Basim M. Al-Khafaji

Endoscopic ultrasound-guided fine needle aspiration of the pancreas. Diagnostic utility and accuracy.

OBJECTIVE Endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) is regarded as a safe and reliable procedure for diagnosing and staging of pancreatic neoplasms. This study retrospectively evaluated both the diagnostic utility and accuracy of pancreatic EUS-FNABs and potential cytologic pitfalls when using Diff-Quik stain for on-site evaluation. STUDY DESIGN Pancreatic EUS-FNABs performed between 1995 and 1998 were identified from the files of the Department of Pathology. All patients were studied via a linear-array ultrasound endoscope with an FNAB device. Immediate evaluation of the specimen by a pathologist using air-dried slides and Diff-Quik stain was done on all cases. An average of five passes (range, three to nine) were performed. Five cytologic categories were identified: nondiagnostic, benign, atypical, suspicious and malignant. EUS disease staging, histologic correlation and clinical follow-up were reviewed. RESULTS Sixty-nine consecutive pancreative FNABs were evaluated in the study period. The patients comprised 38 females and 31 males with a mean age of 65 years (range, 36-83). Histologic correlation was available on 40 patients, and follow-up was available on the remaining 29. The cytologic diagnoses included: 31 malignant, 8 suspicious, 6 atypical, 20 benign and 4 nondiagnostic. Forty-three cases were true positive, 9 were true negative, 2 were false positive, and 11 were false negative. The overall sensitivity was 80% and specificity was 82%. CONCLUSION The study showed that cytologic evaluation of pancreatic EUS-FNABs has 80% sensitivity and 82% specificity. False negative diagnosis was usually due to sampling error. A nondiagnostic cytologic diagnosis should be rendered in the absence of adequate sampling of a lesion. On-site cytologic evaluation of EUS-FNABs aids in guaranteeing specimen adequacy, and the pathologist should be trained to evaluate Diff-Quik-stained samples.

Cytologic artifacts and pitfalls of thyroid fine-needle aspiration using ThinPrep®: A comparative retrospective review

The ThinPrep® Processor has gained popularity as a collection and preparation technique for fine‐needle aspiration biopsy (FNAB). Specific cytologic criteria to evaluate ThinPrep preparation (TP) may differ from those of conventional preparation (CP). The authors retrospectively reviewed the quality, cytologic features, and pitfalls of TP versus CP in thyroid FNABs and addressed the cytomorphologic criteria used to evaluate TP specimens.

Salivary gland fine needle aspiration using the ThinPrep technique: diagnostic accuracy, cytologic artifacts and pitfalls.

OBJECTIVE To retrospectively assess the diagnostic accuracy, cytologic features and pitfalls of ThinPrep (TP) (Cytyc Corporation, Marlborough, Massachusetts, U.S.A.) versus conventional (smear) preparation (CP) in salivary gland fine needle aspiration biopsies (FNABs) and second, to evaluate the reproducibility of the cytomorphologic criteria used in the evaluation of FNABs prepared by CP versus TP. STUDY DESIGN All salivary gland fine needle aspiration biopsies (SGFNABs) between January 1996 and June 1999 were retrieved from the cytology files of the University of Michigan Hospital. Histologic correlation was identified when available. Two cytopathologists reevaluated the slides for artifacts, cellular preservation, background material, cellularity, and cytoplasmic and nuclear details. RESULTS Seventy-four of the 134 (55%) cases identified had histologic follow-up. Fifty (68%) cases were processed by TP and 24 (32%) by CP. FNAB processed by TP and CP correctly identified malignancy in 14 and 9 cases, respectively. There were three (4%) false negative cases. These included two acinic cell carcinomas and one mucoepidermoid carcinoma. There were 37 true negative cases (24 TP and 13 CP) and one false positive case of cellular pleomorphic adenoma (cytologic interpretation, mucoepidermoid carcinoma). All discrepant cases were processed using the TP method. The overall specificity and sensitivity were 98% and 88%, respectively. However, specificity and sensitivity for TP-processed SGFNABs were 96% and 82% as compared to a 100% specificity and sensitivity for CP. Additionally, there were 10 (14%) nondiagnostic cases, 8 of which were processed by TP. Cytologic artifacts associated with TP included diminished/distorted extracellular and stromal elements, cellular shrinkage and tissue fragmentation CONCLUSION The diagnostic accuracy of TP-processed SGFNABs approaches that of the CP. However, there are several artifacts that may lead to erroneous diagnoses. Additional studies, that depend on real-life clinical samples processed by TP are suggested to modify current diagnostic criteria.

Diagnostic utility of thyroid transcription factor-1 expression in adenocarcinomas presenting in serous fluids.

OBJECTIVE To evaluate the diagnostic utility of the immunohistochemical expression of thyroid transcription factor-1 (TTF-1) in adenocarcinomas from serous fluid specimens. STUDY DESIGN Archival paraffin-embedded cell blocks of serous fluids from 82 cases, including 34 cases of metastatic lung adenocarcinoma, 12 of metastatic ovarian adenocarcinoma, 12 of metastatic breast adenocarcinoma, 12 of metastatic gastrointestinal adenocarcinoma and 12 of malignant mesothelioma, were immunostained with anti-TTF-1. All the staining was carried out using a Ventana Automated System. Staining was evaluated according to the intensity of the nuclear staining (1+ to 4+) by two observers. RESULTS Of the metastatic lung adenocarcinomas, 79% (27/34) expressed 3+ to 4+ reactivity against TTF-1. None of the malignant mesotheliomas or other metastatic adenocarcinomas expressed nuclear reactivity. CONCLUSION Immunostaining with TTF-1 is a useful marker that can be applied to cytologic specimens. Anti-TTF-1 can be used as a reliable component of an antibody panel to support the diagnosis of adenocarcinoma of pulmonary origin in patients presenting with metastatic adenocarcinoma in serous fluid with an unknown primary site.

Diagnostic use of muscle markers in the cytologic evaluation of serous fluids

Differentiating reactive mesothelial cells from malignant mesotheliomas and from adenocarcinomas can be diagnostically challenging when based solely on the morphologic examination of serous fluids. The diagnosis even after the use of standard immunohistochemical stains may at times be inconclusive because of the variable reactivity of mesothelial cells for these markers. Pathologists and cytologists underutilize reactivity for desmin, a feature of mesothelial cells apparently not shared by adenocarcinomas. The purpose of this study was to evaluate the extent to which mesothelial cells express muscle differentiation and to assess the diagnostic utility of muscle markers in distinguishing reactive mesothelial cells from malignant mesotheliomas and adenocarcinomas. Archival paraffin-embedded cell blocks of serous fluids from 24 cases of reactive mesothelial cells, 14 cases of malignant mesothelioma, and 56 cases (14 cases from each) of metastatic adenocarcinoma from the lung, breast, ovary, and gastrointestinal tract were retrieved. Five cases of omentum with unremarkable mesothelial cells were also included in the study. All cases were stained for desmin, actin, myoglobin, and myogenin and evaluated independently by two observers. Strong cytoplasmic reactivity for desmin was noted in 22 of 24 cases (92%) of reactive mesothelial cells. The reactive mesothelial cells did not express actin, myoglobin, or myogenin. All cases of malignant mesothelioma and metastatic adenocarcinoma were negative for the four muscle markers. The mesothelial lining and scattered subserosal cells in the omental sections were positive for desmin. Because desmin was expressed only in benign mesothelial cells, it may serve as a reliable marker in distinguishing reactive mesothelial cells from mesothelioma or from adenocarcinoma. Awareness of this staining pattern is also important to avoid pitfalls when evaluating body fluid specimens from patients with a history of tumors expressing muscle differentiation.

Cytologic artifacts and pitfalls of thyroid fine-needle aspiration using ThinPrep®†

The ThinPrep® Processor has gained popularity as a collection and preparation technique for fine‐needle aspiration biopsy (FNAB). Specific cytologic criteria to evaluate ThinPrep preparation (TP) may differ from those of conventional preparation (CP). The authors retrospectively reviewed the quality, cytologic features, and pitfalls of TP versus CP in thyroid FNABs and addressed the cytomorphologic criteria used to evaluate TP specimens.

Respiratory distress of unknown etiology in a transplant recipient: think toxoplasmosis!

Disseminated toxoplasmosis is a life-threatening disease in immunocompromised individuals. Infection is contracted from handling contaminated soil, cat litter, or through the consumption of contaminated water or food. It is the third most common lethal foodborne infection in the United States. In transplant patients, most cases occur as a result of reactivation of a latent infection resulting from immunosuppression. We present a case of disseminated toxoplasmosis diagnosed at the time of autopsy. This case emphasizes the importance of maintaining a high index of clinical suspicion and active disease surveillance in this era of sophisticated diagnostic testing.

Solitary Extranodal Rosai-Dorfman Disease of the Mandible: An Exceedingly Rare Presentation.

Sinus histiocytosis with massive lymphadenopathy, generally known by the name of Rosai-Dorfman disease is a rare benign condition principally affecting cervical lymph nodes. Concurrent extra-nodal disease frequently occurs, however, solitary extra-nodal disease involving the mandible is exceedingly rare with less than five reported cases in the English literature. We describe a case of primary involvement of the mandible in a 27-year-old female, and discuss the differential diagnosis of this disease with other histiocytic lesions.

Cytologic artifacts and pitfalls of thyroid fine-needle aspiration using ThinPrep® The brand names ThinPrep® Cytyc®, Cytolyt®, and PreserveCyt® used throughout this article are registered trademarks of the Cytyc Corporation, Boxborough, MA.

The ThinPrep® Processor has gained popularity as a collection and preparation technique for fine‐needle aspiration biopsy (FNAB). Specific cytologic criteria to evaluate ThinPrep preparation (TP) may differ from those of conventional preparation (CP). The authors retrospectively reviewed the quality, cytologic features, and pitfalls of TP versus CP in thyroid FNABs and addressed the cytomorphologic criteria used to evaluate TP specimens.