Aseem Lal

Role of biliary brush cytology in primary sclerosing cholangitis.

OBJECTIVE To assess the role of brush cytology in the routine evaluation of patients with primary sclerosing cholangitis (PSC). STUDY DESIGN From January 1995 to June 2000, 64 brush cytology specimens were obtained from 21 patients who had at least one cytologic sample obtained during endoscopic retrograde cholangiography. All patients had a diagnosis of primary sclerosing cholangitis. Cases were classified as benign, atypical or malignant according to major cytologic criteria (nuclear contour and chromatin irregularities) and minor cytologic criteria (polarity, cellularity, nuclear enlargement, mitosis, increased nuclear/cytoplasmic ratio) used by us to diagnose biliary brush cytology. Follow-up was available in all cases. RESULTS Diagnoses were benign (13), atypical (5) and malignant (3) on cytology. Follow-up of the 13 benign cases showed bile duct stones (2), gallbladder adenocarcinoma at cholecystectomy (1), ascending cholangitis (1) and clinically/cytologically by benign follow-up (9). Five of 13 benign cases had subsequent liver transplantation for liver failure, with explants showing changes of primary sclerosing cholangitis. Of the 3 malignant cases, 1 had carcinoma in situ on biopsy, with the explanted liver showing high grade dysplasia; the second patient had cholangiocarcinoma on explant; and the third had hepatocellular carcinoma on liver five needle aspiration. The 5 patients with atypical cytology were reclassified on review as reactive (3) and atypical not otherwise specified (2). Follow-up showed benign disease in 3 of 3 atypical cases reclassified as reactive; 2 of 2 reclassified as atypical not otherwise specified showed low grade dysplasia in the explant. CONCLUSION The overall incidence of malignancy was low (3 of 21) in patients with PSC. Bile duct brushing is a sensitive method of detecting neoplasia in the setting of PSC when well-defined cytologic criteria are applied.

Cytologic Features of Granulosa Cell Tumors in Fluids and Fine Needle Aspiration Specimens

OBJECTIVE To describe the cytologic features of granulosa cell tumors in fluids and fine needle aspiration specimens, with histologic confirmation. STUDY DESIGN Histologically confirmed granulosa cell tumors, 6 adult type and 1 juvenile type, were identified. All patients had local recurrences or metastases. Eleven specimens from 7 patients, including cytologic samples, cell blocks and histology, were reviewed. Inhibin immunostaining was performed on cell blocks to aid identification of this group of tumors in the cytologic and histologic samples. RESULTS The patients were 22-72 years old. Sites included ovary and peritoneum; there were pelvic recurrences and metastatic lesions in the spleen, liver, perirectum and cervical lymph node. Cytologic features of adult granulosa cell tumors included 3-dimensional clusters, resettes loose monolayers and individual cells. Other features were Call-Exner bodies, vacuolated cytoplasm, exuberant capillaries associated with papillarylike fronds, a second population of elongated theca cells, and prominent or rare nuclear grooves. In juvenile granulosa cell tumor the features observed were monolayers, loosely cohesive sheets, single cells, occasional larger pleomorphic cells with nuclear clefting and nuclear protrusions, vacuolated cytoplasm, finely granular chromatin and frequent mitoses. The overall cytologic and histologic correlation was good. Inhibin was focally positive in one peritoneal fluid, correlating with the focal pattern of staining seen on histology. CONCLUSION A definitive cytologic diagnosis of granulosa cell tumor can be made based on the above criteria. Aggressive tumors are discohesive and show pleomorphism and nuclear protrusions. Inhibin stain may be helpful in identifying granulosa cell tumors in cell block specimens.

“atypical Condyloma” With Bizarre Cells Mimicking Invasive Keratinizing Squamous Cell Carcinoma

Background: The general cytologic features of the keratinizing form of squamous cell carcinoma are well characterized and include pleomorphic squamous cells present singly or in loosely cohesive aggregates. Abnormal shapes including tadpole/spindled or heavily keratinized cells and nuclear pleomorphism with chromatin abnormalities can all be seen. However, Meisels et al described an unusual form of human papillomavirus infection of the cervix (“atypical condyloma”) that can closely mimic the cytology of keratinizing squamous cell carcinoma. We herein report 2 cases where bizarre human papillomavirus associated changes were noted. One case was associated with tumor diathesis. Both were interpreted as squamous cell carcinoma on cytology. Materials and Methods: The patients were a 34-year-old woman (case A) and 37-year-old woman (case B), with no significant past gynecologic history for case A and unknown for case B. Each patient had a routine screening conventional cervical cytology smear sent for evaluation at Northwestern Memorial Hospital. Results: Cytology showed squamous epithelial cells with pleomorphism of cell size, shape, and nuclei. Morphologic features noted included large or “monstrous,” bizarre cells with hyperchromatic, somewhat smudgy nuclei. Cytoplasmic orangeophilia and karyorrhexis were also present. However, nucleolar prominence and tumor diathesis were lacking in case A and noted in case B. Follow-up surgical biopsy showed moderate dysplasia with bizarre cells (case A) and squamous cell carcinoma with bizarre cells (case B). Conclusion: Human papillomavirus–associated cytopathic effect can mimic invasive squamous cell carcinoma. Awareness of this phenomenon is important for accurate classification of these lesions.

Role of fine needle aspiration in lymphoma.

FNAB has an important role to play in the diagnosis of potential hematopoietic neoplasms. Although surgical biopsy may be more accepted than FNAB in many institutions, it is not always the best approach in every patient. Lack of superficial lymph nodes, extremely ill patients and the need for a rapid diagnosis (i.e. highly proliferative tumors like BL) make the availability of a good FNAB service crucial. To achieve the greatest accuracy in diagnosis, FNAB should combine skilled aspiration and triage techniques to obtain representative material, morphological evaluation of the sample by an experienced cytopathologist, and availability of ancillary techniques, such as flow cytometric immunophenotyping, IHC and molecular analysis.