Cytology should create structured data sets without using synoptic reporting.

Structured data sets can be created from cytology reports without the addition of synoptic reports using either natural language processing or minor changes to laboratory information systems structure.

Improving Reporting of Tumor Size in Synoptic Reports.

CONTEXT.­: Tumor size is an important prognostic feature in many synoptic reports. The best format to report this feature is not clearly defined. OBJECTIVE.­: To define formatting features that impact the significance of tumor size. DESIGN.­: We reviewed multiple formatting features of tumor size in synoptic reports and correlated them with size distribution, reproducibility, and other pathologic features. RESULTS.­: Reporting tumors in millimeters rather than centimeters was more precise because of reduced rounding error and was significantly more reproducible (P = .01). Tumor sizes where the pathologist was concerned that the size may be underestimated are associated with significantly higher tumor N stage than tumors of similar size that are not so identified. Reported tumor sizes in multifocal tumors are also associated with significantly higher N stage than unifocal tumors of the same size. CONCLUSIONS.­: Tumor sizes should be reported in millimeters, and when tumors are reported as either "at least" a specific size or as "multifocal" this information should also be recorded because these sizes likely underestimate the true biologic potential of the tumor.

High-grade urothelial carcinoma with hypochromatic chromatin in urine cytology.

INTRODUCTION: Some high-grade urothelial carcinomas (UCs) in urine cytology have hypochromatic chromatin, but the incidence and criteria for diagnosis are not well described. MATERIALS AND METHODS: Urine cytology cases with biopsy follow up were reviewed. RESULTS: Cytospin preparations from 331 cases with biopsy follow up (230 benign/low-grade UC, 101 malignant) were reviewed. There were no false-positive cases. Cases with malignant cells with hypochromatic chromatin were identified in a total of 17 cases (16.8% of all malignancies). These comprised 2 carcinoma in situ, 11 high-grade papillary UC, 3 invasive UC, and 1 adenocarcinoma. Sixteen of 93 high-grade UCs (17.2%) had cells with hypochromatic chromatin. These cells were the only type of malignant cell in 4 of 101 cases (4.0%). All cases had cells with high nuclear-to-cytoplasmic ratios and markedly indented and irregular nuclear membranes that could be identified on both cytology and subsequent histology. CONCLUSIONS: Malignant urothelial cells in urine cytology with hypochromatic chromatin can be present in 17% of cases and can be diagnosed as "positive for malignancy" based on their high nuclear-to-cytoplasmic ratio, and markedly indented and irregular nuclear membranes.

Thyroid FNA: Is cytopathologist review of ultrasound features useful?

Cytopathologist review of thyroid ultrasound (US) has been proposed to be useful in diagnosis and patient triage. This review explores the implications for practicing cytopathologists of integrating US review into the thyroid fine-needle aspiration diagnosis. At present, there is no agreed-upon system for combining cytologic and US features and communicating those results as a single report. If cytologists are performing tasks that require expertise in US interpretation, then they should know and be fully conversant with US interpretation. Whether cytologists performing aspirations require expertise in US interpretation is not clear. Regardless, cytologists should avoid using US results to alter their cytologic interpretations unless they clearly communicate that this is what they are doing. An evidence-based integrated reporting system that would allow cytologists to clearly explain to other physicians exactly how they reached their interpretation might provide value beyond current standard practice.

Risk of death due to disease for thyroid fine-needle aspirations of well-differentiated thyroid carcinomas.

The risk of malignancy for some diagnoses in thyroid fine-needle aspirations is higher than the actual risk of clinical progression. Other measures of prognosis may be helpful in managing patients with indeterminate thyroid fine-needle aspiration diagnoses. We estimated the risk of death due to disease (RDDD) for well-differentiated thyroid carcinoma using a series of over 15 000 aspirates with over 2000 excisions and data from the SEER database. RDDD was low (1.3% or less for all categories). The RDDD of some indeterminate thyroid aspirates was higher than for malignant aspirates. The RDDD may provide additional information for patients and clinicians seeking to manage patients with indeterminate thyroid fine-needle aspirates.

Effusion cytology of epithelioid rhabdomyosarcoma.

We report a case of epithelioid rhabdomyosarcoma in a pleural effusion. In contrast to most rhabdomyosarcomas in effusions, the cells presented as cohesive clusters of atypical cells with abundant eosinophilic cytoplasm which mimicked an adenocarcinoma. Immunohistochemistry was positive for epithelial membrane antigen and muscle markers and negative for keratins.

Adequacy criteria for voided urine cytology using cytospin preparations.

BACKGROUND: Previous studies have suggested that urine cytology adequacy may be related to both specimen volume and cellularity. METHODS: The authors reviewed cytospin preparations from 314 urine specimens (162 voided and 152 instrumented specimens) found to have high-grade urothelial carcinoma on biopsy. RESULTS: The sensitivity of instrumented urine cytology was significantly higher than that of voided cytology (82% vs 25%; P < .001). The cellularity (at least 30 urothelial cells/10 high-power fields [HPF]) of instrumented urine specimens also was significantly higher than that of voided specimens (57% vs 9%; P < .001). The sensitivity of voided urine cytology with a cellularity of 20 to 39 cells per 10 HPF was significantly higher than that of cases with <20 cells per 10 HPF (77% vs 19%; P < .001). The sensitivity decreased with higher cellularity for both types of specimens. The sensitivity of voided cases with a volume of at least 30 mL was higher than that of cases with a volume <30 mL, but this was not statistically significant (31% vs 17%; P = .07). CONCLUSIONS: The sensitivity of voided urine cytology for high-grade urothelial carcinoma is significantly associated with urothelial cellularity but not specimen volume. Both the cellularity and sensitivity of voided urine specimens are less than that of instrumented specimens.

Needle track seeding in renal mass biopsies.

A review and analysis of the literature demonstrates that needle track seeding in renal mass biopsy has been reported 16 times. This complication occurs almost exclusively among patients with papillary renal cell carcinoma. The incidence is associated with multiple punctures of the mass, the use of core needles of ≥20 gauge, and lack of a coaxial sheath. Needle tract seeding may be associated with tumor upstaging and a worse prognosis. Fine-needle aspiration has a significantly lower rate of needle track seeding compared with large core needle biopsy (>20-gauge needle). A more formalized risk-based system for interpreting renal mass fine-needle aspiration may be useful as clinicians choose among an increasing number of therapeutic options.

Risk stratification of HIV infection for patients needing molecular confirmation with the Abbott 4th generation Architect System.

BACKGROUND: Some patients need their 4th generation HIV testing results confirmed with molecular testing after primary confirmatory testing which may not be immediately available. Further risk stratification of these patients pending the results of molecular testing may be of value not only for patient counseling but also for treatment of women in labor. OBJECTIVES: To determine the risk of a positive test result on molecular testing for these patients. STUDY DESIGN: The risk of a positive molecular test result for patients with a result needing molecular confirmation on a 4th generation HIV testing algorithm (Abbott Architect, Multispot/Geenius confirmatory test) was stratified based on the patient's white blood cell (WBC) count and the magnitude of Architect result Signal Cut Off ratio (S/CO). RESULTS: A total of 61,666 patients were tested with 658 (1.1%) positive results and 76 (0.12%) patients needing molecular confirmation. Patients with an S/CO of <5 or an S/CO of 5-100 with a WBC > 6.5 × 10 9 cells/l had a significantly lower risk of a positive molecular HIV test (0/48, 0%) than patients with an S/CO 5-100 with a WBC < 6.0 s × 10 9 cells/l (5/9, 56%, p < .001) or an S/CO > 100 (2/2, 100%, p < .001). Pregnant women had a significantly lower rate of positive test results (24/6924, 0.4%) than non-pregnant patients (634/54742, 1.1%, p < 0.001). All 12 cases needing molecular confirmation in pregnant women had negative NAT test results. CONCLUSIONS: Patients who need their HIV results confirmed with molecular testing using a 4th generation algorithm that includes the Abbott Architect System can be further stratified into low, intermediate, and high risk groups based on additional laboratory information pending the results of molecular testing. This risk stratification may be of value for patient counseling and treatment of women in labor.

Improving Discrete Data Capture in Synoptic Reports With Optional Free-Text Modifiers.

PURPOSE: Upfront, discrete data capture in synoptic reporting fails when pathologists choose a response not associated with discrete data. We sought to determine the factors associated with this event. METHODS: The results of all "Other" entries in four common tumor sites in synoptic reports were reviewed. RESULTS: "Other" entries occurred in 329 of 13,421 questions (2.5%). In 306 of these 329 questions (93.0%), the pathologist appeared to choose this response because they wished to add additional information to an already existing response that was associated with discrete data capture. As a result, the addition of a free-text modifiers to existing responses would allow pathologist to add this additional information while still selecting a response associated with discrete data capture, significantly improving the total discrete data capture (13,092 of 13,421 questions [97.5%] v 13,398 of 13,421 questions [99.8%]; P < .001). CONCLUSION: The addition of free-text modifiers to structured responses in synoptic reports could significantly improve the discrete data capture rate.

High-grade urothelial carcinoma in urine cytology with jet black and smooth or glassy chromatin.

BACKGROUND: Some high-grade urothelial carcinomas (UCs) in urine cytology can have jet black, smooth, or glassy chromatin, but to the authors' knowledge, the incidence and criteria for diagnosis are not well described. The current study was performed to define the incidence and appearance of high-grade UC in urine cytology in cytospin preparations with jet black and smooth or glassy chromatin. METHODS: Cytospin preparations from 331 cases with biopsy follow-up (230 benign/low-grade UCs and 101 malignant UCs) were reviewed. RESULTS: Cases with malignant cells with jet black and smooth or glassy chromatin were identified in a total of 60 cases (59.4% of all malignancies). These comprised 18 carcinoma in situ cases, 28 high-grade papillary UCs, 8 invasive UCs, 3 squamous cell carcinomas, 2 adenocarcinomas, and 1 melanoma. Of the 93 high-grade UCs, 51 (54.8%) had cells with either jet black and smooth or glassy chromatin. These cells were the only type of malignant cell in 6 of 101 cases (5.9%). All cases had at least 50 cells with jet black nuclei. Nuclei with jet black and smooth chromatin often were smaller than normal urothelial cells, often but not always elongate, had irregular nuclear outlines including pointed areas, and usually were accompanied by necrosis. Cells with glassy chromatin often were larger than normal urothelial cells, had rounder but still irregular nuclei, and also had frequent necrosis. CONCLUSIONS: Malignant urothelial cells in urine cytology with jet black chromatin are common and can be diagnosed as "positive for malignancy" based on their irregular nuclear outline, increased cellularity (≥50 abnormal cells), and frequent necrosis. Cancer Cytopathol 2018;126:64-8. © 2017 American Cancer Society.

High-Grade Urothelial Carcinoma on Urine Cytology Resembling Umbrella Cells.

CONTEXT: High-grade urothelial carcinoma (UC) cells have many appearances on urine cytology, but according to The Paris System, they can be easily distinguished from umbrella cells. OBJECTIVE: We aimed to define the incidence and appearance of high-grade UC cells that resemble umbrella cells in Cytospin preparations on urine cytology. RESULTS: Cytospin preparations from 331 cases with biopsy follow-up (230 benign/low-grade and 101 malignant [22 carcinoma in situ, 52 papillary, 19 invasive UC, 8 other] cases) were reviewed. A total of 18 cases with malignant cells resembling umbrella cells were identified (17.8% of the malignant cases) and were the only type of malignant cell in 3% of the cases. Two patterns were identified. Tumor cells were either identifiable by at least 20 abnormal cells which were large, had abundant cytoplasm but an elevated nuclear-to-cytoplasmic ratio, and markedly enlarged, round-to-elongated nucleoli, or else rare cells with abundant cytoplasm but obviously malignant nuclei. Cells without nucleoli or obviously malignant nuclei were not specific. CONCLUSIONS: Malignant cells resembling umbrella cells can be seen in up to 17% of urine cytology specimens.

Characteristics of False-Negative Thyroid Fine-Needle Aspirates.

INTRODUCTION: False-negative thyroid fine-needle aspirates (FNA) are not well characterized. METHODS: We correlated the results of all thyroid aspirations from 1997 to 2016 with histologic follow-up. RESULTS: There were 13,733 aspirates, 2,112 (15.3%) resections, and 678 malignancies (32.1%). Eighteen (2.7%) false-negative cases were identified (interpretation, n = 6; sampling, n = 7; and new nodules, n = 5). Interpretive false-negative cases were significantly less likely when the indeterminate rate was greater than 13% (p = 0.01). Interpretive errors involved rare cells with poorly developed features of malignancy. Sampling errors were not associated with scant cellularity in the specimen. The majority of false-negative cases were not resected because of a clinical suspicion of malignancy. The sensitivity of FNA for 9-mm papillary carcinomas was 44.3%. CONCLUSION: In this cohort, the false-negative rate of thyroid FNA was 2.7% and the risk of malignancy for a benign diagnosis was 3.5%. Interpretative errors involved rare cells with poorly developed features of malignancy. There is little evidence that either the false-negative rate or the risk of malignancy of a benign thyroid FNA is different in patients who do and do not undergo resection.

Predominance of neutrophils in the cerebrospinal fluid of patients treated with intravenous immunoglobulin.

Patients treated with intravenous immunoglobulin can present with numerous neutrophils in the cerebrospinal fluid.

Evidence-based adequacy criteria for instrumented urine cytology using cytospin preparations.

Cytospin preparations of instrumented urine cytology specimens with less than 10 urothelial cells or more than 50 urothelial cells/10 hpfs are both associated with significantly increased false negative rates compared to cases with 10-49 urothelial cells/10 hpfs.

Ancillary studies in fine needle aspiration of the kidney.

An increasing number of renal cell carcinomas (RCCs) require ancillary studies for diagnosis. The majority of renal fine needle aspirates do not require ancillary studies. Among the most common useful stains are cytokeratin 7 (separating clear cell RCC [negative] from papillary RCC, clear cell papillary RCC, and multilocular cystic RCC [positive] as well as separating chromophobe RCC [diffusely positive] from oncocytoma [focally positive/negative]) and CD117 (separating chromophobe RCC and oncocytoma [positive] from granular variants of clear cell RCC [negative]). CD68 and keratin are helpful in distinguishing RCC from xanthogranulomatous pyelonephritis. HMB45 is useful in recognizing scant aspirates of angiomyolipoma. Less common subtypes of RCC may benefit from the use of more specialized ancillary studies (succinate dehydrogenase B, fumarate hydratase, tumor suppressor gene INI, OCT3/4). While the majority of renal fine needle aspirates can be accurately diagnosed based on morphology alone, improved subtyping and accuracy can be achieved with the use of immunohistochemical and molecular studies. Cancer Cytopathol 2018;000:000-000. © 2018 American Cancer Society.

Fine-needle aspiration of tubulocystic renal cell carcinoma.

We report two cases of tubulocystic renal cell carcinoma, a rare renal tumor the cytology of which has not been previously reported. Both aspirates were cellular and contained large sheets of cells with abundant granular cytoplasm, distinct cell borders and intracellular windows, distinct to prominent nucleoli, rare intracytoplasmic vacuoles, and rare nuclear grooves. Cells with variable amounts of cytoplasm were also arranged in small groups, some of which resembled spherules. The large sheets of cells with windows appeared specific for tubulocystic carcinoma; the spherules could easily be confused with a papillary renal cell carcinoma.

Measuring errors in surgical pathology in real-life practice: defining what does and does not matter.

This review summarizes our experience using blinded review as a method to measure quality in surgical pathology. It details the specifics about how the review is performed, the weaknesses in the method, and then summarizes our results so far. These results suggest that error rates correlate with the individual pathologist, the type of specimen, the type of diagnosis, subspecialization, and the number of pathologists who review a case. Errors do not correlate with workload. This method is relatively unbiased and effective at identifying significant errors in real life clinical practice. The drawback to this method is the amount of work involved. Blinded review, performed so that errors can be corrected in a timely manner, and eventually integrated into an interlaboratory review process, represents a realistic and fair method to provide quantitative quality assurance information.

The value of inking breast cores to reduce specimen mix-up.

Accidental switching of tissue specimens in the histology laboratory can result in significant medical error. We sought to evaluate inking breast core needle specimens as a method to reduce the chance of specimen mix-up. We sequentially inked 1,000 consecutive breast core specimens with 6 different colors. Review of the color of the ink revealed 3 discrepancies: 1 related to blocks being switched, 1 related to incorrect labeling, and 1 was a typographical error. Inking of breast core specimens is a simple, inexpensive, and effective way to help reduce the chance of specimen mix-up.

Incidence and significance of true papillae in thyroid fine needle aspiration.

INTRODUCTION: Whether true papillae without nuclear features of papillary carcinoma in thyroid fine needle aspirates should be diagnosed as atypia of undetermined significance (AUS) is unclear. METHODS: The results of all thyroid FNAs performed from 2014-2016 with corresponding resections as well as aspirates from 2000-2016 with a diagnosis of follicular variant of papillary carcinoma or Noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) were reviewed. RESULTS: Papillae with fibrovascular cores were identified in 17 of 149 consecutive cases (11%), 3 of which had nuclear features of papillary carcinoma and were papillary carcinoma at resection. All 14 cases of papillae without nuclear features of papillary carcinoma were benign. Of 29 papillary carcinomas, papillae were identified in 8 (28%) and "swirls" were identified in 3 (10%) additional cases, all in cases of papillary carcinoma, NOS. Papillae and swirls were not identified in any cases of NIFTP (13 cases) or follicular variants of papillary carcinoma (15 cases). CONCLUSION: True papillae are relatively common. Both papillae with nuclear atypia and swirls are highly specific for papillary carcinoma, NOS and are not seen in NIFTP. True papillae with fibrovascular cores but without cytologic features of papillary carcinoma are benign and should not be diagnosed as AUS. Diagn. Cytopathol. 2017;45:689-692. © 2017 Wiley Periodicals, Inc.