS mutations have been described in differentiated thyroid cancer and they could be used as tumor markers. However, their prevalence varies widely among studies, probably as a result of the detection methods used. We investigated whether the pyrosequencing method can be applied to detect NRAS and KRAS mutations in thyroid aspirates.

PATIENTS AND METHODS

A total of 37 thyroid aspirates, including benign hyperplastic nodules (HBN, N = 16) and follicular thyroid carcinomas (FTC, N = 21) were analyzed for the presence of NRAS(61) and KRAS(13) mutations.

RESULTS

A RAS mutation was found in 31% and 62% of BN and FTC respectively. Most samples displayed a percentage of mutated alleles lower than 50% (median = 30.8% and 15.3% in FTC and HBN respectively), a result compatible with the presence of extra-nodular cells contaminating the FNA or with the subclonal nature of both types of thyroid nodules.

DISCUSSION

Pyrosequencing is a reliable assay to detect RAS mutations in fine-needle thyroid aspirates.

CONCLUSIONS

The low specificity and sensitivity limit the power of this test to distinguish between FTC and benign nodules in inconclusive FNACs.