Tomoko Yoshida

Cytological features of myxomatous fibroadenoma of the breast

Fibroadenoma (FA) is a benign tumor that must be differentiated from carcinomas. FAs often exhibit myxedematous changes (myxomatous FA, M‐FA). We previously reported on the clinical significance of M‐FA. M‐FA and (mucinous) carcinoma share clinical findings, rapid growth and a relatively large size, a high‐depth/width (D/W) ratio, a relatively round shape, and posterior echo enhancement with internal hyperechogenicity on ultrasonography (US). Next, a biopsy is required for differential diagnosis. In this study, we evaluated the diagnostic significance of the cytological findings of M‐FA with US findings. Among 13 FAs that were diagnosed by cytology, we compared (i) a group of six mucinous carcinomas with acellular mucin and a D/W ratio ≥ 0.7 (a suspicious factor for malignancy) with a group with a D/W ratio of <0.7, and (ii) the frequency of metachromasia on Giemsa stain between M‐FAs and non‐M‐FAs among eight FA cases confirmed by histology. (i) FA lesions (7 of 13) showed metachromasia with Giemsa staining significantly more frequently than did mucinous carcinoma (0/6) (Fishers exact test, P < 0.044). FA lesions with a D/W ratio ≥ 0.7 (6/7) showed metachromasia significantly more frequently than did FA with a D/W ratio <0.7 (1/6) (Fishers exact test, P < 0.029). Among eight FA cases confirmed by histology, M‐FA cases (6/6) demonstrated metachromasia significantly more frequently than non‐M‐FA cases (0/2) (P < 0.036). M‐FA cytologically exhibits marked metachromasia on Giemsa staining. Combining cytological examination and understanding the clinical features of M‐FA may allow us to choose cytological examination as a first‐line diagnostic method for tumor‐forming lesions. Diagn. Cytopathol. 2011.

Granulocyte colony-stimulating factor-producing pancreatic anaplastic carcinoma in ascitic fluid at initial diagnosis: A case report: G-CSF EXPRESSION IN PAC

Granulocyte colony‐stimulating factor (G‐CSF)‐producing pancreatic tumors are extremely rare. These tumors have an aggressive clinical course and no established treatment. Here, we report an autopsy case of G‐CSF‐production in pancreatic anaplastic carcinoma (PAC). A 72‐year‐old woman presented with a large pancreatic head mass and multiple liver metastases. Laboratory data showed leukocytosis (leukocyte count 113.3 × 103/µL) and high serum G‐CSF levels (441 pg/mL; normal range: <39.0 pg/mL). The ascitic fluid was submitted to our pathology laboratory at initial diagnosis. Cytopathology showed that smears from the ascitic fluid were highly cellular and contained numerous malignant cells, mainly in loose groupings. Occasional pseudoglandular formations and giant cells were also present. The malignant cells were round, and no spindle‐shaped cells were visible. The nuclei were round to ovoid with coarsely granular chromatin and large prominent nucleoli. Upon immunocytochemistry, tumor cells were positive for G‐CSF and vimentin; there was no E‐cadherin expression. Histopathological examination of the tumor showed a mixed composition of adenocarcinomatous and sarcomatous regions. Upon immunohistochemistry, both components were positive for G‐CSF. Few CD34‐positive myeloblasts were observed in the bone marrow. Thus, we diagnosed this as a case of G‐CSF production in PAC with leukocytosis. To the best of our knowledge, this is the first report on G‐CSF expression immunocytochemically confirmed in PAC. Diagn. Cytopathol. 2017;45:463–467.

Significance of cytodiagnosis in primary carcinoid tumor of the middle ear: A case report

Primary carcinoid tumors of the middle ear are uncommon. Cytodiagnosis of the middle ear is not usually performed as a preoperative examination because of the anatomical structure of the middle ear. To the best of our knowledge, the present study reports for the first time a case of a carcinoid tumor of the middle ear, which was preoperatively diagnosed using cytodiagnosis, and also review current literature. A 22-year-old woman complained of left-sided otalgia. A subcutaneous tumor in the left middle ear was observed. Magnetic resonance imaging revealed that the tumor was primarily present in the tympanic cavity of the middle ear and extended to the mastoid antrum and mastoid cells of the middle ear and to the external acoustic meatus. Fine needle aspiration cytology was performed from the tumor protruding into the external acoustic meatus. Cytologically, the tumor was composed of small uniform cells with small round nuclei and granular eosinophilic cytoplasm, arranged in a nested pattern. Tumor cells were immunocytochemically positive for synaptophysin and cytokeratin CAM5.2. These results indicated that this was a neuroendocrine tumor. No other tumor lesions were identified on computed tomography scans, and the tumor was considered to be the primary lesion. Tympanoplasty and mastidectomy were then performed and carcinoid tumor was diagnosed in the postoperative pathological diagnosis. To the best of our knowledge, the present study is the first to report on preoperative cytodiagnosis for carcinoid tumors of the middle ear.

Neurogenic pulmonary edema following Cryptococcal meningoencephalitis associated with HIV infection

Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by the acute onset of pulmonary edema following a significant central nervous system insult. Only a few cases of NPE after Cryptococcal meningitis have been reported. We report a case of NPE following Cryptococcal meningoencephalitis. A 40‐year‐old man with no medical history was hospitalized for disturbance of consciousness. Blood glucose level was 124 mg/dL. Non‐contrast head computed tomography showed no abnormalities. Lumbar puncture revealed a pressure of over 300 mm H2O and cerebrospinal fluid (CSF) confirmed a white blood cell count of 65/mm3. The CSF glucose level was 0 mg/dL. The patient was empirically started on treatment for presumptive bacterial and viral meningitis. Four days after, the patient died in a sudden severe pulmonary edema. Autopsy was performed. We found at autopsy a brain edema with small hemorrhage of the right basal ganglia, severe pulmonary edema and mild cardiomegaly. Histologically, dilated Virchow‐Robin spaces, crowded with Cryptococci were observed. In the right basal ganglia, Virchow‐Robin spaces were destroyed with hemorrhage and Cryptococci spread to parenchyma of the brain. No inflammatory reaction of the lung was seen. Finally, acute pulmonary edema in this case was diagnosed as NPE following Cryptococcal meningoencephalitis. After autopsy, we found that he was positive for serum antibodies to human immunodeficiency virus.

A study of cluster configuration in breast tumor of aspiration cytology.

目的: 乳腺穿刺吸引細胞診において良悪性の鑑別を正確に行うために良性および悪性腫瘍のおのおのの細胞集塊形の特徴について検討した.対象: 乳頭腺管癌16例 (356 clusters), 線維腺腫15例 (251 clusters) の乳腺穿刺吸引細胞標本を用いた.成績:細胞異型の乏しい乳頭腺管癌の集塊の縦横比は1に近く, 形状は多分岐状で, 個々の細胞の突出による凹凸を有する輪郭を形成していた. 細胞重積性による半島状に突出した複雑形状となるものもみられた. 一方, 線維腺腫の細胞集塊形状は直線的に長いものと滑らかな曲線からなり, 円形に近いものがみられた. 集塊形は集塊内の細胞重積性の有無とその分布と関連し, 複雑な輪郭を来たす機序が異なっていた. 線維腺腫では集塊の辺縁部に重積性を伴い, 核間距離の不整が多くみられた. 一方, 乳頭腺管癌では細胞集塊の中心部から辺縁部にかけて重積性がみられたが, 辺縁部においては比較的重積性は少なく個々の細胞の結合性の不均一性から生じた, 複雑な輪郭を形成していた.結論: 今回の検討により, 良性ならびに悪性腫瘍細胞集塊形状に特徴があることが明らかになり, 乳頭腺管癌では細胞集塊の大きさに依存しない集塊形状が明らかになった.細胞異型の乏しい乳腺腫瘍の細胞診の診断に際しては, 個々の細胞の所見に加え, 細胞集塊形状に注意を払うことにより, より正診率を高めることが期待できる.

Nipple Discharge Cytology in Mass Screening for Breast Cancer.

乳癌検診の課題は, 早期乳癌を発見することである。現在, 乳癌検診は視触診および分泌細胞診を行っている。1989～95年までに乳頭分泌細胞診385例を経験し, そのうち病理組織学的に検討できた84例について検討したので報告する。乳癌症例は, Class I, II58例中8例 (13.8%), Class III13例中4例 (30.8%), Class V 11例中11例 (100%) であった。これらの分泌細胞診の診断能は, sensitivity 66.7%, specificity 83.1%, accuracy 78.3%であった。また, 同時に行った乳頭分泌に対する潜血反応の診断能は, sensitivity 100%, specificity 44.8%, accuracy は68.3%であった。また, 84例中24例が乳癌症例で, TO症例を5例認め, これらは分泌細胞診全例陽性であった。乳汁分泌を主訴に来院し, 視触診, 超音波, マンモグラフィに精査にて発見できた症例が19例あった。乳癌検診において視触診が中心である現在, それの簡便な補助的診断として分泌細胞診は, 正診率は劣るものの乳汁分泌を契機として発見できるTO症例を引き上げるには重要な方法と考える。

Efficiency of Cytology for Breast Carcinomas without Evidence of Malignancy on Imaging Diagnosis.

乳腺の細胞診延べ2,741例を病理組織診と対比し, 細胞診にてClass III以上と診断し乳癌が疑われた症例で, 画像診断上悪性所見を示さず細胞診のみ乳癌の術前診断を行い得た症例の病理形態学的特徴について検討をした。細胞診のクラス分類の内訳としてClass Iは1,470例 (53.6%), Class IIは131例 (4.8%), Class IIIは59例 (2.2%), Class IVは41例 (1.5%), Class Vは224例 (8.2%), さらに検体不良例816例 (29.8%) であった。細胞診にてClass III以上と診断した324症例のうち病理組織診断が施行され, 術後の再発例を除き悪性と診断されたのは234症例であった。234症例の乳癌のうち画像診断上悪性所見の認められなかった症例は17症例 (7.3%) であった。画像診断上悪性所見の認められなかった症例の組織型は, 乳頭腺管癌8例, 粘液癌4例, 硬癌2例, 充実腺管癌1例, 嚢胞内乳頭癌1例, 非浸潤性乳管癌1例であり, 腫瘤の大きさとしては1.0cm以下が9例, 1.1～1.5cmが8例と1例は乳頭分泌物で腫瘤は認められず, 全症例とも1.5cm以下の腫瘤であった。さらに粘液癌では1.5cm以下の大きさの腫瘤ではすべて画像診断上は悪性所見に乏しく, 細胞診のみが乳癌の術前診断に有用であった。

A case of basal cell epithelioma of the breast cytologically suspected ductal carcinoma.

乳腺の穿刺吸引細胞診にて乳管癌が疑われた乳房部原発基底細胞上皮腫の1例の細胞像について報告した.症例は65歳, 女性, 右乳房C領域に1.5×1.5cmの腫瘤が認められ10年来大きさは不変であった.Mammography, 超音波などの画像診断にて乳管癌が疑われ外来受診時に穿刺吸引細胞診が施行された.細胞診所見は出血像を背景に腫瘍細胞は大小の結合性の強い細胞集塊で出現し, 細胞の配列は不均等で細胞の重積性が認められた.核は類円形小型で核クロマチンの増量がみられ, 乳管癌も否定できず術中迅速病理組織診断が行われた.病理組織にて基底細胞上皮腫と診断された.基底細胞上皮腫の一般的な細胞学的所見としては大小の細胞集塊での出現, 細胞は小型類円形で大小不同性に乏しく, 細胞集塊の辺縁に柵状配列が認められることであると思われるが, 乳房部に発生する基底細胞上皮腫は非常にまれであり, 本症例では術前の穿刺吸引細胞診での確定診断は困難であった.

A case of the primary urethral malignant melanoma with an appearance of tumor cells in urine.

尿中に腫瘍細胞が出現した男子尿道原発悪性黒色腫について報告した.症例は64歳男性で尿道球部に発生した悪性黒色腫であった.尿細胞診では腫瘍細胞は孤立散在性に出現し, 一部疎な結合を示す集塊で出現した細胞では移行上皮癌細胞との鑑別が困難であったが, 少数の細胞には明らかなメラニン顆粒が認められた.これら尿中の腫瘍細胞は免疫組織化学染色においてS-100蛋白が陽性を示し, 摘出腫瘤の病理組織標本ではMasson-Fontana染色陽性, 鉄染色陰性, 免疫組織化学染色ではS-100蛋白陽性さらにNSE (Neuron-specifi cenorase) も陽性であった.また, 電顕にて腫瘍細胞の細胞質に多数のmelanosomeが確認された.

A case of pemphigus vulgaris diagnosed by cytology.

尋常性天庖瘡の1例を報告した. 症例は38歳男性で, 口腔粘膜の発赤・びらんを主訴とし, 臨床的に多形性滲出性紅斑が疑われ, 口腔粘膜擦過細胞診が施行された. 多数の労基底～ 中層細胞に類似した異型細胞が孤立散在性あるいは平面的な細胞集塊で出現し, 核の腫大, N/C比の増加と単～3, 4個の著明な核小体を特徴とした. しかし核内は明るく核クロマチンの増加は認められなかった. これらの細胞は尋常性天庖瘡に出現するいわゆるTzanck cell (Acantholytic cell) に相当する細胞と考えられた. また, 免疫螢光抗体直接法にて口腔粘膜表皮有棘細胞間にIgGの沈着が認められ, 血中のIgG, IgA値も軽度上昇していた.