Jose Jessurun

Cytology of metastatic cervical squamous cell carcinoma in pleural fluid: Report of a case confirmed by human papillomavirus typing

Cervical squamous cell carcinomas are rarely the cause of malignant effusions. Their identification can be relatively easy when keratinizing atypical squamous cells are present, but may be very difficult when only nonkeratinizing malignant cells are present. We present the case of a 47‐year‐old woman who presented with a large left pleural effusion after having recently completed chemoradiation therapy for stage IIB cervical squamous cell carcinoma. Cytologic examination of the fluid showed a uniform population of single atypical cells with finely vacuolated cytoplasm, ectoendoplasmic demarcation, cell‐in‐cell arrangements, and short rows of cells with intervening “windows,” all features reminiscent of mesothelial cells. No keratinization or three‐dimensional cell clusters were identified. A panel of immunohistochemical stains was performed on the cell block material, and the atypical cells were positive for cytokeratin 5/6, p63, and p16 but not for cytokeratin 7, calretinin, WT1, or Ber‐EP4 or TTF1. These findings were consistent with metastatic squamous cell carcinoma. HPV DNA determination and typing by PCR confirmed the presence of HPV16 in an aliquot of pleural fluid. This is to our knowledge the first reported case of pleural fluid involved by metastatic squamous cell carcinoma where HPV DNA testing was used to confirm the origin of the metastasis. Despite its rarity, metastatic nonkeratinizing squamous cell carcinoma should be considered when a single cell population of large atypical cells is found in effusions. Immunoperoxidase stains and HPV testing can be performed to establish the diagnosis and confirm the origin from a cervical primary. Diagn. Cytopathol. 2009.

Endoscopic ultrasound-guided fine-needle aspiration diagnosis of large cell neuroendocrine carcinoma of the gallbladder and common bile duct: Report of a case

Endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) allows a reliable and accurate diagnosis of neoplasms of the gallbladder and bile ducts. We report the cytopathologic findings of a case of large cell neuroendocrine carcinoma (LCNEC) of the gallbladder and extrahepatic bile ducts in a 67‐year‐old woman who presented with progressive abdominal pain and jaundice. EUS‐FNA of the mass involving the common bile duct and of a porta hepatis lymph node showed abundant cellularity with tumor cells arranged singly and occasionally in tight and loose clusters and rosette‐like structures in a background showing extensive necrotic debris. The tumor cells were predominantly plasmacytoid, showed a moderate amount of focally vacuolated cytoplasm and large round to oval hyperchromatic nuclei with prominent nucleoli, numerous mitoses, and apoptotic bodies. The differential diagnosis included poorly differentiated adenocarcinoma, lymphoma, melanoma, and poorly differentiated neuroendocrine carcinoma (NEC), large cell type. The tumor cells were strongly and diffusely positive for cytokeratin AE1/AE3, CD56, synaptophysin, and chromogranin and showed a very high proliferative fraction on Ki67 staining, supporting the diagnosis of a high‐grade NEC. Due to the large size of the neoplastic cells, moderate amounts of cytoplasm and prominent nucleoli, a diagnosis of LCNEC was made on the EUS‐FNA sample. Despite the prompt institution of chemotherapy, the patient died shortly thereafter and the diagnosis was confirmed at autopsy. This is to our knowledge the first case of LCNEC of the gallbladder and bile ducts diagnosed by EUS‐FNA. Diagn. Cytopathol. 2013;41:1091–1095.

Histiocytic sarcoma in the bronchoalveolar lavage fluid

A 38-year-old male patient underwent bronchoalveolar lavage (BAL) after completing four cycles of chemotherapy for pulmonary histiocytic sarcoma. Six months previously, the patient presented to an outside institution for the evaluation of dyspnea, hemoptysis, fevers, night sweats, and unintentional weight loss. His medical history was significant only for hypertension, hyperlipidemia, and left-sided hearing loss. Imaging studies performed at that time, including chest X-rays and computed tomography (CT) scans revealed a dominant left upper lobe lung mass (Fig. 1) with scattered milliary lesions through the lungs, associated with mediastinal lymphadenopathy. A fluorodeoxyglucose positron emission tomography (F-FDGPET) scan showed a large hypermetabolic consolidation in the left upper lobe with hypermetabolic hilar and mediastinal lymphadenopathy. The differential diagnosis included an infectious versus neoplastic processes and the patient underwent transbronchial biopsies and fine needle aspiration of the dominant pulmonary lesion, which was diagnosed as histiocytic sarcoma of the lung (Fig. C-1). Wright-stained cytospin preparations, Papanicolaoustained smears from the cell pellet and hematoxylin-eosin-stained cell block sections were prepared from the BAL fluid. Cytologic evaluation showed numerous red blood cells, neutrophils, and eosinophils, occasional benign foamy macrophages, rare lymphocytes and mast cells, and scattered single large neoplastic cells in a background of amorphous granular necrotic debris. The malignant cells were round to polygonal in shape with amoeboid pseudopod-like cytoplasmic extensions, varied in size from 30 to 60 lm and had abundant cytoplasm. In Wright-stained preparations, the cytoplasm varied from light to dark blue and showed variable fine vacuolation (Fig. C-2). In Papanicolaou-stained smears, the cytoplasm ranged from gray to eosinophilic and from finely vacuolated to dense (Fig. C-3). In H&E-stained cell block sections, the cytoplasm was uniformly dense and brightly eosinophilic (Figs. C-4A and B). Neutrophils and occasionally lymphocytes were seen within the cytoplasm suggesting hemophagocytosis. The neoplastic cells contained one to four nuclei which varied in size from 15 to 25 lm, were round to ovoid or slightly indented and had smooth nuclear membranes, and vesicular or reticular chromatin. One to three very large irregular nucleoli measuring from 3 to 7 lm in greatest dimension were present and were sometimes surrounded by a thin clear halo. Some of the malignant cells appeared necrotic or mummified. No mitoses or apoptotic cells were identified. Immunoperoxidase stains showed that the large atypical cells were positive for lysozyme, CD68 (KP-1 and PGM1), CD4, CD45, and S-100 (Figs. 5C and D) and were negative for CD3, CD20, CD79a, CD15, CD30, myeloperoxidase, HMB-45, tyrosinase, and cytokeratin AE1/AE3. Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, Minnesota Division of Surgical Pathology, Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, Minnesota Division of Cytopathology, Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, Minnesota *Correspondence to: Stefan E. Pambuccian, M.D., Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Fairview, C422 Mayo MMC 76, 420 Delaware Street SE, Minneapolis, MN 55455. E-mail: pambu001@umn.edu Received 30 December 2011; Accepted 16 April 2012 DOI 10.1002/dc.22876 Published online 25 September 2012 in Wiley Online Library (wileyonlinelibrary.com).

Endobronchial ultrasound-guided transbronchial needle aspiration diagnosis of mediastinal lymph node metastasis of mucinous adenocarcinoma: Arborizing stromal meshwork fragments as a diagnostic clue

Endobronchial Ultrasound‐Guided Transbronchial Needle Aspiration (EBUS‐TBNA) is a reliable and accurate method for the diagnosis of mediastinal metastases in patients with pulmonary and extrathoracic neoplasms. We report the cytopathologic findings of a case of metastatic signet‐ring cell carcinoma with abundant extracellular mucin production in the mediastinal lymph nodes of a 41‐year‐old woman, who presented with nausea, abdominal pain, and weight loss. Imaging studies showed a renal mass, numerous lung nodules, and mediastinal and retroperitoneal lymphadenopathy. EBUS‐TBNA of level 4R and 7 lymph nodes showed abundant, thick, “clean” mucus with entrapped ciliated bronchial cells, rare histiocytes, and fragments of cartilage. No neoplastic cells could be identified in Diff‐Quik®‐stained smears during the rapid on‐site evaluation, but rare signet‐ring cells were identified in the Papanicolaou‐stained smears and cellblock sections. A distinctive feature of the aspirates was the presence of large branching (arborizing), “spidery” stromal fiber meshwork fragments. These stained metachromatically (magenta) with Romanowsky‐type stains and cyanophilic to orangeophilic with Papanicolaou stains and showed occasional attached bland spindle cells, but had no capillary lumina or CD31‐staining endothelial cells. The tumor cells were strongly and diffusely positive for CEA, CDX2, CK7, CK20, and MUC2, supporting the diagnosis of a metastatic signet‐ring cell adenocarcinoma, most likely of gastrointestinal origin. We believe that the presence of the large spidery stromal fiber fragments is a useful clue to the presence of a mucinous neoplasm in EBUS‐TBNA and allows the differentiation of the neoplastic mucus from contaminating endobronchial mucus. Diagn. Cytopathol. 2013;41:896–900.

Cytologic diagnosis of metastatic seminoma to the prostate and urinary bladder: A case report

A 42‐year‐old man presented with severe abdominal pain, constipation, and hematuria. The patient had a history of seminoma treated by chemotherapy followed by bilateral orchiectomy and retroperitoneal lymph node dissection 16 years earlier. A computed tomography (CT) scan showed a 8.0 × 6.0 × 5.0 cm mass in the retrovesical space, encompassing the left side of his proximal bladder, the prostate, and the rectum. A urine cytologic specimen showed loosely cohesive cell clusters composed of highly atypical large cells and occasional large, single cells with macronucleoli present in a background of mainly lymphocytes and histiocytes was diagnosed as recurrent seminoma. Prostate biopsies showed extensively necrotic seminoma with accompanying granulomatous reaction. The tumor cells were immunoreactive for c‐kit (CD117), placental‐like alkaline phosphatase (PLAP), D2‐40, and OCT4. To our knowledge, this is the second report on urine cytology of metastatic seminoma. Diagn. Cytopathol. 2008;36:734–738.

De novo CD5-positive primary cardiac diffuse large B-cell lymphoma diagnosed by pleural fluid cytology

Primary cardiac lymphomas are exceedingly rare. The presence and extent of the intracardiac mass is determined by echocardiography, computed tomography (CT), or magnetic resonance imaging (MRI); however, the diagnosis is established by endomyocardial biopsy or by pericardial or pleural effusion cytology. We describe the pleural effusion cytologic features of a primary cardiac lymphoma in a 55‐year‐old woman who presented with progressive shortness of breath, fatigue, mild dizziness, dull chest ache, and lower extremity edema. Transthoracic echocardiography, CT, and MRI showed a large mass centered in the right atrium and extending into the right ventricle, associated with pericardial effusion and bilateral pleural effusions. Cytologic examination of the pleural fluid showed very large pleomorphic malignant cell, some of which were binucleated and multinucleated and had anaplastic features. Flow cytometry showed a kappa monotypic population of large cells coexpressing CD5, CD19, and CD20; and immunoperoxidase stains performed on the cell block sections showed that the large neoplastic cells were positive for CD20, PAX5, CD5, and MUM1 and showed a very high proliferation rate (over 90%) by Ki67 staining. The cytologic, flow cytometry, and immunohistochemistry findings established the diagnosis of de novo CD5‐positive primary cardiac diffuse large B‐cell lymphoma (DLBCL), anaplastic variant, which was confirmed by the subsequent endomyocardial biopsy. This is, to the best of our knowledge, the first report of de novo CD5‐positive primary cardiac diffuse large B‐cell lymphoma, and the first report of the anaplastic variant of DLBCL diagnosed by effusion cytology. Diagn. Cytopathol. 2014;42:259–267.

Psammoma bodies and abundant stromal amyloid in an endoscopic ultrasound guided fine needle aspirate (EUS-FNA) of a pancreatic neuroendocrine tumor: A potential pitfall

A 42-year-old male presented to our institution with a 2-month history of several episodes of confusion, double vision, headache, and loss of consciousness. The blood glucose levels measured during these episodes were in the range of 30–40 mg/dl, but randomly drawn blood samples showed normal glucose levels. Further workup showed a fasting blood glucose level of 34 mg/dl at 60 hours and elevated proinsulin levels, while insulin and C-peptide levels were normal. Serum levels of chromogranin A, pancreatic polypeptide, sulfonylurea, human growth hormone, cortisol, TSH, calcium, and creatinine were within normal limits. Computed tomography scan of the head, thorax and abdomen demonstrated no abnormal findings. The patient underwent endoscopic ultrasound evaluation, which showed a round, hypoechoic lesion measuring 14 3 13 mm in the body of the pancreas. Three transgastric EUS-FNA passes of the pancreatic lesion were performed using a 22 gauge needle. The aspirated material was used for the preparation of three airdried rapid Romanowsky (Diff-Quik VR ) stained smears, three paired fixed smears, to be later stained with the Papanicolaou stain, and the remaining material was placed in 10% formalin for cell block preparation. The FNA samples were deemed adequate during rapid onsite evaluation of the Diff-Quik VR -stained smears but a specific diagnosis was deferred to the examination of the alcoholfixed Papanicolaou-stained smears and hematoxylin and eosin stained cell block sections. The smears were hypocellular, but showed abundant large (0.2–0.6 mm) arborizing fragments of amorphous material in a “dirty” background composed of fragments of amorphous debris, red blood cells, proteinaceous material, wisps of mucus and occasional single cells and naked nuclei (Fig. C-1). In Diff-Quik VR -stained smears Department of Laboratory Medicine and Pathology, and Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota Medical School, Minneapolis, Minnesota “Present address Jose Jessurun, Professor of Pathology and Laboratory Medicine, Weill Cornell Medical College, Attending Pathologist, New York-Presbyterian Hospital, 525 East 68th Street, New York, NY 10065.” “Present address: Stefan E. Pambuccian, Professor and Director of Surgical Pathology, Department of Pathology, Loyola University Medical Center, Maywood, IL, 2160 S. First Avenue #110, Room 2230, Maywood, IL 60153” *Correspondence to: Stefan E. Pambuccian, m.d., Department of Pathology, Loyola University Medical Center, Maywood, IL, Loyola University, Chicago Stritch School of Medicine, 2160 S. First Avenue, EMS Building (110), Room 2230, Maywood, IL 60153. Email: spambuccian@lumc.edu Received 29 June 2012; revised 1 December 2012; Accepted 1 January 2013 DOI: 10.1002/dc.22975 Published online 28 February 2013 in Wiley Online Library (wileyonlinelibrary.com).

Cytologic features of pancreatic adenocarcinoma with "vacuolated cell pattern." report of a case diagnosed by endoscopic ultrasound-guided fine-needle aspiration.

The “vacuolated cell pattern” has only been recently described as a distinct morphologic variant of pancreatobiliary adenocarcinoma. Herein, we report the endoscopic ultrasound‐guided fine‐needle aspiration (EUS‐FNA) cytologic features of a case of pancreatic adenocarcinoma with “vacuolated cell pattern” occurring in a 60‐year‐old man. The aspirate smears and cell block sections from the EUS‐FNA of a 23.5 mm hypoechoic pancreatic head mass were highly cellular, showing variably‐sized crowded three‐dimensional cell clusters, flat sheets, and numerous highly atypical single cells. The background was bloody and showed necrotic debris, but no discernible mucus. The most striking feature of the aspirate was the presence of numerous very large (20–50 µm) vacuoles, occupying the entire cytoplasm, pushing the nuclei to the side and indenting them, that imparted a cribriform appearance to the sheets of neoplastic cells. The non‐vacuolated neoplastic cells were large, had abundant dense (squamoid) cytoplasm, irregularly contoured hyperchromatic nuclei, and prominent macronucleoli. Histologic evaluation of the pancreatectomy specimen showed a “vacuolated cell pattern” adenocarcinoma composed of poorly formed glands, solid sheets, and infiltrating single cells with pleomorphic nuclei and large cytoplasmic vacuoles. To our knowledge, this is the first report describing the cytologic features of this rather uncommon morphologic variant of pancreatic adenocarcinoma. Recognition of this morphologic variant of pancreatic adenocarcinoma in ESU‐FNA samples allows its differentiation from primary and metastatic signet‐ring cell carcinomas. Diagn. Cytopathol. 2014;42:302–307.

Intrahepatic recurrence of hepatocellular carcinoma 13 years after orthotopic liver transplantation for hepatitis C–related cirrhosis with occult hepatocellular carcinoma: A case report

Here we report the case of a patient who presented with well-differentiated, multifocal hepatocellular carcinoma (HCC) limited to the allograft 13 years after orthotopic liver transplantation (OLT) for hepatitis C virus (HCV)–related cirrhosis with occult HCC discovered in the explanted liver. Because of the extremely long time interval from the transplant to the recurrence of the carcinoma, molecular genetic techniques were used to determine whether the tumor was an intrahepatic recurrence of the primary tumor or developed de novo from the donor liver. A 61-year-old male presented with a 3-month history of progressively worsening nausea, vomiting, diarrhea, and right upper quadrant pain associated with a 10-lb weight loss. His past medical history was significant for liver transplantation for end-stage cirrhosis secondary to an HCV infection and alcohol abuse in 1998 (13 years before the current presentation). An occult, well-differentiated HCC measuring 4.5 cm in diameter with lymphovascular invasion was found during the pathological examination of the hepatectomy specimen, but no metastasis was present in the single hilar lymph node that was examined. His most recent liver biopsy (performed in 2006) showed recurrent mild HCV (grade 1, stage 1). HCV serum antibody test results were positive at that time. During the current presentation, the serum alphafetoprotein (AFP) levels were not increased. Computed tomography imaging of the abdomen and pelvis revealed 3 large liver lesions between 4 and 9 cm in diameter as well as numerous other smaller lesions. No extrahepatic masses or abdominal lymphadenopathy was noted. Computed tomography–guided fineneedle aspiration biopsy and core-needle biopsy were performed for 1 of the hepatic lesions and revealed well-differentiated HCC. The neoplasm appeared to be morphologically very similar to the HCC diagnosed 13 years previously in the patient’s hepatectomy specimen. Because both tumors were well differentiated (Figs. 1A and 2A), the possibility that the current HCC could represent a recurrence of the original neoplasm in the hepatic allograft was considered, but de novo HCC arising because of recurrent chronic HCV could not be entirely excluded. To address this question, we first performed immunostaining in parallel on the HCC seen in the current biopsy specimen and on the original HCC so that we could compare their immunophenotypes. Both the current tumor and the initial tumor were weakly positive for cytokeratin AE1/AE3 and for cytokeratin 8/18. A b-catenin immunostain showed a membrane-only pattern in both tumors. AFP results were negative for both tumors, and this was consistent with the lack of a serum AFP elevation during the current presentation. CD34 decorated the endothelial cells rimming the expanded hepatocyte cords, and CD10 highlighted the biliary canaliculi in both tumors (Fig. 2C,D). Interestingly, the hepatocyte paraffin 1 (HepPar1) immunostain was completely negative in the current biopsy specimen, whereas the initial tumor showed strong and diffuse positivity (Figs. 1B and 2B). We then performed a polymerase chain reaction (PCR)–based analysis of highly polymorphic DNA short tandem repeat (STR) loci to accurately discern the origin of the HCC after OLT, as previously reported. A PCR-based STR analysis (AmpFlSTR Profiler Plus PCR amplification kit, Applied Biosystems, Foster City, CA) of the current HCC specimen was compared to analyses of specimens from the patient and the donor. Testing demonstrated that the core-needle biopsy sample consisted of recipient-derived tissue (94%)