Role of immunocytochemistry in cervical cancer screening

The cervical cancer screening has been based conventionally on cytologic analysis. With advances in understanding the role of human papillomavirus, cotesting has been applied. But most of the patients subjected to colposcopy did not benefit, except in cases with HSIL [high-grade squamous intraepithelial lesion] cytology. Because of this, a step to increase the sensitivity to detect cancers and pre-cancers but with higher specificity with minimal overdiagnosis leading to prevention of unindicated cervical biopsies is highly desired. Such triaging step in cases with abnormal screening results is expected to minimize invasive interventions because of low false positivity. With availability of methodologies leading to quantitatively and qualitatively enhanced cell-blocks from residual liquid based cytology specimens, immunostaining can be performed for multiple immunomarkers with potential objectivity to triage initial screening test results. This is enhanced further with inclusion of AV marker in the cell-blocks and application of SCIP (subtractive coordinate immunoreactivity pattern) approach. The cell-blocks are also resource for performing other ancillary studies including molecular pathology and proteomics/metabolomics as potential tests in future. This review explores application of residual liquid based cytology specimen for cell-blocking with application of ancillary studies in algorithmic manner as adjunct to ASCCP management guidelines for improved patient care.

Collection and processing of effusion fluids for cytopathologic evaluation

Accumulation of fluid in serous cavities as effusions may have to be drained for therapeutic and diagnostic indications. As compared to many other procedures, the technicality of paracentesis procedures is relatively easy. As a result, effusion fluids comprise a significant proportion of specimens in most of the laboratories, including those in community settings.

Because of relative complexities in the cytopathologic evaluation of effusion fluids, application of appropriately standardized protocol is critical for achieving optimum results by applying standardized steps from handling of specimens during the initial stages of collection to the final interpretation phase. Understanding various limitations and challenges during collection and processing phases by all the personnel involved, including clinicians, pathologists, and technologists is critical for optimum diagnostic yield.

This review highlights various cytopreparatory techniques applicable to effusion cytology in one place. It is organized by projecting the details predominantly in the form of different tables and figures including summary of the recommended protocols with reagents and stains used. Also included is a sample of cytopathology report based on the approach discussed in this series.

Immunocytochemistry of effusion fluids: Introduction to SCIP approach

Due to the remarkably wide morphologic spectrum of reactive mesothelial cells, some of the effusion fluids may be difficult to interpret with objective certainty by cytomorphology alone. Cytomorphology of well to moderately differentiated adenocarcinomas (responsible for the bulk of malignant effusions) may overlap with floridly reactive mesothelial cells. Even mesotheliomas including diffuse malignant epithelioid mesothelioma, are usually cytomorphologically bland without unequivocal features of malignancy. The intensity of challenge depends on the interpreter's training or experience level, institutional demographics of patients (such as type of prevalent diseases, predominant sex and age group), technical support, and quality of cytopreparatory processing. In general immunocytochemistry is valuable adjunct to facilitate objective interpretation with or without other ancillary techniques as indicated. An increasing number of immunomarkers is further refining the contribution of immunohistochemistry to this field. However, application of immunohistochemistry to effusion fluids is relatively challenging because of many variables. Multiple factors such as delay after specimen collection, specimen processing related factors including fixation and storage; ambient conditions under which paraffin blocks are archived (for retrospective testing); antigen retrieval method; duration of antigen retrieval step; antibody clone and dilution; and antibody application time are identical to application of immunohistochemistry in other areas. The significant challenge related to the potential compromization of the immunoreactivity pattern due to exposure to non-formalin fixatives / reagents is also applicable to effusion fluid specimens. The immunoreactivity results would be compared and corelated with cumulative metadata based on the reported studies performed and validated on formalin-fixed paraffin-embedded tissue sections. Deviating from such protocols may lead to suboptimal results, which is not uncommon in clinical practice with potential compromization of patient care and related liability. Because of this, it is critical to perform immunocytochemistry on formalin-fixed cell-block sections only. In addition, unless the interpretation criteria for immunohistochemical evaluation of effusion fluids are not modified specifically, it may not be productive in resolving some challenging cases. However, this aspect is not well elaborated in the literature. A basic and critical challenge is finding and locating the cells of interest in cell-block sections of effusion fluids. A unique approach is to choose a fundamental immunopanel which highlight the mesothelial and inflammatory cells in reactive effusion fluids to create the basic map. This allows detection of a 'second-foreign' population which can be immunocharacterized further with the help of subtractive coordinate immunoreactivity pattern (SCIP) approach elaborated here.

Serous fluid: Reactive conditions

This chapter highlights the steps that would help to analyze any fluid. It highlights importance of knowing gross analysis of fluid along with biochemical information. These parameters along with clinical information are very important in arriving at a differential diagnosis. Morphologic appearances in the fluid can often become challenging and occasionally reactive conditions can reveal changes that may mimic malignancies. This chapter provides not only a framework of approach to assessment of fluid cytology but also shows how to distinguish some of the challenging reactive conditions from the diagnosis of carcinoma. The chapter also utilizes two cases to demonstrate approach to reactive conditions. This review article will be incorporated finally as one of the chapters in CMAS (CytoJournal Monograph/Atlas Series) #2. It is modified slightly from the chapter by the initial authors in the first edition of Cytopathologic Diagnosis of Serous Fluids.

Atypical glandular cells (AGC): Cytology of glandular lesions of the uterine cervix

The Pap smear is a well-known screening tool for squamous lesions of the uterine cervix. However, its screening role in glandular lesions is less effective. The incidence of squamous cell carcinoma of the cervix has dramatically decreased with the advent of Pap smear and recent understanding related to HPV carcinogenesis of cervical cancers including the advent of HPV vaccines. However, in recent years, the incidence of glandular abnormalities, diagnosed on Pap smears, has increased with greater sensitivity and precision.

The incidence of atypical glandular cells (AGC) is approximately 0.18–0.74% of all cervical smears with a reported prevalence of 2.5% among all Pap smears. A high degree of suspicion, good clinical history, and the presence of diagnostic cytomorphological findings are essential for the proper interpretation of glandular cell abnormalities. A methodical approach to evaluate Pap smear greatly helps interpretation and avoids the diagnostic pitfalls. The Bethesda System for reporting cervical cytology has categorized glandular cell abnormalities into various categories as follows:

Endocervical adenocarcinoma in situ (AIS)

Atypical glandular cells (AGCs)

Endocervical cells: a1 NOS or specify in comments; a2 Favor neoplastic

Endometrial cells: NOS or specify in comments

Adenocarcinoma (AdCa)

Endocervical

Endometrial

Extrauterine

NOS

Subtle differences in quantitative and qualitative cytologic features are essential for distinguishing one category from another. In this chapter, we highlight an organized approach for the interpretation of glandular abnormalities in Pap smear for our readers. This is an overview of the Bethesda categories, the reason for classification, and differential diagnosis with key characteristic features. An approach to the methodical evaluation of hyperchromatic crowded groups is discussed with key cytomorphologic differences. An algorithmic approach is suggested to facilitate the interpretation of various AGC categories.

The panorama of different faces of mesothelial cells

All effusions in serous cavities represent a pathologic processes secondary to inflammatory, neoplastic, hemodynamic, or mechanical/traumatic etiologies. This elicits reactive changes in the extremely sensitive mesothelial cells lining the serosal surfaces. The result is hypertrophy and hyperplasia which lead to broad changes with a wide range of morphological appearances. These reversible alterations may resolve entirely after the recovery of underlying pathology.

Under the tertiary care situations, neoplastic effusion specimens are encountered more frequently. Although some non-neoplastic pathologic process may demonstrate a few diagnostic features, cytologic evaluation of malignant effusions usually show diagnostic malignant cells. However, the most versatile mesothelial cells demonstrate a very wide cytomorphological spectrum secondary to reactive challenges. These mesothelial cells are usually referred to as ‘reactive mesothelial cells’. In addition other terms such as reactive mesothelial proliferation, reactive mesothelial hyperplasia, irritated mesothelial cells, activated mesothelial cells, hyperplastic mesothelial cells, hypertrophic mesothelial cells, and proliferative mesothelial cells. Rarely atypical mesothelial cells, although not recommended, is used inadvertently. Although there is a lack of general agreement defining these terms, some of these including atypical mesothelial cells, should not be preferred. With reference to this CMAS series, usually favored term ‘reactive mesothelial cells’ is preferred.

The size of reactive mesothelial cells range from 15 to 30 µm (but may be up to 50 µm). These polyhedral cells with variable amount of cytoplasm and enlarged nuclei may show variation in sizes and shapes with conspicuous nucleoli. Bi- and multi-nucleation is frequent. Cohesive groups of mesothelial cells as sheets and three dimensional groups may be present. Some floridly reactive mesothelial cells with hyperchromatic enlarged nuclei with prominent nucleoli and scant cytoplasm may resemble malignant cells. This astonishingly wide morphological spectrum of reactive mesothelial cells is a significant interpretation challenge in effusion fluid cytology. Methodical interpretation approach with appropriate knowledge about this wide spectrum is important aspect in diagnostic cytopathology of effusion fluids.

Approach to Diagnostic Cytopathology of Serous Effusions

Collection of most serous fluids from various effusions is a relatively simple procedure. Because of this, serous fluids are commonly submitted for pathologic examination including cytopathologic evaluation by various clinical institutions. As a consequence, even a general pathology laboratory which may not have expertise with highly trained cytopathologist would be confronted with serous fluids for cytologic evaluation.

However, cytopathologic evaluation of serous fluids is complex as compared to evaluation of fine needle aspiration cytology. This signifies the fact that all pathologists, irrespective of subspeciality cytopathology training and level of subspeciality expertise, should be conversant with the diagnostic challenges and pitfalls of effusion fluid cytology.

Although, majority of effusions are due to reactive and non-neoplastic etiologies, cancer is one of the causes of an effusion as a manifestation of advanced cancer. Detecting neoplastic cells in effusion specimens in most of clinical settings is related to the advanced status of the disease, which usually is equivalent to incurable stage. Thus, interpretation of cytopathology as positive for cancer cell is highly critical in planning the trajectory of the clinical management with an obvious negative impact of false positive interpretation.

Apart from cancer, effusions may be secondary to hemodynamic pathologies such as heart failure, hypoalbuminemia, cirrhosis etc. in addition to the different inflammatory conditions including parasitic infestations, bacterial, fungal, or viral infections, and other non-neoplastic etiologies including collagen diseases. Due to the cytomorphologic overlap of reactive mesothelial cells with malignant cells, general cytologic criteria for diagnosis of malignancy in single cells cannot be applied in most of the effusion specimens. This challenge is further amplified because of surface tension related phenomenon which ‘round up’ the cells after exfoliation in serous fluids. As a result, the native shapes of cancer cells cannot be a guiding feature. Thus the cytomorphologic features of cancer cells in serous fluids may not be same as seen in routine cytopathology of exfoliative, brushing, and fine-needle aspiration specimens.

The cancer cells may continue to proliferate after exfoliation in the nutrient rich effusion fluids and may form proliferation spheres. It is crucial to consider these factors when interpreting effusion cytology. Amongst malignant effusions, adenocarcinomas are the most common cause of metastatic cancers, but almost any type of malignancy including melanomas, hematopoietic neoplasms, sarcomas, and mesotheliomas may involve serous cavities. The interpreter must be aware of the wide range of the cytomorphologic appearances of reactive mesothelial cells in effusion fluids. It is essential to understand these and other nuances related to effusion fluid cytology. Understanding potential pitfalls during various stages from processing to application of ancillary studies would increase the diagnostic accuracy and minimize atypical interpretations and false positivity.

Diagnostic pitfalls in effusion fluid cytology

Effusion fluid cytology has propensity for both false positives (in up to 0.5%) and false negatives (in up to 30%) results. Methodical approach from collection step to final interpretation stage could prevent both false positives and false negatives, if the interpreter is familiar with various factors responsible for diagnostic pitfalls in effusion fluid cytology. For this discussion, these factors are categorized as mentioned below: Surface tension-related alterations in cytomorphologyImproper specimen processingMany faces of reactive mesothelial cells, overlapping with those of cancer cellsProliferation-related featuresDegenerative changes, such as nuclear hyperchromasia and cytoplasmic vacuolationUnexpected patterns and unusual entities.

Introduction to the second edition of 'Diagnostic Cytopathology of Serous Fluids' as CytoJournal Monograph (CMAS) in Open Access

Serous fluids are excessive accumulation of fluids in a serous cavity as effusion. However, traditionally this area also covers cytopathologic evaluation of washings of these cavities including pelvic/peritoneal washing. This is the introductory review article in series on this topic with the application of simplified algorithmic approaches. The series would be compiled finally as a book after minor modifications of individual review articles to accommodate the book layout on the topic as second edition of 'Diagnostic Cytopathology of Serous Fluids' book. The approach is primarily directed towards detection of neoplastic cells based on morphology alone or with the help of various ancillary tests, including commonly applied immunocytochemistry to be interpreted as second foreign population with application of SCIP (subtractive coordinate immunoreactivity pattern) approach in effusion fluid tapings. As the role of molecular pathology tests is increasing, this component as ancillary testing will also be covered as applicable. Because a picture and sketches are worth a thousand words, illustrations and figures are included generously even at the risk of moderate repetition. The clinically important serous cavities include peritoneal cavity, pericardial cavity, and two pleural cavities. The primary topic of this series is specimens from these cavities as effusion fluids and washings including cytopathologic evaluation of peritoneal/pelvic washing. It is expected that some readers may not read the entire series or the final book from beginning to end, but refer to the individual review articles and chapters sporadically during their clinical practice. Considering this practical limitation, some brief repetition may be observed throughout the book. Some of the important themes will be highlighted as italicized and bolded text for quick reference. Dedicated articles/chapters are assigned for technical and other reference material as appendices. Tables, algorithms, sketches, and combination of pictures are included generously for quick reference. Most of the illustrations are attempted to be labeled appropriately with arrows and other indicators to avoid equivocation, especially for beginners in the field. This introductory review article describes general details under the following three broad headings: Histology and general cytology of serous cavity lining Effusion (general considerations) Ancillary techniques in brief.

Metastatic Carcinoma in Effusions

Serous cavity may be involved by any neoplasm, including very rare examples of involvement by central nervous system tumors leading to a malignant effusion. The serous cavity lining is rich in lymphatics with lymphatic lacunae opening directly through narrow gaps (stoma) in the lining. Carcinomas mainly metastasize to serosa via the lymphatic vessels, which may be blocked leading to effusion. Primary carcinomas of organs such as lung, intestines, liver, ovary, etc., lined by serosal membranes may spread by direct extension, resulting in malignant effusions. As standard of practice, unless specified, cytopathologic examination of serous effusions implies detection of malignant cells.

As compared to a surgical biopsy from a small focal area of an extensive serosal surface, effusion fluid from respective cavity exfoliates the cells from the entire serosal surface with minimal chance of sampling artifact. Because of this, effusion fluid cytology generally provides a higher diagnostic yield as compared to biopsy of the serous lining, as demonstrated by some studies. However, various challenges related to effusion fluid cytology makes the interpretation of effusion fluid cytology a field with potential misinterpretations, especially for those without proper experience or training.

Developing and following a methodical approach is important for appropriate cytologic examination of effusion fluids. Proper approach may achieve definitive interpretation even without ancillary tests. However, lack of appropriate approach and processing may introduce a significant variation in interpretation due to combination of well-recognized diagnostic pitfalls, which may lead to lower reproducibility and even serious misinterpretations.

Current review discusses in brief appropriate approach to processing and evaluating effusion fluid cytology for metastatic carcinoma. At general level, this is comparable to that of other specimens; however, it is critical to modify with reference to the limitations associated with effusion cytology.

Immunocytochemistry of effusions: Processing and commonly used immunomarkers

Definitive cytopathological interpretation of some of the effusion fluids may not be possible based on cytomorphological evaluation alone. As discussed in other reviews, this is due to various reasons specifically applicable to effusion fluids including remarkably wide morphologic spectrum of reactive mesothelial cells overlapping with some well to moderately differentiated metastatic carcinoma. The challenge is subject to various factors including level of interpreter training or experience, institutional demographics (such as type of prevalent diseases, predominant sex and age group), technical advances in ancillary support, and expertise in cytopreparatory processing. In such cases immunohistochemistry performed on cell-block sections is simple objective adjunct with or without other ancillary techniques. Ongoing increase in number of immunomarkers along with rabbit monoclonal antibodies with relatively higher affinity is further refining this field. SCIP (subtractive coordinate immunoreactivity pattern) approach, discussed as separate dedicated review article, facilitates refined interpretation of immunoreactivity pattern in coordinate manner on various serial sections of cell-blocks. However, many variables such as delay after specimen collection, specimen processing related factors including fixation and storage; ambient conditions under which paraffin blocks are archived (for retrospective testing); antigen retrieval method; duration of antigen retrieval step; antibody clone and dilution; and antibody application time are common with application of immunohistochemistry in other areas. This review is dedicated to highlight technical aspects including processing of effusion specimens for optimum immunocytochemical evaluation along with commonly used immunomarkers in effusion cytopathology. This review focuses on the technical and general information about various immunomarkers.

Impact of cytopathology authors work: Comparative analysis based on Open-access cytopathology publications versus non-Open-access conventional publications

Objectives

Open access (OA) is based on a set of principles and a range of practices through which fruits of research are distributed online, free of cost, or other access barriers. According to the 2001 definition, OA publications are without barriers to copy or reuse with free access to readers. Some studies have reported higher rates of citation for OA publications. In this study, we analyzed the citation rates of OA and traditional nonOA (with or without free access) publications for authors publishing in the subspecialty of cytopathology during 2010-2015.

Material and Methods

We observed and compared citation patterns for authors who had published in both OA and traditional non-OA, peer-reviewed, scientific, cytopathology journals. Thirty authors were randomly selected with criteria of publishing a total of at least five cytopathology articles over 2010-2015. Number of citations per article (CPA) (during 2010-2015) for OA publications (in CytoJournal and Journal of Cytology) and non-OA publications (in Diagnostic Cytopathology, Cytopathology, Acta Cytologica, Journal of American of Cytopathology, and Indian Journal of Pathology and Microbiology) was collected and compared statistically using two-tailed Student's t-est. The data were collected manually through science citation analysis sites, mostly Google Scholar.

Results

Thirty authors published 579 cytopathology articles in OA and non-OA journals. Average CPA for OA publications was 26.64. This was 11.35 higher than the average CPA) of non-OA conventional with subscription cytopathology journals (74% increase) and 11.76 higher than the average CPA of conventional cytopathology non-OA journal articles with free access (79% increase). These differences were statistically significantly with P < 0.05.

Conclusion

We observed that the cytopathology publications in the OA journal attained a higher rate of CPA than the publications in the traditional non-OA journals in the field of cytopathology during 2010-2015.

Squamous intraepithelial lesions (SIL: LSIL, HSIL, ASCUS, ASC-H, LSIL-H) of Uterine Cervix and Bethesda System

For every 100,000 women in the United States, eight new cervical cancer cases and two deaths are reported as per the most recent (2017) Center of Disease Control and Prevention statistics. Of all the gynecologic cancers (ovary, uterus, cervix, vagina, and vulva), only cervical cancer has a screening test. Cervical Pap test (or Pap smear) is the best screening method for cervical precancerous lesions and is best reported using a unified and a well-established reporting system like The Bethesda System. In this system, “Epithelial cell abnormality: Squamous” includes squamous intraepithelial lesion (SIL) category which encompasses a spectrum of squamous cell lesions starting from the precancerous lesions of low-grade SIL (LSIL) to high-grade SIL (HSIL), and ultimately invasive squamous cell carcinoma. However, depending on the qualitative and quantitative limitations with the specimen, some equivocal morphological features suggestive of squamous cell abnormality may fall under equivocal category: “Atypical Squamous Cells” (ASCs), which are subdivided into two categories; “Atypical Squamous Cells of Undetermined Significance” (ASC-US) or “Atypical Squamous Cells, HSIL cannot be excluded” (ASC-H), based on the suspected underlying lesion LSIL versus HSIL, respectively. This review provides the key cytologic features that distinguish Bethesda squamous categories from other important entities, using algorithmic approach and illustrations of common cytomorphologic patterns for clear identification of those entities in practice. The important mimickers which may be considered during the differential interpretation of SIL are discussed and presented here in a brief cytomorphologic review.

Pleural effusion in hematological pathology

A 51-year-old male with a history of chronic myelomonocytic leukemia-2 (CMML-2) presented with fatigue, night sweats, dyspnea, and right-sided chest pain exacerbated by deep breath. Computed tomography scan demonstrated right-sided pleural effusion with atelectasis. Pleural fluid cytology showed reactive mesothelial cells mixed with atypical cells [Figure 1]. The immunostains are performed using the SCIP approach.^[1] The atypical cells were immunoreactive for vimentin, CD68, and CD163, while non-immunoreactive for cytokeratin, calretinin, BerEP4, and MOC31.

Cell-blocks and other ancillary studies (including molecular genetic tests and proteomics)

Many types of elective ancillary tests may be required to support the cytopathologic interpretations. Most of these tests can be performed on cell-blocks of different cytology specimens. The cell-block sections can be used for almost any special stains including various histochemistry stains and for special stains for different microorganisms including fungi, Pneumocystis jirovecii (carinii), and various organisms including acid-fast organisms similar to the surgical biopsy specimens. Similarly, in addition to immunochemistry, different molecular tests can be performed on cell-blocks. Molecular tests broadly can be divided into two main types Molecular genetic tests and Proteomics.

Cell-blocks and immunohistochemistry

The interpretation of results on immunostained cell-block sections has to be compared with the cumulative published data derived predominantly from formalin-fixed paraffin-embedded (FFPE) tissue sections. Because of this, it is important to recognize that the fixation and processing protocol should not be different from the routinely processed FFPE surgical pathology tissue. Exposure to non-formalin fixatives or reagents may interfere with the diagnostic immunoreactivity pattern. The immunoprofile observed on such cell-blocks, which are not processed in a manner similar to the surgical pathology specimens, may not be representative resulting in aberrant results. The field of immunohistochemistry (IHC) is advancing continuously with the standardization of many immunomarkers. A variety of technical advances such as multiplex IHC with refined methodologies and automation is increasing its role in clinical applications. The recent addition of rabbit monoclonal antibodies has further improved sensitivity. As compared to the mouse monoclonal antibodies, the rabbit monoclonal antibodies have 10 to 100 fold higher antigen affinity. Most of the scenarios involve the evaluation of coordinate immunostaining patterns in cell-blocks with relatively scant diagnostic material without proper orientation which is usually retained in most of the surgical pathology specimens. These challenges are addressed if cell-blocks are prepared with some dedicated methodologies such as NextGen CelBloking™ (NGCB) kits. Cell-blocks prepared by NGCB kits also facilitate the easy application of the SCIP (subtractive coordinate immunoreactivity pattern) approach for proper evaluation of coordinate immunoreactivity. Various cell-block and IHC-related issues are discussed in detail.

Specimen-specific cell-blocking approaches

The science of CellBlockistry highlights requirement for proper approach to process different types of cytopathology specimens with critical considerations during preparation of cell-blocks. Common cytopathology specimens which may be subjected for cell-blocking include FNA aspirates in addition to anterior fat pad aspirate, bone marrow aspirate, effusion fluids, and other fluids such as various washings and urine. In addition veterinary sciences and research fields including animal experiments and tissue/cell cultures may also be cell-blocked for improved diagnostic yield and research outcome.

Updates in processing of anterior fat pad aspirate for amyloid (with video and sketches)

Fat pad aspiration is a commonly used method for detecting amyloid in tissue. Amyloid is detected in the small blood vessels of the aspirated adipose tissue. Optimum evaluation of amyloid with electron microscopy requires at least 15 blood vessels in the fat pad aspirate. The presence of a significant proportion of adipocytes in the aspirate dilutes the fibrovascular portion. This may compromise the evaluation for amyloid with electron microscopy and in FFPE with proteomic studies by mass spectroscopy for confirmation of the amyloid subtype. This video article describes the updated protocol for processing the anterior fat pad aspirate. It demonstrates how to remove the interference of blood and fatty component in the fat pad aspirate performed by the previously reported procedure.

Pattern of cervical biopsy results in cases with cervical cytology interpreted as higher than low grade in the background with atrophic cellular changes

Objective:

The cytomorphological changes associated with atrophic cellular pattern (ACP) in cervical cytology smears may mimic high-grade squamous intraepithelial lesion (HSIL). Due to this, there may be higher chances of cytomorphological overinterpretation in cases with ACP. Estrogen therapy (ET) (topical or systemic) would reverse the changes related to atrophy and repeat Pap smear after ET should correct the false positives. This approach would minimize the unindicated invasive interventions. However, performing immediate biopsies following “higher than low-grade squamous intraepithelial lesion (LSIL) (atypical squamous cells-cannot exclude HSIL, low-grade squamous intraepithelial lesions-cannot exclude HSIL, and HSIL) interpretations” in such cases, is a general trend. Pap smears with “higher than LSIL interpretations” in association with ACP over a period of 10 years were selected.

Materials and Methods:

A total of 657,871 cases over 10 years were reviewed, of which 188 Pap smears interpreted as higher than LSIL interpretations with ACP were selected randomly for this study.

Result:

Of these 188 cases, 67 underwent biopsies which were reviewed and compared with 67 biopsies performed for “higher than LSIL interpretation” cases without ACP. The follow-up biopsy material was reviewed including elective p16 immunohistochemistry with other clinical details including high-risk HPV test results as indicated.

Conclusion:

The findings demonstrated that Pap smears with ACP have higher false positives due to tendency for cytomorphologic overinterpretation as compared to non-ACP group.

Dual-color immunocytochemistry (Ki-67 with LCA) for precise grading of pancreatic neuroendocrine tumors with applicability to small biopsies and cell blocks

Ki-67 (MIB-1) immunostaining to quantify the proliferative index of neuroendocrine tumors (NETs) has been recommended (especially for small biopsies). However, this has a number of challenges with nonrepresentative Ki-67 index due to interference by Ki-67 immunoreactive proliferating lymphocytes infiltrating the tumor and also some proliferating stromal cells including endothelial cells in the background. Our pilot project showed that dual-color immunostaining with inclusion of leukocyte common antigen (LCA) (Ki-67: nuclear brown; LCA: cytoplasmic red) can facilitate the weeding out of lymphocyte interference. We analyzed the results with 23 surgical cases of pancreatic NETs. This was followed by poststudy examination of 11 cases of endoscopic ultrasound-guided fine-needle aspiration of the pancreatic NETs (PanNETs) to evaluate the findings of the study. Dual-color immunostaining for Ki-67 with LCA increased the precision of quantifying Ki-67 index, due to ability to exclude LCA immunoreactive lymphocytes. Other nontumor Ki-67 immunoreactive cells such as endothelial and stromal cells could be distinguished morphologically. Digital methods were also attempted, but this approach could not distinguish infiltrating lymphocytes and other cells in sections resulting in erroneous results. This study demonstrated that grading of PanNET can be performed with increased precision with dual-color Ki-67 immunostaining protocol standardized in this study. As evaluated on a few cytopathology cases, this protocol is especially useful for the evaluation of small biopsies and cell block sections of fine-needle aspiration biopsy material where 50 high-power fields cannot be evaluated but have >500 tumor cell nuclei.

CellBlockistry: Chemistry and art of cell-block making - A detailed review of various historical options with recent advances

Cell-blocks are paraffin-embedded versions of cytology specimens comparable to the formalin-fixed paraffin-embedded (FFPE) tissue from surgical pathology specimens. They allow various elective ancillary studies on a variety of specimens with enhanced cytopathologic interpretation, including opportunity to perform molecular tests. However, different dictionaries and internet search engines primarily project "cellblock" and "cell block" definition in relation to prisons. Most of the top searches lead to information related to "prison cells" followed by a few cytopathology-related searches. Due to this in the current review, it is recommended that the word for cytopathology purposes should be hyphenated and spelled as "cell-block." Cell-blocks have been increasingly indicated on most cytology specimens. Its role is growing further with the ongoing addition of new immunohistochemistry (IHC) markers with technical advances including multicolor IHC and the SCIP (subtractive coordinate immunoreactivity pattern) approach. In addition, it is an important source of tissue for many ancillary studies even as archived material retrospectively at later stage of management if the cell-blocks are improved qualitatively and quantitatively. Because of this, the significance of cell-block is critical with the increasing number of molecular markers standardized predominantly on FFPE tissue. As compared to core biopsies, high-quality cell-blocks prepared with enhanced methodologies predominantly contain concentrated diagnostic tumor cells required for the molecular tests without significant stromal contamination. This review introduces the terminology of CellBlockistry as the science of studying chemistry and the art of achieving quantitatively and qualitatively improved cell-blocks from different types of specimens. The review addresses the cell-block making process as "cell-blocking" and discusses different historical limitations with emphasis on recent advances.

An algorithmic approach to overcome diagnostic challenges in FNAC in large-cell poorly differentiated thyroid carcinomas

INTRODUCTION

Poorly differentiated thyroid carcinoma (PDTC) is a distinct entity and a rare carcinoma of thyroid follicular origin with an intermediate prognosis. It is defined by the Turin criteria set in 2007. Although this entity is well known, with widely available literature on histological features, specific studies describing the cytological features of PDTC (especially the large cell type) are lacking. In this study, we describe the cytological and clinical features of PDTC showing large cells (PDTC-LC) with abundant cytoplasm.

MATERIALS

Twelve cases of PDTC showing abundant cytoplasm between 2007 and 2016 were retrieved from the departmental archives and studied.

RESULTS

The cases occurred predominantly in women with a mean age of 54.3 years. The mean tumor size was 4.3 cm. Fine-needle aspiration cytology (FNAC) smears showed singly scattered large cells with abundance of cytoplasm admixed with microfollicular and insular pattern. Lymph node metastasis was noted in 7 cases and distant metastasis to bone and visceral organs were also seen in 7 cases.

CONCLUSIONS

Microfollicular pattern may lead to these cases being misinterpreted as a differentiated follicular neoplasm on FNAC, and the dissociated large cells may mimic Hürthle cell neoplasm. Immunocytochemistry is not helpful in this scenario, although it does resolve the diagnostic dilemma when the differential diagnoses include medullary thyroid carcinoma and metastatic tumors. It is important to identify these tumors on FNAC as this facilitates proper management.

Etiologic factors related to unsatisfactory ThinPrep(®) cervical cytology: Evaluation and potential solutions to improve

Background:

In cervical cytology, the unsatisfactory rates for ThinPrep (TP) are slightly higher compared to SurePath. We examined various causes and explored potential for resolution of this discrepancy.

Materials and Methods:

Totally, 19,422 cases were reviewed and 1000 unsatisfactory specimens were selected and analyzed. 531 specimens were available for wash protocol. Out of 114 unsatisfactory specimens associated with atrophic cellular changes (ACC), 48 were resubmitted by provider and reevaluated.

Results:

Lubricant and lubricant-like debris/contamination (LUBE) was the most common cause of unsatisfactory specimens (68%; 681/1000) followed by blood (7.5%); ACC only (without other interfering factors) (2.4%); inflammation (3.0%); and combinations thereof (1.9%). 11.5% showed scant cellularity without an identifiable cause. 3.3% were virtually acellular. Wash protocol improved cellularity in 48% (256/531) of cases. However, only 29% (73/256) of those were satisfactory (with more than 5000 cells). Quantitative reduction in LUBE after wash protocol varied with different morphological subtypes. Interpretation patterns on satisfactory specimens after wash protocol were comparable to the results on selected cohort of specimens during the same study period. Out of 114 ACC, wash protocol was performed on 68 ACC specimens leading to satisfactory TP in 24% (16/68). Totally, 48 cases reported as unsatisfactory with ACC, were resubmitted by the providers between 2 weeks and 2 years. 44 (92%) showed increased cellularity, out of which 52% (23/44) did not show ACC.

Conclusion:

LUBE was the most common cause of unsatisfactory TP in addition to interference by blood and association with atrophic changes. Knowing the morphological spectrum of LUBE would help to identify it as the cause of unsatisfactory TP. Communicating the cause of unsatisfactory TP such as LUBE, ACC, and blood would hint the provider to take appropriate precaution during submission of the repeat specimen, leading to improved patient care.

Abstract 3552: Differential expression of microRNAs in gastrointestinal neuroendocrine tumors

BACKGROUND: Various staging and grading systems are used to classify the gastrointestinal neuroendocrine tumors (GNTs). These systems attempt to stratify tumors, in order to predict survival after resection and the rate of progression to metastatic disease. At present, no specific molecular markers are available for diagnosis, prognosis or therapeutic targeting of GNTs. Microarray profiling analysis for the expression of miRNAs was performed on GNTs of stomach, small intestine, appendix, colon and rectum.

MATERIALS AND METHODS: Database search was carried out for patients with GNTs and pathological staging was performed in accordance with AJCC Cancer Staging manual (7th ed). The tumors evaluated included stomach (Stage I & II: 8 cases, Stage III&IV: 3 cases) , Ileum and cecum (Stage I and II:5, Stage III& IV: 17), appendix (Stage I &II: 3, goblet cell carcinoid: 7), and rectum (Stage I and II: 15, Stage III and IV: 3 cases). Kaplan Meir analysis revealed a worse overall survival of Stage III and IV tumors in comparison to Stage I and II in all subgroups. Formalin Fixed Paraffin Embedded (FFPE) archival tissue was obtained. Total RNA was isolated from FFPE tissue using the RNeasy Kit (Qiagen, Valencia, CA, USA). RNA was quantified and its purity was evaluated by the absorption ratio at 260/280nm using NanoDrop 2000 (Thermo Scientific, Pittsburgh, PA, USA). The microRNA profiling was performed by LC Sciences (Houston, TX) using miRBase v20 and data was normalized using selective housekeeping miRNAs.

RESULTS: The most significantly altered miRNAs amongst various groups are tabulated (Table no.1)

CONCLUSION: Stage III and IV GNTs are biologically distinct in comparison to Stage I and II GNTs. There is a significant up-regulation or down-regulation of specific miRNAs in these tumors. Bioinformatics analysis and further validation by RT-PCR are being performed which will likely provide information on the role of specific genes regulated by these miRNAs in GNTs.

Table no.1: Differential expression of miRNAs in GNTsmiRNAIleum Stage III and IV (G1)Ileum Stage I and II (G2)log G2/G1miR-9-5p(Tumor suppressor gene, TSG)621005-4.02miR-424-5p(TSG)4962853-2.52miR-376c-3p (Tumor oncogene, TO)553862.68miR-301a-3p (TO)7951252.66miRNAStomach Stage III and IV (G1)Stomach Stage I and II (G2)log G2/G1miR-18a-5p (TSG)2843635.39miR-19a-3p (TSG)2864795.17miR-6722-5p (TO)1211278-3.4miR-6858-3p (TO)112820-2.87miRNARectum Stage III and IV (G1)Rectum stage I and II (G2)log G2/G1miR-34a-5p (TSG)216933-2.11miR-150-5p (TSG)3981440-1.85miR-122-5p (TO)17131024.07miR-653-3p (TO)16272142.93miRNAGoblet cell carcinoid Stage III and IV (G1)Appendiceal carcinoid Stage I and II (G2)log G2/G1miR-642a-5p (TSG)11180-17.49miR-642b-5p (TSG)9620-17.28miR-7843-5p (TO)9916944.09miR-6775-5p (TO)134043601.70

Citation Format: Amarpreet Bhalla, Shadan Ali, Fazlul Sarkar, Anthony Shields, Amy Jencks, Romil Nathan, Vinod B. Shidham. Differential expression of microRNAs in gastrointestinal neuroendocrine tumors. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 3552. doi:10.1158/1538-7445.AM2014-3552

Molecular diagnostics in colorectal carcinoma

Molecular pathogenesis and classification of colorectal carcinoma are based on the adenoma-carcinoma sequence in the Vogelstein model, serrated polyp pathway, and microsatellite instability. The genetic basis for hereditary nonpolyposis colorectal cancer is based on detection of genetic mutations. Genetic testing for Lynch syndrome includes microsatellite instability, methylator phenotyping, BRAF mutation, and molecular testing. Molecular makers include quantitative multigene reverse transcriptase-polymerase chain reaction assay and KRAS and BRAF mutation analysis. Potential biomarkers include one-step nucleic acid amplification and epigenetic inactivation of endothelin 2 and endothelin 3 in colon cancer. Molecular screening approaches in colorectal cancer using stool DNA are under investigation.

Authors attain comparable or slightly higher rates of citation publishing in an open access journal (CytoJournal) compared to traditional cytopathology journals - A five year (2007-2011) experience

BACKGROUND

The era of Open Access (OA) publication, a platform which serves to better disseminate scientific knowledge, is upon us, as more OA journals are in existence than ever before. The idea that peer-reviewed OA publication leads to higher rates of citation has been put forth and shown to be true in several publications. This is a significant benefit to authors and is in addition to another relatively less obvious but highly critical component of the OA charter, i.e. retention of the copyright by the authors in the public domain. In this study, we analyzed the citation rates of OA and traditional non-OA publications specifically for authors in the field of cytopathology.

DESIGN

We compared the citation patterns for authors who had published in both OA and traditional non-OA peer-reviewed, scientific, cytopathology journals. Citations in an OA publication (CytoJournal) were analyzed comparatively with traditional non-OA cytopathology journals (Acta Cytologica, Cancer Cytopathology, Cytopathology, and Diagnostic Cytopathology) using the data from web of science citation analysis site (based on which the impact factors (IF) are calculated). After comparing citations per publication, as well as a time adjusted citation quotient (which takes into account the time since publication), we also analyzed the statistics after excluding the data for meeting abstracts.

RESULTS

Total 28 authors published 314 publications as articles and meeting abstracts (25 authors after excluding the abstracts). The rate of citation and time adjusted citation quotient were higher for OA in the group where abstracts were included (P < 0.05 for both). The rates were also slightly higher for OA than non-OA when the meeting abstracts were excluded, but the difference was statistically insignificant (P = 0.57 and P = 0.45).

CONCLUSION

We observed that for the same author, the publications in the OA journal attained a higher rate of citation than the publications in the traditional non-OA journals in the field of cytopathology over a 5 year period (2007-2011). However, this increase was statistically insignificant if the meeting abstracts were excluded from the analysis. Overall, the rates of citation for OA and non-OA were slightly higher to comparable.

MCW melanoma cocktail for the evaluation of micrometastases in sentinel lymph nodes of cutaneous melanoma

Prevailing reports support the status of sentinel lymph node biopsy as the standard of care in the management of cutaneous melanoma. However, the evaluation of sentinel lymph nodes for melanoma metastases with traditionally used immunomarkers such as S100 protein and HMB45 has proved challenging. The MCW melanoma cocktail (a mixture of MART-1 [1:500], Melan-A [1:100] and tyrosinase [1:50] monoclonal antibodies) has demonstrated a highly discriminatory immunostaining pattern. Contrary to conventionally used immunomarkers such as S100 protein, the MCW melanoma cocktail facilitates detection of even singly scattered melanoma cells in sentinel lymph nodes, not only in permanent sections but also in imprint smears.

Molecular diagnostics in the neoplasms of small intestine and appendix

Adenocarcinoma of the small intestine is relatively rare in comparison to colorectal carcinoma. Adenocarcinoma of the small intestine arises through the adenoma-carcinoma sequence in the colon. However, adenocarcinomas arising in the background of inflammatory bowel disease develop through the dysplasia-carcinoma sequence. Most of the cases occur in the duodenum; however, adenocarcinoma occurring in association with Crohn disease is more common in the ileum.

Molecular diagnostics in esophageal and gastric neoplasms

Esophageal carcinoma is the most rapidly increasing tumor in incidence in the United States. It has an established association with a precursor lesion (Barrett esophagus). Gastric carcinoma (GC) is the second leading cause of cancer death in the world. The prognosis for patients with advanced stage GC and esophageal carcinoma is poor. Human epidermal growth factor 2 (HER-2) overexpression is seen in gastroesophageal junction carcinoma and a subset of GC. HER-2 overexpressing tumors are eligible for HER-2 targeted therapies, which lead to a better survival in these patients.

Dual color multiplex TTF-1 + Napsin A and p63 + CK5 immunostaining for subcategorizing of poorly differentiated pulmonary non-small carcinomas into adenocarcinoma and squamous cell carcinoma in fine needle aspiration specimens

Background:

The distinction of lung adenocarcinoma (ADC) from squamous cell carcinoma (SCC) has important therapeutic implications. Napsin A is a recently developed marker, which has shown high specificity for lung tissue in the surgical pathology specimens. In this study, we have evaluated whether the use of a panel of novel multiplex cocktails of TTF-1 + Napsin A and p63 + CK5 for dual color immunostaining will improve the diagnostic accuracy of lung adenocarcinoma and squamous cell carcinoma in fine needle aspiration (FNA) specimens, usually with relatively scant microfragments of diagnostic material.

Materials and Methods:

Formalin-fixed, paraffin-embedded, adequately cellular FNA cell blocks with a confirmed diagnosis of either ADC (n = 22), SCC (n = 20) or poorly differentiated carcinoma (PDC; n = 7), from a total of 49 consecutive cases, were studied. All these cases had subsequently confirmed diagnosis in biopsies or resection specimens. The sections were immunostained with two color methods of TTF-1 + Napsin A and p63 + CK5 multiplex cocktails. The presence of one or more unequivocal individual tumor cells with convincing brown nuclear TTF-1 and red cytoplasmic Napsin A staining, and cells with brown nuclear p63 and membranous / cytoplasmic CK5 staining were interpreted as ‘positive’.

Results:

All 20 FNA cell blocks from SCC cases were positive for dual stain p63 + CK5 and negative for dual stain TTF-1 + Napsin A. The sensitivity and specificity of the dual immunoexpressions of p63 + CK5 for SCC of lung FNAs were both 100%. All 22 ADC cases were positive with dual stain of TTF-1 + Napsin A and negative for dual stain of p63 + CK5. On follow-up of the surgical pathology specimens, 22 cases were confirmed as ADC. The sensitivity of the dual immunoexpression of TTF-1 + Napsin A for ADC of lung FNAs was 100% and the specificity was also 100%. Of the seven PDC cases, five cases that were positive for dual stain p63 + CK5 and negative for dual stain TTF-1 + Napsin A could be categorized as SCC. Two of the seven (2 / 7) PDC cases were positive for dual stain TTF-1 + Napsin A and negative for dual stain p63 + CK5, consistent with ADC.

Conclusions:

Simultaneous coordinate or individual immunostaining for Napsin A / TTF-1 in ADC and p63 / CK5 in SCC demonstrated high sensitivity and specificity. The panel with multiplex Napsin A / TTF-1 and p63 / CK5 dual color immunostains could specifically subcategorize PDC into ADC and SCC in lung FNA specimens. Multiplex dual color Napsin A / TTF-1 and p63 / CK5 immunostaining is especially recommended for evaluation of FNA specimens with relatively scant cellularity.

How to write an article: Preparing a publishable manuscript!

Most of the scientific work presented as abstracts (platforms and posters) at various conferences have the potential to be published as articles in peer-reviewed journals. This DIY (Do It Yourself) article on how to achieve that goal is an extension of the symposium presented at the 36^th European Congress of Cytology, Istanbul, Turkey (presentation available on net at http://alturl.com/q6bfp). The criteria for manuscript authorship should be based on the ICMJE (International Committee of Medical Journal Editors) Uniform Requirements for Manuscripts. The next step is to choose the appropriate journal to submit the manuscript and review the ‘Instructions to the authors’ for that journal. Although initially it may appear to be an insurmountable task, diligent organizational discipline with a little patience and perseverance with input from mentors should lead to the preparation of a nearly perfect publishable manuscript even by a novice. Ultimately, the published article is an excellent track record of academic productivity with contribution to the general public good by encouraging the exchange of experience and innovation. It is a highly rewarding conduit to the personal success and growth leading to the collective achievement of continued scientific progress. Recent emergences of journals and publishers offering the platform and opportunity to publish under an open access charter provides the opportunity for authors to protect their copyright from being lost to conventional publishers. Publishing your work on this open platform is the most rewarding mission and is the recommended option in the current modern era.

[This open access article can be linked (copy-paste link from HTML version of this article) or reproduced FREELY if original reference details are prominently identifiable].

Thank you reviewers – CytoJournal 2011

CytoJournal, with its continued contribution of scientific cytopathology literature to the public domain under open access (OA) charter, thanks its dedicated peer reviewers for devoting significant efforts, time, and resources during 2011. The abstracts of poster-platform submissions to the 59^th Annual Scientific Meeting (November 2011) of the American Society of Cytopathology (ASC) in Baltimore, MD, USA, were peer reviewed by the ASC Scientific Program Committee.

Detection of amyloid in abdominal fat pad aspirates in early amyloidosis: Role of electron microscopy and Congo red stained cell block sections

Background:

Fine-needle aspiration biopsy (FNA) of the abdominal fat pad is a minimally invasive procedure to demonstrate tissue deposits of amyloid. However, protocols to evaluate amyloid in fat pad aspirates are not standardized, especially for detecting scant amyloid in early disease.

Materials and Methods:

We studied abdominal fat pad aspirates from 33 randomly selected patients in whom subsequent tissue biopsy, autopsy, and/or medical history for confirmation of amyloidosis (AL) were also available. All these cases were suspected to have early AL, but had negative results on abdominal fat pad aspirates evaluated by polarizing microscopy of Congo Red stained sections (CRPM). The results with CRPM between four reviewers were compared in 12 cases for studying inter observer reproducibility. 24 cases were also evaluated by ultrastructural study with electron microscopy (EM).

Results:

Nine of thirty-three (27%) cases reported negative by polarizing microscopy had amyloidosis. Reanalysis of 12 mixed positive-negative cases, showed considerable inter-observer variability with frequent lack of agreement between four observers by CRPM alone (Cohen's Kappa index of 0.1, 95% CI -0.1 to 0.36). EM showed amyloid in the walls of small blood vessels in fibroadipose tissue in four out of nine cases (44%) with amyloidosis.

Conclusion:

In addition to poor inter-observer reproducibility, CRPM alone in cases with scant amyloid led to frequent false negative results (9 out of 9, 100%). For improved detection of AL, routine ultrastructural evaluation with EM of fat pad aspirates by evaluating at least 15 small blood vessels in the aspirated fibroadipose tissue is recommended. Given the high false negative rate for CRPM alone in early disease, routine reflex evaluation with EM is highly recommended to avert the invasive option of biopsying various organs in cases with high clinical suspicion for AL.

p16 immunocytochemistry on cell blocks as an adjunct to cervical cytology: Potential reflex testing on specially prepared cell blocks from residual liquid-based cytology specimens

Background:

p16 ^INK4a (p16) is a well-recognized surrogate molecular marker for human papilloma virus (HPV) related squamous dysplasia. Our hypothesis is that the invasive interventions and related morbidities could be avoided by objective stratification of positive cytologic interpretations by p16 immunostaining of cell block sections of cytology specimens.

Materials and Methods:

Nuclear immunoreactivity for p16 was evaluated in cell block sections in 133 adequate cases [20 negative for intraepithelial lesion or malignancy, 28 high-grade squamous intraepithelial lesion (HSIL), 50 low-grade squamous intraepithelial lesion (LSIL), 21 atypical squamous cells, cannot exclude HSIL (ASC-H), and 14 atypical squamous cells of undetermined significance (ASCUS)] and analyzed with cervical biopsy results.

Results:

(a) HSIL cytology (28): 21 (75%) were p16 positive (11 biopsies available — 92% were positive for cervical intraepithelial neoplasia (CIN) 1 and above) and 7 (25%) were p16 negative (3 biopsies available — all showed only HPV with small atypical parakeratotic cells). (b) LSIL cytology (50): 13 (26%) cases were p16 positive (12 biopsies available — all were CIN1 or above) and 37 (74%) were p16 negative (12 biopsies available — all negative for dysplasia. However, 9 (75%) of these biopsies showed HPV). (c) ASC-H cytology (21): 14 (67%) were p16 positive (6 biopsies available — 5 showed CIN 3/Carcinoma in situ/Ca and 1 showed CIN 1 with possibility of under-sampling. Cytomorphologic re-review favored HSIL) and 7 (33%) were p16 negative (5 biopsies available — 3 negative for dysplasia. Remaining 2 cases — 1 positive for CIN 3 and 1 showed CIN 1 with scant ASC-H cells on cytomorphologic re-review with possibility under-sampling in cytology specimen). (d) ASCUS cytology (14): All (100%) were p16 negative on cell block sections of cervical cytology specimen. HPV testing performed in last 6 months in 7 cases was positive in 3 (43%) cases.

Conclusion:

p16 immunostaining on cell block sections of cervical cytology specimens showed distinct correlation patterns with biopsy results. Reflex p16 immunostaining of cell blocks based on the algorithmic approach to be evaluated by a multiinstitutional comprehensive prospective study is proposed.

Performing and processing FNA of anterior fat pad for amyloid

Historically, heart, liver, and kidney biopsies were performed to demonstrate amyloid deposits in amyloidosis. Since the clinical presentation of this disease is so variable and non-specific, the associated risks of these biopsies are too great for the diagnostic yield. Other sites that have a lower biopsy risk, such as skin or gingival, are also relatively invasive and expensive. In addition, these biopsies may not always have sufficient amyloid deposits to establish a diagnosis. Fat pad aspiration has demonstrated good clinical correlation with low cost and minimal morbidity. However, there are no standardized protocols for performing this procedure or processing the aspirated specimen, which leads to variable and nonreproducible results. The most frequently utilized modality for detecting amyloid in tissue is an apple-green birefringence on Congo red stained sections using a polarizing microscope. This technique requires cell block preparation of aspirated material. Unfortunately, patients presenting in early stage of amyloidosis have minimal amounts of amyloid which greatly reduces the sensitivity of Congo red stained cell block sections of fat pad aspirates. Therefore, ultrastructural evaluation of fat pad aspirates by electron microscopy should be utilized, given its increased sensitivity for amyloid detection. This article demonstrates a simple and reproducible procedure for performing anterior fat pad aspiration for the detection of amyloid utilizing both Congo red staining of cell block sections and electron microscopy for ultrastructural identification.

Compensation crisis related to the onsite adequacy evaluation during FNA procedures-Urgent proactive input from cytopathology community is critical to establish appropriate reimbursement for CPT code 88172 (or its new counterpart if introduced in the future)

The confusion centered around appropriate use of the CPT billing code 88172 is addressed in the commentary from the Economic and Government Affairs Committee of the American Society of Cytopathology (ASC) who have written a timely commentary in this issue of Cytojournal, "Adequate Reimbursement is Crucial to Support Cost-Effective Rapid Onsite Cytopathology Evaluations". Currently, lack of standardized use within and between pathology departments is stirring unhealthy practices of denying reimbursements for this critical and legitimate cytopathology service. This editorial discusses the important concerns raised in this commentary and recommends immediate corrective action. (See also Al-Abbadi MA, et al. Adequate reimbursement is crucial to support cost-effective rapid on-site cytopathology evaluations. CytoJournal 2010;7:22).