Denise V.S. De Frias

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.

Thyroid plasmacytoma mimicking medullary carcinoma: A potential pitfall in aspiration cytology

Extramedullary plasmacytoma (EMP), a malignant neoplasm of the soft tissues composed of plasma cells, may occur either as a solitary plasma‐cell tumor (primary EMP) or as a manifestation of multiple myeloma (secondary EMP). We report on the aspiration cytology findings of an intriguing case of EMP of the thyroid that was initially misinterpreted as medullary carcinoma on clinical and cytologic examination. A major contributing cause for the cytologic misinterpretation was the presence of amyloid in the aspirate and the clinical impression of a “thyroid mass.” Based on this experience, we suggest that EMP should be considered in the differential diagnosis of a neck mass that yields discohesive cells associated with amyloid/amyloid‐like material. Clinical correlation and immunocytochemistry are crucial in avoiding pitfalls in this situation. Diagn. Cytopathol. 2000;23:354–358.

Cytomorphologic characteristics of fine needle core biopsy of multicystic peritoneal mesothelioma: A case report and review of the literature

Multicystic peritoneal mesothelioma (MPM) is an uncommon cystic mesothelial proliferative lesion. It occurs predominantly in women of reproductive age and most commonly arises in the pelvis. The preoperative diagnosis of MPM is difficult to establish based on clinical and radiographic findings, and has therefore traditionally been diagnosed following surgical resection. Due to differing management of MPM and its differential diagnoses including both benign and malignant lesions, it would be beneficial to diagnose MPM preoperatively. We report a case of MPM in a middle aged female that was diagnosed by fine needle core biopsy and touch preparations, allowing for appropriate clinical management. The cytomorphologic features of needle core biopsy, immunocytochemical studies and differential diagnosis are discussed. Furthermore, despite its infrequency, the current case emphasizes the importance of the inclusion of this entity in the differential diagnosis of cystic lesions of the abdomen and pelvis at the time of on‐site evaluation and final diagnosis, in order to avoid misinterpretation of strips of benign mesothelial cells as inadequate for diagnosis. Diagn. Cytopathol. 2010.

The immediate postconization endocervical smear: evaluation of its utility in the detection of residual dysplasia.

OBJECTIVE To determine the diagnostic value of obtaining an endocervical smear for cytologic examination immediately following cervical conization (by either the loop electrosurgical excision procedure or large loop excision of the transformation zone) in the detection of residual squamous dysplasia. STUDY DESIGN Thirty-eight cases were identified in which cervical conization was immediately followed by endocervical sampling (most commonly using a brush) and smear. RESULTS Twenty-one of the 38 postconization endocervical smears (55%) were either unsatisfactory or sub-optimal for evaluation due to cellular distortion (i.e., cautery artifact), degeneration or obscuring blood. Histologic in evaluation showed negative endocervical margins in 32 cases (84%) and positive endocervical margins in 6 cases (16%), including both low and high grade squamous intraepithelial lesions. The endocervical smears in the 32 cases with a negative surgical margin did not demonstrate evidence of dysplasia. However, in the six cases with histologically positive margins, postconization endocervical smears also failed to identify any evidence of dysplasia. CONCLUSION Immediate postconization endocervical smears do not appear to be useful for the detection of residual disease in patients undergoing conization for squamous dysplasia of the cervix.

Pulmonary metastasis of a postradiation breast epithelioid angiosarcoma mimicking adenocarcinoma : A case report

BACKGROUND Epithelioid angiosarcoma (EAS) is a mesenchymal neoplasm that may appear indistinguishable from carcinoma, melanoma and other tumors with epithelioid/epithelial differentiation. We report a case of metastatic postradiation EAS to the lungs that was mistaken for adenocarcinoma. CASE A 45-year-old woman who received radiotherapy for ductal carcinoma in situ (DCIS) 5 years previously had a local recurrence a year earlier and recent development of bilateral small pulmonary nodules. Fine needle aspiration biopsy of the lung lesions showed round to oval tumor cells with amphophilic cytoplasm. An interpretation of adenocarcinoma was rendered during assessment for specimen adequacy. The original breast tumor was typical of cribriform DCIS. Review of the recurrent breast tumor (initially reported as DCIS) and a prior wedge resection of the lung nodules (reported as EAS) showed an epithelial-appearing tumor exhibiting an endothelial immunophenotype CONCLUSION The cytologic features of EAS may resemble those of other neoplasms. In evaluating tumors with epithelioid morphology, mesenchymal tumors should also be considered so that appropriate antibodies can be included in the panel for immunohistochemistry. The importance of reviewing the patients previous biopsy materials cannot be overemphasized.

Synovial sarcoma of the heart: Report of a case with diagnosis by endoscopic ultrasound-guided fine needle aspiration biopsy.

BACKGROUND Primary synovial sarcomas of the heart are aggressive and extremely rare tumors. At least 17 cases have been reported in the literature. In all the published cases the diagnosis was based on histologic sections. To our knowledge, this is the first case of primary synovial sarcoma of the heart diagnosed by fine needle aspiration (FNA). CASE A 36-year-old male with an unremarkable past medical history presented with a 4.4-cm mass arising from the left ventricular wall of the heart. Endoscopic ultrasound guided fine needle aspiration biopsy of the mass revealed a high grade tumor showing an intimate admixture of spindle and epithelial cells. A diagnosis of undifferentiated sarcoma, favor synovial sarcoma, was rendered. Reverse transcription-polymerase chain reaction demonstrated the presence of a SYT-SSX fusion transcript. The patient received 6 cycles of chemotherapy followed by resection of the residual tumor. The histology of the viable tumor showed histologic findings typical of biphasic synovial sarcoma. CONCLUSION Synovial sarcoma rarely presents as a primary tumor of the heart. Sampling by FNA allows demonstration of the cytomorphologic appearance typical of the tumor and other ancillary studies. The specific genetic abnormality of these tumors allows confirmation by cytogenetic and molecular studies.

Extradural spinal meningioma as a source of plasmacytoid cells : A case report

BACKGROUND Meningiomas, tumors that often affect middle-aged and elderly people, occasionally arise in the spine, typically at the thoracic level. The cytologic findings in meningiomas include whorls and syncytial clusters of bland-looking cells with scattered, psammomatous calcifications and intranudclear cytoplasmic inclusions. However, in many cases, not all these findings are seen, and in rare cases, unusual cytomorphologic features are observed. CASE A case of spinal meningioma was located in the extradural compartment and composed predominantly of singly scattered cells with a plasmacytoid appearance, demonstrated on fine needle aspiration biopsy smear preparations. The cell block showed more typical features of meningioma, and the diagnosis was supported by the results of immunohistochemical staining. CONCLUSION The diagnosis of spinal meningioma is readily made by employing magnetic resonance imaging. The diagnosis can be difficult to confirm pathologically when atypical histologic findings are present, as in this case, with prominent plasmacytoid features. Sections from the cell block and immunohistochemical stains as well as clinical and radiologic findings were extremely helpful in arriving at the final diagnosis.

Cytology Features of Bing-Neel Syndrome

nique to clarify the case, using the valuable diagnostic material still present in the vial. Figure 2 shows a tissue fragment in the original Papanicolaou-stained thin-layer slide with nuclear blurring in the central part of the minibiopsy sample. The peripheral nuclei are clearly abnormal and display nucleolar prominence, highly suggestive for their malignant nature. In short, in our opinion this is a truly false negative ThinPrep in which the diagnostic cancerous epithelial fragments were overlooked in the original screening process.

A Proposed Methodology for Evaluating Secondary Screening (Rescreening) Instruments for Gynecologic Cytology

The potential benefit of these devices is that they may increase the overall sensitivity of any one gynecologic cytology screening event by detecting the presence of possible abnormal cells missed upon primary screening. Because primary screening (i.e., first-time examination of a slide) is not 100% sensitive, rescreening is used to detect these false negatives. Secondary screening devices are intended to focus manual rescreening on slides that are more likely to harbor missed abnormalities than on slides selected randomly. Secondary screening instruments may be used in place of or in addition to secondary manual rescreening.