Samer Khader

The Application of Molecular Diagnostics to Stained Cytology Smears

Detection of mutational alterations is important for guiding treatment decisions of lung non-small-cell carcinomas and thyroid nodules with atypical cytologic findings. Inoperable lung tumors requiring further testing for staging and thyroid lesions often are diagnosed using only cytology material. Molecular diagnostic tests of these samples typically are performed on cell blocks; however, insufficient cellularity of cell blocks is a limitation for test performance. In addition, some of the fixatives used while preparing cell blocks often introduces artifacts for mutation detection. Here, we applied qClamp xenonucleic technology and quantitative RT-PCR to cells microdissected directly from stained cytology smears to detect common alterations including mutations and translocations in non-small-cell carcinomas and thyroid lesions. By using this approach, we achieved a 1% molecular alteration detection rate from as few as 50 cells. Ultrasensitive methods of molecular alteration detection similar to the one described here will be increasingly important for the evaluation of molecular alterations in clinical scenarios when only tissue samples that are small are available.

Fine needle aspiration of follicular dendritic cell sarcoma in an HIV-positive man: a case report.

BACKGROUND Follicular dendritic cell (FDC) sarcoma is an uncommon neoplasm occurring not only in lymph nodes but also in extranodal sites. Because of an increasing number of case reports, awareness of this tumor has grown. The nature of the disease and its relation to other diseases, treatment, prognosis and immunochemistry findings are being actively studied. So far, only a limited number of cytology cases describing the fine needle aspiration (FNA) biopsy findings of FDC sarcoma have been reported. CASE A 47-year-old man had a history of hypertension and human immunodeficiency virus (HIV) infection treated with antiretroviral therapy. He developed a slowly growing, nontender right neck mass over the course of 3 years. FNA revealed sheets and thick syncytial clusters of bland cells with pale cytoplasm and indistinct cell borders, round to oval nuclei with fine or vesicular chromatin, and small nucleoli. The mass was subsequently excised. A diagnosis of FDC sarcoma was made based on the histologic appearance and the marker studies. Conclusion The diagnosis ofFDC sarcoma in FNA can be suspected if a pathologist is aware of its characteristic features. Research studies have demonstrated the presence of HIV-related FDC hyperplasia. It is likely that HIV infection may have played a role in tumor formation in this patient. (Acta

APTIMA assay on SurePath liquid-based cervical samples compared to endocervical swab samples facilitated by a real time database

Background: Liquid-based cytology (LBC) cervical samples are increasingly being used to test for pathogens, including: HPV, Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) using nucleic acid amplification tests. Several reports have shown the accuracy of such testing on ThinPrep (TP) LBC samples. Fewer studies have evaluated SurePath (SP) LBC samples, which utilize a different specimen preservative. This study was undertaken to assess the performance of the Aptima Combo 2 Assay (AC2) for CT and GC on SP versus endocervical swab samples in our laboratory. Materials and Methods: The live pathology database of Montefiore Medical Center was searched for patients with AC2 endocervical swab specimens and SP Paps taken the same day. SP samples from CT-and/or GC-positive endocervical swab patients and randomly selected negative patients were studied. In each case, 1.5 ml of the residual SP vial sample, which was in SP preservative and stored at room temperature, was transferred within seven days of collection to APTIMA specimen transfer tubes without any sample or patient identifiers. Blind testing with the AC2 assay was performed on the Tigris DTS System (Gen-probe, San Diego, CA). Finalized SP results were compared with the previously reported endocervical swab results for the entire group and separately for patients 25 years and younger and patients over 25 years. Results: SP specimens from 300 patients were tested. This included 181 swab CT-positive, 12 swab GC-positive, 7 CT and GC positive and 100 randomly selected swab CT and GC negative patients. Using the endocervical swab results as the patient’s infection status, AC2 assay of the SP samples showed: CT sensitivity 89.3%, CT specificity 100.0%; GC sensitivity and specificity 100.0%. CT sensitivity for patients 25 years or younger was 93.1%, versus 80.7% for patients over 25 years, a statistically significant difference (P = 0.02). Conclusions: Our results show that AC2 assay of 1.5 ml SP samples transferred to APTIMA specimen transfer medium within seven days is sufficiently sensitive and specific to be used to screen for CT and GC. CT sensitivity may be somewhat reduced in samples from patients over 25 years. SP specimens retained in the original SP fixative for longer time intervals also may have decreased sensitivity, due to deterioration of RNA, but this was not assessed in this study. The ability to tap the live pathology database is a valuable tool that can useful to conduct clinical studies without a costly prospective clinical trial.

SurePath Specimens Versus ThinPrep Specimen Types on the COBAS 4800 Platform: High-Risk HPV Status and Cytology Correlation in an Ethnically Diverse Bronx Population

Objective To compare the cytologic preparations of 130 cervical specimens (from women of various ethnicities at high risk for human papillomavirus [HPV] infection) using the SurePath (SP) collection system with specimens gathered using the ThinPrep (TP) system, as processed on the Cobas 4800 analyzer, to determine which collection method more accurately identifies HPV infection. Methods In our prospective study, specimens were collected from 130 women of various ethnicities residing in or near Bronx County, NY. The SP-collected specimen was first processed for cytologic findings; if clinical HPV testing was requested on that specimen, it was tested using Hybrid Capture II (HC2) methodology. We tested the remnant SP-collected cell concentrate using the Cobas analyzer. Then, the TP-collected and SP-collected specimens were tested in the same run on that analyzer, and the results were compared. We also compared the results with the concurrent cytologic findings. Results The results were concordant for overall HR-HPV status in 93.8% of cases. Also, a statistically significant lower cycle threshold value was observed with Cobas testing of specimen concentrates tested via the BD SurePath Pap Test (P = .001), suggesting higher sensitivity compared with specimens tested via the ThinPrep Pap Test. Conclusion Cobas 4800 HPV testing of SP-collected specimen concentrates yields comparable results to TP-collected specimen concentrates. Based on the limited data that we derived, SP collection may be a more favorable methodology than TP collection for HPV testing of individuals at high risk in our ethnically diverse, urban patient population.

A rare case of chondroma of the parotid gland.

Patient: A 39-year-old Hispanic woman. History of Present Illness: The patient had swelling of the left side of her neck, which she had first noticed 3 to 4 months before consultation and which did not subside after 2 courses of antibiotics. She reported no tenderness, dysphagia, odynophagia, dysphonia, otalgia, fevers, chills, or weight changes. Past medical history: The patient had a past history of gastroesophageal reflux disease, arthritis (knee and cervical disease), and a prior abnormal Pap smear result (high grade squamous intraepithelial lesion). The cervical lesion was treated with a loop electrosurgical excision procedure (LEEP). Her past surgical history is remarkable for cholecystectomy and a left breast biopsy with benign results. Social history: Noncontributory. Family history: Noncontributory. Physical exam: The patient harbored a firm, nontender, fully mobile 2- to 3-cm left parotid tail mass without other abnormalities; her facial nerve function was intact in all branches. Principle Laboratory Findings: See [Image 1][1], [Image 2][2], [Image 3][3], [Image 4][4], [Image 5][5], and [Image 6][6]. * FNA : fine needle aspiration LEEP : loop electrosurgical excision procedure CT : computed tomography [1]: #F1 [2]: #F2 [3]: #F3 [4]: #F4 [5]: #F5 [6]: #F6

Fine needle aspiration of an unusual malignant mixed tumor in the parotid gland.

OBJECTIVE The use of fine needle aspiration (FNA) biopsy in the triage of salivary gland tumors has been well established. The sensitivity and specificity of FNA biopsy for tumor diagnosis is generally very good. However, the diagnosis can be challenging due to the limited amount of tissue sampled, the occasional overlapping tumor morphology, and the presence of a malignant counterpart of a benign tumor. METHODS FNA biopsy was performed with ultrasound guidance. Air-dried slides and alcohol-fixed slides were made for Diff-Quik staining and Papanicolaou staining, respectively. The syringes were rinsed and a cell block was prepared. The resected specimen was fixed in 10% formalin and processed by routine histology techniques. RESULTS We report a rare case of a salivary gland neoplasm with 2 distinct components: adenoid cystic carcinoma and pleomorphic adenoma. These 2 components are clearly identifiable in both cytological materials from fine needle aspiration and histological analysis of surgical resection. CONCLUSION Pleomorphic adenoma is the most common salivary gland tumor for patients in all age groups. The characteristic cytological feature is fibrillary extracellular matrix intermixed with epithelial cells. Malignant transformation occurs in 5% to 10% of cases. Rarely, pleomorphic adenoma exists as one component of a hybrid tumor. The surgical resection will be needed in those cases. The final diagnosis relies on the combination of the clinical information, histological findings and molecular study.

Low-grade squamous intraepithelial lesion, cannot rule out high-grade lesion: Diagnosis, histological outcomes and human papillomavirus results

The 2014 Bethesda System for Reporting Cervical Cytology classifies squamous intraepithelial lesions (SILs) of cervix into two main categories: low‐grade SIL (LSIL) and high‐grade SIL (HSIL). In some clinical practices, the LSIL cannot rule out high‐grade lesion (LROH) interpretive category is used in cases with LSIL and findings that may raise the possibility of HSIL. Our purpose is to assess follow‐up histopathology and high‐risk human papillomavirus (hrHPV) results in patients with LROH, in comparison with LSIL, atypical squamous cells, cannot rule out HSIL (ASC‐H), and HSIL in our institution.

Metastatic Salivary Duct Carcinoma of the Submandibular Gland Presenting as a Poorly Differentiated Carcinoma of Unknown Primary: A Case Report

A 53 year old male presented to his primary care doctor with a palpable neck mass for the past four months. At that time he was given antibiotics with no change in the mass. The patient was a 20 pack-year, current smoker. He was sent for an ultrasound-guided fine needle aspirate (FNA) of the mass. The FNA of a right level I lymph node was performed and findings were consistent with a poorly differentiated carcinoma, possibly reflecting a primary salivary gland lesion or less likely a pulmonary lesion. Upon follow-up physical exam the patient was found to have mild asymmetry and firmness of the right base of tongue as well as a 1.0 x 1.0 cm, firm submandibular mass. The patient was referred to otorhinolaryngology. A PET scan was performed and showed multiple avid cervical lymph nodes in the right neck, focal activity in the supero-medial aspect of the right submandibular gland, as well as very small bilateral lung nodules. At this point, a primary site in the submandibular gland was favored; yet the aerodigestive tract was not excluded. Pleural fluid was sent for cytological analysis and subsequently the patient underwent a diagnostic laryngoscopy, biopsy, esophagoscopy, and right selective neck dissection.

Incidental primary mediastinal choriocarcinoma diagnosed by endobronchial ultrasound-guided fine needle aspiration in a patient presenting with transient ischemic attack and stroke

We describe a case of a 41‐year old male patient with no significant prior medical history who presents with symptoms of Transient Ischemic Attack and stroke. Magnetic Resonance Imaging (MRI) of the brain identified areas of ischemia in the left side, and angiography showed occlusion of the left Medial Cerebral Artery (MCA). Cardiac Transthoracic Echocardiogram (TTE) for stroke evaluation incidentally noted a mediastinal abnormality leading to cancer work‐up. Computer Tomography (CT) and 18F‐fluorodeoxyglucose (FDG) PET‐CT scan of the chest incidentally revealed an avid 6 cm paraesophagial/subcarinal mass. Further diagnostic work‐up with endoscopic and endobronchial ultra sound (EBUS)‐guided fine needle aspiration (FNA) of the mass yielded a cytology diagnosis of Germ Cell Tumor (GCT), with choriocarcinoma component. Additionally, high plasma levels of β‐human chorionic gonadotrophin (β‐HCG) were detected with no evidence of testicular tumor. This exceedingly rare presentation for a primary mediastinal choriocarcinoma underscores the importance of complete investigation of young patients presenting with neurological symptoms compatible with ischemic events. Diagn. Cytopathol. 2017;45:738–743.

Fine Needle Aspiration of a Metastatic Germ Cell Tumor to Supraclavicular Lymph Node

OBJECTIVE Germ cell tumors are the most common tumors in men in their second decade. According to the National Comprehensive Cancer Network, the management of germ cell tumors depends on whether the tumor is diagnosed as a seminoma or a nonseminoma. Fine needle aspiration biopsy, compared to incisional biopsy, is relatively safe and facilitates rapid assessment of these tumors. METHODS An ultrasound guided FNA biopsy was performed, and air-dried slides and alcohol-fixed slides were made for Diff-Quik staining and Papanicolaou staining, respectively. The syringes were rinsed and cell block was prepared. The resected specimen was fixed in 10% formalin and processed by routine histology techniques. RESULTS We report a case of a 22-year-old male with an enlarged scrotal mass and a supraclavicular nodule. A superficial fine needle aspiration biopsy was performed on the nodule and the correct diagnosis was made via cytomorphology and immunohistochemistry. The cytologic diagnosis was correlated with the incisional biopsy results. CONCLUSION Fine needle aspiration biopsy is very helpful in the initial triage of germ cell tumors. When the aspirate contains sufficient diagnostic material, a specific diagnosis may be reached. Likewise, as different germ cell tumors have characteristic immunohistochemical profiles, a cell block from an aspirate may be critical for correct diagnosis. However, because germ cell tumors often contain mixed elements, cytologic diagnosis may not be entirely representative due to incomplete sampling. Thus, it is important to correlate cytologic diagnosis with the excisional tissue biopsy results.