Midline carcinoma expressing NUT in malignant effusion cytology

Nuclear protein in testis (NUT) midline carcinoma (NMC) is a rare and aggressive subset of poorly differentiated squamous cell carcinoma that is defined by t(15,19) and typically presents in the midline structures of the head, neck, and mediastinum. We report two cases of NMC that presented uniquely with malignant pleural and pericardial effusions including one with cardiac tamponade at presentation. The first case is of a 25-year-old male patient who presented with progressive dyspnea associated with palpitations and dizziness on standing, found to have large bilateral pleural effusions. The second case is of a previously healthy 29-year-old male patient who presented with progressive dyspnea, cough with expectoration, and a large right lower neck mass of 3 months onset, and a large left pleural effusion and left lung infiltrate on imaging studies. Both cases showed malignant cells on cytology suggestive of poorly differentiated carcinoma. Subsequent histopathological and immunochemistry studies were consistent with the diagnosis of NMC. Both patients had a rapid decline in status and suffered comorbidities secondary to their carcinoma, inevitably leading to their death. It is important to consider NUT midline carcinomas can present in a variety of clinical scenarios, and it is important to consider in the differential diagnoses when evaluating malignant effusion cytology. Utilization of ancillary testing with a broad immunostain profile including NUT studies, as well as fluorescent in-situ hydridization (FISH) studies are helpful and necessary in making the appropriate diagnosis.

Impact on clinical follow-up of the Milan System for salivary gland cytology: A comparison with a traditional diagnostic classification

INTRODUCTION

No universally accepted classification exists for salivary gland FNA. The proposed Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) offers a uniform classification with management recommendations. We compared FNA diagnoses from a prior study with specific diagnoses with corresponding MSRSGC diagnoses.

METHODS

One-hundred and sixty-four cases from a prior cytological study with histological follow-up were re-reviewed by one of the authors and assigned to one of the MSRSGC categories. The original and MSRSCG diagnoses were compared, as were follow-up recommendations.

RESULTS

The MSRSGC system classified 29 specimens as non-diagnostic (seven histologically shown to be benign salivary gland, two non-mucinous cysts, 14 sialadenitis, one pleomorphic adenoma, one haemangioma, one lymphoma, one adenoid cystic carcinoma, one squamous carcinoma and one benign lymphoid proliferation). The original study diagnosed these lesions as: seven benign cysts, 15 benign salivary gland tissue, one benign neoplasm and two insufficient for diagnosis. In seven cases, MSRSGC disagreed with original diagnoses and surgical resection showed lesions where optimal follow-up was more consistent with original cytological diagnosis. In 10 cases with disagreement, the MSRSGC was associated with a more appropriate follow-up based on the surgical diagnosis. Malignancy risks for the Milan categories were: non-diagnostic (12%), non-neoplastic (5%), atypia of undetermined significance (19%), neoplasm, benign (5%), neoplasm (40%), suspicious for malignancy (60%) and malignant (93%).

CONCLUSION

MSRSGC was comparable with the original reported diagnoses in the majority of cases. Both systems had high accuracy for distinguishing benign from malignant lesions and both were associated with appropriate follow-up in most cases.

The impact of atypia/follicular lesion of undetermined significance and repeat fine-needle aspiration: 5 years before and after implementation of the Bethesda System

BACKGROUND

Limited studies have examined the impact of the Bethesda System for Reporting Thyroid Cytopathology (BSRTC) and specifically the category of atypia or follicular lesion of undetermined significance (AUS/FLUS). We studied their effects on reporting rates, subsequent management, and surgical outcome over a 10-year period, 5 years before and after implementation of the BSRTC.

METHODS

A retrospective review of thyroid fine-needle aspiration (FNA) reports from 2003 to 2012 was performed. Diagnoses made before BSRTC were reclassified into the most appropriate category. Repeat FNA results for all AUS/FLUS cases were recorded. Surgical follow-up results were matched by side and size of the targeted nodule. Incidental microcarcinomas were not considered "malignant" on excision. Malignancy rates were calculated based on excision and by all aspirated specimens.

RESULTS

Initial AUS/FLUS cases increased from 3% to 7% (P = .001) with implementation of the BSRTC. The nondiagnostic rate decreased from 19% to 10% (P = .026). Differences in malignancy rates before and after implementation of the BSRTC were not significant for all diagnostic categories. More repeat FNAs and fewer surgical excisions were performed after an initial AUS/FLUS diagnosis. Repeat FNA reclassified 56% of AUS/FLUS cases into a definitive category. The malignancy risks for AUS/FLUS plus benign and AUS/FLUS plus AUS/FLUS repeat FNAs were elevated compared with single benign and AUS/FLUS diagnoses.

CONCLUSIONS

AUS/FLUS cases are increasing with the implementation of the BSRTC. Given the potential increase in repeat FNAs as a result, it may be important to alert the clinician regarding the elevated malignancy risk of a benign or AUS/FLUS diagnosis associated with a prior AUS/FLUS finding.

Significance of the diagnostic categories "atypical" and "suspicious for malignancy" in the cytologic diagnosis of solid pancreatic masses

Endoscopic ultrasound guided (EUS) fine-needle aspiration (FNA) investigation of solid pancreatic lesions has been shown to have good sensitivity and specificity. Many lesions can be definitely classified as benign or malignant but some can only be cytologically classified as "atypical" or "suspicious for malignancy". Risk for malignancy in these indeterminate categories has not been well categorized. The cytology records of four University Medical centers were searched for all EUS guided FNAs of solid pancreatic lesions. All cases with a diagnosis of "atypical", or "suspicious for malignancy" were selected for analysis when histologic biopsy or over 18 months clinical follow-up was available. Two hundred and ninety-two cases with a diagnosis of "atypical" or "suspicious for malignancy" and adequate follow-up were obtained from the combined data of the four institutions. The percentage malignant for the categories "atypical" and "suspicious for malignancy" were 79.2 and 96.3%, respectively. If the category "atypical" was classified as benign and "suspicious for malignancy" was classified as malignant, the resulting positive predictive value was 96.3 (95% CI: 92.6-98.5) and the negative predictive value 20.8 (95% CI: 13.4-30.0). The categories of "atypical" and "suspicious for malignancy" stratify risk for malignancy in a fashion, which may aid in patient counseling and selection of follow-up protocols. Classification of "suspicious for malignancy" as malignant optimizes diagnostic sensitivity and specificity.

Hints to the diagnosis of mixed acinar-endocrine carcinoma on pancreatic fine-needle aspiration: avoiding a potential diagnostic pitfall

BACKGROUND

Mixed acinar-endocrine carcinoma (MAEC) is a rare mixed tumor of the pancreas defined by both acinar and endocrine cell differentiation.

CASE

We present 2 cases of MAEC initially diagnosed as pancreatic endocrine neoplasm on fine-needle aspiration. Both patients were male, aged 51 and 75 years, and presented with 16-mm and 6-mm pancreatic masses, respectively. Aspirates showed loose aggregates and dispersed single plasmacytoid cells with moderate nuclear size variation, slightly irregular nuclear contours, fine to coarsely granular chromatin, occasional prominent nucleoli, and scant to moderate finely granular cytoplasm. Rare mitotic figures and pyknotic forms were noted in one of the cases. Endocrine differentiation was confirmed by immunocytochemistry which led to an initial diagnosis of pancreatic endocrine neoplasm. Trypsin and lipase immunocytochemistry were later obtained, confirming a component of acinar cell differentiation. Findings were confirmed on surgical excision.

CONCLUSION

Because of their potentially more aggressive clinical course and different therapeutic implications, MAECs are an important consideration in the differential diagnosis of pancreatic neoplasms. Certain cytomorphologic features and immunocytochemical markers of acinar cell differentiation may be helpful in raising the possibility of MAEC on cytology.

Metastatic disease to the pancreas documented by endoscopic ultrasound guided fine-needle aspiration: a seven-year experience

The study was performed to determine the frequency and origin for metastatic disease to the pancreas as found in an endoscopic ultrasound directed fine-needle aspiration series. The records of the Departments of Pathology at the University of Utah School of Medicine and the David Geffen School of Medicine were electronically searched for all fine-needle aspirates obtained from pancreatic masses between January 1, 2002 and March 31, 2010. All cases with a diagnosis of metastatic disease were reviewed and whenever possible correlated with subsequent resection specimens. A total of 17 metastatic malignancies to the pancreas were detected in pancreatic FNAs representing 0.73% of all cases. Primaries included eight renal cell carcinomas, one medullary carcinoma of the thyroid, four lymphomas, one alveolar rhabdomyosarcoma, one squamous cell carcinoma derived from the esophagus, and a second squamous cell carcinoma originating from a lung primary and a small cell carcinoma of the lung. Metastatic renal cell carcinoma was the most frequent metastasis to the pancreas representing 47% of metastatic lesions detected by FNA. The metastatic deposits could be detected in the pancreas as many as 10 years following the original diagnosis and resection of the renal cell carcinoma.

A retrospective clinical study of the treatment of high-grade anal dysplasia by infrared coagulation in a population of HIV-positive men who have sex with men

HIV-positive men who have sex with men (MSM) are at high risk of developing human papillomavirus-associated anal squamous cell cancer. Similar to the management of cervical dysplasia, clinicians are treating high-grade anal dysplasia to prevent progression to cancer. Initial treatments such as cold scalpel excision and electrofulguration have shown limited efficacy in a HIV-positive population. Infrared coagulation (IRC) is an outpatient treatment for high-grade anal dysplasia. This retrospective clinical study reports on 68 HIV-positive MSM with 78 biopsy proven high-grade anal lesions. Each lesion was treated with the IRC with re-biopsy of the treatment site a mean of 140 days later. Of the 74 evaluable lesions; 39 had anal intraepithelial neoplasia (AIN) 1, 20 had AIN 2, seven had AIN 3, and eight had normal epithelium. The IRC showed 64% efficacy per treated lesion and shows promise as a treatment modality for high-grade anal dysplasia in this population.

The prevalence, and predictive value, of abnormal anal cytology to diagnose anal dysplasia in a population of HIV-positive men who have sex with men

Due to the increasing incidence of anal cancer in HIV-positive men who have sex with men, and the potential to detect and treat high-grade anal dysplasia--the putative anal cancer precursor--we have introduced an anal cytology screening service. Patients with abnormal anal cytology have follow-up high-resolution anoscopy (HRA) with biopsy of lesions clinically suspicious for high-grade dysplasia. In total, 244 men were screened and 235 (96%) of the samples were adequate for cytological interpretation using the Bethesda 2001 system. One hundred and sixty-four (67%) men had abnormal anal cytology, and 93 of them had follow-up HRA and anal biopsy. The positive predictive value for any anal cytological abnormality to predict any degree of anal dysplasia was 95.7+/-2.1%, and for any anal cytological abnormality to predict high-grade anal dysplasia was 55.9+/-5.1%. Abnormal anal cytology was highly predicative of anal dysplasia on biopsy.

Fine-needle aspiration biopsy as an adjunct to the diagnosis of a rare adnexal tumor of hair follicle origin: trichoblastoma

Fine-needle aspiration biopsy (FNAB) is a technique used increasingly for the investigation of primary and metastatic cutaneous tumors. Trichoblastoma is a rare benign skin appendage tumor of hair germ origin. We report the diagnosis by FNAB of a rare giant subcutaneous tumor, trichoblastoma, from an 81-yr-old woman with a subcutaneous mass in the interscapular area of her back. The cytologic characteristics of the tumor are discussed in detail in this report. The findings have been compared with the histologic features of the tumor after surgical excision. We have characterized several distinctive cytologic features that may aid in the diagnosis of this rare neoplasm. While most reported cases have been diagnosed from surgical excisional biopsy specimens, FNAB may also be a valuable tool for the accurate diagnosis of trichoblastoma in the proper clinical context.

Simultaneous occurrence of medullary and papillary carcinoma of the thyroid gland identified by fine needle aspiration. A case report

BACKGROUND

Fine needle aspiration (FNA) diagnosis of simultaneous medullary and papillary thyroid carcinoma in independent thyroid lobes is exceedingly rare.

CASE

A 36-year-old female presented with a one-month history of dysphagia. Thyroid ultrasound revealed a multinodular goiter. She was clinically and biochemically euthyroid. FNA of the right thyroid nodule was consistent with medullary carcinoma, and FNA of the left thyroid lobe was consistent with papillary carcinoma. Immunohistochemistry revealed strong calcitonin and CEA positivity in the right lobe and lack of staining in the left lobe. Conversely, staining for thyroglobulin was negative on the right lobe and positive on the left lobe.

CONCLUSION

The patient developed tumors in separate lobes of the thyroid. Immunoreactivity of calcitonin, CEA and thyroglobulin made a sharp distinction between the two tumors. Therefore, we conclude that these tumors were not linked by either embryology or genetics.

Cytokeratin 20 as an immunocytochemical marker for detection of urothelial carcinoma in atypical cytology: preliminary retrospective study on archived urine slides

Previous studies have shown that expression of cytokeratin 20 (CK20), a constituent of intermediate filaments, is increased in malignant versus benign urine samples. To evaluate whether immunocytochemical staining of CK20 on archived urine slides could be used as a potential adjunct marker for triage of atypical urine cytology, we analyzed a total of 77 archived urine slides obtained from a spectrum of patients with various risks of developing urothelial carcinoma. These patients were divided into four groups on the basis of initial urine cytologic results and subsequent follow-up biopsy findings; group 1 had negative results in both evaluations, whereas the results in group 4 were positive for both cytology and biopsy. Groups 2 and 3 had a diagnosis of atypical urine cytology; however, patients in group 3 had a positive follow-up biopsy, and patients in group 2 did not. The Papanicolaou-stained archived urine slides were destained and then restained immunocytochemically with monoclonal antibody against CK20. With 5% positively stained nonumbrella cells as a threshold, CK20 was positive in 94.4% of group 3 or 4 patients. In contrast, CK20 was positive in 27.3% of group 2 patients and in 10.5% of group 1 patients. The overall sensitivity and specificity for CK20 for the detection of urothelial carcinoma in this population of patients were 94.4% and 80.5%, respectively. This study demonstrated that immunocytochemical analysis of CK20 on archived urine slides could be used to triage atypical urine cytology into low- and high-risk categories and that CK20 might be a simple and useful early detection marker for urothelial carcinoma.

Triple test approach to inadequate fine needle aspiration biopsies of palpable breast lesions

OBJECTIVE

To perform a retrospective study evaluating the triple test for inadequate fine needle aspiration (FNA) biopsies of palpable breast lesions with a two-year clinical follow-up.

STUDY DESIGN

All aspirates were reviewed and assessed for cellular adequacy in a one-year period. Specimen adequacy was based on the most stringent criteria, the presence of six or more epithelial cell clusters composed of at least six cells each. In all cases, clinical and radiologic results were reviewed and compared with the histologic outcome.

RESULTS

Aspirates from 61 of 263 (23%) patients with palpable breast lesions that yielded nondiagnostic results were examined. The study showed a misdirected FNA rate of 21% and a misinterpreted rate of 1.6%. The other 77% of cases had benign surgical biopsies and/or clinical follow-up. Three of 61 (4.9%) cases with nondiagnostic smears were found to have cancer; two were inadequate due to misdirected aspirates, and one was misinterpreted microscopically. All cancer cases underwent surgical removal of the mass as a result of clinical or radiologic suspicion.

CONCLUSION

We recommend utilizing the three diagnostic parameters of cytology, clinical findings and radiology, the "triple test," to achieve the best diagnostic accuracy in breast FNAs and to enhance patient management.

Recurrent secondary hyperparathyroidism after autotransplantation into the sternocleidomastoid muscle: report of a case with fine needle aspiration findings

BACKGROUND

Recurrent hyperparathyroidism may occur following parathyroid autotransplantation due to autogenous function of the muscle-engrafted tissue. Parathyroid lesions are uncommonly diagnosed on cytology.

CASE

A 31-year-old female with chronic renal failure presented with an elevated parathyroid hormone level and a neck mass in the left sternocleidomastoid muscle, the site of a previous parathyroid autograft. Fine needle aspiration of the mass revealed high cellularity, with perivascularly arranged, three-dimensional, branching clusters; individual cells; and naked nuclei exhibiting anisonucleosis. A diagnosis of parathyroid graft hyperplasia was made by fine needle aspiration and subsequently by histopathologic examination.

CONCLUSION

Fine needle aspiration is an effective tool for confirming the presence of parathyroid autograft hyperplasia, thus allowing the correct surgical approach.

Fine needle aspiration biopsy of solitary fibrous tumor of the pleura. A report of two cases with a discussion of diagnostic pitfalls

BACKGROUND

The diagnosis of a peripheral pulmonary nodule presents a challenge due to many diagnostic possibilities and pitfalls. We describe the cytologic features of solitary fibrous tumor of the pleura, differential diagnoses, pertinent immunohistochemical stains and histogenesis.

CASES

Two cases of solitary fibrous tumor of the pleura showed two cell populations on cytologic preparations; mesothelial cells and spindle cells. The neoplastic spindle cell component was positive for CD-34 and vimentin but not for cytokeratin.

CONCLUSION

Solitary fibrous tumor of the pleura is rare but should be included in the differential diagnosis of a peripheral pulmonary nodule. Fine needle aspiration biopsy is a safe and rapid method of providing a confirmatory diagnosis.

Fine needle aspiration diagnosis of fibromatosis colli. A report of three cases

BACKGROUND

Fibromatosis colli, a common cause of congenital muscular torticollis, should be differentiated from other neck masses in infants. Invasive diagnostic and therapeutic measures should be avoided.

CASES

Three infants under the age of 2 months presented with neck masses--a clinical suspicion of malignancy, lymphadenopathy and teratoma. The cytologic findings included dyshesive multinucleated skeletal muscle fragments showing degenerative and atrophic changes within a background of scattered reactive fibroblasts.

CONCLUSION

Fine needle aspiration biopsy is a safe and rapid method of providing a confirmatory diagnosis of neck masses in infants.

Pitfalls in the cytologic diagnosis of angiosarcoma of the breast by fine-needle aspiration: a case report

This paper describes a case of angiosarcoma of the breast in a 26-yr-old female. The tumor, originally thought to be granulation tissue on fine-needle aspiration biopsy, was correctly identified as a malignant neoplasm of probable mesenchymal origin on a repeat FNA biopsy 4 mo later. A diagnosis of angiosarcoma was made on a subsequent excisional biopsy. Review of the cytologic features revealed findings that should suggest angiosarcoma, especially when correlated with the clinical history. The authors describe the cytological features seen in this case, and discuss an important pitfall in the diagnosis of angiosarcoma of the breast on FNA.

Initial clinical experience with dextran-coated superparamagnetic iron oxide for detection of lymph node metastases in patients with head and neck cancer

PURPOSE

To investigate the efficacy of magnetic resonance (MR) imaging with dextran-coated superparamagnetic iron oxide in the differentiation of metastatic and benign nodes in patients with head and neck cancer.

MATERIALS AND METHODS

MR imaging was performed before and after intravenous administration of iron oxide in 12 patients. Ninety-one pathologically proved nodes were visually analyzed, and 66 lymph nodes were quantitatively analyzed by measuring signal intensity in visually selected regions of interest.

RESULTS

Forty of 42 histologically proved metastatic nodes and 41 of 49 benign nodes were detected, yielding 95% sensitivity and 84% specificity. The signal intensity ratio of benign nodes was substantially lower than that of metastatic nodes, indicating better differentiation of metastatic and benign nodes. Furthermore, 13 of 14 normal-sized nodes were detected.

CONCLUSION

MR imaging with iron oxide can enable specific differentiation of metastatic and benign nodes in patients with head and neck cancer. This agent may potentially enhance the detection of metastatic lymph nodes and deserves further investigation.

The alcohol-fixed Diff-Quik stain. A novel rapid stain for the immediate interpretation of fine needle aspiration specimens

A rapid alcohol-fixed Diff-Quik stain is described. The technique takes less than five minutes and results in excellent cytologic detail, comparable to that with Papanicolaou stain, as well as superb stromal definition. The stain should be very useful to pathologists and cytotechnologists for immediate interpretation of fine needle aspiration specimens.

Malignant endometrial pathology

This review discusses recent papers on endometrial carcinoma variants, immunohistochemical studies, and prognostic indicators. The aggressive nature of uterine papillary serous carcinoma is confirmed, even in the absence of myometrial or vascular invasion, with a comprehensive review of the histology, clinical presentation, and proposed treatment protocols. The possible etiologic role of radiation in the development of uterine papillary serous carcinoma is alluded to. The virulence of endometrial carcinomas with trophoblastic differentiation, endometrial carcinomas with a malignant giant cell component, and clear cell carcinomas of the endometrium is documented. A series of immunohistochemical studies is presented suggesting that uterine carcinosarcomas are metaplastic carcinomas derived from a common stem cell and that a shared histogenesis of endometrial stromal tumors and uterine mesoderm exists. Immunohistochemical techniques may clarify diagnostic problems of uterine tumors and their metastases and differentiate mucinous tumors of endometrium from endocervical origin. Staining of both carcinoembryonic antigen and ferritin in neoplastic endometria may be helpful in their differentiation from hyperplasias in curettage specimens. Significant prognosticators in endometrial carcinoma are depth of myometrial invasion and lymphovascular space involvement with greatest prognostic information provided by the depth of myometrial invasion above DNA index.

Hypercalcaemia in sarcoidosis co-existing with primary hyperparathyroidism. A case report

Patients presenting with hypercalcaemia caused by the co-existence of sarcoidosis and primary hyperparathyroidism may present a diagnostic problem. Tests for sarcoid activity, together with the cortisone suppression test and an estimation of the immunoreactive parathyroid hormone level are all necessary to differentiate between those conditions.

Kallmann's syndrome. A case report

A patient with hypogonadotrophic hypogonadism and anosmia (Kallmann's syndrome) presenting as delayed puberty is described. The clinical, hormonal and testicular histological features are noted. The basic principles of treatment are discussed.