P5-11-03: Real-Time Imaging of Human Breast Tissue with Reflectance Confocal Microscopy: Correlation with Routine Pathology

Background: Near-infrared reflectance confocal microscopy (RCM) allows for immediate noninvasive 3-D optical sectioning of opaque objects, such as human tissue, without using the potentially destructive staining and fixing methods used with routine pathology. Recently, RCM has been used to differentiate between malignant and non-malignant dermatologic conditions. We hypothesize that this technique can be used to efficiently and reliably evaluate human breast tissue for the presence of malignancy without compromising the ability to perform routine immunohistochemical (IHC) analyses that accompany the diagnosis of invasive breast cancer.

Methods: 45 core needle breast biopsies (12mmx2mm) were collected under sonographic guidance. Biopsy specimens were immediately placed in phosphate buffered saline, injected with 5% acetic acid to enhance reflectivity of the nuclei, and imaged within 5–10 minutes. Digital images of the nuclear and cellular morphology from each intact specimen were acquired and catalogued within 1 hour of biopsy using the VivaCell 5000. Tissue samples were then formalin-fixed and sectioned for routine H&E evaluation or IHC assays. A board certified pathologist trained on 16 paired RCM images and H&E slides was given the blinded test set created from these 45 breast biopsies and asked to evaluate the RCM images for the presence of carcinoma. Preliminary evaluation was also done on 5 biopsy samples with known estrogen receptor (ER) and progesterone receptor (PR) status to determine the feasibility of assessing ER/PR on tissue treated with acetic acid for RCM.

Results: Routine H&E staining identified invasive carcinoma 10/45 biopsy samples (9 invasive ductal [IDC], 1 invasive lobular [ILC]); 2 specimens with IDC also contained ductal carcinoma in situ (DCIS). Evaluation of the RCM images led to the same diagnosis of invasive carcinoma vs. not in all 45 samples and correctly identified 6/9 IDC and 1/1 ILC. RCM correctly identified 1/2 specimens known to contain DCIS. RCM misclassified 3 IDC as DCIS (1), ILC (1), or lobular carcinoma in situ (1), and 1 DCIS as ILC. With respect to the determination of ER/PR status, RCM accurately assessed positivity for both receptors in all 5 specimens.

Conclusions: RCM is comparable to standard microscopy for the reliable identification of carcinoma, and the ability to evaluate breast tissue for malignancy using this technology allows for real-time pathology and may negate the need for repeat diagnostic biopsies to ensure adequate sampling for diagnosis. Importantly, the ability to perform routine IHC for ER/PR status after tissue processing for RCM appears to be preserved. Further evaluation applying the existing technology to a larger sample size for histopathologic correlation, assessment of ER/PR status, and evaluation for HER2 status are planned. These encouraging findings support interest in tailoring RCM for breast tissue to improve the ability to distinguish between invasive vs. in situ disease, and ductal vs. lobular histology.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-11-03.

The spectrum of cytologic features in nonproliferative breast lesions

BACKGROUND

The reliability of cytologic criteria to classify nonproliferative breast lesions (NPBL) is still debated. Sampling error and heterogeneity of breast lesions complicates the histologic correlation of fine-needle aspiration results further.

METHODS

To provide optimal cytohistologic correlation, two smears (one that was stained with hematoxylin and eosin and one that was stained with Diff-Quik [American Scientific Products, McGraw Park, IL]) were prepared from specific tissue sections from breast biopsies without mass lesions. The 42 cases classified as NPBL histologically were included in the current study. The cytologic features of the smears were evaluated.

RESULTS

Cellularity ranged from low (40% of cases) to moderate (50% of cases) to high (7% of cases). The cells were arranged in small clusters in 79% of cases, were mixed with large sheets in 17% of cases, and were in large sheets in 2% of cases. Intact lobules were noted in 31%. The configuration of the epithelial groups was complex in 62% of cases. Myoepithelial cells in the background and within the epithelial groups were noted in all the specimens. The percentage of single epithelial cells was < 10 in 38% of cases, 10-20 in 41%, and 20-30 in 19%. Mild nuclear enlargement and overlap, micronucleoli, and mild chromatin clumping were noted in a significant number of cases.

CONCLUSIONS

NPBL have been found to have a wide spectrum of cytologic appearances. At one end of the spectrum, smears are cellular with up to 30% single cells and large sheets in a complex configuration and exhibit nuclear enlargement and overlap and prominent nucleoli, features that overlap with those described in proliferative breast lesions.

Atypical glandular cells of undetermined significance: clinically significant lesions and means of patient follow-up

BACKGROUND

The clinical significance of atypical glandular cells of undetermined significance (AGUS) remains poorly understood, and patient management is not standardized. The authors evaluated the rate, qualification, and follow-up (FU) findings of AGUS patients.

METHODS

Computerized records from the authors' institution were searched from April 1992 to December 1997 for diagnoses of AGUS. Results of cytologic and histologic FU were evaluated up to 48 months of FU. Clinically significant lesions were defined as squamous intraepithelial lesion (SIL), endometrial pathology of hyperplasia or higher, adenocarcinoma in situ (AIS), or invasive adenocarcinoma.

RESULTS

AGUS was diagnosed in 92 of 87,632 patients (0.11%). FU data were available from 69 patients, consisting of smears and/or surgical pathology specimens from the cervix, endometrium, or ovary. Forty patients had FU smears only, 13 had histologic FU only, and 16 had both. Seventeen patients (25%; 15 patients with unqualified AGUS and 2 patients with "favor endometrial origin" according to the Bethesda System of AGUS subclassification) had clinically significant lesions: high grade SIL (n = 8 patients), low grade SIL (n = 2 patients), endometrial lesion (n = 5 patients), AIS (n = 1 patient), and invasive cervical adenocarcinoma (n = 1 patient). It is noteworthy that 4 patients with carcinoma (3 patients with AIS and 1 patient with invasive carcinoma) were diagnosed after a long FU (36-48 months). The remaining 13 lesions were detected at first FU (1-24 months). Six lesions were detected on FU smear, whereas 15 were detected histologically (4 lesions were detected in both).

CONCLUSIONS

AGUS is associated with clinically significant lesions in 25% of patients who are followed. Most of the lesions were high grade and were detected histologically. Moreover, 4 of 17 lesions were detected after a FU period ranging from 36 months to 48 months. The role of qualifying AGUS needs further study. Cancer (Cancer Cytopathol)

Current issues in breast cytopathology

This article explores 3 aspects of breast diagnosis that are currently under investigation and about which our thinking has recently undergone considerable reshaping. The trend toward more frequent evaluation of clinically subtle lesions has suggested that it might be necessary to understand thefine-needle aspiration (FNA) presentation of proliferative breast disease. Efforts to do so, as well as our suggestions for additional studies and their potential limitations open this discussion. Following this section, the increasingly useful method of intraoperative cytology for evaluation of resected breast masses is considered in detail. In the final section, optimization of nonoperative sampling by combination of mammography, ultrasonography, fine-needle aspiration, and core biopsy is discussed and illustrated.

Cytologic features of proliferative breast disease: a study designed to minimize sampling error

BACKGROUND

Assessment of cytologic features that allow accurate classification of proliferative breast disease has been hampered by sampling errors when fine-needle aspirations have been compared with their corresponding histologic sections.

METHODS

To allow for optimal cytohistologic correlation, 2 smears (1 hematoxylin and eosin-stained and 1 Diff-Quik-stained) were prepared from each of 98 breast biopsies without mass lesions and compared with the corresponding histologic sections of the scraped area. Each smear was reviewed in a blinded fashion and assessed for cellularity, background elements, cytoarchitectural features of cell groups, and nuclear features by 2 reviewers. Smears were then classified as nonproliferative breast disease (NPBD), proliferative breast disease without atypia (PBD) or with atypia (PBDA), or DCIS, based on review of the corresponding histologic sections.

RESULTS

When comparing NPBD/PBD (n = 86) with PBDA/DCIS (n = 12), smears from PBDA/DCIS were significantly (by the Fisher exact test or Wilcoxon rank sum P values with adjustment for multiple comparisons) more likely to be cellular; contain single cells and necrosis; exhibit nuclear overlap and cytoplasmic vacuoles; have large nuclei, macronucleoli, pleomorphism, clumped chromatin, and hyperchromasia; and were less likely to have complex cell groups, monolayers, swirling, cohesion, and myoepithelial cells in epithelial sheets and the smear background. When NPBD (n = 53) and PBD (n = 33) were similarly compared, smears from PBD were more likely to exhibit larger and more complex cell groups, but they were otherwise similar to smears from NPBD.

CONCLUSIONS

There are many cytologic features that will allow a distinction of NPBD/PBD from PBDA/DCIS, but relatively few that can aid in separating NPBD from PBD.

Changing trends in breast fine-needle aspiration: results of the Papanicolaou Society of Cytopathology Survey

Following the NCI-sponsored consensus conference on fine-needle aspiration of the breast, the Criteria and Nomenclature Task Force of the Papanicolaou Society of Cytopathology undertook a survey to assess the status of these issues and recommendations among practicing cytopathologists. The survey was designed to assess the impact of the changing trends in the diagnosis of breast lesions on cytopathology laboratories. It also intended to assess the impact of the recommendations of the consensus conference concerning the inclusion of a statement in breast FNA reports recommending the use of the triple test, the use of the proposed diagnostic terminology, and to evaluate criteria for specimen adequacy in breast FNAs used in different institutions. The results of this survey indicate the impact of an increasing use of core biopsies on the number of breast FNAs performed over the last several years. The recently recommended diagnostic terminology for breast FNA has quickly gained wide acceptance, as has the fundamental concept of the triple test. The issue of specimen adequacy, however, remains controversial, with some laboratories utilizing quantitative criteria, while the majority do not. Diagn. Cytopathol. 2000;22:126-130.

Inflammatory pseudotumor of the spleen associated with a cavernous hemangioma diagnosed at intra-operative cytology: report of a case and review of literature

This report presents a case of a 40 year old Caucasian female with a 15 cm inflammatory pseudotumor (IPT) of the spleen with associated areas of splenic hemangioma of the cavernous type. Abdominal CT showed a largely fatty splenic mass with enhancing septations, and scattered calcifications, and a small density in the liver. Grossly, the splenic lesion showed a lobulated cut surface with areas of myxoid change, necrosis, hemorrhage and cystic softening. The diagnosis of IPT was suggested at intraoperative consultation using cytologic smears and was, subsequently confirmed on permanent sections. Histologically, the lesion consisted of a densely collagenized spindle cell stroma with patchy aggregates of lymphocytes and plasma cells, and scattered foci showing hemosiderin-laden macrophages extracellular calcium deposits and osseous metaplasia. The stromal spindle cells were immuoreactive for smooth muscle actin and vimentin confirming their myofibroblastic phenotype. There were extensive areas of infarction within the mass. The patient, however, remained asymptomatic preoperatively. Histologic analysis in this case raises the possibility that low grade, perhaps repetitive, trauma to the hemangioma may have resulted in intralesional hemorrhages which, through a process of organization, may have evolved into this sizable inflammatory pseudotumor. In addition, this report reviews the current literature on the clinical significance and presentation, morphologic and immunohistochemical findings, prognosis, differential diagnosis, pathogenesis and therapy of the splenic IPT.

The stability of estrogen and progesterone receptor expression on breast carcinoma cells stored as PreservCyt suspensions and as ThinPrep slides

BACKGROUND

Analysis of estrogen receptor (ER) and progesterone receptor (PR) status is an important ancillary test in the evaluation of positive breast fine-needle aspirates. This study compares the detection of ER and PR in breast carcinoma cells suspended in PreservCyt with that achieved with stored ThinPrep slides (TP).

METHODS

ER and PR positive mammary tumor cells (cell line ZR-75-1 spiked in PreservCyt by the American Type Culture Collection) were used to evaluate the stability of immunodetection of ER and PR under two conditions: 1) TP slides prepared immediately from PreservCyt and stored air-dried (stored TP) for up to 56 days, and 2) TP prepared from cells suspended in PreservCyt (newly prepared TP) on Days 1, 2, 5, 14, 21, 42, and 56. At each of the time periods, stored TP and newly prepared TP were analyzed for ER and PR using the same immunocytochemical staining protocol. The percentage of positive cells was calculated by counting 1000 cells/TP.

RESULTS

Positivity for ER and PR was demonstrated in both stored TP and newly prepared TP on Days 1, 2, 5, 14, 21, 42, and 56. Over the 56-day period, the number of ER positive cells ranged from 41% to 57% in stored TP and from 38% to 58% in newly prepared TP. The number of PR positive cells ranged from 31% to 41% in stored TP and from 26% to 37% in newly prepared TP. Mild, nonspecific cytoplasmic and nuclear staining occurred in all newly prepared TP (PR > ER).

CONCLUSIONS

ER and PR antigenicity was preserved in both stored TP and newly prepared TP of mammary tumor cells over a 56-day storage period. This demonstrates that ER and PR status can be evaluated in cytologic material from breast carcinoma using the ThinPrep technique.

Utility of thin-layer preparations in thyroid fine-needle aspiration: diagnostic accuracy, cytomorphology, and optimal sample preparation

BACKGROUND

The efficacy of preparing thyroid fine-needle aspirations (FNAs) as thin-layer slides has not been evaluated extensively.

METHODS

To evaluate the efficacy of thin-layer cytology, the authors examined thyroid FNAs from 135 unselected palpable lesions that were aspirated using uniform procedures and prepared as air-dried, Diff-Quik-stained direct smears (DS) and Papanicolaou-stained thin-layer slides (TL). Diagnoses rendered independently on masked slides from each thyroid nodule were compared with the reported final cytologic or histologic diagnoses based on all available pathologic material. Slides were analyzed for diagnostically important cytologic features and the optimal number of TL slides per sample was assessed.

RESULTS

TL diagnoses agreed with final diagnoses in 85% of cases compared with 96% for DS. All 11 neoplasms were recognized in both preparations. A final diagnosis of chronic lymphocytic thyroiditis (CLT) was missed in 10 of 26 TL (39%) compared with 2 of 26 DS (8%) (P = 0.013, McNemar's test). Cytologic features appreciated less often in TL than DS (McNemar's test) included diffuse colloid, spherules, tissue fragments, and lymphocytes. Multinucleated giant cells were identified more often in TL than DS. Two TL slides were sufficient for diagnosis in 83% of cases.

CONCLUSIONS

The diagnostic accuracy of TL was 85% compared with 96% for DS. CLT was diagnosed accurately in 62% of TL compared with 92% of DS. Cytologic features in TL and DS may differ. Preparation of only two TL slides is adequate for definitive diagnosis in most cases.

Interobserver variability in the classification of proliferative breast lesions by fine-needle aspiration: results of the Papanicolaou Society of Cytopathology Study

This study evaluates the applicability of the published cytologic criteria in the categorization of proliferative breast lesions by assessing the diagnostic accuracy and interobserver reproducibility of a panel of experts. Twelve breast fine-needle aspiration (FNA) specimens of biopsy-proven nonproliferative breast lesion (NPL) (1 case), proliferative lesions without atypia (PL) (7 cases), proliferative lesion with atypia (PLA) (1 case), and low-nuclear grade ductal carcinoma in situ (DCIS) (3 cases) were selected. Six FNAs were Papanicolaou (PAP) and 6 were Diff-Quik-stained (DQ). Six expert cytopathologists classified the smears using a summary of published criteria as a guideline. All 6 participants rendered the same cytologic diagnosis in 2/12 (16%) cases. The agreement among the 6 raters was low (Kappa = 0.35). Cytohistologic correlation was achieved in 26/72 (36%) FNA diagnoses. The correlation of the PAP-stained cases was better than the DQ: 17/36 (47%) PAP and 9/36 (25%) DQ correlated. Improving the correlation was achieved by amalgamation of NPL and PL into "low risk" and PLA and DCIS into "high risk" categories: 47/72 (65%) FNA diagnoses then correlated with histology [29/36 (81%) PAP and 18/36 (50%) DQ]. We conclude that the cytologic criteria of proliferative breast lesions need to be further defined and assessed. Consideration should be given to minimizing the number of diagnostic categories and adopting a terminology that has a direct effect on patient management.

Fine-needle aspiration of thyroid nodules: correlation between cytology and histology and evaluation of discrepant cases

BACKGROUND

The purpose of this study was to evaluate the results of thyroid fine-needle aspiration (FNA) and to determine the reasons for the discrepancies between the cytologic and histologic diagnoses.

METHODS

The authors evaluated the cytologic and histologic results of 133 FNAs obtained from 92 patients who underwent subsequent thyroidectomies.

RESULTS

The initial cytologic results were indeterminate in 39 of 133 cases (29%) because a neoplasm could not be ruled out. These cases corresponded histologically to 9 adenomatoid nodules (ANs), 14 follicular adenomas (FAs), and 16 malignant thyroid neoplasms. The reported FNA diagnoses of the remaining 94 cases (71%) were 48 ANs, 19 follicular neoplasms (FNs), 21 papillary carcinomas (PCs), and 6 cases of Hashimoto's thyroiditis (HT). Correlation of cytology and histology showed that 69 of 94 FNA results (73%) correlated with the histologic diagnoses, whereas 25 (27%) were discrepant. The discrepancies resulted from cytodiagnostic errors in 13 cases (52%), suboptimal smears in 11 (44%), and an FNA sampling error in 1 (4%). The false-negative rate of FNA was 19% and the false-positive rate was 6%.

CONCLUSIONS

Diagnostic pitfalls and indeterminate FNA diagnoses were predominantly due to overlapping cytologic criteria between ANs, FNs, and follicular variants of PCs. Rendering a definite diagnosis on suboptimal FNA samples is also a significant source of pitfalls.

Reactive cellular change: is there an increased risk for squamous intraepithelial lesions?

BACKGROUND

The aim of this study was to evaluate the rate of squamous intraepithelial lesions (SIL) in women with reactive cellular change (RCC) cervical smears and compare the results with a control group with within normal limit (WNL) smears.

METHODS

The study group was comprised of 1000 women with RCC and a control group of 1000 women with WNL cervical smears diagnosed over an 8-month period. Results of the first follow-up (FU) smears were evaluated and compared between the two groups. FU smears with a diagnosis of SIL were reviewed along with the original RCC or WNL smears.

RESULTS

Six hundred and thirteen women from the RCC group and 640 from the WNL group had FU smears. The mean time to FU was 11.0 and 13.8 months, respectively. FU revealed SIL in 24 of 613 smears in the RCC group (20 low grade [L] SIL and 4 high grade [H] SIL), (3.9%) and in 10 of 640 smears in the WNL group (10 LSIL and 0 HSIL) (1.6%). Fisher's exact test (two-tailed) showed statistical significance (P = 0.014). On retrospective review of the FU smears diagnosed as SIL and their corresponding original RCC or WNL smears, four RCC smears were upgraded to atypical squamous cells of undetermined significance (ASCUS). The remaining diagnoses remained unchanged.

CONCLUSIONS

Women with RCC are more likely to have SIL on a FU smear compared with women with WNL smears (3.9% vs. 1.6%). It is important to emphasize that in the authors' laboratory, the rate of SIL in women with ASCUS is much higher (24%). Awareness of these rates combined with the clinical history may help clinicians determine whether women with RCC require closer FU.

Can nonproliferative breast disease and proliferative breast disease without atypia be distinguished by fine-needle aspiration cytology?

BACKGROUND

Cytologic criteria reported to be helpful in the distinction of proliferative breast disease without atypia (PBD) from nonproliferative breast disease (NPBD) have not been rigorously tested.

METHODS

Fifty-one air-dried, Diff-Quik-stained fine-needle aspirates (FNA) of palpable breast lesions with biopsy-proven diagnoses of NPBD (34 cases) or PBD (17 cases) were reviewed. The smears were evaluated for the cellularity, size, and architectural arrangement of the epithelial groups; the presence of single epithelial cells and myoepithelial cells; and nuclear characteristics.

RESULTS

The only cytologic feature found to be significantly different between PBD and NPBD was a swirling pattern of epithelial cells. A swirling pattern was noted in 13 of 17 PBD cases (76%) and 12 of 34 NPBD cases (35%) (P = 0.008).

CONCLUSIONS

Because there is significant overlap in cytologic features between NPBD and PBD, the distinction between the two entities is difficult in cytologic sampling.

Multinucleated giant cells in thyroid neoplasms. A cytologic, histologic and immunohistochemical study

OBJECTIVE

To evaluate the presence of multinucleated foreign body-type giant cells (MGCs) in papillary carcinoma (PC), follicular variant of papillary carcinoma (FV) and follicular adenomas (FA) and to investigate their origin by immunoperoxidase studies.

STUDY DESIGN

The cytologic and histologic material of 10 PCs, 8 FVs, and 11 FAs were evaluated for the presence of MGCs. The immunohistochemical staining pattern of MGCs in paraffin-embedded tissue was studied using cytokeratin, epithelial membrane antigen, thyroglobulin, vimentin, A-1 antichymotrypsin, lysozyme and CD68.

RESULTS

MGCs were demonstrated in 10/10 PCs, 5/8 FVs and 0/11 FAs. In the immunostained sections, MGCs were negative for epithelial markers and positive for histiocytic markers.

CONCLUSION

These results indicate that MGCs are histiocytic and frequently present in PCs and FVs and usually absent from FAs.

Evaluation of the 5-year review of negative cervical smears in patients with high grade squamous intraepithelial lesions

Federal regulations require laboratories to re-examine negative cervical smears from the 5 yr preceding a diagnosis of high-grade squamous intraepithelial lesion (HSIL) or carcinoma. To assess the value of this regulation as a quality assurance measure, we evaluated the previous cervical smears from 47 patients with a diagnosis of HSIL rendered during a 9-mo period. Fifteen patients had a total of 24 previous smears initially reported as squamous intraepithelial lesions (SIL). The remaining 32 patients had a total of 58 smears that carried a diagnosis lesser than SIL. Upon re-screening 22/58 (38%) smears, from 16 patients, were upgraded to SIL (8 low grade, 14 high grade). Underdiagnosed SIL was detected in seven (44%) patients with the 1-yr review, 12 (75%) with the 2-yr review, 15 (94%) with the 3-yr review, and 16 (100%) with the 5-yr review. The authors conclude that the negative smear review is a beneficial quality assurance and teaching method that may lead to quality improvement. A 3-yr retrospective review is effective and detects 94% of the undercalls.

Cytologic features of well-differentiated villoglandular adenocarcinoma of the cervix

OBJECTIVE

To evaluate the cytologic features of villoglandular adenocarcinoma of the cervix in cervical smears.

STUDY DESIGN

Eleven cervical smears from six patients with histologically proven villoglandular adenocarcinoma were reviewed.

RESULTS

All smears were positive for tumor upon retrospective evaluation and revealed similar cytologic features. The tumor cells were abundant and were shed in sheets, tight clusters and tissue fragments. Papillary projections, clusters with smooth borders and flattened cells at the periphery, strips with peripheral nuclear palisading and pseudostratification, and rosettes were present. Nuclear crowding and overlapping were prominent. The nuclei were small, ovoid and hyperchromatic. The chromatin was granular and evenly distributed. Nucleoli were absent or inconspicuous. Mitoses were present.

CONCLUSION

VGA may cause diagnostic difficulty because it shares some morphologic similarities with adenocarcinoma in situ, squamous cell carcinoma in situ involving endocervical glands, endometrial cells directly sampled with the Cytobrush and reactive endocervical cells. However, the above constellation of features should permit a cytologic diagnosis.

Evaluation of the 10% rescreen of negative gynecologic smears as a quality assurance measure

The CLIA '88 regulations require the laboratory to review at least 10% of the gynecologic cases interpreted as negative that are examined by each cytotechnologist. The review must include negative cases selected at random and from patients identified as a high risk group. To evaluate the validity of this regulation, we reviewed the results of the 10% rescreen over a 24-mo period. The rescreening by pathologists detected epithelial abnormalities in 4/2,124 negative cases (0.18%). Subsequently, biopsy-proven squamous intraepithelial lesions were found in all four cases. Three different cytotechnologists were responsible for the four false-negative interpretations. Our results show that 10% rescreen of negative smears may detect a few false-negative cases. However, it is a time-consuming and inefficient mean to evaluate the performance of cytotechnologists. Quality control in gynecologic cytopathology is essential, but it is equally important that laboratories concentrate their resources and energy on methods proven to be effective.

Effect of suppressive therapy on thyroid fine needle aspiration cytology

The effect of suppressive therapy on the cytology of thyroid nodules and its usefulness in classifying lesions with indeterminate fine needle aspiration (FNA) results were evaluated. The study group consisted of 19 thyroid nodules (6 adenomatoid nodules and 13 neoplasms) aspirated before and while the patients were on suppressive therapy. The control group consisted of nine nonsuppressed nodules (four adenomatoid nodules and five neoplasms) aspirated twice. Both aspirates of each nodule were compared for differences in cytologic features. Differences between aspirates were detected in three suppressed and one nonsuppressed adenomatoid nodule. Suppression revealed no effect on the cytology of thyroid neoplasms and on 50% of adenomatoid nodules. Repeat FNAs allowed correct classification of 3/14 suppressed and 2/2 nonsuppressed nodules with indeterminate diagnoses on initial FNA. Our results indicate that lack of a cytologic response to suppressive therapy does not confirm a neoplastic diagnosis since it can be observed in both neoplastic and nonneoplastic nodules. However, repeat FNA, with or without suppressive therapy, may help to establish the correct diagnosis in difficult cases.

The protective effect of vein cuffed anastomoses is not mechanical in origin

PURPOSE

Intimal hyperplasia (IH) is a proliferative process of vascular smooth muscle cells that occurs after an arterial injury, particularly at outflow anastomoses of prosthetic bypass grafts. IH causes stenosis that leads ultimately to graft flow reduction and thrombosis. We have demonstrated previously that vein cuff interposition between an expanded polytetrafluoroethylene (e-PTFE) graft and artery at distal anastomoses diminished IH formation in the arterial outflow as compared with noncuffed anastomoses. Improved long-term patency rates associated with the placement of an interposition vein cuff at the distal anastomosis of e-PTFE grafts to infrageniculate arteries have also been demonstrated clinically. This study examined the mechanical factors that may contribute to the protective effect of cuffed anastomoses. These factors include the expansibility of the vein cuff as compared with e-PTFE, as well as the angle of the cuffed anastomosis.

METHODS

Compatible animals were selected by use of platelet aggregation studies. Nine dogs, group A, received a 4 mm e-PTFE graft plus a 1 cm long interposition vein cuff at the distal anastomosis in the left carotid artery. The same procedure was done on the right side, and in addition the vein cuff was encircled by an e-PTFE jacket incorporated into the anastomosis to prevent the expansion of the vein cuff with arterial pulsation. To study the effect of distal anastomotic angle and geometry on the formation of IH, five dogs, group B, received a 4 mm e-PTFE graft in both sides. On the left, the distal anastomosis was performed between the graft and the artery at an acute angle as it is commonly done when a bypass graft is placed. On the right side a 1 cm long, 6 mm diameter e-PTFE segment was interposed between the artery and the graft at a perpendicular angle. This geometry mimicked the right angle of a vein cuff-to-artery anastomosis. After 10 weeks the grafts were harvested, and the thickness of IH was measured with an ocular micrometer under light microscopy.

RESULTS

In group A, one dog had bilateral graft thrombosis (12%), and these grafts were discarded. In the remaining eight dogs there was no statistically significant difference in the thickness of IH between the right (jacketed group) and the left side (nonjacketed/control group), showing that vein cuff expansibility did not play a role in protecting against the formation of IH. In group B, bilateral graft thrombosis occurred in four of five dogs (80%), suggesting that the perpendicular anastomotic angle was not protective.

CONCLUSION

These results suggested that the protective effect of the vein cuff is not mechanical in origin.

Polymerase chain reaction detection of immunoglobulin gene rearrangement and bcl-2 translocation in archival glass slides of cytologic material

Cytologic evaluation of lymph node fine-needle aspirates and serous effusions is a rapid and useful means for establishing the diagnosis of a variety of lymphoproliferative disorders. However, in some instances, cytologic findings are not sufficient to establish a diagnosis of lymphoma, thus necessitating the use of ancillary procedures, the most frequent of which is immunophenotyping. In this respect, the usefulness of molecular markers, such as clonal immunoglobulin gene rearrangements or chromosomal translocations, have been less well evaluated. Follicular lymphoma constitutes an interesting disease for such a study because these tumors possess characteristic histopathologic features and contain two potential molecular markers, that is, a clonal immunoglobulin gene rearrangement and a bcl-2 gene translocation [t(14;18)]. In the present study, we evaluated, retrospectively, the cytologic material from four lymph node fine-needle aspirates and one pleural effusion of five patients with biopsy-proven follicular lymphoma. In four of the cases, definitive diagnosis of lymphoma had not been possible solely from cytologic evaluation. DNA was isolated from archival air-dried samples present on glass slides and amplified by the polymerase chain reaction (PCR) for detection of either a clonal immunoglobulin heavy chain gene rearrangement or bcl-2 translocation (major breakpoint region). An immunoglobulin heavy chain gene rearrangement was detected in four of five patients, and two patients had the bcl-2 translocation by PCR. The effusion case was identical by gel electrophoresis with product amplified from a lymph node biopsy of the same patient and DNA extracted directly from fresh pleural effusion cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Retrospective analysis of non-correlating cervical smears and colposcopically directed biopsies

The purpose of this study is to evaluate the cause of discrepancies between non-correlating cytologic and histologic cervical samples. The biopsy results of 433 women examined colposcopically were compared to their referral cervical smears (RS). There was a discrepancy between the RS and the subsequent biopsy in 120 women (28%). One hundred of these 120 RS were available for review; and in each case, a reason for the discrepancy was established and classified as RS overcall, RS undercall, RS sampling error, or biopsy sampling error. Fifty-one discrepant RS were overcalled. They were reported initially as condyloma (19), mild dysplasia (22), and moderate dysplasia (10). One RS was undercalled. Nine RS were not diagnostic of the biopsy-proven lesion due to smear sampling error. The discrepancies in the remaining 39 cases were due to biopsy sampling error. Twenty-one of these 39 cases had additional biopsies or smears that confirmed the presence of condyloma/dysplasia, and 18 had negative follow-up. In summary, discrepancies were a result of pathologists' interpretative error, predominantly overcalls, in 52% of non-correlating cases, and smear or biopsy sampling error in the remaining 48%.

The adequacy of the one-slide cervical smear in the detection of squamous intraepithelial lesions

This prospective study evaluated the impact of replacing the two-slide cervical smear by a one-slide smear to detect squamous intraepithelial lesions (SIL). The study population consisted of 87 patients with biopsy-proven SILs, a "referral" (precolposcopy) two-slide cervical smear, and a "one-slide repeat" smear done at the time of biopsy. The detection rate of SIL was compared with that of a control group of 85 patients who fulfilled similar criteria; they had a two-slide referral smear, but a "two-slide repeat" smear. Smears nondiagnostic of SIL occurred in 5.7%, 11.8%, 27.6%, and 15.3% in the referral group of the study population, the referral group of the control population, the one-slide repeat smears, and the two-slide repeat smears, respectively. Statistical analysis showed a higher rate of nondiagnostic smears in the one-slide repeat smear (P = .05). Although this may be attributed to the less-than-optimal quality of the preparation, the above findings do not support the use of a one-slide technique for sampling the ectocervix and endocervix.

Reactive change and atypical squamous cells of undetermined significance in Papanicolaou smears: a cytohistologic correlation

The purposes of this study were to delineate morphologic criteria for the terms reactive/reparative change (RC) and atypical squamous cells of undetermined significance (ASCUS), which were proposed by the Bethesda System, and to evaluate the impact of the new terminology on patient management. Using criteria defined in this article, 88 cervical smears originally reported as "atypia" were reclassified as RC (57) and ASCUS (31). Correlation with the colposcopically directed biopsies was as follows: 3/57 RC showed condyloma and 19/31 ASCUS had squamous lesions (14 condyloma, four mild, and one moderate dysplasia). The remainder of the cases had either cervicitis or no significant abnormality histologically. Using the proposed criteria, 61.3% of ASCUS correlated with positive biopsies, compared to 5.2% of the RC cases. Our results indicate that patients with smears showing RC are significantly less likely to have a squamous lesion as compared to those showing ASCUS, and therefore may be managed more conservatively.

Cytologic evaluation of serous effusions. Processing techniques and optimal number of smears for routine preparation

A double-blind retrospective review of 90 pleural and ascitic fluids was performed to determine the optimal number of smears necessary to produce an accurate evaluation, and to analyze the utility of different preparation techniques. Each case had four Papanicolaou-stained smears (two alcohol fixed and two Saccomanno fixed) and one Diff-Quik-stained, air-dried smear. Forty cases originally were reported as positive (37 adenocarcinoma, 1 lymphoma, and 2 Pneumocystis carinii) and 50 were reported as negative. The results showed that the diagnostic yield of evaluating five smears compared with three (one of each preparation) is identical. Air-dried smears were the most sensitive in identifying malignant cells and infectious organisms. It is concluded that (1) the diagnostic accuracy is enhanced by the use of several preparation techniques to include air-dried smears and (2) when variable processing methods are used, the evaluation of more than three smears does not increase the diagnostic yield.

Should we report cervical smears lacking endocervical component as unsatisfactory?

The purpose of the study is to correlate the accuracy of diagnosis of cervical smears with the presence/absence of an endocervical component. The referral smears and the smears obtained during colposcopic examination of 84 patients with biopsy-proven squamous lesions were evaluated for the presence of an endocervical component, and the cytologic interpretations were compared with the histologic findings. Of the 136 smears containing an endocervical component, 111 (81.6 percent) had good correlation with histology and 25 (18.4%) showed a discrepancy. Of the 30 smears lacking an endocervical component, 24 (80%) had good histologic correlation and 6 (20%) were discrepant. Our data showed no significant difference in the detection of squamous lesions in those smears with an endocervical component from those without. We conclude that, although the presence or absence of an endocervical component should be documented in the cytology report, its absence should not be an indication to report the cervical smears as unsatisfactory.

Human papilloma virus in uterine cervix: a comparison of detection by morphology and by dot-blot hybridization

Colposcopically directed cervical biopsies, smears, and swabs obtained from 210 women with a previous abnormal cervical cytology were evaluated for the presence of human papilloma virus (HPV) using morphology and dot-blot hybridization. The diagnosis of HPV infection in biopsies and smears examined morphologically was rendered using established criteria for condyloma/cervical intraepithelial neoplasia (CIN). In hybridization studies, DNA was isolated from cells obtained from cervical swabs and annealed with probes that detected HPV types 6/11, 16/18, and 31/33/35 using a dot-blot procedure. Ninety-five cases demonstrated morphologic evidence of condyloma/CIN; 51 of these (54%) were positive for HPV DNA (five cases 6/11, 21 cases 6/18, 20 cases 31/33/35, and five cases two different probes). HPV DNA was also detected in 6 of the 115 cases (5.2%) that were morphologically negative (three cases 16/18, three cases 31/33/35). The results demonstrated that morphology was more sensitive than dot-blot hybridization for detection of HPV-related lesions. The dot-blot hybridization did detect HPV DNA in a small percentage of the cases that showed no morphologic abnormality and was useful for typing of the HPV. At this juncture, however, the clinical significance of the latter findings is unclear.

Inflammatory atypia on cervical smears. A diagnostic dilemma for the gynecologist

In light of the current controversy on the significance, follow-up and management of women with cervical smears showing "inflammatory atypia" (IA), a study was conducted to correlate the initial cytologic diagnosis of IA with the follow-up findings in colposcopically directed cervical biopsies and smears. From March 1988 through June 1989, 70 women had two consecutive smears reported as IA; all underwent colposcopy and cervical biopsy. In 58 patients (83%) the biopsies and smears obtained during colposcopy were negative for condyloma and/or cervical intraepithelial neoplasia (CIN). Ten patients (14%) had condylomas, and two (3%) had condylomas with CIN (one CIN I and one II). The initial IA smears from those 12 patients were reviewed retrospectively: 2 showed condylomas (they had been undercalled), 5 were "suggestive of condyloma" (the atypical cells were too few or poorly preserved for a definitive diagnosis), and 5 showed IA. None showed cytologic evidence of CIN, most probably because of sampling error. Our results suggest that colposcopy is warranted after two consecutive diagnoses of IA on cervical smears, considering that 17% of the patients in our study showed underlying intraepithelial lesions of the cervix.

The significance of paravacuolar granules of the thyroid. A histologic, cytologic and ultrastructural study

The presence of the so-called "paravacuolar granules" in thyroid follicular cells has been associated with increased metabolic activity of the gland, regressive changes, degeneration, phagocytic activity and benign papillary hyperplasia. During the course of a review of the intraoperative cytologic preparations and corresponding histologic sections from 73 thyroid cases, the presence of granules within follicular cells was noted in 25 cases (18 adenomatous or colloid goiters, 3 follicular adenomas, 2 papillary carcinomas, 1 follicular carcinoma and in thyroid tissue surrounding a follicular adenoma in 1 case). Histochemical and ultrastructural studies showed the granules to consist of lysosomes containing hemosiderin or lipofuscin pigments. These findings indicate that the presence of paravacuolar granules in thyroid cells is a common nonspecific finding that simply reflects: (1) the erythrophagocytic capability of the follicular epithelial cells, which results in the accumulation of iron within lysosomes, and (2) the accumulation of lipofuscin pigments within lysosomes as a result of degradation of endogenous cellular material.

The recognition of mycobacterial infections by intraoperative cytology in patients with acquired immunodeficiency syndrome

In patients with the acquired immunodeficiency syndrome, mycobacterial lymphadenitis is characterized by the presence of numerous acid-fast bacilli within histiocytes. In Diff-Quik-stained cytologic preparations of such lymph nodes, performed during intraoperative consultations, the presence of mycobacteria is manifested by numerous negatively staining rod-shaped spaces intracellularly within histiocytes, as well as extra-cellularly in the background. Recognition of these characteristic "footprints," or "negative images," of mycobacteria can facilitate early diagnosis and treatment. The morphological characteristics that help to distinguish between Mycobacterium avium-intracellulare and Mycobacterium kansasii are also described.

Follicular lesions of the thyroid: intraoperative cytology

The aim of this study is to evaluate the role and utility of intraoperative cytology in differentiating between follicular adenomas and non-neoplastic adenomatous nodules of the thyroid. We retrospectively reviewed the intraoperative cytologies of 36 adenomatous nodules and 19 follicular adenomas and evaluated several features. chi-square statistics were used to determine a statistically significant difference in cytologic scores between the two groups. We found significant differences in grading scores of the following parameters: follicular adenomas showed greater cellularity, greater follicle formation, larger nuclei, and more nuclear pleomorphism and overlap; adenomatous nodules showed more colloid and honeycomb arrangements. However, inspection of the data in graphic form showed a partial overlap in cytological features between the two groups: an adenomatous nodule revealing a microfollicular pattern histologically will cytologically display numerous follicles and scant colloid, giving a false impression of a neoplasm; while the smear of a macrofollicular adenoma is relatively hypocellular and contains abundant colloid, causing potential misdiagnosis as an adenomatous nodule. In conclusion, intraoperative cytologic examination can help to detect those follicular lesions more likely to be neoplastic, and a systematic approach is proposed when dealing with thyroid follicular lesions during intraoperative consultation in order to improve the diagnostic accuracy.

Thorotrast-associated gliosarcoma. Including comments on thorotrast use and review of sequelae with particular reference to lesions of the central nervous system

The occurrence of a glioblastoma with sarcoma, a gliosarcoma, in the left frontal-temporal area of a 49-year-old woman with a history of Thorotrast exposure, is described. Thorotrast-laden histiocytes and free Thorotrast material were found in both components of the tumor. An overlying, adherent dural cranial lesion was found to contain massive deposits of Thorotrast embedded in a dense fibrotic and sclerotic stroma with focal calcification. These features are typical of "Thorotrastoma." Thorotrast stains greenish-brown with hematoxylin and eosin and appears as refractile granular particles of relatively uniform size either within histiocytes or as free material. The radioactivity of the deposits was confirmed through the use of a scintillation counter, and 232 thorium was definitively identified though the use of scanning electron microscopy with energy-dispersive X-ray analysis. Immunohistochemical studies of the tumor demonstrated glial fibrillary acid protein (GFAP) immunoreactivity in areas of glioma and focal vimentin and actin immunoreactivity in areas of sarcoma. Thorotrast-associated lesions of the central nervous system (CNS) are infrequently reported, and a Thorotrast-associated gliosarcoma has not yet been reported. The use of Thorotrast, its radiobiology, and sequelae are reviewed with particular emphasis on lesions occurring in the CNS.

Endosalpingiosis in female peritoneal washings: a diagnostic pitfall

Endosalpingiosis in female peritoneal washings can be a source of false-positive diagnoses, especially in patients with known ovarian carcinoma. In this article we report the features of endosalpingiosis in the peritoneal washings of four patients, three of whom were initially reported as "suspicious for malignancy." Two of the patients had ovarian serous tumor of borderline malignancy; however, the tumors were confined to the ovaries with no evidence of disseminated peritoneal malignancy. All four patients had histologic evidence of pelvic endosalpingiosis. It is important to recognize this entity cytologically to avoid a misdiagnosis of recurrent or disseminated malignancy.

Detached ciliary tufts in female peritoneal washings. A common finding

Detached ciliary tufts (DCTs) have been observed in sputum, in cervicovaginal smears and, rarely, in fluid from the pouch of Douglas. DCTs occur frequently in peritoneal washings from female patients. Twenty-five consecutive peritoneal washings were studied for DCTs. Fourteen specimens were from women in the reproductive age group (21 to 47 years); all contained DCTs. All of these 14 patients, except for one in the 14th week of pregnancy, were in the secretory phase of the menstrual cycle. The 11 patients without DCTs in their peritoneal washing had an age range of 23 to 88 years. Three were postmenopausal, seven were in the proliferative phase of the menstrual cycle, and one had had a previous hysterectomy and bilateral salpingo-oophorectomy. DCTs most likely represent a physiologic process of cyclic shedding of cilia from the cells of the fallopian tubes during the luteal phase of the menstrual cycle.

Hodgkin's disease in the liver without splenic involvement

We encountered an unusual case of Hodgkin's disease disseminating to the liver without splenic involvement. Ours appears to be the first such case reported in which it was possible to rule out any prior inclusion of the spleen.