Comparison of cytomorphology and histomorphology in myelodysplastic syndromes

Gold standard for the establishment of the diagnosis of myelodysplastic syndromes (MDS) are cytomorphological features of hematopoietic cells in peripheral blood and bone marrow aspirates. There is increasing evidence that bone marrow histomorphology not only aids in the diagnosis of MDS but can provide additional prognostic information, particularly through assessment of fibrosis and cellularity. However, there is only sparse data on direct comparison between histological and cytomorphological findings within the same MDS patient cohort. Therefore, we performed such an analysis under exceptionally well-standardized conditions. We reexamined biopsy material of 128 patients from the Düsseldorf MDS registry who underwent bone marrow trephine biopsy (in addition to bone marrow aspiration) at the time of diagnosis, addressing the following items: a. Analysis of concordance of diagnoses made by histology and cytomorphology b. Analysis of additional information by histology with regard to the diagnosis and prognosis. The respective biomaterials were available at our institution and had been processed according to unchanged protocols between 1992 and 2010. Fresh histopathological sections were obtained from the tissue blocks, stained under identical conditions and re-assessed by a designated expert pathologist (C.B.) without knowledge of the previous histopathological report or the respective cytomorphological diagnosis. The latter, likewise, was uniformly made by the same expert cytomorphologist (U.G.). Histopathology of bone marrow trephine biopsies reliably captured the diagnosis of MDS. Assignment to the diagnostic WHO subgroup was not entirely concordant with cytomorphology, mainly due to incongruences between the proportion of CD34-positive cells on histopathology and the cytomorphological blast count. Histopathology provided additional diagnostic and prognostic information with high diagnostic and prognostic significance, such as fibrosis. Likewise, histopathology allowed more reliable estimation of bone marrow cellularity.

Cytological Perspective in a Case of Doege-Potter Syndrome With Hypoinsulinemic Hypoglycemia

Solitary fibrous tumor (SFT) of the lung is a rare mesenchymal neoplasm of uncertain histogenesis, unknown molecular features, and unpredictable clinical behavior, characterized by NAB2-STAT6 fusion. Hypoglycemia accompanying SFT (Doege-Potter syndrome) is an uncommon presentation. We present the cytomorphological features on biopsy imprint smears of a histopathologically confirmed case of SFT of the lung with an uncommon presentation. A 76-year-old non-smoker, non-alcoholic, and non-diabetic man presented with complaints of intermittent episodes of confusion with syncopal attacks (>10 episodes) for six months. The patient had no respiratory complaints and no history of weight loss. Laboratory investigations revealed fasting blood sugar of 38 mg/dl with low serum insulin and C-peptide levels. Physical examination revealed reduced air entry on the left side of the chest. Chest X-ray showed left-sided homogenous opacity. High-resolution computed tomography (HRCT) of the chest showed a large left-sided lung mass. A biopsy was performed. Biopsy imprint smears were cellular and showed tumor cells arranged in clusters and fragments with traversing capillaries displaying monomorphic pump to oval nuclei, fine granular evenly dispersed chromatin, regular nuclear membrane, inconspicuous nucleoli, and a moderate amount of wispy cytoplasm. Foci of intercellular hyaline stromal material were noted. A cytodiagnosis of low-grade mesenchymal neoplasm was made. Histopathology revealed a cellular tumor comprising tightly packed round to fusiform cells arranged around blood vessels with intervening thick collagen, positive for CD99, vimentin, BCL2, CD34, and STAT6 and negative for EMA, CK AE1/AE3, S100, TLE1, and SMA. Familiarity with cytomorphology plays a pivotal role in clinching an early diagnosis of this rare neoplasm of the lung, particularly in the setting of presentation with hypoglycemia.

Gastrointestinal stromal tumors in fine-needle aspiration biopsies

Gastrointestinal stromal tumors (GISTs), although rare, are the most common mesenchymal neoplasms of the gastrointestinal tract. Their potential for malignancy underscores the significance of identifying them through cytomorphologic findings and pertinent immunohistochemical markers. GISTs can emerge anywhere along the gastrointestinal tract with a predilection for the stomach. The clinical manifestations vary from nonspecific abdominal symptoms to incidental discovery during diagnostic interventions for unrelated signs and symptoms. Cytologically, GIST aspirates contain spindle or epithelioid cells with immunoreactivity for CD117/c-KIT, DOG-1, and CD34. Molecularly, KIT or PDGFRA mutations are prevalent, guiding targeted therapy with tyrosine kinase inhibitors. Distinct subtypes like succinate dehydrogenase-deficient GISTs pose challenges, often affecting younger individuals and displaying unique features. Histologically, GISTs are graded by mitotic rates, aiding prognostication. Distinguishing GISTs from similar entities is pivotal, necessitating attention to their immunostaining patterns for making an accurate diagnosis and molecular alterations for effectively planning treatment. Common differential diagnoses include leiomyoma, schwannoma, and solitary fibrous tumor. This article presents a classic GIST case and showcases relatively simple diagnostic clues for identifying similar lesions that may occur in diverse locations.

Cytomorphologic panorama of giant cell tumour of tendon sheath

BACKGROUND

Giant Cell Tumour of Tendon Sheath (GCTTS) is a slow growing benign soft tissue tumour arising from synovium of tendon sheath or joint. These tumours occur more frequently in upper limbs, especially hands. In the present study, we aimed to evaluate the cytomorphological spectrum of GCTTS.

METHODS

This retrospective study includes a total of 56 cases of GCTTS diagnosed over a period of 8 years. The clinical and radiological details of these cases were retrieved from the cytopathology records and detailed cytomorphological features were studied and analysed. Histopathological correlation was done in 16/56 cases, where follow-up was available.

RESULTS

The mean age of patients at the time of presentation was 32 years and were predominantly females (68%). The most common site of GCTTS was fingers (76%), followed by foot, wrist and toes. The most consistent finding on cytology was stromal cells (100%) of polygonal, spindle and plasmacytoid morphology with interspersed multinucleated osteoclastic giant cells (100%), followed by binucleated stromal cells (75%), xanthoma cells (61%) and hemosiderin laden macrophages (52%). Presence of proteinaceous fluid background was also observed in 50% of the cases.

CONCLUSION

GCTTS can be diagnosed with certainty on FNAC based on characteristic cytomorphological features in an appropriate clinical and radiological setting. FNAC plays a pivotal role in diagnosing GCTTS and differentiating it from other giant cell rich lesions, thus obviating the need of tissue biopsy for diagnosis, which in turn helps the clinician in timely and adequate management of the patient.

Cytomorphologic, immunophenotypical and molecular features of pancreatic acinar cell carcinoma

OBJECTIVES

As a rare tumor in pancreas, pancreatic acinar cell carcinoma (PACC) possesses a distinct molecular feature from pancreatic ductal carcinoma (PDAC). Though the diagnosis of PACC is often established based on cytology specimens, its cytologic diagnosis can be challenging. Furthermore, the correlation between PACC cytomorphology and its unique different molecular alterations have not been fully explored.

METHODS

Cytology features were analyzed in 8 histologically proven PACC and cytohistological correlation was performed. Immunocytochemistry for trypsin, chymotrypsin, BCL10, synaptophysin, chromogranin A, INSM1, β-catenin, and Ki-67 was assessed. Comprehensive molecular profiling and additional targetable treatment biomarker assessment were also performed.

RESULTS

The cohort included 4 mixed acinar-neuroendocrine carcinomas, 3 pure PACCs, and 1 mixed acinar-ductal carcinoma. Immunophenotypical features are consistent with diagnoses of PACC or PACC with neuroendocrine features. Identified genetic alterations included somatic mutations of CTNNB1, TP53, MAP2K1, PTEN, RAC1, germline mutations of NBN and BRAC2, and gene fusion of CCDC6-RET.

CONCLUSIONS

The current study is the first attempt to explore the correlation between the cytomorphology characteristics and molecular features of PACC and a few intriguing findings were observed. Further validation in larger cohorts is warranted.

Phenotypic clues that predict underlying cytogenetic/genetic abnormalities in myeloid malignancies: A contemporary review

Precise subclassification of myeloid malignancies per the World Health Organization (WHO) classification system and the International Consensus Classification of Myeloid Neoplasms and Acute Leukaemias (ICC) requires investigation and documentation of the presence of cytogenetic and/or molecular genetic changes. These ancillary studies not only help in diagnosis, but also the prognosis of disease; however, they take time to be completed. In contrast, morphological evaluation of material from the blood and bone marrow specimens of cases where myeloid malignancies are suspected is usually completed quickly. Cytomorphological assessment may predict genetic changes and can be helpful in triaging acuity. This is especially true in haematological emergencies such as acute promyelocytic leukaemia (APL), where prompt APL-specific therapy can be life changing. Similarly, some morphological clues may help identify core binding factor leukaemias where a diagnosis of acute myeloid leukaemia (AML) could be rendered without reaching the 20% blast cutoff with immediate treatment-decision implications, or even a subset of cases of AML with FLT3 ITD/NPM1 mutation(s) which show characteristic features. Even though FISH/cytogenetics and/or PCR are still required for establishing the final diagnosis, evaluation for the presence of specific cytomorphological features that help predict genetic changes can be a useful tool to help guide early therapy.

Carbohydrate metabolism and cytology of S-type cytoplasmic male sterility in wheat

Introduction

Cytoplasmic male sterility (CMS) is an important tool for hybrid heterosis utilization. However, the underlying mechanisms still need to be discovered. An adequate supply of nutrients is necessary for anther development; pollen abortion would occur if the metabolism of carbohydrates were hampered.

Methods

In order to better understand the relationship between carbohydrate metabolism disorder and pollen abortion in S-CMS wheat, the submicroscopic structure of wheat anthers was observed using light microscopy and transmission electron microscopy; chloroplast proteome changes were explored by comparative proteomic analysis; sugar measuring and enzyme assays were performed; and the expression patterns of carbohydrate metabolism-related genes were studied using quantitative real-time PCR (qRT-PCR) method.

Results

These results indicated that the anther and microspore in S-CMS wheat underwent serious structural damage, including premature tapetum degeneration, nutritional shortage, pollen wall defects, and pollen grain malformations. Furthermore, the number of chloroplasts in the anthers of S-CMS lines decreased significantly, causing abnormal carbohydrate metabolism, and disintegration of osmiophilic granules and thylakoids. Meanwhile, some proteins participating in the Calvin cycle and carbohydrate metabolism were abnormally expressed in the chloroplasts of the S-CMS lines, which might lead to chloroplast dysfunction. Additionally, several key enzymes and genes related to carbohydrate metabolism were significantly inhibited in S-CMS.

Discussion

Based on these results, we proposed a carbohydrate metabolism pathway for anther abortion in S-type cytoplasmic male sterility, which would encourage further exploration of the pollen abortion mechanisms for CMS wheat.

Real-World Diagnostic Accuracy of the On-Site Cytopathology Advance Report (OSCAR) Procedure Performed in a Multidisciplinary One-Stop Breast Clinic

Fine-needle aspiration (FNA) cytology has been widely used for the diagnosis of breast cancer lesions with the objective of differentiating benign from malignant masses. However, the occurrence of unsatisfactory samples and false-negative rates remains a matter of concern. Major improvements have been made thanks to the implementation of rapid on-site evaluation (ROSE) in multidisciplinary and integrated medical settings such as one-stop clinics (OSCs). In these settings, clinical and radiological examinations are combined with a morphological study performed by interventional pathologists. The aim of our study was to assess the diagnostic accuracy of the on-site cytopathology advance report (OSCAR) procedure on breast FNA cytologic samples in our breast OSC during the first three years (April 2004 till March 2007) of its implementation. To this goal, we retrospectively analyzed a series of 1820 breast masses (1740 patients) radiologically classified according to the American College of Radiology (ACR) BI-RADS lexicon (67.6% being either BI-RADS 4 or 5), sampled by FNA and immediately diagnosed by cytomorphology. The clinicoradiological, cytomorphological, and histological characteristics of all consecutive patients were retrieved from the hospital computerized medical records prospectively registered in the central information system. Histopathological analysis and ultrasound (US) follow-up (FU) were the reference diagnostic tests of the study design. In brief, we carried out either a histopathological verification or an 18-month US evaluation when a benign cytology was concordant with the components of the triple test. Overall, histology was available for 1138 masses, whereas 491 masses were analyzed at the 18-month US-FU. FNA specimens were morphologically nondiagnostic in 3.1%, false negatives were observed in 1.5%, and there was only one false positive (0.06%). The breast cancer prevalence was 62%. Diagnostic accuracy measures of the OSCAR procedure with their 95% confidence intervals (95% CI) were the following: sensitivity (Se) = 97.4% (96.19-98.31); specificity (Sp) = 94.98% (92.94-96.56); positive predictive value (PPV) = 96.80% (95.48-97.81); negative predictive value (NPV) = 95.91% (94.02-97.33); positive likelihood ratio (LR+) = 19.39 (13.75-27.32); negative predictive ratio (LR-) = 0.03 (0.02-0.04), and; accuracy = 96.45% (95.42-97.31). The respective positive likelihood ratio (LR+) for each of the four categories of cytopathological diagnoses (with their 95% CI) which are malignant, suspicious, benign, and nondiagnostic were 540 (76-3827); 2.69 (1.8-3.96); 0.03 (0.02-0.04); and 0.37 (0.2-0.66), respectively. In conclusion, our study demonstrates that the OSCAR procedure is a highly reliable diagnostic approach and a perfect test to select patients requiring core-needle biopsy (CNB) when performed by interventional cytopathologists in a multidisciplinary and integrated OSC setting. Besides drastically limiting the rate of nondiagnostic specimens and diagnostic turn-around time, OSCAR is an efficient and powerful first-line diagnostic approach for patient-centered care.

Role of scrape cytology smear preparation in the diagnosis of ovarian masses-utility and pitfalls

BACKGROUND

Scrape cytology technique is useful for rapid intraoperative diagnosis of ovarian mass lesions that acts as an adjunct to frozen section examination. Though ovaries can be accessed by laparoscopy and USG guided FNAC, there are controversial reports regarding the safety of these procedures. The present study has been designed to evaluate the role of scrape cytology in a variety of ovarian mass lesions.

OBJECTIVES

To study the cyto-morphology of ovarian mass lesions and to evaluate the role of scrape cytology technique in correctly diagnosing the ovarian lesions taking histopathological diagnosis as gold standard.

MATERIAL AND METHODS

This is a prospective observational study done on 61 ovarian mass lesions as received from the Obstetrics and Gynecology department of our Institution.

RESULT

Out of 61 cases, 58 (95.08%) cases were correctly diagnosed with respect to categorization and typing. The age ranged from 14 to 65 years with the mean age being 38.1 years. On histopathology, out of 61 cases, 39 (63.93%) were epithelial along with sub categorization of benign, borderline, and malignant, 13 (22.9%) were germ cell tumors, 5(8.19%) were sex cord stromal tumors, 3 (4.91%) were hemorrhagic cysts and the remaining 1 (1.63%) was massive ovarian edema. Thus, on comparing with histopathology, the sensitivity and specificity of scrape cytology technique were 93.55% and 96.67%, and the diagnostic accuracy was 95.08%.

CONCLUSION

Scrape cytology of ovarian lesions can give quick and reliable results. Also, proper training of cytopathologists chiefly regarding the sampling technique, gross presentation of ovarian lesions and interpretation of scrape cytology smears is needed. Further studies to provide standard guidelines and reporting criteria will prove to be helpful.

A Novel and Rapid Smear Cytomorphology Detection Strategy Based on Upconversion Nanoparticles Immunolabeling Integrated with Wright's Staining for Accurate Diagnosis of Leukemia

Background

Accurate, sensitive, and rapid identification of leukemia cells in blood and bone marrow is of paramount significance for clinical diagnosis. An integrative technique combining traditional cytomorphology with immunophenotyping was proposed to improve the diagnostic efficiency in leukemia. On account of high photostability, biocompatibility, and signal-to-background ratio, upconversion nanoparticles (UCNPs) as luminescent labels have drawn substantial research scrutiny in immunolabeling.

Methods

To achieve simultaneous determination, NaYF4:Yb,Er UCNPs were coupled with CD38 antibodies to construct immunofluorescence probes that were developed to bind to diffuse large B cell lymphoma (DLBCL) cells, followed by Wright's staining that has been widely used in clinical work for morphological diagnosis. Further, the experimental conditions were optimized, such as medium, slice-making method, antibody dosage, incubation time, etc.

Results

The cell morphology and immunolabeling could be observed simultaneously, and its simple operation rendered it a possibility for clinical diagnosis. The developed immunolabeling assay could achieve DLBCL cell counting with high reproducibility and stability, and the detection limit was as low as 1.54 cell/slice (>3 σ/s). Moreover, the proposed method also realized real blood and bone marrow sample analysis, and the results were consistent with the clinical diagnosis.

Conclusion

Overall, this strategy can be carried out after simple laboratory training and has prospective biomedical applications in leukemia classification, diagnosis validation, and differential diagnostics.

Morphological Study of Hashimoto Thyroiditis in Fine Needle Aspiration Cytology Specimens

Background

Hashimoto thyroiditis is an autoimmune disease which is diagnosed based on well-defined clinical and cytological criteria.

Purpose

The objective of this research is to study cytomorphological features in patients of Hashimoto thyroiditis and compare the findings with other studies. Literature on morphology of multinucleated giant cells was found to be lacking, and this study has focused on the number and morphology of these cells in this study.

Material and Methods

FNAC was done in patients who met the clinical diagnostic criteria of Hashimoto thyroiditis formulated by "Japan Thyroid Association" and smears were analyzed by light microscopy. Data analysis was done by XLSTAT in Microsoft Excel 2010. The Wilcoxon Signed Rank Test was done to analyze the data on multinucleated giant cells. The null hypothesis was that the median of the population of differences between the paired data of small and large giant cells is zero.

Results

A total of 26 patients were included in a period of one year. Contrary to observations in other studies, multinucleated giant cells were found in most participants. The Wilcoxon Signed Rank Test proved that small multinucleated giant cells were significantly more common than large multinucleated giant cells in Hashimoto thyroiditis; P value (two-tailed) being <0.0001 at significance alpha of 0.05. This study has also revealed that a few patients with Hashimoto thyroiditis can have large and very large multinucleated giant cells in a small number. Data on other cytomorphological features were no different than in other studies.

Conclusion

The presence of multinucleated giant cells in 92.3% of patients in this study is far higher than in other studies which can have important diagnostic implications. Few large multinucleated giant cells can be present in a small number in a few patients as in Hashimoto thyroiditis.

Primary cardiac angiosarcoma initially diagnosed on pericardial fluid cytology with histology and autopsy correlation

Primary cardiac angiosarcoma is an exceedingly rare high-grade malignancy of the heart originating from endothelial cells, with a predilection for the right atrium in male. Clinical diagnosis is extremely challenging because of the nonspecific symptoms and radiological findings. Although almost always presenting with massive recurrent pericardial effusions, cardiac angiosarcoma diagnosed based on pericardial fluid has rarely been reported, either due to the paucity of malignant cells or misdiagnosis due to low familiarity/suspicion and lack of proper workup. Unfortunately, patients with this disease often receive definitive diagnosis post-mortem. We report a case of primary cardiac angiosarcoma initially diagnosed on pericardial fluid. The cytomorphology and immunophenotype of angiosarcoma in fluid, as well as the challenges and practical recommendations in using pericardial fluid cytology for early diagnosis of this deadly disease are discussed.

Cytomorphologic observations on the sclerosing variant of well-differentiated pancreatic neuroendocrine tumors: Towards making specific diagnoses early

BACKGROUND

The recently described sclerosing variant of pancreatic neuroendocrine tumor (spNET) shows prominent stromal fibrosis and decreased tumor cellularity in surgical pathology specimens. Although prognostic data are currently ambivalent, some studies have reported metastatic disease in small primary tumors, highlighting the need for early diagnosis. The aim of our study is to evaluate cytology specimens of spNET to determine its characteristic cytomorphologic features to expedite an early diagnosis.

METHODS

Twenty-five cytology cases of spNET from 23 patients and 29 cytology cases of typical pancreatic neuroendocrine tumor (tpNET) from 29 patients diagnosed as such by surgical pathology evaluation were reviewed by two pathologists to assess adequacy of diagnostic material, cellularity and fibrosis. Radiographic findings and outcome data were collected.

RESULTS

With only 13 of 25 specimens deemed as diagnostic, spNET specimens were more often non-diagnostic (p < .01) and less often hypercellular (p = .03) compared to tpNET counterparts. While at least focal fibrosis was observed in both groups, a subset of spNET cases showed small tumor cell groups entrapped in large fibrotic fragments. Importantly, spNETs tended to be metastatic at diagnosis (both regionally and distant), with a smaller average tumor size.

CONCLUSION

The hypocellular nature of spNET cytology samples makes this variant difficult to diagnose. However, when adequate sample is available, a subset of spNET show characteristic cytomorphology that enables us to consider this specific diagnosis at first diagnostic sampling. It is crucial to diagnose this variant early given the propensity of small tumors with regional lymph node involvement and liver metastases.

Role of renal mass biopsy for diagnosis and management: Review of current trends and future directions

The frequency of detection of renal masses has increased over recent decades, causing a concurrent increase in early intervention by surgery. Growing recognition that this approach was contributing to overtreatment led to the broader use of preoperative renal mass biopsy (RMB) by core biopsy and/or fine-needle aspiration. Because more options for management, such as active surveillance and personalized therapy, are becoming increasingly available, a diagnosis by RMB is becoming a valuable tool for risk stratification and clinical decision making. Guidelines from various professional organizations have outlined situations in which RMB should be used, and it has been shown to be safe and effective. Rapid on-site evaluation (ROSE) using touch preparations of core biopsy or fine-needle aspiration smears provides an immediate assessment of adequacy and appropriate triage. ROSE also ensures sufficient material to perform immunohistochemistry and molecular studies for more accurate characterization of renal masses and personalized treatment. The integral role of cytopathology laboratories in precision medicine can also be successfully used in optimizing the workup of RMB from ROSE to final diagnosis, prognostication, and personalized management of kidney tumors. Herein, the authors review their extensive experience working together with interventional radiology and urology colleagues to use core biopsy and ROSE at the time of RMB for diagnosis and management of these lesions.

Cytological Diagnosis of Classic Myeloproliferative Neoplasms at the Age of Molecular Biology

Myeloproliferative neoplasms (MPN) are clonal hematopoietic stem cell-derived disorders characterized by uncontrolled proliferation of differentiated myeloid cells. Two main groups of MPN, BCR::ABL1-positive (Chronic Myeloid Leukemia) and BCR::ABL1-negative (Polycythemia Vera, Essential Thrombocytosis, Primary Myelofibrosis) are distinguished. For many years, cytomorphologic and histologic features were the only proof of MPN and attempted to distinguish the different entities of the subgroup BCR::ABL1-negative MPN. World Health Organization (WHO) classification of myeloid neoplasms evolves over the years and increasingly considers molecular abnormalities to prove the clonal hematopoiesis. In addition to morphological clues, the detection of JAK2, MPL and CALR mutations are considered driver events belonging to the major diagnostic criteria of BCR::ABL1-negative MPN. This highlights the preponderant place of molecular features in the MPN diagnosis. Moreover, the advent of next-generation sequencing (NGS) allowed the identification of additional somatic mutations involved in clonal hematopoiesis and playing a role in the prognosis of MPN. Nowadays, careful cytomorphology and molecular biology are inseparable and complementary to provide a specific diagnosis and to permit the best follow-up of these diseases.

Immunocytochemical detection by a fully automated immunostainer for assisting subclassification of pulmonary tumors on ThinPrep slides in real-life clinical samples: A single-institution experience

INTRODUCTION

This study aims to investigate the feasibility and reliability of ThinPrep slides in detecting the subclassification of lung cancer and develop a process for immunocytochemistry (ICC) with optimized staining steps of an automated immunostainer.

METHODS

Cytomorphology and ancillary ICC by automated immunostainer on ThinPrep slides were performed to subclassify 271 cytology cases of pulmonary tumor, which were stained with 2 or more of the following antibodies: p40, p63, thyroid transcription factor-1 (TTF-1), Napsin A, synaptophysin (Syn), and CD56.

RESULTS

The accuracy of cytological subtyping was improved from 67.2% to 92.7% (p < .0001) after ICC. The accuracy of cytomorphology combined with ICC results for lung squamous-cell carcinoma (LUSC), lung adenocarcinomas (LUAD), and small cell carcinoma (SCLC) was 89.5% (51 of 57), 97.8% (90 of 92), and 98.8% (85 of 86), respectively. The sensitivity and specificity of 6 antibodies were as follows: p63 (91.2%, 90.4%) and p40 (84.2%, 95.1%) for LUSC, TTF-1(95.6%, 64.6%) and Napsin A (89.7%, 96.7%) for LUAD and Syn (90.7%, 60.0%) and CD56 (97.7%, 50.0%) for SCLC, respectively. P40 expression on ThinPrep slides had the highest agreement (κ = 0.881) with immunohistochemistry (IHC) results, followed by p63 (κ = 0.873), Napsin A (κ = 0.795), TTF-1 (κ = 0.713), CD56 (κ = 0.576), and Syn (κ = 0.491).

CONCLUSION

The result of ancillary ICC on ThinPrep slides by fully automated immunostainer was in good agreement with the gold standard in pulmonary tumors subtype and immunoreactivity, objectively achieving accurate subtyping in cytology.

Cytological characteristics of histological types of lung cancer by cytomorphometric and flow cytometric analyses using liquid-based cytology materials

BACKGROUND

Distinguishing the histological types of lung cancer is essential for determining treatment strategies in clinical practice. In this study, cytomorphological characteristics and proliferative activities were compared among histological types of lung cancer by cytomorphometric and flow cytometric analyses using liquid-based cytology (LBC) samples.

METHODS

Scraped LBC samples from 73 surgically resected specimens were collected between August 2018 and November 2019. Papanicolaou-stained and paired Ki-67-stained slides were used for cytomorphometric analyses. Another sample for each case was analyzed using a flow cytometric system (LC-1000). The cell proliferation index (CPIx) was calculated to evaluate proliferative activity.

RESULTS

In total, 73 cases, including cases of adenocarcinoma (n = 53), squamous cell carcinoma (n = 14), small cell carcinoma (n = 1), large cell neuroendocrine carcinoma (NEC; n = 3), and pleomorphic carcinoma (n = 2) were evaluated. Small cell carcinoma and large cell NEC were categorized into a single group, NEC. The adenocarcinoma group tended to have a larger nuclear area and longer perimeter than other histological types. The NEC group had a considerably higher Ki-67 labeling index and significantly higher CPIx than other histological types (p = .030). A significant positive correlation was observed between the Ki-67 labeling index and CPIx for all cases (r = 0.362, p = .002).

CONCLUSION

The Ki-67 labeling index and flow cytometric analyses focus on proliferative activity for the distinction of histological types of lung cancer, thereby guiding clinical decision-making.

Classification of endoscopic ultrasound guided fine needle aspiration cytology of pancreatic space occupying lesions by Papanicolaou Society of Cytopathology System: A five year study

BACKGROUND

Majority of the pancreatic cancer patients present at an advanced stage and have poor 5 year survival rate. Thus, there is a need for early detection of pancreatic cancer with the initiation of the therapy.

MATERIALS & METHODS

This is a retrospective study including all the endoscopic ultrasound guided (EUS) guided pancreatic FNAs from 2016 to 2020. The aspirate smears were analyzed and classified according to The Papanicolaou Society of Cytopathology System for Reporting Pancreaticobiliary Cytology (PSCPC).

RESULTS

A total of 245 EUS guided FNAs from pancreatic lesions were included. Cyto-histological correlation was done wherever available. Category I (non diagnostic) accounted for 40 cases (16%) cases, Category II (negative) comprised of 44 cases (18%); and Category III (Atypical) had 5 cases (2%). Category IV neoplastic-benign category included 3 cases of serous cystadenoma, while neoplastic-others category included pancreatic neuroendocrine tumors (n = 21), solid pseudo-papillary neoplasms (SPEN) (n = 12) and mucinous cystic neoplasms (n = 4). A total of 7 cases (2.8%) were reported in Category V (Suspicious). A diagnosis of adenocarcinoma (Category VI) was rendered in 105 cases (42.8%) cases. Rarer types included non Hodgkins lymphoma (n = 3) and one case of primary undifferentiated carcinoma with osteoclastic giant cells. Cyto-histological correlation in all categories was available in 58 cases with 8 false negative cases. Thus overall sensitivity of EUS guided FNAC was found to be 87.8% with a diagnostic yield of 83.6% while sensitivity in diagnosing adenocarcinoma was 96.9%.

CONCLUSION

The present study highlights the spectrum of EUS guided FNA of pancreatic lesions in a subset of North Indian population and classified them according to PSCPC. EUS guided FNAC is a sensitive investigation which plays a crucial role in confirming the diagnosis of pancreatic space occupying lesions (SOLs) in advanced stage.

Role of Guided FNA in Gallbladder Cancer: A Retrospective 3-Year Study

Background

A majority of the patients with gall bladder cancer (GBCa) present at an advanced stage and have poor survival. The aim is to retrospectively study the role of guided FNA in the diagnosis of GBCa in a superspecialty institute and to describe the cytomorphologic spectrum of gall bladder (GB) lesions in the North Indian population.

Materials and Methods

All suspected cases of GBCa who underwent guided FNA from the primary GB mass or metastatic liver space-occupying lesion from 2017 to 2019 were included. The aspirate smears were retrieved and analyzed for cytomorphological features independently by two cytopathologists. The neoplastic lesions were classified according to the WHO 2019 classification.

Results

Of 489 cases, fine needle aspiration cytology (FNAC) was diagnostic in 463 cases (94.6%), of which 417 (90.1%) were positive for malignancy, 35 (7.5%) were inflammatory, and 11 (2.4%) were inconclusive for malignancy. Adenocarcinoma not otherwise specified (NOS) was the most common type seen in 330 cases (79.1%) and 87 (20.9%) were unusual variants. These included papillary adenocarcinoma (22, 5.2%), mucinous adenocarcinoma (12, 2.8%), signet ring carcinoma (2,0.4%), adenosquamous carcinoma (8, 1.9%), squamous cell carcinoma (10, 2.4%), neuroendocrine neoplasms (7, 1.7%), undifferentiated carcinoma (24, 5.7%) and non-Hodgkin lymphoma (2,0.4%), respectively. Immunohistochemistry on the cell block confirmed the diagnosis wherever possible. Histopathology was discordant in 5 out of 33 cases.

Conclusion

Guided FNAC is a sensitive investigation that plays a crucial role in confirming the diagnosis and deciding the further treatment options in advanced-stage GBCa patients. The uncommon variants of GBCa can be reliably categorized on cytology.

[New effects of a topical antimicrobial (agent) in the treatment of acute tonsillopharyngitis]

Sore throat is the leading symptom of acute tonsillopharyngitis associated with previous acute respiratory viral infections, including COVID-19. The pathogenesis of these nosologies is based on the cumulative result of the primary direct damaging effect of viruses and secondary alternative inflammatory changes in the mucosal epithelium in the focus of infection, which, against the background of changes in the functions of the regional microbiota, leads to the development of viral-bacterial inflammation that goes beyond the protective-reparative level. In the treatment of acute tonsillopharyngitis after exclusion of GABHS etiology, topical etiotropic drugs are often used. It is desirable to achieve a uniform distribution of active ingredients, and to maximize the use of additional pharmacological capabilities (irrigation-eliminative action, reparative effect). To build up the evidence base for the effectiveness of just such medicines on the basis of the Department of Otorhinolaryngology of the Moscow State Medical University named after. A.I. Evdokimov, an observational prospective comparative study was conducted, using, in addition to the clinical assessment method, cytomorphological approaches (cytomorphometry). The results of the study demonstrated that gargling with a solution of hydroxymethylquinoxylindioxide (Dioxydin 0.25 mg/ml solution for topical application) in adult patients with acute tonsillopharyngitis provides rapid relief of pain, a decrease in the severity of inflammation symptoms, and also makes it possible to achieve limitation of the degree of destruction of the epithelium in the height of inflammation and a more complete and rapid recovery of the damaged mucous membrane by the time of recovery.

Intraductal papillary neoplasm of the bile duct: Cytomorphologic and molecular features

BACKGROUND

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare premalignant neoplasm that can progress to invasive adenocarcinoma. In this retrospective study, cases of IPNB were reviewed to examine cytomorphologic and molecular features.

METHODS

IPNB cytology cases with histopathologic confirmation were retrieved from the pathology archives. The cytomorphologic features such as cellularity, architecture, cell type, and cellular details were analyzed.

RESULTS

The cohort included 13 cases (six brushings, six fine-needle aspirations [FNA], and one combined brushing and FNA). The lesions involved common bile duct in nine cases (69%) and hepatic duct in four cases (31%). Original cytological diagnoses included adenocarcinoma (five, 38%), suspicious for adenocarcinoma (one, 8%), neoplasm (three, 23%), atypical (three, 23%), and reactive (one, 8%). The cytomorphologic features included moderate/high cellularity (12, 92%), papillary and/or complex papillary architecture (10, 77%), columnar cells (11, 85%), vacuolated cytoplasm (12, 92%), enlarged nuclei (13, 100%), and fine granular chromatin (12, 92%). Background mucin, necrosis and acute inflammation were seen in four (31%), four (31%), and two (15%) cases, respectively. KRAS testing was performed in nine cases with mutant KRAS found in five (56%).

CONCLUSIONS

Our study demonstrated that IPNB cytology specimens were relatively cellular with a wide spectrum of cytomorphology; however, most cases harbored adenocarcinoma or high-grade dysplasia. The characteristic cytomorphologic features included papillary/complex papillary clusters of columnar cells with vacuolated cytoplasm, enlarged nuclei, and fine granular chromatin in relatively cellular specimens. KRAS mutations identified may have potential diagnostic and therapeutic implications.

Scalp metastasis of pulmonary blastoma-a rare entity: Cytomorphology with differential diagnoses

Pulmonary blastomas are exceptionally rare tumours. These tumours behave aggressively, with a propensity to metastasise to the brain and mediastinum. A definitive diagnosis of pulmonary blastoma is challenging to obtain on cytomorphology alone. However, in a known case of primary pulmonary blastoma, any newly developing lesion at any anatomical site should be carefully evaluated for metastasis. We herein describe a case of a 59-year-old female who presented with a scalp lesion. Fine needle aspiration cytology was done from the scalp swelling. Cytomorphology supplemented with immunocytochemistry on cell block confirmed the diagnosis of a metastatic pulmonary blastoma.

Isolated myeloid sarcoma with pericardial and pleural effusions as first manifestation: A case report

RATIONALE

Myeloid sarcoma (MS) involves the proliferation of extramedullary blasts from 1 or more myeloid lineages, replacing the original tissue structures, and these neoplasias are called granulocytic sarcoma, chloroma, or extramedullary myeloid neoplasms. These tumors develop in lymphoid organs, bones, skin, soft tissues, various mucous membranes, organs, and the central nervous system. MS is rare in non-leukemic patients, while MS patient with effusion as the first manifestation is even rare.

PATIENT CONCERNS

We report the case of 44-year-old woman with abdominal pain, diarrhea, and vomiting.

DIAGNOSIS

Ultrasound examination and computed tomography of the chest revealed large pericardial effusions and bilateral pleural effusions. Cytomorphological examination of the pericardial and pleural effusion, flow cytometry, and immunohistochemical markers suggested myeloid tumor cells. However, concurrent peripheral blood and bone marrow examinations showed no evidence of acute myeloid leukemia. The patient was eventually diagnosed with isolated MS.

INTERVENTIONS AND OUTCOMES

After chemotherapy with pirarubicin + cytarabine and high-dose cytarabine + etoposide, the pericardial effusion and pleural effusion were absorbed, and the mediastinal mass significantly shrunk. One year after patient gave up treatment, acute myeloid leukemia (AML) was confirmed by bone marrow examinations.

CONCLUSION

The early manifestations of the patient lacked specificity and were highly susceptible to misdiagnosis. Cytomorphology and flow cytology indicated important directions for the diagnosis of the disease in the early stage. Administration of chemotherapy regimen containing cytarabine could prolong disease-free survival and time before progress to AML.

Cytomorphological and immunohistochemical features of pancreatic ductal adenocarcinoma in serous fluids

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) represents the most common primary pancreatic malignancy. An understanding of the cytomorphologic features of conventional ductal adenocarcinoma and its variants is important to ensure accurate diagnoses.

METHODS

The clinicopathological and cytological data of serous fluids in PDAC patients were obtained from the electronic medical records and pathology database. All samples were analyzed and reclassified according to the "The International System for Reporting Serous Fluid Cytopathology" guidelines. Cytomorphologic features were examined with SurePath automatically prepared slides and stained using the Pap method in malignant (MAL) effusion specimens from 21 patients with PDAC. Immunocytochemical staining was conducted on 12 cell blocks from MAL PDAC effusion.

RESULTS

A total of 137 serous fluids specimens of PDACs were included, among which 61 (44.5%), 9 (6.6%), 13 (9.5%), 52 (38.0%), and 2 (1.5%) patients were classified into malignancy, suspicious for malignancy, atypia of undetermined significance, negative for malignancy and nondiagnostic groups, respectively. The key cytologic features for the conventional type of PDAC included cohesive clusters of ductal cells in glandular crowding and disorganized "drunken honeycomb" pattern or intercalated duct-like structure with anisonucleosis, cytoplasmic vacuoles, and concomitant "Indian-file" configuration. Undifferentiated carcinoma was comprised of enlarged, undifferentiated, pleomorphic MAL cells. Adenosquamous carcinoma could show glandular and/or squamous differentiation. Colloid carcinoma was composed of three-dimensional cancer cell clusters floating in thick mucin.

CONCLUSION

Crowding and disorganized "drunken honeycomb" pattern or intercalated duct-like structure with anisonucleosis, may represent an important clue for diagnosing PDAC in serous fluids. Immunocytochemical staining in combination with review of medical records and cytomorphological data can serve as useful adjuncts for distinguishing between PDAC and its variants.

Digital morphology in hematology diagnosis and education: The experience of the European LeukemiaNet WP10

Hematological diagnostics is based on increasingly precise techniques of cellular and molecular analysis. The correct interpretation of the blood and bone marrow smears observed under an optical microscope still represents a cornerstone. Precise quantitative and qualitative cytomorphological criteria have recently been codified by up-to-date guidelines for diagnosing hematopoietic neoplasms. Morphological analysis has found formidable support in digital reproduction techniques, which have simplified the circulation of images for educational or consultation purposes. From 2007 to 2019, the Working Group WP10 of European LeukemiaNet (ELN) used, in annual exercises, digital images to support training in cytomorphology and verify harmonization and comparability in the interpretation of blood and bone marrow smears. We describe the design, development, and results of this program, which had 741 participants in-person or remotely, to which 2055 questions were submitted regarding the interpretation of cytomorphological images. We initially used circulation and presentation of digital microphotographs and then introduced a virtual microscopy (VM). Virtual slides were obtained using a whole slide imaging technique, similar to the one largely used in histopathology, to produce digitized scans of consecutive microscopic fields and reassembles them to obtain a complete virtual smear by stitching. Participants were required to identify cells in labeled fields of view of the virtual slides to obtain a morphological diagnosis. This work has demonstrated substantial improvements in diagnostic accuracy and harmonization with the VM technique. Between-observer concordance increased from 62.5% to 83.0%. The integrity of the digitalized film image, which provides a general context for cell abnormalities, was the main factor for this outcome.

Extensive spindling in medullary thyroid carcinoma posing a diagnostic challenge: A case report

Medullary thyroid carcinoma is a neuroendocrine tumor derived from parafollicular or 'C' cells with sporadic and familial forms. Fine needle aspiration cytology is a quick way to establish the diagnosis. Sometimes a usual tumor may show prominent spindling on cytomorphology due to sampling issues, which poses a diagnostic challenge. When encountering spindled tumor cells on cytology smears from the thyroid, differential diagnoses encompass many benign and malignant lesions. We present cytological findings of the usual type of medullary thyroid carcinoma showing extensive spindling on cytology smears, which was a diagnostic dilemma. An accurate diagnosis was reached with the judicious use of immunocytochemistry on the cell block. We also discuss the available literature, differential diagnoses, and how to troubleshoot.

Observations on the cytomorphology and ultrastructure of the peripheral blood cells of native cattle (Zobawng) of Mizoram, India

This study aims to characterize the cytomorphology and ultrastructure of blood cells of native cattle of Mizoram. Twelve numbers of blood samples (10 ml) were collected from the Zobawng cattle, irrespective of sex. Blood smears were prepared and stained with different stains for cytomorphological study. The standard protocol has been followed for preparing blood samples for electron microscopy. Under a light microscope, erythrocytes of cattle were non-nucleated and round. The neutrophils were round, and the cytoplasm contained cytoplasmic granules. The eosinophils were rounded in outline with distinct cytoplasmic granules. The presence of basophils was infrequent with distinct blue color cytoplasmic granules. Small, medium, and large types of lymphocytes were recorded. The monocytes were round to oval in outline. Platelets were irregular to round. The reticulocytes were recorded occasionally, like small blue thin rods or granules. The cytoplasm and nucleus of granulocytes fluoresced greenish-yellow and red, respectively, with supravital stain. Under scanning electron microscopy (SEM), the erythrocytes appeared as biconcave discs. Different leukocytes were observed with their finger-like, plate-like, and narrow cell processes on their surface. Platelets were irregular structures. In transmission electron microscopy (TEM), the erythrocytes appeared anucleated biconcave elongated, neutrophils were roughly rounded with small cytoplasmic processes, and eosinophils were roughly circular with small cytoplasmic processes, the basophils were roughly circular with oval to elongated cytoplasmic granules, lymphocytes were roughly circular with centrally placed well-marked oval indented nucleus and some cytoplasmic processes, monocytes appeared spherical with long thick cytoplasmic processes and the non-nucleated platelets appeared roughly round to elongated.

Cytomorphology of nodular histiocytic/mesothelial hyperplasia

Nodular histiocytic/mesothelial hyperplasia (NHMH) is a pathologic entity that has not been well characterized in the cytopathology literature. This is unfortunate because if unrecognized, NHMH may be misdiagnosed when encountered in cytology specimens. The aim of this communication is to accordingly alert cytologists about NHMH by means of an illustrative case report.

Cytomorphologic features of SMARCA4-deficient non-small cell lung carcinoma and correlation with immunohistochemical and molecular features

BACKGROUND

SMARCA4/BRG1-deficient tumors and those that have loss of SMARCA/BRG1 have been described as various aggressive carcinomas and sarcomas, including a subset of non-small cell lung carcinoma (NSCLC). Cytomorphologic features of NSCLCs are yet to be described. The objective of this study was to evaluate the cytomorphologic features, immunohistochemical profile, and molecular profile of SMARCA4/BRG1-deficient NSCLC (SMARCA4-dNSCLC).

METHODS

The authors retrospectively searched for cases with SMARCA4/BRG1 functional loss alterations, which were identified in molecular studies and further confirmed by immunocytochemistry, and they reviewed the cytomorphologic features. Tumors with BRG1 loss were also stained with an extensive antibody panel. Molecular profiling and clinical information of the identified cases were scrutinized.

RESULTS

In total, 12 cytopathology cases from different anatomic sites were included. All cases showed variable expression of cytokeratin irrespective of type. One-half of cases had glandular features, followed by squamoid features, and poorly differentiated features. The most common cytologic features included sheets or papillary architecture, round or oval cell shapes, nuclear enlargement, moderate-to-marked pleomorphism, and coarse chromatin. Two cases with poorly differentiated cytomorphology had a predominance of single cells, scant cytoplasm, and macronucleoli. Variable expression of epithelial markers was noted in all cases. TP53 was the most frequently co-mutated gene in SMARCA4-dNSLCs.

CONCLUSIONS

This study demonstrates that SMARCA4-dNSCLCs can have a wide spectrum of cytomorphologic features, ranging from a relatively well differentiated adenocarcinoma to a poorly differentiated/undifferentiated carcinoma, with the majority of cases exhibiting some high-grade features, such as mitosis, apoptosis, necrosis, and marked pleomorphism.

Diagnostic challenges in acute monoblastic/monocytic leukemia in children

Acute monoblastic/monocytic leukemia (AMoL), previously defined as M5 according to FAB classification, is one of the most common subtypes of Acute Myeloid Leukemia (AML) in children, representing ~15-24% of all pediatric AMLs. Currently, the characterization of monocytic-lineage neoplasia at diagnosis includes cytomorphology, cytochemistry, immunophenotyping by multiparametric flow cytometry, cytogenetics, and molecular biology. Moreover, measurable residual disease (MRD) detection is critical in recognizing residual blasts refractory to chemotherapy. Nonetheless, diagnosis and MRD detection may still be challenging in pediatric AMoL since the morphological and immunophenotypic features of leukemic cells potentially overlap with those of normal mature monocytic compartment, as well as differential diagnosis can be troublesome, particularly with Juvenile Myelomonocytic Leukemia and reactive monocytosis in infants and young children. A failure or delay in diagnosis and inaccuracy in MRD assessment may worsen the AMoL prognosis. Therefore, improving diagnosis and monitoring techniques is mandatory to stratify and tailor therapies to the risk profile. This Mini Review aims to provide an updated revision of the scientific evidence on pediatric AMoL diagnostic tools.

Gastric glomus tumor diagnosed by fine needle aspiration of the stomach: A report of two cases and review of the literature

Glomus tumors make up 1% of stromal tumors of the stomach. Radiologic diagnosis of glomus tumors can be challenging as they share imaging characteristics with other neuroendocrine tumors and gastrointestinal stromal tumors. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been reported as a useful method for the evaluation of gastrointestinal lesions. We report two cases of gastric glomus tumors in which EUS-FNA diagnosis was challenging. Cytologically, neoplastic cells were round to oval, uniform, bland appearing epithelioid cells with delicate chromatin and inconspicuous to vague nucleoli. Both samples lacked worrisome features such as high nuclear grade, high mitotic rate, and necrosis. Neoplastic cells were negative for Cam5.2 and AE1/AE3 with focal expression of synaptophysin in one of the cases. A definitive diagnosis was not made based on FNA. Familiarity with glomus tumors in the GI system and procurement of adequate material for cell block allowing the use of immunohistochemistry may allow an accurate preoperative diagnosis.

Cytologic features of small cell melanoma

Small cell melanoma (SCM) is an aggressive variant of malignant melanoma (MM), which has been rarely described in the cytology literature. The aim of this study was to describe the clinical and cytologic features of a series of cases of metastatic SCM with discussion of the differential diagnosis of metastatic SCM diagnosed by fine-needle aspiration (FNA). A retrospective review of cases was performed, identifying two FNA cases and one core biopsy with touch preparation of metastatic SCM. Clinical presentation, cytomorphology features, ancillary tests, and final diagnoses were documented and analyzed. Patients ranged in age from 69 to 85 years-old. Cytomorphologic features included the presence of a monomorphic population of dispersed small round blue cells, with scant cytoplasm, high nuclear to cytoplasmic ratios, dense nuclear chromatin, and inconspicuous nucleoli. Acinar like arrangement (n = 2) and nuclear molding (n = 1) were also present. All cases showed diffuse positivity for the melanocytic markers SOX10 and Melan A by immunohistochemistry (IHC). Expression of neuroendocrine markers was variable. Diagnosing metastatic SCM at unusual anatomic sites by FNA cytology is a challenging task, especially in patients without known prior history of melanoma. Cytomorphology of SCM is unique, differing from conventional MM in many aspects, including the presence of acinar formations and a lack of typical melanoma features, such as large cells, intracytoplasmic melanin, and macronucleoli. IHC is critical for establishing the diagnosis of SCM.

Cytomorphologic features of intraductal salivary gland carcinoma: A multi-institutional study of 13 FNA cases with histologic, molecular, and clinical correlations

BACKGROUND

Intraductal carcinoma of the salivary gland (IDC) is a rare cancer with potential actionable targets, including RET fusions. Histologic and molecular features of IDC were recently reported, but cytomorphologic data are limited. In the largest multi-institutional fine-needle aspiration (FNA) series, the authors describe the cytomorphologic features of 13 IDC cases with available clinical, radiologic, histopathologic, and molecular data.

METHODS

The cases included 13 FNAs for 9 low-grade (LG) IDCs and 4 high-grade (HG) IDCs with corresponding histopathology and available molecular, imaging, and clinical data. Smears and liquid-based preparations available for 12 FNAs were semiquantitatively scored for key cytomorphologic findings and correlated with the corresponding resection.

RESULTS

LG IDC FNAs showed a cellular, biphasic population of large, atypical ductal cells with mildly pleomorphic nuclei in a clean background and a minor population of small, uniform myoepithelial cells. In contrast, all HG IDC FNAs showed predominantly ductal cells with marked nuclear pleomorphism, coarse chromatin, and necrosis. With the Milan system, most LG and HG IDC FNAs were classified as either salivary gland neoplasms of uncertain malignant potential (54%) or malignant (31%). Immunohistochemistry showed ductal epithelial reactivity with mammaglobin, androgen receptor, and S100, whereas myoepithelial cells were positive for p63 and/or calponin. Among cases with next-generation sequencing, 4 LG IDCs showed NCOA4-RET gene fusions, whereas an HG IDC showed HRAS and PIK3CA mutations.

CONCLUSIONS

The cytomorphology of IDC overlaps with other benign and malignant salivary gland neoplasms. Immunohistochemistry limits the differential diagnosis, but definitive classification requires molecular analysis. A diagnosis of IDC has potential implications for patient management.

2021 update of the 2012 ICSH Recommendations for identification, diagnostic value, and quantitation of schistocytes: Impact and revisions

In 2012, the International Council for Standardization in Hematology (ICSH) published recommendations for the identification, quantitation, and diagnostic value of schistocytes. In the present review, the impact of these recommendations is evaluated. This work is based on citations in peer-reviewed papers published since 2012. The first 2012 ICSH Recommendations have also been revised to incorporate newly published data in the literature and current best laboratory practice. Recommended reference ranges have been proposed for healthy adults and full-term neonates of 1% or less schistocytes. More than 1% of morphologically identified schistocytes on the blood film are considered suspicious for thrombotic microangiopathy. For preterm infants, a normal level of 5% or less is recommended. The fragment red cell count (FRC) generated by some automated hematological analyzers provides a valuable screening tool for the presence of schistocytes. Specifically, the absence of FRCs can be used as a valuable parameter to exclude the presence of schistocytes on the blood film. The validity and usefulness of microscope schistocytes and automated FRCs, respectively, are discussed in the context of the laboratory diagnostic tests used for thrombotic microangiopathies.

An Unusual Presentation of Extra-Oral Plasmablastic Lymphoma With Unique Cytomorphology

Plasmablastic lymphomas are high-grade lymphomas most commonly observed in the oral cavity. Their association with HIV-infected patients is now well-known. The occurrence of plasmablastic lymphomas in extra-oral sites in immunocompetent patients is exceedingly rare. We aim to document such a rare case in a 69-year- old female in the gastrointestinal tract along with lymphomatous effusion of the pleural cavity. The discussed case also needs a mention for its unique cytomorphological features. The diagnosis was confirmed by immunohistochemical stains, which play a vital role in the accurate diagnosis of plasmablastic lymphomas and their distinction from other anaplastic non-Hodgkin lymphomas.

Phylogenomic analysis restructures the ulvophyceae

Here, we present new transcriptome sequencing data from seven species of Dasycladales (Ulvophyceae) and a phylogenomic analysis of the Chlorophyta with a particular focus on Ulvophyceae. We have focused on a broad selection of green algal groups and carefully selected genes suitable for reconstructing deep eukaryote evolutionary histories. Increasing the taxon sampling of Dasycladales restructures the Ulvophyceae by identifying Dasycladales as closely related to Scotinosphaerales and Oltmannsiellopsidales. Contrary to previous studies, we do not find support for a close relationship between Dasycladales and a group with Cladophorales and Trentepohliales. Instead, the latter group is sister to the remainder of the Ulvophyceae. Furthermore, our analyses show high and consistent statistical support for a sister relationship between Bryopsidales and Chlorophyceae in trees generated with both homogeneous and heterogeneous (heterotachy) evolutionary models. Our study provides a new framework for interpreting the evolutionary history of Ulvophyceae and the evolution of cellular morphologies.

Phylogenomic analysis restructures the ulvophyceae

Here, we present new transcriptome sequencing data from seven species of Dasycladales (Ulvophyceae) and a phylogenomic analysis of the Chlorophyta with a particular focus on Ulvophyceae. We have focused on a broad selection of green algal groups and carefully selected genes suitable for reconstructing deep eukaryote evolutionary histories. Increasing the taxon sampling of Dasycladales restructures the Ulvophyceae by identifying Dasycladales as closely related to Scotinosphaerales and Oltmannsiellopsidales. Contrary to previous studies, we do not find support for a close relationship between Dasycladales and a group with Cladophorales and Trentepohliales. Instead, the latter group is sister to the remainder of the Ulvophyceae. Furthermore, our analyses show high and consistent statistical support for a sister relationship between Bryopsidales and Chlorophyceae in trees generated with both homogeneous and heterogeneous (heterotachy) evolutionary models. Our study provides a new framework for interpreting the evolutionary history of Ulvophyceae and the evolution of cellular morphologies.

Cytological features of BCOR-CCNB3 sarcoma: Comparison with Ewing sarcoma and synovial sarcoma

INTRODUCTION

BCOR-CCNB3 sarcoma (BCS) is one of the histological types classified as an undifferentiated small round cell sarcoma of bone and soft tissue. This sarcoma frequently develops in males under 20 years of age. Histologically, a delicate capillary network has been reported as a conspicuous finding. In this study, the cytological findings of BCS were observed in two cases of primary lesions and one case of a lung metastatic lesion. The cytological findings of BCS were compared with its histological mimics, and the characteristic findings of BCS were examined.

METHODS

Three cases of BCS were studied, and a cytological comparison was performed with 8 cases of Ewing sarcoma (ES) and 10 cases of synovial sarcoma (SS; monophasic type: 7 cases, biphasic type: 2 cases, poorly differentiated: 1 case).

RESULTS

In all BCS cases, small clusters with thin and delicate vascular cores and tiny vascular fragments were conspicuous. In ES and SS cases, although small clusters with vascular cores were observed, the vascular cores were thicker than in BCS, and no tiny vascular fragments appeared in most cases. Cytomorphological differences of tumour cells were also observed among BCS, ES, and SS. Predominantly rounded nuclei with fine chromatin and inconspicuous nucleoli can be cytological clues for BCS.

CONCLUSIONS

BCS shows characteristic cytological findings that make the diagnosis of BCS more likely than that of ES and SS. Cytological evaluation is a useful tool for appropriate differential diagnosis that leads to a more accurate final diagnosis and rapid treatment.

Diagnosis of bronchobiliary fistula by bilirubin crystallization in the alveolar lavage fluid: case reports and literature review

Bronchobiliary fistula (BBF) refers to the abnormal traffic between the biliary tract and the bronchus. The condition is very rare and usually develops secondary to liver echinococcosis or amebiasis, liver abscess, trauma, biliary obstruction, or tumors. BBF has a high mortality rate and currently, there are no accurate and effective diagnostic methods. This study reports the diagnosis and treatment of two patients with BBF which were confirmed by detecting bilirubin crystallization in the sputum. The first patient was a 45-year-old woman admitted to the hospital with "recurrent cough and lung infection". She had a history of multiple biliary tract surgeries and bilirubin crystallization was detected in bronchoalveolar lavage fluid (BALF) upon examination. Computed tomography (CT) imaging and magnetic resonance cholangiopancreatography (MRCP), together with clinical features, confirmed a diagnosis of BBF. The second patient was a 53-year-old woman admitted to the hospital with coughing and bile-like sputum. She had a history of cholangiocarcinoma surgery and bilirubin crystallization was detected in the cytomorphological BALF examination. Endoscopic retrograde cholangiopancreatography (ERCP) combined with clinical features confirmed a diagnosis of BBF. Both patients recovered after treatment and were discharged from the hospital. The clinical diagnosis of BBF largely relies upon imaging combined with clinical standards, and BALF examinations are rarely performed. This current investigation retrospectively analyzed the diagnosis and treatment of two cases of BBF, and demonstrated that bilirubin crystallization in the BALF may be an important diagnostic indicator for BBF.

Cytopathology and diagnostics of Warthin's tumour

Warthin's tumour (WT) is a benign epithelial salivary tumour, one type of salivary adenoma. Histologically, WT is structured of two components, epithelial tissue that often lines cystic formations and lymphoid tissue in the tumour stroma. FNA is a reliable diagnostic approach in the diagnosis of salivary gland lesions allowing a highly accurate categorization of benign tumour-like lesions, benign tumours and malignant tumours. In the proposed Milan reporting system of salivary gland lesions, WT is categorized in the IVA group of benign neoplasms. Accurate cytological diagnosis is straightforward when three characteristic components are present: oncocytes, either isolated or associated in clusters, lymphocytes and lymphoid cells and often an inflammatory/necrotic-like substance. Also, specific features of scintigraphy and radiological imaging contribute to the diagnosis of WT. WT is categorized according to Seifert G. et al in 4 types, depending on the proportions of the epithelial component and lymphoid stroma. Differential cytopathological and pathohistological diagnosis include other salivary gland lesions with lymphoid, oncocytic epithelial and cystic components. In some cases, such as the metaplastic WT variant, there are additional cytopathological and histological diagnostic difficulties. Moreover, bilateral, multicentric or multiple and infrequently seen extra-salivary localizations of WT are associated with further cytopathological diagnostic difficulties. Also, a rare possibility of malignant transformation of the epithelial or lymphoid component of WT as well as possible association with other primary tumours remains a challenge in accurate cytopathological and histological diagnosis of WT.

The Origin of the Cyathea delgadii Sternb. Somatic Embryos Is Determined by the Developmental State of Donor Tissue and Mutual Balance of Selected Metabolites

Somatic embryogenesis is the formation of a plant embryo from a cell other than the product of gametic fusion. The need to recognize the determinants of somatic cell fate has prompted investigations on how endogenous factors of donor tissues can determine the pattern of somatic embryo origin. The undertaking of this study was enabled by the newly developed experimental system of somatic embryogenesis of the tree fern Cyathea delgadii Sternb., in which the embryos are produced in hormone-free medium. The contents of 89 endogenous compounds (such as sugars, auxins, cytokinins, gibberellins, stress-related hormones, phenolic acids, polyamines, and amino acids) and cytomorphological features were compared between two types of explants giving rise to somatic embryos of unicellular or multicellular origin. We found that a large content of maltose, 1-kestose, abscisic acid, biologically active gibberellins, and phenolic acids was characteristic for single-cell somatic embryo formation pattern. In contrast, high levels of starch, callose, kinetin riboside, arginine, and ethylene promoted their multicellular origin. Networks for visualization of the relations between studied compounds were constructed based on the data obtained from analyses of a Pearson correlation coefficient heatmap. Our findings present for the first time detailed features of donor tissue that can play an important role in the somatic-to-embryogenic transition and the somatic embryo origin.

Cytomorphologic features as predictors of aggressiveness in patients with pT1 papillary thyroid carcinoma: a retrospective study of associations with clinicopathological parameters in 226 fine-needle aspirates

Background

Distinguishing aggressive pT1 papillary thyroid carcinomas (PTCs) from indolent PTCs before or during surgery is important. To the best of our knowledge, few reports in the literature have examined the value of the cytomorphologic features of PTC as predictors of aggressiveness.

Methods

This retrospective study included 226 pT1 PTC patients who underwent preoperative fine-needle aspiration cytology (FNAC) and surgery at Peking University Cancer Hospital between January 2018 and December 2019. Data on the clinical characteristics and pathological results were obtained from the electronic medical record database. All FNAC smears were blindly reviewed by two independent cytopathologists, and the associations between nine cytomorphologic features (lymphocytes, multinucleated giant cells, cellularity, cellular adhesiveness, nuclear size, nuclear pleomorphism, nuclear membrane regularity, intranuclear pseudoinclusions and the amount of cytoplasm) and clinicopathological parameters were statistically analyzed.

Results

Univariate analysis showed that cellularity, intranuclear pseudoinclusions, cellular adhesiveness, nuclear size, and nuclear pleomorphism were strong predictors of some clinicopathological parameters such as extracapsular invasion (ECI) and lymph node metastasis (LNM). Multivariate analysis confirmed that cellular adhesiveness was a strong independent predictor of ECI (P=0.001) and LNM (P<0.001), and the amount of cytoplasm can also predict LNM (P=0.024).

Conclusions

Cytomorphologic features including cellular adhesiveness and the amount of cytoplasm in preoperative FNAC smears could be a valuable tool for predicting ECI or LNM and may be predictors of aggressiveness in patients with pT1 PTC.

Thyroid paraganglioma: A diagnostic pitfall in thyroid FNA

BACKGROUND

Thyroid paragangliomas are extremely rare and often are misdiagnosed by preoperative fine-needle aspiration (FNA) because their cytologic features overlap with those of other thyroid neoplasms. The objective of this study was to review the cytomorphology in a series of thyroid paragangliomas and correlate the findings with histopathology.

METHODS

Five thyroid paraganglioma cases that underwent FNA were reviewed. Their clinical presentation, radiology features, cytomorphology, ancillary tests, and histopathology were analyzed.

RESULTS

All patients were women with an average age of 49 years (age range, 35-61 years) and presented with an asymptomatic, solitary thyroid nodule. Radiologically, these nodules (size range, 1.8-3.0 cm) were well circumscribed, hypoechoic, and hypervascular. FNA smears showed clusters of loosely cohesive, medium-to-large epithelioid cells with clear-to-eosinophilic and occasionally foamy cytoplasm that had indistinct cytoplasmic borders. The nuclei were round to oval with focal nuclear membrane irregularities, inconspicuous nucleoli, focal marked anisonucleosis, and occasional intranuclear pseudoinclusions. Naked nuclei, variable numbers of plasmacytoid cells, multinucleated giant cells, and sustentacular cells were present in the background along with blood vessels and lymphocytes. Cytology diagnoses were incorrect and included follicular neoplasm (n = 4) and follicular lesion of undetermined significance (n = 1). Final histopathology with immunohistochemistry revealed conventional paraganglioma (n = 3) or sclerosing paraganglioma with invasive features (n = 2).

CONCLUSIONS

All thyroid paragangliomas were misdiagnosed on FNA as follicular neoplasms, in part because of the rarity of these tumors in this location and cytomorphology mimicking follicles. The absence of colloid, the presence of naked nuclei, focal marked anisonucleosis, and the presence of sustentacular cells are important cytology clues.

Cytomorphologic features of NTRK-rearranged thyroid carcinoma

BACKGROUND

NTRK-rearranged thyroid carcinomas (NRTC), though rare, harbor a potential therapeutic target. The cytomorphologic features by fine needle aspiration (FNA) and the utility of preoperative molecular testing for NRTC remain largely uncharacterized. We provide a detailed cytomorphologic analysis of an institutional NRTC cohort with clinical, radiologic, histopathologic, and molecular correlations.

METHODS

Our NRTC FNA cohort included 21 specimens from 19 patients. The mean age and female-to-male ratio were 42 years and 2.2:1, respectively. Predominantly alcohol-stained Papanicolaou smears and liquid-based preparations were reviewed for 14 patients with available materials, and histologic review of subsequent resections was conducted for all 19 patients. Imaging and clinical data were accessed through electronic medical records.

RESULTS

Sonographically, NRTC were hypoechoic (87%), predominantly solid (53%) with limited central vascularity (27%), ill-defined borders (67%), and microcalcifications (67%). Observed cytomorphologic features include mixed architectural patterns (79%), fibrosis (93%), oncocytic and vacuolated cytoplasm (36% and 43%, respectively), and abundant intranuclear pseudoinclusions (14%). Most NRTC FNAs were classified as suspicious for malignancy or malignant (89%). One case classified as atypia of uncertain significance underwent ThyroSeq sequencing where a NTRK1 fusion was identified.

CONCLUSION

Although NRTC did not show a consistent cytomorphologic signature, mixed architectural patterns, prominent fibrosis and distinct cytoplasmic or nuclear features should raise suspicion for NRTC and, when accompanied by negative BRAFV600E by immunohistochemistry on cell block material, aid in selecting cases for molecular testing. This algorithmic approach may help identify potential NRTC, maximizing treatment options for patients, especially in patients for whom treatment planning is complicated.

Detection and Classification of Immature Leukocytes for Diagnosis of Acute Myeloid Leukemia Using Random Forest Algorithm

Acute myeloid leukemia (AML) is a fatal blood cancer that progresses rapidly and hinders the function of blood cells and the immune system. The current AML diagnostic method, a manual examination of the peripheral blood smear, is time consuming, labor intensive, and suffers from considerable inter-observer variation. Herein, a machine learning model to detect and classify immature leukocytes for efficient diagnosis of AML is presented. Images of leukocytes in AML patients and healthy controls were obtained from a publicly available dataset in The Cancer Imaging Archive. Image format conversion, multi-Otsu thresholding, and morphological operations were used for segmentation of the nucleus and cytoplasm. From each image, 16 features were extracted, two of which are new nucleus color features proposed in this study. A random forest algorithm was trained for the detection and classification of immature leukocytes. The model achieved 92.99% accuracy for detection and 93.45% accuracy for classification of immature leukocytes into four types. Precision values for each class were above 65%, which is an improvement on the current state of art. Based on Gini importance, the nucleus to cytoplasm area ratio was a discriminative feature for both detection and classification, while the two proposed features were shown to be significant for classification. The proposed model can be used as a support tool for the diagnosis of AML, and the features calculated to be most important serve as a baseline for future research.

Fine-needle aspiration cytomorphology of papillary thyroid carcinoma with NTRK gene rearrangement from a case series with predominantly indeterminate cytology

BACKGROUND

Neurotrophic tyrosine kinase receptor (NTRK) rearrangement has been reported in a subset of papillary thyroid carcinoma (PTC) cases. Little is known about the cytomorphologic features of NTRK-rearranged PTC.

METHODS

We report an institutional series of 13 fine-needle aspiration (FNA) specimens of NTRK-rearranged PTC with a predominantly indeterminate cytology diagnosis. NTRK3 or NTRK1 rearrangements were detected on FNA or surgical specimens by next-generation sequencing.

RESULTS

The 13 patients had a median age of 18 years; 10 patients were female and 3 patients were male. In 10 (77%) cases, cytology was indeterminate, and histopathologic follow-up was predominantly the follicular variant of PTC (n = 8 [62%]), mostly infiltrative subtype. Of 12 FNA specimens available for review, a predominant loosely cohesive group pattern was the most commonly encountered architectural pattern (n = 5 [41%]), followed by single cell (n = 3 [25%]), thick cord (n = 2 [17%]), and microfollicular pattern (n = 2 [17%]). Background lymphocytic thyroiditis was observed in 9 cases. At the cellular level, the cytoplasm was moderate and granular, occasionally vacuolated. Classic PTC nuclear features (eg, nuclear enlargement, elongation, grooves, and nuclear membrane irregularity) were present but were often focal and subtle. Chromatin was often granular. Intranuclear pseudoinclusions were absent or rare.

CONCLUSION

Our study demonstrates that most cases of NTRK rearrangement lack classic PTC cytomorphologic characteristics. Loosely cohesive groups and single cells with granular, sometimes vacuolated cytoplasm and subtle nuclear features are often seen on FNA specimens. Recognizing these characteristics may be helpful to preoperatively prompt molecular testing, including NTRK rearrangement analysis.

When accurate cytomorphology directs clinical decision: Colonic adenocarcinoma presents initially with an isolated vertebral bone metastasis

Liver is the most common site for metastasis of colonic adenocarcinoma. Other relatively common metastatic locations include: peritoneum, lungs and ovaries. Rare metastatic sites include: central nervous system, testis, uterus, oral cavity and bones. Though it is rare to have an isolated bone metastasis without liver or visceral involvement in colonic adenocarcinoma, it can occur. Our case illustrates the vital role of an accurate cytopathologic diagnosis in directing the proper clinical decision and management in our young patient. Our patient's first presentation was acute on chronic back pain radiating to his lower extremities with clinical suspicion of tuberculosis spondylitis. The correct cytopathologic diagnosis of the fine needle aspiration from the destructive vertebral lesion led to the establishment of an isolated metastatic colonic adenocarcinoma diagnosis initially and directed the clinical management of our patient.

Cyto-morphological and clinical approach to infections presenting with discharging sinuses mimicking malignancy

INTRODUCTION

Discharging sinuses is a form of chronic unhealed infection that can present at any site due to a variety of infectious organisms. These discharging sinuses may be associated with mass lesions and lymphadenopathy to mimic some neoplastic processes. Identifying these infections with accuracy and promptness is essential, as the treatment regimens are specific. Fine-needle aspiration (FNA) of these lesions, along with appropriate cytochemical stains, aids in the rapid and precise diagnosis of these infections and excludes neoplasms at these sites. Also, material for culture and other studies can be obtained by FNA.

MATERIAL AND METHODS

This retrospective study was conducted in the Department of pathology from 2018 to 2020. A total of 179 patients with similar clinical presentation and confirmed infection on cytology were identified. On the evaluation of the requisition forms, 32 (18%) patients were identified with discharging sinus associated along with swelling.

RESULTS

The five infections (32 cases) that were identified, included 18 cases of tuberculosis (56.25%) followed by 9 cases of actinomycosis (28.12%), 3 cases of pheohypomycosis (9.37%), and one case each of Nocardia (3.12%) and eumycetoma (3.12%) which presented as swelling with discharging sinus. Special stains were performed in all cases for confirmation. Histopathological/Microbiological correlation was done whenever available.

CONCLUSION

Infections presenting as swelling with discharging sinuses mimicking malignancy can be diagnosed on FNAC with good accuracy.

Clear-cell chondrosarcomas: Fine-needle aspiration cytology, radiological findings, and patient demographics of a rare entity

BACKGROUND

Clear-cell chondrosarcomas (CCCSs) constitute a very rare subtype of chondrosarcoma. CCCS may radiologically mimic chondroblastoma, and given the difference in surgical approach, it is important to distinguish these two entities preoperatively.

DESIGN

Using the institutional digital records, we identified histologically verified CCCS between 1996 and 2013, where preoperative fine-needle aspiration (FNA) cytology was available. Clinical characteristics were categorized and described, and FNAs were reviewed by a panel of senior cytopathologists. In addition, corresponding radiological imaging was reviewed by senior radiologists, and a literature review on CCCS and chondroblastoma was conducted.

RESULTS

A total of seven CCCS FNAs were identified from six patients. The cytomorphology showed low to intermediate cellular smears of clusters and single round or oval tumor cells. Tumor cells had rounded (sometimes binucleated) nuclei with limited pleomorphism and rich vacuolated cytoplasm. Chondroid background matrix was always found. While CCCS patients had a significantly higher age at diagnosis compared to chondroblastoma, no age cut-off would distinctly separate the two.

CONCLUSIONS

CCCS has distinguished cytomorphological features on FNA smears. CCCS should be considered as a possible differential diagnosis in adults (>25 years) with a radiological suspicion of chondroblastoma. Since radiology and patient age cannot conclusively distinguish CCCS from chondroblastoma, FNA may prove an important tool for correct preoperative diagnosis of CCCS.