Larry Kluskens

P-glycoproteins in pathology: The multidrug resistance gene family in humans

Many cancers do not respond to chemotherapy on primary exposure to drugs, thus manifesting intrinsic drug resistance. Other cancers that do initially respond subsequently become resistant to the same drugs and simultaneously to other drugs to which the patient has had no previous exposure. This is a form of acquired drug resistance. There is a pressing need to better understand the mechanisms of drug resistance and to use this information to develop strategies for the chemosensitization of drug-resistant tumors. A goal of the pathology laboratory is to offer chemosensitivity tests that identify intrinsic or acquired resistance of tumors to specific drugs or classes of drugs to enable the clinician to tailor therapy to the biology of cancers in individual patients. Multidrug resistance is one type of drug resistance. It can be present in either an intrinsic or acquired form. The human gene that confers human multidrug resistance, the MDR1 gene, has been cloned and classified as a member of the MDR gene family. Its encoded protein, called Mdr1, is an energy-driven membrane efflux transporter that maintains intracellular concentrations of certain chemotherapeutic drugs at nontoxic levels. Useful model systems for studying multidrug resistance have been developed in several research laboratories. Applying selection pressure by exposing cultured cancer cells to escalating doses of natural product anti-cancer drugs allows cross-resistant cell lines to be produced which share patterns of drug resistance with human cancers. A common feature of these drug-resistant lines is the expression of Mdr1. Using techniques of genetic engineering, molecular probes have been developed that can be used to measure MDR1 mRNA and MDR1 gene amplification. Mdr can be measured by immunochemistry methods. Currently, such measurements are being used to stratify patients in clinical trials designed to determine if chemosensitization by inhibition of the pump function of Mdr is a clinically useful therapeutic strategy. If successful, Mdr/MDR1 mRNA laboratory testing might significantly increase the clinical laboratorys role in cancer patient management.

Fine-needle aspiration of clinically suspicious palpable breast masses with histopathologic correlation

BACKGROUND The purpose of this study was to compare the diagnostic accuracy of fine-needle aspiration (FNA) of clinically suspicious palpable breast masses in women younger and older than 40 years of age. METHODS All women who had FNA biopsy with subsequent tissue biopsy were included. The cytologic diagnoses were classified into three groups: malignant, suspicious, or benign. Histopathologic correlation was based on either a needle core biopsy, an excisional biopsy, or a mastectomy specimen. RESULTS A total of 1,158 fine-needle aspirations performed between 1982 and 2000, on women being evaluated for a clinically palpable breast mass were included in the study. The patients were divided into two groups: group I consisted of 231 patients aged 40 years and younger, and group II consisted of 927 patients aged 41 years and older. In group I there were 117 (51%) malignant FNA diagnoses, and only 1 (1%) false-positive case, subsequently diagnosed on histopathologic material as an atypical papillomatosis. There were 20 (9%) cases diagnosed as suspicious on FNA. On histopathology 10 were malignant, and 10 were benign. Of the 91 (39%) cases interpreted as benign, only 1 (1%) was a false negative. In group II, which comprised 927 patients, there were 693 (74%) malignant FNA diagnoses, and 3 (less than 1%) false-positive cases, which on follow-up histopathologic examination revealed 2 atypical ductal hyperplasias and 1 atypical papilloma. There were 90 (10%) cases diagnosed as suspicious on FNA. On histopathology, 68 were malignant and 22 were benign. Of the 131 (14%) lesions interpreted as benign, there were 18 false-negative cases (14%), which included 17 infiltrating carcinomas and 1 ductal carcinoma in-situ. Twelve (1%) of the cases were inadequate for the study. CONCLUSIONS The sensitivity, specificity, and positive predictive values were remarkably high and comparable in both groups: group I had 99% sensitivity, 99% positive predictive value, 99% specificity, and 99% negative predictive value; and group II had 98% sensitivity, 97% specificity, 99% positive predictive value, and 86% negative predictive value. The overall rate of false-positive (less than 1%) and false-negative cases (9%) is comparable with published literature. Suspicious cases should be further evaluated, as our study revealed more than 50% to be malignant. The incidence of malignancy in patients presenting with a clinically palpable breast mass with follow-up biopsy was 51% in patients aged 40 years and younger and 74% in patients aged 41 years and older. Fine-needle aspiration is an excellent diagnostic tool in assessing clinically palpable breast masses.

Importance of Repeat Fine-Needle Biopsy in the Management of Thyroid Nodules

Fine-needle aspiration (FNA) biopsy of a thyroid nodule was performed in 797 patients. Ninety-six patients had resection of the thyroid nodule performed subsequent to a one-time FNA biopsy. The surgical pathology of these 96 cases demonstrated a 5.8% false-negative rate and a 9.9% false-positive rate. As a consequence, we prospectively evaluated the routine practice of repeat FNA of cytologically benign thyroid nodules. Repeat FNA confirmed the original benign cytology in 183 (93%) of 196 patients. Seventeen of these 183 patients with benign FNA on both biopsies had resection of the nodule performed because of the development of suspicious clinical signs or in response to the patients choice; 1 recurrent cyst was found to be carcinomatous. Of the 13 patients demonstrating a change in cytology on repeat FNA biopsy, 9 had a nodule that was classified as possibly malignant (suspicious); 6 of these patients underwent resection, and 1 patient was found to have a carcinomatous nodule. Four patients had nodules that were classified as probably malignant on repeat FNA biopsy; all of their nodules were resected, and three of them were found to be carcinomatous. This study demonstrates that, although one-time FNA biopsy of thyroid nodules is highly accurate, with a relatively low false-negative rate, repeat fine-needle biopsy improves on this diagnostic accuracy, thereby decreasing the risk of misdiagnosing a thyroid nodule that is malignant.

Update on human polyomavirus BK nephropathy.

Polyomavirus BK (BKV) has ebeen identified as the main cause of polyomavirus‐associated nephropathy, a major cause of renal allograft failure. Although BKV‐associated nephropathy develops in only 2% to 5% of renal transplant recipients, its prognosis when present is very poor, with irreversible graft failure developing in 45% of affected patients. While the use of urine cytology for the detection of decoy cells has been in use for decades, other diagnostic modalities to detect BKV have emerged, including tissue biopsy, polymerase chain reaction, viral culture, and serology. Currently, there is no consensus regarding the laboratory technique best suited for clinical monitoring. This review article will discuss essential and clinical features of polyomavirus, followed by a discussion pertaining to the various diagnostic modalities that contribute to detecting polyomavirus‐associated nephropathy. Diagn. Cytopathol. 2009.

ABO blood type predicts the cytolocalization of anti-P-glycoprotein monoclonal antibody reactivity in human colon and ureter☆

Classic multidrug resistance is mediated by a P-glycoprotein. Using monoclonal antibody C219 (MAb C219) in an immunohistochemical study, we found high levels of putative Golgi P-glycoprotein in normal columnar and transitional epithelium in subpopulations of patients with specific blood types. For example, Golgi staining was present in blood type A patients in 46% of normal colon samples (N = 21) and 88% of normal ureter samples (N = 17). In comparison, Golgi staining was present in blood group O patients in only 6% of normal colon samples (N = 34) and in 0% of normal ureter samples (N = 19). The association of MAb C219 Golgi staining with blood type A and lack of Golgi staining with blood type O was statistically significant in normal colon (P = .001) and normal ureter (P less than .0001). Inappropriate hyperexpression of P-glycoprotein was frequently found in colon carcinomas. Additional evidence that Golgi MAb C219 reactivity represents P-glycoprotein is presented. This includes (1) immunostaining of Golgi with two anti-P-glycoprotein MAbs, C219 and JSB-1, and (2) experiments in which Mab C219 Golgi reactivity was blocked by preincubation of MAb C219 with a specific P-glycoprotein epitope-containing peptide. The high degree of association of Golgi P-glycoprotein with blood type A may suggest a role for P-glycoprotein in processing or trafficking of specific blood group antigens.

Fine-needle aspiration of scalp lesions.

A variety of inflammatory and neoplastic scalp lesions are encountered in surgical pathology. However, the literature on fine‐needle aspirations (FNAs) of the scalp is exceedingly rare. We report on a series of 70 FNAs involving cutaneous and subcutaneous lesions on the scalp. A total of 70 fine‐needle aspirations of cutaneous and subcutaneous scalp lesions was reviewed to identify patterns of metastasis to the scalp and to demonstrate the effectiveness of FNA in diagnosing these lesions. There were 42 male and 28 female patients, ranging in age from 29–91 yr (mean, ∼61 yr). Sixty‐one patients had a previous history of malignancy. Of these aspirates, 59 were neoplastic, consistent with the patients known primary. One case was an abscess, and the remaining case was unsatisfactory for cytologic evaluation. Follow‐up biopsy revealed granulomatous inflammation. The most common primary tumor to metastasize to the scalp was lung carcinoma, which was seen in 18 cases, followed by hematopoietic malignancies in 14 cases. Melanoma was identified in 6 cases, head and neck tumors in 5 cases, renal malignancies in 4 cases, gastrointestinal tumors in 3 cases, sarcoma in 3 cases, breast and prostate malignancy in 2 cases each, and an olfactory neuroblastoma and meningioma in 1 case each. The remaining 9 aspirates were from patients who did not have a previous history of malignancy. These included 6 benign aspirates consisting of 3 epidermal inclusion cysts, 2 lipomas, and 1 neurofibroma. Two aspirates were malignant and included 1 primary squamous‐cell carcinoma and 1 metastatic adenocarcinoma of unknown origin. The remaining case was unsatisfactory for cytologic evaluation. Follow‐up biopsy of this lesion showed noncaseating granulomas. Of the aspirates from patients with a previous history of malignancy, 97% were neoplastic.

Utilization of core wash material in the diagnosis of breast lesions by stereotactic needle biopsy

Several reports have compared the results of fine‐needle aspiration and stereotactic core needle biopsy in nonpalpable breast lesions. In this study the authors describe a simple method to retrieve cytologic material from a core breast biopsy sample that provides the diagnosis within 1 hour of the procedure.

Fine-needle aspiration of primary Rosai-Dorfman disease of the bone without peripheral lymphadenopathy: a challenging diagnosis.

Sinus histiocytosis with massive lymphadenopathy is a rare, benign, histiocytic proliferative disorder, first reported by Rosai and Dorfman in 1969. It mostly affects young patients, within the first two decades of life and follows a benign but sometimes protracted course. This disease mainly involves lymph nodes. However, extranodal involvement can be seen in up to 43% of the cases. Bone is the least likely site of extranodal involvement, with 13 cases published to date. Of these 13 cases, 11 were diagnosed on histologic material and two on cytologic material. An additional case of primary bone Rosai-Dorfman disease is reported here. A 16-year-old boy presented to his primary physician with a complaint of right shoulder pain of 1-year duration. On physical examination, no peripheral lymphadenopathy was detected and a complete blood count failed to reveal any leukocytosis. The patient was referred to a sport medicine physician who performed an magnetic resonance imaging (MRI). The radiologic findings consisted of a 4.7 3 3.2 3 2.7 cm, expansile, multilobulated lesion with extension outside of the cortical margin of the bone into the subscapularis and infraspinatus muscle. Based on the radiologic features, the differential diagnosis included giant cell tumor, eosinophilic granuloma, and a mesenchymal malignant tumor. A week later, the patient underwent a CT-scan guided fine-needle aspiration. A diagnosis of ‘‘negative for malignancy, suggestive of osteomyelitis’’ was rendered. Cytology and special stains were negative for organisms. As the cytologic diagnosis was not reflective of the radiologic or clinical impression, the patient underwent surgical biopsy. Touch preparations were made at the time of frozen section and they were stained with Diff Quik method. The cytologic material consisted of a polymorphous population of cells composed of plasma cells, lymphocytes, neutrophils, red blood cells, and numerous histiocytes with abundant cytoplasm and well-defined cytoplasmic borders (see Fig. C-1). The histiocytic cells contained intact lymphocytes, plasma cells, neutrophils, and red blood cells within their cytoplasm (see Figs. C-2–C-4). The cytologic features were suggestive of Rosai-Dorfman disease. Special studies on the histologic material demonstrated that the large histiocytic cells were positive for CD68 (PGM) and S-100 protein (see Fig. C-4) and negative for CD1a and CD30, excluding the possibility of Langerhan’s cell histiocytosis and anaplastic large cell lymphoma. At this point, the original fine-needle aspiration material was reviewed, and not surprisingly, the cytologic changes of Rosai-Dorfman disease were evident. In summary, the cytologic features of Rosai-Dorfman disease involving lymph nodes are quite characteristic. However, the diagnosis of a primary Rosai-Dorfman of Department of Pathology, Rush University Medical Center, Chicago, Illinois *Correspondence to: Caitlin Schein M.D., Department of Pathology, Rush University Medical Center, 1750 W Harrison, Room 570 Jelke, Chicago, IL 60612, 312-942-5260, USA. E-mail: Caitlin_schein@rush.edu Received 25 July 2011; Accepted 9 August 2011 DOI 10.1002/dc.21826 Published online 24 October 2011 in Wiley Online Library (wileyonlinelibrary.com).

Cytologic findings of acute leukemia in bronchoalveolar lavage fluid

Bronchoalveolar lavage (BAL) is often performed in patients with acute leukemia developed with respiratory failure or pulmonary infiltrates. Patients usually undergo BAL to rule out infection. Occasionally, however, leukemic infiltrate may be detected. We present a series of 11 cases in which the diagnosis of leukemia was made on the BAL material. We retrospectively reviewed all BAL samples from January 1, 2006 to December 31, 2008. There were a total of 1,130 cases, of which 139 showed malignant cytology, including 10 with leukemia. Sixteen samples were unsatisfactory and 904 were benign, of which 32 had identifiable microorganisms. In additional to the 10 leukemia cases identified, two more were reviewed after the search criteria. The 12 patients (seven men, five women) ranged from 22 to 75 years old. All patients had previously biopsy‐proven leukemia [two acute myelomonocytic leukemia, two acute promyelocytic leukemia, two acute myeloid leukemia (AML) with inv16, two therapy‐related AML, one acute monocytic leukemia, one chronic myeloid leukemia in blast face, one AML with maturation, one myelodysplastic syndrome with excess blasts, and one large granular leukemia]. Four had a prior diagnosis of myelodysplastic syndrome. The time from initial diagnosis of leukemia to BAL ranged from 1 to 233 days, with 8 of 10 occurring within 8 days of diagnosis. Symptoms that prompted BAL included shortness of breath/hypoxia (8), fever (3), chest pain (2), and cough (2). Chest X‐rays in all cases revealed opacities or consolidations mimicking an inflammatory process. Seven patients subsequently died, while three were alive, and, in remission, and two were lost to follow‐up. The presence of a leukemic infiltrate can mimic infection. BAL is a relatively safe and useful diagnostic tool in this setting for differentiating a leukemic infiltrate from an infection/inflammatory infiltrate. The prognosis of patients with lung involvement of acute leukemia is poor. Diagn. Cytopathol. 2013.

Cytomorphology and immunohistochemistry of a recurrent clear cell odontogenic carcinoma with molecular analysis: A case report with review of literature.

Clear cell odontogenic carcinoma (CCOC) is a rare, odontogenic tumor of the jaws with mandibular involvement usually present in sixth decade of life with female preponderance. It is classified as a malignant tumor of odontogenic origin in 2005 by the World Health Organization because of its aggressive and destructive growth capacity and potential to metastasize. It needs to be distinguished from other primary and metastatic clear cell tumors of the oral and maxillofacial region. Recently, CCOCs have been noted to harbor a Ewing sarcoma breakpoint region 1 gene RNA‐binding protein 1 (EWSR1) and activating transcription factor (ATF) gene translocation. To date, cytologic features of only one case have been reported in the literature. We report an additional case of 55‐year‐old woman with enlarging mass in the left mandible. This report describes cytologic and immunohistochemical features of CCOC with positive EWSR1 gene rearrangements by fluorescence in situ hybridization (FISH). As diagnosis of CCOC is challenging on fine‐needle aspiration, immunohistochemistry and FISH analysis are very useful diagnostic tool in clear cell lesions of mandible. Diagn. Cytopathol. 2015;43:743–746.