Andrew J. Creager

Intraoperative evaluation of lumpectomy margins by imprint cytology with histologic correlation: a community hospital experience.

BACKGROUND Several well-controlled studies have demonstrated significantly increased local recurrence rates in patients with low-stage breast carcinoma treated with breast conservation therapy in whom focally positive margins were not reexcised. Imprint cytology is a rapid technique for evaluating surgical margins intraoperatively, thus allowing reexcisions to be performed during the initial surgery. The large majority of studies on the use of intraoperative imprint cytologic examination of breast conservation therapy margins have been performed at university-based academic centers. OBJECTIVE To evaluate the utility of intraoperative imprint cytologic evaluation of breast conservation therapy margins in a community hospital setting. METHODS We retrospectively reviewed the intraoperative imprint cytology margins of 141 lumpectomy specimens that had been obtained from 137 patients between May 1997 and May 2001. RESULTS We evaluated 758 separate margins. On a patient basis, the sensitivity was 80%, the specificity was 85%, the positive predictive value was 40%, the negative predictive value was 97%, and the overall accuracy was 85%. There were no cytologically unsatisfactory margins. CONCLUSION Imprint cytology is an accurate, simple, rapid, and cost-effective method for determining the margin status of breast conservation therapy specimens intraoperatively in the community hospital setting. This method allows a survey of the entire surface area of the lumpectomy specimen, which is not practical using frozen section evaluation.

Intraoperative evaluation of sentinel lymph nodes for breast carcinoma: current methodologies.

Sentinel lymph node biopsy is an important new addition to the surgical management of patients with breast carcinoma. Sentinel nodes have a higher chance of containing metastases than do nonsentinel nodes. Sentinel lymph node biopsy provides an opportunity to stage breast carcinoma patients more accurately and to modify subsequent treatment. One of the most exciting current roles of sentinel lymph node biopsy is the ability to stage patients intraoperatively, allowing a one-step axillary lymph node dissection if the sentinel lymph node contains metastatic carcinoma. Currently, intraoperative evaluation of sentinel lymph nodes is performed using imprint cytology with or without rapid cytokeratin staining, frozen sectioning with or without rapid cytokeratin staining, scrape preparations, or some combination of these techniques. We review the relative strengths and weaknesses of these different methodologies. A great deal of controversy exists regarding the management of patients with metastatic breast carcinoma, particularly those patients with occult and micrometastatic disease. These issues are beyond the scope of this article.

Recurrent Intranodal Palisaded Myofibroblastoma With Metaplastic Bone Formation

Intranodal palisaded myofibroblastoma (IPM) is a rare primary nonlymphoid tumor of the lymph node, which can easily be mistaken for other spindle cell tumors. Intranodal palisaded myofibroblastoma is thought to arise from intranodal myofibroblasts, a finding that is supported by its immunophenotype, positive immunostaining for actin and vimentin, and negative immunostaining for desmin. Characterized by a benign clinical course, IPM is treated by simple surgical excision. We describe a 49-year-woman, who had cadaveric renal transplantation in 1992 and recurrent IPM 41/2 years after its original excision. To our knowledge, this case represents only the second known case of recurrent IPM. The histologic feature of metaplastic bone formation in this case has not been previously described in IPM.

Epstein-Barr virus induced renal leiomyoma.

Human immunodeficiency virus (HIV) infection is associated with many malignancies, including lymphoma, Kaposi’s sarcoma and smooth muscle tumors such as leiomyosarcoma and leiomyoma. An association between the Epstein-Bm virus and smooth muscle tumors in immunmmpromised patients has been reported previously in the liver. lung, adrenal gland and gastrointestinal tract. In situ hybridization, polymerase chain reaction and immunostaining have demonstrated Epstein-Bm virus infection of smooth muscle tumor cells in immunocompromised patients.’ To our knowledge we report on the first adult positive for HIV to have Epstein-Barr virus induced renal leiomyoma. CASE REPORT A 37-year-old white man with an 8-year history of HIV presented with fever of unknown origin. Abdominal computerized tomography tCT) revealed a 2 X 3 cm. left renal mass (fig. 1). Repeat scan at 3 months suggested interval growth. Metastatic evaluation by CT, chest x-ray and laboratory analysis was negative. The patient underwent left radical nephrectomy. Convalescence was unremarkable. Pathological examination of the kidney revealed a 3.0 X 2.8 x 2.5 cm. well circumscribed renal leiomyoma (fig. 2). In situ hybridization and immunostaining confirmed EpsteinBarr virus infection of the smooth muscle tumor cells. DISCUSSION The Epstein-Barr virus is a member of the human herpes virus family. Primary infection with this virus manifests as mild self-limited illness to infectious mononucleosis. Disease begins in the oropharyngeal epithelial cells. The Epstein-Barr virus then infects B lymphocytes, which harbor latent virus and are important in the dissemination of the virus to other tissues. A broad immune response to the Epstein-Barr virus controls proliferation.2 In immunocompromised patients this response is suppressed, allowing uncontrolled viral proliferation.

Pseudo-epitheliomatous keratotic and micaceous balanitis

Balanitis is an inflammatory condition of the glans penis that is most frequently associated with candidal infection when a n infectious etiology is found. Although balanitis is common, it is rarely associated with penile neoplasms. Pseudo-epitheliomatous keratotic and micaceous balanitis is a pathological and clinical description of an exceedingly rare condition. The initial report of Lortat-Jacob and Civatte suggested that pseudo-epitheliomatous keratotic and micaceous balanitis was benign, yet they subsequently described a malignant change in their patient.’ More recently others have also documented the development of penile neoplasms in patients with this condition.2.” We report the tenth case of pseudo-epitheliomatous keratotic and micaceous balanitis. epitheliomatous keratotic and micaceous balanitis is unknown, yet most patients are uncircumcised and older than 50 years. Furthermore, to our knowledge there have been no reports of lymph node involvement or metastases in these cases. The clinical differential diagnosis includes balanitis, balanitis xerotica obliterans, genital leukoplakia, lichen planus, kraurosis penis, scleroderma, penile horns, keratoacanthoma, giant condyloma, erythroplasia of Queyrat, Bowen’s disease and squamous cell carcinoma. Treatment of biopsy proved pseudo-epitheliomatous keratotic and micaceous balanitis should be determined by the severity of the disease. We agree with Krunic et a1 that

Fine needle aspiration of pancreatic cysts : Use of ancillary studies and difficulty in identifying surgical candidates

OBJECTIVE To evaluate ancillary biochemical testing after pancreatic cyst fine needle aspiration (FNA) in the clinical setting. STUDY DESIGN Findings from 110 pancreatic guided FNA were reviewed cysts evaluated by image- and correlated with histology, clinical follow-up and biochemical analysis of cyst fluid and serum. Adequate followup was available for 95. RESULTS In terms of identifying cysts requiring surgery, FNA showed 55.3% sensitivity, 95% specificity, 92.9% positive predictive value (PPV) and 64.4% negative predictive value (NPV). FNA showed only nonspecific cyst contents in 51% of cases, but 40% of those patients proved to be surgical candidates at follow-up. Overall, patients with lesions requiring surgery were younger (p = 0.14), more often presented with pain (p = 0.006), had larger cysts (p = 0.05) and less often had a history of chronic pancreatitis (p = 0.12). Among cases in which FNA showed only nonspecific cyst contents, patients with lesions requiring surgery were more often female (p = 0.08), were younger (p = 0.10), had larger cysts (p = 0.06) and had pain at presentation (p = 0.02). Differences in fluid and serum analytes were not statistically significant. CONCLUSION FNA of pancreatic cysts shows high specificity but poor sensitivity, even with cyst fluid and serum biochemical analysis. FNA of cysts requiring surgery often yielded nonspecific cyst cytology and causing a misinterpretation as pseudocysts. Ancillary biochemical analysis of cyst fluid remains problematic in the clinical setting.