Ziyan Salih

Tenosynovial giant cell tumor presenting as a parotid gland mass: Expanding the differential diagnosis of giant cell-rich lesions in salivary glands

Tenosynovial giant cell tumors (TGCT) are rare benign soft tissue tumors affecting mostly young adults. The most common affected sites include the knee, ankle, elbow, shoulder, and fingers. The temporomandibular joint is occasionally affected. Herein, we report a case of a 31-year-old Caucasian male who presented clinically with a parotid gland mass. The initial clinical and radiological work-up failed to reveal any involvement of the adjacent temporomandibular joint. Fine-needle aspiration revealed a cellular tumor composed of mononuclear and multinucleated giant cells with fibrosis and hemosiderin deposition. This was subsequently found to be a TGCT arising from the temporomandibular joint. Giant cell-rich lesions are uncommon in salivary glands. Herein, we describe the cytomorphology and clinico-radiographic features of this tumor with emphasis on the differential diagnosis of giant cell-rich lesions presenting in salivary glands. Despite its rare occurrence, this entity should be considered when giant cells are prominent in specimens acquired from this location.

Ossifying fibromyxoid tumor: report of a case with cytomorphologic description.

Ossifying fibromyxoid tumor (OFMT) is a rare soft tissue neoplasm with uncertain histogenesis. Most cases behave in a clinically benign fashion; however, a small percentage of tumors may locally recur or metastasize. Herein we present a case of a 56‐year‐old man who presented with an enlarging left groin mass, left inner thigh numbness, burning paresthesia and discomfort in his left groin. The mass sampled by fine‐ needle aspiration and needle core biopsy. Cytology showed bland‐appearing epithelioid cells with round nuclei and fine chromatin, with fragments of fibromyxoid stroma in the background. Immunohistochemical stains performed on the core biopsy showed that the lesional cells were focally positive for S100 protein and negative for desmin, smooth muscle actin, CD34 and cytokeratin AE1/AE3. A benign neoplasm was favored with ossifying fibromyxoid tumor as the main entity in the differential diagnosis. A subsequent resection showed a well‐circumscribed 5 cm mass with firm consistency and focal areas of calcifications. Histologically, the tumor had a nodular growth pattern with relatively bland spindle cells containing round to oval nuclei suspended in a variably collagenous to myxoid stroma. Significant ossification and bone formation was also noted. There was no significant atypia, necrosis or increased mitoses. Ossifying fibromyxoid tumors have distinct cytologic features and should be considered in the differential diagnosis of soft tissue tumors with prominent ossification. Diagn. Cytopathol. 2015;43:646–649.

Role of tumor microenvironment in ovarian cancer pathobiology

Ovarian cancer is the fifth most common cancer affecting the female population and at present, stands as the most lethal gynecologic malignancy. Poor prognosis and low five-year survival rate are attributed to nonspecific symptoms and below par diagnostic criteria at early phases along with a lack of effective treatment at advanced stages. It is thus of utmost importance to understand ovarian carcinoma through several lenses including its molecular pathogenesis, epidemiology, histological subtypes, hereditary factors, diagnostic approaches and methods of treatment. Above all, it is crucial to dissect the role that the unique peritoneal tumor microenvironment plays in ovarian cancer progression and metastasis. This review seeks to highlight several important aspects of ovarian cancer pathobiology as a means to provide the necessary background to approach ovarian malignancies in the future.

Role of tumor microenvironment in the pathobiology of ovarian cancer: Insights and therapeutic opportunities

Ovarian cancer is the fifth most common cancer affecting women and at present, stands as the most lethal gynecologic malignancy. The poor disease outcome is due to the nonspecific symptoms and the lack of effective treatment at advanced stages. Thus, it is of utmost importance to understand ovarian carcinoma through several lenses and to dissect the role that the unique peritoneal tumor microenvironment plays in ovarian cancer progression and metastasis. This review seeks to highlight several determinants of this unique tumor microenvironment, their influence on disease outcome and ongoing clinical trials targeting these determinants.

Dual malignancy in a thyroid; papillary thyroid carcinoma and small lymphocytic lymphoma; a report of a case with a cyto‐histologic correlation

Papillary thyroid carcinoma (PTC) is the most common thyroid malignancy. Simultaneous involvement of the thyroid gland by multiple malignancies, is a rare occurrence. Similarly, primary thyroid lymphomas are also rare. We are reporting a rare case of a dual thyroid malignancy; PTC with secondary thyroid involvement by chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), diagnosed on cytology and confirmed with flow cytometry, histology and immunohistochemistry. Imaging showed two hypermetabolic nodules, one in left parotid gland, and the other in the thyroid isthmus. Cytology smears showed features of PTC along with an atypical lymphocytic infiltrate, which co‐expressed CD5, CD19, and CD23 on flowcytometry analysis. Subsequent thyroidectomy showed the atypical lymphocytic infiltrate involving the PTC papillae themselves. The diagnosis of dual malignancies on thyroid FNA is extremely rare and often unexpected, but is possible using appropriate ancillary studies.

Hidradenocarcinoma presenting as soft tissue mass: Case report with cytomorphologic description, histologic correlation, and differential diagnosis

Hidradenocarcinoma (HAC) is a rare adenexal tumor with a propensity for the head and neck region and extremities. We report a case of hidradenocarcinnoma in a 56‐year‐old woman with a mass on her right palm sampled by fine‐needle aspiration and later confirmed on histological examination. Fine‐needle aspiration cytology revealed a dual population of cells including polyhedral eosinophilic cells and glycogen containing cells with pale/clear cytoplasm. The nuclei were pleomorphic with prominent nucleoli. Occassional papillary structures were identified on the cell block material. A series of immunohistochemical stains were performed and an adnexal neoplasm was suggested. The mass was resected. On histologic sections, infiltration into the adjacent soft tissue was identified. After an additional series of immunohistochemical stains, the diagnosis was confirmed as a HAC. Herein, we present our findings and discuss the differential diagnoses. Diagn. Cytopathol. 2016;44:438–441.

Routine Hematoxylin and Eosin Stain Is Specific for the Diagnosis of Cytomegalovirus Infection in Gastrointestinal Biopsy Specimens

Background. Gastrointestinal cytomegalovirus (CMV) infection is a serious complication in immunocompromised patients; clinicians often expect expedited results for biopsy specimens. Our goal is to determine the accuracy of identification of CMV on hematoxylin and eosin (H&E) stain. Methods and Results. A total of 361 biopsy specimens from 273 patients with suspicion for CMV infection were retrieved. CMV was detected by immunohistochemistry (IHC) in 37 specimens acquired from 33 individual patients (average age = 54 years). Among the CMV-positive patients, 29 (88%) were reported to be immunosuppressed. Colon was the most common affected location. Of 37 CMV-positive specimens by IHC, 28 were positive by H&E (76%), 6 were negative (16%), and 3 were suspicious (8%). Of the 29 positive specimens on H&E, 28 were confirmed by IHC (97%) and 1 was indeterminate (3%). The sensitivity and specificity of H&E were 84% and 94%, respectively; the positive predictive value was 97%, and the negative predictive value was 93% (P < .00001). Conclusion. Our results show that a preliminary diagnosis of CMV infection, based on H&E stains, can be reported with high specificity and low risk for false-positive results. Suspicious cases should be deferred pending the result of IHC stains.

Differentiating Intrarenal Ectopic Adrenal Tissue From Renal Cell Carcinoma in the Kidney

Background. Adrenal rest (AR) is the presence of ectopic adrenal cortical tissue, often identified incidentally during autopsy (20% of postmortem examination). In the kidney, AR can be found in 6% of the general population. Ectopic adrenal tissue is of no functional significance but may in some cases, pose a diagnostic challenge for the pathologist, especially in the context of renal clear cell renal cell carcinoma (RCC) and small needle biopsies. Aim. To investigate the utility of immunohistochemical stains in distinguishing AR from RCC. Methods. Archival cases of AR, in our institution, were reviewed and compared with a cohort of RCC cases using a panel of immunohistochemical stains, including PAX2, PAX8, calretinin, and inhibin. Results. Nine of 10 (90%) cases of AR showed positive staining for inhibin and negative staining for calretinin, PAX2 and PAX8. One AR case was positive for PAX2 and PAX8 in addition to inhibin. All (100%) RCC cases were positive for PAX2 and PAX8, but negative for inhibin and calretinin. Conclusions. A panel of PAX2, PAX8 and inhibin may be useful markers for distinguishing AR from RCC. Calretinin was noncontributory in our study.

Pulmonary cryptococcosis diagnosed on a lung fine-needle aspiration

Cryptococcosis is a systemic and opportunistic fungal infection which affects both severely immunosuppressed patients and those with phenotypically “normal” immune systems. In developed countries, the majority cases of cryptococcosis occur among non-human immunodeficiency virus (HIV) patients, such as solid organ transplant recipients. Cryptococcosis is also seen in patients receiving exogenous immunosuppression and patients with innate or acquired immunodeficiency. A large population-based US study shows a prevalence of 0.2-0.9 per 100 000 among the HIV-negative immunocompromised patients. Although cryptococcosis most often involves the central nervous system, it may also involve the lungs, skin, bones, liver, adrenals, kidneys, prostate, endocardium, and pericardium. The clinical symptoms and radiographic features of pulmonary cryptococcosis are non-specific, so it may easily be misdiagnosed or underdiagnosed. Definitive diagnosis most often relies upon pulmonary specimen culture and the isolation of Cryptococcus in the appropriate clinical and radiological context. We present a case of an asymptomatic 41-year-old male with a past medical history of ulcerative colitis and primary sclerosing cholangitis (PSC)/autoimmune hepatitis overlap syndrome, presenting for a follow-up visit to the gastrointestinal clinic. He had been living in North Carolina for years without a documented history of recent travel or bird contact. His list of medications included immunosuppressants such as prednisone, azathioprine, and mycophenolate. He was on mesalamine for six months but discontinued. A few months later, the patient had a magnetic resonance imaging (MRI) of the abdomen due to the concern for cholangiocarcinoma. The MRI revealed unchanged PSC and an incidental 9 mm left lower lobe lung nodule. A computed tomography (CT) scan of the chest revealed multiple nodules in the lung base (Figure 1). Radiologically, the differential diagnosis included infection, mucoid impaction, or a neoplastic process. The patient underwent a CT-guided percutaneous fine-needle aspiration (FNA) of the largest (15 mm) nodule in the left lung lower lobe. Multiple fine-needle aspirates were obtained and handed to the onsite cytopathology team. Using standard procedures, paired aspirate smears were obtained and stained with Papanicolaou and Diff–Quik stains. Cell block material was acquired and stained by hematoxylin and eosin (H&E). The Diff–Quik stained smears were hypocellular and comprised mainly of histiocytes, lymphocytes, and blood. Many of the cellular groups appeared crushed and poorly visualized. Numerous intraand extracellular round-spherical structures were noted and believed to represent fungal organisms (Figure 2A,B.) There was no significant acute inflammatory response or well-formed granulomas. The radiology team was advised to obtain sterile material for fungal culture. Microscopic evaluation of all processed material the next day concluded that the material is benign and confirmed the presence of fungal elements using Grocott-Gomori Methenamine Silver (GMS) special stain (Figure