Imok Cha

Riedel's thyroiditis presenting with hypothyroidism and hypoparathyroidism : dramatic response to glucocorticoid and thyroxine therapy

Riedels thyroiditis is a rare fibro‐inflammatory process originating in the thyroid gland with progressive extension and invasion of surrounding tissues. Patients frequently present with a stony hard thyroid mass suggestive of anaplastic carcinoma. We report a striking case of Riedels thyroiditis associated with hypothyroidism, hypoparathyroidism and bilateral vocal cord paralysis. A dramatic response to high dose prednisone and levothyroxine therapy was seen, with recovery of parathyroid and vocal cord function. Our case suggests that early initiation of combination therapy may be important, particularly in the presence of severe disease.

Testicular fine-needle aspiration in infertile men: correlation of cytologic pattern with biopsy histology.

Open testicular biopsy is the standard method for histopathologic assessment of spermatogenesis. The need for testis biopsy has been questioned with the increased success of minimally invasive techniques such as fine-needle aspiration (FNA) mapping. This study examines whether FNA can provide cytologic information equivalent to histologic patterns by correlating diagnoses from testis FNA cytology with biopsy histology. Men (n = 87) who had undergone both diagnostic FNA mapping and open testis biopsy in the evaluation of infertility were identified. Biopsies were assessed by recognized histologic patterns of normal, hypospermatogenesis, early and late maturation arrest, and Sertoli cell only. FNA cytologic specimens were examined for adequacy and were classified similarly. Mixed patterns were also identified. The correlation between the two methods was 94%, with no differences among the different histologies. Discrepancies between cytology and histology were primarily the result of inadequate sampling and evidence of mixed patterns on FNA mapping. FNA cytology is a minimally invasive method of obtaining testicular tissue for diagnostic purposes. These data demonstrate that FNA cytology can evaluate accurately all classically defined histologic types, and may have the potential to replace testis biopsy in the assessment of spermatogenesis.

Low-grade lymphoma of mucosa-associated tissue in the parotid gland: A case report of fine-needle aspiration cytology diagnosis using flow cytometric immunophenotyping

A 66‐year‐old woman with Sjögrens syndrome for 7 years presented with an enlarged right parotid gland. The left parotid gland, which showed myoepithelial sialadenitis (MESA), had been resected 4 years earlier. A fine‐needle aspiration (FNA) biopsy of the right parotid gland was performed. Examination of the smears revealed cells of intermediate size with a round‐to‐irregular nuclear outline and distinct pale cytoplasm intermixed with small mature round lymphocytes. The chromatin was slightly paler and less clumped than in small mature lymphocytes. A small inconspicuous nucleolus was seen in most of the cells. Flow cytometry immunophenotyping performed on the FNA biopsy material showed a monoclonal population of B cells with kappa light chain restriction. The cytomorphology coupled with the immunophenotyping study in this clinical context suggested the diagnosis of low‐grade B‐cell lymphoma of mucosa‐associated lymphoid tissue (MALT). Extensive staging work‐up revealed no evidence of disseminated disease. The right parotid gland was surgically excised. Histology and gene rearrangement studies confirmed the cytologic diagnosis. To our knowledge, this is the first description of a low‐grade lymphoma of MALT in a salivary gland to be diagnosed by FNA. Diagn. Cytopathol. 16:345–349, 1997.

Fine Needle Aspiration Cytology of Dermatopathic Lymphadenitis

OBJECTIVE Dermatopathic lymphadenitis (DL) can be a nonneoplastic cause of an enlarged lymph node or nodes. Cytologic findings of DL have not been well described. The differential diagnosis includes Langerhans histiocytosis (LH) in children and low grade lymphoma in adults. We present three cases of dermatopathic lymphadenitis with a discussion of cytologic findings and differential diagnosis. STUDY DESIGN Fine needle aspiration (FNA) findings of three cases of lymph nodes involved by DL were reviewed. All three were axillary lymph nodes in patients with skin rashes. Immunoperoxidase stains for S-100 and CD1a were performed on a cell block from one case, and flow cytometric analysis was performed on another. RESULTS FNA of DL yields cellular smears with abundant histiocytoid cells with moderate cytoplasm and ovoid, vesicular nuclei with longitudinal grooves (interdigitating reticulum cells). These histiocytoid cells are S-100 and CD1a positive. The background cells are mature lymphocytes, scattered eosinophils and plasma cells. Case 1 was originally misinterpreted as consistent with LH. In case 2, flow cytometric analysis of a mixed population of lymphocytes was seen, ruling out lymphoma. In case 3, the diagnosis of DL was based on morphologic features. CONCLUSION Interdigitating reticulum cells in dermatopathic lymphadenitis are S-100 and CD1a positive and could be confused with LH in children. In adults, flow cytometry could be used to distinguish them from low grade lymphoma. FNA findings of DL should be interpreted with the clinical history.

Cytology of morcellated renal specimens: significance in diagnosis and dissemination.

PURPOSE Controversy surrounds the process of morcellation for retrieving laparoscopically removed specimens. The inability to assess tumor stage, increased difficulty in pathological examination and the potential for tumor spillage are cited as significant disadvantages of the technique. We examined cytological findings in bag washings after laparoscopic nephrectomy for benign and malignant diseases. MATERIALS AND METHODS We prospectively obtained cytology washings from the retrieval bag after laparoscopic nephrectomy and manual morcellation. In 22 consecutive cases after specimen fragmentation in a LapSac (Cook Urological, Spencer, Indiana) the bag was thoroughly irrigated with 30 cc normal saline. This wash was then processed by ThinPrep (Cytyc Corp., Marlborough, Massachusetts) and stained with Papanicolaou stain. Standard pathological examination of the morcellated specimen was performed to determine renal histology. RESULTS The histological diagnosis was clear cell renal carcinoma in 10 cases, multicystic renal carcinoma in 2, papillary renal cell carcinoma in 1, angiomyolipoma in 1, and oncocytoma in 1. Bag cytological results were accurate in 9 of 13 patients with carcinoma (69%), while in 3 cytological study provided additional information. In all 9 cases of benign histology, cytological findings were consistent with benign cellular features. Neoplastic cells were easily detected and classified into type and grade. CONCLUSIONS Cytological examination of LapSac washings after specimen morcellation provided a pathological diagnosis in the majority of patients. This method may complement existing techniques and be useful for increasing the accuracy of pathological analysis of morcellated specimens. In addition, these data suggest that malignant cells are liberated during the morcellation process, which has significant implications for potential tumor dissemination.

Nonpalpable Leydig's Cell Tumors Diagnosed by Fine Needle Aspiration

Leydigs cell tumor of the testicle is rare, constituting 1 to 2% of all testicular tumors. They are commonly detected as palpable masses but can present with precocious puberty, gynecomastia or infertility. The tumor is usually diagnosed by and definitively treated with orchiectomy. We present a case of nonpalpable, bilateral Leydigs cell tumor presenting as infertility, diagnosed by fine needle aspiration and managed conservatively with serial imaging to allow for paternity. CASE REPORT A 29-year-old man presented with a 1.5-year history of primary infertility. Physical examination was difficult due to a small, thick scrotum but revealed asymmetric fullness in the left spermatic cord and left testicular atrophy. Several semen analyses demonstrated severe oligo-asthenospermia (less than 1 x 106 motile sperm). Scrotal ultrasound revealed no varicocele. However, a 5 X 5 X 6 mm., intraparenchymal hypoechoic lesion was noted in the right testicle. Serum luteinizing hormone, follicle-stimulating hormone, a-fetoprotein, lactate dehydrogenase, p-human chorionic gonadotropin and total testosterone were normal. T2-weighted magnetic resonance imaging revealed that the lesion had low signal intensity consistent with scar tissue. The mass was managed with close observation and serial ultrasound, and the infertility was treated with empiric clomiphene citrate. The patient was advised to bank sperm. Scrotal ultrasound, serum a-fetoprotein and &human chorionic gonadotropin 2 months later were unchanged. Ultrasound at 4 months revealed that the right testicular lesion had increased in size to 9 x 9 X 8 mm. (fig. 1). In addition, a new, ill-defined, 8 x 8 x 7 mm., slightly hypoechoic lesion was noted in the left testicle. Given the improbability that the lesion was fibrotic, a tissue diagnosis was recommended. Fine needle aspiration of both testis lesions was performed with local anesthesia and ultrasound guidance. Through a 23

Correlation of Prognostic Factors and Survival with Classical and Pleomorphic Variants of Invasive Lobular Carcinoma

Abstract: The pleomorphic variant of invasive lobular carcinoma has a worse prognosis than its classical counterpart. To determine if histologically separating invasive lobular carcinoma into either of these variants correlates with other prognostic indicators, we measured the mitotic figure index (number of mitotic figures/100 tumor cells), Ki67 labeling index (Ki67 positive cells/100 tumor cells), intratumoral microvessel density (microvessels/200X field), and the number of positive lymph nodes in 48 patients with invasive lobular carcinoma with a median follow‐up of 63 months. There were 27 cases of classical lobular carcinoma (mean age, 58) and 21 cases of pleomorphic variant (mean age, 57). The mitotic figure index and Ki67 labeling index were significantly higher in the pleomorphic variant compared to the classical lobular carcinoma (p = 0.002, and 0.08 respectively). No significant differences in intratumoral microvessel density, number of positive lymph nodes, or age was found between the two histologic types. Relapse free survival was shorter in patients with pleomorphic variant (p = 0.05), but no difference in overall survival was detected (p = 0.47). Among all patients, lymph node status was the best predictor of relapse free (p = 0.001) and overall survival (p = 0.002), although there were no overall survival differences between patients with 0 to 3 positive lymph nodes. Relapse‐free and overall survivals were better among patients who had lower indices of microvessel density (p = 0.07 and 0.08 respectively), Ki67 (p = 0.02 and 0.11), and mitotic figures (p = 0.10 and 0.07). By multivariate analysis no additional prognostic information was provided beyond that of the number of positive lymph nodes; except for overall survival, the mitotic figure index provided additional significant information. We conclude that the histologic diagnosis of pleomorphic invasive lobular carcinoma significantly correlates with shortened relapse‐free survival, but among all invasive lobular carcinomas axillary nodal status and mitotic figure index provide more prognostic information than histologic subtyping into pleomorphic and classical variants.?

Sperm fine-needle aspiration (FNA) mapping after failed microdissection testicular sperm extraction (TESE): location and patterns of found sperm

We sought to evaluate the ability of fine-needle aspiration (FNA) mapping to find sperm and to guide sperm retrieval after failed microdissection testicular sperm extraction (micro-TESE) in nonobstructive azoospermic men. In this study of consecutive male infertility cases, interventions included testicular FNA mapping and subsequent sperm retrieval. Outcomes included the frequency and location of found sperm on FNA maps after failed micro-TESE and the salvage sperm retrieval success. Among 548 patients undergoing FNA mapping from 2010 to 2016, 82 men with previous micro-TESE procedures were identified. The mean time between micro-TESE and FNA mapping was 2.2 years. A total of 2825 (1424 on right and 1401 on left) sites were mapped. At least one site revealed mature sperm in 24 (29.3%) of 82 men with prior failed micro-TESE procedures. There was an equal likelihood of detecting sperm in either testis (6.1% right; 5.7% left; P = 0.58). Digital “heat maps” revealed differences in sperm findings within the testis with mature sperm more likely found in the testis periphery rather than centrally. Fifteen (62.5%) patients subsequently underwent sperm retrieval procedures guided by FNA maps. Sufficient sperm were retrieved in all cases, and in 10 (66.7%) of 15 cases, extra sperm were frozen for future use. In a significant proportion of failed micro-TESE procedures representing the largest study to date, sperm were detected by FNA mapping and could be reliably retrieved through FNA map-guided surgical sperm retrieval. When present, sperm were more likely to be found in the testis periphery rather than centrally with FNA mapping.