Comparison of the clinic microscopy laboratory with the cytopathology laboratory in the detection of malignant cells in body fluids.

The clinical microscopy (fluids) laboratory evaluates almost every body fluid that is obtained in the hospital. Because the fluids laboratory functions at all hours, it is often the first laboratory to receive a body fluid. In addition to its primary purpose of quantitating categories of cells, the medical technologist in this laboratory has an opportunity to identify malignant cells. To our knowledge, no formal study has ever been undertaken to evaluate the performance of the fluids laboratory in detecting malignancy. The authors therefore retrospectively identified 928 body fluids (pleural, peritoneal, cerebrospinal, and miscellaneous) over a 2-year period that had undergone simultaneous cytologic examination in our cytopathology laboratory and body fluid analysis in our fluids laboratory. Of these, a cytologic diagnosis of malignancy was made by the cytopathology laboratory in 107 cases; 821 were considered to be benign. No false-positive results were rendered by the fluids laboratory (100% specificity), but only 26 of the 107 malignant cases were identified (24% sensitivity); the overall accuracy was 93%. Factors contributing to the inability of the fluids laboratory to identify malignant cells included (1) too few cells to warrant a cytocentrifuge preparation, especially in cerebrospinal fluid specimens; (2) differences in the processing of specimens; (3) differences in staining procedures; and (4) differences in the training of personnel. The authors conclude that although the fluids laboratory correctly identifies neoplastic cells in approximately one fourth of the cases in which they are present, it should not be expected to detect malignant cells in every cytologically malignant case.(ABSTRACT TRUNCATED AT 250 WORDS)

PAPNET-directed rescreening of cervicovaginal smears: a study of 101 cases of atypical squamous cells of undetermined significance.

Many women having cervicovaginal smears interpreted as atypical squamous cells of undetermined significance (ASCUS) ultimately prove to harbor squamous intraepithelial lesions (SIL). The question is whether rare cells diagnostic of SIL are present in so-called "atypical" smears, but simply go undetected. To test whether the PAPNET Cytological Screening System, an automated system, can detect the (assumed) presence of such cells, six reviewers independently evaluated PAPNET video images generated for 101 cases conventionally diagnosed as ASCUS. Using PAPNET-identified microscopic coordinates, selected cases were then manually reviewed and reclassified according to consensus opinion. Overall, 35 cases were reclassified as SIL (22 low grade; 13 high grade). Histologic correlations showed 37 of the 101 cases conventionally interpreted as ASCUS carried tissue diagnoses of SIL, (28 low grade; 8 high grade, 1 ungraded). Using PAPNET, 24 of the 37 (65%) corresponding smears were reclassified as SIL (15 low grades; 9 high grade).

Interobserver variability in subclassification of squamous intraepithelial lesions: Results of the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology.

OBJECTIVE: To determine whether, on a national cytology proficiency test, a competent cytologist can consistently distinguish grades of squamous intraepithelial lesions. DESIGN: Results for low- and high-grade squamous intraepithelial lesion referenced slides from the College of American Pathologists Interlaboratory Comparison Program in Cervicovaginal Cytology for 1996 and 1997 were analyzed including educational, nongraded vs graded validated slides. RESULTS: The discrepant rate between low- and high- grade lesions ranged from 9.8% to 15% for cytotechnologist, pathologist, laboratory, and all responses. There was a statistically significant difference in performance on graded, validated slides vs educational slides with better performance on validated slides. CONCLUSION: This significant interobserver variability in subclassification of squamous lesions should be considered in management guidelines for abnormal Papanicolaou test results and implementation of national cytology proficiency testing.

Cytologic features of necrotizing granulomatous inflammation consistent with cat-scratch disease.

Approximately 2,000 cases of cat-scratch disease are reported annually. It is an uncommon cause of unilateral lymphadenopathy in children and adults. We present the cytologic features of necrotizing granulomatous lesions consistent with cat-scratch disease from various sites. Eleven cases from 10 patients with a mean age of 16 yr (range, 2-33 yr) were biopsied by fine-needle aspiration. All gave a history of previous exposure to cats. Two children had atypical presentations; one with multiple hypodense areas within the liver and spleen, and the other with features of encephalitis. Other locations included lymph nodes from axilla, inguinal, preauricular, and cervical areas, and other body sites such as the scapula and the parotid gland. Histologic staging of the inflammatory process was correlated with cytologic features. There were 5 cases of early features, 3 cases in the middle phase, and 3 cases in late stage. The differential diagnosis of each stage is discussed. The 2 children with atypical presentations are described in detail.

Transitional-cell carcinoma metastatic to cerebrospinal fluid: presentation of two cases.

We present 11 specimens from 2 patients with transitional cell carcinoma metastatic to the cerebrospinal fluid. This is a rare occurrence documented in one previous report in which 5 patients had 28 specimens reviewed (Ehya et al., Acta Cytol 1981;25:599-610). Cytologic features that most likely indicate a bladder origin are the cytoplasmic tails and cytoplasmic pseudopod formation.

Adenoid basal carcinoma of the cervix: a potential pitfall in cervicovaginal cytology.

Adenoid basal carcinoma (ABC) of the cervix is a quite uncommon, indolent, yet invasive neoplasm rarely identified on cervicovaginal smears. This may be due in part to sampling. Unless ABCs become ulcerated, even vigorous brushing of the endocervical canal may not be adequate to dislodge the small, cohesive cells of this neoplasm. Fortunately, the association of ABC with squamous intraepithelial lesions (SIL) often results in its incidental diagnosis on follow-up cervical biopsy or endocervical curettage. We report two cases of ABC. In case 1, a 79-yr-old white woman was diagnosed with squamous-cell carcinoma on cervicovaginal (CV) smear. High-grade SIL, carcinoma in situ, and ABC were identified on subsequent cervical cone biopsy and hysterectomy. Retrospective evaluation of the CV smear revealed a few aggregates of small, uniform cells, with hyperchromatic nuclei representing fragments of ABC. In case 2, atypical basaloid cells suspicious for ABC were recognized on the CV smear of a 67-yr-old black woman, and ABC was subsequently confirmed on cervical cone biopsy. In neither case did the intervening cervical biopsy reveal ABC. In addition to a review of the clinical information useful in the diagnosis of ABC, the cytologic features of these two cases are compared with their subsequent histopathology and contrasted with other similar lesions comprising the differential diagnosis of small neoplastic cells found in cervicovaginal smears.

Fine-needle aspiration biopsy and imprint cytology of small non-cleaved cell (Burkitt's) lymphoma.

We reviewed 13 cases of small non-cleaved cell (Burkitt's) lymphoma diagnosed by fine-needle aspiration biopsy (FNAB) and four cases where that diagnosis was made from touch imprints from surgical biopsy specimens. The most common site was intraabdominal. Histologic confirmation was present in 14/17 cases. General microscopic features on smears included high cellularity and an individual cell pattern. Extracellular lymphoglandular bodies were abundant and tingible body macrophages were prominent. Nuclei were intermediate in size and round with a finely dispersed chromatin pattern on May-Grünwald-Giemsa stained smears. Cytoplasm was basophilic and scant with prominent vacuoles. Extracellular vacuoles and vacuoles within lymphoglandular bodies occurred in all patients. Immunocytochemistry performed on 16/17 cases demonstrated a B cell phenotype in 15. Nine cases were kappa light chain positive and six were lambda light chain positive. Flow cytometry performed in five cases demonstrated diploid cells with a high S phase. We conclude that Burkitt's lymphoma can be diagnosed using combined FNAB and immunophenotyping.

Fine-needle aspiration biopsy of childhood rhabdomyosarcoma: reevaluation of the cytologic criteria for diagnosis.

The distinction between rhabdomyosarcoma (RMS) and the other small round blue cell tumors of childhood has therapeutic implications which stress the importance of a correct diagnosis. In attempts to reevaluate the cytologic criteria of this entity, we reviewed a series of 17 fine-needle aspiration biopsies and three touch imprints from soft tissue masses. All cases had been histologically confirmed except for two cases that only had immunocytochemical and ultrastructural confirmation. The features occurring most commonly include a uniform population of tumor cells arranged as single cells and cohesive aggregates. The cells were predominantly round/polygonal, with uniform nuclei and scant to moderate amounts of cytoplasm. The nuclear chromatin was most often finely granular and hyperchromatic, while nucleoli were inconspicuous. Binucleated and multinucleated cells were found in 17 of the 20 smears. Intracytoplasmic vacuoles were present in 17 cases, ranging from occasional in one case, a few in 10 cases, and very numerous in six cases. We conclude that the presence of bi/multinucleated cells is an important clue for the diagnosis of RMS on fine-needle aspiration biopsy.

Another quality assurance issue--amended reports: what do we really know about them?

The Clinical Laboratory Improvement Amendment (CLIA) of 1988 requires that if a cytology/histology discrepancy is discovered which is significant and affects patient care, an amended report should be issued (Clinical Laboratory Improvement Amendments, Fed Reg 1992;57:7169). Since little is known about such amended reports, a survey was developed to assess how individuals handle discrepancies. The Quality Assurance Task Force from the Papanicolaou Society of Cytopathology created a survey to assess these methods and sent it to all of their members. Fifty-one individuals responded to the survey. Methods vary widely among institutions. On average, 107 cytologic/histologic correlations are performed each month with the discovery of approximately 2 major and 11 minor discrepancies. Thirty-nine responders utilize written amended reports and telephone clinicians when a major discrepancy is found. Thirty-eight individuals indicated that their place of employment has a written policy concerning discrepancies. Time spent in quality assurance issues averaged 8 hr per wk for cytotechnologists and 3 hr per wk for pathologists. Although amended reports are required when significant discrepancies are revealed, a standard practice does not exist.

Diagnosis of primary nerve sheath tumor of the sphenoid sinus by fine needle aspiration biopsy. A case report.

This paper describes the aspiration cytologic characteristics of a histologically proven cellular schwannoma of the sphenoid sinus. The aspirate contained several large clusters of spindle-shaped cells in a compact, fascicular pattern.

Primary lymphoma of the endometrium. A report of two cases diagnosed on cervicovaginal smears.

BACKGROUND: Primary lymphomas of the endometrium are extremely rare. Diagnosis is difficult, especially when the neoplasm is originally evaluated on a cervicovaginal smear. When lymphomas involve the endometrium, the cervix is three times more likely to be the primary site rather than the endometrium. Two of the symptoms of primary lymphoma of the endometrium are abnormal vaginal bleeding and an abdominal or pelvic mass. CASES: Case 1 was a 36-year-old, obese, black female with an abdominal mass and recent onset of ascites. The second case was a 31-year-old, obese, black female with a history of menometrorrhagia. The cytologic findings in both cases revealed an individual cell population, high nuclear/cytoplasmic ratio, small nucleoli and coarsely granular chromatin with some chromatin clearing. Endometrial currettings showed a histologic pattern of malignant non-Hodgkin's lymphoma, diffuse, large cell type. Immunoperoxidase staining was positive for leukocyte common antigen. CONCLUSION: Two cases of lymphoma of the endometrium were diagnosed first by a cervical cytologic smear, supported by a positive body cavity fluid in one case and histology in both. The differential diagnoses included various inflammatory lesions, small cell carcinoma, endometrial stromal sarcoma and granulocytic sarcoma.

Cytologic features of sinus histiocytosis with massive lymphadenopathy. A report of three cases.

BACKGROUND: Sinus histiocytosis with massive lymphadenopathy (SHML) was described over 20 years ago by Rosai and Dorfman. Originally it was described as occurring in young males, predominantly with cervical lymphadenopathy. Since then over 423 histologically documented cases of SHML have been documented, including many extranodal sites. Few studies have characterized the cytologic features of SHML. CASE: Three cases of lymph node involvement by SHML occurred, one also with skin involvement. Cytologic findings included numerous histiocytes with phagocytized lymphocytes, atypical forms of histiocytes and a reactive, lymphoid background. Surgical biopsy and immunohistochemical stain for S-100 protein of all three cases confirmed the cytologic impression. CONCLUSION: Sinus histiocytosis with massive lymphadenopathy can be diagnosed by cytology in conjunction with clinical history and immunohistochemistry.

Rhabdoid cells in peritoneal fluid. A case report.

BACKGROUND: Rhabdoid tumor is an aggressive, malignant renal neoplasm of infants. Many extrarenal sites have been documented. CASE: A poorly differentiated carcinoma of the ovary with rhabdoid features occurred in a 36-year-old woman. The peritoneal fluid contained numerous malignant cells with rhabdoid features. Electron microscopy and immunocytochemistry corroborated the rhabdoid nature of the cells. CONCLUSION: Rhabdoid cells can be distinguished from other neoplasms with similar cytologic features by ancillary studies and clinical history.

Fat embolism syndrome associated with asthma and sickle cell-beta(+)-thalassemia.

A 25-year-old African-American man with sickle cell-beta(+)-thalassemia presented with acute asthma of 2 days' duration. The asthma was well controlled by 48 hr, and parenteral medications were changed to oral bronchodilators and steroids. Sixty hours after presentation, he developed pain similar to that of sickle cell vaso-occlusion, for which he received small amounts of analgesics. He died approximately 84 hours after presentation. Autopsy showed extensive marrow necrosis and massive fat embolism. This is the first reported case of fat embolism syndrome associated with this genotype, the mildest of the clinically significant sickle cell hemoglobinopathies. The relationship between these etiologic factors and indications for transfusions are discussed.

Solitary splenic metastasis of an adenocarcinoma of the ovaries.

Metastatic involvement of the spleen by carcinoma occurs in a setting of widespread malignant disease. Solitary splenic metastasis in the absence of disseminated disease is rare. We report a case of a 55-year-old woman in whom the sole clinical manifestation of recurrent papillary serous cystadenocarcinoma of the ovary was an elevated serum CA125 level due to a solitary splenic metastasis.

The cytopathology of synovial sarcoma: a study of six cases, with emphasis on architecture and histopathologic correlation.

BACKGROUND: In this article, the architectural and cytologic features of synovial sarcoma are described. METHODS: Romanowsky- and Papanicolaou-stained fine-needle aspiration smears and corresponding hematoxylin and eosin sections were retrieved from archival material and examined by light microscopy. RESULTS: Microtissue fragments comprised of spindle cells dominated smears and correlated with fibrosarcoma-like areas prevalent in tissue sections. Characteristic fascicular and whorled patterns were apparent, and matrix material representing collagenous stroma varied from fibrillary to hyalinized. Epithelial components included polygonal and rectangular cells isolated from spindle cells, gland-like formations occurring within otherwise spindle cell microtissue fragments, and clubbed, spindle cell collections lined by flattened epithelial cells. CONCLUSIONS: Features of synovial sarcoma as defined previously by histopathology were apparent in cytologic preparations, facilitating a primary diagnosis by cytology.

Cytokeratins 7 and 20 and carcinoembryonic antigen in ovarian and colonic carcinoma.

The histologic distinction between adenocarcinoma primary to the ovary and metastatic to the ovary can be difficult. In an effort to facilitate this distinction, we have evaluated the use of immunohistochemical techniques with antibodies to cytokeratins 7 and 20, along with antibodies to carcinoembryonic antigen. We studied 24 primary ovarian adenocarcinomas, 11 colonic adenocarcinomas metastatic to the ovary, and 10 primary adenocarcinomas of the colon. Four ovarian adenocarcinomas metastatic to the colon were also studied. All but one of the primary and metastatic colonic carcinomas were negative for cytokeratin 7, whereas all the primary and metastatic ovarian carcinomas were positive for cytokeratin 7. The tumors metastatic to the ovary were all positive for cytokeratin 20 and carcinoembryonic antigen. Among the primary ovarian carcinomas, none of six serous tumors, three of seven endometrioid tumors, and three of 11 mucinous tumors were positive for cytokeratin 20. Ten of the primary ovarian tumors were negative for carcinoembryonic antigen using both monoclonal and polyclonal antibodies. One of the ovarian tumors was negative for carcinoembryonic antigen with the monoclonal antibody but positive using the polyclonal antibody. Cytokeratin 7 is the most helpful marker in the distinction between primary ovarian carcinoma and colonic carcinoma metastatic to the ovary.

Comparison of the costs of fine-needle aspiration and open surgical biopsy as methods for obtaining a pathologic diagnosis.

BACKGROUND: A pathologic diagnosis is usually required to determine definitive management for a palpable lesion. In this era of cost control, fine-needle aspiration (FNA) provides a low-cost alternative to open excisional biopsy. Using a broad range of cases collected over 20 years, the authors of this study sought to quantify the savings resulting from the use of FNA on superficial palpable lesions to obtain a pathologic diagnosis. METHODS: 12,452 cases collected by the cytopathology service at the Medical College of Virginia during the period 1972-1991 were used to produce a profile of case type, diagnosis, and indication for surgery. Charge-based cost estimations or Relative Value Units were calculated using the 1995 Physicians' Fee Reference or published Medicare participant fees. The charges for the FNA procedure and open surgical biopsy were compared, and all other biopsy-related costs were omitted. RESULTS: FNA provided a sufficient pathologic diagnosis to obviate open surgical biopsy in 63-85% of the cases. Estimation of cost savings on the basis of the distribution of cases and indications for surgery suggested a savings of $250,000 to $750,000 per 1000 FNA performed, or approximately 5500 Relative Value Units. CONCLUSIONS: This study quantifies the substantial savings that result from obtaining a pathologic diagnosis by the FNA procedure rather than open surgical biopsy.