Agreement on endoscopic ultrasonography-guided tissue specimens: Comparing a 20-G fine-needle biopsy to a 25-G fine-needle aspiration needle among academic and non-academic pathologists.

BACKGROUND AND AIM: A recently carried out randomized controlled trial showed the benefit of a novel 20-G fine-needle biopsy (FNB) over a 25-G fine-needle aspiration (FNA) needle. The current study evaluated the reproducibility of these findings among expert academic and non-academic pathologists. METHODS: This study was a side-study of the ASPRO (ASpiration versus PROcore) study. Five centers retrieved 74 (59%) consecutive FNB and 51 (41%) FNA samples from the ASPRO study according to randomization; 64 (51%) pancreatic and 61 (49%) lymph node specimens. Samples were re-reviewed by five expert academic and five non-academic pathologists and rated in terms of sample quality and diagnosis. Ratings were compared between needles, expert academic and non-academic pathologists, target lesions, and cytology versus histological specimens. RESULTS: Besides a higher diagnostic accuracy, FNB also provided for a better agreement on diagnosing malignancy (ĸ = 0.59 vs ĸ = 0.76, P < 0.001) and classification according to Bethesda (ĸ = 0.45 vs ĸ = 0.61, P < 0.001). This equally applied for expert academic and non-academic pathologists and for pancreatic and lymph node specimens. Sample quality was also rated higher for FNB, but agreement ranged from poor (ĸ = 0.04) to fair (ĸ = 0.55). Histology provided better agreement than cytology, but only when a core specimen was obtained with FNB (P = 0.004 vs P = 0.432). CONCLUSION: This study shows that the 20-G FNB outperforms the 25-G FNA needle in terms of diagnostic agreement, independent of the background and experience of the pathologist. This endorses use of the 20-G FNB needle in both expert and lower volume EUS centers.

Temporal mandibular joint chondrocalcinosis (tophaceous pseudogout) diagnosed by ultrasound-guided fine-needle aspiration.

Tophaceous pseudogout is a calcium pyrophosphate dihydrate crystal (CPPD) deposition disease that frequently affects elderly patient in the temporomandibular joint (TMJ). A diagnosis of CPPD deposition disease in the TMJ is challenging due to its mimicking of other benign and malignant entities. Surgical exploration followed by histologic examination is by far the most frequently used diagnostic modality. We present a case of an 87-year-old female who presented with a right TMJ mass. A final diagnosis of tophaceous pseudogout was made on cellular material obtained by ultrasound-guided fine-needle aspiration (US-guided FNA). Based on our case and current available literature, ultrasound-guided FNA is a reliable tool for diagnosing tophaceous pseudogout of the TMJ.

A multicenter randomized trial comparing a 25-gauge EUS fine-needle aspiration device with a 20-gauge EUS fine-needle biopsy device.

BACKGROUND AND AIMS: Several studies have compared EUS-guided FNA with fine-needle biopsy (FNB), but none have proven superiority. We performed a multicenter randomized controlled trial to compare the performance of a commonly used 25-gauge FNA needle with a newly designed 20-gauge FNB needle. METHODS: Consecutive patients with a solid lesion were randomized in this international multicenter study between a 25-gauge FNA (EchoTip Ultra) or a 20-gauge FNB needle (ProCore). The primary endpoint was diagnostic accuracy for malignancy and the Bethesda classification (non-diagnostic, benign, atypical, malignant). Technical success, safety, and sample quality were also assessed. Multivariable and supplementary analyses were performed to adjust for confounders. RESULTS: A total of 608 patients were allocated to FNA (n = 306) or FNB (n = 302); 312 pancreatic lesions (51%), 147 lymph nodes (24%), and 149 other lesions (25%). Technical success rate was 100% for the 25-gauge FNA and 99% for the 20-gauge FNB needle (P = .043), with no differences in adverse events. The 20-gauge FNB needle outperformed 25-gauge FNA in terms of histologic yield (77% vs 44%, P < .001), accuracy for malignancy (87% vs 78%, P = .002) and Bethesda classification (82% vs 72%, P = .002). This was robust when corrected for indication, lesion size, number of passes, and presence of an on-site pathologist (odds ratio, 3.53; 95% confidence interval, 1.55-8.56; P = .004), and did not differ among centers (P = .836). CONCLUSION: The 20-gauge FNB needle outperformed the 25-gauge FNA needle in terms of histologic yield and diagnostic accuracy. This benefit was irrespective of the indication and was consistent among participating centers, supporting the general applicability of our findings. (Clinical trial registration number: NCT02167074.).

A rarity in breast pathology: First recurrent male case of Rosai-Dorfman disease.

INTRODUCTION: Rosai-Dorfman Disease (RDD) is a rare pathological finding in the breast. Although it is usually palpated as a breast mass, it can be identified on ultrasound or mammogram. The hallmark of the disease is histiocytes with emperipolesis. The case presented in this study represents the first known documented male breast recurrence of RDD and the first association of the disease with pseudoangiomatous stromal hyperplasia (PASH). PRESENTATION OF CASE: A 55-year-old male, with a prior history of right breast excisional biopsy of a mass in 2015 that showed RDD, presented to our breast clinic for follow up. A breast sonogram showed a hypoechoic mass. Biopsy and excision were performed revealing recurrent RDD along with PASH. DISCUSSION: RDD is a benign condition that normally presents in lymph nodes but can present in extranodal sites, such as the breast. Location and symptoms guide treatment which can include medical or surgical therapy. PASH of the breast is a benign process that may be amenable to treatment by observation, medical management, or surgical excision. Treatment continues to be controversial given the lack of long term sequelae. CONCLUSION: Definitive treatment for RDD of the breast and PASH has not been established. Based on the available data in the literature, our conclusion is that recurrent RDD of the breast can be observed without need for surgical therapy.

Contralateral axillary lymph node metastasis in second primary Breast cancer: Case report and review of the literature.

The rare entity of contra-lateral axillary lymph node metastasis(CAM) has been a debatable topic in the realm of breast cancer management for many years. There remains controversy over whether CAM should be considered distant metastasis or locoregional spread. It is also uncertain why or how CAM occurs. In this case report and review of the literature, we present an 81-year-old female with an apparent second primary breast cancer with synchronous CAM. This paper describes a scenario of altered lymphatic drainage which likely lead to CAM. In this situation, we propose that CAM should be treated with curative intent rather than stage IV disease. We also attempted to gain a better understanding of the histopathology and tumor characteristics of tumors associated with CAM. Our patient was treated with curative intent and remains disease free for over 18 months. This supports the theory that patients with distorted lymphatic drainage from prior interventions who have CAM, should be treated as locoregional extension of the disease.

Esophageal bronchogenic cyst and review of the literature.

BACKGROUND: Bronchogenic cysts are rare foregut abnormalities that arise from aberrant budding of the tracheobronchial tree early in embryological development. These cysts predominantly appear in the mediastinum, where they may compress nearby structures. Intra-abdominal bronchogenic cysts are rare. We report an intra-abdominal bronchogenic cyst that was excised laparoscopically. METHODS: A 40-year old female with a history of gastritis presented for evaluation of recurrent abdominal pain. A previous ultrasound showed cholelithiasis and a presumed portal cyst. Physical examination and laboratory findings were unremarkable. A CT scan with pancreatic protocol was performed and an intra-abdominal mass adherent to the esophagus was visualized. A laparascopic enucleation of the mass was performed. A 3-cm myotomy was made after circumferential dissection of the cyst and the decision was made intraoperatively to reapproximate the muscularis layer. A PubMed literature search on surgical management of esophageal bronchogenic cysts was subsequently performed. RESULTS: The literature search performed on the subject of esophageal bronchogenic cysts found one review article focusing on intramural esophageal bronchogenic cysts in the mediastinum and five case reports of esophageal bronchogenic cysts. Of these, only one was both intraabdominal and managed laparascopically with simple closure of the resulting myotomy. The majority of the bronchogenic cysts mentioned in the literature were located mediastinally and were managed via open thoracotomy. Our findings confirm the rarity of this particular presentation and the unique means by which this cyst was surgically excised. CONCLUSION: This case highlights the management of a rare entity and advocates for enucleation of noncommunicating, extraluminal esophageal bronchogenic cysts and closure of the esophageal muscular layers over intact mucosa as a viable surgical approach to this unusual pathology. Other cases of laparascopic enucleation of bronchogenic cysts have shown similarly uneventful postoperative courses and rapid recovery with no apparent return of symptoms.

Use of telecytology for the immediate assessment of CT guided and endoscopic FNA cytology: diagnostic accuracy, advantages, and pitfalls.

Telecytology (TC) can assist cytopathologists in efficiently providing immediate evaluation for fine needle aspirations (FNAs) performed at remote locations. Our aim was to evaluate the accuracy and feasibility of TC for immediate assessments of FNAs. Phase I: Diff-Quik and Pap stained smears from two retrospective sets of 20 pilot cases each (n = 40) were included for TC assessments. For the first set, diagnoses were rendered by four pathologists and for the second set, in addition, four cytotechnologists also participated. Diagnostic concordance with the final diagnosis was assessed. Phase IIA: These were followed by real time assessments (RTA) of 56 TC FNAs and diagnostic concordance was compared to that of 100 conventional in-person immediate assessments (Phase IIB). Phase I: 79/80 (98.8%) diagnoses (20 cases × 4 pathologists) from the first set were accurate. On the second set, 160 diagnoses were rendered on Pap stained slides and 160 on Diff-Quik stained slides. The accuracy rate was 95% (76/80) for malignant diagnoses and 96.2% (77/80) for benign diagnoses on Pap stain. Diff-Quik stains were more difficult to interpret than Pap stains and accuracy rates for them were lower. Endoscopic bronchial ultrasound guided (EBUS) FNAs of paratracheal nodes were more difficult to interpret. Phase IIA and B: 95% (53/56) RTAs by TC were concordant with the final diagnoses compared with 97% (97/100) for in-person assessments. TC is a useful aid and yields concordance rates comparable to in-person assessments. Individual practices should perform pilot studies to understand the pitfalls and limitations before employing telecytology.

True adrenal mesothelial cyst in a patient with flank pain and hematuria: a case report.

True mesothelial (epithelial) cysts in the adrenal gland are rare lesions. They represent 9% of adrenal cysts and are much less common than vascular adrenal cysts. We report a case of a true adrenal mesothelial cyst in a patient with flank pain and hematuria that was diagnosed on imaging as a renal cyst. Immunohistochemical studies were performed to investigate the nature of the cyst lining. The positive immunostains for calretinin and WT-1 lend support to the postulate of Medeiros et al nearly 20 years ago of a mesothelial origin for these cysts. The clinical presentation and salient radiologic and pathologic features are described.

Stage IV primitive-appearing sinus and orbital rhabdomyosarcoma presenting in a 68-year-old female previously treated for breast cancer.

A 68-year-old female who had undergone treatment several years previously for breast cancer presented with diplopia and unilateral proptosis and exposure keratopathy related to biopsy-proven rhabdomyosarcoma of the sinus and orbit. Further evaluation revealed multiple metastatic lesions felt to have originated from the primary sinus and orbital tumor. Histopathologic examination showed primitive-appearing rhabdomyosarcoma with some features suggestive of the alveolar subtype. Orbital or sinus rhabdomyosarcoma is seen almost exclusively in the pediatric population, but may very rarely occur in adults. There are several genetic mutations that appear to play a role in both rhabdomyosarcoma and certain breast tumors. There is also increasing evidence that even low doses of radiation may contribute to the future development of cancer, particularly in susceptible individuals. In our patient with atypical demographics for rhabdomyosarcoma, the previous neoplasm and treatment thereof may have predisposed to the development of this rare tumor.

Coexistence of malignant struma ovarii and Graves' disease.

OBJECTIVE: To report an unusual case of hyperthyroidism from Graves' disease that was coexistent with malignant struma ovarii. METHODS: We summarize the clinical history, physical findings, laboratory data, imaging studies, pathologic features, and treatment in a patient with recurrent hyperthyroidism and discuss the incidence of ovarian tumors of various histologic origins, including thyroid tissue (that is, struma ovarii). RESULTS: Five years after diagnosis of Graves' disease and resolution of symptoms with 1 year of antithyroid drug therapy, a 53-year-old woman had recurrence of palpitations, tremors, and weight loss. Results of thyroid function tests showed high total and free thyroxine levels and a low thyrotropin level. Thyroid radioiodine uptake was high (69% at 24 hours). Abdominal ultrasound studies disclosed a cystic mass in the right adnexal area. Total abdominal hysterectomy and bilateral oophorectomy revealed a 7.5-cm cystic right ovary that contained a 1.0-cm struma ovarii with a 0.4-cm nodule of follicular variant papillary thyroid carcinoma within it. The patient was treated with methimazole and radioiodine ablation of the thyroid. Three months later, a massive myocardial infarction resulted in her death. CONCLUSION: The concomitant presence of Graves' disease complicates the management of struma ovarii and raises interesting questions about treatment and prognosis.