Grace C.H. Yang

Combined Use of the “Scratch and Smear” Sampling Technique and Ultrafast Papanicolaou Stain for Intraoperative Cytology

OBJECTIVEnTo assess the applicability of Ultrafast Papanicolaou stain (UFP), a 90-second, high-resolution stain incorporating the air-dried rehydration technique, to intraoperative cytology in surgical pathology laboratories.nnnSTUDY DESIGNnTwo hundred sixty-two randomly selected surgical specimens for intraoperative consultations were included in the study. Each specimen was first conventionally prepared by touch imprinting, wet fixation in alcohol and staining by hematoxylin and eosin (H&E); the remaining specimens were then sampled by the scratch and smear technique and subjected to the UFP staining protocol.nnnRESULTSnThe combined use of the scratch and smear sampling technique and UFP staining was superior to the conventional methods of touch imprinting and H&E staining in every case because of the following features: (1) intact tissue fragments composed of both epithelial and stromal elements rather than epithelial cells only, (2) polychromasia rather than bichromasia, (3) sharper nuclear and cytoplasmic details, (4) histologic criteria applicable to thick tissue fragments due to transparency and flatness and (5) clear background devoid of red blood cells and eosin.nnnCONCLUSIONnThe combined use of the scratch and smear sampling technique and UFP enhances intraoperative cytology.

Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: Fine-Needle Aspiration with Ultrasound and Histologic Correlation of 41 Cases

Objective: The encapsulated follicular variant of papillary carcinoma (FVPC) was recently reported to have genetic alterations and biological behavior closer to follicular adenoma/carcinoma than classic papillary carcinoma and unencapsulated FVPC. The objective of this study is to alert cytologists to this new subtype and to report our experience. Study Design: Cytology of 41 cases of surgery-proven encapsulated FVPC was reviewed and correlated with histopathology and ultrasound findings. These cases were collected over 19 years from 188 aspirates reported as ‘suspicious or atypical, cannot exclude FVPC’ and from 245 aspirates reported as follicular neoplasm. Results: Thirteen aspirates had diffusely atypical nuclei, 20 aspirates had mixed normal and atypical nuclei, and 8 aspirates had no atypical nuclei. On histology, papillary nuclei were distributed focally in the second and third groups. Crowded, oval, clear nuclei occurred in nearly 80% of the cases, nuclear grooves occurred in 12.2%, and nuclear pseudoinclusions occurred in 4.9%. Capsular invasion without angioinvasion was present in 30% of encapsulated FVPCs, with angioinvasion in 17.5% and lymph node metastasis in 7.5%. Most encapsulated FVPCs were benign-appearing on ultrasound with round-to-oval, circumscribed nodules with a hypoechoic rim. Conclusions: Encapsulated FVPC is more difficult to recognize on fine-needle aspiration and ultrasound than unencapsulated FVPC.

Predictive Value of Cytologic Atypia in Indeterminate Thyroid Fine-Needle Aspirate Biopsies

BackgroundFine-needle aspiration (FNA) biopsies are the most accurate method for diagnosis of thyroid nodules. Unfortunately, biopsies are indeterminate 15–30% of the time and surgery is thus required for a definitive diagnosis. We aimed to determine whether specific descriptors of cytologic atypia mentioned in indeterminate FNA reports were associated with malignancy on final histopathology.MethodsRetrospective review of 1000 surgery patients identified 466 indeterminate FNA lesions that underwent either a hemi- or total thyroidectomy between 1998 and 2009. We screened FNA reports for specific descriptors of nuclear atypia. Univariate and multivariate analyses were performed to evaluate the independent effect of cytologic atypia descriptors on the risk of malignancy.ResultsNuclear atypia on FNA conferred a risk of malignancy of 42% (Pxa0<xa00.0001). Risk of malignancy increased from 17% for zero descriptors to 81.2% when four or more descriptors of atypia were described. Nuclear grooves and inclusions together conferred a risk of malignancy, specificity, and false positive rate of 79.3%, 98.2% and 1.8% respectively.ConclusionsThe presence of four or more descriptors of cytologic atypia or the presence of both nuclear inclusions and grooves together confers a high risk of malignancy on final histopathology and a low false positive rate. These findings should be taken into consideration when interpreting FNA reports and total thyroidectomy should be considered for those patients at higher risk.

Uncommon Tumors of the Salivary Gland in Fine Needle Aspiration Biopsies

OBJECTIVEnTo determine the utilization of fine needle aspiration (FNA) biopsy in guiding the surgeon in the management of patients with parotid masses and to study the cytohistologic correlations of rare parotid tumors.nnnSTUDY DESIGNnFNA biopsies and parotidectomies performed by a head-and-neck surgeon over an approximate three-year period were analyzed. Cytologic features of rare salivary gland tumors were also studied and correlated with their histology.nnnRESULTSnIn an acinic cell carcinoma in a 15-year-old female whose smears were stained with Diff-Quik, novel negative images of crystals were found intracytoplasmically and extracellularly, corresponding to the crystallized, membrane-bound, exocrine, secretory substance ultrastructurally. A truly malignant mixed tumor from a 73-year-old female showed capsular invasion in the primary site that later metastasized to the lung with both epithelial and mesenchymal components. The tumor cells did not exhibit nuclear atypia except for fine cytoplasmic vacuoles in the Diff-Quik-stained smears. Basal cell adenoma, membranous (dermal analogue) type, from an 87-year-old female had an interesting geographic pattern on smears.nnnCONCLUSIONnWithin three years, a total of 70 FNAs were performed. Of those cases, 46 had surgery. Preoperative FNAs of the salivary gland lesions were utilized by the surgeon in guiding treatment options for large, fixed masses as well as masses < 1 cm, in elderly and acquired immunodeficiency syndrome patients.

Fine-Needle Aspiration of Mucin-Producing Thyroid Tumors

Objective: Mucin-producing thyroid tumors are extremely rare. Nonetheless, we have encountered three such cases in fine-needle aspiration. We report the cytologic and histologic findings and review the literature. Study Design: Cytologic features were studied on direct smears using Romanovsky stain to detect background substance and Papanicolaou stain to analyze nuclear and cytoplasmic features. The cytologic features were correlated with histology. Mucin was demonstrated by mucicarmine, Alcian Blue/PAS, and Alcian Blue (pH 2.5). Results: The cytologic features related to mucin include: (1) thick luminal mucin globules and signet ring cells aspirated from an 83-year-old woman with a 3-cm signet ring cell follicular adenoma, (2) abundant fluffy mucin containing signet ring cells in cohesive fragments aspirated from a 75-year-old man with the bilateral signet ring cell follicular variant of papillary carcinoma, which is the first case in the English literature, and (3) abundant thin mucoid mucin aspirated from the lymph node of an 86-year-old woman with a 5-cm mucinous poorly differentiated thyroid carcinoma. Conclusion: The occurrence of mucin in thyroid fine-needle aspiration does not necessarily indicate metastasis, and the presence of mucin in cervical lymph nodes does not exclude the thyroid gland as a possible primary.

Epithelial-myoepithelial carcinoma of the parotid. A case of ductal-predominant presentation with cytologic, histologic and ultrastructural correlations.

BACKGROUNDnThe cytologic features of the usual type of epithelial-myoepithelial carcinoma (EMC) of the parotid, with myoepithelial cell predominance, is well described in the cytology literature. In contrast, the cytologic features of ductal-predominant-type EMC has not yet been reported.nnnCASEnAn 82-year-old male presented with a 2.7-cm parotid mass of two years duration. Fine needle aspiration smears stained with Diff-Quik showed cohesive tissue fragments outlined by metachromatic fibrils scattered in abundant, smooth, bluish background material. Ultrafast Papanicolaou stain revealed sharply outlined, large ductal cells with smooth, round to oval nuclei, prominent nucleoli and abundant vacuolated cytoplasm; the cells were arranged tridimensionally in occasional follicles that contained thick secretions. Neoplastic myoepithelial cells were occasionally seen at the periphery of tissue fragments, most commonly hidden underneath the neoplastic ductal epithelium at a slightly different focal plane; the cells had small, oval, dark nuclei and inconspicuous cell borders. The nuclear area and cell size of the neoplastic ductal cells was two and three times, respectively, that of neoplastic myoepithelial cells.nnnCONCLUSIONnEMC, depending on the ratio of ductal to myoepithelial cell components, has different cytologic presentations. This case illustrates the ductal-predominant presentation of EMC.

Most Thyroid Cancers Detected by Sonography Lack Intranodular Vascularity on Color Doppler Imaging: Review of the Literature and Sonographic-Pathologic Correlations for 698 Thyroid Neoplasms

This study investigated the controversy of whether hypervascularity on color Doppler sonography correlates with thyroid malignancy by reviewing the literature and sonographic‐pathologic correlation.

Fine-needle Aspiration Biopsy

Minimally invasive biopsy n n nSimple but not trivial n n nAccurate diagnosis depends mostly on meticulous technique li]• n n nCost effective

Pathologic basis of the sonographic differences between thyroid cancer and noninvasive follicular thyroid neoplasm with papillary-like nuclear features

Ultrasonography is pivotal in triage thyroid biopsy in the era after the identification of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). This pictorial essay illustrates the pathologic basis of the sonographic features that distinguish NIFTP from thyroid cancers. In this study, we present the correlations of ultrasonography to ×1 histopathology to assess shape and margin characteristics. Markedly hypoechoic nodules correlate to microfollicular/solid nodules, while isoechoic/hyperechoic thyroid nodules correlate to normofollicular/macrofollicular nodules. The ultrasound findings of NIFTP and minimally invasive encapsulated thyroid cancers are similar. Both are well-circumscribed, oval-to-round nodules with regular margins. Blurred or microlobulated margins indicate infiltrating tumors, while lobulated margins are characteristic of expansile tumors. Overtly invasive encapsulated tumors are characterized by oval-to-round nodules with irregular or lobulated margins. The ultrasound findings for infiltrative thyroid cancers show at least one of the following malignant features: marked hypoechoicity, taller-than-wide shape, microcalcifications, and blurred or microlobulated margins.

Large cell carcinoma of the lacrimal gland diagnosed by fine needle aspiration biopsy.

A 67-year-old man presented with a 6-month history of a malignant appearing left lacrimal gland mass. Fine needle aspiration biopsy was performed in the office, diagnosing the mass as large cell carcinoma (LCCA) of the lacrimal gland. This represents the second reported case of LCCA of the lacrimal gland and details the potential for FNA biopsy to successfully yield the diagnosis. LCCA of the lacrimal gland is rare, but should be considered in cases of malignant lacrimal gland neoplasms.