Articles : CytoJournal as on February 1, 2012)

Comparative evaluation of the modified Scarff-Bloom-Richardson grading system on breast carcinoma aspirates and histopathology

Cherry Bansal — Tue,31 Jan 2012

Cherry Bansal, US Singh, Sanjeev Misra, Kiran Lata Sharma, Vandana Tiwari, AN Srivastava

CytoJournal 2012 9(1):4-4

Background: Fine needle aspiration (FNA) is a quick noninvasive procedure to assess in vivo tumor grade. The Scarff-Bloom-Richardson (SBR) grade on histological sections is a well established tool to guide selection of adjuvant systemic therapy. Grade evaluation is possible on cytology smears to avoid and minimize the morbidity associated with overtreatment of lower grade tumors. Aim : The aim was to test the hypothesis whether breast FNA from peripheral portion of the lesion is representative of Scarff-Bloom-Richardson grade and score on histopathology compared to FNA from central portion. Materials and Methods : Fine-needle aspirates and subsequent tumor tissue specimens of 45 women with ductal carcinoma (not otherwise specified) were studied. FNAs were performed under ultrasound guidance from central as well as peripheral (1/3) portion of the lesion for each case avoiding areas of necrosis/calcification. The SBR grading and score were compared on alcohol fixed aspirates and tissue sections for each case. Results : Comparative analysis of SBR grade on aspirates from peripheral portion and histopathology by the Pearson chi-square test (χ2 =78.00) showed that it was statistically significant (P<0.001) with 93% concordance. The mitotic score on aspirates from peripheral portion was given false low value in only 4 (9%) cases out of 45. Results of the [Pearson chi-square test (χ2 = 75.824) with statistically significant P=0.000]. Conclusion : This prospective study shows that FNA smears from peripheral portion of the lesion are representative of the corresponding histopathological sections and it is possible to score and grade by SBR system on FNA smears.

Authors' Reply

Adrienne Carruth Griffin — Tue,31 Jan 2012

Adrienne Carruth Griffin, Lauren Ende Schwartz, Zubair Baloch

CytoJournal 2012 9(1):3-3

Comparing endobronchial ultrasound-guided fine needle aspiration specimens with and without rapid on-site evaluation

Sara E Monaco — Tue,31 Jan 2012

Sara E Monaco, Liron Pantanowitz, Walid E Khalbuss

CytoJournal 2012 9(1):2-2

How to write an article: Preparing a publishable manuscript!

Vinod B Shidham — Tue,31 Jan 2012

Vinod B Shidham, Martha B Pitman, Richard M DeMay

CytoJournal 2012 9(1):1-1

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

Testicular touch preparation cytology in the evaluation of male infertility

Isil Z Yildiz-Aktas — Tue,27 Dec 2011

Isil Z Yildiz-Aktas, Sara E Monaco, Walid E Khalbuss, Anil V Parwani, Thomas M Jaffe, Liron Pantanowitz

CytoJournal 2011 8(1):24-24

Background: Male infertility is traditionally evaluated by tissue core biopsies of the testes. Touch preparations (TP) of these biopsies have been infrequently used. The aim of this study is to report our experience with using testicular biopsy TP for the evaluation of male infertility. Materials and Methods: A retrospective search was performed for cases of testes biopsies with concurrent TP. These cases were evaluated for clinical information, specimen adequacy, and cytological-histological correlation. Results: A total of 39 cases were identified from men with a mean age of 34 years (range 23 to 50 years). TP slides were satisfactory for evaluation in 31 (89%) cases, and less than optimal in four due to low cellularity, obscuring blood or air drying artifact. Cytopathology showed concordance with the biopsy in almost all cases. In one discordant case where the biopsies showed no active spermatogenesis, a rare sperm were identified on the TP. Conclusions: TP of the testis is a helpful adjunct to biopsy because of its ability to clearly evaluate all stages of spermatogenesis. These data demonstrate that TP cytopathology of the testes in our experience has an excellent correlation with both normal testicular biopsies and those showing pathological spermatogenesis, and in rare cases may provide added benefit in evaluating the presence of spermatogenesis for male infertility. Albeit uncommon, cytopathologists may be required to identify and evaluate spermatogenic elements in cytology specimens being submitted from men with infertility.

Thank you reviewers - CytoJournal 2011

Vinod B Shidham — Tue,27 Dec 2011

Vinod B Shidham, Richard M DeMay, Martha B Pitman

CytoJournal 2011 8(1):23-23

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

Cytomorphology of Erdheim-Chester disease presenting as a retroperitoneal soft tissue lesion

Bibianna Purgina — Tue,27 Dec 2011

Bibianna Purgina, Ronald Jaffe, Sara E Monaco, Walid E Khalbuss, H Scott Beasley, John A Dunn, Liron Pantanowitz

CytoJournal 2011 8(1):22-22

Erdheim-Chester disease (ECD) is a rare, multisystem disorder of macrophages. Patients manifest with histiocytic infiltrates that lead to xanthogranulomatous lesions in multiple organ systems. The cytologic features of this disorder are not well characterized. As a result, the cytologic diagnosis of ECD can be very challenging. The aim of this report is to describe the cytomorphology of ECD in a patient presenting with a retroperitoneal soft tissue lesion. A 54-year-old woman with proptosis and diabetes insipidus was found on imaging studies to have multiple intracranial lesions, sclerosis of both femurs and a retroperitoneal soft tissue mass. Fine needle aspiration (FNA) and a concomitant core biopsy of this abnormal retroperitoneal soft tissue revealed foamy, epithelioid and multinucleated histiocytes associated with fibrosis. The histiocytes were immunoreactive for CD68, CD163, Factor XIIIa and fascin, and negative for S100, confirming the diagnosis of ECD. ECD requires a morphologic diagnosis that fits with the appropriate clinical context. This case describes the cytomorphologic features of ECD and highlights the role of cytology in helping reach a diagnosis of this rare disorder.

Cytological analysis of small branch-duct intraductal papillary mucinous neoplasms provides a more accurate risk assessment of malignancy than symptoms

Jill Ono — Mon,21 Nov 2011

Jill Ono, Kurt A Yaeger, Muriel Genevay, Mari Mino-Kenudson, William R Brugge, Martha B Pitman

CytoJournal 2011 8(1):21-21

Objectives: The Sendai guidelines for management of patients with clinically suspected intraductal papillary mucinous neoplasms (IPMN) recommend resection of cysts > 30 mm, a dilated main pancreatic duct (MPD) > 6 mm, a mural nodule (MN), symptoms or positive cytology. Although sensitive, asymptomatic cysts, nonspecific symptoms, and a high threshold for positive cytology limit the specificity of the guidelines. We have assessed the value of cytology relative to symptom for predicting malignancy in IPMNs without high-risk imaging features. Materials and Methods: We retrospectively reviewed the clinical, radiological, and cytological data of 31 small branch-duct IPMNs without a MN. The cytological presence of high-grade atypical epithelial cells (HGA) was considered true positive, with a corresponding histology of high-grade dysplasia or invasive carcinoma. The performance of cytology versus symptoms was evaluated by calculating the sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy. Results: The sensitivity (0.80), specificity (0.85), and accuracy (0.84) of HGA were higher than the corresponding performance characteristics of symptoms (0.60, 0.45, and 0.48, respectively). The NPV of no HGA on cytology was > 95%. Conclusions: Cytology is a better predictor of malignancy than symptoms, for the conservative management of small branch-duct IPMNs. Cytology contributes to a highly accurate triple negative test for malignancy in small IPMN: No dilated MPD, MN or HGA.

Utility of on-site evaluation of endobronchial ultrasound-guided transbronchial needle aspiration specimens

Adrienne Carruth Griffin — Mon,21 Nov 2011

Adrienne Carruth Griffin, Lauren Ende Schwartz, Zubair W Baloch

CytoJournal 2011 8(1):20-20

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is an integral tool in the diagnosis and staging of malignant tumors of the lung. Rapid on-site evaluation (ROSE) of fine needle aspiration (FNA) samples has been advocated for as a guide for assessing the accuracy and adequacy of biopsy samples. Although ROSE has proven useful for numerous sites and procedures, few studies have specifically investigated its utility in the assessment of EBUS-TBNA specimens. The intention of this study was to explore the utility of ROSE for EBUS-TBNA specimens. Materials and Methods: The pathology files at our institution were searched for all EBUS-TBNA cases performed between January 2010 and June 2010. The data points included number of sites sampled per patient, location of site(s) sampled, on-site evaluation performed, preliminary on-site diagnosis rendered, final cytologic diagnosis, surgical pathology follow-up, cell blocks, and ancillary studies performed. Results: A total of 294 EBUS-TBNA specimens were reviewed and included in the study; 264 of 294 (90%) were lymph nodes and 30 of 294 (10%) were lung mass lesions. ROSE was performed for 140 of 294 (48%) specimens. The on-site and final diagnoses were concordant in 104 (74%) and discordant in 36 (26%) cases. Diagnostic specimens were obtained in 132 of 140 (94%) cases with on-site evaluation and 138 of 154 (90%) without on-site evaluation. The final cytologic diagnosis was malignant in 60 of 132 (45%) cases with ROSE and 46 of 138 (33%) cases without ROSE, and the final diagnosis was benign in 57 of 132 (47%) with ROSE and 82 of 138 (59%) without ROSE. A cell block was obtained in 129 of 140 (92%) cases with ROSE and 136 of 154 (88%) cases without ROSE. Conclusions : The data demonstrate no remarkable difference in diagnostic yield, the number of sites sampled per patient, or clinical decision making between specimens collected via EBUS-TBNA with or without ROSE. As a result, this study challenges the notion that ROSE is beneficial for the evaluation of EBUS-TBNA specimens.

Malignancy rate in nondominant nodules in patients with multinodular goiter: Experience with 1,606 cases evaluated by ultrasound-guided fine needle aspiration cytology

Nadir Paksoy — Mon,31 Oct 2011

Nadir Paksoy, Kadri Yazal, Selin Çorak

CytoJournal 2011 8(1):19-19

Background: Conventional medical sources recommend the use of fine needle aspiration cytology (FNAC) for single thyroid nodules and the dominant nodule in multinodular goiter (MNG). The purpose of the present study was to analyze the utility of FNAC for multiple thyroid nodules in patients with MNG and to determine the rate of malignancy in teh nondominant nodules. Materials and Methods : Our private practice performed ultrasound-guided FNAC on 1,606 patients between February 2001 and February 1, 2010. In the MNG cases, samples were taken from the dominant nodule and from trhee suspicious / nonsuspicious nodules larger than 1 cm on ultrasound. Ninety-four cases were diagnosed as 'suspiciously malignant'(SUS) or 'malignant' (POS) based on FNAC. Results: The rate of an SUS / POS diagnosis was 5.7% in the dominant nodules; 2.3% of the nondominant nodules had a SUS / POS diagnosis in FNAC (p = 0.0003). Follow-up revealed malignancy in 15 (35.7%) nondominant nodules and in 27 (64.2%) dominant nodules, with 42 MNG cases undergoing surgery. X test showed a 'p-level of 0.0003' between the percentages of SUS / POS diagnosis in dominanat and nondominanat nodules. It was less than the significance level of 0.05. Therefore, the result was regarded to be statistically significant. Conclusions: Nondominant nodules could harbor malignancy. The risk of malignancy in nondominant nodules in MNG should not be underestimated. We have shown that the dominant nodule in patients with MNG was in fact about 2.5 times more likely to be malignant than a nondominant nodule. The use of FNAC for nondominant nodules could enhance the likelihood of detecting malignancy in an MNG.

The cytomorphologic spectrum of small-cell carcinoma and large-cell neuroendocrine carcinoma in body cavity effusions: A study of 68 cases

Walid E Khalbuss — Sat,29 Oct 2011

Walid E Khalbuss, Huaitao Yang, Qian Lian, Abdelmonem Elhosseiny, Liron Pantanowitz, Sara E Monaco

CytoJournal 2011 8(1):18-18

Background: Small-cell carcinoma (SCC) and large-cell neuroendocrine carcinoma (LCNEC) are uncommon in serous body cavity effusions. The purpose of this study is to examine the cytomorphological spectrum of SCC and LCNEC in body cavity serous fluids. Materials and Methods: We have 68 cases from 53 patients who had metastatic SCC or LCNEC diagnoses. All cytology slides and the available clinical data, histological follow-up, and ancillary studies were reviewed. Results: A total of 68 cases (60 pleural, 5 peritoneal, and 3 pericardial effusions) from 53 patients with an average age of 73 years (age range 43-92 years) were reported as diagnostic or suspicious of SCC (52 cases) or LCNEC (16 cases). The primary site was lung in 56 cases, pancreas in 6 cases, and 2 cases each from cervix, colon, and the head and neck region. Of the 68 cases, 48 cases had no history of malignancy of the same type. Ancillary studies were used in 46 cases (68%) including flow cytometric studies in 5 cases. There were three predominant cytomorphological patterns observed including small-cell clusters with prominent nuclear molding (33 cases, 49%), large-cell clusters mimicking non-small-cell carcinoma (18 cases, 26%), and single-cell pattern mimicking lymphoma (17 cases, 25%). Significant apoptosis was seen in 22 cases (33%) and marked tumor cell cannibalism was seen in 11 cases (16%). Nucleoli were prominent in 16 cases (24%). The most frequent neuroendocrine markers performed were synaptophysin and chromogranin. Conclusions: The most common cytomorphologic patterns seen in body cavity effusions of SCC and LCNEC were small-cell clusters with nuclear molding. However, in 51% of the cases either a predominant single-cell pattern mimicking lymphoma or large-cell clusters mimicking non-small carcinoma were noted. In our experience, effusions were the first manifestation of disease in the majority of patients diagnosed with neuroendocrine carcinoma. Therefore, familiarity with the cytomorphological spectrum of neuroendocrine carcinomas in fluid cytology may help in rapidly establishing an accurate diagnosis and in directing appropriate management.

Cyto-morphological features of extramedullary acute megakaryoblastic leukemia on fine needle aspiration and cerebrospinal fluid cytology: A case report

Sanjeev Chitragar — Tue,27 Sep 2011

Sanjeev Chitragar, Shipra Agarwal, Venkateswaran K Iyer, Sandeep R Mathur, Asis K Karak, Taher Chharchhodawala, Atul Sharma, Sameer Bakhshi

CytoJournal 2011 8(1):17-17

Extramedullary deposits may be the presenting feature of acute myeloid leukemia. An early and accurate diagnosis on cytology will aid in correct patient management. This is especially true for patients with acute megakaryoblastic leukemia (AML M7), where bone marrow aspiration may yield only a dry tap. While cytomorphological features of myeloid sarcoma of other types are well recognized due to its rarity, there are only two case reports discussing the morphological details of megakaryoblastic differentiation on aspiration cytology. We present the case of a 25-year-old patient with extramedullary involvement of lymph node and cerebrospinal fluid by AML M7, describing in detail, the morphological features on aspiration as well as exfoliative cytology.

Abstracts for the 59th Annual Scientific Meeting (November 2011) by American Society of Cytopathology (ASC) at Baltimore, MD, USA

Fri,16 Sep 2011

CytoJournal 2011 8(1):16-16

These are peer-reviewed poster-platform submissions finalized by the Scientific Program Committee. A total of 153 abstracts (14 Platforms [PP1 through PP14] & 139 Posters [1 through 139]) were selected from 161 submissions to be considered for presentation during November 4 - 8, 2011, at the Hilton Baltimore Hotel, to pathologists, cytopathologists, cytotechnologists, residents, fellows, students, and other members of cytopathology-related medical and scientific fields.

Salivary duct carcinoma with striking neutrophil-tumor cell cannibalism

Payam Arya — Wed,24 Aug 2011

Payam Arya, Walid E Khalbuss, Sara E Monaco, Liron Pantanowitz

CytoJournal 2011 8(1):15-15

Cannibalism of neutrophils by tumor cells has previously been reported in certain carcinomas, lymphoma and melanoma. Tumor cannibalism is believed to serve as a tumor-immune escape mechanism, associated with high-grade aggressive cancers with a significantly increased metastatic potential. This interesting phenomenon has not been previously documented in association with salivary gland tumors. We report, for the first time, striking neutrophil-tumor cell cannibalism associated with a high grade, aggressive and metastatic salivary duct carcinoma of the parotid gland highlighted within cytological and surgical excision pathology specimens.

Utility of a limited panel of calretinin and Ber-EP4 immunocytochemistry on cytospin preparation of serous effusions: A cost-effective measure in resource-limited settings

Raman Arora — Thu,28 Jul 2011

Raman Arora, Shipra Agarwal, Sandeep R Mathur, Kusum Verma, Venkateswaran K Iyer, Manju Aron

CytoJournal 2011 8(1):14-14

Background: Differentiation between reactive, but morphologically atypical, mesothelial cells and adenocarcinoma in effusions can be problematic. Elaborate immunohistochemical panels have been devised. Techniques like DNA analysis, flow/image cytometry, and K-ras mutation analysis are research oriented and difficult to perform in routine, especially in resource-poor centers. We evaluated the efficacy of a limited two-antibody panel comprising calretinin and Ber-EP4 on cytospin and cell block preparations, in 100 effusion samples. Materials and Methods: Fifty cases of reactive mesothelial hyperplasia and 50 cases of adenocarcinoma diagnosed by cytomorphology in ascitic/pleural fluid specimens over a 2-year period were assessed. The diagnoses were confirmed by clinical/histopathologic correlation. Cytospin smears were made in all. Cell blocks were prepared, wherever adequate fluid was available. Immunocytochemistry (ICC) for calretinin and Ber-EP4 was performed. Results: Forty-five of the reactive effusion cases (90%) were calretinin reactive and Ber-EP4 negative. Among the adenocarcinoma cases, 49 (98%) were calretinin negative but Ber-EP4 positive. Thus, both calretinin and Ber-EP4 had a high sensitivity (90% and 98%, respectively), as well as a high specificity (100% and 86%, respectively). In the 21 reactive mesothelial cases, whose cell blocks were made, results were comparable to those on cytospin. However, of the 19 adenocarcinoma cases in which cell blocks were prepared, all were Ber-EP4 immunopositive except for three, which were positive on cytospin, implying false-negative results on cell blocks. Conclusions: A limited panel of two monoclonal antibodies, calretinin and Ber-EP4, may be useful in cytology, as a "primary antibody panel", for accurate diagnosis and patient management. Additionally, ICC can be performed easily on cytospin preparations, which gave results comparable to cell blocks in our study.

A review of uncommon cytopathologic diagnoses of pleural effusions from a chest diseases center in Turkey

Ebru Cakir — Tue,19 Jul 2011

Ebru Cakir, Funda Demirag, Mehtap Aydin, Yurdanur Erdogan

CytoJournal 2011 8(1):13-13

Background : After pneumonia, cancer involving the pleura is the leading cause of exudative pleural effusion. Cytologic examination of pleural effusions is an important initial step in management of malignant effusions. The aim of this study is to evaluate the spectrum of uncommon malignant pleural effusions in a chest disease center in Turkey. Materials and Methods : A retrospective study of samples of pleural effusions submitted to Ataturk Chest Diseases and Chest Surgery Education and Research Hospital Department of Pathology between March 2005 and November 2008 was performed. Results : Out of a total of 4684 samples reviewed 364 (7.8%) were positive for cancer cells. Of the malignant pleural effusions 295 (81%) were classified as adenocarcinoma or carcinoma not otherwise specified (NOS). Pleural effusion specimens revealing a diagnosis other than adenocarcinoma/carcinoma NOS were: 32 (8.8%) malignant mesotheliomas, 14 (3.8%) small cell carcinomas, 13 (3.5%) hematolymphoid malignancies and 10 (2.7%) squamous cell carcinoma. Hematolymphoid malignancies included non- Hodgkin lymphoma (diffuse B large cell lymphoma, mantle cell lymphoma), multiple myeloma, chronic myeloid leukemia, and acute myeloid leukemia. Conclusions: Despite that adenocarcinoma is the most common cause of malignant pleural effusions, there is a significant number of hematological and non-hematological uncommon causes of such effusions. Cytopathologists and clinicians must keep in mind these uncommon entities in routine practice for an accurate diagnosis.

A review of the utilization of fine needle aspiration in clinical practice and research in Nigeria

Sani Abubakar Malami — Thu,23 Jun 2011

Sani Abubakar Malami, Ochicha Ochicha

CytoJournal 2011 8(1):12-12

Background: Research and publications are critical to advancements in the quality of healthcare delivery. This article attempts to highlight the prospects and challenges of fine needle aspiration (FNA) cytology as a tool for research in Nigeria. Materials and Methods: Data available in local and international bibliographic databases for the period 1986-2005 (20 years) were collated and analyzed. Results: The theme of Nigerian FNA-focused studies correlated with the recognized disease patterns in the country which are tuberculous lymphadenitis, breast tumors and Burkitt's lymphoma. The accuracy of FNA in these situations was high and comparable to the experience in developed countries. It was found that the total number of articles published during two contiguous periods (1986-1995 and 1996-2005) had increased from 5 to 18. Also, in majority of cases, the articles were not published in specialized pathology journals. Conclusions: The utilization of FNA is apparently lagging in Nigeria. Given its potential in resource-constrained settings, we are of the opinion that it should be used more often in clinical and translational research.

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

Sumana Devata — Thu,23 Jun 2011

Sumana Devata, Parameswaran Hari, Natalia Markelova, Rongshan Li, Richard Komorowski, Vinod B Shidham

CytoJournal 2011 8(1):11-11

Background: Fine-needle aspiration biopsy (FNA) of the abdominal fat pad is a minimally invasive procedure to demonstrate tissue deposits of amyloid. However, protocols to evaluate amyloid in fat pad aspirates are not standardized, especially for detecting scant amyloid in early disease. Materials and Methods: We studied abdominal fat pad aspirates from 33 randomly selected patients in whom subsequent tissue biopsy, autopsy, and/or medical history for confirmation of amyloidosis (AL) were also available. All these cases were suspected to have early AL, but had negative results on abdominal fat pad aspirates evaluated by polarizing microscopy of Congo Red stained sections (CRPM). The results with CRPM between four reviewers were compared in 12 cases for studying inter observer reproducibility. 24 cases were also evaluated by ultrastructural study with electron microscopy (EM). Results: Nine of thirty-three (27%) cases reported negative by polarizing microscopy had amyloidosis. Reanalysis of 12 mixed positive-negative cases, showed considerable inter-observer variability with frequent lack of agreement between four observers by CRPM alone (Cohen's Kappa index of 0.1, 95% CI -0.1 to 0.36). EM showed amyloid in the walls of small blood vessels in fibroadipose tissue in four out of nine cases (44%) with amyloidosis. Conclusion: In addition to poor inter-observer reproducibility, CRPM alone in cases with scant amyloid led to frequent false negative results (9 out of 9, 100%). For improved detection of AL, routine ultrastructural evaluation with EM of fat pad aspirates by evaluating at least 15 small blood vessels in the aspirated fibroadipose tissue is recommended. Given the high false negative rate for CRPM alone in early disease, routine reflex evaluation with EM is highly recommended to avert the invasive option of biopsying various organs in cases with high clinical suspicion for AL.

Endobronchial ultrasound-guided transbronchial needle aspiration biopsy is useful evaluating mediastinal lymphadenopathy in a cancer center

Laila Khazai — Tue,31 May 2011

Laila Khazai, Uma R Kundu, Betsy Jacob, Shobha Patel, Nour Sneige, George A Eapen, Rodolfo C Morice, Nancy P Caraway

CytoJournal 2011 8(1):10-10

Background: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) biopsy is used to stage mediastinal lymph nodes in cancer patients to optimize treatment strategies. In this retrospective study, the authors determined the utility of EBUS-TBNA biopsy in the evaluation of mediastinal lymphadenopathy at a high-volume cancer center. Materials and Methods: The pathology database was searched for all patients who had undergone EBUS-TBNA biopsy of mediastinal lymph nodes over a one-year period. Cytologic diagnoses were correlated with clinical histories, subsequent resection, and clinical follow-up data. Results: Of 928 lymph node samples, 226 (24%) were diagnosed as malignant, 4 (0.4%) were suspicious for malignancy, 9 (1%) were atypical, 640 (69%) were benign, and 47 (5%) were insufficient for evaluation. In 89 (9.6%) cases, the patients had surgical resection. There was one false positive, in which the primary tumor contained infiltrating lymphocytes, had been sampled. There were five false-negative cases, which resulted from sampling errors, including two with micrometastases. The sensitivity, specificity, and positive and negative predictive value rates for EBUS-TBNA biopsy in the evaluation of mediastinal lymph nodes were 68.7% and 98.6% and 91.6% and 93.5%, respectively on a per lymph node basis. The overall clinical sensitivity, specificity, and positive and negative predictive value rates after one year clinical/radiological and histologic follow-up were 97%, 99.3%, 96.7% and 99.4%, respectively. Conclusions: EBUS-TBNA biopsy is a sensitive and specific method for evaluating mediastinal lymphadenopathy in patients with lung and other primary tumors.

Teenage cervical screening in a high risk American population

Songlin Zhang — Tue,31 May 2011

Songlin Zhang, Jaiyeola Thomas, Joel Thibodeaux, Ami Bhalodia, Fleurette Abreo

CytoJournal 2011 8(1):9-9

Background: The new 2009 ACOG guideline for cervical cytology screening changed the starting age to 21 years regardless of the age of onset of sexual intercourse. However, many recent studies have shown a dramatic increase in the incidence of cervical epithelial abnormalities among adolescents within the past two decades. Materials and Methods: For this study, the reports of 156,342 cervical cytology were available of which 12,226 (7.8%) were from teenagers. A total of 192 teenagers with high grade intraepithelial lesion (HSIL) cervical cytology were identified. The ages ranged from 13 to 19 years with a mean of 17.7 years and a median of 18 years. Among them, 31.3% were pregnant, 12.0% were postpartum, and 13.5% were on oral contraceptive. Ninety-eight had prior cervical cytology. Results: The teenagers had statistically significant higher detection rates of overall abnormal cervical cytology (23.6% vs. 6.6%, P = 0), with 15.4% vs. 3.2% (P = 0) of low grade intraepithelial lesion (LSIL) and 1.8% vs. 1.0% (P = 2.56 Χ 10 -13 ) of HSIL compared to women ≥20 years. The teenage group had the highest abnormal cytology among all age groups. The LSIL/HSIL ratio was 8.5:1 for teenagers and 3.1:1 for women ≥20 years. A total of 131 teenagers had cervical biopsies within 12 months of the HSIL cytology, with diagnoses of 39 CIN 3, 1 VAIN 3, 15 CIN 2, 62 CIN 1, and 14 had a negative histology (CIN 0). Only in 19 of these 39 women, the CIN 2/3 lesion proved to be persistent. Conclusion: We conclude that cytology screening of high risk teenagers is effective in detecting CIN 2/3 lesions. Moreover, treatment and careful follow-up can be realized.

Pattern of epithelial cell abnormality in Pap smear: A clinicopathological and demographic correlation

Urmila Banik — Sat,30 Apr 2011

Urmila Banik, Pradip Bhattacharjee, Shahab Uddin Ahamad, Zillur Rahman

CytoJournal 2011 8(1):8-8

Background: In the low resource settings of a developing country, a conventional Papanicolaou (Pap) test is the mainstay screening system for cervical cancer. In order to counsel women and to organize a public health system for cervical cancer screening by Pap smear examination, it is imperative to know the pattern of premalignant and malignant lesions. This study was undertaken to find out the prevalence of an abnormal Pap smear, in a tertiary hospital of a developing country, and to carry out a clinicopathological and demographical analysis for establishing the pattern of epithelial cell abnormality in a Pap smear. Materials and Methods: A cross-sectional descriptive study was carried out in a total of 1699 patients who underwent Pap smear examination. The prevalence of epithelial cell abnormality in the Pap smear was calculated in proportions / percentages. Specimen adequacy and reporting was assessed according to the revised Bethesda system. Results: Among the total of 1699 patients who had their Pap smear done, 139 (8.18%) revealed epithelial cell abnormality. Altogether 26 smears revealed high-grade lesions and malignancy, most of which were found to be in women belonging to the 30 - 39 and ≥ 45 age group. A total of 75 (53.96%) women were in the 20 - 44 age group and 64 (46.04%) were in the ≥ 45 age group. A bimodal age distribution was detected in the epithelial cell abnormality, with the bulk being diagnosed in patients aged 45 or above. Overall one-third of the patients with an abnormal Pap smear result showed healthy cervix in per vaginal examination. Conclusions: A raised prevalence of epithelial cell abnormality reflects the lack of awareness about cervical cancer screening. Women aged 45 or above harbor the bulk of premalignant and malignant lesions in the Pap smear, signifying that these women are among the under users of cytological screening.

Endoscopic ultrasound-guided fine-needle aspiration of metastases to the pancreas: A study of 25 cases

Christopher M Gilbert — Thu,21 Apr 2011

Christopher M Gilbert, Sara E Monaco, Scott T Cooper, Walid E Khalbuss

CytoJournal 2011 8(1):7-7

Background: Metastases to the pancreas are an uncommon cause of pancreatic masses seen on endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA). The purpose of this study is to retrospectively review the cytomorphology, clinical findings, and results of ancillary studies in a large series of these unusual cases. Materials and Methods: We searched our institution's pathology database for EUS-guided FNAs of the pancreas that were diagnostic of metastatic tumor over a 5-year period. The final cytologic diagnosis, results of ancillary studies, corresponding histological material, and clinical follow-up data were reviewed in these cases. Results: A total of 1172 pancreatic EUS-guided FNAs were identified, of which 25 cases (2.1%) had a confirmed diagnosis of a pancreatic metastasis. This included 12 (48%) cases of renal cell carcinoma, 3 (12%) melanomas, 3 (12%) small cell carcinomas, and 7 (28%) other malignancies. In these metastatic tumors involving the pancreas, 20 (80%) of the lesions were solitary. Four (16%) cases had no prior history of malignancy. The average time to diagnosis of pancreatic metastasis was 5.3 years. Immunohistochemistry and special stains were performed in 22 (88%) and 9 (36%) cases, respectively. Conclusions: Our data shows that although metastases to the pancreas are rare, they can present as a solitary mass many years after the primary malignancy is diagnosed and can even be the first manifestation of an extrapancreatic primary in a small number of cases. It is important to consider the possibility of a metastatic lesion in the pancreas because this may require a different management than a primary pancreatic tumor.

Solitary Tracheobronchial Papilloma: Cytomorphology and ancillary studies with histologic correlation

Tee U Lang — Thu,3 Mar 2011

Tee U Lang, Walid E Khalbuss, Sara E Monaco, Liron Pantanowitz

CytoJournal 2011 8(1):6-6

Solitary tracheobronchial papilloma (STBP) is a rare benign tumor that primarily involves the tracheobronchial tree. Human papilloma virus (HPV) infection is associated with dysplasia and a high risk of carcinoma in these lesions. The cytomorphology of STBP is not well established in the literature. Our aim is to characterize the cytomorphologic features of STBP, with histologic correlation in a series of 6 patients - 4 males and 2 females - with a mean age of 67 years (range, 53-88 years). There were 5 biopsy-proven squamous papillomas and 1 glandular papilloma. On surgical biopsy, squamous papillomas exhibited cytological atypia (4 graded mild and 1 graded moderate with focal severe dysplasia), surface erosion, and inflammation. Cytology specimens available for review included a combination of 4 fine-needle aspirations (FNAs), 2 bronchoalveolar lavages and 2 (of 3) bronchial brushings. Cytologic findings associated with squamous papillomas included atypical squamous cells and rare squamous cell resembling koilocyte in 1 bronchial brushing. Sheets of squamous cells were identified in another specimen. Several cases had a prominent background of acute inflammation, and candida was present in 1 specimen. HPV in-situ hybridization was positive in 1 case and negative in 2 cases. A p16 immunocytochemical stain performed on 1 cell block was negative. In conclusion, although STBP is a rare neoplasm, these cases may be encountered in respiratory cytology samples. FNA of papillomas yields fewer lesional cells compared to exfoliative samples. These lesions may be mistaken in cytology specimens for squamous cell carcinoma, squamous-lined cavitary lesions, an infectious (fungal) process, reactive squamous metaplasia, or oral contamination.

Cytologic features of microcystic adnexal carcinoma

Sasis Sirikanjanapong — Thu,3 Mar 2011

Sasis Sirikanjanapong, Andrew W Seymour, Bijal Amin

CytoJournal 2011 8(1):5-5

Microcystic adnexal carcinoma (MAC) is an uncommon skin neoplasm with a predilection location around the lips. It is characterized by cords and nests of neoplastic cells forming ductular or glandular structures that are embedded in dense collagenous stroma. An eighty-seven year old Caucasian female patient presented with a painless, slowly enlarging mass measuring 3.3 x 2.7 x 1.0 cm on the lower lip for approximately 6 months. The patient underwent 2 fine needle aspiration biopsies (FNAs). Smears made from both FNAs demonstrated similar features including low cellular smears, three dimensional cell clusters forming a glandular structure, round to oval cells with high N:C ratio, occasional cytoplasmic lumens, without distinct hyperchromasia, focal inconspicuous nucleoli, smooth regular nuclear membranes, abundant naked nuclei, occasional squamoid cells and focal acellular stromal fragments in the background. The cytologic differential diagnosis included skin adnexal carcinoma and low grade mucoepidermoid carcinoma arising in the minor salivary gland. The mass was subsequently excised. The diagnosis of microcystic adnexal carcinoma was made. We report cytologic features of MAC and also suggest that MAC can possibly be diagnosed by FNA with the appropriate clinical vignette and immunohistochemical profile..

Microfilariae coexisting with a follicular lesion in thyroid aspirate smears in an uncommon case of a retrosternal thyroid mass, clinically presenting as malignancy

Bharat Rekhi — Sat,12 Feb 2011

Bharat Rekhi, SV Kane

CytoJournal 2011 8(1):4-4

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman Disease): A case report and review of 49 cases with fine needle aspiration cytology

Yuquan Shi — Sat,12 Feb 2011

Yuquan Shi, Adrienne Carruth Griffin, Paul JL Zhang, James N Palmer, Prabodh Gupta

CytoJournal 2011 8(1):3-3

Rosai-Dorfman disease (RDD), a rare, benign, self-limiting histiocytic proliferative disorder, can be encountered in both nodal and extranodal locations, and fine needle aspiration (FNA), a simple, accurate and economic tool, has been widely used for the diagnosis of superficial and deep-seated lesions. Familiarity with the cytomorphologic features of RDD is important as prognosis and treatment are quite different from other benign or malignant diseases for which it may clinically masquerade. Although large numbers of RDD cases have been reported, review of the literature has revealed 49 reported cases of RDD diagnosed by FNA. Here, we report a case of RDD with nasal and sinus involvement. The patient was seen at our institution, carrying a diagnosis of inflammatory pseudotumor rendered by an outside institution, based on material obtained by nasal and sinus surgical biopsies. Cervical lymph node FNA performed at our institution revealed typical features of RDD. The case, as well as a brief review of the literature and 49 RDD cases with FNA cytology, will be discussed.

Diagnosis of metastatic fibrolamellar hepatocellular carcinoma by endoscopic ultrasound-guided fine needle aspiration

Amanda Crowe — Mon,31 Jan 2011

Amanda Crowe, Carrie S Knight, Darshana Jhala, Steve J Bynon, Nirag C Jhala

CytoJournal 2011 8(1):2-2

The fibrolamellar variant of hepatocellular carcinoma (FL-HCC) is distinguished from other hepatocellular carcinomas (HCC) by its unique clinical and pathologic features. Cytological features for this tumor on fine needle aspiration (FNA) of primary tumors have been described earlier. We present here a unique case of metastatic FL-HCC diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of mediastinal adenopathy. A 32-year-old woman with a history of oral contraceptive use presented with nausea and severe abdominal pain but no ascites or stigmata of cirrhosis. She had a past history of resection of a liver lesion. Serial computed tomography scans revealed mediastinal lymphadenopathy and the patient was referred for endoscopic ultrasound (EUS). A transesophageal EUS-FNA was performed and tissue was collected for cytological evaluation by an on-site pathologist with no knowledge of prior history. Based on morphology correlated with prior history received later, a final diagnosis of metastatic FL-HCC in the retrocardiac lymph node was rendered on the EUS-FNA samples. There are very few reports in the literature where a diagnosis of FL-HCC is rendered at unusual sites. This case highlights that EUS-FNA is a relatively non-invasive, rapid, accurate and effective modality in obtaining tissue from otherwise hard-to-reach areas. It also suggests that metastasis of FL-HCC can be observed in mediastinal nodes and that diagnosis based on cytological features can be rendered even when the tumor is identified at unusual locations.

p16 INK4a immunocytochemistry on cell blocks as an adjunct to cervical cytology: Potential reflex testing on specially prepared cell blocks from residual liquid-based cytology specimens

Vinod B Shidham — Mon,31 Jan 2011

Vinod B Shidham, Ravi Mehrotra, George Varsegi, Krista L D'Amore, Bryan Hunt, Raj Narayan

CytoJournal 2011 8(1):1-1

Background: p16 INK4a (p16) is a well-recognized surrogate molecular marker for human papilloma virus (HPV) related squamous dysplasia. Our hypothesis is that the invasive interventions and related morbidities could be avoided by objective stratification of positive cytologic interpretations by p16 immunostaining of cell block sections of cytology specimens. Materials and Methods: Nuclear immunoreactivity for p16 was evaluated in cell block sections in 133 adequate cases [20 negative for intraepithelial lesion or malignancy, 28 high-grade squamous intraepithelial lesion (HSIL), 50 low-grade squamous intraepithelial lesion (LSIL), 21 atypical squamous cells, cannot exclude HSIL (ASC-H), and 14 atypical squamous cells of undetermined significance (ASCUS)] and analyzed with cervical biopsy results. Results: (a) HSIL cytology (28): 21 (75%) were p16 positive (11 biopsies available - 92% were positive for cervical intraepithelial neoplasia (CIN) 1 and above) and 7 (25%) were p16 negative (3 biopsies available - all showed only HPV with small atypical parakeratotic cells). (b) LSIL cytology (50): 13 (26%) cases were p16 positive (12 biopsies available - all were CIN1 or above) and 37 (74%) were p16 negative (12 biopsies available - all negative for dysplasia. However, 9 (75%) of these biopsies showed HPV). (c) ASC-H cytology (21): 14 (67%) were p16 positive (6 biopsies available - 5 showed CIN 3/Carcinoma in situ/Ca and 1 showed CIN 1 with possibility of under-sampling. Cytomorphologic re-review favored HSIL) and 7 (33%) were p16 negative (5 biopsies available - 3 negative for dysplasia. Remaining 2 cases - 1 positive for CIN 3 and 1 showed CIN 1 with scant ASC-H cells on cytomorphologic re-review with possibility under-sampling in cytology specimen). (d) ASCUS cytology (14): All (100%) were p16 negative on cell block sections of cervical cytology specimen. HPV testing performed in last 6 months in 7 cases was positive in 3 (43%) cases. Conclusion: p16 immunostaining on cell block sections of cervical cytology specimens showed distinct correlation patterns with biopsy results. Reflex p16 immunostaining of cell blocks based on the algorithmic approach to be evaluated by a multiinstitutional comprehensive prospective study is proposed.

Thank you CytoJournal reviewers and authors - 2008 through 2010

Vinod B Shidham — Fri,31 Dec 2010

Vinod B Shidham

CytoJournal 2010 7(1):26-26

Cytomorphology of cervicovaginal melanoma: ThinPrep versus conventional Papanicolaou tests

Namrata Setia — Fri,31 Dec 2010

Namrata Setia, Robert A Goulart, Gladywn Leiman, Christopher N Otis, Rukmini Modem, Liron Pantanowitz

CytoJournal 2010 7(1):25-25

Background: Primary cervicovaginal melanoma is a rare malignancy associated with a high risk of recurrence. Prior studies discussing the cytomorphology of cervicovaginal melanoma have been based primarily on review of conventional Papanicolaou (Pap) smears. The aim of this study was to evaluate cervicovaginal melanomas identified in liquid-based Pap tests, in comparison with features seen on conventional Pap smear preparation. Materials and Methods: Cases of cervicovaginal melanoma identified on Pap tests with concurrent or subsequent histopathologic confirmation were collected from the Baystate Medical Center cytopathology files and personal archives of the authors over a total period of 34 years. All cytopathology (n = 6) and the available histology slides (n = 5) were reviewed. Cases were analyzed regarding clinical, histopathologic and cytomorphological findings. Results: A total of six cases with invasive cervicovaginal melanoma diagnosed on Pap tests were identified. Most patients were postmenopausal with contact bleeding, correlating with surface ulceration (identified in biopsy/excision material in 5/5 cases). Most cases had deeply invasive tumors (5/5: modified Breslow's thickness > 5 mm and Chung's level of invasion IV/V). Pap tests included four ThinPrep and two conventional smears. Overall, ThinPrep Pap tests exhibited a higher ratio of tumor cells to background squamous cells. While all Pap tests were bloodstained, tumor diathesis was prominent only within conventional smears. Melanoma cells were present both as clusters and scattered single cells in each Pap test type. Both the preparations contained epithelioid tumor cells, whereas spindled tumor cells were seen in only two ThinPrep cases. Prominent nucleoli and binucleation of tumor cells were seen in both the preparations. Melanin pigment was identified in only ThinPrep (3/4) cases and nuclear pseudo-inclusions in one conventional Pap smear. Cell blocks were made in three ThinPrep cases and immunocytochemistry (S-100, HMB45, Melan-A) performed on additional vial material (one ThinPrep slide and one cell block) was immunoreactive in melanoma cells. Conclusion: Primary cervicovaginal melanoma, a rare malignancy seen predominantly in postmenopausal women, may be successfully diagnosed in either ThinPrep Pap tests or conventional Pap smears. While ThinPrep Pap tests did not demonstrate morphological advantage over conventional smears, liquid-based cytology specimens did provide additional material for cellblock preparation and immunocytochemical evaluation in a subset of cases.

Liquid based material from fine needle aspirates from breast carcinomas offers the possibility of long-time storage without significant loss of immunoreactivity of estrogen and progesterone receptors

Torill Sauer — Fri,31 Dec 2010

Torill Sauer, Kristin Ebeltoft, Mette Kristin Pedersen, Rolf Kåresen

CytoJournal 2010 7(1):24-24

Background: Estrogen receptor (ER) status and progesterone receptor (PgR) status are strong prognostic and predictive markers in breast carcinomas. Steroid receptors are fragile and optimal handling of both cytological and histological material, including fixation, is crucial. Liquid based material offers the possibility to prepare a number of slides from one lesion and is increasingly being used for immunocytochemistry. It also offers the possibility to prepare several smears and to store these at different temperatures as well as storing residual material in the liquid. Materials and Methods: The samples consisted of fine needle aspirate material from 53 breast carcinomas. Direct smears and liquid based preparations were used in parallel for immunocytochemical detection of ER and PgR receptor status. Slides from liquid suspensions were stored at -20°C and -74°C for 3 and 6 months, respectively. Direct smears were fixed primarily in 4% formalin. Liquid based specimens were post-fixed in 4% formalin. All specimens were subjected to microwave-stimulated epitope retrieval. Antibody concentrations were ER 1:150 and PgR 1:200 for both preparation methods. The immunostaining program was identical for both the methods. Results : Liquid based specimens had a statistically non-significant higher percentage of positive cases compared to direct smears. Specimens prepared from liquid suspensions and stored at -20°C and -74°C for 3 and 6 months, respectively, showed a virtually unchanged ER and PgR reactivity (P = 0.002). Conclusions : Liquid suspensions and liquid based slide preparations seem to offer an optimal pre-fixation and preservation of ER/PgR in breast carcinoma cells. Post-fixation with 4% formalin followed by microwave-stimulated epitope retrieval before immunostaining is recommended. Long-time storage of liquid based specimens at -20°C or -74°C for at least 6 months without significant loss of immunoreactivity is feasible. They may be used as internal positive and negative controls.

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

Inderpreet Dhillon — Mon,18 Oct 2010

Inderpreet Dhillon, Martha B Pitman, Richard M DeMay, Pamela Archuletta, Vinod B Shidham

CytoJournal 2010 7(1):23-23

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

Adequate reimbursement is crucial to support cost-effective rapid on-site cytopathology evaluations

Mousa A Al-Abbadi — Mon,18 Oct 2010

Mousa A Al-Abbadi, Leonard I Bloom, Lisa A Fatheree, Lori A Haack, Gerald Minkowitz, David C Wilbur, Marshall R Austin

CytoJournal 2010 7(1):22-22

Determination of HER-2 status on FNAC material from breast carcinomas using in situ hybridization with dual chromogen visualization with silver enhancement (dual SISH)

Elsa Beraki — Mon,11 Oct 2010

Elsa Beraki, Torill Sauer

CytoJournal 2010 7(1):21-21

During the last years, HER-2 status kits and protocols for chromogen visualization of hybridization signals have come on the market. The first generation using chromogen visualization used single color probes. The second generation, now emerging on the market, uses dual chromogen visualization. The aim of this study has been to test a new dual color chromogen kit (Ventana INFORM HER2 Dual Colour ISH Roche ® ) and compare the results with our in-house method(s). The material consisted primarily of cytological material from invasive breast carcinomas in 49 women. Dual SISH was done on all 49 cytological and histological specimens. The histological specimens were treated according to the manufacturer's recommendations. The procedure was modified in several steps in order to adapt it to the cytological material. Hybridization failed in two cytological specimens. Dual SISH showed concordant results on cytological and histological material as to amplified/not amplified. The included cases had the same HER-2 expression in the invasive and the in situ components on histology. Four IDC showed HER-2 amplification (8.5%). Polysomy was found in two cases. All dual SISH results except for one concurred with the results of the in-house method(s) (1/47=2.1%). The dual SISH is suitable for cytological examination of HER-2 status. The protocol must be optimized for cytological material.

The spectrum of coincident entities with small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) diagnosed by cytology

Hannah A Kastenbaum — Mon,11 Oct 2010

Hannah A Kastenbaum, Walid E Khalbuss, Raymond E Felgar, Ronald Stoller, Sara E Monaco

CytoJournal 2010 7(1):20-20

Background: The cytologic diagnosis of Small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) often relies on finding a small lymphoid population with the characteristic immunoprofile by ancillary testing. There are only a few reports of other processes identified with SLL/CLL. The aim of this study was to review the fine needle aspiration (FNA) and touch prep (TP) diagnoses of SLL/CLL in order to identify any coincident entities. Materials and Methods: We retrospectively reviewed all FNA and TP cytology cases between January 2005 and May 2009 with a diagnosis of SLL/CLL to determine the presence of any coincident process. Results: We identified 29 cases, including 23 FNAs and six TPs, from 23 patients. Ancillary studies were utilized in 97% of the cases, including flow cytometry (FC, 79%), immunohistochemistry (IHC, 55%), fluorescent in situ hybridization studies (24%) and special stains (7%). Coincident entities were identified in nine cases (31%) and included seven (28%) neoplastic entities (Hodgkin lymphoma [HL], adenocarcinoma, squamous cell carcinoma, seminoma) and two (7%) non-neoplastic entities (infection and immunoglobulin containing cells). Six cases (21%) suspicious for large cell transformation were also identified. Conclusion: In our review of SLL/CLL, coincident entities were present in 31% of the cases and included a spectrum of non-neoplastic and neoplastic processes. FC was the most frequently utilized ancillary test, but IHC provided important information by excluding a mantle cell lymphoma or confirming a coincident process. Thus, cytomorphologic evaluation in these patients is important due to the high risk of a coincident process that may not be apparent by FC alone and may require clinical management.

Eosinophilic ascites due to severe eosinophilic ileitis

Namrata Setia — Fri,17 Sep 2010

Namrata Setia, Peter Ghobrial, Liron Pantanowitz

CytoJournal 2010 7(1):19-19

Background: There is a broad etiology for effusion eosinophilia that includes allergic, reactive, infectious, immune, neoplastic, and idiopathic causes. We report and describe the cytomorphologic findings of a rare case of eosinophilic ascites due to severe eosinophilic ileitis. Case Presentation: A 17-year-old male manifested acutely with eosinophilic ascites due to severe biopsy-proven subserosal eosinophilic ileitis. Isolated peritoneal fluid submitted for cytologic evaluation revealed that 65% eosinophils were present in a bloody background. The patient responded to corticosteroids, with complete resolution of his ascites. Conclusion: Eosinophilic gastroenteritis with subserosal involvement should be added to the list of causes for eosinophils in peritoneal fluid. The finding of eosinophilic ascites, with appropriate clinical and laboratory findings, may warrant the need to perform laparoscopic intestinal biopsies to confirm the diagnosis.

Fine needle aspiration biopsy of an osteoclast-rich undifferentiated urothelial carcinoma: A cytology case report and review of the literature

Chetna N Purohit — Fri,17 Sep 2010

Chetna N Purohit, Marilyn M Bui, Ardeshir Hakam

CytoJournal 2010 7(1):18-18

Osteoclast-rich undifferentiated carcinoma of urinary bladder (ORUCUB) is a very rare and an unusual variant of high-grade urothelial carcinoma. Here, we report an extraordinary case of metastatic ORUCUB, diagnosed by fine needle aspiration (FNA) biopsy, in a 74-year-old Hispanic male who presented with a palpable, tender left groin mass and a known previous history of high-grade carcinoma of urinary bladder and prostatic cancer. To the best of our knowledge, diagnosis of ORUCUB by FNA is the first case report in FNA cytology to be published to date. A review of the literature is emphasized on the cytological, histological and immunohistochemical features and differential diagnoses of giant cell tumor.

Pleomorphic adenoma: A diagnostic pitfall in the diagnosis of salivary gland lesions on FNAC: Case reports with review of the literature

Renuka Gahine — Fri,17 Sep 2010

Renuka Gahine, Vijaya Sudarshan, Nighat Hussain, Chandani Krishnani

CytoJournal 2010 7(1):17-17

Fine needle aspiration cytology (FNAC) is commonly being used with increasing frequency for the pre-operative evaluation of salivary gland lesions. However, it has areas of considerable interpretational difficulties. The most frequent problems involve variations in the expected cytology of pleomorphic adenoma (PA). Salivary gland FNACs performed at Pt. JNM Medical College, Raipur, Chhattisgarh, during July 2006 to June 2007 were reviewed, and we report four cases of interesting diagnostic dilemma. As PA is the most common salivary gland neoplasm, it should always be considered and ruled out as the first differential in the diagnosis of salivary gland FNACs. In order to avoid diagnostic pitfalls, we emphasize a diagnostic approach based on the mandatory presence of all three elements of PA, i.e. 3-dimensional cohesive clusters of ductal cells, background of singly lying plasmacytoid myoepithelial cells and dense fibrillary brightly metachromatic stroma with partially obscured entrapped myoepithelial cells. To document the same, we advocate liberal use of repeat aspirations with multiple sampling performed from different parts of the tumor. Some differential diagnostic problems, e.g. carcinoma ex PA, may still however remain insolvable by cytologic means.

Colposcopic evaluation of cervix with persistent inflammatory Pap smear: A prospective analytical study

Papa Dasari — Thu,5 Aug 2010

Papa Dasari, S Rajathi, Surendra V Kumar

CytoJournal 2010 7(1):16-16

Background: Inflammatory Pap smear is the most common report received by a gynecologist. The cervical screening algorithm for benign cellular changes on the Pap smear recommends treatment of infection if indicated and a repeat Pap smear in 4 to 6 months time. If the inflammatory changes still persist, subject the patient to colposcopy. However, in practice, this is not followed, especially in developing countries like ours where proper screening protocols are not available. Hence, a good number of patients in the premalignant stage are being missed. This study was undertaken to evaluate patients with persistent inflammatory Pap smears without atypia using colposcopy. Methods: A prospective analytical study of 150 gynecologial patients with persistent inflammatory Pap smear between 2006 and 2008 in an out-patient setting. All of them were subjected to colposcopy and biopsy from the abnormal areas. The incidence of cervical intraepithelial neoplasia (CIN)/invasive carcinoma was calculated by proportions/percentages. Results: The incidence of invasive carcinoma was <1%. But, the incidence of pre-malignant lesions (CIN) was high (20.9%). CIN 2/3 and carcinoma in situ were present in 6.9% of the cases. Conclusions: Patients with persistent inflammatory Pap smears can harbour a high proportion of CIN and hence these patients will need further evaluation.

Evaluation of atypical squamous cells on conventional cytology smears: An experience from a screening program practiced in limited resource settings

Bharat Rekhi — Thu,5 Aug 2010

Bharat Rekhi, Dulhan Ajit, Santhosh K Joseph, Sonali Gawas, Kedar K Deodhar

CytoJournal 2010 7(1):15-15

Background: The Bethesda system (TBS) 2001 has subdivided the category of atypical squamous cells (ASC) into: ASC-US (undetermined significance) and ASC-H (cannot exclude high-grade squamous intraepithelial lesion (HSIL)). The present study is an analysis of ASC-US and ASC-H cases diagnosed in a screening program practiced in limited resource settings. Methods: During the period January 2005 to December 2008, a total of 9190 smears were received, of which 568 were unsatisfactory. Cases initially diagnosed as ASC-US (n=74) and ASC-H (n=29) on conventional cytology smears were reviewed. Biopsy and human papilloma virus (HPV) results were available in limited cases. Results: On review, diagnosis of ASC-US was retained in 49 (66.2%) of the 74 initially diagnosed ASC-US cases. Remaining 12 cases were re-labeled as negative for intraepithelial lesion or malignancy (NILM), nine as low-grade squamous intraepithelial lesion (LSIL), three as ASC-H and one case as squamous carcinoma (SCC). Similarly, on review, diagnosis of ASC-H cases was retained in 17 of the 29 initially diagnosed ASC-H cases. Seven cases were re-labeled as NILM, three as HSIL and one case each as ASC-US and SCC. Overall, 8622 cases (96.6%) were diagnosed as NILM, 72 (0.83%) as LSIL, 121 (1.40%) as HSIL, 23 (0.26%) as SCC, 50 (0.57%) as ASC-US cases, 20 (0.23%) as ASC-H, five (0.05%) as atypical glandular cells (AGC) and two cases as adenocarcinomas. Out of 50 ASC-US cases, biopsy in 23 cases showed presence of CIN 1 in 16 cases (69.5%) and CIN 2 in one case (4.34%), while the remaining six cases were negative for CIN/malignancy. The remaining 20 cases with unavailable biopsy results were HPV-positive. Out of 20 ASC-H cases, biopsy in 15 revealed CIN 2 and above in 11 cases (73.3%). Three cases (20%) revealed CIN 1. Conclusions: Critical review is helpful in further reducing the number of ASC cases. The percentage of cases with CIN 2 and above is higher with ASC-H cases. The reason for relative increase in HSILs in the present study included referral bias in the screening program.

Pituitary carcinoma diagnosed on fine needle aspiration: Report of a case and review of pathogenesis

Tatiana V Yakoushina — Thu,5 Aug 2010

Tatiana V Yakoushina, Ehud Lavi, RS Hoda

CytoJournal 2010 7(1):14-14

Pituitary carcinoma (PC) is a very rare entity (0.2% of all pituitary tumors), with only about 140 cases reported in English literature. There are no reliable histological, immunohistochemical or ultrastructural features distinguishing pituitary adenoma (PA) from PC. By definition, a diagnosis of PC is made after a patient with PA develops non-contiguous central nervous system (CNS) or systemic metastases. To date, only three cases of PC have been reportedly diagnosed on fine needle aspiration (FNA). Two of the reported cases were diagnosed on FNA of the cervical lymph nodes and one on FNA of the vertebral bone lesion. Herein, we present a case of PC, diagnosed on FNA of the liver lesion. In this case, we describe cytologic features of PC and compare them to histologic features of the tumor in the pituitary. Clinical behavior of tumor, pathogenesis of metastasis and immunochemical and prognostic markers will also be described.

Case study documenting the diagnosis of idiopathic CD4+ Lymphocytopenia in a patient with atypical fungal infection (disseminated blastomycosis) by FNA of adrenal mass

Richard H Siderits — Thu,5 Aug 2010

Richard H Siderits, Osman Ouattara, Alan Marcus, Hong Guang Gao, Hong Bing Deng, Janusz Godyn

CytoJournal 2010 7(1):13-13

Idiopathic CD4+ lymphocytopenia, described in 1992 by the Centers for Disease Control, is characterized by persistent CD4+ lymphocytopenia (less than 300 cells per micro-liter) in nonimmunosuppressed, HIV negative individuals, who present with atypical infections. This rare though likely undiagnosed entity is associated with chronic disseminated forms of either fungal or bacterial infections in otherwise healthy adults. We report a case of a 59-year-old male with ring-enhancing brain lesions, bilateral adrenal masses, lung and vocal cord nodules, where the diagnosis of exclusion was metastatic malignancy. Fine needle aspiration (FNA) of the adrenal mass and a subsequent vocal cord biopsy confirmed chronic widely disseminated blastomycosis. Flow cytometric evaluation of peripheral blood documented persistent selective CD4+ lymphocytopenia with T8 (suppressor) T-Lymphocyte count within normal range. We believe that idiopathic CD4+ lymphocytopenia is an important etiologic factor to be considered for patients who present with mass lesions and are diagnosed by FNA with atypical fungal infections. We relate the diagnostic criteria for idiopathic CD4+ lymphocytopenia and the importance of providing on-site triage for FNA samples for fungal studies and correlation for flow cytometry.

Fine needle aspiration diagnosis of Rosai-Dorfman Disease in an osteolytic lesion of bone

Shaoying Li — Fri,2 Jul 2010

Shaoying Li, Zhijie Yan, Nirag Jhala, Darshana Jhala

CytoJournal 2010 7(1):12-12

Sinus histiocytosis with massive lymphadenopathy (SHML) or Rosai-Dorfman disease (RDD) is an uncommon but well-defined benign self-limited clinicopathological entity. It mainly involves lymph nodes. Extranodal involvement is seen in up to 43% of cases, with the most common location in the head and neck region. Primary RDD occurring in the bone is rare with only twelve cases reported in the literature to date, all diagnosed on histology except one by fine needle aspiration (FNA) cytology. We report a case of RDD diagnosed by FNA cytology in a 28 year-old female presented as an osteolytic lesion of superior pubic ramus where the differential diagnosis included a sarcoma and lymphoma. Based on the cytologic findings, a diagnosis of a RDD was considered during the rapid FNA on site with no clinical history provided. The diagnosis of RDD was further confirmed by immunohistochemical stains and histology diagnosis. Our findings show that even in the absence of a clinical history, FNA is a less invasive and a very reliable tool for the diagnosis of SHML (RDD).

APTIMA assay on SurePath liquid-based cervical samples compared to endocervical swab samples facilitated by a real time database

Samer N. Khader — Fri,2 Jul 2010

Samer N. Khader, Kathie Schlesinger, Josh Grossman, Richard I Henry, Mark Suhrland, Amy S Fox

CytoJournal 2010 7(1):11-11

Background: Liquid-based cytology (LBC) cervical samples are increasingly being used to test for pathogens, including: HPV, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) using nucleic acid amplification tests. Several reports have shown the accuracy of such testing on ThinPrep (TP) LBC samples. Fewer studies have evaluated SurePath (SP) LBC samples, which utilize a different specimen preservative. This study was undertaken to assess the performance of the Aptima Combo 2 Assay (AC2) for CT and GC on SP versus endocervical swab samples in our laboratory. Materials and Methods: The live pathology database of Montefiore Medical Center was searched for patients with AC2 endocervical swab specimens and SP Paps taken the same day. SP samples from CT- and/or GC-positive endocervical swab patients and randomly selected negative patients were studied. In each case, 1.5 ml of the residual SP vial sample, which was in SP preservative and stored at room temperature, was transferred within seven days of collection to APTIMA specimen transfer tubes without any sample or patient identifiers. Blind testing with the AC2 assay was performed on the Tigris DTS System (Gen-probe, San Diego, CA). Finalized SP results were compared with the previously reported endocervical swab results for the entire group and separately for patients 25 years and younger and patients over 25 years. Results: SP specimens from 300 patients were tested. This included 181 swab CT-positive, 12 swab GC-positive, 7 CT and GC positive and 100 randomly selected swab CT and GC negative patients. Using the endocervical swab results as the patient's infection status, AC2 assay of the SP samples showed: CT sensitivity 89.3%, CT specificity 100.0%; GC sensitivity and specificity 100.0%. CT sensitivity for patients 25 years or younger was 93.1%, versus 80.7% for patients over 25 years, a statistically significant difference (P = 0.02). Conclusions: Our results show that AC2 assay of 1.5 ml SP samples transferred to APTIMA specimen transfer medium within seven days is sufficiently sensitive and specific to be used to screen for CT and GC. CT sensitivity may be somewhat reduced in samples from patients over 25 years. SP specimens retained in the original SP fixative for longer time intervals also may have decreased sensitivity, due to deterioration of RNA, but this was not assessed in this study. The ability to tap the live pathology database is a valuable tool that can useful to conduct clinical studies without a costly prospective clinical trial.

Fine-needle aspiration cytology of extra mammary metastatic lesions in the breast: A retrospective study of 36 cases diagnosed during 18 years

Torill Sauer — Fri,2 Jul 2010

Torill Sauer

CytoJournal 2010 7(1):10-10

Background: Metastatic tumors in the breast require treatment according to origin and type of tumor. It is important to recognize these lesions in fine-needle aspiration cytology (FNAC) in order to avoid unnecessary mastectomy or non-relevant chemotherapy. The aim of this study was to evaluate the cytological features of metastatic tumors and possible criteria that could alert us as to the possibility of a metastasis from an extra mammary malignancy. Methods: The material included 36 confirmed or suspected metastases in the breast registered in the pathology files at Oslo University Hospital, Ulleval, during 1990-2007. There were a total of 6,325 cases of malignant breast FNAC, representing 30 men and 6,295 women. Smears were evaluated for the amount of material, presence or absence of myoepithelial cells, microcalcifications, mitoses and necrotic material. All carcinomas were graded. Results: There were seven men (7/30 = 23.3%) and 29 women (29/6,295 = 0.46%). The primary tumor was known in 22 cases (22/36 = 61.1%). No other primary tumor was known and metastatic lesion was not initially suspected in 14 cases (14/36 = 38.9%). The most common origin was lung (15/36 = 41.7%). In five cases (5/36 = 13.9%), the origin remained uncertain. Conclusions: Metastases from extra mammary sites are (relatively) common in males (23.3%). In women, metastatic lesions are rare (0.46%). A large proportion of them (88%) are high-grade adenocarcinomas and poorly differentiated carcinomas that may resemble grade 3 ductal carcinomas. Unusual clinical and/or radiological presentation in combination with high-grade malignant cells should alert us to consider the possibility of a metastasis.

Diagnostic difficulties and pitfalls in rapid on-site evaluation of endobronchial ultrasound guided fine needle aspiration

Sara E Monaco — Mon,14 Jun 2010

Sara E Monaco, Matthew J Schuchert, Walid E Khalbuss

CytoJournal 2010 7(1):9-9

Background: One of the novel techniques utilizing fine needle aspiration (FNA) in the diagnosis of mediastinal and lung lesions is the endobronchial ultrasound (EBUS)-guided FNA. In this study, we describe five cases which had a discrepancy between on-site evaluation and final diagnosis, or a diagnostic dilemma when rendering the preliminary diagnosis, in order to illustrate some of the diagnostic difficulties and pitfalls that can occur in EBUS FNA. Methods: A total of five EBUS FNA cases from five patients were identified in our records with a discrepancy between the rapid on-site evaluation (ROSE) and final diagnosis, or that addressed a diagnostic dilemma. All of the cases had histological confirmation or follow-up. The cytomorphology in the direct smears, cell block, and immunohistochemical stains were reviewed, along with the clinical history and other available information. Results: Two cases were identified with a nondefinitive diagnosis at ROSE that were later diagnosed as malignant (metastatic signet-ring cell adenocarcinoma and metastatic renal cell carcinoma (RCC)) on the final cytological diagnosis. Three additional cases were identified with a ROSE and final diagnosis of malignant (large cell neuroendocrine carcinoma (LCNEC) and two squamous cell carcinomas), but raised important diagnostic dilemmas. These cases highlight the importance of recognizing discohesive malignant cells and bland neoplasms on EBUS FNA, which may lead to a negative or a nondefinitive preliminary diagnosis. Neuroendocrine tumors can also be difficult due to the wide range of entities in the differential diagnosis, including benign lymphocytes, lymphomas, small and nonsmall cell carcinomas, and the lack of immunohistochemical stains at the time of ROSE. Finally, the background material in EBUS FNAs may be misleading and unrelated to the cells of interest. Conclusions: This study illustrates the cytomorphology of five EBUS FNA cases that address some of the diagnostic challenges witnessed while examining these specimens during ROSE. Many of the difficulties faced can be attributed to the baseline cellularity of the aspirates, the bronchial contamination, the difficulty identifying neoplasms with bland cytology, the wide spectrum of diseases that can occur in the mediastinum with overlapping cytomorphologic features, the mismatch between the background material and the cell populations present, and the overall unfamiliarity with these types of specimens.

Atypical squamous cells, cannot exclude high grade squamous intraepithelial (ASC-H) in HIV-positive women

Pam Michelow — Sat,12 Jun 2010

Pam Michelow, Ingrid Hartman, Doreen Schulze, Stella Lamla-Hillie, Sophie Williams, Simon Levin, Cynthia Firnhaber

CytoJournal 2010 7(1):8-8

Objective: South Africa has very high rates of both HIV infection and cervical pathology. The management of ASC-H is colposcopy and directed biopsy, but with so many women diagnosed with HSIL and a dearth of colposcopy centres in South Africa, women with cytologic diagnosis of ASC-H may not be prioritized for colposcopy. The aim of this study was to determine if HIV-positive women with a cytologic diagnosis of ASC-H should undergo immediate colposcopy or whether colposcopy can be delayed, within the context of an underfunded health care setting with so many competing health needs. Materials and Methods: A computer database search was performed from the archives of an NGO-administered clinic that offers comprehensive HIV care. All women with a cytologic diagnosis of ASC-H on cervical smears from September 2005 until August 2009 were identified. Histologic follow up was sought in all patients. Results: A total of 2111 cervical smears were performed and 41 diagnosed as ASC-H (1.94%). No histologic follow up data was available in 15 cases. Follow up histologic results were as follows: three negative (11.5%), five koilocytosis and/ or CIN1 (19.2%), ten CIN2 (38.5%) and eight CIN3 (30.8%). There were no cases of invasive carcinoma on follow up. Conclusion: The current appropriate management of HIV-positive women in low-resource settings with a diagnosis of ASC-H on cervical smear is colposcopy, despite the costs involved. In the future and if cost-effective in developing nations, use of novel markers may help select which HIV-positive women can be managed conservatively and which ones referred for more active treatment. More research in this regard is warranted.

Clinical history of HIV infection may be misleading in cytopathology

Liron Pantanowitz — Sat,12 Jun 2010

Liron Pantanowitz, Michael Kuperman, Robert A Goulart

CytoJournal 2010 7(1):7-7

Human immunodeficiency virus (HIV)-infected patients are at an increased risk for developing opportunistic infections, reactive conditions and neoplasms. As a result, a broad range of conditions are frequently included in the differential diagnosis of HIV-related lesions. The clinical history of HIV infection may, however, be misleading in some cases. Illustrative cases are presented in which knowledge of a patient's HIV status proved to be misleading and increased the degree of complexity of the cytologic evaluation. Case 1 involved the fine needle aspiration (FNA) of a painful 3 cm unilateral neck mass in a 38-year-old female with generalized lymphadenopathy. Her aspirate revealed a spindle cell proliferation devoid of mycobacteria that was immunoreactive for S-100 and macrophage markers (KP-1, PGM1). Multiple noncontributory repeat procedures were performed until a final excision revealed a schwannoma. Case 2 was a CT-guided FNA of a positron emission tomography positive lung mass in a 53-year-old man. The acellular aspirate in this case contained structures resembling fungal spore forms that were negative for mucicarmine and GMS stains, as well as cryptococcal antigen immunocytochemistry. A Von Kossa stain confirmed that these pseudo-fungal structures were calcified debris. Follow up revealed multiple calcified lung and hilar node based granulomata. Case 3 involved the cytologic evaluation of pleural fluid from a 47-year-old man with Kaposi sarcoma and recurrent chylous pleural effusions. Large atypical cells identified in his effusion were concerning for primary effusion lymphoma. Subsequent pleural biopsy revealed extramedullary hematopoiesis, documenting these atypical cells as megakaryocytes. These cases demonstrate that knowledge of a patient's HIV status can be misleading in the evaluation of cytology specimens, with potential for misdiagnosis and/or multiple procedures. To avoid this pitfall in the setting of HIV infection, common entities unrelated to HIV infection and artifacts should always be included in the differential diagnosis.

Progression from on-site to point-of-care fine needle aspiration service: Opportunities and challenges

Prabodh K Gupta — Wed,12 May 2010

Prabodh K Gupta

CytoJournal 2010 7(1):6-6

Background: Standard-of-care requires the availability of an efficient, economical and accurate on-site fine needle aspiration (FNA) service. Presence of a trained individual during the procedure ensures an improved patient care. Appropriate selection of the equipment, interaction with the clinicians and compliance with the various regulations during the procedure is essential. This is often done by an on-site FNA service. Organization and implementation of such a system in a large academic center is challenging. Method: we reviewed the ambulatory care needs in the new Perelman Center for Advanced Medicine (PeCAM). Multiple (9) FNA sites have been established keeping in view the patient's convenience, clinic demands, various regulatory requirements and laboratory staff. Each location has dedicated FNA station with microscopes and supplies. In addition, state- ofthe -art technologies including a mobile FNA cart (Penn-A- Cart), remote specimen evaluation (TeleCyP) have been incorporated. Results: The new set up is extremely efficient and much valued by the patients and the clinicians. It has improved patient care. Conclusion: With necessary investments and resources a point-of-care FNA service has been created which has improved patient care. This, albeit with certain modifications may serve as a model for FNA service.

Fine needle aspiration biopsy diagnosis of dedifferentiated liposarcoma: Cytomorphology and MDM2 amplification by FISH

Hatem Q Al-Maghraby — Tue,6 Apr 2010

Hatem Q Al-Maghraby, Walid E Khalbuss, Uma N.M Rao, Kathleen Cieply, Sanja Dacic, Sara E Monaco

CytoJournal 2010 7(1):5-5

Lipomatous mesenchymal tumors constitute the most common type of soft tissue tumors. Well-differentiated liposarcoma (WDLS) can undergo dedifferentiation to a nonlipogenic sarcoma of variable histologic grade. In the recent literature, amplification of the murine double minute 2 (MDM2) oncogene, which has a role in cell cycle control, has been successful in distinguishing WDLS from benign lesions. We present a case of dedifferentiated liposarcoma diagnosed by fine-needle aspiration (FNA), using cytomorphology and ancillary studies (immunocytochemistry and fluorescent in-situ hybridization). An 85-year old female presented to our institution with a firm soft tissue mass of the right buttock. The FNA showed atypical spindle cells, osteoclast-like giant cells and extracellular dense matrix material. The cell block showed cellular groups of highly atypical spindle cells with osteoid and adipose tissue. Fluorescence in situ hybridization (FISH) studies performed on the cell block demonstrated amplification of the MDM2 gene. In addition, the findings were morphologically compatible with the previously resected retroperitoneal dedifferentiated liposarcoma with areas of osteosarcoma. This rare case illustrates the usefulness of FNA and ancillary studies in the diagnosis and subclassification of soft tissue tumors. To the best of our knowledge, this is the first report of MDM2 FISH positivity in a liposarcoma diagnosed by FNA.

Cytomorphologic consideration in malignant ascites with renal cell carcinoma: A report of two cases

Ruchika Gupta — Tue,6 Apr 2010

Ruchika Gupta, Sandeep R Mathur, Venkateswaran K Iyer, Sudheer A Kumar, Amlesh Seth

CytoJournal 2010 7(1):4-4

Effusions, especially peritoneal, are seen in less than 2% of patients with renal cell carcinoma (RCC). Since the tumor cells in RCC are bland and nondescript, the involvement of serous effusions is difficult to diagnose. An accurate recognition of malignant effusion and differentiation from reactive mesothelial cells is imperative. A 55-year-old male presented with gradually progressive ascites. Cytospin preparations from ascitic fluid showed reactive mesothelial cells admixed with few smooth-contoured clusters of cells with moderate cytoplasm, vesicular nuclei with prominent nucleolus. He had undergone nephrectomy for papillary RCC two years earlier. Another 36-year-old man underwent left nephrectomy for suspected RCC. Intra-operative ascitic fluid was sent for cytologic examination and showed numerous reactive mesothelial cells along with few clusters of cells with scant to moderate amount of cytoplasm, vesicular nucleus and a small nucleolus. Considering the histomorphology of the primary renal tumor in both cases, a cytologic diagnosis of malignant peritoneal effusion, morphologically compatible with RCC was rendered. RCC, due to its bland cytologic features, is easily overlooked in effusions. In a known patient, the cytopathologist must be extra vigilant to pick up the few cell clusters present in the fluid preparations and differentiate them from reactive mesothelial cells. A close inspection of the cytologic features and comparison with the histopathology of the primary tumor helps in making an accurate diagnosis.

Integrating a FISH imaging system into the cytology laboratory

G Denice Smith — Tue,6 Apr 2010

G Denice Smith, Matt Riding, Kim Oswald, Joel S Bentz

CytoJournal 2010 7(1):3-3

We have implemented an interactive imaging system for the interpretation of UroVysion fluorescence in situ hybridization (FISH) to improve throughput, productivity, quality control and diagnostic accuracy. We describe the Duet imaging system, our experiences with implementation, and outline the financial investment, space requirements, information technology needs, validation, and training of cytotechnologists needed to integrate such a system into a cytology laboratory. Before purchasing the imaging system, we evaluated and validated the instrument at our facility. Implementation required slide preparation changes, IT modifications, development of training programs, and revision of job descriptions for cytotechnologists. A darkened room was built to house the automated scanning station and microscope, as well as two imaging stations. IT changes included generation of storage for archival images on the LAN, addition of external hard drives for back-up, and changes to cable connections for communication between remote locations. Training programs for cytotechnologists, and pathologists/fellows/residents were developed, and cytotechnologists were integrated into multiple steps of the process. The imaging system has resulted in increased productivity for pathologists, concomitant with an expanded role of cytotechnologists in multiple critical steps, including FISH, scan setup, reclassification, and initial interpretation.

A Shandon PapSpin liquid-based gynecological test: A split-sample and direct-to-vial test with histology follow-up study

J Rimiene — Sat,20 Mar 2010

J Rimiene, J Petronyte, Z Gudleviciene, Giedre Smailyte, Ingrida Krasauskaite, A Laurinavicius

CytoJournal 2010 7(1):2-2

Background: Studies for liquid-based Papanicolaou (Pap) tests reveal that liquid-based cytology (LBC) is a safe and effective alternative to the conventional Pap smear. Although there is research on ThinPrep and SurePath systems, information is lacking to evaluate the efficiency and effectiveness of systems based on cytocentrifugation. This study is designed to determine the sensitivity and specificity of the Shandon PapSpin (ThermoShandon, Pittsburgh, Pennsylvania, USA) liquid-based gynecological system. We used split-sample and direct-to-vial study design. Materials and Methods: 2,945 women referred to prophylactic check-up were enrolled in this study. Split sample design was used in 1,500 women and residual cervical cytology specimen from all these cases was placed in fluid for PapSpin preparation after performing conventional smear. The direct-to-vial study was carried out in another cohort of 1,445 women in whom the entire cervical material was investigated using only the PapSpin technique. Follow up histological diagnoses for 141 women were obtained from both study arms following 189 abnormal cytology cases. 80 LBC cases from the split sample group and 61 LBC cases in the direct-to-vial group were correlated with the histology results. The sensitivity and secificity of the conventional smear and PapSpin tests in both study arms were compared. Results: In the split sample group, conventional smears showed a higher proportion of ASC-US (atypical cells undetermined significance): 31 (2.1%) vs 10 (0.7%) in PapSpin (P = 0.001). A higher proportion of unsatisfactory samples was found in the conventional smear group: 25 (1.7%) vs 6 (0.4%) cases (P = 0.001). In the split sample group, the sensitivity of the conventional and PapSpin tests was 68.7% vs 78.1%, and the specificity 93.8% vs 91.8%, respectively. In the direct to vial group PapSpin sensitivity was 75.9% and specificity 96.5%. The differences in sensitivity and specificity were not significant. The positive predictive values for the conventional and PapSpin methods were not different in the split sample group: 88.0% vs 86.2% and 95.7% in the direct-to-vial group. Also, no differences were found for negative predictive value (82.1, 86.8% and 80.0% respectively). Conclusions: PapSpin showed good qualitative results in both study arms, even after the material splitting in the first study arm, and is a good alternative to the conventional Pap smear. Additionally, the PapSpin method offers several advantages such as the opportunity to prepare duplicate slides, option for HPV DNA testing and cell block preparations from residual material. Microscopic evaluation of thinner cell preparations is less time consuming than the conventional Pap smears.

Two-color immunocytochemistry for evaluation of effusion fluids for metastatic adenocarcinoma

Vinod B Shidham — Wed,10 Feb 2010

Vinod B Shidham, George Varsegi, Krista D'Amore

CytoJournal 2010 7(1):1-1

Background: The evaluation of serous fluids by conventional one color immunocytochemistry is complex and challenging. Design: We selected and studied 37 serous fluid cytology specimens (23 pleural, 13 peritoneal, 1 pericardial), collected over a 4-year period. They were unequivocally positive for metastatic adenocarcinoma based on clinical correlation, cytomorphology, and one color immunocytochemistry on cell block sections. 3 µm serial sections of cell blocks were immunostained by a two chromogen method (peroxidase with brown chromogen followed by alkaline phosphatase with red chromogen). Combinations evaluated were: A- vimentin followed by cytokeratin (CK) 7; B- calretinin followed by BerEP4, C- calretinin followed by CK 20. Additionally, difficulty of interpretation was evaluated on a scale of 1(easy) to 5 (difficult). Cases demonstrating decreased or complete loss of immunoreactivity with alkaline phosphatase red chromogen system were also evaluated with routine one color immunostaining by alkaline phosphatase and peroxidase individually. The pretreatments for antigen retrieval and antibody dilutions were identical to those used for conventional one color immunostaining with respective immunomarker. Result: Combination 'A' showed correlation with the immunoreactivity pattern observed with one color immunostaining. However, the immunoreactivity of the second immunomarker was compromised in combinations B and C. In the latter group, the sections immunostained with one color alkaline phosphatase indicator system also showed weak immunoreactivity or complete loss of immunoreactivity for the corresponding second immunomarker. However, the peroxidase system showed proper immunoreactivity for those immunomarkers. Average difficulty of interpretation for the two color method was 1.06 (range- 1 to 2) as compared to 2.95 (range: 1 to 5) with the one color method. This difference was statistically significant (two-tailed P<.0001, paired t test). The higher scores of difficulty were observed in cases with a paucity of tumor cells and cases with predominance of isolated tumor cells. Conclusion: Dual immunostaining facilitated identification of the foreign population of malignant cells in effusion fluids with objective, reproducible precision. However, due to relatively lower sensitivity of alkaline phosphatase as a second indicator system, immunoreactivity was diminished for BerEP4 and lost for CK 20.

Hepatic epithelioid hemangioendothelioma: A diagnostic pitfall in aspiration cytology

Ruchika Gupta — Fri,15 Jan 2010

Ruchika Gupta, Sandeep R Mathur, S Datta Gupta, Prashant Durgapal, Venkateswaran K Iyer, Chandan Jyoti Das, Shalimar , Subrat K Acharya

CytoJournal 2009 6(1):25-25

Hepatic epithelioid hemangioendothelioma (EH) is a rare vascular neoplasm. An accurate radiologic diagnosis is usually difficult due to the presence of multiple nodules, simulating metastatic carcinoma. Though histologic features of this tumor are well described, cytologic reports of hepatic EH are very few in the available literature. We describe a case of a young healthy adult male who was found to have multiple hepatic masses on radiologic investigations. A guided fine needle aspiration demonstrated a poorly differentiated neoplasm. The diagnosis was made on core biopsy assisted by immunohistochemistry, which showed characteristic features of EH. He is doing well 14 months after diagnosis, without surgical excision or chemotherapy. An accurate diagnosis of hepatic EH on aspiration cytology requires an adequate specimen and awareness of its cytologic features, including discohesive atypical cells with intracytoplasmic lumina and intranuclear inclusions. Since this tumor is usually unresectable but has a favorable prognosis as compared to hepatocellular carcinoma, a correct diagnosis is essential for appropriate management and prognostication.

Diagnosis and typing of systemic amyloidosis: The role of abdominal fat pad fine needle aspiration biopsy

Ruba A Halloush — Fri,15 Jan 2010

Ruba A Halloush, Elena Lavrovskaya, Dina R Mody, Donna Lager, Luan Truong

CytoJournal 2009 6(1):24-24

Introduction: Systemic amyloidosis (SA) has a broad nonspecific clinical presentation. Its diagnosis depends on identifying amyloid in tissues. Abdominal fat pad fine needle aspiration (FPFNA) has been suggested as a sensitive and specific test for diagnosing SA. Materials and Methods: Thirty-nine FPFNA from 38 patients (16 women and 20 men, age range 40-88 years) during a 15-year period were reviewed. Smears and cell blocks were stained with Congo red (CR). A panel of antibodies (serum amyloid protein, serum amyloid A, albumin, transthyretin, kappa light chain and lambda light chain) was used on six cell blocks from five patients. The FNA findings were correlated with clinical and histological follow-up. Results: FPFNAs were positive, confirmed by CR in 5/39 (13%), suspicious in 1/39 (3%), negative in 28/39 (72%), and insufficient for diagnosis in 5/39 (13%) of cases. In all the positive cases, SA was confirmed within 2-16 weeks. Among the 28 negative cases, SA was diagnosed in 21, the rest were lost to follow-up. Among the insufficient cases, SA was diagnosed in four and one was lost to follow-up. Specificity was 100%, whereas sensitivity was 19%. SA typing using cell block sections was successful in three, un-interpretable in one, and negative in two cases. Conclusion: FPFNA for SA is not as good as previously reported. This may be due to different practice setting, level of experience, diagnostic technique, or absence of abdominal soft tissue involvement. A negative result of FPFNA does not exclude SA. Immune phenotyping of amyloid is possible on cell block.

Reply to: Austin et al. CytoJournal 2009;6:12 (Unfounded claims mar scientific critique)

Jose Jeronimo — Tue,17 Nov 2009

Jose Jeronimo, Mark A Barone, Silvana Luciani, Ricky Lu, Jacqueline Sherris, Julie Torod, Vivien Tsu

CytoJournal 2009 6(1):23-23

Ciliated foregut cyst of the pancreas: Preoperative diagnosis using endoscopic ultrasound guided fine needle aspiration cytology-A case report with a review of the literature

Kulwinder S Dua — Fri,9 Oct 2009

Kulwinder S Dua, Aravind S Vijayapal, Janis Kengis, Vinod B Shidham

CytoJournal 2009 6(1):22-22

A 51-year-old male presented with a 4-month history of abdominal pain, decreased appetite, and postprandial bloating. A CT scan showed a solitary, 5.3 Χ 4.4 cm, cystic lesion in the body/tail of the pancreas. Endoscopic retrograde cholangiopancreatography did not show communication between the pancreatic duct and the cystic lesion. Endoscopic ultrasound (EUS) examination revealed a 6.9 Χ 2.4 cm cystic lesion in the body/tail region of the pancreas without septae or solid components. The pancreatic parenchyma, pancreatic duct, and common bile duct were unremarkable. EUS-guided fine needle aspiration (EUS-FNA) was performed using a 22-gauge EchotipTM needle. Only a few drops of viscous fluid could be aspirated. Papanicolaou-stained direct smears and SurePath (Autocyte) preparations were evaluated. The direct smears were hypocellular; however, the concentration method producing liquid-based cytology preparation showed detached ciliary tufts (degenerated debris with ciliated cellular fragments of cell tops without nuclei) and occasional intact ciliated cells consistent with a ciliated foregut cyst. Although benign, the cyst was resected to alleviate the symptoms. The surgical pathology confirmed the benign preoperative interpretation of the ciliated foregut cyst. To the best of our knowledge, this is the ﬁrst case of pancreatic ciliated foregut cyst reported to be diagnosed preoperatively by EUS-FNA. For a proper preoperative cytologic diagnosis, the needle rinses should be processed adequately. Otherwise, these hypocellular specimens with mucin may be misinterpreted as mucinous cystic lesions.

Primary effusion lymphoma involving three body cavities

Fadi Brimo — Fri,9 Oct 2009

Fadi Brimo, Gizelle Popradi, Rene P Michel, Manon Auger

CytoJournal 2009 6(1):21-21

Primary effusion lymphoma (PEL) is a human herpes virus-8 (HHV8)-associated large-cell non-Hodgkin lymphoma localized in body cavities and presenting as pleural, peritoneal, or pericardial lymphomatous effusions. It typically affects immunocompromised patients and usually involves only one body site. We describe herein a case of PEL affecting three body cavity sites in an immunocompetent patient. A 69-year-old HIV-negative man presented with upper gastrointestinal bleeding and ascites. An examination of the fluid by cytology showed large atypical lymphocytes with abundant basophilic cytoplasm, either central or eccentric nuclei having irregular outlines, and multiple prominent nucleoli. The neoplastic cells showed positive staining for CD45, CD3, HHV8 latent nuclear antigen (LNA), and Epstein-Barr virus-encoded RNA. A diagnosis of PEL was rendered. Despite chemotherapy and valganciclovir, the disease progressed to involve the pleural and pericardial cavities and the patient died 5 months following the initial diagnosis. Although PEL is a B-cell lymphoma, it is usually of null phenotype by immunohistochemistry, and can rarely aberrantly express T-cell markers, as seen in the current case. The key to the diagnosis of PEL rests on identifying HHV8 in the neoplastic cells. Therefore, restricting the term of PEL only to those cases that are HHV8 positive is important in order to differentiate PEL from other lymphomas that can present as serous effusions and that carry, in general, a more favorable prognosis than PEL

Broom versus broom-and-brush: A comparison of surepath® liquid-based papanicolaou test (LBPT) collection devices

Min Yi Ngae — Fri,9 Oct 2009

Min Yi Ngae, Clinton D Crowder, Klint Kjeldahl, Roberto Gamez, Samantha Paulson, Daniel M McKeon, Priti Goyal, Stefan E Pambuccian

CytoJournal 2009 6(1):20-20

Surrogate indicators of sensitivity in gynecologic cytology: Can they be used to improve the measurement of sensitivity in the laboratory?

Andrew A Renshaw — Fri,9 Oct 2009

Andrew A Renshaw, Fadi Brimo, Manon Auger

CytoJournal 2009 6(1):19-19

Background: Measuring the sensitivity of screening in gynecologic cytology in real life is problematic. However, other quality measures may correlate with sensitivity, including the atypical squamous cells (ASC)/squamous intraepithelial lesion (SIL) ratio. Whether these other measures can function as "surrogate indicators" for sensitivity and improve the assessment of sensitivity in the laboratory is not known. Materials and Methods: We compared multiple quality measures with true screening sensitivity in a variety of situations. Results: The abnormal rate, ASC rate, and ASC/SIL ratio were all highly correlated (r = .83 or greater) with sensitivity when the overall laboratory sensitivity was low (85%) but became less correlated (.64 or less) or uncorrelated when the screening sensitivity was higher (88% or 95%, respectively). Sensitivity was more highly correlated with the abnormal rate than the ASC/SIL ratio at low screening sensitivity. While thresholds could be set that were highly sensitive and specific for suboptimal screening, these thresholds were often less than one standard deviation away from the mean. Conclusion: The correlation of the abnormal rate and the ASC/SIL ratio with sensitivity depends on overall sensitivity. Standards to define minimum screening sensitivity can be defined, but these standards are relatively narrow. These features may limit the utility of these quality measures as surrogates for sensitivity.

Differential expression of galectin-3, CK19, HBME1, and Ret oncoprotein in the diagnosis of thyroid neoplasms by fine needle aspiration biopsy

Husain A Saleh — Fri,18 Sep 2009

Husain A Saleh, Jining Feng, Farah Tabassum, Opada Al-Zohaili, Muji Husain, Tamara Giorgadze

CytoJournal 2009 6(1):18-18

Background: Fine needle aspiration biopsy (FNAB) is a common and excellent procedure for the evaluation of thyroid lesions that require surgical resection. At times, the FNAB diagnosis can be difficult, particularly of follicular-patterned lesions. Previous studies have shown that some immunohistochemical (IHC) markers may be helpful in establishing more accurate diagnosis. In this study, our goal was to evaluate four of the recently investigated markers in differentiating benign from malignant thyroid nodules on FNABs. Materials and Methods: We performed IHC staining of galectin-3, Ret oncoprotein (Ret), HBME-1, and cytokeratin 19 (CK19), on cell block sections of thyroid FNAB cases that had corresponding surgical resections. They included 44 benign lesions (37 hyperplastic or cellular nodules, HN; and 7 follicular adenomas, FA) and 27 malignant tumors (6 follicular carcinoma, FC; 19 classic papillary carcinoma, PTC; and 2 follicular variant of papillary carcinoma, FVPC). The stains were done according to the standard avidin-biotin-peroxidase method. Results: Statistical analysis showed that immunoexpression was significantly higher in the malignant group for all four markers. The sensitivity for positive expression for all benign lesions versus malignant tumors was as follows: 10/44 (22.7%) versus 25/27 (92.6%) for galectin-3; 14/44 (31.8%) versus 23/27 (85%) for Ret; 12/44 (27.3%) versus 24/27 (88.8%) for HBME-1; and 13/44 (29.5%) versus 23/27 (85%) for CK19. The sensitivity and specificity was highest for galectin-3 (92.6% and 77.3%, respectively) followed by HMBE-1 (88.9% and 72.7%, respectively). When combining the markers' expressions, the panel of galectin-3 + HBME-1 showed the highest sensitivity and specificity (90.7% and 75%, respectively), but this was, however, lower than galectin-3 alone (92.3% and 77.3%, respectively). Conclusion: We conclude that galectin-3 is the best single marker in differentiating benign from malignant thyroid lesions with the highest sensitivity and specificity. The galectin-3 + HBME-1 was the best combination for distinguishing benign from malignant lesions. Because they were the best two independent and combined markers, we recommend the use of the galectin-3 + HBME-1 panel to enhance the diagnostic accuracy of follicular-patterned thyroid lesions on FNABs.

Market survey predictions on the future of US Pap testing

R Marshall Austin — Fri,18 Sep 2009

R Marshall Austin, Barbara Benstein, Joel Bentz, Sandra Bigner, Gregory G Freund, Gregory La Rocco, Ibrahim Ramzy, Lynnette Savaloja, Vinod B Shidham

CytoJournal 2009 6(1):17-17

Routine review of ascites fluid from patients with cirrhosis or hepatocellular carcinoma is a low-yield procedure: An observational study

Michael J Thrall — Fri,7 Aug 2009

Michael J Thrall, Ellen J Giampoli

CytoJournal 2009 6(1):16-16

Background: Patients with cirrhosis develop ascites for physiologic reasons that are unrelated to malignant progression. However, physicians performing paracentesis in these patients, often send fluid to the cytology laboratory, sometimes specifically looking for hepatocellular carcinoma (HCC). We have investigated the diagnostic yield of these specimens. Materials and Methods: A computerized pathology database search for all ascites fluid cases submitted to the cytology laboratory at a major liver transplant center between November 2004 and April 2008 was performed. Clinical history was obtained for each case. Patients with cirrhosis, with or without HCC, were included in the study. Cytologic diagnoses were compiled and follow-up information was obtained for cases with non-negative findings. Results: A total of 167 specimens from 133 patients ranging from 29 to 85 years of age (mean 56 years) were submitted over the said time period. The causes of cirrhosis included: alcohol - 44; Hepatitis C - 30; Hepatitis B - 6; non-alcoholic steatohepatitis - 7; cryptogenic - 18; other single causes - 6; and multifactorial (alcohol and hepatitis viruses) - 22. Hepatocellular carcinoma (HCC) was present or strongly suspected in 17 patients and had been previously resected in two others. The status of fifteen patients was post liver transplant, with recurrent liver failure. Human immunodeficiency virus was present in seven patients and eight patients had a history of non hepatic malignancies. Among the specimens, 162 were negative, two had atypical lymphocytes worked up for lymphoma, and three had atypical epithelioid cells; none was positive for HCC. Immunohistochemistry demonstrated a mesothelial origin for the atypical epithelioid cells in two cases; in the third case, the patient died shortly after the specimen was collected, with no radiological evidence of HCC. Conclusion: Ascites fluid cytology specimens in patients with cirrhosis, even those known or suspected to have HCC, are almost always negative. Atypical cells seen in such specimens should be treated with skepticism since the likelihood that they represent peritoneal spread of HCC is low.

Does the ThinPrep Imaging System increase the detection of high-risk HPV-positive ASC-US and AGUS? The Women and Infants Hospital experience with over 200,000 cervical cytology cases

M Ruhul Quddus — Thu,6 Aug 2009

M Ruhul Quddus, Theresa Neves, Mary E Reilly, Margaret M Steinhoff, C James Sung

CytoJournal 2009 6(1):15-15

Background: Published reports have demonstrated that introduction of the ThinPrep Imaging System (Imager) to the cytology screening services has increased the detection rate of high-grade squamous intraepithelial lesions (HSILs). In accordance with recent clinical treatment guidelines, patients with atypical squamous or glandular cells of undetermined significance (ASC-US or AGUS) are often tested for high-risk HPV infection using the Hybrid Capture HPV DNA test. We took the opportunity to investigate whether the Imager had resulted in any significant differences in our diagnostic categories, as well as whether the Imager increased the detection of high-risk HPV-DNA-positive (HRHPV+) ASC-US or AGUS. Materials and Methods: Cytology cases with the diagnosis of ASC-US and AGUS were retrieved from the archival files of our institution during periods of 11 months prior to and 11 months after the introduction of the Imager. The total number of cases in each category was correlated with results of reflex high-risk HPV DNA testing when the latter were available. All AGUS diagnoses were correlated with subsequent biopsy follow-up. Statistical analyses were performed using the chi-Square test with Yate's Correction and Fisher's Exact test. Results: A total of 108,371 and 104,555 of ThinPrep ® Pap Test (TPPT) cases were reviewed during 11 months pre- and post-imager introduction. The ASC-US rate was 5.4% in the pre-Imager and 5.3% in the post-Imager period. The HPV reflex test was 38% and 34% positive respectively in the pre- and post-Imager period ( P >0.124). Similarly, 0.14% and 0.12% AGUS were found in the pre- and post-Imager period. The positive HPV reflex test was 14% versus 23% ( P = 0.1690). The abnormal biopsy follow-up rate in the AGUS category was increased from 20.9% in the pre-Imager period to 31% in the post-Imager period ( P = 0.1471). The ASCUS/SIL ratios were 1.9 and 1.6 respectively. Conclusions: The ASC-US and AGUS rates did not change statistically before and after the introduction of the Imager in our cytology laboratory. Although use of the Imager did not increase detection of HPV+ ASC-US, it did appear to increase the detection rate of HPV+ AGUS and subsequent abnormal biopsy follow-up rates in all categories. However, the increase in the detection rate did not reach the point of statistical significance

The status of cervical cytology in Swaziland, Southern Africa: A descriptive study

Sylvain Okonda — Thu,6 Aug 2009

Sylvain Okonda, Colleen Wright, Pam Michelow

CytoJournal 2009 6(1):14-14

Background: Cancer of the cervix is the most common cancer in women in Swaziland where most women never undergo cervical screening. The extremely high prevalence of HIV/AIDS in Swaziland complicates the management of preinvasive and invasive cervical cancer. The purpose of this study was to assess the current status of cervical cytology in Swaziland, its strengths and limitations. Methods: The study is a retrospective review of 12,188 conventional cervical smears received by the Central Public Health Laboratory in Swaziland from June 2004 to May 2006. Results: Review of results showed very high rates of cytologic abnormalities with 43.2% of smears screened reported as abnormal. The percentages of abnormalities were as follows: atypical squamous cells of undermined significance (ASC-US), 19.8%; atypical squamous cells, cannot exclude HSILs (ASC-H), 8.8%; low-grade squamous intraepithelial lesions (LSIL), 9.0%; high-grade squamous intraepithelial lesions (HSIL), 4.6%; squamous cell carcinomas, 0.5%; atypical endocervical cells, 0.6%; and atypical endometrial cells, 0.4%. Just over 5% of smears were inadequate. The highest rates of HSILs and invasive squamous carcinoma occurred in women aged 50-59 years. Conclusions: This study underscores the need to reduce the incidence of cervical cancer and its precursor lesions in Swaziland women. Based on studies of human papillomavirus (HPV) types in other Southern African countries, current HPV vaccines would reduce the incidence and mortality from cervical cancer in the future, but cervical screening would still be required, both for women already infected with the HPV and for HPV subtypes not covered by current vaccines. The most cost-effective combination of screening modalities such as visual inspection, HPV DNA testing, and cytology should be investigated. Cervical cancer reduction needs to be managed within the greater framework of the HIV/AIDS epidemic.

Comparison of the modified fluorescent method and conventional Ziehl-Neelsen method in the detection of acidfast bacilli in lymphnode aspirates

Vamseedhar Annam — Sat,18 Jul 2009

Vamseedhar Annam, Mohan H Kulkarni, Rekha B Puranik

CytoJournal 2009 6(1):13-13

Objectives: The objectives were to correlate the modified fluorescent method with the conventional Ziehl-Neelsen (ZN) method for the detection of acid-fast bacilli (AFB) and, also to study the efficacy and advantages of using the auramine-rhodamine stain on lymph node aspirates under fluorescent microscopy. Methods: In 108 consecutive patients with a clinical suspicion of tuberculosis (TB) presenting with lymphadenopathy, fine needle aspirations were performed. Smears from the aspirates were processed for routine cytology, the conventional ZN method, and the modified fluorescent method. The significance of the modified fluorescent method over the conventional ZN method was analyzed using the chi-square test. Results: Out of 108 aspirates, 102 were studied and remaining 6 were excluded from the study due to diagnosis of malignancy in 4.04% (4/6) and inadequate aspiration in 2.02% (2/6). Among the 102 aspirates, 44.11% (45/102) were positive for AFB on the conventional ZN method, 58.9% (60/102) were indicative of TB on cytology, while the smear positive increased to 81.37% (83/102) on the modified fluorescent method. Conclusions: Fluorescent microscopy has the advantage of speed and ease of screening, and reduces observer fatigue. The modified fluorescent method was found to be more advantageous than routine cytology and conventional ZN method, particularly in paucibacillary cases. The bacillary positivity rates were higher in the modified fluorescent method than in the ZN method. Hence, the modified fluorescent method can be an adjuvant when used with routine cytology for the identification of AFB.

Test group biases and ethical concerns mar New England Journal of Medicine articles promoting HPV screening for cervical cancer in rural India

R Marshall Austin — Thu,16 Jul 2009

R Marshall Austin, Chengquan Zhao

CytoJournal 2009 6(1):12-12

Assessment of quality of data provided on Pap test requisitions: Implications for quality of care and patient safety

Sonya Naryshkin — Sat,11 Jul 2009

Sonya Naryshkin, Brenda L Schultz

CytoJournal 2009 6(1):11-11

Background: The reliability of patient history and clinical information on Pap test requisitions has been questioned but not previously objectively determined. The effect of incomplete/inaccurate information on quality of patient care has not been previously quantified. Our objectives were (1) to find out how clinicians and their assistants viewed the requisition slip, and whether they understood the reasons for supplying the information requested, (2) to measure the completeness and accuracy of information on the requisition slips, and (3) to determine whether the clinical information and patient history provided on Pap test requisitions could be relied upon to accurately assign a Pap test to the laboratory's "high-risk rescreen" pool. Methods: Clinicians and their assistants were surveyed. A total of 899 consecutive Pap test requisition slips were reviewed. Patient history and clinical information from the slips were compared to data from our laboratory information system and/or electronic patient medical records. Results: Most survey respondents felt that proper completion of requisitions was important, but only 17% of clinicians and less staff realized that negative high-risk Pap tests underwent a quality assurance rescreen. Clinicians and/or staff recorded the last menstrual period, specimen source, and clinical information on the requisition slips 96%, 97%, and 88% of the time, respectively. Of 695 Pap tests with applicable computerized records, 172 (25%) qualified for high-risk rescreen based upon information provided on the requisition slip alone. An additional 52 Pap tests (7%), or 23% of the total high-risk Pap tests were discovered to be of high risk only after review of the electronic records. Conclusions: Clinicians and staff were receptive to discussions concerning the completion of requisition slips, but laboratory expectations could be better communicated. Requisition slips were properly completed with a high frequency, but the check boxes did not elicit all the information expected, so revision was necessary. The high accuracy of the completion of requisition slips permitted 77% of high-risk Pap tests to be identified via the requisition slip alone. Our findings challenge the conventional anecdotal impressions of "notoriously unreliable" information on Pap test requisition slips, but our experience may not be applicable to other settings.

Penile metastasis of urothelial carcinoma diagnosed by fine-needle aspiration

Gilda da Cunha Santos — Thu,18 Jun 2009

Gilda da Cunha Santos, Marcia Lanzoni de Alvarenga, Vinicius Freitas Borlot, Michel Antonio Kiyota Moutinho, Marcello Fabiano de Franco

CytoJournal 2009 6(1):10-10

Penile neoplasms are rare and can be primary or represent metastasis or local recurrence. The most common primary cancer of the penis is squamous cell carcinoma, accounting for 95% of all cancers. In spite of the rich vascularity of the organ, penile metastases are uncommon. Cutaneous metastasis of urothelial carcinoma (UC) is extremely rare and generally accepted as the late manifestation of a systemic spread. By 1998, approximately 500 cases of penile metastasis had been reported worldwide. However, only few case reports and series of fine-needle aspiration cytology (FNAC) of penile tumors have been documented. We report a case of penile metastasis from UC diagnosed by FNAC and describe the cytomorphological findings with an emphasis on cercariform cells. Although not commonly used, FNA of penile nodules can be effective in diagnosing recurrence or metastasis and avoiding surgical procedures, thus being an excellent initial procedure in the diagnostic approach.

Inadequate fine needle aspiration biopsy samples: Pathologists versus other specialists

GS Gomez-Macias — Thu,18 Jun 2009

GS Gomez-Macias, R Garza-Guajardo, J Segura-Luna, O Barboza-Quintana

CytoJournal 2009 6(1):9-9

Background: Fine needle aspiration biopsy (FNAB) is a simple, sensitive, quick and inexpensive method in which operator experience is essential for obtaining the best results. Methods: A descriptive study in which the aspiration biopsy cases of the Pathology and Cytopathology Service of the University Hospital of the UANL (2003-2005) were analyzed. These were divided into three study groups: Group 1, FNAB performed by a pathologist; Group 2, FNAB performed by specialists who are not pathologists, Group 3, FNAB guided by an imaging study with immediate evaluation by a pathologist. The samples were classified as adequate and inadequate for diagnosis, the organ, the size and characteristics of the lesions were taken into consideration. Results: A total of 1905 FNAB were included. In Group 1: 1347 were performed of which 1242 (92.2%) were adequate and 105 (7.7%) were inadequate. Of the 237 from Group 2, 178 were adequate (75.1%) and 59 inadequate (24.8%); in Group 3 there were 321 of which 283 (88.1%) were adequate and 38 (11.8%) inadequate. A statistically significant difference was found between FNAB performed by Group 1 (p< 0.001) and the other groups. A multivariate analysis was done where the organ punctured, the study groups, the size and characteristics of the lesion by study group were compared, finding that the most important variable was the person who performed the procedure. Conclusion: The experience and training of the person performing the aspiration biopsy, as well as immediate evaluation of the material when it is guided, substantially reduces the number of inadequate samples, improving the sensitivity of the method as well as reducing the need for open biopsies to reach a diagnosis.

Assessment of oral cytological changes associated with exposure to chemotherapy and/or radiotherapy

Hussain G Ahmed — Sat,16 May 2009

Hussain G Ahmed, Dalia AI Elemirri

CytoJournal 2009 6(1):8-8

Background: Death from cancer is high in Sudan, with low survival rates, as most of the patients present with advanced disease. Most patients receive high and repeated doses of radiotherapy or chemotherapy. The aim of this study was to investigate the feasibility of using cytological evaluation to detect oral epithelial atypia amongst these patients. As a part of the continuous development in cancer therapy, this case control study was conducted in Khartoum, Sudan. Methods: Papanicolaou stained oral mucosal cells were obtained from 100 cancer patients receiving radiotherapy and/or chemotherapy (ascertained as cases), 50 cancer patients not exposed to either therapy (control 1), and 50 apparently healthy individuals (control 2). Statistical analysis: The data was analyzed by using a computer SPSS program, to obtain the Chi-square test. Results: Without prior knowledge of the subjects' group, oral epithelial atypia was detected in 7% of the cases. Inconclusive features of cytological atypia were observed in 13% of the cases. Atypia was not observed in both the control groups. Inflammatory infiltrate and viral cytopathic effects were identified in 32% and 8% of the cases respectively. Conclusion: Cytological atypia, viral infections, and inflammatory infiltrates were detected after exposure to radiotherapy and/or chemotherapy.

Cytologic features of metanephric adenoma of the kidney

Jose A Jimenez-Heffernan — Sat,4 Apr 2009

Jose A Jimenez-Heffernan, Eva Tejerina, Pilar Gonzalez-Peramato, Blanca Vicandi, Ana Lopez-Garcia

CytoJournal 2009 6(1):7-7

The impact of digital imaging in the field of cytopathology

Liron Pantanowitz — Fri,6 Mar 2009

Liron Pantanowitz, Maryanne Hornish, Robert A Goulart

CytoJournal 2009 6(1):6-6

With the introduction of digital imaging, pathology is undergoing a digital transformation. In the field of cytology, digital images are being used for telecytology, automated screening of Pap test slides, training and education (e.g. online digital atlases), and proficiency testing. To date, there has been no systematic review on the impact of digital imaging on the practice of cytopathology. This article critically addresses the emerging role of computer-assisted screening and the application of digital imaging to the field of cytology, including telecytology, virtual microscopy, and the impact of online cytology resources. The role of novel diagnostic techniques like image cytometry is also reviewed.

Pleomorphic adenoma with squamous and appendageal metaplasia mimicking mucoepidermoid carcinoma on cytology

Meenakshi Batrani — Thu,12 Feb 2009

Meenakshi Batrani, Manju Kaushal, AK Sen, Rajbala Yadav, NK Chaturvedi

CytoJournal 2009 6(1):5-5

Background: Histological diversity is the hallmark of pleomorphic adenoma, the most common salivary gland tumor. It may cause difficulty in cytological interpretation, due to limited and selective sampling. Case presentation: A 16-year-old female patient presented with right cheek swelling. Fine needle aspiration cytology showed squamous cells, basaloid cells, and foamy cells, along with extracellular keratin and foreign body giant cells. Characteristic metachromatic fibrillary chondromyxoid stroma, which is usually seen in pleomorphic adenoma, was not seen in the aspirate. A diagnosis of mucoepidermoid carcinoma was given on cytology. Subsequent resection revealed an encapsulated pleomorphic adenoma, with extensive squamous metaplasia and appendageal differentiation on histology. Conclusion: This case illustrates that pleomorphic adenoma with squamous metaplasia presents a potential for misinterpretation as mucoepidermoid carcinoma on cytology. We discuss the various pitfalls and the features that are helpful in distinguishing these two lesions.

Collection of the BD SurePath Pap Test with a broom device plus endocervical brush improves disease detection when compared to the broom device alone or the spatula plus endocervical brush combination

Sharon Davis-Devine — Thu,12 Feb 2009

Sharon Davis-Devine, Sarah J Day, Amy Anderson, Ashley French, Darcy Madison-Henness, Naomi Mohar, Danielle Tansy, Adarsh Hiremath, Jeffrey A Douglas, Gregory G Freund

CytoJournal 2009 6(1):4-4

Objective: Here we examine the diagnostic utility of the US Food And Drug Administration (FDA) approved Spatula + endocervical brush combination for the BD SurePath Pap Test (SPPT) and compare it to SPPT collection with the broom alone or to an off-label combination of broom + EC brush. This question is important due to lingering concerns over the value of EC detection to a satisfactory Pap test. Methods: 20,125 SPPT vials were examined for the collection devices contained. The SPPT collection device combinations allowed were: Rovers Cervex-Brush (broom, FDA approved), Medscand Pap Perfect Spatula + Medscand CytoBrush Plus GT (spatula + GT brush, FDA approved) or Rovers Cervex-Brush + Surgipath C-E Brush (broom + CE brush, off label). Results: Examination of SPPT vials revealed 11,130 collected with the broom, 4,687 collected with the spatula + GT brush and 2,921 collected with the broom + CE brush. Absence of an endocervical/transformation zone was seen in 22.86% of broom cases, 13.10% of spatula + GT brush cases (p= 0.00005 vs broom) and 10.17% of broom + CE brush cases (p= 0.00005 vs broom, p= 0.00005 vs spatula + GT brush). Importantly, LSIL detection was: broom 2.99%; spatula + GT brush 2.45% (p= 0.053 vs broom); broom + CE brush 4.18% (p= 0.034 vs broom, p= 0.0001 vs spatula + GT brush). Conclusion: When broom + brush combination is compared to broom alone or to spatula + GT brush, the broom + CE brush combination better sampled the endocervical/transformation zone and increased LSIL detection.

Hemosiderin laden macrophages and hemosiderin within follicular cells distinguish benign follicular lesions from follicular neoplasms

Reema Jaffar — Tue,20 Jan 2009

Reema Jaffar, Sambit K Mohanty, Ashraf Khan, Andrew H Fischer

CytoJournal 2009 6(1):3-3

Background: Published criteria to distinguish benign colloid nodules from follicular neoplasms emphasize only three interdependent features: size of follicles, amount of colloid, and cellularity. There is a need for the validation of other independent criteria. Methods: This study quantified the significance of cystic change, defined as presence of macrophages, and the presence of hemosiderin in either the macrophages or follicular cells. The cohort consisted of 165 patients with fine needle aspiration (FNA) and histologic follow-up of either goiter (101), follicular adenoma (47), or follicular carcinoma (17). Papillary thyroid carcinomas and Hürthle cell neoplasms were excluded from the cohort, because these categories are known to show cystic change and hemosiderin. FNAs were reviewed blindly with the most cellular slide scored for the presence of macrophages and/or hemosiderin. Results: Hemosiderin within macrophages were seen in 67% (68 of 101) of the goiters and only 6% (four of 64) of follicular neoplasms ( P <.0001). All four follicular neoplasms with hemosiderin in macrophages were adenomas. Three of these four had equivocal features of a benign colloid nodule histologically. None of the 17 follicular carcinomas had hemosiderin in macrophages ( P <.12). Macrophages without hemosiderin also strongly distinguished goiters from neoplasms (83% vs 17%) but appears less useful as a criterion since macrophages were present within 3 of 17 follicular carcinomas. Hemosiderin within follicular epithelial cells was present in 18% (18 of 101) of goiters, whereas none of the 64 follicular neoplasms had intraepithelial hemosiderin ( P <.0003). Conclusions: If papillary thyroid carcinoma and Hürthle cell neoplasm are ruled out, our findings indicate that the presence of hemosiderin virtually excludes a clinically significant follicular neoplasm.

Comparison of the efficacy of the cervex brush and the extended-tip wooden spatula with conventional cytology: A longitudinal study

Caroline J Whitaker — Tue,20 Jan 2009

Caroline J Whitaker, Elaine C Stamp, William Young, Lesley A Greenwood

CytoJournal 2009 6(1):2-2

Background: Within the United Kingdom, the change from conventional to liquid based cytology (LBC) has brought with it the universal introduction of broom style samplers, as represented by the Cervex sampler. The aim of this study was to assess whether or not there were benefits associated with a change from wooden spatulae to broom style samplers for those countries where conversion to LBC might not be readily available or is not fully supported. Methods: A longitudinal study was designed to compare the performance of Cervex brushes and extended-tip wooden spatulae as sampling devices for conventionally prepared cervical smears. General Practices serving the population of Hull and East Yorkshire (UK) were provided with Cervex brushes for a period of nine months to routinely collect cervical smears. The results of 66,931 cervical smear tests were compared between those practices that were using extended-tip wooden spatulae before the trial and then returned to their use afterwards, and those who were previously using Cervex samplers and continued to use them throughout. Analyses comparing both specimen inadequacy, as recorded on the standard cervical screening request form (HMR101), and also the presence of identified transformation zone (TZ) elements in smears, both indicated significant advantages associated with the Cervex brush. Results: Inadequate smears decreased from 5.96% with extended-tip spatulae to 4.77% with Cervex brushes (p<0.001) and increased back to 7.34% when practices reverted to extended-tip spatulae after nine months. Under the same conditions, the proportion of smears containing identified TZ elements increased from 50.52% to 54.75% (p<0.001), before reverting to 45.47% (p<0.001). In contrast, for a control group of practices using the Cervex brush throughout, inadequate smears decreased in all phases of the study, with no significant variation in TZ sampling rates. Conclusions: Using the Cervex brush with conventional cytology significantly decreases inadequate smears and increases TZ sampling when compared to the extended-tip spatula and can offer improved cervical screening in countries unable or unwilling to convert to LBC.

FNA of misclassified primary malignant neoplasms of the thyroid: Impact on clinical management

Sejal S Shah — Tue,20 Jan 2009

Sejal S Shah, William C Faquin, Roberto Izquierdo, Kamal K Khurana

CytoJournal 2009 6(1):1-1

Background: Fine needle aspiration (FNA) cytology is a popular, reliable and cost effective technique for the diagnosis of thyroid lesions. The aim of our study was to review cases of misclassified primary malignant neoplasms of the thyroid by FNA, and assess the causes of cytologic misdiagnosis and their impact on clinical management. Methods: Clinical data, FNA smears and follow-up surgical specimens of cases diagnosed with primary thyroid carcinoma were reviewed. Results: Of the 365 cases with a malignant diagnosis by FNA over a period of 11 years, nine (2.4 %) were identified with discrepant histologic diagnosis with regard to the type of primary thyroid malignancy. In addition, four cases were added from the consultation files of the Massachusetts General Hospital. Areas of difficulty contributing to misclassification included overlapping cytologic features (n = 6), rarity of tumors (n = 3), and sampling limitations (n = 4). Of the 13 cases, 12 underwent total or near total thyroidectomy and one patient had concurrent surgical biopsy. Measurement of serum calcitonin levels in one case, with an initial cytologic diagnosis of medullary carcinoma, prevented unnecessary lymph node dissection. Misclassification of medullary carcinoma as papillary carcinoma precluded lymph node dissection in one case. Further management decisions were based on the final histologic diagnosis and did not require additional surgery. Two cases of undifferentiated (anaplastic) thyroid carcinoma were misdiagnosed as papillary thyroid carcinoma. Both patients received total thyroidectomies, which may not otherwise have been performed. Conclusions: A small subset of primary malignant neoplasms of the thyroid may be misclassified with regard to the type of malignancy on FNA. The majority of primary malignant neoplasms diagnosed on FNA require thyroidectomy. However, initial cytologic misclassification of medullary carcinoma or undifferentiated carcinoma as other malignant neoplasms or vice versa may have an impact on clinical management.

Informatics applied to cytology

Liron Pantanowitz — Mon,29 Dec 2008

Liron Pantanowitz, Maryanne Hornish, Robert A Goulart

CytoJournal 2008 5(1):16-16

Automation and emerging information technologies are being adopted by cytology laboratories to augment Pap test screening and improve diagnostic accuracy. As a result, informatics, the application of computers and information systems to information management, has become essential for the successful operation of the cytopathology laboratory. This review describes how laboratory information management systems can be used to achieve an automated and seamless workflow process. The utilization of software, electronic databases and spreadsheets to perform necessary quality control measures are discussed, as well as a Lean production system and Six Sigma approach, to reduce errors in the cytopathology laboratory.

CytoJournal's move to the new platform: More on financial model to the support open-access charter in cytopathology, publication quality indicators, and other issues

Vinod B Shidham — Tue,16 Dec 2008

Vinod B Shidham, Martha B Pitman, Richard M DeMay, Barbara F Atkinson

CytoJournal 2008 5(1):15-15

Nodular fasciitis of the external ear masquerading as pleomorphic adenoma: A potential diagnostic pitfall in fine needle aspiration cytology

Deepali Jain — Wed,26 Nov 2008

Deepali Jain, Nita Khurana, Shyama Jain

CytoJournal 2008 5(1):14-14

Background: Nodular fasciitis (NF) is a benign myofibroblastic proliferation in soft tissue. The most common sites are extremities, followed by the trunk and head and neck region. It is infrequently seen in the post-auricular region of pinna. Case presentation: We present here an interesting case of a young male who had a swelling in the post-auricular region; on cytology, it was diagnosed as pleomorphic adenoma; however, biopsy revealed characteristic morphology of NF. Conclusion: The case highlights the potential pitfall of cytology in diagnosing NF, especially because of unusual site and morphologic overlap.

Review of thyroid cytopathology: An Atlas and text

Melina Flanagan — Fri,3 Oct 2008

Melina Flanagan, Prabodh Gupta

CytoJournal 2008 5(1):13-13

Entamoeba gingivalis pulmonary abscess - Diagnosed by fine needle aspiration

Bo Jian — Tue,30 Sep 2008

Bo Jian, Ana S Kolansky, Zubair W Baloach, Prabodh K Gupta

CytoJournal 2008 5(1):12-12

Entamoeba gingivalis ( E. gingivalis ) is a parasitic protozoa of the oral cavity, most often found in gingival tissues around the teeth associated with poor oral hygiene. Here, we report a case of E. gingivalis in a pulmonary CT guided fine needle aspiration material, from a 60-year-old man with newly found lung mass. On site Diff-Quik ® smear examination revealed the presence of marked acute inflammation, colonies of actinomyces, and a number of 'large macrophages-like organisms'. Upon examination of the additional material, organisms morphologically consistent with E. gingivalis were identified. Pulmonary mass resolved after six weeks of treatment with antibiotics (Clindamycin followed by Penicillin). Proper recognition and distinction between E. gingivalis and other species of Entamoeba is important for the management of patients.

Transabdominal Fine-Needle Aspiration Biopsy: A Colour Atlas and Monograph (Grace Chia-yu Hsu Yang and Liang-Che Tao), Second Edition: A book review

Prabodh K Gupta — Fri,25 Apr 2008

Prabodh K Gupta

CytoJournal 2008 5(1):11-11

Use of the ThinPrep(R) Imaging System does not alter the frequency of interpreting Papanicolaou tests as atypical squamous cells of undetermined significance

Michael J Thrall — Thu,24 Apr 2008

Michael J Thrall, Donna K Russell, Thomas A Bonfiglio, Rana S Hoda

CytoJournal 2008 5(1):10-10

Background: Automated screening of Papanicolaou tests (Pap tests) improves the productivity of cytopathology laboratories. The ThinPrep ® Imaging System (TIS) has been widely adopted primarily for this reason for use on ThinPrep ® Pap tests (TPPT). However, TIS may also influence the interpretation of Pap tests, leading to changes in the frequency of various interpretive categories. The effect of the TIS on rates of TPPT interpretation as atypical squamous cells of undetermined significance (ASC-US) is of concern because any shift in the frequency of ASC-US will alter the sensitivity and specificity of the Pap test. We have sought to determine whether automated screening of TPPT has altered ASC-US rates in our institution when compared with manual screening (MS) of TPPT. Methods: A computerized search for all ASC-US with reflex Human Papillomavirus (HPV) testing over a one-year-period (7/1/06 to 6/30/07) was conducted. Cases included both TPPT screened utilizing TIS and screened manually. HPV test results for both groups were recorded. Pertinent follow-up cervical cytology and histology results were retrieved for the period extending to 11/30/07. Automated screening was in clinical use for 10 months prior to the start of the study. Results: Automated screening was performed on 23,103 TPPT, of which 977 (4.23%) were interpreted as ASC-US. Over the same period, MS was performed on 45,789 TPPT, of which 1924 (4.20%) were interpreted as ASC-US. Reflex HPV testing was positive for high risk (HR) types in 47.4% of the TIS cases and 50.2% of MS cases. Follow-up cervical dysplasia found by colposcopy was also distributed proportionally between the two groups. Cervical intraepithelial neoplasia (CIN) was found on follow-up biopsy of 20.1% of the TIS cases (5.2% CIN 2/3) and 21.2% of MS cases (5.1% CIN 2/3). None of these differences were statistically significant. Conclusion: Use of the ThinPrep ® Imaging System did not appreciably change ASC-US rates or follow-up reflex HPV test results in our laboratory. This demonstrates that the benefits of automated screening may be obtained without increasing the rate of referral to colposcopy for ASC-US follow-up.

Myoepithelial Cells : Any role in aspiration cytology smears of breast tumors?

Sanjib Kumar Pattari — Mon,21 Apr 2008

Sanjib Kumar Pattari, Pranab Dey, Subhash K Gupta, Kusum Joshi

CytoJournal 2008 5(1):9-9

Aims and Objective: To study the role of myoepithelial (ME) cells in distinguishing benign, proliferative breast diseases (PBD) and frank malignant breast lesions. Materials and methods: In this study, histology proven 71 cases of fine needle aspiration cytology (FNAC) of palpable breast lesions were selected. There were 30 invasive carcinomas (24 infiltrating duct carcinoma and 6 infiltrating lobular carcinoma), 25 cases of benign lesion (21 fibroadenomas and 4 fibrocystic lesions) and 11 proliferative breast diseases (other than carcinoma in situ) and five cases of carcinoma in situ. The number of ME cells were estimated in respect to 1000 ductal cells. In every case at least 20 high power fields (x 40) were studied. Quantitative estimation of ME cell was correlated with the final diagnosis. Corresponding histopathology cases were also evaluated for diagnostic confirmation along with the pattern of distribution of ME cells. The ME cells were also quantitated on histopathology sections on smooth muscle actin (SMA) immunostained sections. Results: The mean number of ME cells per 1000 ductal cells on cytology smears was 5.1 ± 5.5, 30.8 ± 25, 28.3 ± 20.2, and 38.4 ± 38.8 in malignant, carcinoma in situ, PBD and benign breast lesions respectively. The non parametric Mann Whitney test showed significant difference in number of the ME cells between benign and malignant groups (p < .000), PBD and malignant groups (p < .000) and carcinoma in situ and malignant group (p < .001). However, it was insignificant between benign and PBD group, and PBD and carcinoma in situ (p > .01). In SMA stained histopathology sections, ME cell in benign, PBD, carcinoma in situ and malignant cases were 741.12 ± 248, 238 ± 172, 121.6 ± 115 and 15.6 ± 25.1 respectively. Statistical analysis showed significantly different number of ME cell between benign versus PBD group, carcinoma in situ and malignant group. It was also significant between PBD versus malignant, and carcinoma in situ versus malignant (p < .001, Mann Whitney test). However number of ME cell was not significant between PBD versus carcinoma in situ. Conclusion: The number of ME cell in breast lesions may be helpful in distinguishing PBD versus invasive malignant tumors on FNAC smears. However it is not helpful to distinguish benign lesions versus PBD.

Calcium pyrophosphate dihydrate deposition disease (CPPD)/Pseudogout of the temporomandibular joint - FNA findings and microanalysis.

Asghar H Naqvi — Mon,21 Apr 2008

Asghar H Naqvi, Jerrold L Abraham, Robert M Kellman, Kamal K Khurana

CytoJournal 2008 5(1):8-8

We report a case of a Calcium pyrophosphate dihydrate deposition disease (CPPD) presenting as a mass in the parotid and temporomandibular joint (TMJ) that simulated a parotid tumor. A 35 year-old man presented with pain in the left ear area. A CT Scan of the area showed a large, calcified mass surrounding the left condylar head, and extending into the infratemporal fossa. FNA of the mass showed birefringent crystals, most of which were rhomboid with occasional ones being needle shaped, embedded in an amorphous pink substance. Scanning electron microscopy (SEM) with energy dispersive x-ray spectroscopy (EDS) of these crystals showed peaks corresponding to calcium and phosphorus. SEM/EDS is a rapid method of diagnosing calcium pyrophosphate dihydrate deposition disease (CPPD) and an alternative to more commonly used method of special staining of cell block sections coupled with polarizing microscopy.

Prevalence and significance of psammoma bodies in cervicovaginal smears in a cervical cancer screening program with emphasis on a case of primary bilateral ovarian psammocarcinoma

Teresa Pusiol — Wed,16 Apr 2008

Teresa Pusiol, Anna M Parolari, Irene Piscioli, Luca Morelli, Franca Del Nonno, Stefano Licci

CytoJournal 2008 5(1):7-7

Background: The purpose of our study was to determine the prevalence and significance of psammoma bodies (PBs) in the cervicovaginal smears of the screening population of Trento district (Italy), with the description of the cytological presentation of an asymptomatic bilateral ovarian psammocarcinoma. Methods: From 1993 to 2006, women with PBs detected on consecutively screened cervical smears were identified from the computerized pathology database of Rovereto Hospital. The follow-up period was set from the time of cytological diagnosis to May 31 st , 2007. Clinical information was obtained from retrospective review of women's medical records. The source of PBs was identified with adequate diagnostic procedures. Results: PBs were found in six of the 201,231 Papanicolaou screening smears (0.0029%). Benign conditions (intrauterine device, inclusion ovarian cysts and ovarian cystoadenofibroma with PBs) were found in four patients. In two cases, PBs were associated with malignant cells; a bilateral ovarian malignancy was diagnosed in both cases, a serous adenocarcinoma and a psammocarcinoma. Conclusion: PBs in the cervicovaginal smears are a rare finding, associated more often with benign conditions than with malignancies. Moreover, to our knowledge, our case of primary ovarian psammocarcinoma is the first report in which the presence of malignant cells and PBs in the cervicovaginal and endometrial smears represents the first manifestation of disease.

The National Cancer Institute Thyroid fine needle aspiration state of the science conference : A summation

Zubair W Baloch — Mon,7 Apr 2008

Zubair W Baloch, Edmund S Cibas, Douglas P Clark, Lester J Layfield, Britt-Marie Ljung, Martha Bishop Pitman, Andrea Abati

CytoJournal 2008 5(1):6-6

A 5-year-old girl with a congenital ganglioneuroma diagnosed by fine needle aspiration biopsy : A case report

Marco A Ponce-Camacho — Sun,30 Mar 2008

Marco A Ponce-Camacho, Ricardo Diaz de Leon-Medina, Ivet Miranda-Maldonado, Raquel Garza-Guajardo, Jorge Hernandez-Salazar, Oralia Barboza-Quintana

CytoJournal 2008 5(1):5-5

Introduction: Ganglioneuroma is a rare, benign, neuroblastic tumor arising mainly from the central or peripheral autonomic nervous system, especially the sympathetic system. The most affected anatomical sites are the posterior mediastinum, retroperitoneum, adrenal gland and head and neck soft tissue. In the current literature, reports of ganglioneuroma diagnosed by fine-needle aspiration and its cytological appearance are scarce. Case Presentation: A 5-year-old girl presented with a mass in the cervical region since birth. Laboratory routine tests were within normal limits, ultrasonography demonstrated a solid and well-circumscribed lesion in the soft tissues of the cervical region. Fine needle aspiration biopsy was carried out, and the obtained smears showed a mixture of mature ganglion cells and groups of spindle cells suggestive of schwann cell origin. A diagnosis of ganglioneuroma was suggested. Core biopsy and surgical resection confirmed this diagnosis. Conclusion: Congenital ganglioneuroma of the cervical region is an uncommon soft tissue benign neoplasm of neuroblastic origin, and it should be considered in the differential diagnosis of head and neck pediatric soft tissue tumors. Fine needle aspiration biopsy technique is a reliable method that can be used with confidence when dealing with pediatric soft tissue tumors.

Fine needle aspiration biopsy of intraoral and oropharyngeal mass lesions

Husain A Saleh — Fri,28 Mar 2008

Husain A Saleh, Lewis Clayman, Haitham Masri

CytoJournal 2008 5(1):4-4

Background: Fine needle aspiration (FNA) biopsy has been rarely used in oral and oropharyngeal lesions. The goal of this study was to assess the value and accuracy of FNA biopsy in the diagnosis of oral and oropharyngeal lesions particularly in regards to discriminating benign from malignant tumors. Methods: Sixteen cases of FNA biopsies obtained of various intraoral and oropharyngeal masses or lesions performed at our institution during the eight-year period from 1998 to 2006 were retrospectively reviewed. The aspiration cytologic diagnoses were correlated with the histologic examination of the corresponding resected lesions. Results: Sixteen cases of intraoral lesions evaluated by FNA biopsies during the period of 1998-2006 were reviewed. The sites of involvement were: lip [1], maxillary sinus [3], pharynx/oropharynx [5], floor of mouth [4], buccal mucosa [2] and peritonsillar area [1]. Patients' age ranged from 30 to 87 with an average of 54 years. Male to female ratio was 1:3. Cytologically, 7 cases were diagnosed as suspicious/malignant, and 9 cases as benign (including 6 benign neoplasm, 1 atypical, and 2 reactive or "descriptive"). Fifteen cases had corresponding surgical resection for histologic examination, of these, 9 cases were interpreted as malignant, and 6 as benign. There were no false positive diagnoses of malignancy on FNA. Two cases were interpreted as benign or atypical cytologically, but were found to be malignant on histologic examination. Conclusion: FNA biopsy of intraoral and oropharyngeal masses is a valuable procedure for the initial evaluation of various lesions. It provides helpful information about these lesions and avoids hasty or unnecessary surgical biopsy. It is a rapid and relatively noninvasive procedure. Furthermore, aspiration biopsy is an important tool in the diagnosis and management of these lesions, both neoplastic and non-neoplastic, and can be sometimes complemented by ancillary studies for more accurate interpretation. However, its sensitivity in the diagnosis of malignancy is lower than that of histologic samples. This is probably due to the superficial nature and small size of these lesions, the limited space for maneuvering the needle and difficulty in immobilizing the lesion to obtain adequate samples, rather than to interpretation or inherent limitations of the technique itself.

Comparison of Thin-Prep and cell block preparation for the evaluation of Thyroid epithelial lesions on fine needle aspiration biopsy

Husain A Saleh — Tue,25 Mar 2008

Husain A Saleh, Jamal Hammoud, Richard Zakaria, Aurang Zeb Khan

CytoJournal 2008 5(1):3-3

Background: The objective of this study was to compare the utility of Thin-Prep (TP) cytologic preparation with that of Cell Block (CB) preparation in the diagnosis of thyroid lesions, mainly follicular epithelial lesions, by fine needle aspiration biopsy (FNAB). Feasibility of using the TP slides for immunocytochemical stains is also discussed. Methods: A total of 126 consecutive cases of thyroid FNAB with TP slides and 128 consecutive cases of thyroid FNAB with CB slides were reviewed blindly by two cytopathologists. The presence of colloid, follicular cells, macrophages and lymphocytes/plasma cells were recorded and scored 0-4 on each case based on TP or CB slide review. The cytologic diagnoses were grouped as follows: cyst, colloid nodule, colloid nodule with cystic change, chronic thyroiditis, atypical/neoplastic and non-diagnostic. Results: The TP slides had higher diagnostic rate than CB slides. The diagnostic yield was 68% of the TP slides whereas only 24% of the CB slides were diagnostic. Also, only 4 atypical/neoplastic lesions were diagnosed on the TP slides and the corresponding direct smears, while 5 cases of atypical/neoplastic lesions were diagnosed on the smears but could not be diagnosed on the corresponding CB slides. Additionally, the TP slides revealed cytologic features that were not observed on the direct traditional smears of the same case. Conclusion: In thyroid FNAB cases, TP slide preparation is superior to CB slide preparation and is more likely to have greater cellularity for diagnosis and detect atypical/neoplastic thyroid lesions, particularly those of follicular cell origin. Furthermore, TP slides appear to detect helpful diagnostic cytologic features and should be considered complementary to, rather than replacing, direct smears.

Cytological and molecular diagnosis of solid variant of papillary thyroid carcinoma: A case report

Giancarlo Troncone — Wed,19 Mar 2008

Giancarlo Troncone, Maria Russo, Umberto Malapelle, Marina Accardo, Angelo Ferraro, Immacolata Cozzolino, Lucio Palombini

CytoJournal 2008 5(1):2-2

Papillary thyroid carcinoma (PTC) composed by predominant solid areas is diagnosed as a distinct variant on histological samples. Here we present a case of PTC recognized preoperatively by fine needle cytology as a solid variant. This diagnosis was made by combining cytology with the detection of the BRAFVK600-1E mutation, the molecular hallmark of the solid variant of PTC. Histological and molecular evaluation of the surgical specimen confirmed this pre-operative diagnosis. Thus combining cytology to BRAF molecular analysis is useful to refine the cytological diagnosis of this variant also on FNC specimens.

Utility of Thyroglobulin measurement in fine-needle aspiration biopsy specimens of lymph nodes in the diagnosis of recurrent thyroid carcinoma

Zubair W Baloch — Thu,31 Jan 2008

Zubair W Baloch, Julieta E Barroeta, Janet Walsh, Prabodh K Gupta, Virginia A Livolsi, Jill E Langer, Susan J Mandel

CytoJournal 2008 5(1):1-1

Introduction The most common site for the metastasis of papillary carcinoma of the thyroid (PTC) is regional lymph nodes. Ultrasound (US) imaging may identify abnormal appearing lymph nodes, suspicious for PTC recurrence. Although fine needle aspiration biopsy (FNAB) of abnormal lymph nodes is often diagnostic of recurrence, small or cystic lymph nodes may be non-diagnostic due to lack of tumor cells. The measurement of thyroglobulin (TG) levels in FNAB specimens from lymph nodes suspicious for recurrent PTC can serve as an adjunct to the cytologic diagnosis. Materials and methods 115 abnormal appearing lymph nodes were aspirated under ultrasound guidance in 89 patients with history of thyroid carcinoma. In addition to obtaining material for cytologic interpretation, an additional aspirate was obtained by FNAB and rinsed in 1 ml of normal saline for TG level measurements. Results The cytologic diagnoses included: 35 (30%) reactive lymph node, no tumor seen (NTS), 39 (34%) PTC, 23 (20%) inadequate for evaluation due to lack of lymphoid or epithelial cells (NDX) 15 (13%) atypical/suspicious for PTC, and 3 (3%) other (e.g. paraganglioma, poorly differentiated carcinoma and carcinoma not otherwise specified). TG levels were markedly elevated (median 312 ng/ml; normal < 10 ng/ml) in 28 (72%) cases of PTC lymph node recurrence identified on cytology. TG measurements were also elevated in 5 lymph nodes classified as NTS and 4 NDX on cytology which resulted in 5 and 3 carcinoma diagnoses respectively on histological follow-up. Of the 9 atypical/suspicious cases with elevated TG levels all resulted in carcinoma diagnoses on follow-up. Conclusion The measurement of TG in FNAB specimens from lymph node in patients with history of PTC is useful in detecting recurrent disease, especially in cases when the specimen is known to be or likely to be inadequate for cytologic evaluation.

Scope of FNAC in the diagnosis of soft tissue tumors-A study from a tertiary cancer referral center in India

Bharat Rekhi — Wed,31 Oct 2007

Bharat Rekhi, Biru D Gorad, Anagha C Kakade, RF Chinoy

CytoJournal 2007 4(1):20-20

Background: Fine needle aspiration cytology (FNAC) forms one of the first diagnostic tools in the evaluation of tumors. Its role in diagnosing soft tissue tumors (STT) has been fairly documented, as well as debated. Present study was aimed at evaluating its scope in diagnosing 127 cases of soft tissue tumors. Methods: Conventional Pap and MGG staining was available in all the cases. Immunocytochemistry (ICC) was performed in 15 cases. Histopathological details were available in 115 cases. Results: 50% cases were referred for a primary diagnosis, while 26.8% & 22.8% cases were evaluated for recurrent and metastatic lesions, respectively. Extremities were the commonest sites. On FNAC, 101 cases (79.5%) were labeled as malignant, whereas 10 cases (7.9%) were labeled as benign. The remaining 16 cases (11%) were not categorized and were labeled as 'unsure/not specified'. Histopathological confirmation in 115 cases, gave a diagnostic accuracy of 98%, with a positive predictive value of 98% in malignant cases and a negative predictive value of 100% in benign cases. Two cases were false positive. Among the various cytological categories, 60 cases (47.2%) were of spindle cell type, followed by 32 (25.2%) of round cell type and 14 cases (11%) of lipomatous type. Other 12 cases (9.4%) were of pleomorphic type; 7 (5.5%) cases of epithelioid type and remaining 2 cases were of myxoid type. All the round cell, pleomorphic and myxoid type of tumors were sarcomas, whereas 73.3% cases of spindle cell type were labeled as 'malignant'. Exact cytological sub typing was offered in 58 cases, with rhabdomyosarcoma (RMS) as the most frequently sub typed tumor. The two false positive malignant cases were of fibromatosis and a pigmented schwannoma, on biopsy. Out of 28 metastatic lesions, lymph nodes were the commonest site for metastasis, with epithelioid tumors that formed highest percentage of metastatic cases. Conclusion: FNAC is fairly specific and sensitive in STT diagnoses for primary, recurrent and metastatic lesions. The cytological types, especially round cell and pleomorphic sarcomas, can be quickly identified. Clinicopathological correlation with ICC as an adjunct, are valuable in exact sub typing.

Pathologist performed fine needle aspirations & implementation of JCAHO Universal Protocol and "Time out"

Momin T Siddiqui — Thu,20 Sep 2007

Momin T Siddiqui

CytoJournal 2007 4(1):19-19

The adherence to the principles of the Universal Protocol for preventing wrong site, wrong procedure and wrong person surgical or invasive procedures is a requirement for all Joint Commission accredited organizations. Fine needle aspirations are considered invasive procedures, and cytopathologists performing this procedure need to be cognizant and compliant with the requirements of this Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Protocol. This article gives background perspective on the development of the Universal Protocol. It also elaborates the JCAHO National Patients Safety Goals regarding the performance of fine needle aspirations. The compliance with the Universal Protocol for performance of fine needle aspirations is now mandated for all cytopathologists who perform fine needle aspirations and this present paper provides a guideline for fulfilling the requirements of the Universal Protocol for practicing cytopathologists.

Desmoplastic melanoma morphology on Thinprep: A report of two cases

Becky L Van Ells — Wed,19 Sep 2007

Becky L Van Ells, James E Madory, Rana S Hoda

CytoJournal 2007 4(1):18-18

Background: Desmoplastic melanoma is a variant of malignant melanoma that can range in appearance from sarcomatoid to scar-like. Cytomorphology of desmoplastic melanoma has been previously described on conventional smears; however, to our knowledge, detailed cytomorphology on ThinPrep has so far not been described. Herein, we describe the cytomorphology of two cases of desmoplastic melanoma on fine needle aspiration processed as ThinPrep slides and compare it to that seen on conventional smears. Pertinent immunocytochemical stains, performed on ThinPrep slides are also discussed. Case presentation: The first case is a woman with a history of desmoplastic melanoma of the scalp with previous local recurrences and lymph node metastasis with a new submandibular mass. The second case is a man with a previously resected desmoplastic melanoma with his first local recurrence. Conventional smears, including air-dried Diff-Quik-stained and alcohol-fixed Papanicolaou-stained smears, demonstrated aggregates of pleomorphic spindle cells admixed with fibrous stroma and single spindle cells. In both cases, nuclei were elongated and plump with irregular nuclear contours, deep grooves, and folds. Chromatin was dark and coarse with either inconspicuous or multiple prominent nucleoli. Cytoplasm was located at the nuclear poles and was fine, wispy, and delicate. The background was clean with no evidence of necrosis or melanin pigment. Papanicolaou-stained ThinPrep slides were prepared from needle rinses and demonstrated excellent correlation of nuclear and cytoplasmic detail of single spindle cells to that seen on conventional smears with the exception of only slight decrease in nuclear size; however, nuclear and cytoplasmic detail of spindle cells embedded in stroma was markedly attenuated. Confirmatory immunostain for S-100 protein in both cases was performed on ThinPrep slides demonstrating crisp cytoplasmic staining in the spindle cells. Conclusion: The cytomorphology of desmoplastic melanoma shows excellent correlation between cytomorphology of single spindle cells on conventional smears and on ThinPrep slides. The major difference noted on ThinPrep slides was attenuated nuclear and cytoplasmic detail of spindle cells embedded in fibrous stoma.

Unsuspected multiples myeloma presenting as bilateral pleural effusion - a cytological diagnosis

Kajal Kiran Dhingra — Fri,7 Sep 2007

Kajal Kiran Dhingra, Niti Singhal, Sonu Nigam, Shayama Jain

CytoJournal 2007 4(1):17-17

Background: Multiple Myeloma presenting as a pleural effusion is extremely rare. It is usually a late complication and is associated with a poor prognosis. Case Presentation: A 40-year-old male presented with dyspnea and fever of six months duration. Clinical diagnosis of pulmonary tuberculosis was considered. X-ray chest showed bilateral pleural effusion. Pleural cytology revealed numerous plasma cells, some of which were binucleated and atypical. Cytological differential diagnosis included: Myelomatous effusion and Non-Hodgkin's Lymphoma deposit (Immunoblastic type). Bone marrow biopsy, serum protein electrophoresis and bone scan confirmed the diagnosis of multiple myeloma (Plasmablastic type). Conclusion: Myelomatous pleural effusion as an initial presentation although extremely rare, should always be considered in presence of atypical plasma cells irrespective of age.

Barriers to adoption of recent technology in cervical screening

Darshana Jhala — Thu,16 Aug 2007

Darshana Jhala, Isam Eltoum

CytoJournal 2007 4(1):16-16

The Pap smear is one of the modern success stories in the field of preventive medicine. Since its introduction as a screening test, there has been a dramatic reduction in the incidence of cervical cancer. However, the search for a better screening test continues. The new technologies, including liquid-based cytology (LBC), Human Papilloma Virus (HPV) testing and automated or machine-assisted screening have been introduced. However, there is continuous debate about whether society's limited resources are better spent on reaching the underserved rather than on these technologies. Another question is whether these technologies create yet another kind of disparity in delivering preventive care. For example, despite the wide use of LBC (99% of tests submitted to our laboratory are LBC), conventional Pap smears are still used to screen/follow up some women. It is not clear why some providers continue to prefer conventional smear over LBC and what are the barriers for adopting LBC in cervical cancer screening. We hypothesize the lower cost of conventional compared to LBC Pap testing, patient's lower socio-economic indices, a patient's medical history and provider's subspecialty/training all appear to play a role in the choice of using conventional Pap testing rather than LBC. Unintentionally, this choice results in repeat testing, delayed treatment and potentially higher costs than intended. The ultimate goal of this review article is to understand and explore possible barriers and disparities to adopting new technology in cancer screening.

Clear cell sarcoma of the soft parts arising in the rectus abdominis in a child - aspiration cytology of a rare case

Paari Murugan — Sun,15 Jul 2007

Paari Murugan, Debdatta Basu, Surendra Kumar, Sadasivan Jagadish

CytoJournal 2007 4(1):15-15

Background: Clear cell sarcoma of soft parts is most commonly found associated with the tendons and aponeuroses of distal extremities in young adults with a peak incidence in the third decade. Location in the abdominal wall and in a child is very rare. Case presentation: A nine-year-old female child presented with a swelling in the anterior abdominal wall in the suprapubic region. Fine needle aspiration revealed predominantly discrete cells with loose clustering at places. The cytoplasm was abundant, finely granular, and eosinophilic with some cells exhibiting clear vacuolated zones. No pigment was seen. The nuclei were rounded and eccentrically placed with a striking single eosinophilic macro nucleolus present in all the cells. Taking into consideration, the history, age of the patient, location of the tumor and absence of melanin pigment, a diagnosis of soft tissue sarcoma was made, the differential including Clear cell sarcoma. This was subsequently confirmed on histopathological examination and immunohistochemistry Conclusion: The atypical presentation of the case made the cytological diagnosis rather challenging. Clear cell sarcoma should be considered when cytology of a soft-tissue tumor shows uncharacteristically high cellularity and relatively uniform cells with macronucleoli.

Nevoid melanoma of the vagina: Report of one case diagnosed on thin layer cytological preparations

Franco Fulciniti — Tue,3 Jul 2007

Franco Fulciniti, Paolo Antonio Ascierto, Ester Simeone, Patrizia Bove, Simona Losito, Serena Russo, Maria Stella Gallo, Stefano Greggi

CytoJournal 2007 4(1):14-14

Background:Primary melanoma of the vagina is an extremely rare neoplasm with approximately 250 reported cases in the world literature [1-4]. In its amelanotic variant this lesion may raise several differential diagnostic problems in cytological specimens [5]. In this setting, the usage of thin layer cytopathological techniques (Liquid Based Preparations = LBP) may enhance the diagnostic sensitivity by permitting immunocytochemical study without having to repeat the sampling procedure. The aim of this paper is to describe the cytomorphological presentation of primary vaginal melanoma on LBP since it has not previously been reported up to now, to our knowledge. Case presentation: a 79-y-o female complaining of vulvar itching and yellowish vaginal discharge underwent a complete gynaecological evaluation during which a LBP cytological sample was taken from a suspicious whitish mass protruding into the vaginal lumen. A cytopathological diagnosis of amelanotic melanoma was rendered. The mass was radically excised and the patient was treated with α-Interferon. Conclusion: amelanotic melanoma may be successfully diagnosed on LBP cytological preparations. Thin layer preparations may enhance the diagnostic cytomorphological clues to its diagnosis and may permit an adequate immunocytochemical characterization of the neoplasm

Immunohistochemical expression of SMAD4, CK19, and CA19-9 in fine needle aspiration samples of pancreatic adenocarcinoma: Utility and potential role

Mauricio Zapata — Fri,22 Jun 2007

Mauricio Zapata, Cynthia Cohen, Momin T Siddiqui

CytoJournal 2007 4(1):13-13

Background: Pancreatic adenocarcinoma comprises 85% of all cases of pancreatic malignancies. From a diagnostic standpoint, these tumors are readily diagnosed by fine needle aspiration, with an accuracy of greater than 90%; however it is often difficult to ascertain whether these are primary or metastatic in nature. This study was undertaken to see the usefulness of CK19, CA19-9 and a newly described marker, SMAD4 in confirming the pancreatic origin of these tumors. Briefly, SMAD4 (DPC4) is a tumor-suppressor gene located on chromosome 18q which has been shown to mediate the downstream effects of TGF-β superfamily signaling, resulting in growth inhibition. The loss of SMAD4, which as been reported to occur in 55% of pancreatic ductal adenocarcinomas may lead to up regulation of cell cycle proteins and hence increase cellular proliferation. In addition, SMAD4 has been suggested to possibly have prognostic potential, with the presence of SMAD4, indicating shorter survival after resection. Design: Clinical data was reviewed to identify patients with proven, primary pancreatic adenocarcinoma. A total of 25 patients with diagnostic material from fine needle aspiration cell blocks, were retrieved from our files at Emory University Hospital. In addition cell blocks from clinically diagnosed non-pancreatic adenocarcinomas were also selected as controls for this study (10 cases of colonic adenocarcinoma, 10 cases of pulmonary adenocarcinoma, 10 cases of breast ductal carcinoma and 10 cases of ovarian mucinous adenocarcinoma). Formalin fixed, paraffin-embedded sections from these were stained with SMAD4, CK19, and CA19-9, using pressure cooker antigen retrieval, labeled polymer HRP (DAKO), and the DAKO autostainer. Results: Immunohistochemical staining was reviewed based on intensity (negative, low-positive, and high-positive) and percentage of cells. In primary pancreatic ductal adenocarcinoma, CK 19 showed diffuse cytoplasmic positivity in 23 of 25 cases, CA 19-9 showed apical cytoplasmic staining in all 25 cases, and SMAD4 showed nuclear staining in 20 of 25 cases. In the control group comprising of non-pancreatic adenocarcinoma SMAD4 was negative (100%) in all 10 cases of colonic and pulmonary adenocarcinoma. However 1 of 10 cases (10%) of breast and ovarian adenocarcinoma did show low positivity nuclear staining. However the expression of CA19-9 and CK19 was more variable in these different non-pancreatic malignancies. Conclusion :Pancreatic adenocarcinoma showed positive immunohistochemical staining for SMAD4 in 80%, CK19 in 100% and CA19-9 in 100% of the selected cases. These markers, when used as a panel, may confirm the diagnosis of pancreatic adenocarcinoma in fine needle aspiration samples, and help in differentiating from metastatic adenocarcinoma. This may help in determination of appropriate surgical and chemotherapeutic options.

The Best in CytoJournal: 2006

Michael B Cohen — Mon,11 Jun 2007

Michael B Cohen

CytoJournal 2007 4(1):12-12

This year CytoJournal celebrates the second full year of publication with its Best of CytoJournal: 2006. Like last year, it recognizes the work of the authors in thyroid FNAB. And, importantly, this years award, which was handed out at USCAP, was endowed by a gift from the Pathikonda family.

Sequential use of bronchial aspirates, biopsies and washings in the preoperative management of lung cancers

Eric Piaton — Mon,4 Jun 2007

Eric Piaton, Djamal Djelid, Bernard Duvert, Marielle Perrichon, Bernard Saugier

CytoJournal 2007 4(1):11-11

Background: The combination of cytology and biopsies improves the recognition and typing of small cell (SCLC) versus non small cell (NSCLC) lung cancers in the fiberoptic bronchoscopy assessment of centrally located tumours. Methods: We studied whether bronchial aspirates performed before biopsies (BA) and washings performed after biopsies (BW) could increase the diagnostic yield of fiberoptic bronchoscopy. A series of 334 consecutive samples taken in patients with suspicious fiberoptic bronchoscopy findings was studied. Two hundred primary tumours were included in the study. The actual diagnosis was based on surgical tissue specimen analysis and/or imaging techniques. The typing used was that of the 1999 WHO/IASLC classification. Results: The diagnosis of malignancy and tumour typing were analyzed according to the sequential (combined) or single use of tests. Malignancy was assessed by cytology in 144/164 (87.8%) positive biopsy cases and in 174/200 tumour cases (87.0%). BA before biopsies allowed 84.0% of cancers to be diagnosed, whereas BW after biopsies allowed 79.0% of cancers to be found (p = ns). However, combining biopsies with BW allowed 94.0% of cancers to be diagnosed, whereas 82.0% were diagnosed by biopsies alone (p < 0.001). The highest diagnostic yield was obtained with the combination of BA, biopsies and BW, with 97.0% sensitivity. Exact concordance in typing was obtained in 83.8% of cases. The six surgically resected cases (3.0%) with negative cytology and biopsy results included four squamous cell carcinomas with necrotizing or fibrous surface and two adenocarcinomas, pT1 stage. Conclusion: Fiberoptic bronchoscopy may reach a yield of close to 100% in the diagnosis and typing of centrally located, primary lung cancers by combining bronchial aspirates, biopsies and washings.

Lymphocytic Thyroiditis - is cytological grading significant? A correlation of grades with clinical, biochemical, ultrasonographic and radionuclide parameters

Alka Bhatia — Mon,30 Apr 2007

Alka Bhatia, Arvind Rajwanshi, Radharaman J Dash, Bhagwant R Mittal, Akshay K Saxena

CytoJournal 2007 4(1):10-10

Background: Clinical, biochemical, ultrasonographic, radionuclide and cytomorphological observations in Lymphocytic thyroiditis (LT), to define the cytological grading criteria on smears and correlation of grades with above parameters. Methods: This prospective study was conducted on 76 patients attending the Fine needle aspiration cytology clinic of a tertiary care institute in North India. The various parameters like patients' clinical presentation, thyroid antimicrosomal antibodies, hormonal profiles, radionuclide thyroid scan and thyroid ultrasound were studied. Fine needle aspiration of thyroid gland and grading of thyroiditis was done on smears. The grades were correlated with above parameters and the correlation indices were evaluated statistically. Results: Most of the patients were females (70, 92.11%) who presented with a diffuse goiter (68, 89.47%). Hypothyroid features (56, 73.68%) and elevated TSH (75, 98.68%) were common, but radioiodide uptake was low or normal in majority of patients. Thyroid antimicrosomal antibody was elevated in 46/70 (65.71%) patients. Cytomorphology in fine needle aspirates was diagnostic of lymphocytic thyroiditis in 75 (98.68%) patients. Most of them had grade I/II disease by cytology. No correlation was observed between grades of cytomorphology and clinical, biochemical, ultrasonographic and radionuclide parameters. Conclusion: Despite the availability of several tests for diagnosis of LT, FNAC remains the gold standard. The grades of thyroiditis at cytology however do not correlate with clinical, biochemical, radionuclide and ultrasonographic parameters.

Should fine needle aspiration biopsy be the first pathological investigation in the diagnosis of a bone lesion? An algorithmic approach with review of literature

Ravi Mehrotra — Tue,17 Apr 2007

Ravi Mehrotra, Mamta Singh, Premala A Singh, Rahul Mannan, Vinod K Ojha, Pradumyn Singh

CytoJournal 2007 4(1):9-9

Background: Fine needle aspiration biopsy (FNAB) is gaining increasing popularity in the diagnosis of musculoskeletal lesions; and in many patients, a definitive diagnosis can be rendered from aspiration smears alone. Its applicability in bone pathology, however, has been controversial due to a high percentage of inadequate smears, difficulty in evaluation of tissue architecture and nonspecific results in the diagnosis of primary bone lesions. In this study, the value of aspiration as the first pathological investigation in the diagnosis of a bone lesion was evaluated. Methods: 91 cases of clinically suspected cases of bone lesions were aspirated over a period of two years. Direct or cytospin smears were fixed in 95% alcohol and stained by Hematoxylin and Eosin or air-dried and later fixed in methanol for May Grŭnwald Giemsa staining. Results: Of the 91 patients who were subjected to FNAB, 81 were considered satisfactory and 10.9 % (10) were inadequate\inconclusive for diagnosis. Cyto-histological concordance was obtained in 78.5 % (51/65) patients. Positive and negative predictive values were 87.5% and 97.2 % respectively. Sensitivity as a preliminary diagnostic technique was 93.3%, whereas specificity was 94.5 %. Overall, diagnostic accuracy was 94.2 %. Metastatic lesions were detected with 100% accuracy. Two cases were reported as false positive and one case as false negative. Conclusion: Cytology provides valuable information to the clinician to make an informed decision regarding appropriate therapy. We conclude that time-consuming and costly investigations may be reduced by choosing FNAB as the initial pathological diagnostic method for skeletal lesions of unknown origin. The choice of radiological examinations, laboratory tests and surgical biopsies can be determined after the FNAB diagnosis.

Book Review on "Modern Uterine Cytopathology: Moving to the Molecular Smear" by Alexander Meisels MD and Carol Morin, MSc, PhD

Barbara Mahoney — Fri,13 Apr 2007

Barbara Mahoney

CytoJournal 2007 4(1):8-8

Should LSIL with ASC-H (LSIL-H) in cervical smears be an independent category? A study on SurePath™ specimens with review of literature

Vinod B Shidham — Tue,20 Mar 2007

Vinod B Shidham, Nidhi Kumar, Raj Narayan, Gregory L Brotzman

CytoJournal 2007 4(1):7-7

Background: Cervical smears exhibiting unequivocal features of 'low grade squamous intraepithelial lesion' (LSIL) are occasionally also admixed with some cells suspicious for, but not diagnostic of, 'high grade squamous intraepithelial lesion' (HSIL). Only a few studies, mostly reported as abstracts, have evaluated this concurrence. In this study, we evaluate the current evidence that favors a distinct category for "LSIL, cannot exclude HSIL" (LSIL-H), and suggest a management algorithm based on combinations of current ASCCP guidelines for related interpretations. Methods: We studied SurePath™ preparations of cervical specimens from various institutions during one year period. Cytohisto correlation was performed in cases with cervical biopsies submitted to our institution. The status of HPV DNA testing was also noted in some LSIL-H cases with biopsy results. Results: Out of 77,979 cases 1,970 interpreted as LSIL (1,523), LSIL-H (146), 'atypical squamous cells, cannot exclude HSIL' (ASC-H) (109), and HSIL (192) were selected. Concurrent biopsy results were available in 40% (Total 792 cases: 557 LSIL, 88 LSIL-H, 38 ASCH, and 109 HSIL). Biopsy results were grouped into A . negative for dysplasia (ND), B . low grade (HPV, CIN1, CIN1 with HPV), and C . high grade (CIN 2 and above). The positive predictive values for various biopsy results in relation to initial cytopathologic interpretation were: a . LSIL: (557 cases): ND 32% (179), low grade- 58% (323), high grade- 10% (55); b . LSIL-H: (88 cases): ND 24% (21), low grade- 43% (38), high grade- 33% (29); c . ASCH: (38 cases): ND 32% (12), low grade- 37% (14), high grade- 31% (12); d . HSIL (109 cases): ND 5% (6), low grade 26% (28), high grade 69% (75). The patterns of cervical biopsy results in cases reported as LSIL-H were compared with that observed in cases with LSIL, ASC-H, and HSIL. 94% (32 of 34) of LSIL-H were positive for high risk (HR) HPV, 1 was negative for HR HPV but positive for low risk (LR), and 1 LSIL-H was negative for HR and LR both. Conclusion: LSIL-H overlapped with LSIL and ASC-H, but was distinct from HSIL. A management algorithm comparable to ASC-H and HSIL appears to be appropriate in LSIL-H cases.

Introduction of the Thin Prep Imaging System™ (TIS): Experience in a high volume academic practice

Mamatha Chivukula — Thu,8 Feb 2007

Mamatha Chivukula, Reda S Saad, Esther Elishaev, Susan White, Nancy Mauser, David J Dabbs

CytoJournal 2007 4(1):6-6

Objective: Since the introduction of the liquid-based ThinPrep testing in 1996, most cytology laboratories across the country have adopted the liquid-based cytology (LBC) for Pap test screening. Subsequent to wide-spread adoption of the ThinPrep Pap test, the ThinPrep Imaging System (TIS) Cytyc Corp, Marlborough, MA was introduced to improve the accuracy and efficiency of screening interpretation. We report our initial experience with the TIS at Magee Women's Hospital. We introduced the TIS in December 2004. Methods: The imager assisted Pap test results over the first 12 months (December 2004 to December 2005) of implementation were reviewed and analyzed. Our implementation protocol included each cytotechnologist manually prescreening 200 negative slides to gain experience with the imager slides and serve as a quality check for the TIS. We re-screened 3400 slides (200 slides each for 17 cytotechnologists) manually which were initially determined to be negative using the TIS. 104,457 Pap tests were imaged on the TIS. 95,899 manually screened Pap tests, 12 months prior to the introduction of the TIS (December 2003-November 2004) are taken as the historic control group for our study. Results :The mean ASC-US rate employing the automated imager was 8.70% [9088/104,457]. The mean LSIL detection rate was 4.22% [4409/104,457]. The imager did not miss any detectible high-grade lesions during these months, with a HSIL (+) detection rate of 0.68% in comparison to 0.60% by manual screening confirmed by follow-up biopsies. The difference is statistically significant with a p value of 0.022 . The definition of false negative rate for purposes of this study is calculated as the number of false negative cases identified out of number of negatives re-screened. The TIS false negative rate was estimated at 0.012% [4/3400]. Conclusion :The overall performance of the TIS in our lab appears to be highly satisfactory in terms of improving sensitivity in screening cervical precursor lesions. The increased accuracy of detection of HSIL indicates a positive impact of the TIS in our laboratory.

Solitary metastatic cancer to the thyroid: A report of five cases with fine-needle aspiration cytology

Mark W Lee — Tue,30 Jan 2007

Mark W Lee, Yuri K Batoroev, Alexandre N Odashiro, Gia-Khanh Nguyen

CytoJournal 2007 4(1):5-5

Three men and 2 women with ages ranging from 37 to 70 years, clinically and histologically confirmed solitary, palpable metastatic cancers to the thyroid (SMCT) and preoperative cytologic investigation of their thyroid lesions by fine-needle aspiration (FNA), were reviewed. Four patients were known to have a solid cancer treated by radical surgery 1 to 4 years prior [1 bronchogenic squamous cell carcinoma, 1 parotid adenoid cystic carcinoma, 1 renal cell carcinoma (RCC) and 1 cutaneous melanoma], and 1 patient had no past history of cancer. Direct smears prepared from the patients' thyroid FNAs were fixed in 95% ethanol and stained with the Papanicolaou method. In 3 cases, immunostaining of the aspirated tumor cells with thyroglobulin antibody was performed, and in 1 case an aspiration smear was stained with commercial HMB-45 antibody. A correct cytodiagnosis of metastatic cancer to the thyroid was made in all 5 cases. In 1 patient the thyroid FNA revealed a metastatic RCC that led to the discovery of a clinically occult RCC. All 5 patients died of metastatic disease 27 to 40 months after surgical resection of their SMCTs.

Thank you reviewers- CytoJournal 2007

Vinod B Shidham — Tue,30 Jan 2007

Vinod B Shidham, Barbara F Atkinson

CytoJournal 2007 4(1):4-4

Significant efforts, time, and resources are devoted for peer-reviewing numerous CytoJournal manuscripts. The Editorial Board of CytoJournal shares a significant proportion of this activity. Additional peers are requested to join periodically as 'academic editors' and reviewers to review CytoJournal manuscripts. We thank all the reviewers and academic editors for their time and efforts for completing the peer-review of CytoJournal manuscripts during 2006. The continued success of this important academic exercise depends on their continued enthusiasm to support with their highest standards. We also thank all the contributing authors for selecting CytoJournal and supporting open access initiative, which allows retention of the copyrights to their corresponding academic accomplishments.

Cytologic findings in malignant myoepithelioma: a case report and review of the literature

Torill Sauer — Thu,25 Jan 2007

Torill Sauer

CytoJournal 2007 4(1):3-3

Background: Myoepithelioma of the breast is a rare tumor and the cytologic features have only been described in one previous report. Case presentation: The present case comprises a 70 year old woman with a mammographic equivocal and ultrasonographic suspicious lesion. The aspirates were cellular and consisted mainly of single spindle or polymorphic, polygonal cells. The nuclei were generally large, ranging from 2 - > 5 x RBC. Most nuclei had a distinct medium-sized nucleolus. The nuclear outlines were irregular with buds and folds. The chromatin was granular. In the background there was abundant granular metachromatic ground substance and some metachromatic stromal fragments. A few mitotic figures were found. The cytologic diagnosis was suspicious for malignancy and a metaplastic carcinoma where only the non-epithelial component had been aspirated, or a non-epithelial lesion, was suggested. Macroscopically the tumor was round, seemingly well circumscribed, firm and with a white cut surface. The lesion consisted of spindled and polygonal cells with distinct pleomorphism. There were 6-9 mitoses per high power field (HPF). The tumor infiltrated in the surrounding fatty tissue. On immunohistochemistry, tumor cells were positive for smooth muscle actin, keratin MNF 116 and vimentin. Desmin and S-100 were negative. Ultrastructurally, there were abundant tonofilaments, including globular filamentous bodies and granulated endocytoplasmic reticulum with many dilated cisterns. The histologic diagnosis was malignant myoepithelioma. Conclusion: The case mirrors completely the WHO definition and the previous cytological and histological descriptions of malignant myoepitheliomas in the literature which describe a spindle cell population with unequivocal nuclear atypia, metachromatic background substance and mitoses.

Evaluation and significance of hyperchromatic crowded groups (HCG) in liquid-based paps

Mamatha Chivukula — Mon,22 Jan 2007

Mamatha Chivukula, R Marshall Austin, Vinod B Shidham

CytoJournal 2007 4(1):2-2

Objective: Hyperchromatic crowded groups (HCG), a term first introduced into the cytology literature by DeMay in 1995, are commonly observed in Pap tests and may rarely be associated with serious but difficult to interpret lesions. In this study, we specifically defined HCG as dark crowded cell groups with more than 15 cells which can be identified at 10x screening magnification. Methods: We evaluated consecutive liquid-based (Surepath) Pap tests from 601 women (age 17-74 years, mean age 29.4 yrs) and observed HCG in 477 cases. In all 477 HCG cases, Pap tests were found to be satisfactory and to contain an endocervical sample. HCG were easily detectible at 10x screening magnification (size up to 400 um, mean 239.5 um) and ranged from 1 to 50 (mean 19.5) per Pap slide. Results: HCG predominantly represented 3-Dimensional groups of endocervical cells with some nuclear overlap (379/477 - 79%), reactive endocervical cells with relatively prominent nucleoli and some nuclear crowding (29/477 - 6%), clusters of inflammatory cells (25/477 - 5.2%), parabasal cells (22/477 - 4.6%), endometrial cells (1/477 - 0.2%). Epithelial cell abnormalities (ECA) were present in only 21 of 477 cases (4.6%). 18 of 21 women with HCG-associated ECA were less than 40 years old; only 3 were =/> 40 years. HCG-associated final abnormal Pap test interpretations were as follows: ASCUS (6/21 - 28%), LSIL (12/21 - 57%), ASC-H (2/21 - 9.5%), and HSIL/CIN2-3 (3/21 - 14%). The association of HCG with ECA was statistically significant (p = 0.0174. chi-square test). In patients with ECA, biopsy results were available in 10 cases, and 4 cases of biopsy-proven CIN2/3 were detected. Among these four cases, HCG in the Pap tests, in retrospect represented the lesional high grade cells in three cases (one HSIL case and two ASC-H cases). Interestingly, none of the 124 cases without HCG were found to have an epithelial cell abnormality. Conclusion :We conclude: a. HCG are observed in a high proportion of cervical smears. b . In the vast majority of cases, HCG are benign. c. ECA were only observed in cases with HCG. This observation is consistent with the hypothesis that the presence of HCG in Pap tests most often represents adequate sampling of the transformation zone, thus increasing the chances of detecting an epithelial cell abnormality. d. Only a few cases with HCG were associated with a serious ECA, but careful scrutiny of all HCG appears warranted to avoid the potential diagnostic pitfall of a significant false negative interpretation.

Time for evidence-based cytology

Pranab Dey — Mon,8 Jan 2007

Pranab Dey

CytoJournal 2007 4(1):1-1

Evidence-based medicine (EBM) is a fashionable and an extremely hot topic for clinicians, patients and the health service planners. Evidence-based cytology (EBC) is an offshoot of EBM. The EBC is concerned with generating a reproducible, high quality and clinically relevant test result in the field of cytology. This is a rapidly evolving area with high practical importance. EBC is based entirely on research data. The various professional bodies on cytology design and recommend guidelines on the basis of evidences. Once the guideline is implemented and practiced then the experiences of the practicing cytopathologists may be used as a feed back to alter the existing guideline. The various facets of EBC are sampling and specimen adequacy, morphological identification and computer based expert system, integrated reporting, identification of the controversial areas and high quality researches for evidences. It is the duty of the individuals and institutions to practice EBC for better diagnosis and management of the patients. In this present paper, the various aspects of EBC have been discussed.

Liver metastases of pancreatic acinar cell carcinoma with marked nuclear atypia and pleomorphism diagnosed by EUS FNA cytology : A case report with emphasis on FNA cytological findings

Hong Q Peng — Sat,30 Dec 2006

Hong Q Peng, Peter Darwin, John C Papadimitriou, Cinthia B Drachenberg

CytoJournal 2006 3(1):29-29

Background: Acinar cell carcinoma of the pancreas is a rare neoplasm. Although this tumor has been well characterized histologically, the morphological patterns in Fine Needle Aspiration Cytology have not been well defined. Unlike ductal adenocarcinomas, endocrine tumors, and solid pseudopapillary tumors of the pancreas with their characteristic FNA cytological features, acinar cell carcinomas pose a particular diagnostic challenge by sharing many cytomorphologic features with endocrine tumors of the pancreas. Case presentation: A 37-year-old man presented with lower chest and left upper quadrant abdominal pain. Computed tomography revealed a 7.8 x 7.3 cm irregular, partially cystic mass in the body and tail of the pancreas, and two lesions in the liver compatible with metastases. Subsequently, the patient underwent endoscopic ultrasound-guided fine needle aspiration on one of the two metastatic liver masses. FNA cytology revealed abundant, loosely cohesive clusters of malignant epithelial cells with vaguely acinar and trabecular formations. The pleomorphic nuclei had fine granular chromatin and occasionally small nucleoli. There were scant to moderate amounts of cytoplasm. Scattered, strikingly large tumor cells with giant nuclei, prominent mitoses and associated necrosis were evident. A pancreatic endocrine tumor was suspected initially, but acinar cell carcinoma of the pancreas was confirmed by immunohistochemistry, cytochemical and ultrastructural studies. Conclusion: We describe a case of pancreatic acinar cell carcinoma with unusual cytomorphologic features mimicking an endocrine tumor of pancreas, encountered in endoscopic ultrasound-guided fine needle aspiration of a metastatic liver mass and discuss the diagnostic approach for this unusual pancreatic tumor in fine needle aspiration cytology.

Malignant atypical cell in urine cytology : A diagnostic dilemma

Alka Bhatia — Fri,15 Dec 2006

Alka Bhatia, Pranab Dey, Nandita Kakkar, Radhika Srinivasan, Raje Nijhawan

CytoJournal 2006 3(1):28-28

Aims: The aim of this study was to find out the characteristic morphology of malignant atypical cells which were missed on routine cytology of urine. Materials and methods: In this retrospective study, we examined detailed cytomorphology of 18 cases of atypical urinary cytology which were missed on routine examination and were further proved on histopathology as transitional cell carcinoma (TCC) of bladder. The cytological features of these cases were compared with 10 cases of benign urine samples. Results: There were 11 cases of high grade TCC and 7 cases of low grade TCC on histopathology of the atypical urine samples. Necrosis in the background and necrosed papillae were mostly seen in malignant atypical cells. The comet cells and cells with India ink nuclei (single cells with deep black structure-less nuclei) were only observed in malignant atypical cells. The most consistent features in malignant atypical cells were: i) high nuclear and cytoplasmic (N/C) ratio ii) nuclear pleomorphism iii) nuclear margin irregularity iv) hyperchromasia and v) chromatin abnormalities Conclusion: The present study emphasizes that nuclear features such as high N/C ratio, hyperchromasia and chromatin abnormalities are particularly useful for assessing the malignant atypical cells. Other cytological features such as comet cells and cells with India ink nuclei are also helpful for diagnosis but have limited value because they are less frequently seen.

Dynamic telecytopathology of on site rapid cytology diagnoses for pancreatic carcinoma

Burton Kim — Mon,11 Dec 2006

Burton Kim, David C Chhieng, David R Crowe, Darshana Jhala, Nirag Jhala, Thomas Winokur, Mohamad A Eloubeidi, Isam E Eltoum

CytoJournal 2006 3(1):27-27

Background: Diagnosis of pancreatic lesions can be accurately performed by endoscopic ultrasound guided fine needle aspiration (EUS-FNA) with onsite cytopathologists to assess specimen adequacy and to determine a preliminary diagnosis. Considerable time is needed to perform on-site assessments. This takes away work time of cytopathologists and prohibits them from serving remote locations. It is therefore logical to ask if real-time telecytopathology could be used to assess specimen adequacy and if telecytopathology diagnosis has the same level of agreement to the final diagnosis as that of onsite evaluation. In this study, we compare agreement between cytodiagnoses rendered using telecytopathology with onsite and final interpretations. Method: 40 Diff-Quik-stained EUS-FNA were re-evaluated retrospectively (patient ages 31-62, 19:21 male:female, 15 non-malignant lesions, 25 malignant lesions as classified by final diagnosis). Each previously assessed by a cytopathologist and finally reviewed by the same or different cytopathologist. Blinded to the final diagnosis, a resident pathologist re-screened all slides for each case, selected a slide and marked the diagnostic cells most representative of the lesion. Blinded to the diagnosis, one cytopathologist assessed the marked cells through a real time remotely operated telecytopathology system (MedMicroscopy). Diagnosis and time spent were recorded. Kappa statistic was used to compare agreements between telecytopathology vs. original onsite vs. final diagnoses. Results: Time spent for prescreening ranged from 1 to 5 minutes (mean 2.6 +/- 1.3 minutes) and time spent for telecytopathology diagnosis ranged from 2-20 minutes (mean 7.5 +/- 4.5 minutes). Kappa statistics, K, was as follows: telecytopathology versus onsite diagnosis K, 95% CI = 0.65, 0.41-0.88, for telecytopathology versus final K, 95% CI = 0.61, 0.37-0.85 and for onsite diagnosis versus final K, 95% CI = 0.79, 0.61-0.98. There is no significant difference in agreement between onsite and telecytopathology diagnoses. Kappa values for telecytopathology were less than onsite evaluation when compared to the final diagnosis; however, the difference was not statistically significant. Conclusion: This retrospective study demonstrates the potential use of telecytopathology as a valid substitute for onsite evaluation of pancreatic carcinoma by EUS-FNA.

Atlas of Salivary Gland Tumor Cytopathology, Oral & Surgical Pathology - CD-ROM Disk 2: by Kini S. & Dardick I. Pathology Images Inc, 2006

Zainab Basir — Tue,21 Nov 2006

Zainab Basir

CytoJournal 2006 3(1):26-26

This CD-ROM version of Atlas of Salivary Gland Tumor Cytopathology, Oral & Surgical Pathology is an excellent and concise tool for easy reference during sign out of cytology and surgical cases. It is also invaluable as a teaching tool for residents and fellows. Atlas of Salivary Gland Tumor Cytopathology, Oral & Surgical Pathology CD-ROM (ISBN 0-9736518-0-7), Published by Pathology images Inc Ottawa, Ontario K2B 7L4, Canada

Rapid assessment of fine needle aspiration and the final diagnosis--how often and why the diagnoses are changed

Carolyn Woon — Mon,6 Nov 2006

Carolyn Woon, Ricardo H Bardales, Michael W Stanley, Edward B Stelow

CytoJournal 2006 3(1):25-25

Background: On-site rapid interpretation (RI) of fine needle aspiration (FNA) has been shown to increase the diagnostic yield of FNA and decrease the need for repeat diagnostic procedures. Because the pathologist interprets only a fraction of the sample and has limited resources available at such times, an occasional RI diagnosis will be changed at the time of the final diagnosis. We investigated how often these changes in diagnoses occur and the possible reasons for the changes. Methods: All cytology reports from 1/1/02 to 12/31/03 from a single institution were reviewed. Cases with RI with discrepant final diagnoses were noted. The discrepant diagnoses were categorized depending on how they were changed. Possible sources for changed diagnoses were noted. Results: Between 1/1/02 and 12/31/03 there were 1368 RIs of FNAs. Of these 80 (5.8%) had discrepancies between the RIs and final diagnoses. Seventy-eight cases had additional slides and/or cell block at time of final diagnosis. 16 cases had ancillary studies available at final diagnosis. Consultant pathologists were used in 7 cases. Different pathologists interpreted the RI and final diagnosis in 31 cases. Conclusion: Although uncommon, discrepancies between RIs and final diagnoses occur 5.8% of the time at our institution. Most commonly, this involves a change of diagnosis from either "non-diagnostic" or "benign" to "malignancy". Although much of this is likely due to the presence of additional material and information at the time of final diagnosis, the number of cases that had different pathologists involved in the RI and final diagnosis suggests that inter-observer variability may also play some role. This data was originally presented at the 2005 meeting of the United States and Canadian Academy of Pathology in San Antonio, Texas, March, 2005.

Combined applications of fine needle aspiration cytology and flow cytometric immunphenotyping for diagnosis and classification of non Hodgkin lymphoma

Pranab Dey — Fri,27 Oct 2006

Pranab Dey, Thasneem Amir, Aisha Al Jassar, Salem Al Shemmari, Sanjay Jogai, Ganapathi M Bhat, Aisha Al Quallaf, Zahia Al Shammari

CytoJournal 2006 3(1):24-24

Aims and objectives: In this present study we have evaluated the feasibility of sub-classification of non-Hodgkin's lymphoma (NHL) cases according to World Health Organization's (WHO) classification on fine needle aspiration cytology (FNAC) material along with flow cytometric immunotyping (FCI) as an adjunct. Materials and methods: In this five years study, only cases suggested or confirmed as NHL by FNAC were selected and FCI was performed with a complete panel of antibodies (CD3, CD2, CD 4, CD5, CD8, CD7, CD10, CD19, CD20, CD23, CD45, κ and λ) by dual color flow cytometry. Both cytologic findings and FCI data were interpreted together to diagnose and sub-classify NHL according to WHO classification. Wherever possible the diagnoses were compared with cytology. Results: There were total 48 cases included in this study. The cases were classified on FNAC as predominant small cells (12), mixed small and large cells (5) and large cells (26). In five cases a suggestion of NHL was offered on FNAC material and these cases were labeled as NHL not otherwise specified (NHL-NOS). Flow cytometry could be performed in 45 cases (93.8%) and in rest of the three cases the material was inadequate because of scanty blood mixed aspirate. Light chain restriction was demonstrated in 30 cases out of 40 cases of B-NHL (75%). There were 15 cases each of ? and ? light chain restriction in these 30 cases. With the help of combined FCI and FNAC, it was possible to sub-classify 38 cases of NHL (79%) according to WHO classification. Combined FNAC and FCI data helped to diagnose 9 cases of small lymphocytic lymphoma (SLL), 2 cases of mantle cell lymphoma (MCL), 4 cases of follicular lymphoma (FL), 17 cases of diffuse large B lymphoma (DLBL) and 6 cases of lymphoblastic lymphoma. Histopathology diagnosis was available in 31 cases of NHL out of which there were 14 recurrent and 17 cases of primary NHL. Out of 15 DLBL cases diagnosed on FCI and FNAC, histology confirmed 14 cases and one of these cases was diagnosed as Burkitt's lymphoma on histology. Cases of FL (4), SLL (3) and MCL (2) were well correlated with histopathology. Out of the five cases suggestive of NHL on cytology, histopathology was available in four cases. Histology diagnosis was given as DLBL (1), SLL (1), anaplastic large cell lymphoma (1) and FL transformed into large cell NHL (1). Considering histopathology as gold standard, diagnostic specificity of combined FNAC and FCI was 100% (31/31) and sensitivity in sub-classification was 83.8% (26/31). Conclusion: FNAC combined with FCI may be helpful in accurately sub-classifying NHL according to WHO classification. Many of the subtypes of NHL such as FL and MCL which were previously recognized as a pure morphologic entity can be diagnosed by combined use of FNAC and FCI. Other ancillary investigations such as chromosomal changes, cell proliferation markers etc. may be helpful in this aspect.

Diffuse large B cell lymphoma of thyroid as a masquerader of anaplastic carcinoma of thyroid, diagnosed by FNA : A case report

Yahya Daneshbod — Thu,19 Oct 2006

Yahya Daneshbod, Shapour Omidvari, Khosrow Daneshbod, Shahrzad Negahban, Mehdi Dehghani

CytoJournal 2006 3(1):23-23

Background: Both thyroid lymphoma and anaplastic carcinoma of thyroid present with rapidly growing mass in eldery patients. Anaplastic carcinoma has high mortality rate and combination of surgery, radiation therapy and multidrug chemotherapy are the best chance for cure. Prognosis of thyroid lymphoma is excellent and chemotherapy for widespred lymphoms and radiotherapy with or without adjuvant chemotherapy for tumors localized to the gland, are the treatment of choice. Case report: This article reports a 70 year old man presenting with diffuse neck swelling and hoarseness of few weeks duration. Fine needle aspiration was done and reported as anaplastic carcinoma of thyroid which thyroidectomy was planned. The slides were sent for second opinion. After review, with initial diagnosis of anaplastic carcinoma versus lymphoma, immunocytochemical study was performed. Smears were positive for B cell markers and negative for cytokeratin, so with the impression of diffuse large B cell lymphoma, the patient received two courses of chemotherapy by which the tumor disappeared during two weaks. Conclusion: Despite previous reports, stating easy diagnosis of high-grade thyroid lymphoma on the grounds of cytomorphological features we like to emphasize, overlapping cytologic features of the curable high grade thyroid lymphoma form noncurable anaplastic thyroid carcinoma and usefulness of immunocytochemistry to differentiate these two disease.

Alveolar proteinosis in a patient recovering from Pneumocystis carinii infection : A case report with a review of literature

Petio V Kotov — Thu,12 Oct 2006

Petio V Kotov, Vinod B Shidham

CytoJournal 2006 3(1):22-22

Background: Pulmonary alveolar proteinosis is a rare lung disorder, which was first reported as idiopathic condition in 1958. The prevalence of acquired pulmonary alveolar proteinosis has been estimated to be 0.37 per 100,000 population. The cause of this condition is not entirely clear. We present alveolar proteinosis in a case recently treated for pulmonary Pneumocystis carinii infection. Case presentation: A 25-year-old Caucasian female presented with shortness of breath during management of acute pancreatitis. She had a heart-transplant six years ago, a distal pancreatectomy secondary to pancreatitis two years ago, chronic renal failure secondary to Prograft taken for six years to suppress transplant rejection, and a more recent history of Pneumocystis carinii infection treated in the preceding 21 days with augmented doses of Bactrim (Trimethoprim, Sulfamethoxazole). She had bilateral pleural effusions with radiological and clinical features suspicious for interstitial lung disease. Cytopathologic evaluation of broncho-alveolar lavage (BAL) showed hyaline alveolar casts admixed with amorphous debris and scant chronic inflammatory cells, consistent with alveolar proteinosis. GMS and PAS stains were negative for P. carinii. Direct Fluorescent Antibody (DFA) test for P. carinii performed on the BAL specimen in our Microbiology Lab had been repeatedly negative. Conclusion: Cytopathological findings in bronchoalveolar lavage, with clinical differential diagnosis of interstitial lung disease, were diagnostic. Pulmonary alveolar proteinosis after recent treatment for P. carinii infection suggests a relationship of pulmonary alveolar proteinosis with P. carinii infection in the immunocompromised patient.

The Best in CytoJournal: 2005

Michael B Cohen — Wed,13 Sep 2006

Michael B Cohen

CytoJournal 2006 3(1):21-21

CytoJournal opened its doors in late 2004 and 2005 was the first full year of publication. In order to celebrate this event as well as recognize the contributing authors works, CytoJournal has initiated a Best Article of the Year, in this case 2005. This year's Best of CytoJournal: 2005 is an excellent review of thyroid FNAB.

Biphasic parapharyngeal synovial sarcoma : A cytologic and immunocytologic report of a case

Bijan Khademi — Mon,14 Aug 2006

Bijan Khademi, Yahya Daneshbod, Shahrzad Negahban, Khosrow Daneshbod, Massud Kaviani, Mohammad Mohammadianpanah, Mohammad J Ashraf

CytoJournal 2006 3(1):20-20

Background: Synovial sarcoma is a rare soft tissue sarcoma in the head and neck region and parapharyngeal space. There is no previous cytologic report of synovial sarcoma of parapharynx. The cytologic and immunocytochemical findings of a parapharyngeal biphasic synovial sarcoma together with diagnostic pitfalls are described. Case report: A 21-year-old girl presented with a 6-month history of progressive right arm pain, neck mass and upper aerodigestive tract obstruction. On physical examination there was a large painless mass arising from the right-sided parapharyngeal space causing airway obstruction. Initial magnetic resonance imaging (MRI) revealed a large tumor in the right-sided parapharyngeal space. Fine needle aspiration through cervical region was performed and was reported as benign spindle cell tumor. Smears were cellular and composed mostly of tight and loose clusters of spindle cells. Epitheloid cells could also be identified intermingled with them. She underwent near total resection of the tumor. Pathologic report disclosed the diagnosis of synovial sarcoma. She then received postoperative adjuvant external radiotherapy. Conclusion: Due to rarity of this tumor in this region and nonspecific cytologic features, we could not differentiate this tumor from the other more common spindle cell neoplasms. Considering synovial sarcoma in this region and immunocytochemistry can be helpful in rendering a correct initial diagnosis of this tumor.

Cytodiagnosis of multiple myeloma presenting as orbital involvement : A case report

Alok Sharma — Thu,10 Aug 2006

Alok Sharma, Manju Kaushal, Nishith K Chaturvedi, Rajbala Yadav

CytoJournal 2006 3(1):19-19

Background: Plasma cell neoplasms represent autonomous proliferations of plasma cells and can manifest as diffuse myeloma with systemic involvement (plasma cell myeloma or multiple myeloma), monoclonal gammopathy of undetermined significance (MGUS), or as variants of plasma cell myeloma such as indolent myeloma, smoldering myeloma, osteosclerotic myeloma, plasma cell leukaemia and non-secretory myeloma. Localized neoplastic proliferation of plasma cells presents as solitary plasmacytoma of bone or extramedullary plasmacytoma. Involvement of orbit can occur as a solitary plasmacytoma, or as part of systemic involvement in multiple myeloma, the clinical outcome being significantly worse in the latter setting. Orbital involvement in multiple myeloma is very rare with less than 50 cases reported in the literature. Early cytological diagnosis of such lesions is vital for timely institution of appropriate therapy. As far as we are aware only six previous cases of cytological diagnosis of multiple myeloma involving the orbit are on record. Case presentation: A 37 year old male presented with low grade fever showing evening rise, headache, diplopia and swelling in the right periorbital and temporal region. Imaging studies revealed destructive lesion of sphenoid, frontal bone and zygomatic arch with soft tissue component extending to infratemporal fossa and orbit. A fine needle aspirate from the temporal region swelling showed features of a plasmacytoma, and subsequent workup confirmed the presence of systemic disease. A final diagnosis of multiple myeloma with orbital involvement at presentation was made. Conclusion: Present case describes the extremely rare presentation of multiple myeloma with orbital involvement and highlights the utility of cytology in such lesions. Fine needle aspiration diagnosis of plasmacytoma at extramedullary sites offers an opportunity for non-invasive verification of systemic involvement, and thus plays a major role in early diagnosis and management of these patients.

Immunohistochemical detection of hTERT in urothelial lesions : A potential adjunct to urine cytology

Walid Khalbuss — Thu,10 Aug 2006

Walid Khalbuss, Steve Goodison

CytoJournal 2006 3(1):18-18

Background: Urine cytology has a critical role in evaluation for bladder carcinoma. Due to the low sensitivity of this technique, ancillary modalities such as the detection of markers of malignancy by immunochemistry are desirable. Promising factors in this context are components of the human telomerase enzyme complex. Telomerase repairs and extend telomeres, which when eroded beyond a critical limit trigger a senescence checkpoint. Accordingly, while absent in normal somatic cells, telomerase activity has been detected in the great majority of malignant tumor specimens tested, and so has potential value for the recognition of malignant cells in clinical specimens. Methods: In this study, we investigated whether the immunohistochemical detection of the catalytic subunit of telomerase (hTERT) can aid cytology in the diagnosis of bladder lesions. Findings from the retrospective evaluation of over 100 cell blocks, including urine sediments from confirmed malignant and benign conditions, were compared with routine urine cytology data. Results: The presence of hTERT protein was indicative of the transformation of urothelia to a malignant phenotype. Nucleolar hTERT was expressed in 27 (93%) of 29 samples obtained from patients with confirmed primary bladder cancer. Conversely, hTERT was detectable in only 3 (0.8%) of 39 samples from benign conditions. The hTERT assay showed higher diagnostic sensitivity (84.8%) than published urine cytology data (~65%) for confirmed bladder carcinoma, however, the hTERT assay was less specific than cytology (65.2% vs. ~95% respectively). Conclusion : As a highly sensitive marker, immunohistochemical hTERT detection in urine sediments represents a reliable adjunct to cytology in the accurate diagnosis of urothelial neoplasms.

Lack of BRAF mutations in hyalinizing trabecular neoplasm

Zubair W Baloch — Tue,25 Jul 2006

Zubair W Baloch, Kanchan Puttaswamy, Marcia Brose, Virginia A LiVolsi

CytoJournal 2006 3(1):17-17

The hyalinizing trabecular neoplasm (HTN) of the thyroid is an unusual and controversial lesion. Some consider it a peculiar type of papillary thyroid carcinoma (PTC) because of its nuclear features and presence of psammoma bodies. Others consider it an adenoma. Molecular studies have found RET/PTC translocations in some examples, supporting HTN as a PTC; however mutations in BRAF (another marker for PTC) have not been found. We report two cases of classic HTN and a case of trabecular PTC and show BRAF mutations in the latter and not in HTN. Trabecular growth pattern is insufficient for a diagnosis of HTN and lesions with such a pattern and nuclear features of PTC are cancers. Morphologically classic HTN are not associated with metastatic potential and should be considered adenomas.

Fine needle aspiration cytology of bone tumours--the experience from the National Orthopaedic and Lagos University Teaching Hospitals, Lagos, Nigeria

Obiageli E Nnodu — Thu,15 Jun 2006

Obiageli E Nnodu, SO Giwa, Samuel U Eyesan, Fatima B Abdulkareem

CytoJournal 2006 3(1):16-16

Background: Due to difficulty in confirming clinical suspicions of malignancy in patients presenting with bone tumours, the cost of surgical biopsies where hospital charges are borne almost entirely by patients, competition with bone setters and healing homes with high rate of loss to follow up; we set out to find if sufficient material could be obtained to arrive at reliable tissue diagnosis in patients with clinical and radiological evidence of bone tumours in our hospitals. Methods: After initial clinical and plain radiographic examinations, patients were sent for fine needle aspirations. Aspirations were carried out with size 23G needles of varying lengths with 10 ml syringes in a syringe holder (CAMECO, Sebre Medical, Vellinge, Sweden). The aspirates were air dried, stained by the MGG method and examined microscopically. Histology was performed on patients who had subsequent surgical biopsy. These were then correlated with the cytology reports. Results: Out of 96 patients evaluated, [57 males, 39 females, Mean age 31.52 years, Age Range 4-76 years,] material sufficient for diagnosis was obtained in 90 patients. Cytological diagnosis of benign lesions was made in 40 patients and malignant in 47. Of these, 27 were metastases, osteogenic sarcoma 16, giant cell tumour 19, infection 11. Histology was obtained in 41 patients. Correct diagnosis of benignity was made in 17 out of 18 cases, malignancy in 21 out of 22 cases. One non-diagnostic case was malignant. The accuracy of specific cytological diagnosis was 36/41 (87.8%) and incorrect in 5/41 (12.2%). Conclusion: We conclude that FNAC can be useful in the pre-operative assessment of bone tumours especially where other diagnostic modalities are unavailable.

High grade squamous intraepithelial lesion in inmates from Ohio : Cervical screening and biopsy follow-up

Daniela M Proca — Wed,10 May 2006

Daniela M Proca, Soraya Rofagha, Sedigheh Keyhani-Rofagha

CytoJournal 2006 3(1):15-15

Background: Cervical carcinoma remains the second leading cause of cancer death in women worldwide and sexual behavior is regarded as the main contributing factor. We studied cervical cytology screening with surgical biopsy follow-up in women prisoners and compared the findings to those in the general population. Methods: We reviewed 1024 conventional cervical smears, 73 cervical biopsies and 2 loop electrosurgical excision procedure (LEEP) specimens referred to us from the Correctional Center in Columbus, Ohio during a 12-month period. The results were compared to 40,993 Pap smears from the general population for the same 12-month period. Results: High grade squamous intraepithelial lesion (HGSIL) was diagnosed in 1.3% of the cervical smears from the inmate population versus 0.6% in the general population (p < 0.01). The unsatisfactory rate was 1.6% compared to 0.3% in the general population (p < 0.01). Among the study population, follow-up tissue diagnosis was obtained in 24.3% of the abnormal cytology results (ASCUS, LGSIL, and HGSIL). Of the HGSIL Pap smears, 61.5% had a subsequent tissue diagnosis. Thirty-nine biopsies (52% of the all inmate biopsies and LEEP) showed CIN II/III (cervical intraepithelial neoplasia II/III). Eight of these thirty-nine follow-up biopsies diagnosed as CIN II/III had a previous cervical cytology diagnosis of ASCUS. The average age for HGSIL was 30.5 years (S.D. = 5.7) and for low grade squamous intraepithelial lesion (LGSIL) was 27.2 years (S.D. = 6.1). Conclusion: A significantly higher prevalence of HGSIL cervical cytology and unsatisfactory smears was encountered in female inmates, with tissue follow-up performed in less than two thirds of the patients with HGSIL. These results are in keeping with data available in the literature suggesting that the inmate population is high-risk and may be subject to less screening and tissue follow-up than the general population. Clinicians should proceed with urgency to improve screening and follow-up with treatment. The inmate population should be targeted for HPV vaccination promptly after FDA approval.

ASC-H in Pap test--definitive categorization of cytomorphological spectrum

Mamatha Chivukula — Wed,10 May 2006

Mamatha Chivukula, Vinod B Shidham

CytoJournal 2006 3(1):14-14

Objective: The American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines for management of ASC-H is colposcopic examination followed by biopsy. HPV testing (HPVT) is recommended after a negative biopsy result. More definitive interpretation of ASC-H could prevent discomfort and minimize the cost. The purpose of this study was to evaluate association of various cytomorphological patterns of ASC-H with various clinical scenarios. Methods: We reviewed SurePath™ (TriPath Imaging, Inc. Burlington, NC, USA) cervical smears interpreted as ASC-H in 161 women (mean age, 37 {15 to 78} years), over 24 months (2002 to 2003). HPVT (Digene, Hybrid Capture ® II HPV test, Digene Corporation, Gaithersburg, MD, USA) was performed in 20% of cases (33/161) and biopsy results were available in 54 cases (19 with and 35 without HPVT). Results: HPVT was positive in 64% (21/33) cases, and negative in 36% (12/33) cases. In the follow-up biopsies of 71% (15/21) of cases with positive HPVT, 27% showed HPV changes or CIN1, 27% showed CIN2-3, and 46% were negative for epithelial abnormality. Follow-up biopsies from cases with negative HPVT (33%, 4/12 cases), 8% showed CIN1 and 25% were negative for any epithelial abnormality. Six cytomorphological patterns of ASC-H correlated with different clinical categories in relation to HPVT and biopsy results. 35% (19 out of 54 ASC-H cases in which biopsy results were available) could be interpreted definitively as HSIL by cytopathology, 11% (6/54) cases as LSIL with cyanophilic atypical parakeratotic pattern, and 31% (17/54) cases as reactive, with HPV status. The interpretation had to be continued as ASC-H in 22% (12/54) cases. Conclusion: ASC-H demonstrated a spectrum of cytomorphological patterns. Some of these patterns in liquid-based cervical smears may be more specifically interpreted as LSIL, HSIL, or benign if HPV status is known.

T-cell lymphoproliferative disorder of hand-mirror cell morphology presenting in an eosinophilic loculated peritoneal effusion, with omental "caking"

Richard Siderits — Mon,8 May 2006

Richard Siderits, Janusz Godyn, Dearon Tufankjian, Osman Ouattara

CytoJournal 2006 3(1):13-13

Background: Cells with "hand mirror" morphology have not, to the best of our knowledge, been described in a primary effusion sample. This paper describes a case of T-cell lymphoma with eosinophilia in a patient with suspected peritoneal carcinomatosis. Rarely, a T-cell lymphoproliferative process may mimic primary peritoneal carcinomatosis, clinically suggested by a presentation in CT imaging of omental caking with bilateral massive loculated effusions in a patient without lymphadenopathy or splenomegaly. Methods: A 60 year old caucasian male presented with vague abdominal discomfort and increasing abdominal girth. Computed tomography showed a two centimeter thick omental cake and a small loculated effusion. The clinical presentation and imaging findings were most consistent with peritoneal carcinomatosis. Cytologic evaluation of the effusion was undertaken for diagnostic study. Results: Rapid intraprocedural interpretation of the effusion sample showed a monomorphic population of cells with "hand-mirror" cell morphology exhibiting cytoplasmic extensions (uropodia) with 3-5 course dark cytoplasmic granules and a rim of vacuolated cytoplasm capping the opposing "mirror head" side. These cells were seen within a background of mature eosinophils. Flow cytometric evaluation of the ascites fluid demonstrated an atypical T-cell population with the following immunophenotype: CD2-, CD3+, CD4-, CD5-, CD7-, CD8+, CD56+. T-cell receptor (TCR) gene rearrangement was positive for clonal TCR-gamma gene rearrangement, supporting the diagnosis of a T-lymphoprolifereative disorder. Conclusion: A T-cell lymphoproliferative process may present with "hand mirror" morphology in an effusion sample. These cells may show polar cytoplasmic vacuolization and 3-5 course granules within the "handle" of these unique cells. Cytoplasm shows peripheral constriction around the nucleus.

Fast drying of Fine Needle Aspiration slides using a hand held fan : Impact on turn around time and staining quality

Mirza A Baig — Wed,19 Apr 2006

Mirza A Baig, Lamia Fathallah, Jining Feng, Mujtaba Husain, David G Grignon, Mousa A Al-Abbadi

CytoJournal 2006 3(1):12-12

To analyze the impact of using a hand held fan to speed the air-drying process during immediate adequacy evaluation of Fine Needle Aspirations. The effect on turn around time and staining quality is evaluated. Two mirror image air-dried smears for each pass were prepared. One was subjected to a small hand-held fan with a fan diameter of 7 cm held an average distance of 3 to 5 cm from the slide. The other smear was left to dry without a fan. A total of 93 consecutive pairs were evaluated over a 2-month duration. The average time needed for air-drying using the fan was 73 seconds (range 10-300 seconds, standard error 6.986), while it was 200 seconds (range 15-645 seconds, standard error 17.799) for those without fan. This difference was statistically significant (p < 0.001). Smears were then evaluated for single cells, cell clusters and background material and no appreciable difference in stain quality was noted between the 2 groups. The use of a small hand-held fan for air-drying shortened the drying time for FNA adequacy by an average of 127 seconds (63% time reduction) for each pass. The quality of staining was comparable. Using a fan is highly recommended.

Scientific issues related to the cytology proficiency testing regulations

George Birdsong — Tue,18 Apr 2006

George Birdsong, Lydia Howell, Karen Atkison, R Marshall Austin, Marluce Bibbo, Thomas A Bonfiglio, Diane D Davey, Catherine Keebler, Dina Mody, Lynnette Savaloja, Jacalyn Papillo, Marianne Prey, Stephen Raab, Brenda L Schultz, Diane Solomon

CytoJournal 2006 3(1):11-11

The member organizations of the Cytology Education and Technology Consortium believe there are significant flaws in current cytology proficiency testing regulations. The most immediate needed modifications include lengthening the required testing interval, utilizing stringently validated and continuously monitored slides, changing the grading scheme, and changing the focus of the test from the individual to laboratory level testing. Integration of new computer-assisted and located-guided screening technologies into the testing protocols is necessary for the testing protocol to be compliant with the law.

Utility of BRAF V600E mutation detection in cytologically indeterminate thyroid nodules

Leslie R Rowe — Mon,10 Apr 2006

Leslie R Rowe, Brandon G Bentz, Joel S Bentz

CytoJournal 2006 3(1):10-10

Background: Fine needle aspiration (FNA) is widely utilized for evaluation of patients with thyroid nodules. However, approximately 30% are indeterminate for malignancy. Recently, a mutation in the BRAF gene has been reported to be the most common genetic event in papillary thyroid carcinoma (PTC). In this retrospective study, we assessed the utility of BRAF V600E mutation detection for refining indeterminate preoperative cytologic diagnoses in patients with PTC. Methods: Archival indeterminate thyroid FNAs and corresponding formalin-fixed, paraffin-embedded (FFPE) surgical samples with PTC were identified in our patient files. DNA extracted from slide scape lysates and 5 μm FFPE sections were evaluated for the BRAF V600E mutation using LightCycler PCR and fluorescent melting curve analysis (LCPCR). Amplification products that showed deviation from the wild-type genomic DNA melting peak, discordant FNA and FFPE matched pairs, and all benign control samples, underwent direct DNA sequencing. Results: A total of 19 indeterminate thyroid FNAs demonstrating PTC on FFPE surgical samples were included in the study. Using BRAF mutation analysis, the preoperative diagnosis of PTC was confirmed in 3/19 (15.8%) FNA samples that could not be conclusively diagnosed on cytology alone. However, 9/19 (47.4%) FFPE tissue samples were positive for the V600E mutation. Of the discordant pairs, 5/6 FNAs contained less than 50% tumor cells. Conclusion: When used with indeterminate FNA samples, BRAF mutation analysis may be a useful adjunct technique for confirming the diagnosis of malignancy in an otherwise equivocal case. However, overall tumor cell content of some archival FNA smear slides is a limiting factor for mutation detection.

Fine-needle aspiration of follicular lesions of the thyroid. Diagnosis and follow-Up

M Salih Deveci — Fri,7 Apr 2006

M Salih Deveci, Güzin Deveci, Virginia A LiVolsi, Zubair W Baloch

CytoJournal 2006 3(1):9-9

The differential diagnosis of a follicular lesion/neoplasm in thyroid FNA specimens includes hyperplastic/adenomatoid nodule, follicular adenoma and carcinoma, and follicular variant of papillary thyroid carcinoma. In our laboratory we separate follicular lesions of thyroid into hyperplastic/adenomatoid nodule (HN), follicular neoplasm (FON) and follicular derived neoplasm with focal nuclear features suspicious for papillary thyroid carcinoma (FDN). This study reports our experience with 339 cases diagnosed as FON and 120 as FDN. All cases were evaluated for histologic diagnosis, age, sex and size of the nodule. Histopathologic follow-up was available in all cases. The malignancy rate was 22% (74/359) and 72% (86/120) for cases diagnosed as FON and FDN, respectively. In the FON category almost half of the malignant cases were papillary carcinoma. The risk of malignancy was higher in patients younger than 40 yr (53% vs. 30%) than in patients 40 year or more years old and greater in males (41% vs. 33%) than females. No statistically significant relationship was noted between the sizes of the nodules and benign vs. malignant diagnosis. According to this study it is important to divide follicular patterned lesions of thyroid into FON and FDN in the cytology specimens due to significantly different risk of malignancy (22% vs. 72%). In addition, clinical features, including gender and age can be part of the decision analysis in selecting patients for surgery.

Sclerosing lobular hyperplasia of breast : Cytomorphologic and histomorphologic features : A case report

Payal Kapur — Mon,3 Apr 2006

Payal Kapur, Dinesh Rakheja, Dominick C Cavuoti, Sarah F Johnson-Welch

CytoJournal 2006 3(1):8-8

Background: Mammary sclerosing lobular hyperplasia is an uncommon benign lesion of adolescent and young women. Fine-needle aspiration cytology of mammary sclerosing lobular hyperplasia is said to show characteristic features that include an absence of stromal fragments. Case presentation: In this article, we describe a case of sclerosing lobular hyperplasia that occurred in the right breast of a 12-year-old girl. Fine-needle aspiration cytology showed some fibroadenoma-like features including the presence of stromal fragments, while branched tubular fragments were not seen. The diagnosis of sclerosing lobular hyperplasia was made on histologic examination that showed preserved acinar architecture with lobular hyperplasia and sclerosis of intralobular and interlobular stroma. Conclusion: Fine-needle aspiration cytology features of mammary sclerosing lobular hyperplasia are not diagnostic and overlap with those of fibroadenoma; however, a distinction between the two benign entities is of no clinical significance. The definitive diagnosis of sclerosing lobular hyperplasia requires histopathologic evaluation.

Aspergillosis with pulmonary echinococcosis

Nalini Gupta — Thu,30 Mar 2006

Nalini Gupta, Julie Arora, Raje Nijhawan, Ritesh Aggarwal, Anupam Lal

CytoJournal 2006 3(1):7-7

Ultrasound guided fine needle aspiration biopsy of parathyroid gland and lesions

Haytham Dimashkieh — Tue,28 Mar 2006

Haytham Dimashkieh, Savitri Krishnamurthy

CytoJournal 2006 3(1):6-6

Background: Parathyroid gland and their tumors comprise a small proportion of non-palpable neck masses that are investigated by ultrasound (US) guided fine needle aspiration biopsy. We reviewed our institution's cases of US guided FNAB of parathyroid gland and their lesions to determine the role of cytology for the preoperative diagnosis of parathyroid gland and their lesions. Method: All cases of FNAB of parathyroid gland and lesions in the last 10 years were reviewed in detail with respect to clinical history and correlated with the histopathologic findings in available cases. The cytologic parameters that were evaluated included cellularity assessed semiquantitatively as scant, intermediate or abundant (<50, 51-500 or >500 cells), cellular distribution (loose clusters, single cells/naked nuclei, rounded clusters, two- and three-dimensional clusters, and presence of prominent vascular proliferation), cellular characteristics (cell size, nuclear shape, presence/absence of a nucleolus, degree of mitosis, amount of cytoplasm, and appearance of nuclear chromatin), and background (colloid-like material and macrophages). Immunostaining for parathyroid hormone (PTH) was performed on selected cases using either destained Pap smears or cell block sections. Results: Twenty cases of US-guided FNAB of parathyroid glands and their lesions including 13 in the expected locations in the neck, 3 in intrathyroid region, 3 in thyroid bed, and 1 metastatic to liver were studied. Majority of the cases showed intermediate cellularity (51-500 cells) with round to oval cells that exhibited a stippled nuclear chromatin, without significant pleomorphism or mitotic activity. The cells were arranged in loose two dimensional groups with many single cells/naked nuclei around the groups. Occasionally macrophages and colloid like material was also encountered. There was no significant difference in the cytomorphologic features between normal gland, hyperplasia adenoma, or carcinoma. Immunocytochemical analysis for PHT was performed for 14 cases (6 destained smears and 8 cell blocks) which showed distinct cytoplasmic positivity. Conclusion: US-guided FNAB is a useful test for confirming the diagnosis of not only clinically suspected parathyroid gland and lesions but also for detecting parathyroid glands in unexpected locations such as in thyroid bed or within the thyroid gland. Although there is significant overlap in the cytomorphologic features of cells derived from parathyroid and thyroid gland, the presence of stippled nuclear chromatin, prominent vascular proliferation with attached epithelial cells, and frequent occurrence of single cells/naked nuclei are useful clues that favor parathyroid origin. Distinction of the different parathyroid lesions including hyperplasia, adenoma, and carcinoma cannot be made solely on cytology. Immunostaining for PTH can be performed on destained Pap smears and cell block sections which can be valuable for confirming parathyroid origin of the cells.

First CytoJournal Peer-Reviewer's Retreat in 2006 - Open access, peer-review, and impact factor

Vinod B Shidham — Mon,27 Mar 2006

Vinod B Shidham, Lynn Sandweiss, Barbara F Atkinson

CytoJournal 2006 3(1):5-5

CytoJournal organized its first Peer-Reviewer's Retreat of 2006 during the United States and Canadian Academy of Pathology Annual Meeting at Atlanta on Feb 12, 2006. The major topics discussed were open access, peer review, and impact factors. Representative participants volunteered to join the task force to prepare an instructional guide for peer-reviewing cytopathology manuscripts. Concern about the impact factor for CytoJournal was discussed. A feedback to its readers and authors was recommended. Impact factor calculation needs at least three years of journal statistics. It is only possible after two years from the time a journal is first accepted by Thomson-ISI for citation tracking. CytoJournal is still too new for an impact factor to be calculated. However, general progress of CytoJournal suggests an encouraging pattern for high impact factor.

Randomized clinical evaluation of self-screening for anal cancer precursors in men who have sex with men

Thomas M Lampinen — Mon,20 Mar 2006

Thomas M Lampinen, Mary Lou Miller, Keith Chan, Aranka Anema, Dirk van Niekerk, Arn J Schilder, Robert Taylor, Robert S Hogg

CytoJournal 2006 3(1):4-4

Background: Self-collection of anorectal swab specimens could greatly facilitate the completion of prerequisite studies and future implementation of anal cancer screening among men who have sex with men (MSM). We therefore compared self- versus clinician- collection procedures with respect to specimen adequacy for cytological evaluation, concordance of paired cytological results, and concordance of cytological with biopsy results. Methods: Paired self- and clinician- collected anorectal Dacron ® swabs for liquid-based (Thin Prep ® ) cytological evaluation were collected in random sequence from a mostly HIV-1 seronegative cohort of young MSM in Vancouver. Slides were reviewed by one cytopathologist. Presence of any cytological abnormality (atypical squamous cells of uncertain significance, ASCUS, or above) prompted referral for high-resolution anoscopy and possible biopsy. Results: Among 222 patient-clinician specimen pairs, most were adequate for cytological evaluation, though self-collected specimens were less likely to be so (83% versus 92%, McNemar's test p < 0.001). Cytological abnormalities, noted in 47 (21%) of self-collected and 47 (21%) of clinician-collected specimens (with fair agreement, kappa = 0.414) included, respectively: ASCUS (5%, 5%), and low-grade (13%, 13%) and high-grade (3%, 3%) squamous intraepithelial lesions. Among 12 men with biopsy-confirmed high-grade neoplasia, most had abnormal cytological results (including 6 patient and 9 clinician swabs) but few (2 patient and 1 clinician swab) were high-grade. Conclusion: Self-collection of anorectal swab specimens for cytologic screening in research and possibly clinical settings appears feasible, particularly if specimen adequacy can be further improved. The severity of biopsy-confirmed anorectal disease is seriously underestimated by cytological screening, regardless of collector.

Cytologic findings of peripheral T-cell lymphoma (PTCL) with high epitheloid cell content (Lennert's lymphoma) in imprint smear. A case report

Yahya Daneshbod — Mon,6 Feb 2006

Yahya Daneshbod

CytoJournal 2006 3(1):3-3

Background: Lymphoepitheloid lymphoma is a T-cell lymphoma with peculiar histologic picture with massive proliferation of epitheloid cell clusters intermingled with many, mostly small-sized lymphoid cells. The cytomorphologic features in imprint of a case of lymphoepitheloid T-cell lymphoma is described together with diagnostic pitfalls. Case report: A 74 years old man presented with weight loss, anemia and fever. Physical examination showed bilateral cervical lymphadenopathy with hepatosplenomegaly. With the clinical impression of hypersplenic syndrome vs lymphoma, excisional biopsy of a lymph node was performed and both imprints and histologic sections made. Cytologic findings showed uniform isolated small lympocytes with closely intermingled scattered and aggregates of epitheloid cells. Histologic sections were diagnosed as lymphoepitheloid lymphoma (Lennert's lymphoma). Conclusion: Cytologic findings of this variant of lymphoma is distinctive enough for a correct initial suggestive diagnosis. However the presence of high content of epitheloid cell clusters can cause cytologic misinterpretation with other benign and malignant conditions.

Thank you reviewers- CytoJournal 2006

Vinod B Shidham — Fri,3 Feb 2006

Vinod B Shidham, Barbara F Atkinson

CytoJournal 2006 3(1):2-2

The Editorial Board of CytoJournal devotes significant efforts, time, and resources to review numerous manuscripts. As it is impossible to include all the experts on the editorial board, there is always a need for additional peers who are requested to join periodically to act as 'academic editors' and reviewers. We take this opportunity to thank all the reviewers and academic editors who offered their time and efforts by participating in peer-review process for CytoJournal manuscripts. We request their continued enthusiasm to support this important academic exercise.

Hairy cell leukemia : A diagnosis by endoscopic ultrasound guided fine needle aspiration

Regina S Meara — Mon,23 Jan 2006

Regina S Meara, Vishnu Reddy, Juan Pablo Arnoletti, Darshana Jhala, Shyam Varadarajulu, Nirag Jhala

CytoJournal 2006 3(1):1-1

Background: Endosonography (EUS) guided FNA is a relatively new imaging modality which is increasingly used for sampling deep-seated lymph nodes in the diagnosis and staging of various malignancies, both primary as well as metastatic. It is also useful for staging of non-Hodgkin's lymphoma as well as diagnosing recurrence. The diagnosis of leukemia on FNA samples from deep-seated lymphadenopathy poses an even greater challenge. Hairy cell leukemia (HCL) is an uncommon, but distinct, lympho-proliferative disorder of B cell origin. It usually affects the spleen and bone marrow and uncommonly involves lymph nodes. There are only a few cases reported where HCL was diagnosed on FNA specimens. Case presentation: We report the first case of HCL accurately rendered on EUS-FNA samples. Conclusion: This report underscores the concept that the presence of a cytopathologist in the endoscopy suite plays an important role in providing accurate diagnoses of lymphoid lesions biopsied with EUS-FNA.

Fine needle aspiration cytology of primary thyroid lymphoma: A report of ten cases

Nalini Gupta — Fri,9 Dec 2005

Nalini Gupta, Raje Nijhawan, Radhika Srinivasan, Arvind Rajwanshi, Pinaki Dutta, Anil Bhansaliy, SC Sharma

CytoJournal 2005 2(1):21-21

Primary lymphoma is an uncommon malignancy of the thyroid, comprising of 0.6 to 5 per cent of thyroid cancers in most series. Primary thyroid lymphomas (PTL) occur most commonly in elderly women and are commonly of B- cell origin. These frequently present in clinical stage IE and IIE. We report here ten cases of PTL diagnosed over a period of about 7 years in our institute. Out of these ten cases, nine were diagnosed on fine needle aspiration cytology (FNAC) and one case was misdiagnosed as lymphocytic thyroiditis. This case was diagnosed as Non- Hodgkin's lymphoma on surgical specimen. Five patients are disease free and doing well, while two died of disease and the other two were lost to follow-up. One patient is currently on chemotherapy. The salient clinical, biochemical, radiological features, FNA findings along with diagnostic difficulties are discussed.

Primary fallopian tubal transitional cell carcinoma with exfoliation of malignant cells in cervical Pap smear

Nalini Gupta — Fri,9 Dec 2005

Nalini Gupta, Radhika Srinivasan, Raje Nijhawan, Lakhbir Kaur Dhaliwal

CytoJournal 2005 2(1):20-20

Fine needle aspiration diagnosis of extracranial glioblastoma multiforme: Case report and review of the literature

Stacey Schultz — Mon,14 Nov 2005

Stacey Schultz, Gregory S Pinsky, Nancy C Wu, Marc C Chamberlain, A Sonali Rodrigo, Sue E Martin

CytoJournal 2005 2(1):19-19

Background :Hitherto uncommon, the incidence of extracranial metastases of primary brain malignancies may increase, with improved treatment methods and longer patient survival. Fine needle aspiration biopsy is a simple, safe and reliable method to diagnose metastatic malignancy. It has definite advantages over tissue biopsy, which is more invasive and is of higher risk to the patient. Ours is a case of glioblastoma multiforme, which metastasized to the scalp and was diagnosed on fine needle aspiration biopsy. Only a few articles document the cytological features of extracranial glioblastoma multiforme, diagnosed by fine needle aspiration biopsy. Case presentation :We report the case of an elderly female who presented with focal neurological symptoms. She was diagnosed radiologically with an intracranial lesion in the left temporal region, which was subsequently resected. Histology revealed a glioblastoma multiforme confirmed by immunohistochemistry. The tumor recurred subsequently and the patient was treated with chemotherapy, intraoperatively. At a later stage, she presented with a scalp mass on which fine needle aspiration biopsy was performed. The cytomorphological features aided by immunohistochemistry supported a diagnosis of metastatic glioblastoma multiforme. The mass was later resected and histology confirmed the fine needle aspiration diagnosis of glioblastoma multiforme. Conclusion :Reports of extracranial metastases of primary brain tumors are few. When they do occur, the primary cause is implantation during surgery or biopsy. However, spontaneous metastases to other organs do occur rarely. We believe fine needle aspiration biopsy to be very useful in the diagnosis of metastatic glioblastoma multiforme. The ability to use a cellblock for immunohistochemical studies is greatly advantageous and helpful in differentiating this tumor, from other malignancies that can occur in the scalp. A detailed discussion of the material obtained from fine needle aspiration biopsy of metastatic glioblastoma multiforme is presented, as well as a review of previous accounts in the literature.

Primary small cell neuroendocrine carcinoma of the urinary bladder with coexisting high-grade urothelial carcinoma: a case report and a review of the literature

Marilyn Bui — Fri,4 Nov 2005

Marilyn Bui, Walid E Khalbuss

CytoJournal 2005 2(1):18-18

Primary neuroendocrine carcinomas of the urinary bladder are rare. Here, we report a case of an 82-year-old man who presented with hematuria and was found to have an ulcerated lesion in the bladder. A diagnosis of small neuroendocrine cell carcinoma with coexisting minor high-grade urothelial components was rendered. In this report, the clinical, cytological, histological, and immunohistochemical features of this case are described, and a review of the literature about this neoplasm is presented. The differential diagnoses of small cell tumor in urinary bladder washing specimens are discussed.

Fine needle aspiration biopsy diagnosis of metastatic neoplasms of the breast. A three-case report

Raquel Garza-Guajardo — Tue,20 Sep 2005

Raquel Garza-Guajardo, Nora Mendez-Olvera, Juan Pablo Flores-Gutierrez, Silvia Hernandez-Martinez, Cann Michelle Candanosa-Mc, Jesus Ancer-Rodriguez, Oralia Barboza-Quintana

CytoJournal 2005 2(1):17-17

Metastases to the breast are unusual lesions that make up approximately 2% of all malignant mammary neoplasms and may mimic both benign and malignant primary neoplasms from a clinical point of view, as well as in imaging studies. Arriving at a correct diagnosis is therefore essential in order to establish appropriate management. We present three cases of metastatic neoplasms diagnosed through fine needle aspiration biopsy and immunocytochemistry. The cytological diagnoses were: medulloblastoma in an 18-year-old woman, melanoma in a 26-year-old man, and an exceptional case of ovarian sarcoma originating from a granulosa cell tumor with metastases to both breasts. A metastatic disease should be considered in the differential diagnosis of a palpable mass in the breast, especially if there is a history of an extramammary malignant neoplasm. Fine needle aspiration biopsy is the method of choice for the management of these cases. Whenever possible the exam of the material obtained should be compared to the previous biopsy, which is usually enough to arrive at a correct diagnosis, thus preventing unnecessary surgical procedures.

Disseminated primary diffuse leptomeningeal gliomatosis: a case report with liquid based and conventional smear cytology

Masha Bilic — Tue,20 Sep 2005

Masha Bilic, Cynthia T Welsh, Zoran Rumboldt, Rana S Hoda

CytoJournal 2005 2(1):16-16

Background :Primary diffuse leptomeningeal gliomatosis is a rare neoplasm confined to the meninges without evidence of primary tumor in the brain or spinal cord parenchyma. Cerebrospinal fluid diversion via ventriculoperitoneal shunt may be used as a therapeutic modality. Herein, we describe the first report of cytologic findings of a case of this neoplasm with shunt-related peritoneal metastasis. Case presentation :A 19-year-old male presented with a 6-month history of severe headaches. He had bilateral papilledema on physical exam. Cerebrospinal fluid examination was negative. Four months later a ventriculoperitoneal shunt was placed. Shortly thereafter, he was diagnosed with primary diffuse leptomeningeal gliomatosis based on the biopsy of an intradural extramedullary lesion adjacent to the lumbar spinal cord at a referral cancer center. The histology featured an infiltrating growth pattern of pleomorphic astrocytes with diffuse positivity for glial fibrillary acidic protein. A couple of months later he presented at our institution with ascites and an anterior peritoneal mass. Repeat cerebrospinal fluid cytology and fine needle aspiration of the mass confirmed disseminated gliomatosis. Cytologic characteristics included clusters of anaplastic cells of variable size, high nuclear to cytoplasm ratio and scant to moderate cytoplasm. Occasional single bizarre multinucleated cells were seen with eccentric "partial wreath-like" nuclei, clumped chromatin and prominent nucleoli. Patient expired 13 months after initial presentation. Conclusion :Disseminated primary diffuse leptomeningeal gliomatosis should be considered in the differential diagnosis of chronic aseptic meningitis and in the presence of a peritoneal tumor in patients with ventriculoperitoneal shunts. Immunocytochemistry may be of diagnostic value.

Efficiency of an inexpensive liquid-based cytology performed by cytocentrifugations: a comparative study using the histology as reference standard

Christian Garbar — Thu,15 Sep 2005

Christian Garbar, Corinne Mascaux, Veronique Fontaine

CytoJournal 2005 2(1):15-15

Background :Although liquid-based cytology (LBC) is now recommended for cervical cancer screening, it requires expensive automated devices and materials. To evaluate the efficiency of inexpensive LBC methods relying on an inexpensive fixative liquid, Easyfix ® , we compared the results obtained by the liquid-based cytology (LBC) diagnoses performed by cytocentrifugations (Papspin ® and Turbitec ® ) with those obtained by histology. Furthermore, we evaluated the efficiency of the fixative liquid, Easyfix ® , to preserve HPV DNA in the collected samples. Method :266 LBC were compared with 174 colposcopies and 91 Loop Electrosurgical Excision Procedure (LEEP). Among the LBC, 51 were performed using the Papspin ® system and 215 were performed using the Turbitec ® system. To control the quality of the preservation liquid, Easyfix ® , we correlated the results of HCII assays with those of HPV PCR. Results :For Papspin ® and Turbitec ® systems, the sensitivities were respectively 82.6% (95% CI: 61.2-95.0%, p < 0.001) and 75.0% (95% CI: 64.4-89.8%, p < 0.001) and the specificities were 92.6% (95%CI: 76.5-99.1%, p < 0.001) and 96.2% (95% CI: 91.3-98.7%, p < 0.001). We find no statistical difference between the results of the both systems (p = ns). The sensitivity of the HCII was 86.4% (95% IC: 77.4-92.8%, p < 0.001) and the specificity was 39.4% (95% CI: 31.2-48.1%, p < 0.001). The comparison between HCII and HPV-PCR shows a good correlation: the kappa was 0.89. Conclusion :LBC performed by cytocentrifugations are inexpensive, reduce inadequate smears, show excellent efficiency and allow HPV detection by molecular biology.

Is an increase in CD4/CD8 T-cell ratio in lymph node fine needle aspiration helpful for diagnosing Hodgkin lymphoma? A study of 85 lymph node FNAs with increased CD4/CD8 ratio

Osvaldo Hernandez — Fri,9 Sep 2005

Osvaldo Hernandez, Thaira Oweity, Sherif Ibrahim

CytoJournal 2005 2(1):14-14

Background :An elevated CD4/CD8 T-cell ratio on flow cytometry (FCM) analysis has been reported in the literature to be associated with Hodgkin lymphoma (HL). The purpose of our study was to determine the diagnostic significance of an elevated CD4/CD8 ratio in lymph node fine needle aspiration (FNA) specimens. Design :Between 1996 and 2002, out of 837 lymph node FNAs submitted for flow cytometry analysis, 85 cases showed an elevated CD4/CD8 ratio, defined as greater than or equal to 4, without definitive evidence of a lymphoproliferative disorder. The cytologic diagnoses of these 85 cases were grouped into four categories: reactive, atypical, Hodgkin lymphoma (HL), and non-Hodgkin lymphoma (NHL). Histologic follow-up was available in 17/85 (20%) of the cases. Results :5 of the 64 cases in which FCM and cytology did not reveal evidence of a lymphoproliferative disease had tissue follow-up because of persistent lymphadenopathy and high clinical suspicion. 3/5 (60%) confirmed the diagnosis of reactive lymphadenopathy. The two remaining cases (40%) were positive for lymphoma (1HL, 1NHL). 8/15 cases called atypical on cytology had histologic follow-up. 7/8 (87.5%) cases were positive for lymphoma (3HL, 4NHL). 3/4 cases called HL on cytology had tissue follow-up and all 3 (100%) confirmed the diagnosis of HL. One case diagnosed as NHL on cytology was found to be a diffuse large B-cell lymphoma. In summary, out of 17 cases with histologic follow-up 4/17 (24%) were reactive with CD4/CD8 T-cell ratio of 4.1-29, 7/17 (41%) were HLs with CD4/CD8 T-cell ratio of 5.3 - 11, and 6/17 (35%) were NHLs with CD4/CD8 T-cell ratio of 4.2 - 14. Conclusion :An elevated CD4/CD8 ratio on FCM is a nonspecific finding which may be seen in both reactive and lymphoproliferative disorders. The cytomorphologic features of the smear are more relevant than the sole flow cytometric finding of an elevated CD4/CD8 ratio.

Hodgkin lymphoma: flow me?

Michael W Beaty — Thu,8 Sep 2005

Michael W Beaty, Kim R Geisinger

CytoJournal 2005 2(1):13-13

Combining fine needle aspirate cytology with flow cytometry immunophenotyping for the rapid diagnosis of lymphoproliferative lesions is commonplace practice in many institutions. Yet, a definitive diagnosis of Hodgkin lymphoma in many cases remains elusive, requiring subsequent tissue biopsy confirmation. In this issue of CytoJournal, Hernandez et al explore the potential role of using the increased CD4/CD8 T-cell ratio in lymph node fine needle aspiration specimens as a specific feature in diagnosing Hodgkin lymphoma. CD4/CD8 T-cell ratio comparisons are made with cytomorphologic diagnoses of reactive, atypical, non-Hodgkin lymphoma, and Hodgkin lymphoma cases.

Fine-needle aspiration of the thyroid: an overview

Gia-Khanh Nguyen — Wed,29 Jun 2005

Gia-Khanh Nguyen, Mark W Lee, Jody Ginsberg, Tina Wragg, Darcy Bilodeau

CytoJournal 2005 2(1):12-12

Thyroid nodules (TN) are a common clinical problem. Fine needle aspiration (FNA) of the thyroid now is practiced worldwide and proves to be the most economical and reliable diagnostic procedure to identify TNs that need surgical excision and TNs that can be managed conservatively. The key for the success of thyroid FNA consists of an adequate or representative cell sample and the expertise in thyroid cytology. The FNA cytologic manifestations of TNs may be classified into seven working cytodiagnostic groups consisting of a few heterogenous lesions each to facilitate the differential diagnosis. Recent application of diagnostic molecular techniques to aspirated thyroid cells proved to be useful in separating benign from malignant TNs in several cases of indeterminate lesions.

Diagnostic utility of p16 immunocytochemistry for Trichomonas in urine cytology

Liron Pantanowitz — Wed,29 Jun 2005

Liron Pantanowitz, Q Jackie Cao, Robert A Goulart, Christopher N Otis

CytoJournal 2005 2(1):11-11

We present a case in which p16 immunocytochemistry helped establish the diagnosis of Trichomonas in urine from a male patient. Based on this finding, we recommend p16 immunocytochemistry as a diagnostic tool for unexpected patients or specimen types in which potential trichomonads are identified following routine cytologic evaluation.

Review of "Fine Needle Aspiration Cytology of the Liver: Diagnostic algorithm a Southeast Asian Perspective" by A Wee and P Sampatankul

Isam A Eltoum — Tue,21 Jun 2005

Isam A Eltoum

CytoJournal 2005 2(1):10-10

FNAB cytology of extra-cranial metastasis of glioblastoma multiforme may resemble a lung primary: A diagnostic pitfall

Mamatha Chivukula — Mon,20 Jun 2005

Mamatha Chivukula, HE Dincer, Julie A Biller, Hendrikus G Krouwer, Grant Simon, Vinod Shidham

CytoJournal 2005 2(1):9-9

Background :As extra-cranial metastasis of glioblastoma multiforme (GBM) is rare, it may create a diagnostic dilemma especially during interpretation of fine needle aspiration biopsy (FNAB) cytology. Case presentation :We present transbronchial FNAB findings in a 62-year-old smoker with lung mass clinically suspicious for a lung primary. The smears of transbronchial FNAB showed groups of cells with ill-defined cell margins and cytological features overlapping with poorly differentiated non-small cell carcinoma. The tumor cells demonstrated lack of immunoreactivity for cytokeratin, thyroid transcription factor-1, and usual neuroendocrine markers, synaptophysin and chromogranin in formalin-fixed cellblock sections. However, they were immunoreactive for the other neuroendocrine immunomarker, CD56, suggesting neural nature of the cells. Further scrutiny of clinical details revealed a history of GBM, 13 months status-post surgical excision with radiation therapy and systemic chemotherapy. The tumor recurred 7 months earlier and was debulked surgically and with intra-cranial chemotherapy. Additional evaluation of tumor cells for glial fibrillary acidic protein (GFAP) immunoreactivity with clinical details resulted in final interpretation of metastatic GBM. Conclusion :Lack of clinical history and immunophenotyping may lead to a diagnostic pitfall with possible misinterpretation of metastatic GBM as poorly differentiated non-small cell carcinoma of lung in a smoker.

Preoperative diagnosis of a mediastinal granular cell tumor by EUS-FNA : A case report and review of the literature

Sarah M Bean — Wed,8 Jun 2005

Sarah M Bean, Mohamad A Eloubeidi, Isam A Eltoum, Robert J Cerfolio, Darshana N Jhala

CytoJournal 2005 2(1):8-8

We report the first case of a posterior mediastinal granular cell tumor initially diagnosed on cytologic material obtained via endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) in a 51-year-old male with a prior history of colon cancer. Aspirates obtained were cellular and composed of polygonal cells with abundant granular cytoplasm and small, round dark nuclei. An immunoperoxidase stain performed on the cell block for antibodies to S-100 protein showed strong, diffuse staining of the cytoplasmic granules. Electron microscopy performed on the cell block revealed numerous cytoplasmic lysosomes. This is the first case report in the English literature of a definitive preoperative diagnosis of a mediastinal granular cell tumor utilizing material obtained via EUS-FNA.

Fine needle aspiration biopsy of the liver : Algorithmic approach and current issues in the diagnosis of hepatocellular carcinoma

Aileen Wee — Wed,8 Jun 2005

Aileen Wee

CytoJournal 2005 2(1):7-7

The role of fine needle aspiration biopsy (FNAB) in the evaluation of focal liver lesions has evolved. Guided FNAB is still useful to procure a tissue diagnosis if clinical, biochemical and radiologic findings are inconclusive. Major diagnostic issues include: (i) Distinction of benign hepatocellular nodular lesions from reactive hepatocytes, (ii) Distinction of well-differentiated hepatocellular carcinoma (WD-HCC) from benign hepatocellular nodular lesions, (iii) Distinction of poorly differentiated HCC from cholangiocarcinoma and metastatic carcinomas, (iv) Determination of histogenesis of malignant tumor, and (v) Determination of primary site of origin of malignant tumor. This review gives a general overview of hepatic FNAB; outlines an algorithmic approach to cytodiagnosis with emphasis on HCC, its variants and their mimics; and addresses current diagnostic issues. Close radiologic surveillance of high-risk cirrhotic patients has resulted in the increasing detection of smaller lesions with many subjected to biopsy for tissue characterization. The need for tissue confirmation in clinically obvious HCC is questioned due to risk of malignant seeding. When a biopsy is indicated, core needle biopsy is favored over FNAB. The inherent difficulty of distinguishing small/early HCC from benign hepatocellular nodular lesions has resulted in indeterminate reports. Changing concepts in the understanding of the biological behavior and morphologic evolution of HCC and its precursors; and the current lack of agreement on the morphologic criteria for distinguishing high-grade dysplastic lesions (with small cell change) from WD-HCC, have profound impact on nomenclature, cytohistologic interpretation and management. Optimization of hepatic FNAB to enhance the yield and accuracy of diagnoses requires close clinicopathologic correlation; combined cytohistologic approach; judicious use of ancillary tests; and skilled healthcare teams.

Desmoplastic small round cell tumour : Cytological and immunocytochemical features

Nara M Granja — Fri,18 Mar 2005

Nara M Granja, Maria D Begnami, Jeni Bortolan, Adhemar Longatto Filho, Fernando C Schmitt

CytoJournal 2005 2(1):6-6

Background: Desmoplastic small round cell tumor (DSRCT) is a rare and highly aggressive neoplasm. The cytological diagnosis of these tumors can be difficult because they show morphological features quite similar to other small round blue cells tumors. We described four cases of DSRCT with cytological sampling: one obtained by fine needle aspiration biopsy (FNAB) and three from serous effusions. The corresponding immunocytochemical panel was also reviewed. Methods: Papanicolaou stained samples from FNAB and effusions were morphologically described. Immunoreaction with WT1 antibody was performed in all cytological samples. An immunohistochemical panel including the following antibodies was performed in the corresponding biopsies: 34BE12, AE1/AE3, Chromogranin A, CK20, CK7, CK8, Desmin, EMA, NSE, Vimentin and WT1. Results: The smears showed high cellularity with minor size alteration. Nuclei were round to oval, some of them with inconspicuous nucleoli. Tumor cells are clustered, showing rosette-like feature. Tumor cells in effusions and FNA were positive to WT1 in 3 of 4 cytology specimens (2 out 3 effusions and one FNA). Immunohistochemical reactions for vimentin, NSE, AE1/AE3 and WT1 were positive in all cases in tissue sections. Conclusion: The use of an adjunct immunocytochemical panel coupled with the cytomorphological characteristics allows the diagnosis of DSRCT in cytological specimens.

Anal screening cytology

Gladwyn Leiman — Wed,16 Feb 2005

Gladwyn Leiman

CytoJournal 2005 2(1):5-5

This issue of CytoJournal contains an article on screening for anal intraepithelial neoplasia in high-risk male patients. This accompanying Editorial focuses on current understanding of this relatively new disease entity, with insights as to the potential role of screening cytopathology in the epidemiology, pathophysiology and clinical management of this HIV and HPV related anal lesion, which predominates in male patients living long-term with AIDS. Mention is made of techniques of obtaining samples, methods of preparation, and morphologic classification. Issues of anoscopic confirmation, as well as topical and surgical management are emphasized. The similarity of initial experiences in anal screening to problems encountered early in cervical cancer screening programs several decades ago, are highlighted.

The Anal Pap smear : Cytomorphology of squamous intraepithelial lesions

Shehla Arain — Wed,16 Feb 2005

Shehla Arain, Ann E Walts, Premi Thomas, Shikha Bose

CytoJournal 2005 2(1):4-4

Background: Anal smears are increasingly being used as a screening test for anal squamous intraepithelial lesions (ASILs). This study was undertaken to assess the usefulness and limitations of anal smears in screening for ASILs. Methods: The cytomorphological features of 200 consecutive anal smears collected in liquid medium from 198 patients were studied and findings were correlated with results of surgical biopsies and/or repeat smears that became available for 71 patients within six months. Results: Adequate cellularity was defined as an average of 6 or more nucleated squamous cells/hpf. A glandular/transitional component was not required for adequacy. Dysplastic cells, atypical parakeratotic cells and bi/multinucleated cells were frequent findings in ASIL while koilocytes were infrequent. Smears from LSIL cases most frequently showed mildly dysplastic and bi/multinucleate squamous cells followed by parakeratotic cells (PK), atypical parakeratotic cells (APK), and koilocytes. HSIL smears contained squamous cells with features of moderate/severe dysplasia and many APKs. Features of LSIL were also found in most HSIL smears. Conclusions: In this study liquid based anal smears had a high sensitivity (98%) for detection of ASIL but a low specificity (50%) for predicting the severity of the abnormality in subsequent biopsy. Patients with cytologic diagnoses of ASC-US and LSIL had a significant risk (46-56%) of HSIL at biopsy. We suggest that all patients with a diagnosis of ASC-US and above be recommended for high resolution anoscopy with biopsy.

CytoJournal's move to fund Open Access

Vinod B Shidham — Thu,10 Feb 2005

Vinod B Shidham, Anthony F Cafaro, Barbara F Atkinson

CytoJournal 2005 2(1):3-3

CytoJournal is published by an independent publisher BioMed Central, which is committed to ensuring that the peer-reviewed biomedical research is Open Access. Since its launch, BioMed Central has graciously supported the processing of all the articles published during CytoJournal' s first 6 months. However, for long term viability, CytoJournal has to achieve financial viability to support publication expenses. From 1st March, 2005, authors will be asked by the publisher to pay a flat article-processing charge. This editorial discusses how a significant proportion of authors may not have to pay this fee directly under a variety of different mechanisms such as institutional and society memberships with BioMed Central.

Remembering George L. Wied, M.D., February 7, 1921-July 25, 2004

Dorothy L Rosenthal — Tue,8 Feb 2005

Dorothy L Rosenthal

CytoJournal 2005 2(1):2-2

A personal tribute to George L. Wied, M.D., a founder of the medical subspecialty, cytopathology, who died July 25, 2004.

Desmoplastic Infantile Ganglioglioma: cytologic findings and differential diagnosis on aspiration material

Oluwole Fadare — Tue,11 Jan 2005

Oluwole Fadare, M Rajan Mariappan, Denise Hileeto, Arthur W Zieske, Jung H Kim, Idris Tolgay Ocal

CytoJournal 2005 2(1):1-1

Background :Desmoplastic infantile ganglioglioma (DIG) is a rare WHO Grade I tumor of infancy that is characterized by large volume, superficial location, invariable supratentoriality, fronto-parietal lobe predilection and morphologically, by an admixture of astroglial and neuroepithelial elements in a desmoplastic milieu. With over 50 cases described, the histologic and radiographic spectrum of DIG has been well-characterized. The superficial location of DIGs may render them greatly amenable to preoperative assessment utilizing aspiration cytology; however, the cytologic features of this rare tumor have only been reported once previously. Case Presentation :We present herein cytomorphologic findings from the intraoperative aspiration of a typical case of DIG diagnosed in a 1-year-old male. As evaluated on a single liquid-based preparation, the specimen showed low cellularity and was comprised predominantly of a population of dispersed (occasionally clustered) large neuronal cells with eccentrically located hyperchromatic nuclei (which were occasionally binucleated) and abundant unipolar cytoplasm. Rare smaller astroglial cells were intermixed. Despite the tumor's characteristic desmoplastic histologic appearance, no stromal fragments were identified on the aspiration material. Conclusions :A differential diagnosis is presented and analyzed in detail and it is concluded that when these large neuronal cells are encountered in an aspirate of a brain mass in a child, a combination of clinical, radiologic and immunohistochemical parameters can eliminate most of the differential possibilities.

FNAC of Bacillus- Calmette- Guerin lymphadenitis masquerading as Langerhans cell histiocytosis

Nalini Gupta — Tue,21 Dec 2004

Nalini Gupta, Vijay Kumar, Raje Nijhawan, Radhika Srinivasan, Arvind Rajwanshi

CytoJournal 2004 1(1):6-6

Bacillus Calmette Guerin (BCG) lymphadenitis is a well known entity. Disseminated BCG infection usually presents as generalized lymphadenopathy, skin rash and hepatosplenomegaly and at times, can pose a diagnostic challenge to clinicians. There are only a few published studies on the cytological findings of BCG lymphadenitis. In this letter we report the fine needle aspiration cytology (FNAC) of BCG lymphadenitis clinically masquerading as Langerhans cell histiocytosis (LCH). FNA smears showed sheets of foamy macrophages and many polymorphs in a dirty necrotic background with many macrophages as well as polymorphs showing negatively stained rod like structures within their cytoplasm. Zeihl Neelson stain revealed that these cells were heavily loaded with acid fast bacilli (AFB). In the index case, AFB were also seen within the cytoplasm of polymorphs, which has not been documented earlier in the literature.

Merkel cell carcinoma in a malignant pleural effusion : Case report

Misty M Payne — Thu,18 Nov 2004

Misty M Payne, Anne E Rader, Denis M McCarthy, William H Rodgers

CytoJournal 2004 1(1):5-5

Background: Merkel cell (neuroendocrine) carcinoma is a small round blue cell malignant neoplasm that primarily presents in the skin. The diagnosis of Merkel cell carcinoma in a pleural fluid is challenging because of the morphological similarity to many other malignant neoplasms. Immunohistochemical stains can be essential to establish the diagnosis of Merkel cell carcinoma. Case presentation: A 77 year-old woman presented with a mass in her right buttock thought clinically to be a boil or sebaceous cyst. Upon histopathologic review including immunohistochemical analysis, a diagnosis of Merkel cell carcinoma was rendered. Wide-excision and sentinel lymph node biopsy revealed negative margins and no evidence of metastasis. Ten months later she complained of bone pain and a bone scan revealed multiple lesions. An abdominal CT scan revealed a T4 vertebral mass and local radiotherapy was administered. Two months later the patient presented with shortness of breath. A chest radiograph showed an effusion and thoracentesis was performed. The fluid was confirmed to contain metastatic Merkel cell carcinoma by cytology and immunohistochemical analysis. Conclusions: Merkel cell carcinoma is an aggressive neoplasm that can, despite careful surgical management, occasionally present as a malignant pleural effusion in a relatively short time period. Immunohistochemical analysis can aid in confirming this rare outcome.

Second edition of 'The Bethesda System for reporting cervical cytology' - Atlas, website, and Bethesda interobserver reproducibility project

Ritu Nayar — Thu,21 Oct 2004

Ritu Nayar, Diane Solomon

CytoJournal 2004 1(1):4-4

A joint task force of the American Society of Cytopathology (ASC) and the National Cancer Institute (NCI) recently completed a 2-year effort to revise the Bethesda System "blue book" atlas and develop a complementary web-based collection of cervical cytology images. The web-based collection of images is housed on the ASC website, which went live on November 5 th , 2003; it can be directly accessed at http://www.cytopathology.org/NIH/ .

The big problem of the missing cytology slides

Ken M Gatter — Fri,24 Sep 2004

Ken M Gatter

CytoJournal 2004 1(1):3-3

Cytology slides are often unique and irreplaceable. Unlike surgical pathology cases, where additional paraffin sections can be cut, cytology slides often cannot be duplicated because there are only a few direct smears or the diagnostic material is present on a single slide. Cytology slides are often "sent out" to other physicians, laboratories or hospitals, typically so that the pathologist at the institution where the patient will receive treatment can review the slides. Less often, a cytology lab sends out the slides for a second opinion or as part of the discovery process in a lawsuit, where they may or may not be defendants. Rarely, unique and irreplaceable cytology slides are lost. This article presents a hypothetical scenario that is based on reported state appellate court decisions. The article discusses some of the legal issues that will affect the defendant cytologist/cytology lab and the "expert cytologist," and suggests some steps a cytologist/cytology lab can take to minimize the risk of repercussions from a lost unique and irreplaceable cytology slide.

Optimization of an immunostaining protocol for the rapid intraoperative evaluation of melanoma sentinel lymph node imprint smears with the 'MCW melanoma cocktail'

Vinod B Shidham — Fri,6 Aug 2004

Vinod B Shidham, Richard Komorowski, Virgilia Macias, Sushma Kaul, Glen Dawson, William W Dzwierzynski

CytoJournal 2004 1(1):2-2

Background: In the management of cutaneous melanoma, it is desirable to complete the regional lymphadenectomy during the initial surgical procedure for wide excision of biopsy site and sentinel lymph node (SLN) biopsy. In this study, we optimized and evaluated a rapid 17 minutes immunostaining protocol. The discriminatory immunostaining pattern associated with the 'MCW Melanoma Cocktail' (mixture of Melan- A, MART- 1, and tyrosinase) facilitated the feasibility of intraoperative evaluation of imprint smears of SLNs for melanoma metastases. Methods: Imprint smears of 51 lymph nodes from 25 cases (48 SLNs and 3 non-SLNs, 1 to 4 SLNs/case) of cutaneous melanoma were evaluated. Results: Sixteen percent, 8/51 lymph nodes (28%, 7/25 cases) were positive for melanoma metastases in immunostained permanent sections with the 'MCW melanoma cocktail'. All of these melanoma metastases, except 1 SLN from 1 case, were also detected in rapidly immunostained wet-fixed and air-dried smears (rehydrated in saline and postfixed in alcoholic formalin). The cytomorphology was superior in air-dried smears, which were rehydrated in saline and postfixed in alcoholic formalin. Wet-fixed smears frequently showed air-drying artifacts, which lead to the focal loss of immunostaining. None of the 5 SLNs from 5 cases exhibiting capsular nevi showed a false positive result with immunostained imprint smears. Conclusions: Melanoma metastases can be detected intraoperatively in both air-dried smears and wet-fixed smears immunostained with the MCW Melanoma cocktail. Air-dried smears rehydrated in saline and postfixed in alcoholic formalin provide superior results and many practical benefits.

CytoJournal joins 'open access' philosophy

Vinod B Shidham — Thu,29 Jul 2004

Vinod B Shidham, Anthony Cafaro, Barbara F Atkinson

CytoJournal 2004 1(1):1-1

Welcome to CytoJournal ! We would like to introduce you to your journal, one that is run by and for the scientific cytopathology community with incontestable benefits of Open Access, and support from Cytopathology Foundation, Inc. http://www.cytopathology-foundation.org/index.html webcite CytoJournal is a peer-reviewed, PubMed indexed, online journal, publishing research in the field of cytopathology and related areas, with world wide free access. Authors submitting to CytoJournal retain the copyright to their hard earned work.