Ibrahim Ramzy

Glandular lesions of the cervix on thin-layer Pap tests: Validity of cytologic criteria used in identifying significant lesions

OBJECTIVE To determine the cytologic features that are most helpful in characterizing significant glandular lesions of the cervix observed on the ThinPrep (TP) Pap test (Cytyc Corp., Boxborough, Massachusetts, U.S.A.) and to compare these features with those published for conventional smears. STUDY DESIGN Thirty-nine TP preparations with cytologic evidence of glandular lesions of the cervix and histologic and/or clinical correlation were studied. These lesions included (1) 11 cases of benign/reactive conditions; (2) 10 cases of adenocarcinoma in situ (AIS), of which 1 had both AIS and carcinoma in situ; (3) 1 case of invasive adenocarcinoma; (4) 15 cases of squamous intraepithelial lesions and squamous cell carcinoma, including 4 with glandular involvement, and (5) 2 cases of adenosquamous cell carcinoma. These cases were reviewed by the first author without knowledge of the histologic diagnosis. Twenty-five previously published cytologic criteria were used to evaluate glandular cells on TP slides. Statistical analysis was performed using Fishers exact test to determine the significance of the features studied. RESULTS All glandular lesions had cytologic features on TP similar to those previously described on conventional smears. However, TP slides demonstrated enhanced nuclear features but less-preserved architectural patterns. Reactive lesions showed minimal overlapping without hyperchromasia or mitotic figures and with normal nuclear/cytoplasmic ratios. AIS and invasive adenocarcinoma cases had similar features. Increased cellularity and overcrowding were prominent, whereas feathering, rosettes and cell strips were present but subtle. CONCLUSION Glandular lesions of the cervix on TP slides shared many of the characteristic features reported for conventional smears. However, nuclear details were more pronounced in TP slides, while architectural patterns, although present, were relatively subtle.

Diagnostic and prognostic significance of image cytometric DNA ploidy measurement in cytological samples of cervical squamous intraepithelial lesions

D. Demirel, N. Akyürek and I. Ramzy 
Diagnostic and prognostic significance of image cytometric DNA ploidy measurement in cytological samples of cervical squamous intraepithelial lesions

Signet ring stromal cell tumor revisited and related signet ring cell lesions of the ovary

In this article, we revisit the first reported case of ovarian signet ring stromal cell tumor (SRSCT) using modern immunohistochemical techniques and compare it to a case of signet ring cell transformation of lutein cells in an ovarian stromal tumor having components of luteinized thecoma and sclerosing stromal tumor. We introduce a new classification of signet ring stromal cell lesions of the ovary that serves as a framework to distinguish pathogenetically distinct ovarian stromal lesions that may be confused with cases of true SRSCT. The SRSCT in our first case most likely arose directly from the ovarian stroma without an identifiable precursor neoplasm. In our second case, the association of the signet ring cells with lutein cells and the positive staining of the signet ring cells for inhibin and steroidogenic factor 1 confirm that in some instances signet ring cells are derived from lutein cells.

Perspectives on signet ring stromal cell tumor and related signet ring cell lesions of the gonads.

In this article, we discuss advances in our knowledge of the pathology of signet ring stromal cell tumor and related signet ring cell lesions of the ovary and a single case of signet ring stromal cell tumor of the testis. We divide ovarian signet ring cell lesions into 3 categories that reflect differences in their pathogenesis and histologic appearance. With 1 exception, all authentic cases of signet ring stromal cell tumor have been unilateral. Cases of ovarian signet ring stromal cell tumor from the literature can arise in 2 ways. The majority of cases arise multifocally from fibroma, whereas the remainder likely arise directly from the ovarian stroma. In difficult cases, immunocytochemistry provides improved diagnostic accuracy in distinguishing signet ring stromal cell tumor and its mimics from Krukenberg tumor. The most useful antibodies in this regard are epithelial membrane antigen and vimentin.

Testicular choriocarcinoma metastatic to the stomach: cytological, histological and immunocyto‐histochemical findings

Dear Editor, Choriocarcinoma metastatic to the stomach is an extremely uncommon tumour that was first reported by Aydiner et al. Although some cases metastatic to other sites such as the breast, lung and oesophagus have been previously reported with their cytological findings, this is the first such report of choriocarcinoma metastatic to the stomach. The patient was a 20-year-old male who presented to the emergency service with a 10-day history of fatigue, vomiting, nausea, abdominal pain and tarry stools. He was hospitalized with a preliminary diagnosis of upper gastrointestinal bleeding and an emergency gastroscopy was performed. It revealed a 2.5-cm, erythematous, bleeding polypoid and a fragile lesion covered with clot at the junction of the gastric corpus and fundus. Sclerotherapy in controlling a gastric haemorrhage and a partial wedge gastrectomy was performed. Intra-operative imprint cytology and a frozen section revealed a malignant neoplasm, and a total gastrectomy was performed. Histological examination of paraffin sections of the lesion established the diagnosis of choriocarcinoma. At this stage, the serum b-hCG level was found to reach 225 000 mIU/ ml. A left testicular mass suggestive of choriocarcinoma was found at ultrasonography, favouring the possibility of the gastric tumour being metastatic. A computed tomography scan revealed brain, liver and retroperitoneal metastases. Although chemotherapy was started at postoperative day 7, the patient died at day 10 as a result of cerebral herniation and intracranial pressure owing to the brain metastases. Intra-operative imprint preparations revealed a bloody background with cohesive sheets of reactive gastric cells. There were also cytotrophoblastic cells in small groups or as isolated cells (Figure 1a). These appeared as round to polygonal, mononucleated medium to large cells, showing large central vesicular nuclei with granular chromatin and small nucleoli. Some mitotic figures were seen. Additionally, there were some isolated multinucleated syncitiotrophoblastic cells (Figure 1b). Haematoxylin and eosin (H&E)-stained frozen and paraffin sections showed an ulcerated tumour infiltrating the entire thickness of the gastric wall and reaching the subserosa. The tumour, which showed extensive haemorrhage and necrosis, consisted of two cell populations, syncitiotrophoblastic cells and cytotrophoblastic cells, corresponding to those encountered in the cytology material (Figure 2a). Immunostains were performed on histological sections and Papanicolaou-stained cytology smears using ‘Cell Marque’ antibodies and an automated immunostainer (BenchMark XT; Ventana Medical Systems, Tucson, AZ, USA). Cytotrophoblastic cells in the histological sections were negative for