Nora Morgenstern

Endobronchial ultrasound-guided transbronchial needle aspirate (EBUS-TBNA): a proposal for on-site adequacy criteria.

This is a retrospective study of 48 patients who underwent EBUS‐TBNA procedure between the periods January 2008 to September 2009 at Long Island Jewish Medical Center. The study was undertaken with the following objectives: First, to define practical and useful on‐site adequacy criteria for EBUS‐TBNA samples; Second, to understand the diagnostic pitfalls associated with accurate interpretation of EBUS‐TBNA samples. EBUS‐TBNA procedure was able to diagnose 24/48 (50%) patients with malignancy, 1/48 (2%) suspicious for malignancy, 9/48 (19%) with granulomatous process, and 9/48 (19%) negative for disease. Only five cases (10%) could not be diagnosed with this procedure. Based on our experience, any smear with presence of > 5 low power fields (×100) with ≥ 100 lymphocytes in each and containing < 2 groups of bronchial cells/low power field (×100) can be considered adequate for evaluation. Also, the presence of germinal center fragments renders a smear adequate for evaluation, irrespective of the above mentioned criteria. Adequacy criteria are to be applied only to the smears not showing any identifiable pathology such as malignancy or granuloma. An understanding of diagnostic pitfalls associated with accurate interpretation of EBUS‐TBNA samples is essential to avoid false‐positive and false‐negative diagnosis. To conclude, an effective communication between the clinician and cytologist, an algorithmic approach to diagnosis, and the on‐site adequacy criteria proposed in this study can markedly improve the diagnostic yield of the procedure. Diagn. Cytopathol. 2011.

Reconstruction of rabbit urethra with Surgisis® small intestinal submucosa

PURPOSE To evaluate the efficacy of Surgisis, porcine small intestinal submucosa, in the reconstruction of iatrogenic urethral defects in rabbits. MATERIALS AND METHODS Eight male white rabbits were enrolled in this protocol. A 2.5-cm segment of urethra was excised. One control consisted of a normal urethra. The other rabbits underwent urethroplasty with Surgisis and 6-0 Vicryl running suture. An 8F feeding tube was left in place to divert urine for 2 weeks after surgery. Retrograde urethrograms were performed to assess the patency of the urethras and to rule out fistula formation prior to sacrifice of the animals. The sacrifice protocol began with the control and a urethroplasty animal 6 weeks after surgery. The other rabbits were euthanized at 2-week intervals thereafter. RESULTS Surgisis promoted epithelial regeneration in all cases. One animal developed a wound infection; this was associated with a small fistula at the proximal end of the anastomosis. Good cosmetic and functional results were documented. Retrograde urethrograms showed no stricture formation at the site of the anastomosis in six rabbits. The histopathologic examination showed complete regeneration of all urethral layers, almost indistinguishable from the normal urethra. CONCLUSION Surgisis is an excellent material for urethral reconstruction in rabbits. It promotes regeneration of all the components of the host urethral layers and is biodegradable.

Clinical impact of second opinion in thyroid fine needle aspiration cytology (FNAC): A study of 922 interinstitutional consultations†

Interinstitutional consultation in pathology has shown to improve patient safety by detecting interpretive errors that may significantly impact clinical management. We conducted a study of 922 cases of thyroid FNAC slides, referred to our institution over a 2‐year period, to assess the magnitude of discrepancies and determine the clinical impact of second opinion. Disagreements were categorized as none, minor or major, the latter two defined as one‐ or two‐step deviations respectively on the NCI diagnostic categories scale. There were 122 disagreements (13%), including 44 major and 78 minor. Seventy‐five patients underwent a change in management based on second opinion, in conjunction with clinical and radiologic findings (age, size of nodule, family history, ultrasonographic appearance, and solitary versus multiple nodules). The second opinion was supported on follow‐up in 57% of major discrepancies, and the initial diagnosis was concurrent with the surgical diagnosis in 7% cases. The remainder (36%) of major discrepancy cases did not undergo surgery, precluding tissue confirmation. Critics have alleged increased costs due to interinstitutional consultations. However, cost avoidance from lost wages, potential surgical complications, and litigation is not easily quantified. Using a simplified calculation to objectively measure the costs associated with changed diagnoses, we estimate that second opinion of these 922 cases resulted in potential cost saving of

Small cell carcinoma arising from the proximal urethra.

940,166 based on current Medicare reimbursement codes. Our study indicates the need for a quality‐control program of outside thyroid FNA slides, especially in “high discrepancy categories” as discussed in the article. Diagn. Cytopathol. 2011;.

Pulmonary adenofibroma: Cytologic and clinicopathologic features of a rare benign primary lung lesion

Abstract  Primary neuroendocrine carcinomas of the lower urinary tract are distinctly rare, locally aggressive neoplasms with a high rate of metastasis. We present a case of primary small cell carcinoma of the urethra occurring in a 64‐year‐old man. The clinical, histological and immunohistochemical features of urethral small cell carcinoma are highlighted with respect to the differential diagnosis of neuroendocrine and other urethral tumors. The possible histogenesis of urethral small cell carcinoma, reported at this location in only a small number of cases, is briefly discussed. We favor an origin from pluripotent epithelial stem cells as one of the possible histogenic pathways.

Monophasic parapharyngeal synovial sarcoma diagnosed by cytology, immunocytochemistry, and molecular pathology: case report and review of the literature.

We report a case of pulmonary adenofibroma in a 29‐year‐old female found by CT scan during work‐up for midline chest pain. To our knowledge, the cytological features of this entity have not been previously reported. Cytology demonstrated bland epithelial and stromal cells of varying size without karyorrhexis, pyknosis, or necrosis and with very rare mitoses. Stromal cells were present as either naked bipolar nuclei, as spindle cells with fragile eosinophilic cytoplasm, or as rare larger carrot shaped nuclei. Epithelial cells were present as small loosely cohesive groups with smooth round nuclei and moderate amounts of cytoplasm. Histologically, this lesion consisted of a leaf‐like fibroepithelial pattern in which the clefts were lined by a single layer of cuboidal epithelium reminiscent of adenofibroma occurring in the female genital tract. Immunohistochemical analysis demonstrated epithelium that stained positively for pan‐cytokeratin and TTF‐1. The stroma stained positively for vimentin and desmin, and was weakly positive for SMA‐1. The lesion was confirmed to be pulmonary adenofibroma with a smooth muscle component. The differential diagnosis for this lesion includes, but is not limited to, pulmonary hamartoma, pulmonary blastoma, adenomyofibroma, synovial sarcoma, and visceral metastases. It is important for cytopathologists to be aware of this benign entity because it can be encountered on lung FNA specimens. Considering this benign lesion in the differential diagnosis may help plan for minimal lung resection. Confirmatory intraoperative frozen section is a reasonable option. Diagn. Cytopathol. 2013;41:991–996.

Role of Acellular Collagen Matrix (Surgisis®) in the Endoscopic Management of Ureteropelvic Junction Obstruction

Synovial sarcoma (SS) of the head and neck region are rare, accounting for less than 10% of all head and neck soft tissue sarcomas. A limited number of SS have been reported in the parapharyngeal space and these reports have all been based on histological examination of resection material. The diagnosis of monophasic SS on cytology is extremely difficult. We report the first case where a SS was correctly diagnosed on a fine needle aspirate by cytology with the assistance of immunocytochemistry and fluorescence in situ hybridization. We will emphasize the importance of ancillary techniques, such as immunocytochemistry and cytogenetic/molecular pathology, in avoiding diagnostic pitfalls and correctly diagnosing monophasic SS on cytologic material. We will propose an algorithmic approach to accurately diagnose parapharyngeal spindle cell neoplasms with the use of appropriate ancillary studies in conjunction to morphological features. Diagn. Cytopathol. 2010;38:822–827.

Endoscopic management of renal lymphangioma: A case report

PURPOSE To investigate the role of acellular collagen matrix (Surgisis during endopyelotomy. MATERIALS AND METHODS Nine female pigs (25-35 kg) were enrolled in our protocol. The pigs were categorized as follows. Group I (N = 3) had endopyelotomy + insertion of SIS, Group II (N = 3) creation of UPJ stricture + endopyelotomy + insertion of SIS, and Group III (N = 3) Davis intubated ureterotomy using SIS. The contralateral side served as a control for each group (one pig in each group). In three pigs (two in Group III and one in Group II), Surgisis was treated with India ink prior to insertion at the endopyelotomy site. An endopyelotomy stent (14/8 F x 24 cm) was used to stent the ureteropelvic junction (UPJ) for 4 weeks. Four weeks after the stent was removed, laparoscopic nephroureterectomy was performed, and the animals were euthanized. Histopathologic analysis of the Surgisis-regenerated segment of the UPJ was performed using hematoxylin and eosin, reticular (collagen), smooth muscle actin, and S-100 (nerve) stains. RESULTS All animals tolerated the procedure. The mean operative time was 162 minutes. One pig (Group II) developed pyonephrosis; one pig (Group III) developed significant ascites and was sacrificed 2 week before the end of the experiment. Histopathologic analysis showed complete epithelializaton at 8 weeks. Reticular stain demonstrated abundant collagen matrix in the submucosa. Smooth muscle staining revealed myofibroblastic proliferation within the SIS-regenerated tissue adjacent to disorganized smooth muscle cells. India ink-stained SIS-regenerated tissue did not show smooth muscle cells. The S-100 stain did not demonstrate neurons at 8 weeks; however, in three pigs, peristaltic activity was noted across the UPJ. CONCLUSION The use of acellular collagen matrix in the endoscopic management of UPJ obstruction is a promising technique. The abundance of myofibroblasts and absence of abundant smooth muscle regeneration indicates a need to investigate the role of growth factors in SIS regeneration of host tissue.

Optimal Lesion Assessment Following Acute Radio Frequency Ablation of Porcine Kidney: Cellular Viability or Histopathology?

A 46-year-old woman presented with total painless gross hematuria, an 8-mm polypoid mass that proved to be a lymphangioma was found in the upper pole collecting system of the left kidney. The mass was resected ureteroscopically with holmium laser fulguration of the base. The few reported cases of this rare lesion suggest that rigorous postoperative surveillance is not necessary for this benign condition.